Volume 27, Issue 2 - Special Issue: Forensic adolescent psychiatry / Issue Editors: Leo Sher and Joav Merrick

Forensic psychiatry is frequently defined as the branch of psychiatry that deals with issues arising in the interface between psychiatry and the law. Psychiatrists are called on by the legal system to provide testimony in a wide variety of cases, criminal and civil. In criminal cases, forensic psychiatrists may be asked to comment on the competence of a person to make decisions throughout all the phases of criminal investigation, trial, and punishment. These include the competence to stand trial, to plead guilty, to be sentenced, to waive appeal, and to be executed. In civil cases, forensic psychiatric experts are asked to evaluate a number of civil competences, including competence to make a will or contract or to make decisions about one’s person and property. Psychiatrists are also called on to testify about many other issues related to civil cases. Forensic psychiatrists who work with children and adolescents are frequently involved in evaluations and testimonies concerning juvenile delinquency, child custody, termination of parental rights, and other issues. As such, forensic psychiatric experts have now developed into a reputable and well-known group of professionals. Forensic evaluation methods, ethical issues related to forensic psychiatric practice, and some common criminal and civil forensic psychiatric evaluations are discussed in this overview.

Underage drinking is a significant problem in the US. It is responsible for several thousand mortalities and fatalities each year, both among minors and other members of society. Additionally, underage alcohol consumption produces a severe economic burden in the US. Introduction to alcohol in youth poses serious long-term risks for adolescents, including occupational, educational, and psychosocial impairments, and increases the risk for developing alcohol abuse disorders in adulthood. In order to address and mitigate this problem, the US has set a minimum age drinking law of 21 in all 50 states, and has implemented several supplementary laws limiting the possession and consumption of alcohol. Though these laws have successfully reduced underage drinking, several additional strategies are noteworthy, including preventative and intervention efforts incorporating environmental, individual, communal, and parental factors. The following literature review describes these concepts as they relate to underage drinking laws in the US. Directions for future research, interventions, and ongoing challenges related to the minimum drinking age in the US are also discussed.

Introduction: Adolescent suicide is a complex phenomenon that has similarities and differences with adult suicidal behavior. Serotonergic (5-HT) dysfunction has extensively been studied in adults and has been postulated as a biological marker for suicide. Methods: We conducted a comprehensive review of the studies available in MEDLINE from January 1998 until January 2014 on the role of “serotonin” both in adults’ and adolescents’ “completed suicide”, “suicide attempts”, and “suicidal ideation”. Results: Studies on 5-HT conducted in adults and replicated in adolescents have yielded inconsistent results. Although some genes related to the serotonergic system have been associated with an increased risk of suicide, attempts to reproduce those findings have been unsuccessful and a common genetic variant associated to suicidal behavior has yet to be identified. Discussion: Studies on the neurobiology of adolescent suicide should consider the biological specificities of this life stage and of gender differences during this period. Future research designs should also try to integrate findings in the psychological and biological domains. Prospective studies may help understand the process that leads from suicidal ideation to suicide attempts or completed suicides in this population.

Most children and adolescents attending mental health services exhibit severe affective and behavioral dysregulation. The dysregulation profile (DP) seems to be an indicator of self-regulatory problems, overall psychopathology, symptom severity, and functional impairment. Although there are studies signaling its importance as a marker of severe psychopathology and long-term impairment, little is known about its predictors. We reviewed the existing literature and found biological and environmental factors associated with the DP. The DP seems to have high heritability rates, blunted hypothalamic-pituitary-adrenal axis responses at stress tasks, and attention problems regardless of emotional context. Some family factors (such as abnormal qualities of upbringing, lower effortful control, parental hostility, and parental substance use disorders) are also related to the DP. More research about specific predictors of the DP is clearly needed. Longitudinal studies would help identify them more clearly.

This is a literature review discussing previous studies on the associations between impulsive aggression and the serotonergic system in adults, adolescents, and children. The review demonstrates that there is a clear association between low cerebrospinal fluid serotonin and impulsive aggression. However, studies on neurotransmitter receptor profiles, functional imaging, genetics, and epigenetics reviewed in this article suggest a more complicated picture that includes consideration of gene vs. environment in the evaluation of risk. Serotonin supplementation studies suggest that selective serotonin reuptake inhibitors may reduce impulsive aggression in some adults but are less effective in adults with pathological aggression and also in children and adolescents. Child and adolescent studies are less conclusive, in part due to the heterogeneous physiologic and psychosocial changes occurring over the course of development. The author thus concludes that psychiatrists can reduce risk in these special patient populations by creating safer environments in the form of changes in policy and increased support services.

There is a well-established and growing body of evidence from research that adolescents who commit crimes differ in many regards from their adult counterparts and are more susceptible to the negative effects of adjudication and incarceration in adult criminal justice systems. The age of criminal court jurisdiction in the United States has varied throughout history; yet, there are only two remaining states, New York and North Carolina, that continue to automatically charge 16 year olds as adults. This review traces the statutory history of juvenile justice in these two states with an emphasis on political and social factors that have contributed to their outlier status related to the age of criminal court jurisdiction. The neurobiological, psychological, and developmental aspects of the adolescent brain and personality, and how those issues relate both to a greater likelihood of rehabilitation in appropriate settings and to greater vulnerability in adult correctional facilities, are also reviewed. The importance of raising the age in New York and North Carolina not only lies in protecting incarcerated youths but also in preventing the associated stigma following release. Mental health practitioners are vital to the process of local and national juvenile justice reform. They can serve as experts on and advocates for appropriate mental health care and as experts on the adverse effects of the adult criminal justice system on adolescents.

The association between attention-deficit hyperactivity disorder (ADHD) and criminality has been increasingly recognized as an important societal concern. Studies conducted in different settings have revealed high rates of ADHD among adolescent offenders. The risk for criminal behavior among individuals with ADHD is increased when there is psychiatric comorbidity, particularly conduct disorder and substance use disorder. In the present report, it is aimed to systematically review the literature on the epidemiological, neurobiological, and other risk factors contributing to this association, as well as the key aspects of the assessment, diagnosis, and treatment of ADHD among offenders. A systematic literature search of electronic databases (PubMed, EMBASE, and PsycINFO) was conducted to identify potentially relevant studies published in English, in peer-reviewed journals. Studies conducted in various settings within the judicial system and in many different countries suggest that the rate of adolescent and adult inmates with ADHD far exceeds that reported in the general population; however, underdiagnosis is common. Similarly, follow-up studies of children with ADHD have revealed high rates of criminal behaviors, arrests, convictions, and imprisonment in adolescence and adulthood. Assessment of ADHD and comorbid condition requires an ongoing and careful process. When treating offenders or inmates with ADHD, who commonly present other comorbid psychiatric disorder complex, comprehensive and tailored interventions, combining pharmacological and psychosocial strategies are likely to be needed.

Suicide and homicide are much more commonly committed by adolescent males than females. Herein, a proposal in favor of gender-specific understanding and approach to these violent behaviors is presented. Social and healthcare service system factors, including issues of male adolescents’ access to care and help-seeking behaviors, are reviewed alongside the epidemiology of adolescent suicide and homicide as a transition into a detailed discussion of the putative biological factors at play. An emphasis upon the male androgen testosterone organizes the discussion. Behavioral manifestations of this brain-based organizational model are presented with a focus on impulsivity, aggression, and externalizing dysregulated emotionality. Treatment considerations and implications are developed.

Adolescent mass shootings are a special subset of mass killings, which continue despite significant preventative public health efforts. It is often held that these individuals have few salient warning signs that could have been identified. This piece proposes that mass shootings committed by adolescent and post-adolescent young males must be understood from a developmental perspective. The hypothesis proposed in this paper is that such killings occur as the result of the adolescent’s frustrated effort to progress along normative development. The goal of normative separation from maternal figures by the boy is presented as a potential risk factor when this goal is thwarted. Childhood case material from the perpetrator of a recent adolescent mass shooting, the Sandy Hook shooting, is discussed as an illustration of this hypothesis. Implications for public health measures and for individualized treatment are presented and developed.

Suicide is the second leading cause of death among adolescents aged 14–19 years. Pediatricians report strong interest in receiving additional training to reduce suicide mortality, and physician education is one of the most robust means of suicide prevention. However, many studies suggest that existing educational methods and means leave much room for improvement. In light of the emerging evidence that emotion regulation (ER) deficits are significantly associated with adolescent suicide, this paper proposes the untested hypothesis that a module on the brain-based ER system may strengthen existing methods of provider education. The ER system and the evidence supporting its association with adolescent suicide are reviewed. The ability to ground an approach to suicide prevention within this brain-based medical model may be appealing to pediatricians; its transdiagnostic breadth and dimensional makeup may also be appealing to pediatricians. Most importantly, its emphasis on the negative effects of impoverished self-regulation broaden non-specialist concern from a restriction upon withdrawn, depressed adolescents to those with a wide range of psychopathology. Implications and further considerations are discussed.

Callous-unemotional (CU) traits in children and adolescents are an important risk factor for forensic behaviors in youth and in adulthood. There is a strong biologic basis in CU traits, offering the possibility to design biological interventions to address this risk factor. This paper advances the hypothesis that the administration of exogenous oxytocin is a biological intervention worthy of further investigation to address CU traits and moderate future risk factors for forensic behaviors. The evidence for this assertion rests in the empiric evidence that social cognitive deficits play a major role in child and adolescent CU traits and psychopathy. Simultaneously, emerging evidence suggests that youth with CU traits have defined neuroendocrinological correlates within the oxytocin system. A review of the normal neurohormonal physiology of this system is presented to provide a groundwork for the delineation of these correlates. That deficits in this system are found in alternate psychopathologies that present with deficits in social cognition serves as the basis for the hypothesis that these deficits may play a key role in the development and manifestation of CU traits. Their correction through psychopharmacologic and alternate means may provide a future route to addressing a central area of adolescent forensic psychiatry.

A malpractice lawsuit is in the legal category of an action in tort, which is a demand for compensation for the damages that have occurred. For a physician to be found liable to a patient for malpractice, four essential elements must be proved to sustain an assertion of malpractice: duty, negligence, harm, and causation. The incidence of malpractice litigation in the field of psychiatry is increasing. The most common malpractice claim related to psychiatric practice is the failure to provide reasonable protection to patients from killing themselves. A psychiatrist should be able to evaluate suicide risk on the basis of all available information, including patient responses to direct and indirect questions, known risk factors, information on how the patient behaved under similar circumstances in the past, and collateral information. Reasonable care necessitates that a patient who is either thought of being or established to be suicidal must be the subject of some precautions. A failure either to soundly assess a patient’s suicide risk or to employ an appropriate safety plan after the suicide potential becomes foreseeable is likely to make a physician liable if the patient is harmed because of a suicide event. It is imperative for a psychiatric office or facility to have a good documentation. Careful documentation of evaluations and treatment interventions with a description of changes related to the patient’s clinical condition indicates clinically and legally appropriate psychiatric care.

Alcohol and drug use continues to be a significant global problem with many health and economic consequences. Multiple studies have shown that the majority of adults who end up with an alcohol/drug use disorder have their first contact with these substances as adolescents. This article aims to briefly summarize current prevalence and impact on society, as well as its etiology, comorbid psychiatric disorders, and treatment and prevention of adolescent drug and alcohol use. Alcohol and substance use impacts both the user and society at large, from health risks to the user to increased early pregnancies, car accidents, financial cost, and productivity cost. Substance use and abuse results from intricate interactions between genetic and environmental influences. Also, substance abuse along with a comorbid psychiatric disorder is more common than a solitary substance use disorder in adolescents. Current options for the treatment of substance abuse disorders range from various therapy-based strategies, including behavioral and family-based therapies, to the use of medications. More attention must be placed on the importance of prevention of use, as well as progression of use to dependence. Successful prevention requires a comprehensive plan that needs to include, but should not be limited to, increasing education of all gatekeepers and limiting access of substances and alcohol through policy and reinforcement of those policies. Education of parents, pediatricians, school nurses, teachers, and mental health workers is essential to ensure that children at risk are identified in time to provide appropriate interventions.

Suicidal ideation among adolescents has been associated with victimization in various studies; however, the nature of this association is not clear. Our aim was to examine the influence of victimization exposure on suicidal ideation in a clinical sample of adolescents. Eleven to 17-year-old subjects were recruited from Child and Adolescent Outpatient Psychiatric Services. They completed the Self-Injurious Thoughts and Behaviors Interview, the Stressful Life Events Scale, the State-Trait Anger Expression Inventory, the Children’s Depression Inventory, the Strengths and Difficulties Questionnaire, and the Family APGAR. Demographic data, developmental features, medical and psychiatric history, family history, and treatment histories were also evaluated. A backward stepwise logistic regression analysis was conducted to examine the influence of victimization exposure on suicidal ideation controlling for potential confounding variables. Two hundred and thirty-nine adolescents (62.3% male; mean age 14.31 years, SD=1.9) took part in this investigation. Of these, 20.9% reported victimization exposure. Adolescents who experienced peer victimization and/or were victims of a crime were significantly more likely to report suicidal ideation (χ 2 =10.05, df=1, p=0.002). However, suicidal ideation was only predicted by emotional and behavioral problems (χ 2 =4.79, df=1, p=0.029), depressive sympthomatology (χ 2 =3.17, df=1, p=0.075), and number of total stressful life events (χ 2 =4.02, df=1, p=0.045). Behavioral and emotional problems, as well as the accumulation of stressful life events may have a direct relation to suicidal ideation among adolescents evaluated at Child and Adolescent Mental Health Outpatient Services. Future studies might consider a comprehensive assessment of victimization and the cumulative effects of exposure to multiple stressful life events. Longitudinal designs are warranted.

Suicide is a major public health problem and the 10th leading cause of death in the United States. Due to low base rates and the numerous comorbid risk factors associated with suicide, accurate prediction is difficult. This is particularly true for adolescents and young adults. In this article, some associated risk factors are discussed in the context of two high-risk populations (young adult prison inmates and young adult veterans) and several recommendations are made for conducting suicide risk assesments. General prescriptions for intervention are also outlined with the goal of reducing overly defensive practice and increasing the likelihood that high-risk individuals will receive effective intervention. Finally, several suggestions for future research are made.

Adolescent forensic behavior can have a variety of meanings. A consideration of the range of meanings can inform the practice of the psychiatric forensic evaluation. This case report describes the history of an adolescent in individual treatment for disruptive and self-defeating behaviors who brought a concealed toy gun into his high school in the aftermath of the Sandy Hook shooting. The overdetermined nature of this act, as well as a consideration of its multiple meanings in the context of the young man’s psychology, his educational and family systems, and his relationship with his treatment provider, will be described and developed. The discussion will broaden to consider the parameters of indicated therapeutic programs to address this subset of adolescent forensic behaviors. The role of deficient implicit emotion regulation capacities in adolescents and the corrective measures to target these neurobehavioral deficits will be described. The report concludes with implications for primary prevention of future adolescent forensic behaviors.

Here, we publish a report of a previously practicing nurse practitioner who presented to a community hospital with severely depressed mood and neurovegetative symptoms in the context of recent relapse to alcohol and cocaine abuse. This patient had a long history of depression and polysubstance abuse. Additionally, the patient had a history of multiple previous suicide attempts with a high possibility for lethality. All of his attempts occurred in the setting of depression, escalating substance use, and interpersonal difficulties. Due to his chronic struggles with mental health and substance abuse issues, the patient lost his marriage, many close friends, and, eventually, his license to practice medicine. In this report, we highlight the increased risk of suicidal behavior or completed suicide in patients with co-occurring depressive and substance abuse disorders. We also look to highlight the often unmet need of mental health and substance abuse treatment for healthcare professionals. Studies suggest that healthcare providers experience increasing rates of burnout, mood and anxiety disorders, and substance use disorders, but available treatment resources remain scarce. This is a serious public health issue that will require increased vigilance by the community at large to ensure the safety and wellbeing of both patients and their providers.

Suicide and suicidal behaviors amongst combat veterans is an important public health issue. Exposure to military combat predisposes patients to increased levels of major depression, post-traumatic stress disorder (PTSD), substance abuse, and chronic pain – all of which are important risk factors for suicide. Here, we present a case study of a young combat veteran who presented with an impulsive suicide attempt that had a high potential for lethality in the context of depression, PTSD, and substance use. On routine admission laboratory work, his serum level of testosterone was seen to be low. Given the important role that testosterone plays in the regulation of mood and behavior, we posit that it is a potentially important marker for suicide risk in an already at-risk population.