the context to adolescence professor graham martin oam md, franzcp, dpm g.martin@uq.edu.au professor...

THE CONTEXT TO ADOLESCENCE

Professor Graham Martin OAMMD, FRANZCP, DPM

g.martin@uq.edu.au

Professor Graham Martin OAMMD, FRANZCP, DPM

g.martin@uq.edu.au

ADOLESCENCEADOLESCENCE

A transition period from immaturity to maturity

Early 11-14yrs Middle 15-18yrs Late 19-21 yrs

A transition period from immaturity to maturity

Early 11-14yrs Middle 15-18yrs Late 19-21 yrs

There is no ‘one’ adolescenceThere 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

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

Adolescence used to have3 stages

Based on physiological status Early (from Puberty) - Identity Confusion Middle - Working through Late - Identity re-formation

Now the variability is what is obvious

Based on physiological status Early (from Puberty) - Identity Confusion Middle - Working through Late - Identity re-formation

Now the variability is what is obvious

Rites of PassageRites of Passage

Work Keys to the door Alcohol Cars Circumcision Sex Challenge

TEENAGE LABOUR FORCE PARTICIPATION 1978-1997TEENAGE LABOUR FORCE PARTICIPATION 1978-1997

1978198019821984198619881990199219941996

Male FTFemale FTMale ptFemale pt

The TrajectoryThe Trajectory

Indicated

Case identification

Cousin MichaelCousin Michael

The trajectory interruptedThe trajectory interrupted

Growth of the Ego(after Erik H. Erikson)

Basic Trust vs MistrustBasic Trust vs Mistrust

Autonomy vs Shame & DoubtAutonomy vs Shame & Doubt

Initiative vs GuiltInitiative vs Guilt

Industry vs InferiorityIndustry vs Inferiority

Identity vs Role ConfusionIdentity vs Role Confusion

Intimacy vs IsolationIntimacy vs Isolation

Generativity vs StagnationGenerativity vs Stagnation

Ego Integrity vs DespairEgo Integrity vs Despair

Key Developmental IssuesKey Developmental Issues

Identity Autonomy Intimacy Sexuality Achievement

Toward What?Toward What?

Clear Identity Body Image

Relative Autonomy Task Orientation Commitment ‘Adult’ relationship development

Clear Identity Body Image

Relative Autonomy Task Orientation Commitment ‘Adult’ relationship development

Hierarchy of NeedsHierarchy of Needs

Basic Biological and Physiological Needs

Air, Food, Water, Shelter, Warmth, Sex, Sleep

Basic Biological and Physiological Needs

Air, Food, Water, Shelter, Warmth, Sex, Sleep

Need for Safety and SecurityProtection, Security, Order, Law, Limits, Stability

Social Needs - BelongingFamily Affection, Relationships, Work, Group relationships

Need for Self-EsteemAchievement, Affection, Responsibility,

Reputation

Need for Self-EsteemAchievement, Affection, Responsibility,

Reputation

Need for Self-ActualisationPersonal Growth and Fulfilment

Abraham Maslow,‘Motivation and Personality’, 1954)Abraham Maslow,‘Motivation and Personality’, 1954)

eg McKelvey/Vietnameg McKelvey/Vietnam

Development of HealthDevelopment of Health

ResilienceResilience

“the ability to bounce back, recover from, or adjust to misfortune or change”

Burns, 1996

“the ability to bounce back, recover from, or adjust to misfortune or change”

Burns, 1996

Resilience facing AdversityFergusson and Lynskey, 1996

intelligence problem solving ability female gender ?? external interests/affiliations +ve parental attachment and bonding easy early temperament good peer relationships

Profile of the Resilient ChildBenard 1991

Social Competence responsiveness, flexibility, empathy, caring,

communication skills, sense of humour;

Problem Solving Skills critical thinking, generating alternatives,

planning, produces change;

Social Competence responsiveness, flexibility, empathy, caring,

communication skills, sense of humour;

Problem Solving Skills critical thinking, generating alternatives,

planning, produces change;

Profile of the Resilient ChildBenard 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;

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;

INFLUENCESINFLUENCES

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

Factors Influencing Body ImageFactors Influencing Body Image

Puberty and Adolescence

Role Models - Parents, Family(heredity) Teachers, and Coaches

Peers Society and the Media

Puberty and Adolescence

Role Models - Parents, Family(heredity) Teachers, and Coaches

Peers Society and the Media

Influence of PubertyInfluence 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

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

Influence of PeersInfluence 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

Influence of friends increases

Emphasis on fitting in and being alike

Self absorbed

Focus: girls - how they look

boys - what they can do

Body Image Dissatisfaction% of Respondents Who Do Not Like How Their Body Looks

10 & 11 yrs 12 yrs 13 & 14 yrs

Females

Halton Region - October 2001

Fear of Fat% of Respondents Who are Afraid of Becoming Fat or Fatter

10 & 11 yrs 12 yrs 13 & 14 yrs

Females

Weight Control Behaviours% of Respondents Who Are Trying to Lose Weight

10 & 11 yrs 12 yrs 13 & 14 yrs

Females

Frequency of Exercise % of Frequency of Exercise

23.615.5

43.835.5

20.527

12.122

Females

Body Dissatisfaction USA 1972-97

Men/stomachs Women/stomachs Men/chest Women/breasts

197219851997

Percent dissatisfied

Sex / Body Partn of 4,000 refers to the 1997 survey only. Garner (1997).

Body Image DissatisfactionBody 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 vomitingJennifer Jones, Disordered eating attitudes and behaviours in teenaged girls: a school based study 2001

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 vomitingJennifer Jones, Disordered eating attitudes and behaviours in teenaged girls: a school based study 2001

Influence of the MediaInfluence 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

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

CONTAGIONCONTAGION

CONTAGION2CONTAGION2

Bio-Psycho-Socio-Cultural Influences

BioBio

PsychoPsycho

SocioSocio

CulturalCultural

The Family ContextThe Family Context

Sig. otherSig. other

FatherFather

MotherMother

SelfSelf SiblingSibling

PARAMETERS OF FAMILY FUNCTIONING

after Epstein & Bishop (MCMASTER)

PARAMETERS OF FAMILY FUNCTIONING

after Epstein & Bishop (MCMASTER)

Roles Problem Solving Communication Affective Involvement Affective Responsiveness Behaviour Control General Functioning

TRANSITION POINTS IN FAMILY DEVELOPMENT

After Barnhill and Longo, 1978

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)

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)

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)

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)

TRANSITION POINTS IN FAMILY DEVELOPMENTTRANSITION 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)

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)

TRANSITION POINTS IN FAMILY DEVELOPMENTTRANSITION POINTS IN FAMILY DEVELOPMENT

HannahHannah

The reconstituted familyThe reconstituted family

The Protective FamilyBenard 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

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

Development of Ill-HealthDevelopment of Ill-Health

THEORETICAL MODELSTHEORETICAL MODELS

Vulnerability-Stressimpairment becomes manifest when vulnerability and stress factors overwhelm biopsychosocial responses (Falloon, 1993)

Vulnerability-Stresssocial 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)

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)

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)

THEORETICAL MODELSTHEORETICAL MODELSEcological Transactional adapted from (Cichetti & Tucker, 1994; (Cichetti & Toth, 1998)

Ecological Transactional adapted from (Cichetti & Tucker, 1994; (Cichetti & Toth, 1998)

CognitiveCognitive

RepresentationalRepresentationalBiologicalBiological

SocioemotionalSocioemotional

depressotypicorganizationdepressotypicorganization

THEORETICAL MODELSTHEORETICAL MODELSEcological Transactional adapted from (Cichetti & Tucker, 1994; (Cichetti & Toth, 1998)

Ecological Transactional adapted from (Cichetti & Tucker, 1994; (Cichetti & Toth, 1998)

CognitiveCognitive

RepresentationalRepresentationalBiologicalBiological

SocioemotionalSocioemotional

depressotypicorganizationdepressotypicorganization

MacroMacro

ExoExo

MicroMicro

OntogenicOntogenic

DEPRESSIONDEPRESSION

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

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

Cortisol as a predictorCortisol 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

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

Disorders: Mean Age of OnsetDisorders: 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

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

Unipolar Major DepressionUnipolar 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

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

Depression in Young PeopleDepression in Young People

Mood Depressive Syndrome

or Symptom Complex

Disorder or Illness

Mood Depressive Syndrome

or Symptom Complex

Disorder or Illness

So what is Depression ?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

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

Psychosocial DifficultiesPsychosocial Difficulties

Self-consciousness Low self-esteem Reduction in activity

are key issues in depressed young peopleLewinsohn, Gotlib & Seeley, 1997

Self-consciousness Low self-esteem Reduction in activity

are key issues in depressed young peopleLewinsohn, Gotlib & Seeley, 1997

The different forms of DepressionThe different forms of Depression

Dysthymia Unipolar Major Depression Bipolar Illness

(may be diagnosed using the

same criteria as for adults)

Dysthymia Unipolar Major Depression Bipolar Illness

(may be diagnosed using the

same criteria as for adults)

Depression in Young PeopleDepression 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.

Case identificationCase identification

Prevalence

In a community sample, 30% had at least one symptom of DSM-IIIR Major Depression

only 2.6% were diagnosed

using structured interviewRoberts, Lewinsohn & Seeley, 1995

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

Comorbidity

Personality Disorder traits significantly increased to 3.8%

May be associated with negative course

Lewinsohn, Rohde, Seeley & Klein, 1997

Comorbidity (contd.)

First episode schizophreniaAddington, Addington & Patten, 1998

ADHDButler, Arredondo & McCloskey, 1995

AutismHellings, Kelley, Gabrielli et al., 1996

Intellectual disabilityMasi, Marchesi & Pfanner, 1997

Somatic disorderCohen, Pine, Must, Kasen & Brook, 1998

Comorbidity (contd.)

Diabetes (IDDM)Kovacs, Goldston, Obrosky & Bonar, 1997

Sickle Cell DiseaseYang, Cepeda, Price, Shah & Mankad, 1994

Post Traumatic Stress DisorderHubbard, Realmuto, Northwood & Masten, 1995

Young PregnancyDeal & Holt, 1998

HomelessnessReilly, Herrman, Clarke, Neil & McNamara, 1994

Psychotic Symptoms

Delusions and/or hallucinations occur in 10% of major depression

Quinlan, King, Hanna & Ghaziuddin, 1997

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

‘Out of the Blues’‘Out of the Blues’

Referrals(186) 50% male

Appointments Offered(108) 53.7% male

Assessed(94) 50% male

One session only12 males; 6 femalesOne session only

12 males; 6 females

94 Assessmentsmean age 18.2 years

DISTRIBUTION OF AGE

13 14 15 16 17 18 19 20 21 22 23 24

Primary DiagnosisPrimary 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%)

Beck Depression InventoryScores at Time 1

LEVELS OF DEPRESSION Time 1.

0 to 9 10 to 18 19 to 29 30+

BECK DEPRESSION INVENTORY (BDI) Scores

LEVELS OF DEPRESSION Time 1.

0 to 9 10 to 18 19 to 29 30+

BECK DEPRESSION INVENTORY (BDI) Scores

Suicidal BehavioursSuicidal Behaviours

26 (36%) scores in >10 on the ASQ-R; 37 denied an attempt; 34 attempters:

More than a year ago = 53-12 months ago = 101-3 months ago = 4In last 1 month = 15

26 (36%) scores in >10 on the ASQ-R; 37 denied an attempt; 34 attempters:

More than a year ago = 53-12 months ago = 101-3 months ago = 4In last 1 month = 15

Out of the BluesOut of the Blues

Individual (11)Individual (11)

Individual plus Medication (46)Individual plus Medication (46)

CBT (6)CBT (6)

CBT plus Medication (9)CBT plus Medication (9)

Family Therapy (1)Family Therapy (1)

Family Therapy plus Medication (3)Family Therapy plus Medication (3)

Therapy(76)Therapy(76)

OOTB - BDI scores over time

Depression from Time 1 to Time 3

BDI -T1 BDI-T2 BDI-T3

OOTB - Ham-D scoresOOTB - Ham-D scoresHAMILTON DEPRESSION RATING

SCALE - DEPRESSION

TIME 1 TIME 3

OOTB - HoNOS over timeOOTB - HoNOS over timeHoNOS

TIME 1 TIME 3

OOTB - Suicidal BehavioursOOTB - 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)

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)

Overall ConclusionOverall Conclusion

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

INITIAL PHONE CALL initial management &

safety issues interim supports appointment time no

more than 2 weeks

INITIAL PHONE CALL initial management &

safety issues interim supports appointment time no

more than 2 weeks

Access is Crucial Referral Process

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

“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

Prevention of DepressionPrevention of Depression

Resilience

Prevention of DepressionPrevention of DepressionFamily Dysfunction, Parental Conflict, DivorceTraumatic experience*Physical IllnessGrief and LossTarget PessimismParental Mental Illness, particularly DepressionSocio-economic deprivation and UnemploymentBeing in care or in the juvenile justice systemHomelessnessAbuse, particularly sexual abusePregnancy in young people

Family Dysfunction, Parental Conflict, DivorceTraumatic experience*Physical IllnessGrief and LossTarget PessimismParental Mental Illness, particularly DepressionSocio-economic deprivation and UnemploymentBeing in care or in the juvenile justice systemHomelessnessAbuse, particularly sexual abusePregnancy in young people

Prevention of DepressionPrevention 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

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

the context to adolescence professor graham martin oam md, franzcp, dpm g.martin@uq.edu.au professor...

Documents

optisens oam 1050

prof graham martin oam franzcp, dpm professor & director,...

configuring mpls oam

in wyeth, g & upcroft, b (eds.) proceedings of the 2010...

nms oam system user's · pdf fileowners. every effort has...

efm oam tutorial

configuring ethernet cfm and oam - cisco.com · configuring...

oam install & config

cricos provider no 00025b uq.edu.au the bsc review 2014

oam edg training

oam bookletenglish r

configuring ethernet oam and cfm - ciscoethernet oam manager...

ebs oam con5246_pdf_5246_0001

gwconfig oam en

draft recommendation y.17ethoam oam functions and ... ·...

mpls transport profile - cisco · support formplstransport...

draft annual report 2009 annual...tracey belbin oam dean...

ethernet oam monitoring - · pdf fileethernet oam monitoring...

efm oam tutorial -...

admin guide oam