From the Editor-in-Chief's Desk

I am pleased to report that this issue of the journal contains an investigation of a central, and reliably contentious, issue in our field: research in child and adolescent subjects below the age of consent. Rid et al. give us a thorough primer in how we have historically approached and approved of minimally beneficial research, the ethical considerations involved, and potential approaches to evaluating research risks in a more objective matter. This leads the authors to propose a “systematic method” of risk assessment called “direct comparative analysis” (DCA).

I should note that Rid et al. are refreshingly even-handed in their motivation for developing this metric, a drive towards “ensuring that pediatric research subjects are not exposed to excessive risks, while allowing important and appropriate research in pediatric psychiatry and psychopharmacology to proceed.” The need to balance these considerations is clear, and boils down to something of a risk-benefit analysis: Doing no harm by doing nothing vs. doing harm by learning nothing new.

Rid et al. propose to follow current standards of minimal risk in exploratory research with minors, based on limiting risk to the equivalent of daily life activities. However, the authors, building on previous work, make the crucial point that without a robust comparative tool equivalencies are too often drawn to exaggerate research risks. Using the example of a CO2 challenge as compared to the likelihood of increased anxiety in everyday life, the researchers argue convincingly that we may too often overstate the negative impacts of valuable research because of our outsized concerns for those very children we are trying to help.

Still, the authors wisely remind us, sound judgment will always be necessary when dealing with the persistent uncertainties of pediatric psychiatry. “A finding that a research intervention poses minimal risk,” they write, “does not necessarily imply that it is acceptable.” But we can hope that our consciences, aided by tools like the DCA, will continue to improve care and push the science forward.

I would also like to draw your attention to two other examinations of risk. Stein et al. interrogate a large data set to determine if prior authorization policies impact antipsychotic prescription rates in the pediatric Medicaid population, adding to the growing literature of an at-risk population that requires our full attention.

Elsewhere, Greenstein et al. discuss novel algorithms that may increase the likelihood of identifying and treating childhood onset schizophrenia earlier, leading to much improved outcomes. Please enjoy and learn from these and the other articles in these pages.