Every so often the stars align themselves in such a way that you will be referred an "easy" adolescent. This is a teenager who looks and dresses like you, who is seeking help on his or her own urging, who describes depressive or anxiety symptoms articulately, and who responds well to standard treatment.

This article is for the rest of the time.

In the typical scenario, the family brings an unhappy teen (or pre-teen) into your office for an evaluation. The child may be uncommunicative, the family frantic.

As a clinician, your task is to distinguish “normal” teen-family conflict from true pathology. In doing your assessment, remember to always spend some time with the teen away from their parents and to be clear with all parties about confidential information and who will be privy to it. No teen is going to tell you he’s been drinking if he thinks you’re going to tell mom and dad. You should inform the entire family that any delicate information will be protected, unless you feel that the child’s life is in danger.

Below are the top 5 parental complaints about teens brought in for psychiatric evaluation, with suggestions for how to approach them.

1. "My daughter has a bad attitude."
   Remember that an adolescent’s developmental “job” is to separate from her parents and to attain autonomy. This process, much like a toddler’s development, can be painful, loud, and chock-full of tantrums. If a child is yelling at the parents, refusing to go on family outings, and is generally embarrassed to be seen with them, she may still be psychiatrically fine. Counsel parents to keep the lines of communication open, to be firm but reasonable about limits, and to try not to take it all too personally. Like a toddler, a teenager still really needs to know that her parents are there for her and that they love her unconditionally.


2. "He’s hanging out with a bad crowd."
   Adolescents may or may not experiment with various things, but they are almost certainly doing the same stuff as their friends. If this means wearing low-slung jeans and listening to rap, so be it. But if the friends are smoking, drinking, and having sex, chances are good that your patient is too. Thus, asking about what activities friends are involved in is always an excellent way of getting the low-down on worrisome behavior.


3. "My daughter has stopped her extracurricular activities."
   This is usually a red flag for a real problem. Teens may need to express their individuality, but they normally do not stop favorite sports or hobbies. Do the parents report that their daughter lies in her room all day and won’t go to her gymnastics meet or school dance? Not good: rejecting parental figures is one thing, abandoning activities with peers is often a sign of significant depression.


4. "His grades are going down."
   When you hear about a kid who used to do well but is now failing classes, you should be concerned about depression or other significant psychiatric problems. Often, you will hear about other behavioral issues, such as slamming doors and being uncommunicative with parents, and your patient may try to blame his “overcontrolling” parents for everything. But uncharacteristically poor school work should always prompt more in depth probing for psychopathology.


5. "We suspect drug use and we want our daughter drug-tested."
   The big question in these situations is always: when is drug use "normal" experimentation and when does it cross the line? According to the latest CDC report, (2001 Youth Risk Behavior Surveillance System: www.cdc.gov/yrbs) 47% of American adolescents use alcohol, 24% use marijuana (47% have tried it), and 4% use cocaine (9% have tried it). These figures are helpful to share with parents, not because they imply that it's perfectly fine to use drugs, but because they indicate the kind of peer pressures adolescents are exposed to when making decisions about their behaviors. Ultimately, you should evaluate the seriousness of drug use by considering the patient’s age (the younger, the more you should be concerned), the amount consumed and frequency of use, and whether it leads to risky behavior, such as drunk driving or unprotected sex. Kids with family histories of substance abuse should be warned that they are at increased risk of addiction.

Drug testing per se is not always a good idea. It can put damaging information in the patient’s medical chart. In addition, it’s set-up for more teen/parent struggle since most psychiatrists and pediatricians require a patient’s consent for a drug screen, and the teen may very well refuse.

Better than testing is old fashioned rapport-building and conversation about risks.

TCR VERDICT:
Adolescence: It’s All About Autonomy