About That Jean Twenge Smartphone Article

Note: As you may notice, this is my first blog post in over 2 years. This blog isn’t dead, it was just resting! I’m thinking about writing a post about why I haven’t blogged in so long; maybe it'll even be done less than 2 years from now.

For the past 3 months, my most frequently-visited blog post has been my critique of Jean Twenge’s claims of a “narcissism epidemic” from 2013. Google tells me that it’s one of the top results in searches for “jean twenge criticism.” So in this post, I would like to share my views on her latest work.

I read her article for The Atlantic, “Have Smartphones Destroyed a Generation?” (an excerpt from her new book iGen), the day that it came out, because as a psychiatrist who works with adolescents, it’s clear to me that smartphones have been changing their lives in ways profound and subtle. I actually like many aspects of the article, including her sympathetic portrayal of the complexity that smartphones have brought into teenagers’ already complex lives. Also, I think she presents the data well, and the data sources that she uses are nationally representative surveys that have been around a long time and are well-respected. I think she makes a rather convincing case that many teens today are living their social lives online rather than hanging out with their friends in person.

However, I do have some criticisms of Twenge’s far-reaching claims about the effects of smartphones, but first, that ridiculous title:

The bubonic plague & WWI certainly destroyed some generations. Smartphones? 😂 Not so much. "Hampered", maybe. https://t.co/clZpBKFjJN

— Psycritic (@psycrit) August 3, 2017

Thankfully, it seems the author agrees:

As is customary with these types of pieces, I did not write the headline. Not sure that is the word I would have chosen.

— Jean Twenge (@jean_twenge) August 3, 2017

One criticism that others have voiced is that Twenge seems to draw conclusions based primarily on the correlation between the rise in smartphone use and increases in mental health issues in teens over the same span. While she acknowledges that many of the trends she highlights, such as adolescents taking longer to take on adult responsibilities, predate the introduction of smartphones, she sees the rising use of smartphones as some sort of inflection point. But there are so many other trends going on in our culture, including parents becoming more over-protective, rising political/racial/economic divides, etc., to pin the blame on smartphones seems overly facile. Heck, if I were being cheeky, I would point out that the sale of yoga pants has drastically increased since 2011, corresponding to increases in teen depression:

Source: Business Insider

But just because they correlate does not mean that one has anything to do with the other.

Thus, my biggest criticism stems from Twenge’s seeming certainty about the decisive role of smartphones coupled with a seeming lack of curiosity about examining deeper causes for why these trends are happening. In a recent NY Times Magazine article about increasing rates of anxiety in teens, Twenge had this to say:

“The use of social media and smartphones look culpable for the increase in teen mental-health issues,” [Twenge] told me. “It’s enough for an arrest — and as we get more data, it might be enough for a conviction.”

I’m sorry, but I think the situation is closer to her finding evidence of a crime, and possibly even a weapon, but she is nowhere near identifying—much less convicting—a suspect.

I find it vexing that Twenge seems to view each generation as a distinct and determinative entity, rather than some arbitrary line drawn by demographers, as she shows in this tweet:

They don't look mad! Sure, send some questions via e-mail. Also: If they are 22 or less, they're iGen -- so GenMe might not apply as much.

— Jean Twenge (@jean_twenge) October 10, 2017

That is just preposterous. She writes as though each generation somehow pops into existence with its own innate characteristics, rather than being influenced by—and reacting to—the generations that have come before. However, one of the few things I know for sure is the huge extent to which young people are influenced by their elders. For example, this recent article (also in The Atlantic, lol) highlighted just how much even 1-year-old infants learn from observing the actions of the adults around them. And what are kids observing these days?

In my own practice, I often hear from kids and teens who say that their parents are on their laptops checking work email or on their phones checking Facebook all the time. These kids are bored and lonely, so as soon as they have access to a smart device, what do they do? Twenge’s work makes it easy for parents to blame the devices and not think about how their own actions may be influencing their children. While that may protect parents’ egos and sell more books, it’s a very incomplete and misleading picture, to say the least.

I have not yet read Twenge’s new book, but I was hoping that it would take a deeper look at the culture as a whole, especially the critical role that parents can play in changing the situation. However, one look at the book’s table of contents reveals that only the last 26 pages are devoted to a chapter on “Understanding—and Saving—iGen”. This scathing review from NY Mag further breaks down the book and the motivations of the author. The reviewer takes the view that Twenge is less a scholar who investigates all aspects of a complex issue than she is someone positioning herself as a guru for marketers looking to understand the latest generation of teens.

In conclusion, while there certainly is a mental health crisis going on in today’s teens (and adults!) and pinning the blame on smartphones is understandable, I believe it will take far more than getting rid of everyone’s favorite devices to make our culture healthier for future generations.

A Child Psychiatrist's Review of Pixar's Inside Out

I finally watched Disney/Pixar's Inside Out, and I agree with the consensus opinion that Pixar has done it again, making a movie that's both fun and poignant, with a narrative that young children can understand while containing deeper messages for adults. Read on for more of my thoughts, but be aware that MAJOR SPOILERS FOLLOW, since it is hard to discuss my thoughts as a child psychiatrist on the movie's depiction of emotions without going into the details.

The main characters: Fear, Disgust, Joy, Anger, and (sigh) Sadness.

The plot of Inside Out is fairly straightforward: a preteen girl named Riley moves with her parents from Minnesota to San Francisco, and she experiences a crisis in her emotional state, in her relationship with her parents, and in her concept of herself. Most of the action takes place inside Riley's head, where 5 different emotions (Joy, Sadness, Anger, Disgust, and Fear) take turns at the control center of the brain's headquarters, directing Riley's actions depending on which emotion is at the controls. Joy is the energetic (cheer)leader who attempts to remain in control as much as possible, especially over Sadness. The crux of the movie is about Joy going on a journey in which she (and everyone else) learns to value Sadness.

How the Pixar filmmakers takes us on the journey, though, is where they show off their delightful imagination and remarkably decent grasp of psychology. Here are my thoughts on the aspects of Inside Out that delighted me the most:

• The movie demonstrates the inner workings of memory in a visually coherent and fairly accurate way. I especially like how Riley's incoming memories, which look like softball-sized glowing orbs, are temporarily kept at headquarters until Riley sleeps, at which point they are sent into long term memory. They also find a way to neatly show core aspects of Riley's identity/personality as floating islands that serve as repositories of concepts such as Family, Honesty, and Goofiness.
• The depiction of the weight of parental expectations is very well-done. When Riley becomes upset after the move, her parents say to her: "Where's my happy girl?", clearly indicating their preference for how she should feel. This is one way that parents insidiously and inadvertently tell their children it's not OK to be sad, and the fact that (if I recall correctly) each parent says this to Riley on separate occasions shows that Pixar is emphasizing the harm that this sort of communication can do.
• A critical scene that works incredibly well both as a turning point in the plot and a learning opportunity is when Sadness convinces a character to do something that Joy could not, simply by listening and showing empathy for that character's feelings. This teaches Joy (and us) the importance of validating another person's emotions.
• Some of my favorite moments in the movie are when it delves into the minds of characters other than Riley. I really enjoyed how each character has a different predominant emotion, and the emotions work together in different ways depending on the individual. For example, inside the head of Riley's mother, the different emotions sit around like a committee with Sadness presiding, while a teen boy's mind is dominated by fear, with all his emotions running amok.
• When Riley and her father get into an argument during dinner, the camera dives into each person's mind and clearly shows how Anger in one person leads to escalating Anger in the other, in a mutually assured destruction kind of way. This is a good example of an amygdala hijack, which comes up frequently when I discuss family conflict with patients.
• Despite being a primary emotion, each of the emotion characters are capable of expressing other emotions. This helps make them more interesting and less one-dimensional; it also helps subtly reinforce the point that having one emotion dominate all the time may not be desirable.
• Initially, each of Riley's memories passing through the control center is a distinct color, corresponding to the emotion associated with the memory. By the end of the movie, memories have become multi-hued, nicely illustrating Riley reaching a developmental stage where she is capable of more emotional nuance.

However, I do have one major criticism, and that is the portrayal of Sadness as short, rotund, and bespectacled. How…sad that Pixar uses such obvious stereotypes to depict her appearance! Sure, this may get more laughs from the audience and fit the look of the actress supplying the voice, and the movie does try to redeem itself by turning Sadness into a heroine. But how would kids fitting that description feel inside early on, even if they're laughing along with everyone else on the outside? I wish Pixar had simply portrayed Sadness on the basis of her facial expressions and body language without adhering to our cultural norms regarding the physical characteristics of a sad person; they're good enough animators to be capable of that. A few of other nitpicks:

• A scary clown is locked away in Riley's subconscious, visually depicted as a vault in a deep cavern. I'm not sure if even the psychoanalysts still use the term "subconscious," yet it persists in the popular culture, perhaps because it's so easy to conjure up that visual image of something deeply buried.
• Memories, of course, are not accurate recordings preserved in amber, but are malleable and often unreliable. While it would have been nice for the movie to show this, I understand that it would probably overcomplicate things. Similarly, expanding beyond just the 5 emotions featured would have been nice but too complicated.
• Though dramatic, I do not feel that the scene of Riley taking a credit card from her mother's wallet and getting on a bus back to Minnesota is very believable. Given her generally good relationship with her parents in the past, it would take much more than a couple of arguments to make a kid who did not have previous conduct problems steal and run away from home.

Despite my criticisms, Inside Out is easily one of my three favorite Pixar movies of all time, along with Wall-E and Ratatouille. I can even envision it being useful in therapy. Asking a child to think about a situation and consider what Joy would say versus what Sadness or Fear would say about it might help make cognitive-behavior therapy more engaging and fun. If you're a child therapist/psychologist/psychiatrist and haven't seen it yet, what are you waiting for? It's the only Pixar movie where I'm eagerly anticipating a sequel, given the portents at the end about Riley turning 12. I'd love to see what Pixar does with the even more tangled emotions and relationships of adolescence.

The Tragedy of Palo Alto

Sorry for the long absence. I'm going to try to shake off the winter doldrums and resume blogging semi-regularly.

Palo Alto, CA (est. 2013 population: 66,642) is one of the wealthiest cities in America, with nationally-ranked public high schools, quiet tree-lined streets, and exceedingly low crime rates. Since 2000, the city has averaged about 1 murder per year. Sadly, that number has been dwarfed by the number of Palo Alto teens committing suicide every year.

In 2009, Palo Alto gained national notoriety when a cluster of suicides occurred amongst students at Henry Gunn High School. The attention-grabbing nature of the suicides (most occurred by jumping in front of an oncoming train) and the relative ease of access to the suicide method likely contributed to subsequent suicides. The national youth suicide rate is about 10 per 100,000 per year, so any suicide in a district that has several thousand high school students is a cause for concern. Multiple suicides in such a short span of time understandably led to alarm.

At the 2011 AACAP meeting in Toronto, I attended the session Teaching the Community in Times of Crisis: Responding to Teen Suicide. The main speaker (Madeline Gould, MPH, PhD) was very informative and presented a wealth of research-based data emphasizing how suicides can cluster and spread, while media reports on the suicides can either help or hurt the situation. Dr. Shashank Joshi, a psychiatrist at Stanford, discussed the school-based suicide prevention program that Stanford helped the Palo Alto school district put in place after the suicides. The program has similarities to public health approaches designed to combat disease outbreaks: There are efforts to decrease stigma, provide education about depression how it can lead to suicide with emphasis on the effectiveness of available treatments, train teachers and parents to recognize signs of depression, teach coping skills, and identify vulnerable teens through screening and then making appropriate referrals. From what I gather, this program is still in place, and Dr. Joshi just published an article titled School-Based Suicide Prevention: Content, Process, and the Role of Trusted Adults and Peers, with one of the key points being: "Prevention efforts must focus on school-based mental health education and promotion."

What was not addressed at the AACAP session was what may have been happening at the community level that was triggering the suicides in the first place. Given the relative rarity of suicides, it is hard to prove what causes each suicide or how effective current school-based prevention methods are. Unfortunately, what we do know is that suicides amongst Palo Alto students are still occurring, with another one earlier this month, bringing the total to 3 for the year.

In this past week, Palo Alto Weekly has published two opinion pieces, one by Palo Alto psychiatrist and parent Dr. Adam Strassberg, the other by pediatricians from the Palo Alto Medical Foundation. Both are worth reading in full, because in my opinion they make a valiant attempt to get to the root of the problem. Neither one mentioned anything about screening for depression or increasing access to mental health care. Dr. Strassberg emphasized the pressure that parents place upon their children to succeed:

We are so many of us wealthy and secure beyond imagining, and yet we have such enormous anxiety. We fear the future harm that we will lose our wealth and privilege and be unable to pass it on to our future generations. Maintaining and advancing insidiously high educational standards in our children is a way to soothe this anxiety.

But it harms our children.

The pediatricians make a similar point:

While we are not education specialists, as pediatricians we do recognize dangerously unhealthy lifestyle patterns and habits that are known to exacerbate stress, anxiety, depression and physical illness. These include chronic sleep deprivation, lack of unscheduled time for thought and relaxation, unhealthy eating habits, lack of exercise and unrealistic pressures (real or perceived) to achieve. Those unrealistic pressures include excessive homework, overly ambitious course loads and a seeming demand for perfection in grades, sports and extracurricular activities.

We see these problems day after day in our teen patients. We believe there are specific factors that could be targeted for change.

Sleep: Surveys have shown that Palo Alto teens sleep an average of 6.5 hours per night. Studies have shown that teens need 9 hours of sleep to function at their best. […]

Six-and-a-half hours of sleep, average. So for every teen sleeping 8 hours a night, there's one who's only getting 5. I know that I feel grumpy and foggy even with 7 hours, so it's hard for me to imagine what these teens are going through. I'm not saying that the school-based mental health programs are useless, but it's clear as day to me that they do not go far enough up the chain of causality to address the most important factors leading to all of these adolescent suicides. And it's not just Palo Alto, but achievement-driven communities everywhere, that have this problem. Hopefully, more professionals will start engaging families in a discussion of these root causes, rather than only trying to treat surface symptoms.

Boyhood Movie Review

Putin. Gaza. Ebola. ISIS. Ferguson. Robin Williams. This has been one of the more unsettling summers in recently memory. However, as we head towards Labor Day and I look back on the last couple of months, what I recall most clearly and fondly (besides some personal and family matters that are irrelevant here) is watching Boyhood, by director Richard Linklater.

The film stars Ellar Coltrane as Mason, who is 6 at the beginning of the story. We watch as he grows year by year into an 18 year-old young man. Forget all those gimmicky 3D movies; this is a 4D film, where the genuine passage of 12 years of time adds an extra dimension that cannot be faked by CG.

Boyhood succeeds in capturing something about the essence of our times when it comes to parenting and childhood. The parents have split, and the dad, played by Ethan Hawke, is barely around initially, only occasionally swooping into his kids lives like a tornado of fun. Meanwhile, the mom (Patricia Arquette) struggles to raise her children while trying to go back to school so her family could break free from the struggles of low-wage America.

Amazingly, the director found a young actor in Coltrane who was able to deliver a consistently convincing performance from childhood to adolescence. The film opens with him lying on the grass staring into the sky, leaving us to wonder what he makes of life. Coltrane was able to project this introspective nature throughout, and as a young man engages in the kind of philosophical discussions that Linklater's characters are known to do.

However, Boyhood is as much a coming of age movie about Mason's parents as it is about Mason's own journey. I found it interesting that the adults seemed to be engaged in a search for identity as much or more so than the children. The character who evolves the most over the 12 years is Mason's father, who becomes a minivan-driving, church-going actuary in middle age. Mason's mother ends up as a somewhat tragic figure who has to balance her career with parenting while dealing with a string of bad relationships. Our culture really is harder on women, and this film reflects that reality.

Boyhood has been the best reviewed movie of the summer and deservedly so. One may look at the box office receipts for the latest Transformers assault on the senses ($243.8M) vs. Boyhood ($16.3M) and despair; I choose to see the fact that this movie was made at all as a sign that there is still hope.

The Risks to Adolescents of Legalizing Marijuana

2014 is a banner year for proponents of marijuana legalization, with cannabis becoming legal in Colorado and Washington state. The upcoming Super Bowl will go down in history as the Marijuana Bowl. Even President Obama has weighed in, saying in a New Yorker profile that he believes marijuana is less dangerous than alcohol "in terms of its impact on the individual consumer."

I acknowledge that there are probably going to be societal benefits to decriminalizing cannabis. Fewer people would be locked up on minor drug charges, police departments can devote their resources elsewhere, and there would be higher revenues for states. I also believe that most adults can smoke weed responsibly without abusing the privilege.

However, what I don't see mentioned much in the popular press is the deleterious effect of marijuana on adolescent brains, and how the drug could fundamentally alter a young person's life. As a psychiatric resident working in a university hospital ER, I saw a slew of college students who became extremely paranoid and had disturbing hallucinations after taking just a few hits of marijuana. At first, I and some of the other doctors thought that their weed had to have been laced with amphetamines, but all of their urine tests came back positive only for THC's. Since I've completed my training, I have seen numerous people in their late teens and early 20's with no family history of schizophrenia, who became very psychotic after months or years of regular cannabis use. Sadly, the psychosis does not always go away even after they stop smoking.

For the past decade, there has been convincing evidence that cannabis use is correlated with higher rates of psychosis. What was not clear was whether this correlation meant causation, as it was also plausible that people who go on to develop psychosis like to use cannabis to self-medicate. However, study after study has now shown that people who use cannabis earlier in adolescence (or use more of it) also develop psychosis earlier, with the same effect not being true for alcohol or tobacco, strongly implying that cannabis causes psychosis.

One of the latest studies, published in December 2013, had the following results:

The prevalence of psychosis and schizotypal personality disorder increased significantly with greater cannabis use in a dose-dependent manner. The associations between cannabis use and psychosis were 1.27 (95% CI 1.03-1.57) for lifetime cannabis use, 1.79 (95% CI 1.35-2.38) for lifetime cannabis abuse, and 3.69 (95% CI 2.49-5.47) for lifetime cannabis dependence. There was a similar dose-response relationship between the extent of cannabis use and schizotypal personality disorder (OR=2.02 for lifetime cannabis use, 95% CI 1.69-2.42; OR=2.83 for lifetime cannabis abuse, 95% CI 2.33-2.43; OR=7.32 for lifetime cannabis dependence, 95% CI 5.51-9.72). Likelihood of individual schizotypal features increased significantly with increased extent of cannabis use in a dose-dependent manner.

Even if the worst-case scenario of psychosis does not occur, there's the potential for other harmful outcomes. I have had patients who became physically dependent on cannabis to the extent that they felt nauseated and could not keep food down unless they have smoked. Not surprisingly, cannabis use also appears to be correlated with lower educational attainment, especially for those who started using before age 15.

Already, even before it had been legalized anywhere, there were some unsettling trends among teenagers when it comes to marijuana. The good news is that teenage use of alcohol, tobacco, and most illicit substances is trending down. However, use of marijuana has steadily increased in recent years, such that it is now the second-most abused substance after alcohol. Teens are also increasingly perceiving marijuana as being not so risky, with the percentage of 12th graders who see regular marijuana use as posing "great risk" decreasing from about 56% to 42% between 2006 ad 2012. And now, with the legalization of cannabis in some states and comments like those from our President, the perceived risk will only continue to decrease.

What are the societal and ethical implications of this? Perhaps marijuana is safer for most people than alcohol or tobacco. But for those who are susceptible to the psychosis-inducing effects of marijuana, its effects can be horrendous. Is it acceptable to permanently mess up some people's minds for the enjoyment of many? Strange how this is starting to sound like the NFL and the concussion issue. In the New Yorker interview, Obama had this to say about pro football and concussions:

"At this point, there’s a little bit of caveat emptor," he went on. "These guys, they know what they’re doing. They know what they’re buying into. It is no longer a secret. It’s sort of the feeling I have about smokers, you know?"

Do all these young people who are regularly using marijuana have a similarly informed view of what they're buying into?

What Jean Twenge Gets Wrong About Narcissism

Earlier this week, a New York Times article, Seeing Narcissists Everywhere, featured psychologist Jean Twenge, who has documented the rise of narcissism in Millenials in academic papers and two books. She has also made numerous appearances on TV programs such as Good Morning America and Today touting her view that the promotion of self-esteem over the past few decades has led to the current generation's sense of entitlement. She bases much of her views on standardized questionnaires given to college students, especially the Narcissistic Personality Inventory (NPI).

Unfortunately, the article featured only the most superficial criticism of Dr. Twenge's work, including other researchers who "calculated self-esteem scores" over time and did not find a change, or who disagree that the NPI actually measures narcissism, or who analyzed other sets of NPI data and did not see a significant change over time. I would like to offer some more in-depth critiques. To be clear, I absolutely agree that narcissism is prevalent in our society and that it leads to a host of ills.

Endemic, not epidemic

First, I find the title of one of Twenge's books, The Narcissism Epidemic, to be deeply misleading and alarmist. According to the MedlinePlus Medical Dictionary, "epidemic" is defined:

affecting or tending to affect an atypically large number of individuals within a population, community, or region at the same time

What's "atypically large" about the prevalence of narcissism, given our status and wealth-obsessed culture? I think it would be more accurate to call narcissism "endemic" rather than "epidemic." We all have narcissistic tendencies, and to characterize it as an epidemic externalizes and puts the focus on others. It's as misguided as those "how to spot a narcissist" articles. The title also implies that Twenge has somehow discovered something new, which is certainly not the case. In 1979, Christopher Lasch published The Culture of Narcissism: American Life in an Age of Diminishing Expectations, a deeper critique of our culture that obviously predates the "self-esteem movement" of the 1980's.

More than meets the eye

Narcissism presents in more than just one way. There is the stereotypical view of a self-absorbed, overconfident, extroverted, somewhat callous individual, and this is likely the construct that the NPI measures. However, there's also covert narcissism, which is well-recognized in the literature, but which Twenge does not seem to appreciate. For example, suppose there are people who think I'm more altruistic than anyone else or no one else can appreciate the uniqueness of my suffering, or who base their sense of self-worth entirely on what other people think while outwardly appearing anxious or depressed. I would argue that these people also have narcissistic issues, even though their form of narcissism is not well-measured by the NPI or formally a part of the DSM definition of narcissistic personality disorder (NPD). Originally, the DSM-5 draft had proposed changes to NPD that encompassed the covert form as well, but ultimately (and unfortunately) those changes did not make the cut.

Beyond the explicit message

Twenge seems to think that there's a direct path from parents telling their children how special they are to the children becoming narcissistic and entitled adults. That may be true, but people are a bit more complicated than that. I won't talk about any particular person, since it's unethical for me to diagnose someone I'm not treating. But let's say there's a politician who has done little over his career other than appearing on TV and provoking the opposition. And suppose this politician admits in a major interview that when growing up, his parents were distant and far from the self-esteem boosting types. And then suppose that this man's sexually-charged text messages are released to the public and reveal a deep fount of insecurity rather than confidence.

Thus, the implicit message that children and adolescents receive from parents and from society is just as influential or more so than the explicit message. Take for example this passage from the NYT article:

 "I got a onesie as a gift that I gave away on principle," said Dr. Twenge, 41, a professor of psychology at San Diego State University and a mother of three girls under 7, in an interview at a diner on the West Side of Manhattan.

"It said, 'One of a Kind,' " she said, poking at a fruit salad. "That actually isn’t so bad, because it’s true of any baby. But it’s just not something I want to emphasize."

So she's not telling her children they are "unique" or "special." That's all well and good, but what if she's reinforcing society's message that to be successful, one has to publish best-selling books or appear on the Today show? How she handles these issues with her children is far more important than what's on the onesies that they wear. If she truly is not aware of this, then perhaps the article would be better titled: "Seeing Narcissists Everywhere, Except the One in the Mirror."

Movie Review: The Bling Ring

Sofia Coppola's The Bling Ring is one of my favorite movies of the year. Set in 2009 and "based on actual events," it tells the tale of a group of SoCal teens obsessed with celebrities and their bling, who end up stealing millions from the homes of Paris Hilton, Lindsay Lohan, Audrina Patridge, Orlando Bloom, etc. The ringleader Rebecca (played by Katie Chang) is fearless and quite possibly a psychopath. The closest thing to a protagonist in movie is Marc (Israel Broussard), a social outcast whose fortunes rise after he meets Rebecca at his new school. Also part of the group are best friends Nicki (Emma Watson) and Sam (Taissa Farmiga), and Rebecca's friend Chloe (Claire Julien).

Although the acting is fantastic, many professional film critics were lukewarm about the movie as a whole, as exemplified by the concluding paragraph of A. O. Scott's New York Times review:

“The Bling Ring” occupies a vertiginous middle ground between banality and transcendence, and its refusal to commit to one or the other is both a mark of integrity and a source of frustration. The audience is neither inside the experience of the characters nor at a safe distance from them. We don’t know how (or if) they think, and we don’t know quite what to think of them. Are they empty, depraved or opaque? Which would be worse?

Ignatiy Vishnevetsky has a similar conclusion in his review at rogerebert.com:

[...] Coppola neither makes a case for her characters nor places them inside of some kind of moral or critical framework; they simply pass through the frame, listing off name brands and staring at their phones. About an hour into the film, one starts to get the nagging feeling that Coppola's "neutrality" is a dodge; she avoids moral commitment, thereby creating a movie ambiguous enough to be interpreted in several ways, but too vague to have much meaning in any interpretation.

I disagree completely. I don't believe the movie is neutral or uncomitted at all; it is a satire aimed at not just the adolescents who browse TMZ, but also at their parents and society as well. Certainly, how I interpret the movie is a reflection of my own experiences working with families in which parents are at a loss as to how to rein in their teen's behavior. When I suggest setting some sensible limits, like no electronics after 10pm, I sometimes hear parents say things like: "That wouldn't work. He's like water, he always finds a way around things." Well, that's completely normal! The job of a teenager is to test the limits, to see what they can get away with. What's not normal is parents who cannot set limits or teach the teenager about acceptable behavior. The more the teen is like water, the more the parent needs to be like a vessel that can provide structure for the water.

In The Bling Ring, we see what happens when there is no such water container. For most of the main characters, we only get brief glimpses of their interactions with their parents, which I think was intentional, to reflect the fact that their parents are just not very involved. Katie's parents are divorced and her father lives in another state. Marc's father is often away on business. Chloe's parents are around but barely involved: there is a great shot of Chloe and her parents at breakfast, each separated from the others by the maximal distance that would allow them to still be in the same room. Sam was abandoned by her parents and adopted by Laurie, Nicki's mother. Laurie is the parent who gets the most screen time. Though she means well, she is portrayed as clueless and ineffective, a dispenser of Adderall who tries to teach her children lessons about character using a collage of Angelina Jolie photos. Instead of chastising her daughter after the teens are arrested, she tries to steal the limelight when a reporter interviews Nicki at their home.

In his review, Vishnevetsky's found the movie's use of celebrity cameos problematic:

[...] Paris Hilton and Kirsten Dunst have non-speaking cameos as themselves; more importantly, Hilton's real house is used throughout the film. The characters gawk at Hilton's real possessions and rifle through her real closets.

This points to the movie's most serious problem: the "impartial" viewpoint. Is "The Bling Ring" a movie about characters ogling at celebrities, or is it an excuse for the audience to ogle along with them? [...]

I really believe that Coppola was being subversive in her use of Paris Hilton's mansion. Sure, filming in Paris Hilton's home causes the audience to ogle, but my impression is that Coppola's goal was to show how ridiculous the place was, with its overstuffed glitz and wall-to-wall monuments to Paris herself. She returned to that location repeatedly, I believe, as a way of evoking disgust in the audience. After forming this opinion, I came across an interview that Coppola gave in which she was asked about the experience of filming at Paris Hilton's house (starting at 3:25). Here's what she had to say: "When we first got to see Paris Hilton's real house, it was like nothing I've ever seen before, and I had heard that she had a nightclub room, but then to really see it, and just all her pictures, and the pillows, with her pictures and stuff, it was very, um...exotic [shrugs]. I really appreciate how she let us into her, you know, real private world [smiles]." All that was missing was a wink.

The Bling Ring may not be a Great Movie, but it is certainly an important and alarming one. It's unfortunate that so many missed its subtly, and only 47% of film-goers on Rotten Tomatoes liked it. However, I do wonder about the reasons for audience members not liking the movie. Did it make them feel uncomfortable with themselves? If so, then perhaps Sofia Coppola has achieved her desired effect.

ADHD, Laziness, or Neither?

Child and adolescent psychiatry, like much of life in general, has its seasonal variations. Around September, I tend to get a cluster of new patients (usually kindergartners and first graders) whose parents or teachers are concerned that they cannot seem to sit still or keep on task during school. The winter months bring in more people with depression and anxiety as the stress of work/school, decreased hours of sunlight, and more time spent indoors take their toll.

In the past month, as the school year ended, I've seen multiple new patient evaluations for another reason: high schoolers or college students who have made it through the academic year, but just barely. Most of them have gotten good grades in the past, but have had gradually declining academic performance over the past few years. Now their parents—and it's almost always the parents who make them come in—want to know if they have ADHD, or if it's "just laziness."

I'm fairly confident whether I can diagnose ADHD, but I'm not even sure how to answer the second part of that question. How does one determine whether someone is lazy? Is being lazy equivalent to "procrastinating" or "avoiding hard work?" It definitely feels more pejorative, like a character flaw that will never go away. Fortunately, I've been able to avoid the issue somewhat, since it seems there is always something else going on besides laziness.

In general, I do not readily diagnose older adolescents with ADHD if they had been able to focus on schoolwork previously. ADHD generally manifests long before high school, though it's still possible that an older teen may have previously undiagnosed ADHD. Often, these teens have a fairly high IQ and never had to study much prior to high school, but they eventually get overwhelmed by academic demands. However, multiple other causes of poor school performance are much more likely. Below are some of the ones that I've come across lately.

Depression: An obvious contributor to lower grades, but it surprises me how often parents (and even the patients themselves) miss this. Perhaps it's because they have difficulty telling depression apart from the normal moodiness of adolescence, or perhaps depression often manifests in adolescence as anger, irritability, and mood swings. However, a teen doesn't have to be clinically depressed to be unhappy, and I believe that unhappiness can also lead to academic decline. One example I saw recently is a patient who moved across the country right before 11th grade, and her grades went from A's to C's. Not having any friends at her new school and being somewhat shy, she spent most of her evening time trying to stay connected with old friends via texts and social media. Studying made her feel less happy, so she did much less of it.

Anxiety: I often see teens who are perfectionists, afraid of making a mistake, and stay up late at night unable to sleep because they can't stop worrying about an upcoming test or assignment. The anxiety can also contribute to procrastination, because thinking about the work brings up unpleasant feelings that dissipate when the teen does something else, like checking Facebook. Of course, actually starting the assignment can decrease the anxiety as focus shifts and a sense of self-efficacy builds, but Facebook is often easier and more fun.

Sleep: Teens often go to bed late and have to wake up early. However, in recent years this has been greatly exacerbated with the proliferation of bright back-lit devices that teens have access to their bedrooms, combined with a dearth of parental monitoring/control. It's amazing to me how much coffee or energy drinks teens are consuming these days to avoid falling asleep at school.

Substance use: Yes, drinking and smoking weed (and/or hanging out with those who often do) can make it harder to focus on doing schoolwork.

Family conflict: Family dynamics are complex, but needless to say, many different types of stress within the family can contribute to a teen not doing well in school. For example, I saw one teenager whose drop in grades seemed to have no rational explanation, until I found out that his parents were alcoholics who had recently both taken up drinking again, leading to a big decrease in the time the family spent together doing other things. Even though this patient insisted that his parents' drinking did not bother him, it seems that when he started to fail in school, his parents ended up engaging with him more, even though they continued to drink. In another case, I had a patient whose parents divorced and her mother almost immediately found a boyfriend, who moved in a few months later. The patient denied feeling upset by this, but her grades tanked when she "just couldn't motivate myself to do homework" after school. This caused considerable distress for her mother, who valued academic success.

Habitual avoidance: This is certainly not a DSM diagnosis, but I do believe avoiding work in favor of fun can become a habit that is difficult to change. I'm not calling it laziness, which implies a flawed character. Rather, I think this has a lot to do with the interaction of culture, parenting style, and a child's temperament. Most of us would rather not do hard or tedious work if we didn't have to. Society tells adolescents that they should have fun and enjoy themselves while they're still young, while parents often tell their children to work hard for some benefit that will accrue years down the road. Unfortunately, some parents want to avoid conflict themselves, so they may not impose the necessary consequences or structure to back their words. Furthermore, adolescents can avoid the tedium of work by multitasking like mad: simultaneously listening to music, texting friends, checking social media, all while trying to study with the TV on in the background. Thus, many teens never develop good study skills (to say nothing of the capacity for deep, focused thought); it's amazing to me that more aren't failing school.

More often than not, the reason for an adolescent's falling grades is a combination of the above factors. I used to be a big believer in laziness, in the sense that I was quite sure it existed as a trait. However, after being asked to evaluate for laziness many times and finding more plausible explanations, now I'm not so sure.

Preventing Transition to Schizophrenia: What Doesn't Work, What Might

One of the reasons I decided to become a child psychiatrist was seeing the devastating effects of schizophrenia in adult patients during medical school, and knowing even then how inadequate the treatments were. I thought that by working with children and adolescents, that someday I might be a part of preventing someone from developing schizophrenia in the first place.

However, during residency, I became more jaded about early intervention in treating "prodromal" symptoms, in large part because the institution where I was training emphasized biological treatments above all else. One professor, who had close ties to multiple pharmaceutical companies, exhorted us to use antipsychotic medications not only for teenagers with odd thinking or behaviors, but also for those with paranoid or schizotypal personalities, despite there not being a damn bit of evidence this would help anything.

When the evidence did start coming in for the use of antipsychotics to prevent transition to schizophrenia, it was not encouraging. From the most recent meta-analysis I could find:

One study compared CBT and risperidone with CBT and placebo. Very low quality evidence within the first six months of treatment suggested no difference in transition to psychosis (risk ratio 1.02 (95% confidence interval 0.15 to 6.94)), which remained at 12 months (1.02 (0.39 to 2.67)). Differences in symptoms of psychosis (total, positive, or negative), depression, and quality of life were not significant. Dropout was similar between groups (1.09 (0.62 to 1.92)), although the evidence was also rated as very low quality.

There was very low quality evidence for the benefits and harms associated with olanzapine, from one study comparing olanzapine with placebo. We saw no difference in transition to psychosis after 12 months (risk ratio 0.44 (95% confidence interval 0.17 to 1.08)). Dropout was similar between groups at 12 months (1.59 (0.88 to 2.88)). For participants taking olanzapine, there was a large effect on weight during the first eight weeks (standardised mean difference 0.81 (0.28 to 1.34)), which remained large at 12 months (1.18 (0.62 to 1.73)). Effects on symptoms of psychosis (total, positive, or negative), depression, and mania were not significant. Data at 24 months were not analysed because fewer than 50% of participants remained.

Thus, I was somewhat skeptical when I saw this on the Twitter yesterday:

Early detection and intervention program prevents conversion to psychosis bit.ly/12xVJmI #APAAM13
— Medscape Psychiatry (@MedscapePsych) May 23, 2013

Looking at the article (link is to Google's cached version in case you don't have a Medscape login), it described a comprehensive treatment program, implemented community-wide in Portland, Maine, that has "significantly reduced hospitalization rates for initial psychosis by one third." More encouraging was the fact that this program has successfully been replicated at 5 other locations across the country, and according to lead investigator Dr. William McFarlane, rates of conversion to psychosis were "almost identical" between the prodromal group and a control group. What the program actually entails is interesting, and a very different approach to just using an antipsychotic or doing CBT:

As part of the program, at-risk youth, identified with the Structured Interview for the Prodromal Syndromes (SIPS), are offered a comprehensive package of treatment consisting of family education, assertive community treatment, supported education/employment, and low-dose psychotropic medication.

Looking elsewhere, I found more details about the 8 components of the family-aided community treatment (FACT) program in this dissertation. I've truncated each of the bullet points to save space:

• Community education and outreach: Early Assessment and Support Team/Alliance representatives go into the community to increase awareness about psychosis and to encourage early referrals. These education efforts are offered to a wide range of audiences...
• Targeted outreach to those in need: Psychosis is often frightening, and even the thought of being diagnosed with such a serious mental health condition may cause a young person to refuse to seek help. Team members meet the youth and family at their level of readiness to form a relationship built on trust. Services are strengths focused and oriented toward issues young people find relevant...
• Consistent services in the transition from adolescence to adulthood: Services are provided to teens and young adults by the same team...there is no discontinuity of care or caregiver teams just because a person ages out of childhood services.
• Supported employment/education specialist: This specialist works closely with each program participant...the majority of young people involved with [this program] do not pursue federal disability funding.
• Psychopharmacology treatment options: When it comes to medications, [the program] emphasizes education and choice. Medications are used cautiously, and close attention is paid to the side effects experienced by the individual.
• Occupational therapists: These specialists are available to help assess and provide treatment for underlying sensory, cognitive, and functional issues.
• Family inclusion: Families are viewed as essential partners in the decision making process. Most families participate in evidence-based multifamily psychoeducation treatment focused on increasing knowledge, reducing conflict, and problem solving.
• Commitment from systems leaders: State and regional leaders work together to develop and realign funding streams, regulations, and workplace policies to best serve individuals in a flexible way, without barriers such as insurance restrictions and gaps between child and adult systems.

Since I was not at the APA, I have no idea how many of the participants in this program were on antipsychotic medications, or whether they could estimate how much the medications actually contributed to the overall outcome. However, I would be willing to bet that the program would work quite well even without the medication component.

Notably, this research is supported not by the NIMH, but by the Robert Wood Johnson Foundation, "the nation's largest philanthropy devoted solely to the public's health." This public health approach is what we need more of in mental health: It takes a village, not just a pill.

Movie Review: The Perks of Being a Wallflower

I recently watched The Perks of Being a Wallflower, and it is one of the best depictions I have ever seen of an adolescent's struggles with trauma and grief. The protagonist is Charlie, played convincingly by Logan Lerman as a quiet teen entering his freshman year. He is utterly friendless at the start of the movie, and the details of his past experiences are only gradually revealed, bit by bit.

Here's what I loved about the movie, and why I think all psychiatrists should see it: Charlie is never treated like a psychiatric label. In fact, no terms like "depression" are used at all in the movie. He, like most of the patients I see, has been through some pretty terrible things. He suffers from a mix of sadness, grief, guilt, anger, and dissociative tendencies,  yet he probably does not fit neatly into one specific DSM category. Most importantly, his life is not defined by those symptoms. He likes music and writing, he has hopelessly fallen for a girl named Sam (Emma Watson), and he is a loving brother to two older siblings. The best scenes involve him becoming friends with the school's band of misfits, led by Sam and Patrick (Ezra Miller, in a wonderful performance). We clearly see how these relationships give Charlie joy and a sense of identity.

I also thought the depiction of Charlie's psychiatric hospitalization was very well done. The movie takes place in the early 90's, shortly before the DSM-IV era of psychiatry. Back then, the average length of stay on child and adolescent psychiatry units was on the order of weeks to months, rather than the under one week stays that are so common today. Though the movie does not show how much time elapsed in the hospital, it does give the sense that Charlie was moving into his room for a while. The psychiatrist Dr. Burton (Joan Cusack) appears only briefly, but even so, her concern for Charlie comes through. She is not running down a symptom checklist, spewing psychiatric diagnoses, or pushing pills; rather, she tries to engage Charlie as a person first and foremost, hoping to gain his trust so he would feel safe sharing his most hidden secrets.

The story was certainly clichéd in places: There's the obligatory scene of getting high for the first time, and Charlie's English teacher (Paul Rudd) gives Charlie his treasured copy of The Catcher in the Rye. Are there no other books about teenage alienation? Also, Sam seems remarkably well adjusted given her chaotic backstory. Never once did the movie convince me that her character was someone who would have trouble getting into Penn State.

Still, the brilliance of the actors and the compelling story makes this one of the great coming-of-age tales.