From the Editor-in-Chief's Desk

T his issue of the Journal contains intriguing investigations of pharmacotherapy for autism and attention-deficit/hyperactivity disorder (ADHD)—and for autism spectrum disorders (ASD) patients presenting with significant ADHD symptoms. For instance, Wake et al.'s investigation of a Japanese herbal remedy's use to treat severe irritability in patients with autism is welcome both for its results but also for the detailed look at the pharmacokinetics of TJ-54. Pearson et al. probe the effectiveness of methylphenidate in treating ADHD symptoms in the ASD population, a significant comorbidity that is only now receiving the attention it deserves.

Shechner et al. provide insight into at a critically important phenomenon as we accelerate the use of neuroimaging in psychiatric research: Can the anxious children we want to image tolerate MRI? In a study of more than 300 anxious children, non-anxious children, and non-anxious adults, fMRI scans were found to affect all equally. MRI isn't anxiety-free, the authors conclude, “but the potential for fMRI to produce anxiety should not impede its widespread use in clinical research.”

With polypharmacy a significant issue both to professionals and to the public at large, I particularly recommend Turkel et al.'s paper on the management of delirium with antipsychotics in very young patients in critical care. Many factors recommend this investigation, from its focus on an understudied population to its role as a healthy reminder that pediatric psychopharmacology is in no way limited to the psychiatric profession. Their results are fairly straightforward: A retrospective study of 19 children, mean age about 20 months, responded well to olanzapine and risperidone for treatment of delirium. Their use “appears to be safe and effective in this population,” the authors write.

Turkel et al.'s discussion of these cases, however, reveals more nuanced insight—particularly in regard to the problems of neuropsychiatric diagnosis in very young patients and the intricacies of polypharmacy. The authors ably lay out the rationale for diagnosis and the effectiveness of the Delirium Rating Scale even in young, nonverbal patients, producing “scores similar to those of adults.” And the need to treat delirium in these patients is amplified by the clinical reality of their situation.

As Turkel et al. write, “many of the patients with delirium were seen in the intensive care setting, where opioids and benzodiazepines were used to address agitation,” agents that “may induce or exacerbate delirium.” Their suggestion, based on the effectiveness of antipsychotics, emerges from a nuanced understanding of drug interactions and is an intriguing argument for enlightened polypharmacy in this context. “Antipsychotic use may facilitate lower sedative-hypnotic and narcotic use, providing an alternate option to address excessive agitation without exacerbating delirium.”