The Psychiatric Treatment
of the Young Adult
at Ridgeview Institute
by
Steven R. Lee, MD
Program Director
Young Adult Psychiatric Outpatient Services
TABLE OF CONTENTS
Chapter Page
1 - Who is the Young Adult in the 21st Century 2
- The Brain of the Young Adult 3
- Stages of Development 4
- Parents of the Young Adult 5
2 - General Treatment Issues 6
- What to Expect from Treatment 8
- How Long Does it Take? 10
- Parents Role in Treatment 11
3 - Behaviors that Adversely Affect the Group 12
- The Use of Mood Altering Substances of Abuse
- What is Pairing? 14
4 - Specific Psychiatric Disorders 15
- Depressive Disorders 16
- What is the Potential for a Suicide Attempt? 18
- Anxiety Disorders 19
- Trauma and Stress-Related Disorders 21
- Attention Deficit Hyperactivity Disorder 22
- ADHD and Substance Abuse 25
- Personality Disorders 24
- The Parents Role in the Treatment of a Personality Disorder 27
- Autism Spectrum Disorders 27
- Asperger Syndrome
- Mood Disorders 28
- Bipolar Disorder (See Appendix A)
- Cyclothymic Disorder
- Mood Disorder secondary to:
- Medical Condition
- Medication, Alcohol, other drugs
- Psychotic Disorders 29
- Schizophrenia (See Appendix B)
- Schizoaffective Disorder
- Learning Disorders 30
- Somataform Disorders 31
- Bibliography 32
Appendix A Treatment of Bipolar Disorder: drleemd.org
A Guide for Patients and Families
Appendix B Expert Consensus Treatment Guidelines for Schizophrenia:
A Guide for Patients and Families
Forward
Welcome to the Young Adult Psychiatric Program. This booklet has been written to help the parents of a young adult who has psychiatric problems understand our treatment approach, the psychiatric problem that is affecting your child, and to understand a young adult. This program is designed to meet the special needs of young adults (ages 18 to 26 yo) who have a primary psychiatric problem (versus a primary addiction problem) and need a comprehensive approach to treatment. These young adults may also be abusing substances ( i.e. marijuana) but addiction is not their primary problem. 25 to 30% of young adults in our program have substance abuse issues and these issues will be thoroughly addressed along with the psychiatric issues.
Individuals with a primary addiction problem need to be in the Young Adult Addiction Program. Sometimes deciding which is the primary problem can be difficult. Also, since most psychiatric disorders do not begin until someone is in their 20's, it is hard to know if the addiction issue caused the psychiatric problem or if the psychiatric problem is a psychiatric disorder that would have developed even if the young adult did not have a substance abuse problem. A young adult is a work in progress and has not fully developed into the adult that they will be. The problems that caused the young adult to believe that they were a failure and a burden on their family can be resolved and theycan see that what they thought was their personality was actually a treatable problem. When their self image changes, then the young adult can see their potential and will strive to reach it. When the young adult has hope that they can change, then their motivation returns and theywill take responsibility for their life.
The average young adult in our program is ~20 years old, has been in college, is unemployed, lives at home, is not sure what they want to do in life, has a depression and /or anxiety problem, and has attempted some outpatient, individual therapy with medication and it did not work. He is a male, is not the most responsible person in society, feels entitled to be taken care of by his parents and does not understand the need to be grateful for what he has. He does not verbalize how he feels unless he is forced to do something that he does not want to do and then he seems to be able to explain this in no uncertain terms. The young adult is a paradox in that he is an adult and he is still dependent on his parents for financial support. In fact, if a 23 year old male is married, has one child, is the night supervisor at a Chick Fillet, spent two years in Iraq, and has his own insurance (not the parents insurance), then, this individual would not fit into our program.
In summary, the young adult is just about the worst candidate for traditional psychological therapies. Most therapists and Psychiatrists cringe when they realize that their new outpatient is a young adult. The anticipation of dealing with smartalick, angry responses; the patient coming late to appointments (if they remember to come at all); noncompliance with their medication; probable use of at least marijuana and alcohol; someone else paying for the sessions; and having to call the parents on every change in the treatment plan (which doubles the Psychiatrist’s time versus their other adult patients) is not what most doctors and therapists want to do.
The lack of positive results and the young adult's inability to connect with his emotions in a way that he can verbally process his problems becomes clear after the first couple of outpatient individual sessions. At this point, a parent and the young adult begin to feel hopeless that change can occur. This is when The Young Adult Psychiatric Program at Ridgeveiw Institute can be an oasis of relief to the hopelessness everyone feels when trying to treat the young adult through traditional outpatient, individual therapy and medication.
Young adults need structure. They need other young adults that can understand how they feel in order for the young adult to trust those around them enough to bring out their own feelings of inadequacy. They need therapists that understand that they are no longer an adolescent but not yet a mature adultand who want to work with all of their idiocycrasies. That is why they need the Young Adult Program at Ridgeview Institute.
As the father of two daughters who are now grown, I had to buckle my seat belt during their adolescent and young adult years. It was a wild ride. Just because I am a specialist in the field, I had the full range or reactions (good and bad) that a father could have. There were times when I did not know if my daughters were going to make it and there were times when my wife and I blamed each other for our children's problems.
A redeeming benefit from that period of my life is my first hand experience of the full range of issues that are addressed in this document. Hopefully, this information will be helpful as you navigate your way through the obstacle course of dealing with your young adult while they struggle with their emotional problems.
Steven R. Lee, MD
Program Director of the YoungAdultCenter of Excellence
Page 2
Who is the Young Adult in the 21st Century
The mental health issues of the young adult are not much different than those of adults older than 26 years old. The difference is the way each problem presents itself and how it must be treated and managed. Young adults are in many ways “professional adolescents”. At 18 years old a young adult is legally capable of making their own decisions but those decisions are based on their desires with little or no experience as to the range of possible outcomes that may occur because of those decisions. As parents, we remember the errors in judgment we made at this age and thank God that somehow we lived through those years. Now, consider what all of this may be like if the young adult is impaired with depression, anxiety and/or substance abuse.
Each young adult is an individual with their own unique set of assets and liabilities. Their ability to understand their problem areas and to make positive changes in these areas are affected by these assets and liabilities. Also, how quickly a young adult will trust a therapist is based on the young adults past experiences with other adults. A young adult can be categorized into one of the following categories which affects the approach taken by the therapist to develop a therapeutic alliance with the young adult.
1 – Responsible / Age Appropriate / Intact family
2 – Irresponsible/ Apathetic
3 – Angry / Oppositional–Defiant
4 – Immature (Socially / Emotionally)
5 – Antisocial / Breaking the Law
6 – Chronic Emotional Problems / Hopeless
7 – Drugs, Alcohol, or Eating Disorder
8 – Personality Disorders
9 - Autistic / Problemsconnecting with others (Asperger's)
10 - ADHD / Learning Disabilities / Problems processing new information
11 - No Consistent Parents (orphan, multiple foster homes) / Chronic child abuse
The young adult today is not the same young adult as 30 years ago. Today, one third of young adults move to a new residence every year and 40% move back home with their parents at least once. They go through an average of seven jobs and two-thirds spend at least some time living with a romantic partner without being married. The median age of marriage in the early 1970's was 21 for women and 23 for men. In 2009 the age climbed to 26 for women and 28 for men.
The young adult's self-confidence is a paradox both for society and the young adult. When asked if they are confident that they will get to where they want to be in life someday, 96 percent say emphatically, “Yes!". When asked if they feel like they are grown up and ready to be on their own, 60 percent say that they feel both grown up and "not-quite-grown up". Most young adults charge into life being told that they can do anything they want to do. They are taught through television, their parents, and at school to stand up for themselves and demand that they will only accept the best that life has to offer. Many young adults find out, through the "school of hard knocks", that having the best has to be earned through many years of hard work and experience. Having an attitude of gratitude for what you have versus an attitude of always wanting more is a lesson that many young adults do not understand before they come into treatment.
Many young adults, unfortunately, are disrespectful to their elders and are primarily focused on themselves. Most often this is the result of ignorance and not because they have a selfish personality. The prosperity of the baby-boomers gave parents of young adults the means to give to their children opportunities that they did not have. The young adult often takes these opportunities for granted because they did not have to earn them.
Lay-offs, unemployment and being relocated to other cities (when they finally get a job), was not the same environment of their parents ("baby boomers") when they were young adults. These facts create great fear, anxiety and frustration for the young adult which their baby boomer parents, in general, did not have. There is a constant feeling of uncertainty in this generation, yet they have been told all of their life that they could do
Page 3
anything since they have been given so many opportunities. Even the young adults who have worked hard and obtained a college degree many times have to move back home because they cannot find a job. A report by the U.S. Congress Joint Economic Committee published in May, 2010 states: "Although the economy has gained strength and overall labor market conditions have improved in recent months, younger workers have continued to struggle finding work. Employers added over half a million jobs in the last four months, yet the unemployment rate for young workers reached a record 19.6 percent in April 2010, the highest level for this age group since the Bureau of Labor Statistics began tracking unemployment in 1947".
The Brain of the Young Adult
The NIMH (National Institute of Mental Health) did a study that began in 1991. Neuroscientists once thought that the brain stopped growing shortly after puberty, but this study pointed out how the brain keeps maturing well into the 20's. 5,000 children from ages 3 to 16 were studied. They found that their brains did not fully mature until age 25. The most significant changes that took place were in the prefrontal cortex and the cerebellum. The prefrontal cortex of the brain is involved in emotional control and higher-order cognitive functioning (problem solving) (1).
NIMH scientists also found a time lag between the growth of the limbic system, where emotions originate, and the prefrontal cortex, which manages those emotions. The limbic system explodes during puberty, but the prefrontal cortex does not develop as fast as the limbic system. This area of the brain keeps maturing for another 10 – 15 years. This means that emotions and impulsive actions might outweigh good judgment for some young adults especially if they are intoxicated. The limbic system is our "flight or fight" center that takes over in an emergency to make us act even before we can have time to think through all of the possible choices. If a car is about to hit us and we can sense that this is imminent, in order to survive, we have to act before we think through what is happening.
The limbic system tells the body to act in order to deal with danger but it does not have memories of all of the consequences of that action. It does remember that a particular action gave relief to a particular stressor but it does not remember the details of all the complications that occurred because of the action taken. The cortex is supposed to remind the young adult of the dangerous consequences of any behavior before that individual does anything but the cortex is not fully developed until around 26 years old while the limbic system is fully developed at 18 years old. What this means is that the limbic system is in the drivers seat and any advice given to the driver by the cortex can be followed only if the limbic system believes it is in the best interest of the person. If the driver (the limbic system) of this car (the young adult) believes that the body needs to act immediately, it can override the immature cortex's concerns and proceed with the behavior.
If we continue to use the same analogy as above, the limbic system would be like an 20 yo driving a car. They have only limited experience as to the range of possible outcomes that may occur with every decision they make while driving that car. The cortex, which is about 10 years younger as compared to the limbic system, would be like the 20 year old's 10 year old brother sitting in the back seat of the same car. This 10 year old has seen a video in school of some consequences of driving dangerously. As the 10 yo realizes that the car is going greater than 100 miles per hour, he will begin to point out to his 20 yo brother the dangers of this excessive speed from what he learned in the video he saw in school including going to jail, serious injury to himself and others, etc. This 10 yo brother will tell the 20 yo to slow down and that he is frightened. The 20 yo may hear the concerns but, he believes he can manage the consequences of going this fast, plus he enjoys the wild ride which is more important to him. The point here is that the limbic system is in total control of driving the car.
The one thing that insurance companies know is that the risk factors are much higher for unmarried, young adults 25 years old or younger, than for older, married adults. This is an actuarial (statistical) fact based on the number of accidents and traffic violations that are dramatically higher for teenagers and young adults. This, of course, means about 30 to 50% higher premiums for auto insurance for a young adult.
The limbic system is also where most drugs and alcohol do their work. When someone uses a substance or performs a certain behavior (i.e. video games, sex) and gets relief from stress or feels extra good, the
Page 4
limbicsystem records that memory. The limbic system then drives the young adult back to that substance and/or behavior again and again because this is the quickest way to get immediate relief. Unfortunately, without
having more comprehensive experiences in life, they do not have enough knowledge to appreciate the real dangers of such behaviors as driving a car too fast or of having unprotected, sexual activity.
Since the part of the brain that is responsible for mature judgment and self reflection (the Cortex) does not fully develop until around 26 yo, the process of recovery for a young adult takes longer than that of a 35 yo.
Also,if that young adulthas experienced years of living in an abusive situation as a victim; has a personality disorder; has a learning disability; has been habitually smoking marijuana (and/or using other drugs); then,this young adult will need more time to deal with their depression or anxiety disorder than someone who does not have these other issues. Years of living an unhealthy life style during adolescence or the young adult period sets up lifestyle patterns of behavior that can be hard to change once this individual reaches their late