Re-thinking treatment targets in child and adolescent psychiatry

European Child & Adolescent Psychiatry, Feb 2019

Carmen Moreno, Alessandro Zuddas

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Re-thinking treatment targets in child and adolescent psychiatry

European Child & Adolescent Psychiatry March 2019, Volume 28, Issue 3, pp 289–291 | Cite as Re-thinking treatment targets in child and adolescent psychiatry AuthorsAuthors and affiliations Carmen MorenoAlessandro Zuddas Editorial First Online: 28 February 2019 1 Shares 433 Downloads In 1970, Robins and Guze proposed five steps to achieve valid classification of mental disorders: clinical description, laboratory study, exclusion of other disorders, follow-up study, and family history [1]. Those steps helped establish significant validity (defined as a coherent syndrome clinicians can describe and measure) and reliability (meaning different clinicians agree on the same diagnosis) for specific psychiatric disorders, leading to consistent definitions of “natural” outcomes, specific responses to therapeutic interventions, and prognosis. Diagnoses in psychiatry are still based on clinical constructs defined by observation and patient’s reports. The ways diagnoses are formulated influence the design of innovative treatments and not always for the better. Patients are usually included in clinical trials based on specific mental diagnoses and narrow enrolment standards to ensure homogeneous samples. That limits the applicability of findings in everyday practice because specific symptoms often overlap among psychiatric diagnoses, as do psychiatric and medical comorbidities, with significant impact on diagnostic formulation, prognosis and treatment choices. Initiatives such as RDoC or ROAMER [2, 3] call for increasing clinical and biological research to develop innovative research-oriented diagnostic formulations based on dimensions of observable behaviour and associated neurobiological characteristics, rather than on specific diagnostic “categorical” entities. This approach may be particularly relevant in the case of child and adolescent psychiatry. In fact, with the significant exceptions of conditions such as attention deficit/hyperactivity disorder (ADHD) and autism spectrum disorders (ASD), in which the full clinical symptomatology usually appears in early years, the clinical description (and corresponding validity and reliability) of many mental disorders in children are adapted from the corresponding adulthood clinical presentations. Yet, in children and adolescents, the age-specific clinical presentations for these disorders frequently include a combination of non-specific symptoms, leading to delays of diagnosis and treatment implementation, which in turn may increase clinical impairment and reduce patient wellness. Highly impairing clinical presentations such as severe irritability and emotional lability frequently appear as unspecific symptoms of different developmental psychiatric disorders such as ADHD, oppositional defiant disorder (ODD), conduct disorder (CD)/disruptive behaviour disorder (DBD), intermittent explosive disorder (IED), disruptive mood dysregulation disorder (DMDD), or anxiety disorder (AD) and often also ASD. In fact, severe irritability is one of the most common reasons for referral to child and adolescent mental health services [4], and is associated with significant functional impairments and exceptionally poor long-term outcomes [5] as well as increased suicidality [6]. Those associations are independent of the specific categorical diagnosis, and there is a significant gap between their impact on clinical burden and the available therapies we can offer to our patients. The article by Wesselhoeft et al. [7] in this issue, using data from 3435 children aged 7–10 years from the Danish National Birth Cohort, provides evidence to support the importance of severe irritability in mental health. The authors studied dimensions and subtypes of oppositionality, and find that, among the dimensions emerging from a three-factor model (angry/irritable, argumentative behaviour, and vindictiveness), the angry/irritable dimension was associated with high emotional problems and disorders and fewer social skills or positive attributes. Among the four oppositional defiant disorders identified, those with a predominance of angry/irritable symptoms were characterized by comorbid psychopathology, increased functional impairment and psychosocial problems. The study suggests that irritability is a clinical characteristic modulating presentation and prognosis and, therefore, a potential treatment target. Irritability has been defined as an increased predisposition to anger compared with peers at the same developmental level including both behavioural and mood dysregulation components [8]. Irritability rises during normal early childhood development, peaking in preschool years, and declines thereafter, with another increase in adolescence. Self-regulation of irritable mood and behaviour occurs thanks to the development of cortical structures mediating emotion regulation and early executive function capability [9]. Emotion regulation plays a central role for the modulation of irr (...truncated)


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Carmen Moreno, Alessandro Zuddas. Re-thinking treatment targets in child and adolescent psychiatry, European Child & Adolescent Psychiatry, 2019, pp. 289-291, Volume 28, Issue 3, DOI: 10.1007/s00787-019-01299-4