Steven C. Schlozman

Adolescent Psychological Development : A Review

1. Eric Hazen, MD* 2. Steven Schlozman, MD† 3. Eugene Beresin, MD‡ 1. *Instructor in Psychiatry, Harvard Medical School, Boston, Mass 2. †Assistant Professor of Psychiatry, Harvard Medical School, Boston, Mass 3. ‡Professor of Psychiatry, Harvard Medical School, Boston, Mass After reading this article, readers should be able to: 1. Discuss the processes of physical, emotional, social, cognitive, and moral development in adolescence. 2. Know the contributions of major developmental theorists, including Erik Erikson, Jean Piaget, and Lawrence Kohlberg, to the understanding of adolescent development. 3. Describe the relationship between adolescent behavior and recent findings from studies of brain development. 4. Identify the primary tasks of adolescent development. Adolescent patients present a unique set of challenges to pediatricians. A polite, compliant child can appear to transform into a surly, rebellious teen before a doctors eyes. Adolescence can be a tumultuous time, even when it is unfolding in a healthy manner. For this reason, and because there is so much individual variation in adolescent development, it can be particularly challenging to determine what is “normal” in adolescent development. Although previously believed to be uniformly a time of turmoil, this view has not been substantiated by large-scale studies. (1) Most teenagers progress through this period of life with few obvious behavioral problems. However, a sound and trusting doctor-patient relationship is required to appreciate the inner struggles many adolescents endure. A working understanding of the developmental tasks of adolescence and the processes through which they are achieved provides the best tool for a pediatrician in evaluating an adolescents development. Any discussion of adolescent development should include a definition of adolescence itself. Determining the exact onset and conclusion of adolescent development can be difficult, with complex biologic, psychological, and social paradigms all playing roles. Cultural factors also must be considered in determining the developmental norms of adolescence. Normal development from one cultural perspective may appear aberrant when viewed through the lens of another culture, and in an increasingly multicultural society, such considerations are especially important. For example, an Asian youth who begins to question his parents’ values may …

Treatment of depression in children and adolescents.

Depression occurs in children and adolescents, although it may appear differently in younger patients. Research suggests juvenile depression may respond to psychotherapy and to pharmacologic agents, and that antidepressants remain a valuable treatment for juveniles with depression. Diagnostic considerations in juveniles with mood symptoms are discussed. A brief overview is provided of the evidence supporting psychotherapy for juveniles with depression. Controlled antidepressant trials in juveniles with depression provide some support for the use of some selective serotonin reuptake inhibitors and little support for atypical antidepressants, tricyclic antidepressants, or monoamine oxidase inhibitors. Evidence from suicide rates over time, autopsy findings among juvenile suicides, and impacts of antidepressant prescribing trends are related to the current controversy over suicidality and antidepressant use in juvenile patients. Based on this evidence, practical guidelines for treatment of juvenile depression are provided.

Training Pediatric Residents and Pediatricians about Adolescent Mental Health Problems: A Proof-of-Concept Pilot for a Proposed National Curriculum.

ObjectiveThis article presents a DVD-based educational program intended to help pediatric residents and practicing pediatricians recognize and respond to adolescent depression in busy primary care settings.MethodsRepresentatives from pediatrics and adolescent medicine, child and adolescent psychiatry and psychology, and experts in the creation of educational mental health programs met to design a multimedia approach to improving the mental health diagnostic skills among pediatric residents. The authors chose depression as the initial topic because of its relatively high prevalence among children and adolescents, and evidence suggesting that pediatricians may have difficulty diagnosing this disorder in the primary care setting. The authors created a 30-minute DVD program featuring depressed adolescents and experts in child psychiatry and adolescent medicine. After viewing the DVD, residents in the training program, as well as practicing pediatricians, completed a standardized survey to assess the usefulness and attractiveness of this approach to pediatric education.ResultsThe survey results support the potential value of this type of material and the feasibility of similar programs in addressing an array of mental health concerns in pediatric residencies. Participants found the program useful and indicated interest in receiving more educational programs in this format.ConclusionThe authors suggest that the relative ease with which initiatives such as this media-based approach can be implemented make this educational technique appropriate and feasible on a large scale for programs throughout the nation and for a variety of mental health concerns.

Vampires and Those Who Slay Them

Psychodynamic concepts are frequent themes throughout popular culture. For this reason, movies, books, and even television shows offer rich opportunities for the examination of important psychological constructs. Given the current popularity of vampire stories within adolescent groups, the psychodynamic themes woven throughout the vampire myth deserve special attention. In particular, the television program Buffy the Vampire Slayer uniquely displays key adolescent developmental challenges. In discussing the psychodynamic significance of vampires, with special attention to the characteristics of Buffy the Vampire Slayer, this article demonstrates both the use of displacement in adolescent therapy, as well the utilization of the Buffy’s story as a means of teaching important psychodynamic concepts.

Improving child and adolescent psychiatry education for medical students: An inter-organizational collaborative action plan

ObjectiveA new Child and Adolescent Psychiatry in Medical Education (CAPME) Task Force, sponsored by the Association for Directors of Medical Student Education in Psychiatry (ADMSEP), has created an inter-organizational partnership between child and adolescent psychiatry (CAP) educators and medical student educators in psychiatry. This paper outlines the task force design and strategic plan to address the longstanding dearth of CAP training for medical students.MethodThe CAPME ADMSEP Task Force, formed in 2010, identified common challenges to teaching CAP among ADMSEP’s CAPME Task Force members, utilizing focus-group discussions and a needs-assessment survey. The Task Force was organized into five major sections, with inter-organizational action plans to address identified areas of need, such as portable modules and development of benchmark CAP competencies.ResultsThe authors predict that all new physicians, regardless of specialty, will be better trained in CAP. Increased exposure may also improve recruitment into this underserved area.

Frustration and Opportunity: Teaching Child and Adolescent Psychiatry Throughout Medical Education

If you care about psychiatric education, you probably already know everything we are going to mention in this introduction. If you care about child and adolescent psychiatry, you probably already know this introduction even better. And if you have ever been asked to teach child and adolescent psychiatry at a medical school, you probably could sit down and write with passion and not a little frustration the very arguments we hope to stress in this commentary. Many of the articles in this issue seem to begin with the same set of data. They make clear their case for more education in child psychiatry throughout every stage of medical teaching by noting the crises facing psychiatrically ill children and adolescents. We have heard these alarms before (1), and they help us appreciate something deceptively obvious and of paramount importance: the data alone are not enough. We must add even more passion to our purpose. As virtually every article on this topic shows, child and adolescent psychiatrists are needed now more than ever, yet we are forced now more than ever to compete with an ever-growing set of curricular demands in the seemingly shrinking space currently available for a well-rounded medical education. The arguments for more child and adolescent psychiatry across all realms of medical education seem to rest on a relentless Mobius strip. We keep coming back to the same dire statistics and predictions for need and the same desire and firmly held belief, especially among child psychiatrists themselves, that if only we could show students what we know and do, and generally how happy we are in our work, they would gravitate with relative ease toward our field. And yet, as the articles in this issue show, these arguments have not materialized into large-scale changes across medical schools. Here are some points to put the problems into perspective:

Stigma and Mental Health: A Proposal for Next Steps

It might be difficult for yet another commentary exploring the effects of stigma onmental illness to sound fresh and exciting. For this reason, we want to begin by accentuating and actively guarding against the phenomena of intellectual and emotional fatigue that accompanies stringent calls to action that seem nevertheless continually ignored. In this way, we can both recognize the laudable advances that we have made in the fight against stigma, such as in the case where insurance policies in the USA have been challenged and amended in favor of mental health parity [1] and also keep in mind that much remains to be done. In this editorial, we intend to identify some areas for further attention and to argue that the practice of psychiatry will be advanced and enriched by an intermingling of coherent and consistent policy initiatives with grass-root actionable endeavors.

An Approach to the Psychosocial Treatment of the Medically Ill Patient

This article discusses some of the practices of psychosocial treatment. Broadly speaking, these practices include an emphasis on the doctor-patient relationship, the creation of a sound and lasting alliance, and the experience of trust and partnership that the physician fosters in helping the patient to negotiate the complex and uniquely individual experience of being ill. An argument is proposed that unless practitioners of medicine are mindful of the threats to the way they would like and are expected by their patients to practice medicine, they are unlikely to endorse changes actively or to pass the need for these changes onto the next generation of physicians. In this sense, keeping these concerns alive and the subject of ongoing discussion is crucial to the ongoing conceptualization of what it means to be a doctor.

A unique tool for teaching development: a review of Dr. Geri Fox's 20 years of family video material created to teach human development.

On the occasion of the release of the latest 10-year installment of Dr. Fox’s project, it is appropriate that we take this opportunity to review her unique contribution to human-development educational efforts. After all, she has shown us 20 years of her family, and one cannot watch these videos without feeling warmly connected to the children and adults in her life. This observation in and of itself is important from a teaching perspective. We cannot present our students with material for which they do not develop empathy and devotion and expect them to learn. That has been proven time and again in educational research (1). To this end, Dr. Fox’s videos, intended to teach the deceptivelytricky, albeit LCMEand ACGME-required topic (2) of Normal Development, is a clear success. Educators who teach human development to medical students as well as residents in psychiatry, pediatrics, and primary care have long struggled with how best to present this material. Stale projections outlining Erikson’s and Piaget’s impressive accomplishments, even when coupled with the astounding and emerging neurobiological evidence that jibes well with the largely empirical conclusions of these developmental pioneers, often falls flat with students who may lack both the context and the life experiences to conceptualize the importance of learning about normal development in the course of becoming a doctor (2). In short, human development is very hard to teach to medical students. However, couple these notions with real stories, viscerally experienced through the immediacy that film, and probably only film affords, and you engage students limbically, such that they cannot help but to ponder their newfound curiosity. The question, then, is not whether Dr. Fox’s videos are useful. Anecdotally, many medical educators, including me, have found her films to be invaluable teaching devices. The question is reallywhether herfilms are anybetter thanfictional films depicting normal development that have often also been used in classrooms (3). Perhaps even more salient: Why are Dr. Fox’s films better than somebody else’s family films? First, and probably most important, Dr. Fox made these films for a clearly-expressed purpose: the better elucidation of developmental principles to medical students and residents. She happens to be an expert in development, so her editing turns out to be, by definition, immeasurably better than a popular movie onto which we force developmental doctrines. Her videos are also better than another educator’s films that were preserved as personal mementos and then later employed as teaching devices. Dr. Fox made these videos to teach specific lessons, and, in that sense, she has given us a gift. Her videos of her family, long-celebrated in academic circles as one of the gold standards for teaching development, have maintained a kind of intimacy that one just cannot find in popular films or any other teaching device that has as its primary goal human-development pedagogy. For example, we see Dr. Fox’s own toddler playing “mother” in the backyard; that same toddler later wishing to be “perfect” by the time she is 10; that 10-year-old dancing to Brittany Spears when she is 11; that 11-year-old decrying, when she is 15, the sanctity of her own bedroom and the absurdity that it ought to be clean, as it is, in fact, her room; that 15-year-old turned 18 and crying in the face of her first trip to college. . .all of this capturing the developing complexity of the human brain in ways no other medium has or can. One might ask, however, whether these films hold the same prowess as teaching devices, absent Dr. Fox herself ReceivedMarch 17, 2011; revised December 18, 2011; accepted January 4, 2012. From the Dept. of Psychiatry, Harvard Medical School, and Dept. of Child andAdolescent Psychiatry,Massachusetts General Hospital/McLean Hospital, Boston, MA. Send correspondence to Dr. Schlozman; e-mail: sschlozman@partners.org Copyright

Fainting, Swooning, and Syncope

Have you ever been curious about how serious fainting, swooning, and syncope are or can be? Have you wondered whether, when, and how to work up these conditions? Have you ever considered how to best treat a patient with single or multiple episodes of syncope? If you have, then the following case vignette should provide a useful stimulus for discussion.