In This Issue/Abstract Thinking: Personalized Medicine And Pharmacogenomics in Child Psychiatry

Work presented in this month’s Journal explores a variety of environmental and genetic influences on the development and treatment of psychopathology. This issue highlights advances in our understanding of factors that modify expectations related to diagnoses, treatment, and outcomes in children. First, Wang (p. 1137) provides an editorial of China’s single-child policy. Traditionally, single children have been associated with negative behavioral characteristics, such as self-centeredness, willfulness, the need for instant gratification, and disrespect of others. However, impressions of single children in China have become more positive since the implementation of the one-child policy. Survey research in China suggests that the desirability of having only a single child has improved both parental and societal attitudes toward singletons and that the resulting societal changes have resulted in self-reported positive adjustment among singletons. China’s one-child policy provides an example where cultural attitudes and expectations changed over time and affected childhood outcomes. This finding supports the hypothesis that environmental changes, in this case parental and societal expectations, can affect behavior and self-image in children. Expectations may influence treatment compliance as well. Gould et al. (p. 1193) followed a population of youths at risk for suicidal behavior. The majority of the youths identified as at risk were not in treatment at the time of the screen, supporting the value of screenings for identification of at-risk youths. Seventy percent of the youths referred for treatment had accessed new services at the end of a year, and depressed youths were more likely to follow through on treatment recommendations than nondepressed youths, supporting the value of mental health referrals in the context of research. Those youths who did not enter treatment most often did not acknowledge a psychiatric problem or thought that their condition was not serious enough to require treatment, suggesting that their expectations about symptoms and treatment played a role in their willingness to accept the referral. In the future, genetic factors might inform clinician’s expectations about treatment modalities. McGough et al. (p. 1155) examined genetic variability as a potential moderator of stimulant response and side effects in a prospective, placebo-controlled, double-blind study of children with attention-deficit/hyperactivity disorder. They found one genetic polymorphism strongly associated with positive medication response and a second genetic variant in another gene weakly associated with medication response. They also found specific polymorphisms associated with irritability and vegetative symptoms, suggesting that symptoms within a given disorder may be genetically influenced. This ambitious study explored multiple genes, used a relatively large sample size, and examined both gene effects and gene-by-dose effects using principal components analysis to derive composite outcome measures. Newcorn et al. (p. 1165) examined the expectations of patients treated for attention-deficit/hyperactivity disorder. Specifically, they explored the characteristics of children and adolescents with significant positive placebo response in randomized controlled medication trials. Child medication studies often include a large placebo response, and this study had the unique ability to pool a large number of subjects to examine this important issue. Study design, demographic, and clinical characteristics were considered. Inattentive subtype and stimulant naı̈veté were the most robust predictors of placebo response, suggesting that consideration of these factors may inform the design of future clinical trials. Finally, Brent et al. (p. 1182) provide guidance for our expectations of treatment outcome for depression in the context of cooccurring disorders. They examined subthreshold substance use among youths with treatment-resistant depression and found that more than half of the subjects had used one or more substances at least once, and 28% had used at least one substance multiple times in the previous month. The majority of the subjects had no change in substance-related impairment rating during the 12-week study. Baseline substance useYrelated functional impairment was related to self-reported and parent-reported depression severity. Positive depression treatment response was not associated with substance use frequency. However, treatment response was associated with decreased ratings of substance-use related impairment, including relationship impairment, even after controlling for severity of depression, family conflict, and presence of self-harm behavior. Overall, these articles help change our own expectations and the expectations of our patients as we consider the increasing complexity of diagnosis and treatment modalities, the heterogeneity of study and clinical populations, and seek to personalize treatments. Movement toward personalized treatment and pharmacogenomics are the topics of this month’s There section. H E R E In This Issue