Perspectives on child and adolescent psychiatry from Brazil

It is a pleasure to introduce this special supplement on child and adolescent psychiatry, which is emerging as a dynamic subspecialty in Brazil. Child psychiatry has however increasingly been recognized as integral to general psychiatry. The prevalence of mental disorders in children and adolescents in astonishingly high¹; in contrast, service utilization is very low, even in the United States.² When the first signs of onset of mental illness are queried, half of the “adult” disorders are found to have had their onset during adolescence, with frequent failure and delay in getting treatment.³,⁴ Finally, there are now neurodevelopmental hypotheses for not just schizophrenia,⁵ but almost every other major adult psychiatric disorder. Based on these data, one might even argue that child and adolescent psychiatry could be regarded as the parent field of adult and geriatric psychiatry!

The past 50 years have seen dramatic changes in childhood psychopathology research. A landmark early study by Robins et al.⁶ showed us that children with externalizing behaviors (attention-deficit/hyperactivity disorder and conduct disorder) had far poorer outcomes than children with internalizing disorders (e.g., anxiety disorders) and focused interest on the predictive validity of diagnosis. The Isle of Wight epidemiological studies of Rutter et al.⁷ showed (among many important findings) the dramatic association between chronic neurological disorders such as epilepsy or cerebral palsy and psychiatric disorders. Both clinical follow-up and epidemiology remain mainstays of research.

The discovery of drug treatments with large effect sizes brought experimental study methodology to child psychiatry.⁸ The success of stimulant drug treatment and useful pediatric indications for antidepressants and antipsychotics created a dynamic field.

For the future, it is likely that brain imaging studies will continue to contribute through developmental information and newer ways of measuring brain connectivity.⁹,¹⁰ Large networks of pediatric imaging studies will provide stronger, more developmentally sensitive information.

Contributions from genetics have shown the etiological complexity of most psychiatric disorders. There is as yet limited effect of genetics on clinical diagnosis and treatment.¹¹ Even for diagnoses such as Rett syndrome, for example, for which a major gene has been found, the clinical syndrome remains important because of the many atypical and spectrum cases with and without the MECP2 gene.¹²

Child and adolescent psychiatry is in a very different place today. As is clear from this supplement, many of the ongoing studies in Brazil with and without international collaborators are at the forefront of these changes. Our understanding of the development and treatment of attention-deficit/hyperactivity disorder, pediatric mood and anxiety disorders, behavior, and substance abuse is far from complete. I am confident that Brazil's investment in these research areas will provide meaningful contributions to our field.

References

• ¹
  Merikangas KR, Nakamura EF, Kessler RC. Epidemiology of mental disorders in children and adolescents. Dialogues Clin Neurosci. 2009;11:7-20.
• ²
  Merikangas KR, He JP, Burstein M, Swendsen J, Avenevoli S, Case B, et al. Service utilization for lifetime mental disorders in U.S. adolescents: results of the National Comorbidity Survey-Adolescent Supplement (NCS-A). J Am Acad Child Adolesc Psychiatry. 2011;50:32-45.
• ³
  Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62:593-602.
• ⁴
  Wang PS, Berglund P, Olfson M, Pincus HA, Wells KB, Kessler RC. Failure and delay in initial treatment contact after first onset of mental disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62:603-13.
• ⁵
  Weinberger DR. Implications of normal brain development for the pathogenesis of schizophrenia. Arch Gen Psychiatry. 1987;44:660-9.
• ⁶
  Robins L. Deviant children grown up: a sociological and psychiatric study of sociopathic personality. Baltimore: The Williams & Wilkins Company; 1966.
• ⁷
  Rutter M, Tizard J, Whitmore K. Education, health and behavior. London: Longman; 1970.
• ⁸
  Rapoport JL. Personal reflections on observational and experimental research approaches to childhood psychopathology. J Child Psychol Psychiatry. 2009;50:36-43.
• ⁹
  Giedd JN, Rapoport JL. Personal reflections on observational and experimental research approaches to childhood psychopathology. Neuron. 2010;67:728-34.
• ¹⁰
  Raznahan A, Lerch JP, Lee N, Greenstein D, Wallace GL, Stockman M, et al. Patterns of coordinated anatomical change in human cortical development: a longitudinal neuroimaging study of maturational coupling. Neuron. 2011;72:873-84.
• ¹¹
  Addington AM, Rapoport JL. Annual research review: impact of advances in genetics in understanding developmental psychopathology. J Child Psychol Psychiatry. 2012;53:510-8.
• ¹²
  Zoghbi HY. Postnatal neurodevelopmental disorders: meeting at the synapse? Science. 2003;302:826-30.

Publication Dates

• Publication in this collection
  2013