INTRODUCTION TO SPECIAL SECTION
Becker, Daniel F
THE COMMITTEE ON ADOLESCENCE OF THE GROUP FOR THE ADVANCEMENT OF PSYCHIATRY
The Group for the Advancement of Psychiatry (GAP) is an organization of some 300 psychiatrists dedicated to shaping psychiatric thinking, public programs, and clinical practice in mental health. It was founded in 1946 by a group of physicians whose wartime experiences had brought them to realize the urgency of greater public awareness of the need for new programs in mental health for the people of the United States. Since its beginnings under the dynamic leadership of the late Dr. William C. Menninger, GAP has been influential in shaping psychiatric thinking, public programs, and clinical practice in mental health. It continues today to pioneer in exploring issues and ideas on the frontiers of psychiatry and in applying psychiatric insights into the general medical, social, and interpersonal problems of our times. Its objectives are to analyze significant data in psychiatry and human relations, reevaluate old concepts, develop new ones, and apply this knowledge for the advancement of mental health. Membership in GAP is by invitation only. Each member belongs to a committee that is working in his or her area of special interest and expertise. The 25 committees meet regularly, select their own topics for exploration, invite participation by expert consultants from other disciplines, collect and evaluate data, and present the resulting work to the entire GAP membership for further and rigorous scrutiny before publication.
The GAP Committee on Adolescence, which came into being in 1969, has over the years included many distinguished ASAP members, among them Lois Flaherty, Clarice Kestenbaum, Richard Marohn, Derek Miller, Michael Kalogerakis, Joseph Noshpitz, Vivian Rakoff, and Harvey Horowitz.
Since its inception, the Committee on Adolescence of the Group for the Advancement of Psychiatry has concerned itself with the process of adolescence. Its first report (1968) examined normal adolescent development and its impact on the individual and on society as a whole. Its second report (1978) focused on the transfer of power and authority from established adults to developing adolescents. The third (1986) and fourth (1996) reports began the consideration of how situations that have immediate biological psychological and social consequences for the individual and society also put the adolescent process itself at risk. In the 1986 report, we stated,
Adolescence, even under the best of circumstances, is a stressful phase of life. Nevertheless, most adolescents negotiate this difficult period without serious harmful behavior. The ability to do so requires adequate developmental preparations, contributed to by appropriate biological, cognitive, emotional, familial, and societal influences. Conditions that compromise the developmental preparation for adolescence render the individual at far greater risk for a range of behaviors that constitute crises with potentially damaging consequences [p. xviii].
In this special section, we have focused our attention on how adolescents respond to stress, given their preparation (adequate or inadequate) to deal with it. These chapters consider the relationship of stress to trauma, trauma to injury, and injury to subsequent repair, psychopathology, or developmental impairment. They explore the questions of when and why stress becomes traumatic; what protects the individual and what makes the individual vulnerable; when a trauma becomes injurious; what internal and external factors support repair; what factors prevent repair and lead to psychopathology; what, above all, is the impact of stress, trauma, injury, repair, and psychopathology on adolescent development.
What do we mean when we state that stress has become traumatic? Krugman (1987) notes that, to use the construct of trauma fully, the definition of a traumatic event must be specific and the impact of the trauma as it radiates through all levels of the biopsychosocial system must be elaborated. One definition is implied by van der Kolk (1987): “The book considers the impact of experiences that overwhelm both psychological and biological coping mechanisms” (p. xii). Regarding outcome, he noted that long-term adjustments will be affected by the severity of the Stressor and the individual’s genetic predisposition, developmental phase, social support system, prior traumatizations, and preexisting personality.
It is understood that the biopsychosocial system of adolescents during their transition from childhood dependency to adult responsibility continually adjusts to the stress produced by their biological maturation, psychological perception, and social expectation. To that and additional stress, the adolescent responds according to the meaning of the situation within the adolescent’s intellectual and emotional capacity to understand it, bear it, and cope with it. How the adolescent succeeds or fails will be manifested from the spectrum of adolescent response: from violence or detachment to engagement and mastery. The response will influence the adolescent’s capacity to address and master future developmental tasks and stressful situations that must be dealt with one way or another.
Adolescents throughout the world have a high probability of being exposed to potentially traumatic events. This occurs in part by virtue of the unique features of adolescence, such as increased risk-taking behavior and involvement in activities outside the protective orbit of the family, and in part it is due to imposed or chosen social roles such as military combat or gang activity.
Trauma during the adolescent years comes at a vulnerable period as young people move beyond the protection of their families. Although most teenagers negotiate their adolescent years without serious harmful behavior, adolescence-even under the best of circumstances-is a stressful phase of life (GAP, 1986; 1996). Young people’s successful coping with the stresses of adolescence is based on certain essential cognitive, emotional, familial, societal and cultural prerequisites. When these are lacking the adolescent’s developmental preparation is compromised, placing the a youngster is then at far greater risk for a range of behaviors with potentially damaging consequences (GAP, 1986; 1996).
DSM-IV describes posttraumatic stress disorder (PTSD) as a specific group of serious symptoms following experiences that meet the above criteria. In this section, PTSD refers only to the full symptom complex defined by DSM-IV; posttraumatic symptoms (PTS) refer to the broader range of pathological consequences not subsumed under PTSD. PTSD and PTS are not the only consequences of traumatic events: There may be no clinically significant consequences, or other psychiatrically impairing or disabling conditions may result. This section will attempt to portray the enormous range of responses and extent to which individual vulnerability and risk factors play a role.
Trauma can stunt or derail emotional growth and result in the development of specific psychopathological syndromes. Acute and chronic posttraumatic disorders are not the only, or necessarily the most debilitating, consequences of trauma. Other possible sequelae include anxiety and depression, substance abuse, suicide, violent behavior, and enduring maladaptive personality patterns of thinking and feeling. Without successful intervention, these problems continue into adulthood.
Adolescents who have experienced trauma in childhood are at high risk for repetitively experiencing subsequent trauma with ever-morepernicious outcomes. However, not all victims of trauma show noxious sequelae. The following vignettes illustrate how disparate the outcomes of trauma can be.
The body of an 11 -year-old boy is found in the woods near an area where he had been selling candy door-to-door to raise money for school activities. Police detectives remember that in the neighborhood near the woods where the body was found lives a 15-year-old boy who had been cooperating with the investigation of a man who had seduced and sexually victimized him. In the days prior to the murder, however, the teenager has suddenly stopped talking with the detectives, has smashed surveillance equipment that was placed in his home, has become uncommunicative with his parents, and has refused to attend therapy sessions. The youth is arrested and charged with murdering the younger boy (New York Times, October 2, 1997).
Another 15-year-old witnesses the hanging of a child in a Nazi death camp. After surviving a year of brutalization and being haunted by memories of horror, he goes on to become an eloquent spokesperson against genocide, winning a Nobel peace prize (Wiesel, 1960).
Both of these adolescents were victims of trauma, but the outcomes for them were radically different. Why? Why does trauma affect some persons differently than others? Are there unique aspects of adolescence that make the impact of trauma différent for this period than for other phases of life? To what extent is traumatization of adolescents a public health problem? How does trauma experienced during childhood affect adolescent development? What is the effect of trauma on personality development? What are risk and protective factors? Are there important gender differences in response to trauma? Is sexual trauma uniquely different from other kinds of trauma? Are there some kinds of traumatization that irreparably damage individuals?
Methodology of Literature Review
The primary method used was the collection of references by individual committee members, each of whom focused on specific areas of their own research and expertise. A consensus process was used to identify studies that used standardized methods of data collection, identified sampling methods, and specified age and demographic characteristics of the study population. In addition, Medline searches were done using the words trauma and adolescence, as well as various subcategories such as disasters and abuse to retrieve articles published between 1980 and 2001 pertaining to the topic. We particularly attempted to find studies that compared adolescents’ traumatic exposure and their responses to those of other age groups, both younger and older; unfortunately, these are relatively rare. The studies cited in the chapters in this section represent the current body of knowledge with respect to trauma and adolescents.
Organization of the Special Section
This section includes three chapters by the GAP Committee on Adolescence-“The Nature and Scope of Trauma,” “The Impact of Trauma,” and “Issues of Identification, Intervention, and Social Policy.” In addition, three other chapters are included, by authors who were or are members of the committee: “Cross-Cultural and Gender Considerations of Trauma,” “The Neurobiological Effects of Trauma,” and “Interventions for Traumatized Adolescents.” Although these latter chapters reflect input from all members of the committee, they are primarily the work of their authors. Finally, a chapter is included on “Late Adolescence and Combat PTSD” by Max Sugar, which discusses developmental aspects of the vulnerability of young soldiers to PTSD and other problems and is solely the author’s work.
Group for the Advancement of Psychiatry. (1968), Normal Adolescence: Its Dynamics and Impact, GAP Report No. 68. New York: Scribner.
______ (1978), Power and Authority in Adolescence: The Origins and Resolutions of Inter-generational Conflict, GAP Report No. 101. New York: Mental Health Materials Center.
______ (1986), Crises of Adolescence: Teenage Pregnancy Impact on Adolescent Development. GAP Report No. 118. New York: Brunner/Mazel.
______ (1996), Adolescent Suicide. GAP Report No. 140. Washington, DC: American Psychiatric Association.
Krugman, S. (1987), Trauma in the family: Perspectives on the intergenerational transmission of violence. In: Psychological Trauma, ed. B. A. van der Kolk. Washington, DC: American Psychiatric Press.
New York Times, October 2, 1997, 15-year-old held in young fundraiser’s slaying, p. 1.
van der Kolk, B. A., ed. (1987), Psychological Trauma. Washington, DC: American Psychiatrie Press.
Wiesel, E. (1960), Night. New York: Hill & Wang.
Members of the GAP Committee on Adolescence who contributed to this special section include: Daniel F. Becker, Melita Daley, Monica R. Green, Robert L. Hendren, Lois T. Flaherty (Committee Chair), Warren J. Gadpaille, Gordon Harper, Robert A. King, Patricia Lester, Silvio J. Onesti, Mary Schwab-Stone, and Susan W. Wong.
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