From the Editor-in-Chief's Desk

W e often lament the small cohorts, limited resources, and incomplete clinical records that often characterize epidemiological work in pediatric psychiatry in much of the world. It is precisely because of this current state of affairs that we should pay particularly keen attention to investigations that utilize large, well-documented registries, which is the case in the article from Dalsgaard et al. in this issue of the Journal.

The authors interrogate a group of Danish national health registries with a crucial question, one that has sparked much debate not least in the United States: Who is getting attention-deficit/hyperactivity disorder (ADHD) medication—in this case broadly construed as psychostimulants and atomoxetine—and how fast are prescriptions increasing? The answer to this question in this country is always vague, but Dalsgaard et al. are able to make a more scientific assessment thanks to the quality of their data—and their analysis tells an interesting story. Perhaps the most stunning conclusion is that “16% of all youth with a clinical diagnosis of ASD [autism spectrum disorder] were treated with ADHD medications in 2010,” a number the authors show is an “almost fourfold increase in prescription rates…in Denmark over the past decade.”

These results are part of a larger analysis that is valuable for its power but also thought provoking in the context of cultural and societal differences in the diagnosis and treatment of pediatric mental illness. Dalgaard et al.'s study of the 852,711 Danes born between 1990 and 2001 yields a familiar percentage of autism diagnoses, about 1%. However, the number identified with ADHD—around 1.5%—is incredibly low when compared against other Western countries, particularly the United States.

The authors caution that “the increasing prescription rates of ADHD medications for youth with ASD should be viewed in context of the limited evidence for efficacy in this population of patients.” This is sage advice. But the study's population of ASD subjects “may also have been given a diagnosis of ADHD or other psychiatric disorders at some point,” which invites an observation. Yes, stimulant medications are not an evidence-based treatment for autism; conversely, however, young people with autism can also be properly diagnosed with ADHD and should be treated. Therefore, the study reminds us of the need to build a better understanding of the comorbidity of autism and ADHD, which may someday help erode false treatment orthodoxies imposed by a diagnostic system that continues to evolve.

Also in this issue, Germinario et al. engage a large Italian population of ADHD youth to assess the impacts on growth of stimulant treatment. Their well-designed study confirms midterm impacts but no lasting effects, a welcome validation of the use of these medications. And elsewhere, Findling et al. make a valuable contribution to the literature of adolescent depression, showing that escitalopram (Lexapro) is well tolerated in patients 12 to 17 years of age.

I hope you will find these and the other informative articles in this issue enjoyable and instructive.