Steve Schlozman, MD

I went back to the doctor
To get another shrink.
I sit and tell him about my weekend
But he never betrays what he thinks.
Can you see the real me doctor, doctor?
Can you see the real me doctor, whoa doctor!


-Pete Townsend and The Who, Quadrophenia

To some it may seem immature, perhaps even irreverent, to introduce the Special Report on child and adolescent psychiatry with a quotation from The Who. Yet, those of us who treat children and adolescents are keenly aware that their culture and, by extension, their world often tells us as much and sometimes more than all of our carefully designed studies and inquiries. The fact that a patient of mine recently referenced this lyric (to my delight, by the way, as it is from a favorite album that I first enjoyed when I was blessed with a more impressive head of hair) suggests that kids today still struggle to make their needs, their identities, and their pain understood.

Enter child psychiatry and all of its complex controversies. We have diagnoses that are largely derived from adult phenotypes and some would say forced onto the backs of children and adolescents. We have therapeutic approaches that are hailed as groundbreaking and life-changing, or attacked as reductionist and overly simplified. And, we have, by all epidemiological measures, a vast shortage of psychiatrists who are comfortable treating young patients who have psychiatric disorders. Consequently, psychiatric treatment of children is not left to child psychiatrists alone. There are simply too many children with problems and not enough child psychiatrists to go around. General psychiatrists will continue to share the burden and the exhilaration of treating children and adolescents. This is, in fact, the impetus for this month’s Special Report.

The articles that follow have been chosen for their appeal to the general psychiatrist. Children live in a dizzying and changing world. Cyber bullying was not even a term a decade ago, and now its prevalence demands space in any review. Aggressive behavior can be categorized diagnostically, symptomatically, culturally, and psychologically. The authors have tried to review the basics of this complex issue.

Trauma is increasingly common, but the study of trauma in children is still in its infancy. We need to have a framework to make certain that our interventions are balanced, safe, and a function of the existing evidence. Similar statements can be made about psychosis, substance abuse, and psychotropic prescribing. We need to treat our patients and at the same time continue our quest to better understand the complexities of their challenges and ours.

In Townsend’s lyrics, the adolescent in Quadrophenia asks whether the doctor can see the “real” person. This is, after all, the goal of all of psychiatry-one that is especially relevant in the treatment of children and adolescents. Treating young people is fascinating, intellectually intriguing, and immensely rewarding-and we get to listen to The Who.

The Differential Diagnosis of Childhood Developmental Disorders, by Jarrett Barnhill, MD

Adolescent Psychosis, by Shermin Imran, MRCPsych and Andrew Clark, FRCPsych

Cyber Bullying, by Robin M. Kowalski, PhD

Theoretical Models of Health Behavior, by Alice Charach, MD

Articles

We need to have a framework to make certain that our interventions are balanced, safe, and a function of the existing evidence. 

Child & Adolescent Psychiatry: An Overview of the Complex Challenges

Child and adolescent psychosomatic medicine, usually in the realm of the pediatric psychiatric consultation-liaison service, seeks to address the complex relationship between a child's physical illness and affective state with the goal of improving the child's emotional well-being.

 As with adult psychiatry consultation services, child and adolescent consultation-liaison teams must define their psychiatric formulations based on the interplay between the child's medical illness and the needs of the treatment service requesting the consultation. For example, requests such as "please evaluate for possible depression," can mean anything from concern that the child is displaying signs of a mood disorder, to worry that the child's behavior is complicating the recovery process, to frustration that the child's progress has been slow and has not led to recovery.

These concerns are not exclusive, and the role of the consultation psychiatrist is to assess all of these potential issues and then to create a practical, accessible treatment plan. Thus, pediatric psychosomatic medicine can be defined as a combination of the psychiatrist's assessment of the psychiatric concerns in a medically ill child with a formulation and presentation to the pediatric service of all of the means by which psychiatric intervention might help in that child's coping and recovery.

The consultation process begins with the identification of the service requesting the consultation. Requests can be generated in an inpatient, outpatient, intensive care,or emergency department (ED) setting, and each setting carries distinct challenges for the psychiatric consultant. Inpatient medical or surgical services provide an opportunity for daily visits, constant observation, and rapid interventions. However, the consultant must also be cognizant of the varying needs of the different services providing care for the patient. Psychiatric evaluations in an ED are usually time limited and can be more focused on interventions such as hospitalization or mobilization of outpatient resources. In an outpatient setting, there is the opportunity to coordinate long-term care with the patient's various treatment teams, provide a more thorough assessment through continued visits, and implement, monitor, and modify treatment interventions. Nevertheless, treatment interventions may be affected by noncompliance outside of the hospital and/ or in a chaotic home environment.

Within each of these settings, the consultant should begin by identifying a "point person" from the requesting service--an individual, usually another physician, with whom the consultant can share impressions and recommendations, and from whom the consultant can obtain feedback and updates. Maintaining these open lines of communication is important, because the inclination is for busy services with multiple tasks to separate psychiatric issues and interventions from nonpsychiatric ones. Early establishment of a multidisciplinary approach is central to the success of the consultation.

Identifying a need for a psychiatric consultant

Before performing an evaluation, the consultant should clarify that the patient and his or her family are aware of the pediatric service's request for psychiatric consultation and that they understand the rationale for psychiatric involvement. It is essential that there is a united message from all members of the patient's treatment team that psychological concerns may contribute to the patient's symptoms and that a psychiatric evaluation is a valuable and necessary part of the comprehensive care of the child. Preparation of the family is essential in establishing an alliance between the psychiatric consultant and the treatment team and in facilitating openness to psychiatric intervention for the child, his family, and other involved caregivers.

The psychiatric consultant should ask the requesting service to formulate a clear consultation question. Common concerns that prompt a request for consultation include observations made by the medical or surgical service regarding worrisome behavior in the patient, uncomfortable family interactions, or a sense among other caregivers that the patient's symptoms are not entirely accounted for by the existing medical, nonpsychiatric formulations. The consultant may also want to ask the requesting service to specify why the consultation request was generated at that particular time, and to offer an indication of the allotted time frame for the assessment, impressions, and recommendations. It is frustrating and disappointing to be asked to provide psychiatric consultation for a patient who is to be discharged within several hours.

For the consultation to be most successful, the entire treatment team must set realistic goals for psychiatric input and involvement. For example, psychiatric or psychosocial distress felt by the patient, his family, and/or the primary service might not disappear despite psychiatric involvement. Nevertheless, the consultation service can help the child tolerate and/or manage the distress. In this light, questions posed to psychiatry can range from requests for assessment of a primary, underlying, or comorbid psychiatric disorder to assistance in the management of pain, delirium, or general agitation, an acute psychiatric safety evaluation, or, more broadly, helping the patient and the treatment team to cope with chronic illness.

In all of these scenarios, the consultant may be asked to provide both behavioral and psychopharmacological interventions. Goals for the consultation should focus on assisting the primary pediatric team to understand the interplay between the developmental level of the child and his corresponding interpretation/understanding of the illness. It is also important that there is an appreciation of the child's strengths and capacity for resilience, particularly with questions about coping with a serious illness such as cancer. Central to all of these goals is the necessity of helping the primary team to develop appropriate language for discussion of key issues with the patient and the family in empathic and ultimately therapeutic terms.

An essential aspect of consultation is the psychiatrist's role in assisting the team, the patient, and the family to manage difficult emotional responses to troubling circumstances. Transference and countertransference reactions are common in complicated cases and are especially likely with emotionally laden issues such as somatoform disorders, eating disorders, and terminal illnesses.

A 12-year-old girl with no formal past psychiatric history was admitted to the pediatric service with the chief complaint of inability to walk. She had been in her usual state of health until just days before admission when, while running during an activity at her overnight camp, she fell and hurt her ankle. She was brought to the camp infirmary where the nurse diagnosed a minor ankle sprain. However, by the next morning, the patient was unable to stand or bear any weight, and she was transferred by ambulance to the hospital near her home.

Neurological evaluation revealed full motor strength in all extremities and intact sensation. MRI scan, electromyograms, and CSF fluid analysis (biochemical, microbiological, and cytological) from the lumbar puncture were normal and unremarkable. Family history was notable in that the patient's mother had suffered a broken leg earlier in the spring but had since made a full recovery. The pediatric service was prepared to discharge the patient, but the patient remained unable to walk. Psychiatry was therefore consulted to rule out a psychogenic component to the patient's presentation and assist in identifying the appropriate disposition for the patient from the hospital.

In this case, physical therapy, treatment team meetings with family, and daily visits with psychiatry were implemented. The option for transfer to an inpatient psychiatric unit with an ability to address medical issues was discussed and the patient was subsequently transferred.

In managing this consultation request, the psychiatric consultant had to first ascertain the anticipated duration of hospital stay for this child (given the lack of a definitive organic cause to explain the symptoms) and clarify with the team that the child and her family had been informed of the request for psychiatric involvement. The consultant agreed that there likely was a psychogenic component to the child's presentation but needed to help the pediatric team appreciate the child's need for continued medical care (eg, physical therapy) to help her "regain" her strength, as well as her need for ongoing psychiatric treatment to address the reasons that she felt she could not walk.

The consultant might also have considered facilitating a discussion of the unconscious nature of the child's problems to deflect some of the angry feelings that members of the pediatric team may have experienced, such as "she's faking," or "she's taking up the time we could devote to someone who is really sick!"

With all consultations, treatment recommendations should be clear and concise. Lengthy notes with complex psychiatric formulations will be less valuable to the requesting services than suggestions for multidisciplinary approaches to address the issues that triggered the consultation request. In most circumstances, the consultation service provides assistance to the primary treatment team but does not assume primary responsibility or care for the patient unless the patient is transferred to a psychiatric setting. This process ameliorates the potential for unrealistic expectations of the treatment team by patient and family.

Finally, all recommended interventions should be discussed and agreed upon by the entire team before discussion with the family or treatment implementation. These practices can prevent the division of responsibility and emotional responses to the patient among different teams caring for the same patient. A notable exception to these limits includes psychiatric disposition planning. Because insurance regulations, approval processes, and available psychiatric transfer locations are rarely the purview of treaters other than those with psychiatric responsibility, the psychiatric consultant usually assumes substantially more responsibility in this arena.

A 16-year-old girl with no psychiatric history was brought to the hospital after a motor vehicle accident in which she was a passenger. She was not wearing a seatbelt, and she experienced bilateral tibia/fibula fractures that required open reduction and a right distal radial fracture. The driver, her 18-year-old boyfriend, suffered only minor injuries. At presentation the patient's toxic screen was negative. The nurses noted that the patient frequently lay in bed with the covers pulled over her head, and psychiatric consultation was requested to assess for anxiety and depression.

On evaluation, the patient reported ongoing nightmares of the accident that she remembered in detail. She found herself ruminating about the events leading up to the accident; these thoughts made her extremely anxious. The pediatric service felt somewhat frustrated and angry that she did not recognize how lucky she was. She remained reluctant to speak about the accident because she found it too painful to remember. She also refused to see her boyfriend or any of her other friends, and she steadfastly refused to participate in physical therapy and, eventually, even to eat.

After an assessment by the psychiatrist, a complex acute stress reaction, which required more specialized services, was diagnosed, and she was transferred to a psychiatric facility with physical rehabilitation capacity.

In addition to her physical injuries, this patient sustained psychological trauma that required specialized care and attention. She evoked feelings of anger on the part of her treatment team because she could not see how minor her physical injuries were given the potential severity of her accident.

In a case such as this, psychoeducation, including defining and differentiating acute stress reactions and posttraumatic stress disorder (PTSD) for the patient, the family, and the nonpsychiatric medical team, may be helpful. In particular, the consultant can explicitly stress that the severity of the nonpsychiatric injuries (or lack thereof) does not always correlate with the degree of emotional or affective response or subsequent psychiatric sequelae.

Increasingly, medical centers with multiple specialty services are incorporating child psychiatric consultants who subspecialize in consultation and liaison to fields as diverse as pediatric gastroenterology, cystic fibrosis, epilepsy, pediatric hematology and oncology, and organ transplantation.

 This subspecialization has led to new findings that are both specific to the disease processes being considered and generalizable to other medical predicaments. For example, some time ago it was observed that children and adolescents who survive malignancies through aggressive and often noxious treatment regimens are at risk for the development of PTSD and other anxiety and cognitive disorders later in life.

 This research has now been generalized to include examination for similar risks in solid organ transplantation. Current studies suggest that posttraumatic symptoms are more likely to develop if patients sense that their predicament is dire, regardless of the actual state of their health.

Child and adolescent psychosomatic medicine involves a rich mixture of psychosocial, cultural, and biological concerns embroiled in the increasingly complex world of modern medical care. The pediatric consultation-liaison psychiatrist must take into consideration the patient's disease, the team responsible for treating the patient, the patient's family, the socio-cultural milieu, and possible comorbid psychiatric illnesses. In addition, for the child and adolescent psychiatrist who serves as a consultant, psychotherapeutic, biological, and multisystemic interventions all require equal consideration and careful implementation firmly grounded in a developmental context.

 Rauch PK, Jellinek MS. Paediatric consultation. In: Rutter M, Taylor E, eds. 

 4th ed. Malden, Mass: Blackwell Publishing; 2003:1051-1066.


 Pao M, Ballard ED, Raza H, Rosenstein DL. Pediatric psychosomatic medicine: an annotated bibliography. 

 Shaw RJ, Wamboldt M, Bursch B, Stuber M. Practice patterns in pediatric consultation-liaison psychiatry: a national survey. 

 Smith GC, Clarke DM, Handrinos D, et al. Consultation-liaison psychiatrists' management of somatoform disorders. 

 Kozlowska K, Nunn KP, Rose D, et al. Conversion disorder in Australian pediatric practice. 

 Ziegler MF, Greenwald MH, DeGuzman MA, Simon HK. Posttraumatic stress responses in children: awareness and practice among a sample of pediatric emergency care providers. 

 Stuber ML, Kazak AE, Meeske K, et al. Predictors of posttraumatic stress symptoms in childhood cancer survivors. 

 Mintzer LL, Stuber ML, Seacord D, et al. Traumatic stress symptoms in adolescent organ transplant recipients. 

Perspectives on Consultation-Liaison in Child and Adolescent Psychiatry

Adolescents of every generation reject their parents' icons as they seek out and empower their own. These icons fall along a continuum, from mainstream hero figures--usually tolerable to parents and the adult generation, such as Kelly Clarkson, Beyoncé, and Usher--to the antiheroes at the other end, such as Marilyn Manson, Courtney Love, Eminem, Dennis Rodman, and perhaps even fictional video game characters such as Hitman and the protagonist CJ in 

 These antiheroes seem deliberately provocative, assailing almost every social convention of the adult generation, and parents often fear they are leading youth astray.

 Indeed, identification with some youth subcultures (eg, goth) may be associated with increased risk of self-harm.

Yet every generation repeats this pattern, elevating their own rebel leaders while dismissing their parents' icons. All along the spectrum, icons resonate with important themes inherent to adolescent development and provide clinical opportunities to engage both adolescents struggling with individuation and parents seeking skills to facilitate this process despite feeling stymied by their adolescents.

Whether Eminem in the 2000s, Marilyn Manson in the 1990s, Alice Cooper in the 1970s, or Elvis Presley or James Dean in the 1950s, antiheroes possess similar characteristics (

), and these characteristics amplify important developmental challenges faced by the adolescent. Moreover, these antiheroes challenge the adolescent's parents, who are contending with their own developmental hurdles imposed by the adolescent's separation/individuation process.

The appeal of antiheroes coincides with 2 intertwined developmental tasks that are important in adolescence. First, adolescents must separate enough from parents to identify their own interests and to construct an identity. Second, adolescents must be able to connect to other peers as they separate from parents. This is not a linear process, and the adolescent intermittently rejects and then approaches parents for support during times when the adolescent experiences a failure or is ostracized by his or her peer group. The adolescent may be harsh and critical of his parents at one moment, fearing dependency and making an effort to separate, yet expect parents to be compassionate the next moment, when the adolescent feels shunned or neglected by even a subgroup of peers.

The phenomenon of adolescent antihero admiration can thus be viewed as a developmentally important part of an adolescent's psychological growth toward individuation. Inclusion of temporary identifications, even with outrageous figures, by adolescents is part of their process of deriving a cohesive sense of self.

 Adolescents who struggle with feelings of alienation may be more prone to try on an antihero identity among their explorations. Even this phase may ultimately strengthen their final identity, since adolescents may distill antihero traits to manage their own fears of being outcast as they strive for autonomy.

Both heroes and antiheroes may provide an identity way station, facilitating separation from parents and offering the adolescent identifiable means (clothes, music, specific interests) to be recognized by like-minded others, which helps adolescents identify potential peer connections. In the effort to connect with similar peers, and to distance from dissimilar peers, adolescents exaggerate differences among peer groups, including their musical preferences.

 However, the personas tried on by the adolescent often wear poorly and may be abandoned relatively quickly, particularly if they do not lead to useful connections to peers.

Antiheroes may particularly appeal to adolescents who, sensitive to their own flaws, see the antihero as similarly flawed and shunned by adults. These adolescents also hope to find the ability to flourish without depending on adults. Few have suggested that the appeal of Alice Cooper, Courtney Love, or Marilyn Manson was primarily based on their vocal abilities. What antiheroes do possess, beyond outrageous behavior, are uniqueness, creativity, and cour-age, which predominate over traits such as perfect pitch or physical strength. In addition, they may help adolescents view their own flaws as acceptable or even heroic badges of honor.

Adolescents often imitate the antihero, even in appearance, as they try to fashion themselves into a figure similarly powerful to stand against authority figures, despite lacking attributes or talents recognized by mainstream culture. Looking the part may be the most effective means by which adolescents can demonstrate their need to play out the fantasy of emerging victorious. Antihero identities adopted by adolescents are almost invariably temporary holding identities, as the adolescent figures out that portraying the stage persona of the antihero does not work in real life as fantasized.

J, a 15-year-old boy with depressive disorder and a propensity for fighting in school, excitedly directed his therapist to a Web site featuring a famous and somewhat disreputable sports figure physically attacking a commentator who was ridiculing the player on national television. The patient stressed that many of his friends felt strongly that this video gave credence to the argument that physical assault was a necessary and justifiable response to verbal insults. As the video progresses, the sports figure leaps across the interview table and attacks the broadcaster before he is pulled out of the fight by station attendants.

The patient noted that many of his friends saw this scene as an example of how one can be pushed toward violence as the only response to ongoing insults and therefore justified his own continual pugilism in school and in the neighborhood. The therapist identified with the patient, noting that it felt good to see the broadcaster deftly "handled" by the professional ballplayer. However, both the therapist and patient also wondered whether the player and the broadcaster were following a kind of unwritten script that, in the end, made the player seem potentially even more foolish than expected. After all, it was obvious, barring some unknown martial arts expertise on the part of the broadcaster, that the athlete could easily overcome this adversary and that his response was therefore particularly uncreative and predictable. A quick Google search revealed that the incident had left the athlete in a state of media infamy, and the patient wondered whether it would have been even more effective for the player to simply have walked off the set, leaving the puerile broadcaster alone with his mockery.

While adolescents are seeking autonomy, parents may become fearful that their offspring may be irreparably harmed by exposure to antiheroes.

 Indeed, violent imagery in the media may negatively influence the development of adolescent attitudes such as empathy.

 The expansion of mass media and the decrease in censorship provide adolescents more exposure to more extreme images,

 desensitizing them to previously unspeakable behaviors.

Antiheroes have been implicated in promoting negative, self-destructive adolescent behaviors and, at the extreme, adolescent tragedies such as teen suicides.

 While a small fraction of severely psychiatrically ill adolescents imitate the potentially violent antics of antihero personas, the vast majority of adolescents can distinguish these staged acts from real lifestyles.

Antihero imitation may become an acceptable part of adolescent culture for healthy adolescents, but when is it a sign of maladaptive behavior? Signs of potentially worrisome adolescent antihero worship occur when it results in alienation, isolation, or humiliation rather than serving as a form of connection. Furthermore, when imitation is coupled with expressions of any self-injurious behavior or violence toward self or others, this signals the need for intervention.

T, a 14-year-old girl, described in outpatient therapy how she felt alienated by peers after dying her hair black, wearing black nail polish, and changing her cell phone ringtone to a rap song. She complained that peers she had known since elementary school stopped talking to her. In therapy, T began showing her therapist her MySpace profile as well as those of boyfriends, including one whose profile included pictures of marijuana leaves. T's profile included photos of multiple friends, some in sexually provocative positions.

The therapist examined not only T's profile but others' profiles on MySpace, as well, as T and the therapist imagined what the "real person" was like who put up various profiles. They soon recognized that T's sexually provocative material made some boys expect that she would "put out," which put her in uncomfortable situations, including other girls talking badly about her. T recognized that she wished others would think she was "hot" so that she might become more popular among peers, and she could not think of other ways to attract their attention or respect. Although she had relatively little insight into the reasons behind her music choices, she thought others would think she was "mature" and "hip-hop," which would elevate her over other girls. T's fears of being neglected, as well as her choice of ways to attract attention, became a focus of therapy. While she dyed her hair multiple other colors to imitate the female singer Pink during the course of treatment, connections between feeling "not special" and then taking such actions led T to recognize her overwhelming impulses to do anything to avoid loneliness. As T examined the consequences of such acts, she realized that she often did not obtain what she wanted. She began articulating her feelings to others during the times when she felt lonely and needy of attention.

Clinical opportunities with adolescents and their parents

As shown in these case illustrations, antiheroes may be useful clinically as a vehicle for addressing adolescent struggles with separation and identity development. Specifically, antiheroes may provide an additional window to the soul of the adolescent. Based on the adolescent's passion for what the antihero represents, discussions of antiheroes may serve as a projection device for clinicians and parents. Antiheroes may also facilitate discussion of complex issues, since the adolescent describes reactions to the antihero that in reality reflect the adolescent's own worries and concerns.

While the adolescent may experience anxiety caused by separation/individuation fears, parents may also feel anxious in that they fear losing control over their child, fear criticism from other parents, and perhaps most important, fear their child will abandon their values and instead emulate the antihero du jour. The adult's familiar psychological defense system may be challenged in these circumstances. Parental regression to authoritarianism or denial manifesting as avoidance or neglect may emerge, causing the parents to overlook the underlying needs of the separating adolescent. Even small tensions may become too much to bear when both the adolescent and parent cannot harness their own anxieties, and then both may rely on more primitive defenses that undermine efforts toward constructive negotiation. While disconnection and avoidance of anxiety-provoking interactions occur, perhaps facilitating adolescent separation, this scenario does not allow parents to model or provide the adolescent with useful responses to employ as coping skills.

The clinical opportunity available amid these parent-adolescent conflicts is to examine optimal coping skills to navigate this complicated separation/individuation process with parents and adolescents. The adolescent's interests in icons, even antiheroes, provide important channels of communication and cues. If these are recognized in a developmental context, adults can attune and assist the adolescent in separating while minimizing their own distress. Clinical opportunities for both adolescents and parents are outlined in 

Negative impacts of the antihero on the adolescent, based on observed behavior or suspicion of impending harm to the adolescent or others, warrant attention by the clinician. The function served by the antihero can inform the clinician as to which interventions are most likely to benefit the patient and family members. Functional assessments usually involve the identification of the settings or context in which the adolescent's troublesome behaviors occur.

 In addition, functional assessments examine the antecedents leading to the inappropriate behavior and the consequences of these behaviors.

For example, an adolescent may frighten parents and teachers by dressing like a particular icon. This behavior may occur only at school, or everywhere, and may have emerged after the adolescent was not accepted for a sports team or school musical group, or simply following rejection by peers. The consequences of this behavior may include formation of bonds with similar peers, expanding a group of accepting peers, and the added pressures of increased conflicts with parents that the new peers may bring.

For some adolescents, role-modeling an antihero may serve as a behavior that emerges in response to disappointed or disapproving adults and peers. Moreover, the antihero remains available to the adolescent through the media for ongoing direction about what to wear and how to act. Yet the adolescent can never fully identify with the antihero, so this costume can ultimately be discarded; that is, since the adolescent did not create this persona, it resides with the antihero when the adolescent is ready to abandon it. What is harder for the adolescent to abandon is the circle of peers who may similarly be identified by their interest in an antihero.

Ultimately, antiheroes and what they represent suffer the fate of other antithetical ideas in society: they become somehow assimilated into the current adolescent culture. To continue as antiheroes, these characters have to rebel against their socially acknowledged role. This does not mean antiheroes necessarily sell out, but instead that antiheroes provoke a response from mainstream society, which most often adjusts to them. To this end, it is helpful to remind parents that the values of antiheroes are reflections of the prevailing culture as much as they are reactions to the values of the prevailing culture. Every era has its heroes and villains, and most past villains are eventually understood in the context of more mainstream ideals.

Adolescents often need help in negotiating the sometimes turbulent trail toward adulthood. Adults can be an invaluable support to adolescents by preparing (beyond protecting) them to contend with the media barrage to which they are currently exposed. Adults can promote understanding of adolescent developmental issues through thoughtful examination of adolescent choices in music, media, and pop culture icons--including antiheroes. Adults who deal with adolescents may set goals to model tolerance of adolescents' individual choices while setting guidelines for behavior that demonstrate the basic values that are important to adults and to successful societal integration. Media pop culture icons and antiheroes present clinicians and adults with the opportunity to work through critical developmental challenges with adolescents by using sometimes distressing images to address struggles leading to individuation and autonomy.

Dr Bostic is director of school psychiatry at Massachusetts General Hospital in Boston and McLean Hospital, Belmont, Mass. Dr Pataki is director of residency training in child psychiatry at the University of Southern California Keck School of Medicine, Los Angeles. Dr Rho is a child psychiatry fellow at Cambridge Hospital, Mass. Dr Schlozman is associate director of residency training in child psychiatry at Massachusetts General Hospital and McLean Hospital. Dr Martin is director of the child psychiatry inpatient service at Yale-New Haven Hospital, Conn.

Dr Bostic has received grant support and/or honoraria from Abbott, Forest, GlaxoSmithKline, Eli Lilly, and Pfizer. Dr Pataki has received research support from Eli Lilly, Pfizer, Novartis, and Shire. Drs Rho, Schlozman, and Martin have no financial relationships to disclose.

 Bostic JQ, Schlozman S, Pataki C, et al. From Alice Cooper to Marilyn Manson: the significance of adolescent antiheroes. 

 Young R, Sweeting H, West P. Prevalence of deliberate self harm and attempted suicide within contemporary Goth youth subculture: longitudinal cohort study. 

 Tarrant M, North AC, Hargreaves DJ. Adolescents' intergroup attributions: a comparison of two social identities. 

 Ashby SL, Rich M. Video killed the radio star: the effects of music videos on adolescent health. 

 Greenfield PM, Bruzzone L, Koyamatsu K, et al. What is rock music doing to the minds of our youth? A first experimental look at the effects of rock music lyrics and music videos. 

 Villani S. Impact of media on children and adolescents: a 10-year review of the research. 

 Roberts DF. Media and youth: access, exposure, and privatization. 

 Zillmann D. Influence of unrestrained access to erotica on adolescents' and young adults' dispositions toward sexuality. 

 Sargent JD, Heatherton TF, Ahrens MB, et al. Adolescent exposure to extremely violent movies. 

 L'Engle KL, Brown JD, Kenneavy K. The mass media are an important context for adolescents' sexual behavior. 

 Hogan MJ. Adolescents and media violence: six crucial issues for practitioners. 

 Scheel KR, Westefeld JS. Heavy metal music and adolescent suicidality: an empirical investigation. 

 Stack S, Gundlach J, Reeves JL. The heavy metal subculture and suicide. 

Adolescents reject their parents’ icons and seek out and empower their own. Antiheroes seem deliberately provocative, assailing almost every social convention of the adult generation, and parents often fear they are leading youth astray.

Author | Steve Schlozman, MD

Articles

Child & Adolescent Psychiatry: An Overview of the Complex Challenges

Perspectives on Consultation-Liaison in Child and Adolescent Psychiatry

Rebels Without a Cause? Adolescents and Their Antiheroes