Suicidal thinking and behavior remains difficult to predict and challenging to address. As a resident in the mid-1980s, I made an annual trek from Naval Hospital San Diego to UCLA, bringing a year of painful experiences to the renowned Dr. Edwin Schneidman.

Historically, psychiatrists did not focus on identifying and treating risk factors for child and adolescent suicidal behavior. But after an increase in youth suicide rates in the 1980s, we started doing more research to get clarity about the issues. For example, we became aware that there were clusters of youth committing suicide—doing so in the same community and during the same time period. We suddenly recognized that hearing about a peer committing suicide would raise the risk for that peer’s close friends.

Tourette’s disorder (TD) is a movement disorder emerging during childhood that causes persistent motor and vocal tics. TD is treated with a variety of medications, but often with an off-label designation.

Since the 2004 FDA black-box warning on all antidepressants for pediatric use, controversy continues over the use of SSRIs and SNRIs in children and adolescents. Both classes of medication are still commonly used for pediatric depressive disorders, anxiety disorders, and obsessive-compulsive disorder.

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Discussing medications with adolescents can be challenging. Because there is so much variation in family structure and the problems that kids and families face, it’s important to maintain some flexibility in how clinicians evaluate adolescents.

In this interview, Dr. Shatkin talks about how the adolescent brain works, and how we can use this understanding to work more effectively in our practices with both adolescents and their parents. There’s a misconception that dopamine equates to pleasure. It’s not pleasure; it’s the promise of pleasure. Dopamine is the idea that something great might happen. And so high dopamine levels drive kids into high-risk situations with high amounts of potential pleasure. This is aggravated by the fact that the frontal cortical areas are not well myelinated yet and not well connected to the limbic system. So, when kids are younger, they have less control over those impulsive drives.

Tic disorders, including Tourette’s, often co-occur with ADHD, OCD, and anxiety disorders. Guanfacine is often tried for all of these conditions. Randomized placebo-controlled trials of immediate release guanfacine have been mixed, with one showing 31% improvement in tics but another showing no significant improvement.

Some studies have indicated that patients with ADHD may be at an increased risk of suicide. While these studies have shown associations between methylphenidate use and suicide, it is not clear whether the stimulant actually causes suicidality or whether patients taking stimulants are suicidal for other reasons.