A 16-year-old boy is brought to the office by his mother due to behavioral concerns. The patient has been coming home after curfew most nights and arguing with his parents more than usual. The mother notes that he has been spending most of his time at home alone in his room with the door closed and seems less interested in attending family get-togethers. The mother also shares that she found a marijuana joint under the patient's bed last week; when asked about the joint, he stated it belongs to a friend and he does not use drugs. The patient maintains a B average in school and plays in the high school band. When interviewed alone, the patient states he has tried marijuana a few times and lied to his mother because he was afraid that she would tell his father. The patient says he would rather avoid talking to his father for as long as possible and shares that his father refers to him as a disappointment. He has no chronic medical conditions and takes no medications. Vital signs are normal; growth curves are tracking consistently. Physical examination shows no abnormalities. Which of the following is the most appropriate next step in management of this patient?

Question

A 16-year-old boy is brought to the office by his mother due to behavioral concerns.  The patient has been coming home after curfew most nights and arguing with his parents more than usual.  The mother notes that he has been spending most of his time at home alone in his room with the door closed and seems less interested in attending family get-togethers.  The mother also shares that she found a marijuana joint under the patient's bed last week; when asked about the joint, he stated it belongs to a friend and he does not use drugs.  The patient maintains a B average in school and plays in the high school band.  When interviewed alone, the patient states he has tried marijuana a few times and lied to his mother because he was afraid that she would tell his father.  The patient says he would rather avoid talking to his father for as long as possible and shares that his father refers to him as a disappointment.  He has no chronic medical conditions and takes no medications.  Vital signs are normal; growth curves are tracking consistently.  Physical examination shows no abnormalities.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

This adolescent's behavioral concerns appear to center around his relationship with his parents (ie, lying to his mother, breaking curfew rules, increased arguing, avoiding conversations with his father). When seen individually, he expresses fear about his father's judgments and reactions. The most appropriate approach is to conceptualize the patient's behavior in a family context and to recommend family therapy with the goal of improving communication between the patient and his parents and resolving family conflict. Rather than pathologizing the adolescent as the identified patient, this approach is a means of helping the entire family improve their communication and conflict resolution skills and develop mutual understanding and respect. Family therapy is conducted by a trained family therapist and focuses on changing dysfunctional patterns of interaction among family members to enhance family functioning. The therapist can help family members resolve disagreements about rules and expectations and develop strategies to defuse escalating arguments. Family therapy has been shown to increase positive outcomes in adolescent behavioral problems, substance use disorders, and depression. (Choice A) This patient is having significant difficulty communicating with his father. Simply encouraging the patient to communicate more with his father places the burden on the patient to resolve the family dysfunction. In addition, this would likely lead only to the patient and his father reenacting their conflicts. Family therapy, in which a therapist can observe the interactions and facilitate communication between family members, would be more likely to resolve the conflict. (Choice B) This patient's behavior (eg, avoidance of the father, withdrawal from the family) is not normal, and the current dysfunctional interaction between the patient and his parents is unlikely to improve without therapeutic intervention. (Choice D) Fluoxetine is a selective serotonin reuptake inhibitor indicated for the treatment of moderate to severe pediatric depression. This patient lacks key features of depression (eg, loss of interest, sleep and appetite disturbance, lethargy, suicidality); his change in behavior appears to be in response to a strained relationship with his father. (Choice E) This patient has been open with the physician about his experimentation with marijuana and shows no signs of drug abuse or dependence that would necessitate referral for drug counseling. This approach would mistakenly conceptualize the concern as a substance use issue and fail to address the dysfunctional family dynamics. Educational objective: Family therapy is a type of counseling that focuses on changing dysfunctional patterns of interaction among family members to enhance family functioning. It has been shown to increase positive outcomes in adolescent behavioral problems, substance use disorders, and depression. References: The effectiveness of functional family therapy for adolescent behavioral and substance misuse problems: a meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/27731494) Overview of the evidence base for family interventions in child psychiatry. (http://www.ncbi.nlm.nih.gov/pubmed/26092734)

A 16-Year-Old Boy Is Brought to the Office by His