The risk of overlooking risks

Abstract

In routine clinical practice, the child and adolescent psychiatrist must take diagnostic and therapeutic decisions in a context of relative “uncertainty”. Indeed, reference frameworks based on solid evidence offer more and more often guidelines for our strategies [1]. Protocols and tools are available in order to improve prescription [2], prediction [3] and prevention [4]. In the present issue of European Child and Adolescent Psychiatry, several papers are representative of this process of informed risk management geared to guarantee the effectiveness and safety of our interventions. The European guidelines group for Hyperkinetic disorders [5] have already considerably contributed to the delivery of guidelines for comprehensive and state of the art therapeutic strategies in ADHD [6]. The warnings about the possible adverse effects of ADHD medication led the group to review the literature and consult specialists in paediatrics, cardiology and endocrinology, examining incident causality and potential impact of risk. Evidence and advice are classified according to different domains: cardiac dysfunction, suicide-related events, growth, sleep disturbances, tics, substance abuse, seizures, and psychotic symptoms. The adverse side effects are usually mild or temporary. The very severe adverse effects such as cardiac dysfunction are extremely uncommon. A series of recommendations for monitoring are given, but in the end “the primary responsibility for ensuring the safety of the patient lies with the prescriber” through his careful appreciation of the risk-benefit ratio. The original study presented by Knook et al [7] illustrates the relevance of a joint paediatric and childhood psychiatric approach, previously described in 2006 [8], to detect psychiatric morbidity in children and adolescents initially referred to paediatric departments and outpatient clinics. They assessed psychiatric disorders and their predictors in children and adolescents with unexplained chronic musculoskeletal or abdominal pains or headache (UCP). In this at risk population they found a high prevalence of relevant psychiatric disorders: anxiety, affective and disruptive disorders with an additional risk in children presenting with headache. A careful psychiatric assessment is therefore recommended to detect, in the population with UCP, treatable psychiatric disorders in order to increase the chance that they be incorporated into a tailored treatment plan. Considering psychopathology from a developmental perspective and extending a previous study published in 2007 [9], Perren et al [10] employed a longitudinal and multi-informant approach to assess psychopathology in young children in order to describe the characteristics of psychosocial functioning that could emerge as protective or risk factor for later emotional and conduct problems. The interplay between self-oriented and other-oriented social skills is identified as a multifactorial pivot process in psychological development that could help to predict vulnerability towards later emotional disorders. This work opens new pathways for training and intervention that could promote healthy emotional development and prevent later psychopathological problems. This issue gathers innovative research which highlights the relevance of multidisciplinary and longitudinal studies in assessing the efficacy and safety of early intervention and in detecting high-risk groups. It is a step of major importance towards new preventive strategies in child and adolescent psychopathology.