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Bhatia, Richa

doi: 10.1097/YCO.0000000000000459

3 Waters Park Drive, Suite 224, San Mateo, California, USA

Correspondence to Richa Bhatia, MD, San Mateo, CA, USA. Tel: 001 650 393 4205; fax: 650 393 4061; e-mail:

This section is themed on reviewing evidence in specific areas in child and adolescent psychiatry that have typically had a relative paucity of research emphasis, with the goal to enhance our understanding of recent updates in these areas. The review articles in this section bring forward a plethora of research that has recently been done in these areas while also indicating the need for further studies.

Autism is one of the most challenging clinical entities in the field of child and adolescent psychiatry. It continues to impair and pose debilitation in school, home, and social settings for a large percentage of affected children and adolescents. For individuals affected with autism, social deficits contribute heavily to a lower level of integration in occupational, school, and family settings. At a time where the field faces an ongoing dearth of effective treatment options to address social reciprocity skill deficits in individuals with autism, Cohen et al.'s (pp. 474–483) unique review of interactive technologies in autism care, sheds light on recent evidence regarding use of serious games and innovative, robotic technologies for improving social skills, emotional recognition in youth with autism. With the rapid growth of technological innovations in the last several years, media use has been growing globally, especially among children and adolescents. Although in general, the use of technology can have both positive and negative effects on developing brains, it is high time that the field of child and adolescent psychiatry leverage the vast technological advantage of current times in directing the development of applications in the much-needed arena of autism care. Cohen et al. (pp. 474–483) describe in their review how virtual environments (that can simulate real-life scenarios) and various other forms of interactive technologies offer exciting possibilities in the realm of improving social skills, emotion identification in those affected with autism.

Cohen et al.'s (pp. 474–483) review in this section indicates that the relatively simplistic and predictable nature of robotic interactions can make robots a better agent for training aspects of social skills to children with autism. The article points out to recent evidence suggesting that individuals with autism may respond better in interactions with robots than with humans. The review article brings forth several serious games and robots designed in different parts of the world, to address emotional recognition, joint attention and other key, social reciprocity functions in children and adolescents with autism, through modeling and teaching. However, many of the recent studies involve individuals with high functioning autism and have yet to show generalizability in clinical settings, as shown by the review. Current evidence available so far clearly suggests that this is an area with great potential for growth and usage in future as further research establishes, solidifies and fine tunes the functions, benefits and applicability of interactive technologies in the treatment of autism. Given the promise robots and serious games offer in this area, the review article delineates that larger, controlled studies assessing long-term and maintenance effects and further application in actual, clinical settings are needed, in addition to studies evaluating effects in individuals with low-functioning autism. To this effect, the need for greater collaboration between clinicians and technological design professionals has been suggested by some.

In regards to technological interventions for anxiety disorders, while more research is needed for establishing efficacy of digitally delivered cognitive behavioral therapy (CBT) for anxiety disorders, evidence shows that the use of therapist-supported digital CBT may lead to better rates of adherence, as indicated by the review article by Heiervang et al. (pp. 484–489) provide a comprehensive review, in this section, on the vital subject of recent evidence and updates on CBT in childhood and adolescent anxiety disorders. The authors discuss short-term, long-term outcomes and efficacy, along with moderators and determinants of outcome in CBT treatment.

Anxiety disorders are the most prevalent psychiatric conditions. Even though CBT is widely known for having shown efficacy for anxiety disorders through a multitude of studies, a significant proportion of children and adolescents experience persisting anxiety-related impairments in the long term. So far, recent evidence appears to suggest that the proportion of children and adolescents reaching stable remission in the long term is not high and more long-term follow-up studies of CBT treatment are needed in this realm, as shown in this review.

In addition, this review highlights recent updates in CBT treatment that describe novel, little known evidence-based strategies to enhance access and efficacy for children and adolescents suffering from anxiety disorders. The article points out to some evidence examining parent-delivered CBT that may achieve outcomes not inferior to those achieved with traditional CBT while also increasing access to treatment. The present review also discusses how a stepped care CBT approach has been shown to have similar outcomes as standard CBT, while accomplishing greater cost-effectiveness. These approaches need to be researched more to further establish efficacy.

The present review article suggests, among several other themes, that in order to achieve optimal outcomes, community clinical settings are likely to benefit from choosing CBT treatment protocols from research studies with settings that bear a close resemblance to their own. Certain conditions, such as social anxiety disorder, might benefit from additional components, such as those addressing loneliness.

Anxiety disorders in children and teens are highly comorbid with depressive, other anxiety disorders, and other psychiatric conditions. The article by Heiervang et al. (pp. 484–489) cites evidence that confirms that comorbid disorders may be detrimental for CBT outcomes. Comorbid conditions may require addition of techniques specifically designed to target those conditions. Given the chronic nature of anxiety disorders, further research examining long-term follow up outcomes of CBT and specific approaches, strategies, or techniques that could enhance its access, cost, and efficacy for children and adolescents especially those with persisting anxiety disorders and/or with comorbid conditions, is much needed at this time, which is one of the key themes of this review article.

Bass and Skuse, (pp. 490–495) through their review, illuminate an area that has not received adequate attention in the field of child and adolescent psychiatry, namely genetic testing in children and adolescents with intellectual disability. Intellectual disability is typically permanent or irreversible, even though some suggest that intellectual abilities may possibly improve with certain targeted interventions. The cause of intellectual disability is not entirely well understood. Single-gene mutations, chromosomal anomalies, neurodevelopmental disorders are thought to be some of the causes [1].

The arena of genetic testing in individuals with intellectual disability is often not well understood by practicing child and adolescent psychiatrists. The authors of this review article demystify complex nuances and advances in this field. The authors note that single nucleotide variants in hundreds of genes have been found to contribute to intellectual disability. They mention the ‘deciphering developmental disorders project’ that conducted a nationwide survey in the United Kingdom of children with developmental difficulties suspected to be genetic in nature and found de-novo mutations in more than 40% of children, utilizing whole exome sequencing (WES) and genome wide microarray. Thus, evidence indicates the value of furthering our understanding of genetic pathogenesis in intellectual disability. This is especially important as certain anomalous genetic variants may determine risk for other impairing conditions, such as ADHD, autism, schizophrenia as noted by this review.

Bass and Skuse's (pp. 490–495) review in this section, highlights that WES can identify variants in about half of young individuals affected by intellectual disability, including identifying de-novo variants that are thought to underlie severe or profound intellectual disability. However, because of significant locus heterogeneity, WES may not offer definitive decision-making clinically in terms of determining if a particular de-novo mutation is contributing to the pathogenesis of intellectual disability. The authors suggest that whole genome sequencing (WGS) offers a greater likelihood of recognizing even rare variants in intergenic areas, which are not picked up by WES. The authors find evidence showing that WGS can catch structural anomalies in about 60% of severe or profound intellectual disability patients. They also note that evidence from the United Kingdom has shown that practicing physicians have generally found genetic testing beneficial for the family. Testing can also help in recurrence risk determination in other family members and in counseling the family.

Overall, this review article shows that there is still an ongoing gap in our understanding in terms of which psychiatric disorder may correlate with which variant implicated in the pathogenesis of intellectual disability. Except for autism and ADHD, other psychiatric disorders and their genetic correlations have not been studied much in children and adolescents with intellectual disability. Further research is warranted, specifically, in regards to psychiatric phenotyping in order to guide early intervention in individuals with intellectual disability, as suggested by the review.

These review articles throw light on valuable, recent updates enhancing our understanding of debilitating disorders and treatments in child and adolescent psychiatry and guide us towards specific areas where more research would be beneficial.

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Conflicts of interest

There are no conflicts of interest.

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1. Alvaro SM, Rafael PM. Understanding intellectual disability through rasopathies. J Physiol Paris 2014; 108:232–239.
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