Child & Adolescent Psychiatry: An Overview of the Complex Challenges

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.

In This Special Report:

• 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