Adolescent dysphoria, sexual behavior and spirituality.
Adolescent behavior and mental health have increasingly become matters of public concern. While the biologic aspects of depression were recently emphasized, the etiology of affective disorder affective disorder
Mental disorder characterized by dramatic changes or extremes of mood. Affective disorders may include manic or depressive episodes less severe than those of bipolar disorder, such as anxiety and depression. in adolescence remains multifactorial multifactorial /mul·ti·fac·to·ri·al/ (mul?te-fak-tor´e-al)
1. of or pertaining to, or arising through the action of many factors.
2. . Most models suggest that depressive states develop when a (genetically) vulnerable individual encounters a social stressor (eg, an abusive relationship). (1)
The relationship between adolescent sexual behavior
To make susceptible, as to a disease. youth to depression. (2) An analysis of these complex relationships is beyond the scope of this paper. It is clear, however, that a clinical presentation of adolescent depression necessitates a review of the adolescent's sexual behavior.
In addition, since the family is the primary context for all development, adolescent depression requires a careful assessment of family functioning. Current literature focuses on the attachment of parent to child and, particularly in adolescence, to the adolescent's emerging independence. (3)
Therefore, a clinician assessing a dysphoric adolescent must consider both sexuality and family. Children learn from parents about sexuality either directly through instruction or indirectly through observation of parental interaction. Parents' spiritual perspective or worldview world·view
n. In both senses also called Weltanschauung.
1. The overall perspective from which one sees and interprets the world.
2. A collection of beliefs about life and the universe held by an individual or a group. clearly influences attitudes toward sexuality. (4)
With respect to sexual behavior associated with adolescent depression, spirituality may serve as either a protective factor or as a risk factor. Early sexual behavior is universally seen as a risk factor in adolescent health. (5) Spiritual and religious involvement of the adolescent and the family are associated with delaying sexual intercourse sexual intercourse
or coitus or copulation
Act in which the male reproductive organ enters the female reproductive tract (see reproductive system). . (6,7) Research has found a positive correlation Noun 1. positive correlation - a correlation in which large values of one variable are associated with large values of the other and small with small; the correlation coefficient is between 0 and +1
direct correlation between spirituality/religiousness and a family environment with a high degree of marital commitment and stability, seen as conferring mental health benefits to children and adolescents. (8) Spirituality can also model forgiveness for sexual and other transgressions, a component in healing that is increasingly recognized in secular settings. (9)
Religious and spiritual perspectives can also serve as a risk factor when developmentally normal adolescent sexual urges are not respected and openly discussed. Spiritually based codes of sexual behavior may cease to provide a healthy structure and become harsh and rigid when implemented by an emotionally distant family.
The following two cases illustrate both the presence and the absence of spirituality as a clinical risk factor.
Amanda, a 16-year-old, tenth grade Tenth grade is a year of education in many nations. United States
The tenth grade is the tenth school year after kindergarten and is called Grade 10 in some regions. Students are usually 15–16 years old. student and an only child, was admitted to a psychiatric hospital psychiatric hospital
A hospital for the care and treatment of patients affected with acute or chronic mental illness. Also called mental hospital. after an ingestion ingestion /in·ges·tion/ (-chun) the taking of food, drugs, etc., into the body by mouth.
1. The act of taking food and drink into the body by the mouth.
2. of eight pills of the antidepressant antidepressant, any of a wide range of drugs used to treat psychic depression. They are given to elevate mood, counter suicidal thoughts, and increase the effectiveness of psychotherapy. sertraline sertraline /ser·tra·line/ (ser´trah-len) a selective serotonin reuptake inhibitor used as the hydrochloride salt in the treatment of depression, obsessive-compulsive disorder, and panic disorder. . After stabilization, she was referred for outpatient treatment, including psychotherapy. Her depressive symptoms had begun several months earlier, with decreased school performance and mild insomnia as the primary symptoms. Her hospitalization was triggered when her mother found a note from her boyfriend, Colin, which made reference to increasingly intimate behavior between the two. Amanda's religiously devout parents were significantly distressed when they confronted her. They restricted her from seeing the boy and, as one way to monitor her behavior, her mother began to surreptitiously sur·rep·ti·tious
1. Obtained, done, or made by clandestine or stealthy means.
2. Acting with or marked by stealth. See Synonyms at secret. read her daily diary.
Therapy was intense and involved numerous early interchanges during which trust was a constant theme. Her parents were convinced that she had had sexual intercourse with Colin, something Amanda vehemently denied. Over a several year course of therapy, Amanda resisted the family's religiously based conservatism, which included a subservient sub·ser·vi·ent
1. Subordinate in capacity or function.
2. Obsequious; servile.
3. Useful as a means or an instrument; serving to promote an end. view of women that angered Amanda. Her parents attempted to control Amanda's friendships with those who did not share their own religious beliefs. Over time, they reached compromises. Amanda told her parents that she believed in God but primarily had problems with organized religions. The family allowed her to attend another church, comfortable that "at least she was going." Amanda became more respectful of her parents. She continued to try to see Colin and was angered at her father's hypocrisy: when she wanted to invite Colin to church, and her father did not allow her to do so, she wondered, "Isn't that what the church is for--to reach out to people?"
In this case, the family's religious rigidity appeared to provoke a negative reaction against organized religion. The spirituality that her parents represented seemed to worsen her depression, to the point of desperation and attempted suicide. The therapist had to carefully monitor the influence of spirituality in treating Amanda's depression.
Derek, a 16-year-old, tenth grade student, the second of four children, was referred by his pediatrician to a child and adolescent psychiatrist for evaluation of anger, depression and impulsivity. He had no previous psychiatric history psychiatric history A person's mental profile, which includes information about chief complaint, present illness, psychological adjustments made before onset of disease, individual and family Hx of psychiatric or mental disorders, and an early developmental Hx , apart from being treated for attention difficulties as a young boy. He was sexually intimate with his girlfriend, although they had not had intercourse. Derek described her as someone whom he "could never live without."
In the first several sessions, Derek related a troubled relationship with his father. As he described the father's constant criticism, he shared his rage toward his father for having an ongoing affair with a woman for whom his sister was employed as a babysitter babysitter A person, often an intelligent family member, who stays by the bedside of a Pt requiring mechanical ventilation, and guards for equipment malfunctions or other problems . While his parents remained together, his father remained unrepentant for his behavior. At the time of initial evaluation, Derek described routinely calling his father to inquire regarding his whereabouts if he did not arrive home at an expected time. He related to the therapist that from the ages of 9 years to 11 years, he had harbored the secret of the affair and painfully related the burden of anxiety that accompanied this knowledge. Derek shared with the therapist that he would not tolerate his father ever hurting his mother again. As a concomitant, he acknowledged that it was difficult for him to trust his girlfriend and her fidelity to him.
This nominally religious family had no prior psychiatric history. Derek's anger and dysphoria dysphoria /dys·pho·ria/ (-for´e-ah) [Gr.] disquiet; restlessness; malaise.dysphoret´icdysphor´ic
gender dysphoria seemed powerfully influenced by his knowledge that his father had never asked his mother for forgiveness. He was also plagued with insecurity in his own dating relationship, seemingly influenced by his parents' troubled marriage. In addition to relationship dynamics, Derek seemed deeply troubled by his father's lack of reconciliation toward his mother. In this instance, the absence of a religious/spiritual source of coping, such as reconciliation and forgiveness, seemed most troubling to Derek.
In Amanda's case, her parents' religiously mediated impulse to provide a safe structure for the modulation of her adolescent sexuality became overly rigid and provoked her depression and resistance to change. In Derek's case, his depression seemed powerfully influenced by parental sexual behavior which subsequently influenced his dating relationship. The protective functions of spirituality, such as living by a higher standard, acknowledging one's moral failures and seeking forgiveness, were absent.
What are the implications for the busy clinician? By asking relevant questions, the physician underscores the importance of the spiritual component of care. This indicates to the patient and to the family that open dialogue about problematic aspects of spirituality is possible and suggests the potential for utilizing spiritual resources.
Adolescent depressive symptoms necessitate inquiry regarding sexual behavior and family relationships. This inevitably leads to a consideration of the family's spiritual perspective, or worldview. This perspective may be part of the problem, as in Amanda's case, or a needed resource as in Derek's case. While confidentiality of the adolescent must be respected, the clinician should promote needed dialogue with parents about sexual behaviors which have the potential for life-changing consequences (eg, pregnancy, sexually transmitted disease sexually transmitted disease (STD) or venereal disease, term for infections acquired mainly through sexual contact. Five diseases were traditionally known as venereal diseases: gonorrhea, syphilis, and the less common granuloma inguinale, ). The therapist's own religious or antireligious attitudes must not prevent such interaction between parents and adolescent.
In Amanda's case, the clinician could allow her to express concerns about parental restrictions while supporting her parents' adherence to their own worldview and expectations for Amanda's sexual behavior. A brief exploration of the reasons for mutual mistrust would also be helpful, since they seem to reflect differing perspectives on how the parents should fairly and respectfully address concerns rather than differences over core spiritual beliefs.
A clinician treating Derek would want to openly acknowledge his demoralization de·mor·al·ize
tr.v. de·mor·al·ized, de·mor·al·iz·ing, de·mor·al·iz·es
1. To undermine the confidence or morale of; dishearten: an inconsistent policy that demoralized the staff. and longing for integrity in his father. The clinician would also want to help Derek to consider his models for living, and how he might better relate to women: "Has he seen examples of behavior that he admires?" "Where does he hope to find ideals that he can live by?" These are questions that require spiritual answers. Although the clinician needs to respect the confidentiality of this adolescent patient, he also should consider encouraging Derek to express his wish that his father be a role model for his family. If interest is expressed, the clinician even could offer to help the father with this challenge.
Both of these cases were appropriately referred for mental health treatment because of their complex family dynamics and significant parental emotional needs. Mental health clinicians in such cases should address spiritual issues as they arise, and consult with clergy if unsure how to best help patients meet their clinically important spiritual needs. (10)
1. Shaffer D, Waslick BD. The Many Faces of Depression in Children and Adolescents. Washington, DC, American Psychiatric Publishing, 2002.
2. Hallfors D, Waller M, Bauer D, et al. Which comes first in adolescence-sex and drugs or depression? Am J Prev Med 2005;29:163-170.
3. Sexson SB, Glanville DN, Kaslow NJ. Attachment and depression. Implications for family therapy. Child Adolesc Psychiatr Clin N Am 2001;10:465-486.
4. Josephson AM, Peteet JR (eds). Handbook of Spirituality and Worldview in Clinical Practice. Washington, DC, American Psychiatric Publishing, 2004.
5. Albert B, Brown S, Flanigan C: Fourteen and Younger: The Sexual Behavior of Young Adolescents. Washington, DC, National Campaign to Prevent Teen Pregnancy, 2003.
6. Weaver AJ, Samford JA, Morgan V, et al. Research on religious variables in five major adolescent research journals: 1992 to 1996. J Nerv Ment Dis 2000;188:36-44.
7. Mabe PA, Josephson AM. Child and adolescent psychopathology psychopathology /psy·cho·pa·thol·o·gy/ (-pah-thol´ah-je)
1. the branch of medicine dealing with the causes and processes of mental disorders.
2. abnormal, maladaptive behavior or mental activity. : spiritual and religious perspectives. Child Adolesc Psychiatr Clin N Am 2004;13:111-125.
8. Murstein BI, Mercy T. Sex, drugs, relationships, contraception, and fears of disease on a college campus over 17 years. Adolescence 1994;29:303-322.
9. McCullough ME, Pargament KI, Thoresen CE. Forgiveness: Theory, Research, and Practice. New York New York, state, United States
New York, Middle Atlantic state of the United States. It is bordered by Vermont, Massachusetts, Connecticut, and the Atlantic Ocean (E), New Jersey and Pennsylvania (S), Lakes Erie and Ontario and the Canadian province of , Guilford Press, 2000.
10. Peteet JR. Approaching spiritual problems in psychotherapy: A conceptual framework For the concept in aesthetics and art criticism, see .
A conceptual framework is used in research to outline possible courses of action or to present a preferred approach to a system analysis project. . J Psychother Pract Res 1994;3:237-245.
Allan M. Josephson, MD, Christopher K. Peters, MD, and Mary Lynn Dell, MD, MTS (1) See Microsoft Transaction Server.
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1. MTS - Message Transport System.
2. , ThM
From the Division of Child and Adolescent Psychiatry A branch of psychiatry that specialises in work with children, teenagers, and their families. History
An important antecedent to the specialty of child psychiatry was the social recognition of childhood as a special phase of life with its own developmental stages, starting with , Department of Psychiatry and Behavioral Sciences behavioral sciences,
n.pl those sciences devoted to the study of human and animal behavior. , University of Louisville See also
1. ^ 
2. ^  URL accessed on June 8 2006
3. , Louisville, KY and the Department of Psychiatry, Emory University Emory University (ĕm`ərē), near Atlanta, Ga.; coeducational; United Methodist; chartered as Emory College 1836, opened 1837 at Oxford. It became Emory Univ. in 1915 and in 1919 moved to Atlanta. , Atlanta, GA.
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