Psychiatry - August 2008 - (Page 44)

requires an approach that is truly biopsychosocial. The case presented in this article also demonstrates the opportunity for focal psychotherapy in a crisis or emergency setting that can lead to lasting change. CASE EXAMPLE Mr. S, a 15-year-old Caucasian boy, was brought to the emergency room late on a Saturday night by law enforcement personnel. His mother, father, and a 12-year-old brother, who could not be left at home alone, arrived at the hospital shortly thereafter. A psychiatrist and social worker were paged to evaluate Mr. S. Earlier that evening, a passerby had noticed Mr. S and a group of boys and girls turning into a shopping mall parking lot with Mr. S hanging onto the top of the car. The police were called and found the boys and girls sitting in the car in the parking lot. The smell of marijuana was evident. There was a physical altercation when Mr. S and another boy tried to get away. During the struggle, Mr. S stated he should “just kill himself.” All were taken into custody, with Mr. S brought to the emergency room because of his statement about suicide. The police told the staff at the hospital that they had been called before about disturbances involving Mr. S, including the offense of minor in possession of cigarettes. When interviewed alone initially by the social worker, Mr. S was angry and withdrawn, with one leg hung over the arm of the chair. He was a well-groomed, attractive boy, but his hair hung over his face, obscuring his features. He swore at the social worker, refusing to talk and stated that he did not need to be in the emergency room. He was told that his talking might hasten his leaving the emergency room. He was also told that verbal abuse was not acceptable, and in turn, by eliminating his use of verbal abuse, he would be treated with respect. Mr. S calmed down somewhat and agreed to discuss what had 44 Psychiatry 2008 [ A U G U S T ] happened earlier in the evening. Mr. S’s parents were also interviewed. This was not the first time they had been involved with the police regarding Mr. S. They were frustrated and angry, but were also scared to learn that Mr. S had talked about suicide. Mr. S described the situation that had occurred that evening. He and his friends had been driving around, and “on a dare” he had agreed to hang onto the ski rack of the car. As soon as the car started moving, he said he was scared, but did not shout for the car to stop because he did not want his friends to think he was “weak” and he wanted to impress one of the girls in the car. At the time, he did not remember thinking at all about the potential danger involved in what he had done. He did remember saying he should “just kill himself,” but he denied really wanting to kill himself. He just said it was because he was angry and upset. He had never made a suicide attempt, nor even entertained the thought of doing it or how he would do it. He admitted he sometimes wished he were dead because he kept “f g up.” PRACTICE POINT: THE RISKS OF UNTREATED ADHD ADHD, if untreated, is highly correlated with substance abuse in adolescents.5,6 It should be considered in the differential diagnosis of these patients. Tobacco abuse is commonly seen in children and adolescents with ADHD, in excess of the general population.7 Mr. S’s situation also demonstrates a sequence of impulsivity, selfdefeating behavior, and dysphoria or depression that marks the lives of many of these youths.8 The intervention in the case of Mr. S demonstrates the need for simultaneous respect and structure of the patient. Mr. S’s unhappiness over his current situation was acknowledged and validated. At the same time, he was told clearly what the rules were in such a situation.9 Like many youths with ADHD, he needed and may have tacitly welcomed the imposition of external structure and control, lest he succumbed to his own fearsome impulses. Risk-taking behavior and poor social judgment are frequently seen in patients with ADHD. These are an obvious consequence of impulsivity, a cardinal sign of ADHD. However, they can also be related to self-esteem issues.10 These youths frequently enter adolescence with a heritage of failure and social rejection, leaving them especially vulnerable to the peer pressure of early and midadolescence. Parents may often exhibit what appears to be denial or unawareness of children’s affective status. Clinicians must be on guard against belittling or underestimating parents in this situation. Often what is in fact happening is an isolation of affect in an effort to preserve their own emotional well being and maintain the homeostasis of the family. This can often be seen in the context of chronic parental anger over a challenging, obnoxious, or disappointing child.11 In the case of Mr. S, the clinician was able to induce Mr. S to identify his feelings by using a firm but respectful approach and recognizing that this situation may have embodied a focal crisis for the patient. This may have represented the beginning of a focal conflict intervention, which as part of a multimodal treatment can lead to improvement.12 The clinician ruled out symptoms of major depressive disorder in Mr. S, which avoided premature and unwarranted employment of an antidepressant. The possibility of substance abuse was noted. CASE EXAMPLE, CONTINUED His parents described Mr. S as an active, happy baby. His verbal and particularly his physical milestones had been reached very early, and the parents remembered having to lay down mattresses around his crib because Mr. S kept

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Psychiatry - August 2008 Editor’s Message Editorial Advisory Board Contents Borderline Personality Disorder: Are Proliferative Symptoms Characteristic? Short-acting versus Long-acting Medications for the Treatment of ADHD Baby Stimuli and the Parent Brain: Functional Neuroimaging of the Neural Substrates of Parent-Infant Attachment These Boots Are Made for Stalking: Characteristics of Female Stalkers Managing Attention Deficit Hyperactivity Disorder in the Emergency Department Obstructive Sleep Apnea, Hypoxia, and Metabolic Syndrome in Psychiatric and Nonpsychiatric Settings Improving the Quality of Life in Patients with Alzheimer’s Disease The Process of Getting New Drugs to Market Journal Watch Classified Advertising Information for Authors

Psychiatry - August 2008

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