From the Editor-in-Chief’s Desk: Maximizing Adherence,Digital Platforms,and Early Response for Precision Pediatric Psychopharmacology

TO OUR READERS:

Precision psychiatry aims to customize prevention, diagnostics, and treatments for each patient. This emerging strategy considers the unique neurobiological, developmental, environmental, lifestyle, preferences, and social determinants of health for each patient. Precision approaches recognize the nuances and heterogeneity of patients and psychiatric disorders (Cortese, 2021). Child and Adolescent Psychopharmacology is replete with opportunities for a precision framework (Cortese et al., 2024). Attention-deficit/hyperactivity disorder (ADHD) is an important area of focus for precision approaches. Despite considerable prior efforts and advances for the diagnosis and management of ADHD, patients and families continue to struggle with this prevalent neurodevelopmental disorder (Baweja et al., 2024).

Our current issue includes forward thinking contributions to inform ongoing efforts for precision psychiatry in the treatment of children and adolescents. Two contributions from experts with the University of Southampton highlight future opportunities to advance precision approaches for the identification, diagnosis, and treatment of ADHD (Parlatini et al., 2024; Roy et al., 2024). Electronic health records (EHRs) are valuable tools for data collection with standard methodological approaches, digital platform research, predictive modeling, and the study of social determinants of health. Roy and colleagues completed an exhaustive review of prior studies focused on patients with ADHD that leveraged EHR data. This important paper addresses key knowledge gaps and provides an important reference regarding EHR data for ADHD. Notably, there are pressing needs to enrich information regarding medication dosage, duration of treatment, clinical rating scales, and changes in clinical symptoms within EHR studies of ADHD (Roy et al., 2024). This paper provides an important reference and vision for clinical practice and research focused on improving the lives of youth with ADHD.

A second paper focused on ADHD examines a promising approach advancing precision approaches to treatment with stimulant medications. Parlatini and colleagues note that translational studies suggest that neurobiological changes after a single dose of stimulant medication provide clues of potential long-term benefit. However, less is known about the clinical implications of single-dose stimulant effects and clinical response, and the group completed a systematic review of randomized controlled trials focused on the putative association between single-dose effects and clinical response to stimulants. The review identified and synthesized information from 63 randomized controlled trials. One secondary analysis demonstrated that in a sample of children with ADHD (N = 46) clinical improvement after one dose of methylphenidate was associated with subsequent clinical improvement 4 weeks later (Parlatini et al., 2024). Parlatini and colleagues have identified a key research priority for future efforts focused on precision approaches for the treatment of ADHD.

Can and colleagues present an update on the pharmacological treatment of Tourette Syndrome in children. The authors emphasize that comprehensive behavioral intervention for tics is the first-line approach for the treatment of patients with tic disorders. Pharmacological interventions are reserved for patients with refractory symptoms, complex presentations, and co-occurring. The authors relate that alpha-2 adrenergic agonists such as guanfacine are preferred initial treatment options given the favorable safety and side effect profile. Secondary approaches to consider include treatment with dopamine antagonists after careful consideration of the related risks and side effects. Agents that modulate gamma-aminobutyric acid neurotransmission such as clonazepam, baclofen, and topiramate have been previously studied and used for the treatment of Tourette Syndrome. Extant experience with vesicular monoamine transport-2 inhibitors, dopamine agonists, botulinum toxin injections, complementary alternative medicine, supplements, and investigational compounds are also examined in this concise, scholarly review (Can et al., 2024).

Second-generation antipsychotics or mixed serotonin dopamine antagonists are effective treatments for youth with bipolar disorder (Vita et al., 2024) but patients and families often struggle with the side effect burden related to weight gain (Lyu et al., 2024). These concerns about side effects are a barrier for adherence to treatment, which is a common clinical challenge. Young patients with bipolar disorder and elevated body mass indices may have unique perspectives and barriers to adherence with second-generation antipsychotic treatments. Klein and colleagues examined this question within the framework of a pragmatic clinical trial. It was reassuring that the overall adherence rate was high in this large sample but 50% of the sample reported challenges with adherence. Common themes included forgetting to take the medication, embarrassment, side effect burden, and a preference for other activities. This paper provides an important foundation for developing patient-centered approaches for youth with bipolar disorder and concurrent elevations in body mass index (Klein et al., 2024).

Another contribution from Sanyal and colleagues focuses on another key challenge related to the clinical management of children and adolescents treated with second generation antipsychotics. Child psychiatrists have their own challenges with adherence related to the routine clinical monitoring for patients taking second-generation antipsychotics. This qualitative study examined interviews with child psychiatrists to identify barriers. This paper identifies important future opportunities for quality improvement efforts, precision medicine, and enhanced care for patients treated by child and adolescent psychiatrists (Sanyal et al., 2024).

We hope you enjoy this issue of the Journal of Child and Adolescent Psychopharmacology.