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THE CONTEXT TO ADOLESCENCE

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Lebanese young people in Sydney compared with Asian kids in Cabramatta ... Anxiety - Different forms throughout childhood (Separation, GAD, Phobic, OCD) ... – PowerPoint PPT presentation

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Title: THE CONTEXT TO ADOLESCENCE


1
THE CONTEXT TO ADOLESCENCE
  • Professor Graham Martin OAM
  • MD, FRANZCP, DPM
  • g.martin_at_uq.edu.au

2
ADOLESCENCE
  • A transition period from immaturity to maturity
  • Early 11-14yrs
  • Middle 15-18yrs
  • Late 19-21 yrs

3
There is no one adolescence
  • At last count there were over 190 different
    cultural backgrounds in Australia
  • Life is different for
  • Lebanese young people in Sydney compared with
    Asian kids in Cabramatta
  • Young People from Thursday Island compared with
    those from OAFS in Adelaide

4
Adolescence used to have 3 stages
  • Based on physiological status
  • Early (from Puberty) - Identity Confusion
  • Middle - Working through
  • Late - Identity re-formation
  • Now the variability is what is obvious

5
Rites of Passage
  • Work
  • Keys to the door
  • Alcohol
  • Cars
  • Circumcision
  • Sex
  • Challenge

6
TEENAGE LABOUR FORCE PARTICIPATION 1978-1997
7
The Trajectory
8
Cousin Michael
  • The trajectory interrupted

9
Growth of the Ego (after Erik H. Erikson)
Ego Integrity vs Despair
Generativity vs Stagnation
Intimacy vs Isolation
Identity vs Role Confusion
Industry vs Inferiority
Initiative vs Guilt
Autonomy vs Shame Doubt
Basic Trust vs Mistrust
10
Key Developmental Issues
  • Identity
  • Autonomy
  • Intimacy
  • Sexuality
  • Achievement

11
Toward What?
  • Clear Identity
  • Body Image
  • Relative Autonomy
  • Task Orientation
  • Commitment
  • Adult relationship development

12
Hierarchy of Needs
Need for Self-Actualisation Personal Growth and
Fulfilment
Need for Self-Esteem Achievement, Affection,
Responsibility, Reputation
Social Needs - Belonging Family Affection,
Relationships, Work, Group relationships
Need for Safety and Security Protection,
Security, Order, Law, Limits, Stability
  • Basic Biological and Physiological Needs
  • Air, Food, Water, Shelter, Warmth, Sex, Sleep

Abraham Maslow,Motivation and Personality, 1954)
eg McKelvey/Vietnam
13
Development of Health
14
Resilience
  • the ability to bounce back, recover from, or
    adjust to misfortune or change
  • Burns, 1996

15
Resilience facing Adversity Fergusson and
Lynskey, 1996
  • intelligence
  • problem solving ability
  • female gender ??
  • external interests/affiliations
  • ve parental attachment and bonding
  • easy early temperament
  • good peer relationships

16
Profile of the Resilient Child Benard 1991
  • Social Competence
  • responsiveness, flexibility, empathy, caring,
    communication skills, sense of humour
  • Problem Solving Skills
  • critical thinking, generating alternatives,
    planning, produces change

17
Profile of the Resilient Child Benard 1991
  • Autonomy
  • self-esteem, self-efficacy, internal locus of
    control, independence, adaptive/healthy
    distancing
  • Sense of Purpose and Future
  • goal directedness, achievement orientation, high
    motivation, educational aspiration, persistence,
    hopefulness, coherence

18
INFLUENCES
  • Successful Ego Maturation
  • Family Parameters
  • Family Developmental Stage
  • Gender and Same Sex Peers
  • Education and Employment

19
Factors Influencing Body Image
  • Puberty and Adolescence
  • Role Models - Parents, Family(heredity) Teachers,
    and Coaches
  • Peers
  • Society and the Media

20
Influence of Puberty
  • Girls
  • natural weight gain necessary for shifts away
    from society's ideal body shape
  • Boys
  • natural weight gain shifts towards society's
    ideal body shape

21
Influence of Peers
  • Influence of friends increases
  • Emphasis on fitting in and being alike
  • Self absorbed
  • Focus girls - how they look
  • boys - what they can do

22
Body Image Dissatisfaction of Respondents Who
Do Not Like How Their Body Looks
Halton Region - October 2001
23
Fear of Fat of Respondents Who are Afraid of
Becoming Fat or Fatter
Halton Region - October 2001
24
Weight Control Behaviours of Respondents Who
Are Trying to Lose Weight
Halton Region - October 2001
25
Frequency of Exercise of Frequency of Exercise
Halton Region - October 2001
26
Body Dissatisfaction USA 1972-97
Percent dissatisfied
Sex / Body Part
n of 4,000 refers to the 1997 survey only. Garner
(1997).
27
Body Image Dissatisfaction
  • 27 of girls 12 - 18 years reported disordered
    attitudes about food
  • 20 of these girls were 12 - 14 years
  • dieting was the most prevalent weight loss
    strategy
  • 12 of girls 12 - 14 report binge-eating and 5
    report self-induced vomiting
  • Jennifer Jones, Disordered eating attitudes and
    behaviours in teenaged girls a school based
    study 2001

28
Influence of the Media
  • Media creates a distorted image of reality
  • normalizes glamorizes what is a abnormal
  • creates false impression that all women and men
    are the same
  • sends the message that one must continually
    improve and is never good enough
  • uses technology to alter and create an image

29
CONTAGION
30
CONTAGION2
31
Bio-Psycho-Socio-Cultural Influences
32
The Family Context
Father
Sig. other
Mother
Self
Sibling
33
PARAMETERS OF FAMILY FUNCTIONING after Epstein
Bishop (MCMASTER)
  • Roles
  • Problem Solving
  • Communication
  • Affective Involvement
  • Affective Responsiveness
  • Behaviour Control
  • General Functioning

34
TRANSITION POINTS IN FAMILY DEVELOPMENT After
Barnhill and Longo, 1978
  • Creation of the Couple
  • (Commitment)
  • Entry of the First Child
  • (Development of Parenting Roles)
  • First Child Development
  • (Acceptance of Child/New Marital Roles)
  • First Child enters the Wider World
  • (Accepting other institutions as responsible)

35
TRANSITION POINTS IN FAMILY DEVELOPMENT
  • Adolescence
  • (Acceptance of changed physique, Sexuality,
    Social Roles toward leaving home)
  • First Child leaves the family
  • (Accepting/Permitting/Encouraging Independence)
  • Separation of Parents
  • (Continuation of Parenting without Marital Role)

36
TRANSITION POINTS IN FAMILY DEVELOPMENT
  • Remarriage of Parent
  • (Acceptance of Extended Adoptive Family)
  • Last Child leaves the family
  • (Facing each other and the Empty Nest)
  • Retirement
  • (Developing New Career/Grandparent Status)
  • Death of a Spouse
  • (Acceptance of Single Status)

37
Hannah
  • The reconstituted family

38
The Protective Family Benard 1991
  • Caring and Support
  • close relationship with one person, affection
    expressed physically and verbally
  • High Expectations
  • structure , order, discipline, values, explicit
    expectation, faith, hope for the future
  • Participation
  • valued participant, domestic responsibility,
    independence encouraged, autonomy respected

39
Development of Ill-Health
40
THEORETICAL MODELS
  • Vulnerability-Stress
  • impairment becomes manifest when vulnerability
    and stress factors overwhelm biopsychosocial
    responses (Falloon, 1993)

41
THEORETICAL MODELS
  • Vulnerability-Stress
  • social factors interact with prior maternal loss
    current vulnerability factors to produce
    cognitive set of low self esteem, reducing the
    ability to work through current loss. This leads
    to hopelessness (Brown, 1987 1994)

42
THEORETICAL MODELS
  • Cognitive
  • Depression is based in the development of a
    negative sense of self from childhood loss
    reinforced over time and leading to cognitive
    distortions (Beck, 1973)
  • Helplessness is a learned maladaptive style
    (Seligman, 1975)
  • Attributions for failure are learned (Abramson,
    1978)

43
THEORETICAL MODELS
  • Ecological Transactional
  • adapted from (Cichetti Tucker, 1994 (Cichetti
    Toth, 1998)

depressotypic organization
44
THEORETICAL MODELS
  • Ecological Transactional
  • adapted from (Cichetti Tucker, 1994 (Cichetti
    Toth, 1998)

Macro
depressotypic organization
Exo
Ontogenic
DEPRESSION
45
Hypothalamic-Pituitary Adrenal (HPA) axis
  • Stress related - fight or flight
  • Corticotrophin releasing factor (hypothalamus)
  • Adrenocortocotrophic hormone (anterior pituitary)
  • Glucocorticoids (Cortisol) (Adrenal Cortex)
  • Increases blood sugar, heart rate, and inhibits
    overreaction of the immune system
  • Serotonin modulates the threshold of stimulation

46
Cortisol as a predictor
  • Depressed Adolescents followed 10 years
  • Suicide attempters had increased Cortisol in 4,
    6, 12 hours prior to sleep, but reduced at 2-4
    hours before sleep (ie dysregulation of HPA axis)
  • Matthew et al. 2003 Columbia group

47
Disorders Mean Age of Onset
  • ADHD - symptoms prior to age 7 (by definition)
  • Anxiety - Different forms throughout childhood
    (Separation, GAD, Phobic, OCD)
  • Post-traumatic Stress Disorder throughout
    childhood
  • Oppositional Defiant Disorder from about 6yrs
  • Conduct Disorder from about 10yrs
  • Delinquency from about 12yrs
  • Depression from peak mean age of onset 15yrs
  • Psychosis from peak mean age of onset 18yrs

48
Unipolar Major Depression
  • Currently the 4th most costly illness in the
    world, but will be 2nd by the year 2020.
  • WHO Global Burden of Disease Study
  • Murray and Lopez, 1997

49
Depression in Young People
  • Mood
  • Depressive Syndrome
  • or Symptom Complex
  • Disorder or Illness

50
So what is Depression ?
  • Sad Mood over time
  • Appetite Disturbance
  • Sleep Disturbance
  • Agitation or Retardation
  • Loss of Interest and Pleasure
  • Low Energy or Fatigue
  • Worthlessness or Guilt
  • Slow Cognition with poor Concentration and
    Memory

51
Psychosocial Difficulties
  • Self-consciousness
  • Low self-esteem
  • Reduction in activity
  • are key issues in depressed young people
  • Lewinsohn, Gotlib Seeley, 1997

52
The different forms of Depression
  • Dysthymia
  • Unipolar Major Depression
  • Bipolar Illness
  • (may be diagnosed using the
  • same criteria as for adults)

53
Depression in Young People
  • Major studies in USA, Canada, Dunedin and
    Christchurch all conclude that Major Depression
    occurs in 6-7 of 15 year olds and up to 15 by
    the age of 18 yrs.

54
Prevalence
  • In a community sample, 30 had at least one
    symptom of DSM-IIIR Major Depression
  • But
  • only 2.6 were diagnosed
  • using structured interview
  • Roberts, Lewinsohn Seeley, 1995

55
Recurrence
  • After 1st episode Major Depression, 47 recur
    within 1 year, and 69 by 2nd year
  • Emslie, Rush, Weinberg et al, 1997
  • Episodes may be more brief, but occur more
    frequently

56
Comorbidity
  • Personality Disorder traits significantly
    increased to 3.8
  • May be associated with negative course
  • Lewinsohn, Rohde, Seeley Klein, 1997

57
Comorbidity (contd.)
  • First episode schizophrenia
  • Addington, Addington Patten, 1998
  • ADHD
  • Butler, Arredondo McCloskey, 1995
  • Autism
  • Hellings, Kelley, Gabrielli et al., 1996
  • Intellectual disability
  • Masi, Marchesi Pfanner, 1997
  • Somatic disorder
  • Cohen, Pine, Must, Kasen Brook, 1998

58
Comorbidity (contd.)
  • Diabetes (IDDM)
  • Kovacs, Goldston, Obrosky Bonar, 1997
  • Sickle Cell Disease
  • Yang, Cepeda, Price, Shah Mankad, 1994
  • Post Traumatic Stress Disorder
  • Hubbard, Realmuto, Northwood Masten, 1995
  • Young Pregnancy
  • Deal Holt, 1998
  • Homelessness
  • Reilly, Herrman, Clarke, Neil McNamara, 1994

59
Psychotic Symptoms
  • Delusions and/or hallucinations occur in 10 of
    major depression
  • Quinlan, King, Hanna Ghaziuddin, 1997

60
Structural changes
  • MRI scan showed depressed teens had a 17
    reduction in the size of the hippocampus
    (motivation, emotion and memory formation)
  • Thought to be related to depression, though
    stress and trauma can also cause shrinkage
  • McMaster Kusamakar, 2003 Nova Scotia, Canada

61
Out of the Blues
62
94 Assessments mean age 18.2 years
63
Primary Diagnosis
MAJOR DEPRESSION 30 (39.5) DYSTHYMIA 18
(23.7) ADJUST. DIS. w. DEP. MOOD 13
(17.1) BIPOLAR DISORDER 5 (6.6) ANXIETY 4
(5.3) PTSD 2 (2.6) ADHD 2
(2.6) BEREAVEMENT 1 (1.3) DRUG -INDUCED
PSYCHOSIS 1 (1.3)
64
Beck Depression Inventory Scores at Time 1
65
Suicidal Behaviours
  • 26 (36) scores in gt10 on the ASQ-R
  • 37 denied an attempt
  • 34 attempters
  • More than a year ago 5
  • 3-12 months ago 10
  • 1-3 months ago 4
  • In last 1 month 15

66
Out of the Blues
Therapy(76)
67
OOTB - BDI scores over time
68
OOTB - Ham-D scores
69
OOTB - HoNOS over time
70
OOTB - Suicidal Behaviours
  • 5 attempts between Time 1 and Time 2
  • (2 medically serious)
  • 3 attempts between Time 2 and Time 3
  • (one a repeat attempter)
  • (none medically serious)

71
Overall Conclusion
  • Within the limitations of the study, it did not
    appear to make much difference which combinations
    of therapy young people received.

72
Access is Crucial Referral Process
  • INITIAL PHONE CALL
  • initial management safety issues
  • interim supports
  • appointment time no more than 2 weeks

73
Resources and Prevention
  • Although therapeutic intervention is humane,
    desirable, and rewarding to....both therapists
    and clients, it does....little or nothing to
    reduce the number of new cases (the incidence) of
    any particular disorder
  • Albee, 1982

74
Prevention of Depression
  • Resilience
  • Risk

75
Prevention of Depression
  • Family Dysfunction, Parental Conflict, Divorce
  • Traumatic experience
  • Physical Illness
  • Grief and Loss
  • Target Pessimism
  • Parental Mental Illness, particularly Depression
  • Socio-economic deprivation and Unemployment
  • Being in care or in the juvenile justice system
  • Homelessness
  • Abuse, particularly sexual abuse
  • Pregnancy in young people
  • Risk

76
Prevention of Depression
  • Protective Factors Resilience
  • Temperament building
  • Resilience building in school
  • Learned Optimism programs
  • Options and Choices personal judgment
  • Developing sense of self through sport, games,
    drama
  • Developing supportive relationships at peer level
  • and with adults
  • Stress inoculation
  • Developing national pride
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