From the Editor-in-Chief's Desk

A s readers of this Journal well know, the past couple of decades have seen a rise in both the inquiry into and prescription of psychotropic medications for the treatment of child and adolescent psychiatric disorders. In this issue of the Journal two papers address the pros and cons of psychotropic medications in children, the barriers that continue to hamper research and a clear understanding of the efficacy of pediatric psychopharmacology, and offer concrete steps and assessments moving forward.

Yuill and Carandang begin by painting a stark picture in their paper advocating for increased use of data and safety monitoring boards (DSMBs). “Research in pediatric psychopharmacology presents an ethical dilemma,” they write. This is dipartite: on the one hand, “administering pharmacotherapy for mental illness in a pediatric population has numerous safety concerns, as this population is inherently vulnerable.” As physicians, we know this to be true—but we also know that the benefits often outweigh the risks. Yuill and Carandang acknowledge this: Because of these risks, “this area has traditionally been under-researched, which also has ethical implications.” And thus the other hand: “This population has not had the opportunity to benefit from innovations in technology and pharmaceuticals to the same extent that adults have.”

Yuill and Carandang propose a solution that addresses both sides of this dilemma, a solution that we must admit has been discussed and even mandated before but with poor compliance: DSMBs. More rigorous attention to safety in clinical trials—which their study finds severely lacking—will not stifle inquiry but will further legitimize the field and lead more quickly to breakthroughs, they suggest.

Senior Editor Gaye Carlson provides a complementary and invaluable clinical portrait of pediatric psychopharmacology in her commentary, “The Dramatic Rise in Neuroleptic Use In Children: Why Do We Do It and What Does It Buy Us?” She ably lays out the question: Why have we seen such a dramatic increase in neuroleptic prescribing in pediatric populations in the past 20 years, and what are the benefits? Her conclusions, based on available records from Stony Brook University's psychiatric inpatient unit, are both sobering and invite—even demand—further inquiry.

But, Carlson reminds us, the clinical reality must not be dismissed when alternatives—intensive behavioral therapy, clinician time, beds—are in short supply. In her view, complaining about or even vilifying the use of atypical antipsychotics in troubled children is “disingenuous” if these practices stem from a global lack of will or dedication to alternatives. Is it the best intervention we have? Perhaps not, she admits. Is it the best we are willing to commit to at present? Seems so.

Elsewhere in this issue Treuer et al., Jin et al., and Harfterkamp et al. present valuable inquiries into the increasingly common use of selective norepinephrine reuptake inhibitors to treat the symptoms of attention-deficit/hyperactivity disorder in a variety of distinct clinical circumstances. Adding to the literature here are welcome investigations into issues including polypharmacy and the use of atomoxetine in children with autism spectrum disorders.