Black Boxes, Xboxes, and Other Current Concerns

October 1, 2007

The articles in this Special Report, although far from comprehensive, address an intriguing sample of the many key topics in child and adolescent psychiatry today.

The articles in this Special Report, although far from comprehensive, address an intriguing sample of the many key topics in child and adolescent psychiatry today. The discussion of the black-box warning applied to SSRIs is a good place to start. We are all trying to practice evidenced-based medicine and yet defining risk/benefit, even with a common condition such as adolescent depression, is no easy task. Black-box warnings are meant to reduce the risk for an individual patient as the physician decides whether to prescribe a specific medication. However, what is the impact of the black box beyond the individual?

There are many difficult questions. Is there a linear or clear relationship between suicide ideation and suicide attempt and suicide completion? Can we extrapolate from suicidal ideation to an accurate prediction of real suicidal intent? Furthermore, we must determine where in time we are in the depressive episode-where is the snapshot we are taking located in the movie that is a specific teenager's depression?

Beyond the individual, a black-box warning has a broader impact. Do measures designed to inform or protect an individual have a chilling effect on the recognition and treatment of depression? Does the warning tip the scale even further away from pediatricians who recognize and treat depression in adolescents, because caring for these patients is difficult, risky, and poorly reimbursed? Does even a minor shift away from recognition and treatment of teenage depression lead to increased morbidity and mortality from accidents (eg, drunk driving), substance use, and suicide secondary to untreated depression?

On a conceptual level, how much risk are we willing to accept for what benefit when treating psychiatric disorders in children? Does a low threshold for risk-the prevailing sentiment-have unanticipated, indirect, or long-term consequences that are harder to quantify? The articles on the Treatment for Adolescents with Depression Study (TADS) and on the impact of the black-box warning begin to address these questions.

Of course, video games are bad, dangerous, and watching all that violence will lead to violent behavior. Is this oft-stated view evidence based? Does a violent video game played by a lonely teenager who has been physically abused have the same meaning and impact as the same game played by a group of teenagers who have been loved, well treated, and live in a safe neighborhood? Could playing an aggressive video game be good? Could an hour of video gaming be a safe way-much like football practice or roughhousing-to vent violent or aggressive impulses? Could a game be a relaxing break for a hard working teenager, a welcomed relief for a child with attention-deficit/hyperactivity disorder after a hard day at school, or a vehicle for a shy child to make friends?

Many individuals who are concerned about video game violence recommend strict parental monitoring even for midadolescents. How controlling should parents be? Is the risk of impairing the adolescents' sense of autonomy and trust worth the imagined gain of limiting video gaming? Does strict parental surveillance work with teenagers who are constantly on the move and reachable largely by cell phone? On the other hand, is there a combination of factors, such as past history of abuse, social isolation, a history of violent threats or behavior, or hours and hours of especially violent video gaming that are indications for a psychiatric evaluation?

These are but some of the issues that make practicing child and adolescent psychiatry so exciting and complex. In addition to these topics, this Special Report looks at consulting on medically ill children and classification of attachment disorders that impact infants and children (topics that resonate with the core issues of self-esteem and affection).

Beyond the rich range of topics presented in this Special Report, there are a myriad of other issues that are of interest to child and adolescent psychiatrists, including autism, prepubertal bipolar disorder, the critical shortage of child and adolescent psychiatrists, approaches to quality assurance, and mental health in special settings, such as foster care and prisons.

Despite the constraints placed on child and adolescent psychiatry by managed care, the relatively low priority of children as we set public policy, and the difficulty of accessing care, I remain optimistic. The current and potential future topics of these Special Reports reflect the excitement and privilege of being a child and adolescent psychiatrist.