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In adolescents, as in adults, most depressive persons are not suicidal, and many suicidal persons are not depressed. However, accurate diagnosis and treatment of depression in adolescent patients is essential to suicide prevention. Unfortunately, depression and suicidality remain widely undiagnosed and untreated in the adolescent population.

Psychotic behavior in adolescent patients is uncommon but occasionally encountered in adolescent medicine practice. Although a physician may not be able to distinguish the precise diagnosis initially, immediate symptomatic management of acute psychotic symptoms is indicated to allay the patient's anxiety and tQ begin treatment. In chronic and more subtle conditions, their recognition is the essential first step. In all cases, referral to a mental health specialist is indicated for comprehensive evaluation and appropriate management. Continuing support of patient and family by the primary care physician avoids a perception of abandonment and can help ensure effective long-term care.

Although conversion disorder rarely is diagnosed formally in ordinary pediatric practice, busy pediatricians often do encounter the phenomenon of conversion. Conversion is the experiencing of unacceptable emotional conflicts as symptoms, usually but not always physical, rather than as mental events. Conversion is commonplace, affecting almost all body systems. It must be recognized and managed appropriately early in its course, lest inappropriate evaluations and treatments occur; in addition to their other costs, such unnecessary procedures may introduce the child inadvertently to such symptomatization as a life-long pattern of behavior. More than a century ago, Briquet recognized that at least 50% of adult "professional patients" begin their symptomatic careers before puberty; thus, inappropriate care of the young patient who has conversion symptoms may have serious, long-lasting consequences. Problems in Diagnosing Conversion The traditional diagnostic elements of conversion often are difficult to demonstrate in pediatric practice. Almost all are either not specific to conversion or hard to confirm in young patients for reasons of developmental immaturity. These "standard" elements include the following: • Stress or conflict preceding symptoms (true of many illnesses) • Unconscious symptom production outside the patient's awareness (thus often inaccessible to the pediatrician) • A model for the symptom (either unverifiable or prone to observer bias) • Primary gain or relief of underlying conflict (again, difficult to confirm)

Depression and suicidal behavior in the pediatric population represent two associated areas of concern often avoided by practitioners. This will continue to be so until depression and suicidal behavior are appropriately seen as treatable medical conditions. At that time, they will gain the routine attention of practitioners, who will discover that these conditions can be treated successfully if acknowledged and diagnosed.

As stated initially, a significant proportion of health problems of youths have genetic predispositions and potentially identifiable antecedents of disease during childhood and adolescence. Until there is advancement in delineating the multiple dimensions and relationships of a psychobiologic developmental framework, interventions may fall short of their potential to either prevent or ameliorate these problems. To date, research has been limited by narrow definitions, lack of uniformity among measures, small samples, and homogenous populations. As a forward step, longitudinal investigations of subpopulations of youths may provide an opportunity for definitive study of the basic processes of puberty and be fruitful in evaluating the deleterious effects that stresses of contemporary life place on children and adolescents. In addition, efforts to communicate existing knowledge across disciplines and to approach psychobiologic research from an interdisciplinary perspective will enhance an understanding of the interplay of social, biologic, and environmental factors that are essential in the maturational process. This multidimensional approach with newer, broader perspectives is critical to advancing the development of a psychobiologic framework that will shed further light on the mechanisms of maturation and the interferences of this pubertal process that is the hallmark of adolescence.

This manuscript describes the development and utility of a questionnaire assessing interpersonal attitudes relevant to pediatric practice. Entitled the Behavioral Pediatrics Questionnaire, the scale measures a wide array of beliefs ranging from attitudes toward physical disabilities to parenting and empathy. Scale development, reliability and normative data from two samples of pediatric residents are presented. Finally, the spectrum ofpotential usage of this questionnaire is discussed.

The management of adolescent suicidal behavior in the practices of 48 pediatricians from Rochester and Syracuse, New York, was reviewed in the context of a rising local and national incidence. Alternative resources were found to be used much more heavily by suicidal adolescents in the two communities. Few pediatricians ask routinely about suicidal thoughts. The fatality rate is low enough to reinforce present practice, but suicidal symptoms are far more frequent than fatalities. It is hypothesized that avoidance of the issue by the pediatrician results in underutilization of this potentially valuable resource. Asking about the problem may result in a higher contact rate and, it is proposed, a better outcome. Depressive symptoms and appropriate responses to suicidal thinking are discussed.

Adolescent psychiatry as a body of knowledge has shown encouraging growth in recent years, as research findings from general psychiatry have been added to new data on adolescent psychological and physical development. The author reviews recent findings on selected topics in adolescent psychopathology, including adaptive disorders, obsessive-compulsive disorders, phobias, attention deficit disorders, depression, manic-depressive illness, suicidal impulses, schizophrenia, anorexia nervosa, and borderline states. He also outlines findings on normal adolescent development and discusses the problems of diagnosing children and adolescents with psychological problems. Studies in anxiety, attention deficit, and conduct disorders, he says, are yielding important new findings by combining biological and psychological insights.

Adolescents who have grand mal epilepsy and their parents were interviewed, and the adolescents were evaluated neurologically. Better seizure control and less neurologic disability were unexpectedly associated with less open communication between the adolescents and their families and friends, and with a poorer self-image and poorer expectations for the future. These findings were unrelated to IQ or school performance. This outcome is consistent with other studies of invisible defects and stigmatization, and suggests that youngsters who have relatively mild defects involving social disability may be more troubled than those with more apparent defects, for which denial may be operative. An incidental finding in the study was that a question more predictive of overall family, social, and academic function than the neurologic findings was simply whether or not the youngster was attending the appropriate grade in school for his or her age.

Four cases are presented of school refusal behavior in university students. Similarities to younger patients are noted. Differences include the greater separation and challenge of the setting, absence of supportive authority figures, and enhanced difficulties in therapy for parents. The college psychiatrist must attempt early detection, an initially directive pyschotherapy, and energetic definition of the problem to assure proper psychotherapy whatever the outcome.

In the six years since the authors' Child Psychiatry and the Law , much has occurred in the child forensic field. The value of their present text, however, is less in its currency—although many of its references date from the last year or two—and more in its broad overview of the topic. Indeed, my only quibble is that the book's title implies much less than it delivers: a seasoned summary of forensic child psychiatry as it currently exists in all its complexities. This is an era in which malpractice suits are finally confronting child psychiatrists, diagnostic techniques are increasingly complex, new psychopharmacologic interventions entail new complications, and increasing surveillance and demands are coupled with increasing insistence on short hospital stays. Schetky and Benedek have assembled an all-star cast, the members of which write well and whose case reports enliven their content. An interesting preliminary explication of the ethical issues underlying the

Adolescent depression and suicide are currently the focus of lively investigation. While diagnostic terminology and prevalence of depression remain unresolved, promising clarification is likely from the new assessment techniques readily available. These range from vigorous history taking and the use of questionnaires to biological tests. Associated depressive spectrum conditions are being defined. Like depression itself, they often respond to the new biological and psychological treatment methods of demonstrated effectiveness. Compounds are under development which may lessen side effects, and plasma antidepressant measurements are of proven value. Even with respect to adolescent suicidal behavior, where similar biological and psychological approaches have yielded less impressive results to date, energetic diagnosis and intervention can be lifesaving.

Bruno Bettelheim has spent his lifetime working on behalf of children and their secure upbringing. Having survived two concentration camps, he came to the United States and created a new therapeutic environment to help psychotic children survive their illnesses. He has frequently written about that experience; now he turns to a seemingly different subject, the fairy tale. He perceives an underlying continuity in his work, maintaining that the familiar fairy tale is, in fact, an art form, delineating the ultimate goal of child and man alike, a life with meaning. He indicates why other children's stories fail to attain this goal, and at the same time, why fairy tales themselves have fallen into disuse. In discussing their virtues, the author employs his extensive clinical experience, his engaging style, and, of course, the fairy tales themselves. Psychoanalytic assumptions constitute the organizing principle of his book, its consistency, and its occasional shortcomings

"One more accident and that ought to do it," Brian, aged 9 years, remarks in one of many arresting case examples in an impressive book. A monograph that discusses virtually every aspect of self-destruction in children,The Suicidal Childis balanced in its emphasis: psychoanalytic, cognitive, and psychopharmacological aspects of the problem and its treatment each receive equal time. Devoted to suicide in childhood, the work avoids the common error of labeling all patients younger than 19 years as "children," so this is not a book about the more common problem of adolescent suicide. Nevertheless, its lucid explication of the problem in childhood is of value to anyone interested in suicide prevention at any age. As Brian's comment suggests, children can contemplate self-destruction even at an early age. Whether or not we believe younger patients understand death's permanence, we can surely agree with Pfeffer's assertion that a child's death sought