Caring for the transgender adolescent and young adult: Current concepts of an evolving process in the 21st century.

The term transgender youth commonly refers to those whose gender identity, or personal core sense of self as a particular gender, differs from their assigned sex at birth; this is often designated by what external genitalia are present. These youths are presenting to multidisciplinary clinics worldwide at exponentially higher rates than in decades past, and clinics themselves have grown in number to meet the specialized demands of these youth. Additionally, the scientific and medical community has moved towards understanding the construct of gender dimensionally (i.e., across a spectrum from male to female) as opposed to dichotomous or binary "male or female" categories. This is reflected in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM 5); in this publication, the diagnostic classification of gender dysphoria, GD, (which has two subtypes: childhood and adolescence/adulthood) provides a set of criteria that many transgender people meet. GD describes the affective distress that arises as a result of the incongruence between gender identity and sex anatomy. The DSM uses language to indicate that a person may identify as another gender instead of the other gender, which further captures the complexity of the human experience of gender. Also, research regarding how current adolescents are describing their identity development and experience along this spectrum within today's society is only now being addressed in the literature. Therefore, the clinical needs of the transgender population have outpaced medical training and scientific advancement, which has opened up gaps on how to define best practices. This article provides current concepts of evaluation and management for transgender persons with emphasis on hormonal therapy (i.e., puberty blockers and gender affirming hormone therapy). Other management issues are briefly considered including gender confirming surgery and changes in the face as well as voice.

Use of psychotropic medications in children with developmental disabilities.

Working with children who have developmental disorders is challenging. Besides having physical deficits, or intellectual deficits, or both, these children are at high risk for developing psychiatric disorders. This article describes three developmental disorders-autistic spectrum disorders, fragile X syndrome, and fetal alcohol syndrome-and their associated mental health issues, and provides recommendations for pharmacologic interventions.

Depression in children and adolescents.

Primary care physicians are often the first health care providers to have contact with depressed children and adolescents. This article discusses the epidemiology, clinical features, comorbid conditions, risk and protective factors, treatment modalities, and clinical course of early-onset depression.

Psychopharmacology for the violent adolescent.

Psychotropic medications for the violent adolescent can be used safely and effectively as long as a thorough evaluation is conducted beforehand,and appropriate monitoring is attended to for the duration of treatment. Table 1 summarizes several clinical conditions associated with aggressive and violent behaviors, and the recommendations for first-, second-, and third-line pharmacotherapeutic agents to treat them.

Psychopharmacologic control of aggression and violence in children and adolescents.

Aggression in children and adolescents is commonly displayed in the community and is even more commonly seen in clinical settings. As symptoms of an underlying disorder, aggressive behaviors should be comprehensively evaluated, and developmental, medical, and substance-use disorders should be identified and treated. This article reviews the most common psychiatric conditions associated with aggression and suggests appropriate psychopharmacologic interventions. Tables with recommended agents for each psychiatric disorder, as well as dosing ranges for each agent, are included.

Cognitive-adaptive disabilities.

Cognitive-adaptive disabilities (CADs) are not frequently seen in the general pediatric setting. Yet, given the high rates of comorbidity in that population, they commonly demand a lot of time and effort on the part of clinicians. One aspect of comorbidity is the degree to which psychiatric disorders occur in children, adolescents, and young adults with CADs. This article reviews the epidemiology, associated psychopathology, and pharmacologic treatment of selected CADs.

Genetic and nongenetic factors influencing substance use by adolescents.

Substance use by adolescents can lead to mortality, physical and social morbidity, and a brain disorder called substance dependence if allowed to progress to chronic, repetitive self-administration. Substance abuse and dependence can begin in adolescence or adulthood, but many of the attitudes and behaviors that affect risk become established during adolescence. Genetic risk factors have been identified for at least two distinct disorders and more are under active study to determine the cause and pathophysiology of addictive disorders. Although much remains to be done, a complex interplay of numerous genetic and environmental risk factors clearly is involved. An understanding of the most important environmental risk factors has led to effective primary prevention approaches; knowledge of the genetic risk factors and neuropharmacology of drugs of abuse in the brain is beginning to influence secondary prevention efforts and treatment, including better medications for addictive disorders. A large proportion of adolescents carry a genetic vulnerability that can be expressed when they accept peer and societal influences that promote experimentation with substances of abuse. At that point, the genetic factors take over, maintaining the drug self-administration pattern. Decay of social status results from association with drug-using peers and shifts in priorities supportive of drug use rather than education and productivity. More research into the genetic risk factors and applications of current knowledge to treatment is needed.