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Middle school age youth are those from ages 10–14 years old. This period is also referred as prepuberty , preadolescence , and early adolescence . During this period, youth experience biological, psychological, and social changes. There are dramatic changes in the physical development, encompassing height, weight, and sexual development. Although maturity during this period occurs at varied rates, generally in girls it occurs 1.5–2 years earlier than in boys.

Children typically begin elementary school—primary education—at 5 years old, after kindergarten. Elementary school generally goes through the sixth grade, typically to 11 years old. In elementary school, children learn the basics of reading, math, science, and other subjects on which later learning will build. Socialization skills are an important aspect of this period. Granic and Patterson (Psychol Rev 113(1):101–131, 2006) eloquently stated, “Parents and children are confronted with a variety of daily tasks (e.g., clean-up time, playing games, problem solving when conflict arises, eating dinner together). From our perspective, the extent to which parents and children can flexibly and appropriately respond, emotionally, cognitively, and behaviorally, to shifts in contexts may tap a repertoire of alternative strategies that correspond to how children will adapt to future challenges at school and with peers.” Thus, during this age, the child’s most skilled way in communicating his or her affective states is initially through playing and making drawings, and later, in preadolescent years, verbal communication takes hold.

Adolescence is a developmental period of life that commences with the onset of puberty and artificially ends with adulthood. The twenty-first century saw substantial advances in understanding the biological, psychological, and sociological aspects of adolescent development. Moreover, accumulating data support the notion that adolescent behavior cannot be reduced to purely psychological or biological phenomena. Rather, an understanding of any aspect of adolescence is best derived from an appreciation of biology and psychology and their respective interfaces. For example, imaging studies of adolescent brains confirm aspects of fluidity in decision making and a number of other cognitive capacities. Giedd explains that during adolescence, the area of the brain responsible for organization, planning, and strategizing is not fully developed, as the gray matter continues to thicken. In turn, these neuroanatomic changes likely occur in tandem with changes in the implicit relational memory processes. Further, the scientific literature confirms the belief that adolescence is a period of inordinate risk taking and complexities in decision-making processes.

Attachment theory and infant developmental research have confirmed the ubiquitous nature of the innate bidirectional mode of communication that exists in everyday human interactions. From birth, the infant learns to make meaning of the experiences with its caregivers in order to develop internal working models of attachment that reflect implicit patterns of stable or unstable mental representations of self and others. When the internal working models of attachment are created in a secure and stable manner, it allows the child to understand and predict the intent of others in their environment, and it implicitly becomes a survival-promoting tool allowing for proximity with others, establishing a psychological sense of “felt” security. Further research has provided a better understanding of how cognitive and memory systems shape a person’s experiences when interacting with others in what are called moments of intersubjectivity —the dynamic interplay between two people’s subjective experiences (Chap. 5). Intersubjective experiences allow for “being with” and “getting” another person’s state of mind and their intentions. It is this dynamic interplay of subjectivity that, when things go well, lead to adaptive models of relating with others. These models are stored in nonconscious and nondeclarative memory systems in what is known as “implicit relational knowing ,” which begins to be represented before the availability of language. Intersubjectivity promotes a cohesive and more flexible way of reflective abilities to know what works for healthy social reciprocity with implicit aspects of morality. Rustin and Sekaer (2004) aptly state: “Experience, in an average expectable environment, enables genetic programs to unfold and puts the fine tuning on the genetic framework. From this new perspective the brain itself is relationally constructed.”

In this chapter, we discuss some of the everyday challenges facing the psychotherapist who embarks upon the regular practice of two-person relational psychodynamic psychotherapy. By actively “setting the frame” for the patient and parents, a psychotherapist starts the psychotherapeutic process on a strong foundation. There is consensus that in most forms of psychotherapy, the psychotherapist benefits by providing an outline of what the patient and his or her family can expect once they agree to participate. It is best to launch the psychotherapeutic process after the psychotherapist sets the frame with the patient and their parents or caregivers so they can have some predictability about what will occur during the process and avoid having surprises when conflict arises.

Ethical and medicolegal issues are an inherent part of difficult psychiatric consultations and, as we have illustrated, create special challenges for the consulting psychiatrist working with both pediatric [Ascherman and Rubin (Child Adolesc Psychiatr Clin N Am 17:21–35, 2008)] and adult populations [Arras and Steinbock (Ethical issues in modern medicine, Mayfield, 1998); Gutheil et al. (J Am Acad Psychiatry Law 33(4):432–436, 2005)]. Among the key issues which must frequently be addressed include: autonomy , nonmaleficence , beneficence , and justice . Additionally, the consulting psychiatrist should be savvy regarding the state laws related to involuntary hospitalization as well as the process by which this occurs. Finally, it is critical for the consulting psychiatrist working with the difficult psychiatric consultation to have a strong working understanding of confidentiality , privilege , and the limits limitations of these concepts.

In addition to providing standard consultation (e.g., clarifying diagnosis, providing psychopharmacologic recommendations, ordering diagnostic studies), an added goal of the consultant may be to influence, over time, the treatment team's ability to use psychodynamic and attachment theory concepts in difficult cases. It is helpful for the psychiatric consultant to teach treatment-team members that the way patients and families perceive the team is a replay of a dynamic that’s familiar to them and that they therefore unconsciously seek to recreate. When the consultant works with the same treatment team over time, he or she may be in a position to familiarize members with psychodynamic and attachment theory concepts in the medical setting, thus improving the manner in which the team approaches patients. Treatment-team members frequently have countertransference reactions to patients, families, and to psychiatric consultants. The members who are especially at risk are those with a limited ability to mentalize. However, it is important to remember that in contemporary theory, the psychiatric consultant’s countertransference also contributes to consultative process interactions in here-and-now moments.

In psychodynamic psychotherapy with adolescents, termination-the phase of treatment during which the patient and his or her parents end a therapeutic relationship with a therapist-has received limited attention in the extant literature. Despite this oversight, termination is of critical clinical importance. This phase of psychotherapy with adolescents is heralded by the integration and consolidation of progress, relational changes, and the relinquishing of the symptoms that brought the adolescent to treatment. Herein, the relevant literature surrounding termination in psychodynamic psychotherapeutic work with adolescents will be reviewed. Important aspects of termination will be highlighted and discussed, including (1) criteria for termination, (2) techniques for working with parents, (3) "forced terminations," (4) countertransference, and (5) common complications that arise during this phase of treatment. Finally, the complexities of the termination process as well as recent contributions to our understanding of this critically important process from attachment theory and intersubjectivity will be illustrated with clinical material.