Violence and Depression in Adolescents - Violence in Adolescents

Written by M. Allan Cooperstein, Ph.D.

A January peer encounter exacerbated the fulminating depression (unaffected by the medication), worsening his sleep, making Ronny unable to attend school regularly for fear of uncontrollably falling asleep in class. After being awakened for school one morning, he dissociated, revealing a level of psychopathology never before suspected by either the psychologist or psychiatrist. It exposed internalized rage, quasi-hallucinatory experiences and paranoid ideations.

By January's end, Ronny—when he spoke at all--complained that nothing helped his moods, showed agitated despair and hopelessness, admitted to suicidal ideations, began self-mutilative behaviors (picking at his forearms) and had evening rage reactions. After resisting attempts to voluntarily admit him as an inpatient, an involuntarily commitment for emergency services and treatment became necessary (Section 7302 of the Mental Health Procedures Act of 1976; see Knapp, VandeCreek, & Tepper, 1998). Due to his geographical location, however, rather than being transported to a hospital adolescent unit, Ronny was taken to a generic, County emergency services facility. The staff was caring and skilled, but the surroundings were reminiscent of the "snake pit" atmosphere found years earlier in State mental hospitals.

Committed by law for up to 5 days, this acutely depressed, non-drug-addicted teen was placed in a population of primarily adult, some acutely psychotic, some self-mutilative, some drug-addicted and dual-diagnosed adults, many of whom had been committed numerous times before.

After a "303 hearing" (Section 7303 for review of extended involuntary emergency treatment), he was transferred to a hospital young persons unit. With Ronny's agreement, in preparation for his eventual discharge, another outpatient psychotherapist and psychiatrist were found, each having excellent records of accomplishment with adolescents. During this search, however, I became acutely aware of the scarcity of appropriate inpatient and outpatient adolescent practitioners and resources.

Following release from inpatient and partial care, Ronny's recovery was slow. By chance, I spoke with a psychiatric colleague who suggested a medication change. Ronny's psychiatrist agreed and, within a month, he responded to the new antidepressant and was weaned from the antipsychotic that had been prescribed earlier (Note: a Rorschach I requested while at the hospital indicated depression and no psychosis). His mood brightened at times and his sense of humor reappeared.

About the same time, he spent three weeks in another partial hospital program. In combination with the new medication, this provided a positive start towards recovery. However, despite the gains, just as his social needs were being addressed and positive changes started to take hold, partial treatment was abruptly terminated by the insurer as he was "no longer acute". He is now continuing with his outpatient therapist and psychiatrist, supported by a proactive school counselor and teaching staff, receiving homebound instruction. The episodic rages are gone as are the feelings of hopelessness. However, although wraparound services are available, his functioning is too high for partial hospitalization and other forms of supervised, therapeutic adolescent social activities—including group psychotherapy--are rare or unavailable.

Research Trends and Conclusions

Curiosity prompted a search of APA's Psychinfo Online for the period from 1980-1999 for 5 keywords: hormone, adolescent, adult, male and female. The results demonstrate a 2:1 relationship between adult and adolescent studies (not accounting for animal studies).

Murray Rosenthal, M.D., Director of Behavioral & Medical Research in California, reports "While the advances in the opportunities for treatment have clearly expanded, making accurate diagnosis remains for the most part an enigma, The reason for this enigma is manifold, not the least of which is the time required to make a proper diagnosis... Often the individuals to perform these tests and the tests themselves are unavailable in routine clinical practice... As such, many children end up with what have become popular diagnoses such as ADHD. In research facilities, children who have previously been diagnosed with ADHD and go through a full diagnostic panel are often reclassified into such illnesses as generalized anxiety disorder, agitated depression, and incipient bipolar illness." (personal communication, June 17, 1, italics added).

The primary focus is less on the adolescent than on the challenges that dealing with the adolescent presents to parents and adults in general in this society, according to Michael Silver, M.D. Director of the Adolescent Unit at Friends Hospital. "The first challenge is that dealing with an adolescent offspring offers us the opportunity (if we're willing to seize and confront it) to assess where we are with our lives, and to review our own satisfactions, accomplishments, disappointments, and losses as manifested and reflected in the hopes and fears we have for our child. The second is that adolescents behaviors continually give us opportunities to deal with our own issues regarding interpersonal power and control. It's a wonderful (and terrifying) arena in which to struggle with the limits of our ability to influence our children, and by extension, to influence our own lives and the world at large." (personal communication, June 15, 1999).