Parenting an Adolescent

Adolescence is a time of transition. Most parents find themselves bewildered by the changes in their previously affectionate and obedient children. Mood changes, withdrawal, monosyllabic answers and arguments find most parents asking, “What have we done wrong?”

Adolescence is marked by profound changes brought about by the hormonal surge at puberty. The physical changes are accompanied by emotional, behavioural and intellectual changes to which the child has to adapt rapidly.

“As their bodies, brains and worlds rearrange themselves, you (parents) will need to do your own reshuffling.”

Changing role of parenting adolescents

The need for autonomy, independence and a search for one’s own unique identity is an essential part of adolescence. Often, this is achieved by questioning and testing existing rules and norms. Make space for this quest. Handle an occasional error of judgement with explanations rather than with accusations and confrontation.

The essentials of parenting at this age are

1. Trust
2. Empathy
3. Respect
4. Support

Trust is important in all relationships. Trust your teen to do what is right. As far as possible, avoid correcting them and pointing out mistakes. Allow them to learn on their own.

Empathise. Your adolescent child is often plagued by self-doubts and insecurities. Remember you were an adolescent once, and do not trivialise their problems.

Respect their need to be away from you, alone or with friends. Listen to their opinions and try not to be dismissive of their views and values.

Support. Assure them of your love and support without being intrusive; this will encourage them to come to you in need.

Parenting styles

An authoritative parenting style provides the adolescent with opportunities to become self-reliant within a set of rules, limits and guidelines appropriate for his/her developmental age. The personality and temperament of the child may also influence your parenting style (a co-operative and responsible teen requiring much less supervision). The environment (e.g an unsafe neighbourhood) can also dictate your parenting style. Privileges and limits may be set with the active participation of the child. It helps to state your expectations without ambiguity (what is acceptable behaviour and what is not), set clear limits and enforce consequences (loss of privileges) when limits are not adhered to.

When parents differ in their parenting styles.

One parent (often a father who is away a great deal) may tend to be permissive in his parenting. Adolescents (and children!) are quick to take advantage of differences between parents. It is important for the parents to arrive at a consensus privately and present a united front when dealing with limits and consequences.

Autonomy vs Monitoring

There are no hard and fast rules. Monitoring does not mean constant surveillance. Safety concerns entail knowing about the whereabouts of the adolescent outside school hours, friends they are with and contact information. A schedule to return home should be worked out. Similar limits should be set for time spent on social media. Be honest in communicating your concerns and avoid doing things behind their backs. It only leads to lack of trust and a tendency to conceal things from you.

Do not seek to control. Often, clashes between parents and adolescent children are about who has control. Adolescents struggle for control over what they feel is their own life, while parents struggle to hold onto the control they had earlier.

Peers

Sometimes, you may be uncomfortable with the company your adolescent keeps. Do not rush into judgements and accusations. Observe for yourself if there is a genuine cause for concern. Teach your adolescents to say ‘no’ to what they feel uncomfortable about. Explain the harmful effects of risky behaviour (alcohol, drugs, sexual activity) at a young age.

When to seek help

Repetitive problem behaviours and high-risk behaviours require professional help and guidance. Aggressive and violent behaviour, progressive academic deterioration, school refusal or truancy, lying or cheating demand immediate attention. Increasing moodiness, lack of communication, inattention to personal hygiene are other warning signs of psychological distress.

Making the Cut—Self-cutting in Adolescents

Self-cutting in adolescents is the strongest predictor for subsequent suicide attempts. It is a clear signal of severe psychological pain being released physically by the act of self-cutting. However, relief is only temporary, and if ignored self-cutting can progress to suicide.

Self-cutting and Suicide

Repeated self-cutting in adolescents is the strongest predictor of attempted suicide. 70% of those who self-cut will attempt suicide at least once. The number of suicide attempts increases with the number of years engaged in self-cutting (Nock 2006). The risk of attempted suicide is higher than with any other psychiatric disorder including depression and borderline personality disorder. Self-cutting may be a uniquely important risk factor for suicide because its presence is associated with both increased desire and capability for suicide (Klonsky 2013).

Ms LM, 15 years old, was brought by her parents for counselling after a suicide attempt. She subsequently revealed repeated self-cutting over the upper, inner thighs after sexual abuse two years previously.

Self-cutting and Psychological Pain

The majority of people who self-cut do so to relieve intense psychological pain. It occurs independently of a diagnosis of borderline personality disorder, or history of sexual abuse in childhood (Klonsky 2014). Self-cutting has a calming effect. (Klonsky 2006). This is much the same way as applying a balm, the superficial irritation suppresses the underlying deep pain. Individuals who self-cut continue to do so because it decreases feelings of anxiety (Haines 1995). Some people self-cut to punish themselves. A small minority self-cut for attention seeking or to escape from responsibilities.

Ms RX, 24 years old: 'When I cut myself  I feel calm, I don't feel the pain'.

Self-cutting Scars

The scars of self-cutting can trigger distressing memories of a time of psychological pain. Seeing self-cutting scars on friends or hearing of self-cutting incidents can induce the urge to self-cut.

Ms KJ, 19 years old, had a history of self-cutting since middle school and was now coping well in a professional course while staying in hostel. She accidently saw self-cutting scars on her room mate. Since then she is anxious and fighting urges to self-cut.

An increasing number of self-cutting scars is associated with presence of suicide ideation and a history of suicide attempts (Taylor 2016). Visible scars on exposed parts of the body can restrict career and social choices. Skin grafting may be required in some cases (Todd 2012)

Mr JS, 21 years old, underwent training and qualified for an initial pilots license. During medical evaluation for a commercial pilots license self-cutting scars were noted on his chest. He was medically disqualified as a hazard to flight safety.

Why do some people self-cut and not others?

Biology may have an answer. A particular gene for serotonin regulation (5-HTTLPR) may be defective. Youths who face severe chronic interpersonal stress and have the defectives gene self-cut more than those with the fully functioning gene (Hankin 2014). Those who self-cut have reduced autonomic and stress responses to anticipation of pain making them less likely to avoid it. They also have increased responses after pain which reduces feelings of numbness and distress, and increases body awareness. This combination serves to reinforce self-cutting behaviour (Koenig 2017).

Self-cutting is a unique physical marker of severe psychiatric problems. Approach a mental-health professional for treatment.

References

1. Rebecca C. Brown and Paul L. Plener. Non-suicidal Self-Injury in Adolescence. Curr Psychiatry Rep. 2017; 19(3): 20. Published online 2017 Mar 17. doi: 10.1007/s11920-017-0767-9. Accessed 2018-09-14.
2. Haines J, Williams CL, Brain KL, Wilson GV. The psychophysiology of self-mutilation. J Abnorm Psychol. 1995 Aug;104(3):471-89.
3. Benjamin L. Hankin, Andrea L. Barrocas, Jami F. Young, Brett Haberstick, and Andrew Smolen. 5-HTTLPR x interpersonal stress interaction and nonsuicidal self-injury in general community sample of youth. Psychiatry Res. 2015 Feb 28; 225(3): 609–612. Published online 2014 Dec 3. doi: 10.1016/j.psychres.2014.11.037. Accessed 2018-09-13
4. Klonsky ED. The functions of deliberate self-injury: a review of the evidence. Clin Psychol Rev. 2007 Mar;27(2):226-39. Epub 2006 Oct 2. Accessed 2018-09-12.
   
5. Klonsky ED, May AM, Glenn CR. The relationship between nonsuicidal self-injury and attempted suicide: converging evidence from four samples. J Abnorm Psychol. 2013 Feb;122(1):231-237. doi: 10.1037/a0030278. Epub 2012 Oct 15. Accessed 2018-09-11
6. E David Klonsky, Sarah E Victor, and Boaz Y Saffer. Nonsuicidal Self-Injury: What We Know, and What We Need to Know. Can J Psychiatry. 2014 Nov; 59(11): 565–568. doi: 10.1177/070674371405901101. Accessed 2018-09-13
7. Julian Koenig, Lena Rinnewitz, Marco Warth,Thomas K. Hillecke, Romuald Brunner, Franz Resch, and Michael Kaess. Psychobiological response to pain in female adolescents with nonsuicidal self-injury. J Psychiatry Neurosci. 2017 May; 42(3): 189–199. Published online 2016 Nov 29. doi: 10.1503/jpn.160074. Accessed 2018-09-13
8. Nock MK, Joiner TE, Gordon KH, et al. Non-suicidal self-injury among adolescents: diagnostic correlates and relation to suicide attempts.  Psychiatry Res. 2006;144(1):65–72. Accessed 2018-09-08
9. Taylor A. Burke, Jessica L. Hamilton, Jonah N. Cohen, Jonathan P. Stange, and Lauren B. Alloy. Identifying a Physical Indicator of Suicide Risk: Non-Suicidal Self-Injury Scars Predict Suicidal Ideation and Suicide Attempts. Compr Psychiatry. 2016 Feb; 65: 79–87. Accessed 2018-09-11
10. Jodi Todd, Sara Ud-Din, and Ardeshir Bayat. Extensive Self-Harm Scarring: Successful Treatment With Simultaneous Use of a Single Layer Skin Substitute and Split-Thickness Skin Graft. Eplasty. 2012; 12: e23. Accessed 2018-09-11

Treat schizophrenia even if your teenager refuses

Treat schizophrenia as you would any other serious medical illness in your teenager

"My 18yr son is aggressive, hearing voices, and not sleeping."

"Since the last two months he is not attending college. He talks to himself in his room and is not going out with his friends."

"He feels he is being tracked through the TV and yesterday assaulted his mother when she put it on."

"We tried taking him to our doctor but he refuses saying there is nothing wrong with him."

This is a common introduction to the more severely ill teenagers presenting at Pathfinder Clinic.

Why teenagers with schizophrenia refuse to see a psychiatrist 

Teenagers refuse to see a psychiatrist for illness related and personal reasons

Illness related factors

Schizophrenia is a brain disease. Your teenager has difficulties recognising his own symptoms. In schizophrenia there are changes in brain structure, chemistry and functioning. The individual is unable to recognise the problems in thinking, and perception. They hear voices threatening harm to themselves and their families. The  same voices command them not to see the doctor. Reality is distorted and they are unable to correct it through feedback from others. Your teenager perceives this distorted internal image of the world as the real one. They attribute their problems to the external environment. Technically this is termed as a lack of insight. The disease process prevents them from seeing these distortions as an illness. Because of the illness they refuse to see the doctor or take medications.

Personal reasons

Many adolescents refuse or drop out of treatment due to stigma of mental illness. They have high levels of self-stigma. They believe that schizophrenia is a result of a laziness, weakness or incompetence. This belief is reinforced by parents, society and friends who give advice like

"You really need to get your act together"

or

"You better snap out of it or people will think you’re crazy."

So in their mind your adolescent rationalises the problems as being outside themselves

 – "You won’t let me do what I want and now you are trying to label me as crazy, you need therapy, you go to the doctor."

Taking medication is seen as an acknowledgement of their own failure. To the teenager denial of illness and rejection of medical care appears more acceptable.

Parents

Parents of an adolescent with schizophrenia are working through their own public stigma. They may see schizophrenia as occurring due to faulty parenting and lack of control. They struggle against the stereotype of their son or daughter as incompetent and requiring supervision. They mistakenly fear they will need to protect the teenager from being labelled and shunned socially. In their mind going to the doctor will accelerate the stigmatising process. So the symptoms are ignored or controlled to the greatest extent possible. This may include keeping the teenager out of school or college for months until the exams are due. When the illness makes life unbearable at home they seek medical help. This is often in an atmosphere of shame and a sense of failure. Many families are unable to overcome these prejudices. They delay treatment for decades until they realise there may be no one to care for their son or daughter when they are gone.

The advisers and 'well wishers' of teenagers and their families are a third set of influencers whose lack of specific knowledge can reinforce self-stigma. Statements like

"Send him to us for a few weeks and he’ll be OK"

and

"Avoid ‘psychiatric’ medications because they are addictive"

or

"Medicines will cause permanent damage"

add further obstacles to the path to standard and adequate treatment.

When the adolescent is functioning well on the medication these misinformed 'well wishers' are the ones who advise

"What do you need the medicine for? I can see nothing wrong with you"

and set the stage for relapse and refusal to meet with the doctor when the illness relapses

 – "Chacha said there is nothing wrong with me, why are you trying to label me?"

What to do?

Refusing help for schizophrenia is not an option.

• We have already seen what can be done to get a reluctant patient to see the psychiatrist. 
• However, for schizophrenia, more urgent measures may be required.  Involuntary admission to a mental health facility for initiation of treatment may be needed. This is especially so when the adolescent is violent, suicidal, using addictive substances, or repeatedly missing from home. Involuntary admission helps in the same way that it helps get your adolescent admitted to hospital if they had dengue fever even if they did not want it. There are provisions in the Mental Health Act to ensure this is done in safety with respect for your adolescent’s rights. After they receive treatment and brain function returns to normal they will thank you. For they will be relieved from the terrors of reality distortions and desperation of suicide thoughts. 
• Once treatment is initiated ensure they take medications every day as prescribed. Don’t take on any other responsibility regarding the medication. Leave that as a dialogue between your teenager and their psychiatrist. Just make sure it continues to happen.

Why teenagers with schizophrenia must get treatment even if  they don't want it

Brain cell death

Schizophrenia is associated with death of brain cells and shrinking of brain volume. The longer the duration of untreated symptoms the greater the toxic “dose” of delusions and hallucinations delivered to the developing adolescent brain. Delusions and hallucinations are merely the tip of the iceberg – underlying brain changes have already set in. When treatments are delayed for more than a week the illness becomes even more severe and impairing. The person is less likely to recover, and is at greater risk for addiction to cannabis and other substances. These negative changes related to delay persist even after a year when treatment is finally started.

Academic impact

Schizophrenia symptoms make it difficult for the teenager to attend school or college. There is difficulty focusing. In the earliest stages there is an accelerated deterioration in academic performance. This usually takes place in late adolescence. Research suggests this may be a marker for schizophrenia onset. Deteriorating academic performance is seen even before social or other symptoms to appear. Unfortunately this is the very stage of life at which academic performance is critical and shapes career choices for adult employment. Many formerly brilliant students are anguished when they are suddenly struggling to even pass their exams. In fact studies have shown schizophrenia is more likely to affect those who excel at academics, making it all the more devastating. Missing or failing in board exams has an adverse impact that timely treatment can obviate.

References

1. Compton MT, Gordon TL, Weiss PS, Walker EF. The "doses" of initial, untreated hallucinations and delusions: a proof-of-concept study of enhanced predictors of first-episode symptomatology and functioning relative to duration of untreated psychosis. J Clin Psychiatry. 2011 Nov;72(11):1487-93. doi: 10.4088/JCP.09m05841yel. Epub 2011 Jan 11.
2. Fung KM, Tsang HW, Corrigan PW. Self-stigma of people with schizophrenia as predictor of their adherence to psychosocial treatment. Psychiatr Rehabil J. 2008 Fall;32(2):95-104. doi: 10.2975/32.2.2008.95.104.
3. Guo X, Li J, Wei Q, Fan X, Kennedy DN, Shen Y, Chen H, Zhao J. Duration of untreated psychosis is associated with temporal and occipitotemporal gray matter volume decrease in treatment naïve schizophrenia. PLoS One. 2013 Dec 31;8(12):e83679. doi: 10.1371/journal.pone.0083679. eCollection 2013.
4. Harrigan SM, McGorry PD, Krstev H. Does treatment delay in first-episode psychosis really matter? Psychol Med. 2003 Jan;33(1):97-110.
5. Karlsson JL. Psychosis and academic performance. Br J Psychiatry. 2004 Apr;184:327-9.
6. Strauss GP1, Allen DN, Miski P, Buchanan RW, Kirkpatrick B, Carpenter WT Jr. Differential patterns of premorbid social and academic deterioration in deficit and nondeficit schizophrenia. Schizophr Res. 2012 Mar;135(1-3):134-8. doi: 10.1016/j.schres.2011.11.007. Epub 2011 Nov 29.
7. Penttilä M, Jääskeläinen E, Haapea M, Tanskanen P, Veijola J, Ridler K, Murray GK, Barnes A, Jones PB, Isohanni M, Koponen H, Miettunen J. Association between duration of untreated psychosis and brain morphology in schizophrenia within the Northern Finland 1966 Birth Cohort.Schizophr Res. 2010 Nov;123(2-3):145-52. doi: 10.1016/j.schres.2010.08.016. Epub 2010 Sep 15.

Want more references? View my collection, "Teenagers with schizophrenia need treatment even if they don't want it" from PubMed

Is your ADHD teenager ready for hostel?

ADHD teens with appropriate life skills can live independently

Does your teenager with ADHD have the life skills to survive in hostel? She did well in her 12th board exams and scored high in the CET. To attend the engineering college of her choice she has to move from home to a hostel in another city. Given her difficulty organising her daily schedule, would she be better off doing the same subjects at the local engineering college? The answer would depend on her personality and the life skills she has acquired.

ADHD teenager personality types

Teenagers with ADHD are of 3 character types: the optimistic, the terrified and the lost. They are placed into these categories depending on their productivity and anxiety (either too much or too little).

• The optimistic teen does not worry. He is excited about the independence that college life will bring, but may not realise that freedom comes with responsibilities (financial, social and personal). If he's still disorganised at home he will be more so in hostel where the distractions are multiple and there is no guiding hand.
• The terrified teen is intensely anxious. She needs reassurance and help in planning the future step by step. If she still waits for you to clear her way round a difficulty she will hesitate to seek help when she is in hostel.
• The lost teen displays a lack of energy and positive view towards life. He is easily depressed and defeated. He has to be repeatedly reminded and encouraged to do what needs to be done. If you still have to push him to get work done he's unlikely to function well from hostel.

Life skills for teenagers with ADHD

ADHD hinders development of the  coping and self-management component of life skills due to inattention and impulsivity. Adolescents with ADHD need to focus on three aspects of this component for transition to independent living away from home.

1. Motivation is first – there has to be the will to achieve. The ADHD teen needs clear goals and has to evaluate them objectively — are they achievable? Clear short-term, mid-term and long term goals are necessary – persistence is required. If a particular course is not available in the local colleges, can he take the initiative to locate an alumnus from school who is pursuing the same elsewhere? He must make a list of pros and cons  – then make a choice – and not procrastinate.
   
2. Time management is a big challenge for most students with ADHD. They should not take on too much initially. ADD adolescents should concentrate on their classes, keep track of assignments, and organize daily notes. They should use a planner to schedule daily activities. A large calendar on the wall for upcoming assignments, project submissions, and exam dates is a big help. The teenager with ADHD needs to get to know her limits, then push them a little at a time to see if more is achievable. She should set some daily routines – get up at the same time everyday, have healthy, regular meals (this is often neglected when staying away from home), and do the laundry.
   Attendance at classes is non-negotiable (all colleges insist on a minimum attendance). The teenager with ADHD must ensure she takes her medication on time and follow-up regularly for refills. When taking a break she should do something that has a limited time span. For example she could read a few pages of a book, watch TV for 15 minutes, or chat with a friend for 10 min.  She must make time for the additional administrative tasks college entails: paying her college fees, creating and sticking to a budget, making time to go to the ATM. These tasks should be entered in the weekly planner.
3. Self-understanding and awareness of strengths and challenges is the key to making intelligent choices. The ADHD adolescent should not hesitate to seek help, from teachers, friends and the counsellor specially if falling back in his schedule. Strategies for learning and study skills training with the counsellor are helpful.

The ADD teenager, like any other adolescent, is transitioning from dependence on the family to increasing adult independence. The life skills he acquires would dictate the ease of this transition. Teenagers with ADHD who have acquired the necessary life skills would be better able to cope with the transition from home to hostel without adversely affecting academic performance.

References

1. Economic and Social Commission for Asia and the Pacific. Life Skills Training Guide for Young People. United Nations. 2003 (Accessed 08-Nov-2014)
2. ADDitude. The Real Whirled: 8 Essential Life Skills for ADHD Teens. Accessed 25-Nov-14.

Conduct Disorder and Behaviour Problems in Children



 

Conduct disorder and behaviour problems in children make the news when a 5-year old or a grandmother is killed while extorting money. Aggression in children  is just one of the offenses associated with conduct disorders . The seemingly lesser offenses of stealing in thousands from the home, or smoking 'weed' with their friends, pale in contrast. At the lowest end of the spectrum are those children who repeatedly confront authority in school or at home. Dubbed as 'monster kids' these children are viewed indulgently as being mischievous, naughty, 'bad', or 'delinquent'. Very seldom are they seen as having a mental health problem - a conduct disorder.

What is Conduct Disorder?

Behaviour problems that are persistent, violate the rights of others, go against societal norms, and disrupt family life, indicate a conduct disorder and merit psychiatric assessment. Conduct disorder is amongst the commonest childhood disorders seen in our clinic. Every one of us knows or has heard of a child with conduct disorders . Conduct disorder is characterised by the following behaviour problems .

Aggression

This child (maybe a 2 year old preschool cherub) picks fights, bullies, or physically hurts younger siblings at home. He is frequently taken to the principal's office for fighting in school. When this child enters the park the other children get ready to leave. He has often used a weapon (stick, cricket bat, stone or brick) to deliberately assault a person or hurt an animal.

Destruction of property

These children are wilfully destructive. They are the ones who scratch the paint off your new car, slash the seats of parked 2 wheelers, deface the lift, cut up a mothers dress, and tear the library book. More seriously they set fire to clothes and in extreme cases to vehicles.

Lying and deceit

These are children who steal from parents, grandparents, and classmates. They forge their parent's signature on school reports, cheques, and credit cards.They lie,  cheat and pilfer from shops.

Violation of rules

They stay out until late at night against home rules and curfews. They 'bunk' school to hang out with other antisocial friends, and run away from home overnight.

What happens to children with conduct disorder behaviours ?

Most parents feel a child will outgrow behaviour problems and conduct disorders .  However studies show this is not so. If not addressed and treated, children with conduct disorders are suspended from school, and have brushes with the law. Half of these children also have ADHD (Attention Deficit Hyperactivity Disorder) which further impacts their schooling. Broken relationships and marriages, and substance abuse including alcohol and cannabis abuse are common. As adults children with behaviour problems develop antisocial personalities and lead a criminal lifestyle. In the extreme a child with conduct disorder will murder his grandmother or a hapless neighbour's toddler.

Cannabis, teenagers and schizophrenia

Cannabis or marijuana use by teenagers and adolescents is highly associated with the onset of psychosis and schizophrenia. Cannabis goes by many names including hash, pot, grass, weed, or ganja. This gateway drug is falsely thought to be innocuous and as having no lasting effects. Cannabis use by teenagers is often not recognised as a problem. Cannabis is cheap and easily accessible in most student populations. Pune is a major hub for the cannabis drug trade. This week a quarter tonnne of ganja was found dumped in a well. Cannabis use is rampant in Pune colleges and hostels, where students assiduosly guard and maintain their 'stash'. During the 57th National School Games the highest number of students testing positive for marijuana came from Maharashtra.

Regular cannabis use increases the risk for schizophrenia and psychosis by upto 4 times. There is increasing evidence that cannabis use can precipitate schizophrenia in vulnerable individuals. This is especially so with early onset use of cannabis. Cannabis also exacerbates symptoms of schizophrenia in those who have already developed the disorder. Psychotic disorders like schizophrenia involve disturbances in the dopamine neurotransmitter systems of the brain. Δ9-tetrahydrocannabinol (THC) - the key neurochemical in cannabis - interacts with dopamine to adversely affect its functioning by multiple mechanisms.

Teenagers are especially vulnnerable to the schizophrenia-inducing effects of cannabis. Cannabis like substances (anandamide) called endocannabinoids, produced by the body, play an important role in several processes of brain maturation. Regular marijuana use affects this process of brain maturation in teenagers. Schizophrenia is also a disorder of brain maturation. Disruption of the endocannabinoid system in the adolescent brain by exposure to cannabis interferes with brain maturation. This provides a mechanism to increase the risk for development of schizophrenia in adolescence.

How to cut down and stop cannabis use

1. Write down a list of reasons for wanting to stop - you will need to review this at times when you are feeling low or experiencing craving.
2. Tell someone you trust that you are quitting
3. Get rid of the paraphernelia for smoking cannabis - the stash, wrappers, lighters, matches. You may be surprised at the number of places where small amounts are hidden. Get rid of it all.
4. Take measures to prevent fresh procurements - avoid places and people associated with replenishments
5. Make a list of things to do to occupy the time freed-up from procuring and using cannabis.
6. Review your list of reasons and things to do when you feel low and when craving is intense.

References

1. Paola Casadioa, Cathy Fernandesb, Robin M. Murray, Marta Di Forti. Cannabis use in young people: The risk for schizophrenia.  Neuroscience & Biobehavioral Reviews. Volume 35, Issue 8, August 2011, Pages 1779–1787. doi:10.1016/j.neubiorev.2011.04.007
2. Degenhardt L, Hall W. Is cannabis use a contributory cause of psychosis? Can J Psychiatry. Aug 2006;51(9):556-65.
3. Deepak Cyril D’Souza,Richard Andrew Sewell,and Mohini Ranganathan. Cannabis and psychosis/schizophrenia: human studies. Eur Arch Psychiatry Clin Neurosci. 2009 October; 259(7): 413–431. Published online 2009 July 16. doi: 10.1007/s00406-009-0024-2

Diet and mental health

Mental health and diet quality are closely linked. The food choices you made as a teenager affect the development of conduct and emotional problems that continue into adulthood. Lifestyle diseases such as heart disease, diabetes and obesity are attributed to changes in diet and exercise habits. Recently there is increasing evidence that diet and exercise also have a major influence on mental health. Dieting peaks after the festival season. This post will help you avoid the 'isms' and fads and point you in the direction indicated by current research.

A good quality diet predicts better mental health

Evaluating the quality of the complete diet provides a better and more consistent picture of nutrition status than focusing on individual nutrients like magnesium or food groups like various fatty acids (omega, polyunsaturated). A traditional diet of vegetables, fruit, meat, fish, and whole grains is associated with lower risk for depression and for anxiety disorders as compared to a "western" diet of processed or fried foods, refined grains, sugary products, and beer (Jacka 2010).

Switching to a high quality diet improves mental health

Switching to a healthy diet improves mental health. Unhealthy diets are associated with lower scores on mental health tests. The best part is that improvements in diet quality are mirrored by improvements in mental health (Jacka 2011). Also the reverse, when diet quality deteriorates psychological functioning is adversely affected.

What constitutes a high quality diet?

The quality of diet is assessed using food frequency questionnaires. Points are allotted for each type and frequency of food consumed. For example one point is allotted for each of at least two fruit servings per day, at least four vegetable servings per day; using reduced fat or skimmed milk, using soy milk, consuming at least 500mL of milk per day; using high fibre, wholemeal, rye or multigrain breads; having at least four slices of bread per day; using polyunsaturated or monounsaturated spreads or no fat spread; having one or two eggs per week, using cottage cheese, using low fat cheese. Out of a maximum possible score of 74, the average is about 33.0 (+9.0).You can get some idea of your diet quality score from this chart (Collins 2008).

Preventive psychiatry

Improving diet quality improves mental health outcomes. Especially for adolescents this is an important preventive intervention. Three quarters of all long term psychiatric illness manifest during adolescence and early adulthood (Kessler 2005) . These illness are among the most disabling. They occur with a high enough frequency to contribute a major portion of life years lost due to disability. Mental health illnesses cause long-term problems at work and at home. They usually persist over the lifetime and require medication and support at various stages. Adopting a high quality diet is an important primary preventive intervention for improved mental health - easy to implement and proven to be effective.

References

1. Collins CE, Young AF, Hodge A (2008). Diet quality is associated with higher nutrient intake and self-rated health in mid-aged women. J Am Coll Nutr 27: 146–157.
2. Jacka FN, Pasco JA, Mykletun A, Williams LJ, Hodge AM, O'Reilly SL, Nicholson GC, Kotowicz MA, Berk M. Association of Western and traditional diets with depression and anxiety in women. Am J Psychiatry. 2010 Mar;167(3):305-11. Epub 2010 Jan 4.
3. Jacka FN, Kremer PJ, Berk M, de Silva-Sanigorski AM, Moodie M, Leslie ER, Pasco JA, Swinburn BA.A prospective study of diet quality and mental health in adolescents. PLoS One. 2011;6(9):e24805. Epub 2011 Sep 21.
4. Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, et al. (2005) Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 62: 593–602.

Parental supervision of children and adolescents

Parental supervision protects boisterous children from injury:
More time unsupervised corresponds to more injury 

“To my parents we were just two girls in the bedroom”. What exactly was going on? Without adequate supervision the parents of this teenager never found out; the memories returned to haunt her in adulthood. Studies comparing children with and without parental supervision show that lax parental supervision is associated with injury in toddlers and preschoolers; conduct problems in school going children; and road accidents, addictions, gambling and sexual risk taking in teenagers.

Parental supervision has three dimensions (Gitanjali 2004)

1. Attention - watching or listening 
2. Proximity - within or beyond reach 
3. Continuity - constant, intermittent, or not at all 

Two factors determine the degree to which a child would be left unsupervised (Morrongiello 2008)

1. Parent’s conscientiousness - the more conscientious the parent more the supervision
2. Child’s propensity for risky behaviour - the more impulsive and sensation seeking the child the more likely the child will be kept in direct view. 

Distinguishing adequate from neglectful supervision is not straight forward. The consequences of lower levels of supervision are not uniform for all children. The consequences depend to a great extent on child attributes. For children with high sensation seeking, even close supervision is not adequate to prevent injury. For children who are high in behavioural control, even not supervising does not elevate risk of injury.

Whether or not children comply with their parents’ requests to behave in safe ways is a complex interaction of parenting style, attachment style,  and child temperament. The level of supervision necessary to ensure a child’s safety should finally be based on the child’s characteristics. The only reliable maxim is that the time children could be safely left unsupervised generally increases with child age.

Parental supervision of an adolescent differs from supervising a younger child (DeVore 2005). Direct parental observation gradually gives way to indirect parental ‘‘monitoring’. This indirect supervision involves ongoing communication between parents and adolescents about the adolescents’

• Whereabouts
• Friends they are with
• Schedule to return home
• Contact information enabling parents to directly communicate with adolescents. 

Effective supervision entails active participation of the adolescent, and honest communication between adolescent and parents.

Parental monitoring buffers negative peer influence. Strong peer attachments and increasing independence from the family is a normal part of adolescent development. Unfortunately, youth whose peers engage in high-risk behaviour are at high risk for the development of similar behaviours. Not only are high levels of monitoring protective, low levels of parental monitoring have been associated with numerous risk behaviours.

More unsupervised time is associated with more sexual activity in youth (Cohen 2002). In one urban study more than half of sexually active youth had sex at home after school. For boys, sex and drug-related risks increase with amount of unsupervised time. Trust and communication did not predict decreases in problem behaviour as strongly as did monitoring. Parental monitoring may be particularly protective for high-risk young urban adolescents; those who spend a significant amount of non-school time unsupervised. 

References 

1. Cohen DA, Farley TA, Taylor SN, et al. When and where do youths have sex? The potential role of adult supervision. Pediatrics 2002; 110:e66 
2. DeVore ER, Ginsburg KR. The protective effects of good parenting on adolescents. Curr Opin Pediatr. 2005 Aug;17(4):460-5. 
3. Gitanjali S, Brenner R, Morrongiello BA, Haynie D, Rivera M, Cheng T. The role of supervision in child injury risk: Definition, conceptual, and measurement issues. Journal of Injury Control & Safety Promotion 2004;11(1):17-22. 
4. Morrongiello BA, Klemencic N, Corbett M. Interactions between child behavior patterns and parent supervision: Implications for children’s risk of unintentional injury. Child Development 2008;79(3):627-638.  

Neurotoxic effects of alcohol on the adolescent and young adult brain

(or why the 25 year age-bar on alcohol consumption could be reasonable)

Does alcohol have specific neurotoxic effects on the adolescent or young adult brain? This question is the only important one for deciding whether the 25 year age-bar on alcohol consumption in Maharashtra is justifiable. While the debate rages two students from the premier medical college of India drowned in an alcohol fuelled swimming pool misadventure, and in an unrelated incident on the same night five inebriated youths were arrested for disturbing the peace in a residential area. We have seen how to recognise problem alcohol drinking in teenagers, and how to refuse alcohol. This article probes the specific effects of alcohol on the maturing brain.

Infancy

Alcohol is a neurotoxin. It distorts the normal architecture of the developing brain. This distortion starts during pregnancy when imbibed maternal alcohol crosses the placenta into the foetus. In the foetus alcohol acts on the specially vulnerable immature insulating cells (oligodendroglia) of the brain. The child is born with Fetal Alcohol Syndrome, characterised by irreversible mental retardation, a small head, small stature and facial abnormalities. Because the exact amount of alcohol required and the most vulnerable periods of pregnancy have not been definitively established all pregnant women are advised to abstain from any use of alcohol.

Childhood

By the second year of life the number of connections between brain cells (synapses) are at a maximum. These synapses are gradually reduced to the adult number (synaptic pruning). This process is controlled by immature excitatory (glutamate) receptors in the synapses. These receptors differ from adult ones by allowing quicker and longer excitation. Immature glutamate receptors are vulnerable to the effects of alcohol. Their over-stimulation distorts synaptic pruning (Johnston 1995).

Adolescence

In adolescence there is a rapid growth of gray matter and the formation of new connections (proliferation) in the brain. Elimination of some synaptic connections (pruning) enables the adolescent or young adult brain to change in response to environmental demands. Stability of these connections is enhanced through insulation of neuronal fibres (myelination). Myelination increases the overall speed of information processing within the brain. These maturational processes are critical for cognitive development. They are all adversely affected by alcohol (Guerri 2010).
These adverse effects specifically impact the frontal lobes of the brain and are highly associated with level of intelligence. In addition the brain area essential for working memory (hippocampus) is preferentially damaged by alcohol (De Bellis 2000). Gender effects render female adolescents more vulnerable than males to these alcohol effects.
The reward system of the brain is responsible for motivation and learning. The immature reward system has an adolescent-specific vulnerability for alcohol and drug addiction. Early exposure to alcohol sensitises the brain regions involved in drug addiction and alters gene expression in the brain reward regions (nucleus accumbens).
The pattern of brain electrical activity changes during the transition from adolescence to adulthood. Alcohol also has a premature aging effect on brain electrical activity during wakefulness and sleep. Animal models have shown that even brief exposure to alcohol in adolescence can cause long lasting changes in brain electrical activity. These changes place the adolescent at a high risk for later substance abuse and addiction (Ehlers 2010).

Youth

Alcohol differentially impairs the young persons judgement and motor skills. The evidence for this is so robust that some administrations have placed a lower legal blood alcohol level limit on drivers less than 21 years old (Hingson 1994). This differential susceptibility to alcohol has been shown to persist up to 30 years of age when a specific impact is seen on frontal lobe functions related to driving skills (Domniques 2009).

Whether the authorities considered the neurotoxic effects of alcohol while imposing the 25 year age-ban on alcohol consumption is a moot point. However, educating adolescents and youth regarding these adverse alcohol effects should be the duty of every parent.

References

1. De Bellis MD, Clark DB, Beers SR, Soloff PH, Boring AM, Hall J, Kersh A, Keshavan MS. Hippocampal volume in adolescent-onset alcohol use disorders. Am J Psychiatry. 2000 May;157(5):737-44.
2. Domingues SC, Mendonça JB, Laranjeira R, Nakamura-Palacios EM. Drinking and driving: a decrease in executive frontal functions in young drivers with high blood alcohol concentration. Alcohol. 2009 Dec;43(8):657-64.
3. Ehlers CL, Criado JR. Adolescent ethanol exposure: does it produce long-lasting electrophysiological effects? Alcohol. 2010 Feb;44(1):27-37.
4. Guerri C, Pascual M. Mechanisms involved in the neurotoxic, cognitive, and neurobehavioral effects of alcohol consumption during adolescence. Alcohol. 2010 Feb;44(1):15-26.
5. R Hingson, T Heeren, and M Winter. Lower legal blood alcohol limits for young drivers. Public Health Rep. 1994 Nov-Dec; 109(6): 738–744.
6. Johnston MV. Neurotransmitters and vulnerability of the developing brain. Brain Dev. 1995 Sep-Oct;17(5):301-6.

Whitener Addiction - Death by Inhalant

Whitener (correction fluid) inhalation caused the death of a Pune student recently. Whitener is abused as an inhalant in India. Whitener exerts its effects through trichloroethane, a volatile solvent. Inhalants include other substances such as petrol and toluene. These substances are cheap, accessible and readily available to children and adolescents.

Epidemiology

Solvent abuse is prevalent among street children and working kids. Teenagers start using solvents to gain entry into a gang, and occasionally as experimentation. Its use in a college student is unusual. But this may be a developing pattern indicating spread of the habit into middle class homes. (Kumar S 2008). Most adolescents are one-time or short-term users. Those who abuse inhalants persistently usually have conduct disorders.

Methods of inhalant abuse

1. Sniffing - direct inhalation from a container or piece of clothing sprayed with the substance.
2. Huffing - holding a soaked cloth over the nose or mouth to increase the concentration of vapours.
3. Bagging - breathing from a paper or plastic bag containing the volatile substance to further increase the concentration (Henretig, 1996).

Mechanism of action

Young people abuse volatile solventsby deliberately inhaling available vapours 15–20 times over 10-15 minutes. This results in concentrations of up to 10000ppm as against the industrial standard of 50-100ppm (Bowen et al., 2006).

Inhaled organic solvents like toluene cross from the blood into the brain within minutes. In the brain cells solvents act on specific receptors (NMDA and GABA) to produce effects similar to those of alcohol. Toluene, a common solvent in thinner and paint, increases opiate receptors in the Nucleus Accumbens - a key brain area associated with the reward system and the experience of pleasure. Toluene enhances dopamine release in the Nucleus Accumbens.

Effects on the body

(Lubman 2008)

• At low concentration (500-4000ppm) transient euphoria and disinhibition make abusers prone to risk taking and accidents.
• At higher concentrations (6000-15000ppm) dizziness, sleepiness, slurred speech, blurred vision and headaches appear. Users appear confused, unbalanced, or begin responding to hallucinations.
• Higher doses result in seizures, coma and cardiopulmonary arrest .

Death by inhalant

• Sudden sniffing death is the most common cause. Even first-time experimental users are at risk of sudden sniffing death as a result of heart rhythm abnormalities especially if the user is startled or agitated. 
• Suffocation and burns from exploding solvents
• Accidental injury as a result of impulsive risk taking and impaired motor skills while intoxicated. 
• Suicide accounts for up to 40% of inhalant-related deaths
• First-time users are also likely to die, perhaps because they are inexperienced at this dangerous pastime.

Recognition

Inhalant abuse should be suspected in teenagers showing intermittent intoxication,and signs of recent inhalant abuse including paint or oil stains on clothing or skin, spots or sores around the mouth, red eyes, runny nose, chemical odor on the breath, and a dazed appearance (Anderson, 2003).

Mass screening in schools could be undertaken as part of the annual health check. The mental health component for middle and high schoolers should include the CRAFFT. The CRAFFT is a validated short screening instrument for substance abuse in teenagers.

Laboratory diagnosis is not reliable as these volatile substances

• Do not persist in the body beyond a few hours
• They are undetectable in urine samples because of their volatility
• Hippuric acid, a long lasting toluene metabolite is also produced by foods and  raises the question of false positives. Also, it is usually not available for testing in emergency

Outcome

For most adolescents inhalant use should be regarded as a passing phase or fad. A few persistent users have antisocial personality disorder and abuse other substances. Chronic users develop damage to all organ systems - heart, lungs, brain, kidneys, and liver. The good news (Cairney et al., 2005) -

Damage to the brain is reversible with abstinence

Treatment

There is no specific medication to treat intoxication or for abstinence.

If you suspect a child is intoxicated with an inhalant stay calm and do not alarm him or her. Startling or frightening the child precipitates hallucinations and can also lead to ‘sudden sniffing death’ due to the effect on heart rhythm. Initiate cardio-pulmonary resuscitation (CPR) until help arrives if there is no heart beat or breathing.

When the child or adolescent recovers the incident should be discussed non-confrontationally. Remember, even a single inhalation can kill the child. Also abuse of other substances is frequent with regular whitener abusers. After talking it over commit to seeking psychiatric help. Social, environmental and recreational opportunities need to be addressed.

References

1. Carrie E. Anderson, and Glenn A. Loomis. Recognition and Prevention of Inhalant Abuse. Am Fam Physician. 2003 Sep 1;68(5):869-874. (Also gives good links for information on inhalant abuse and prevention)
2. Bowen SE, Batis JC, Paez-Martinez N, Cruz SL. The last decade of solvent research in animal models of abuse: mechanistic and behavioral studies. Neurotoxicol Teratol. 2006;28:636–647.
3. Cairney S, Maruff P, Burns CB, Currie J, Currie BJ. Neurological and cognitive recovery following abstinence from petrol sniffing. Neuropsychopharmacology. 2005 May;30(5):1019-27.
4. Henretig F. Inhalant abuse in children and adolescents. Pediatr Ann. 1996 Jan;25(1):47-52.
5. Kumar S, Grover S, Kulhara P, Mattoo SK, Basu D, Biswas P, Shah R. Inhalant abuse: A clinic-based study. Indian J Psychiatry. 2008 Apr;50(2):117-20.
6. D I Lubman, M Yücel and A J Lawrence. Inhalant abuse among adolescents: neurobiological considerations. Br J Pharmacol. 2008 May; 154(2): 316–326. Published online 2008 March 10. doi: 10.1038/bjp.2008.76.

Academic stress in youth

Stressed youths relaxing

Academic stress is a significant aspect of youth. Youth is the developmental phase between puberty and working adulthood. It is a period of continuing student-hood. This is a distinctive feature of youth - it exists only for those who undergo post-secondary education. This is for the privileged few who do not join the workforce full-time after schooling.

Youth is a valuable time for serious experimentation. The young person is not fettered by long-term commitments. In contrast to adolescence, youth is a period of independence - the peer group is no longer a dominant influence. There is greater freedom to develop as an individual. The young person evolves a personal perspective on life and develops a sense of direction before tackling the duties of adulthood.

However this stage of life is by no means stress-free. By definition youth is associated with academics. Academic demands are perceived as significant stressors by youths (Rao 2000, Goff 2011). These demands include workload and time constraints (Jungbluth and colleagues 2011). On entering college the youth is suddenly exposed to an unsupervised life of parties, college events, projects, and an intense curriculum, all of which make demands on time.

Why do academic stressors acquire such significance in youth? Why do students who have done well in their 12th and got into good courses find it difficult to cope with the academics? Well, until high school the student has a limited syllabus. Students in good schools rely almost entirely on the notes dictated by their teachers. Also the exam system is designed so that most students can achieve high scores with minimal time spent on study. All this changes in college. When the youth enters college, he or she is confronted with the entire gamut of knowledge in a particular field. Without the skills to filter, assimilate and reproduce information in context the youth experiences stress.

There is also the problem of youths whose career path was chosen by their parents despite their protests or otherwise. These youth may find themselves completely out of their depth in a course for which they have little interest or aptitude.

Students cope with academic stressors using a combination of emotion-focused strategies like self-blame, or bunking, and problem-focused strategies like reading guide books, and cheating. Study skills training and the acquisition of good learning habits are essential life-skills for students. We have already shown that study skills are effective and can be successfully acquired.

Study skills training should be a part of every freshers curriculum.

References

1. Jungbluth C, Macfarlane IM, Veach PM, Leroy BS.Why is Everyone So Anxious?: An Exploration of Stress and Anxiety in Genetic Counseling Graduate Students. J Genet Couns. 2011 Jan 25. [Epub ahead of print]. PubMed
2. Goff AM. Stressors, academic performance, and learned resourcefulness in baccalaureate nursing students. Int J Nurs Educ Scholarsh. 2011;8(1):Article1. Epub 2011 Jan 24.
3. Rao K; Moudud S; Subbakrishna DK. Appraisal of stress and coping behaviour in college students . Journal of Indian Academy of Applied Psychology. 2000 Jan- Jul; 26(1-2):5-13

Social Networking - Psychological Effects on Teenagers

Parents worry that social networks like Facebook could have harmful psychological effects on their children. They seek consultation for social network related behaviour of their teenagers when academic grades fall due to excessive time spent on Facebook, when the teenager is subjected to cyberstalking, or when they themselves are disturbed by the online self-profile of their child. What do we know about some of these social networking behaviours that bring parents and their children to the Clinic?

Friends, self-presentation and self-esteem

Posting a profile assists the teenager in gaining self-awareness. Becoming self-aware by viewing one's own Facebook profile enhances self-esteem (Gonzales and Hanock, 2010).

A larger number of Facebook friends and  an exaggerated positive self-presentation does enhance the teenager’s well-being. However this is not necessarily associated with a sense of belonging to a supportive group. A more honest self-presentation does increase happiness and is also grounded in social support provided by Facebook friends (Kim and Lee, 2010). However, adolescents having more than 300 FB friends have increased levels of cortisol, a stress hormone, that makes them prone to depression in later life (Morin-Major et al, 2016)

Children whose self-worth is based on public contingencies (others' approval, physical appearance, outdoing others in competition) indulge in more photo sharing. People whose self-worth is contingent on appearance have a higher intensity of online photo sharing. Those with private-based contingencies (academic competence, family love and support, being a virtuous or moral person, and God's love) spend less time online (Stefanone et al 2010).

Facebook vs face-face

Impressions formed from face-to-face interaction and from personal web pages generally correspond. So, people liked in face-to-face interaction are also liked on the basis of their Facebook pages. Whether online or offline, people who are socially expressive are liked. People who express themselves non-verbally though gestures and body language in face-to-face interaction are also expressive online. The same goes with self-disclosure - when there is more disclosure offline there is more disclosure on line (Weisbuch et al, 2009).

Facebook and WhatsApp mostly act as an extension of face-to-face interaction. However, some users do rely on Facebook and WhatsApp for interpersonal communication more than face-to-face interaction (Kujath 2010).

Predictors of excessive use

• Extroverted and unconscientious individuals spend more time on social networking sites and their usage tends to be addictive (Wilson K et al, 2010).
• Shy people  also like Facebook and spend more time on it. However, they have few Facebook "Friends” (Orr et al, 2009).
• Narcissistic personalities also have high levels of online social activity. They are recognised online  by the quantity of their social interactions, their main photo self-promotion, and attractiveness of their main photo (Buffardi LE 2008, Mehdizadeh 2010).

Needs satisfied by Facebook

The four primary needs for participating in groups within Facebook are socialising, entertainment, self-status seeking, and information (Park et al 2009). The majority of students use friend-networking sites for just that - making new friends and locating and keeping in touch with old ones (Raacke and  Bonds-Raacke 2008).

Negative outcomes

Broad claims of unwanted sexual solicitation or harassment, associated with social networking sites may be unjustified. The risk of victimisation for a teenage is more likely through instant messaging (IM) and chat (Ybarra and Mitchell 2008).

Parental supervision is a key protective factor against adolescent risk-taking behavior

Unmonitored internet use may expose adolescents to risks such as cyberbullying, unwanted exposure to pornography, and revealing personal information to sexual predators  (Pujazon-Zazik and Park 2010).

References

1. Buffardi LE, Campbell WK. Narcissism and social networking Web sites.Pers Soc Psychol Bull. 2008 Oct;34(10):1303-14. Epub 2008 Jul 3. PubMed
2. Gonzales AL, Hancock JT. Mirror, Mirror on my Facebook Wall: Effects of Exposure to Facebook on Self-Esteem. Cyberpsychol Behav Soc Netw. 2010 Jun 24. [Epub ahead of print] PubMed
3. Kim J, Lee JE. The Facebook Paths to Happiness: Effects of the Number of Facebook Friends and Self-Presentation on Subjective Well-Being. Cyberpsychol Behav Soc Netw. 2010 Nov 30. [Epub ahead of print]. PubMed
4. Kujath CL. Facebook and MySpace: Complement or Substitute for Face-to-Face Interaction?
5. Cyberpsychol Behav Soc Netw. 2010 Jun 24. [Epub ahead of print]. PubMed
6. Mehdizadeh S. Self-presentation 2.0: narcissism and self-esteem on Facebook. Cyberpsychol Behav Soc Netw. 2010 Aug;13(4):357-64. PubMed
7. Julie Katia Morin-Major, Marie-France Marin, Nadia Durand, Nathalie Wan, Robert-Paul Juster, Sonia J. Lupien. Facebook behaviors associated with diurnal cortisol in adolescents: Is befriending stressful? Psychoneuroendocrinology. 2016. 63: 238–246. 
8. Orr ES, Sisic M, Ross C, Simmering MG, Arseneault JM, Orr RR. The influence of shyness on the use of Facebook in an undergraduate sample. Cyberpsychol Behav. 2009 Jun;12(3):337-40. PubMed
9. Park N, Kee KF, Valenzuela S. Being immersed in social networking environment: Facebook groups, uses and gratifications, and social outcomes. Cyberpsychol Behav. 2009 Dec;12(6):729-33. PubMed
10. Pujazon-Zazik M, Park MJ. To tweet, or not to tweet: gender differences and potential positive and negative health outcomes of adolescents' social internet use.Am J Mens Health. 2010 Mar;4(1):77-85..PubMed
11. Raacke J, Bonds-Raacke J. MySpace and Facebook: applying the uses and gratifications theory to exploring friend-networking sites. Cyberpsychol Behav. 2008 Apr;11(2):169-74. PubMed
12. Stefanone MA, Lackaff D, Rosen D. Contingencies of Self-Worth and Social-Networking-Site
13. Behavior. Cyberpsychol Behav Soc Netw. 2010 Jun 24. [Epub ahead of print]. PubMed
14. Weisbuch M, Ivcevic Z, Ambady N. On Being Liked on the Web and in the "Real World": Consistency in First Impressions across Personal Webpages and Spontaneous Behavior. J Exp Soc Psychol. 2009 May;45(3):573-576. PubMed
15. Wilson K, Fornasier S, White KM. Psychological predictors of young adults' use of social networking sites. Cyberpsychol Behav Soc Netw. 2010 Apr;13(2):173-7. PubMed
16. Ybarra ML, Mitchell KJ. How risky are social networking sites? A comparison of places online where youth sexual solicitation and harassment occurs. Pediatrics. 2008 Feb;121(2):e350-7. Epub 2008 Jan 28. PubMed