Psychiatric Annals

Editorial Free

Damage Control for the Young

Jan Fawcett, MD

This month our guest editor is Psychiatric Annals Board member Robert J. Hilt, MD, FAAP, a pediatrician and psychiatrist at Seattle Children’s Hospital, and this issue reviews areas of damage inflicted on the young, providing a guide for both pediatricians and psychiatrists working with children and adolescents, and parents, to limit and prevent damage.

Because none of us get to choose our parents, including their socioeconomic status or genetics, and many of us were conceived without a plan (who among us, including our parents, received a course on how to raise children?), mental and emotional damage during childhood is quite common. This damage tends to take an increasing toll as we age and negotiate life.

The contribution by David Buxton, MD, Mona Patel Potter, MD, and Jeff Q. Bostic, MD, EdD, on the damages resulting from reported bullying shows the frequency of this problem and suggests responses to reduce its effects at several levels.

The contribution of Howard Dubowitz, MD, MS, describes various types and levels of neglect while being realistic about the difficulties of detection and reporting this problem in a fashion that will reduce the damages.

David R. Camenisch, MD, MPH, and Robert J. Hilt, MD, FAAP, have contributed an excellent review of the use of selective serotonin reuptake inhibitor (SSRI) medications for anxiety disorders and depression in children and adolescents that presents evidence of positive effects as well as data that will help the clinician to select a specific medication. This article is of particular value because of the relative dearth of studies of SSRI efficacy in children and adolescents.

Adolescent Marijuana Use and Lower IQ

Harm reduction and prevention in the young should carry a high priority. In addition to the adverse effects of bullying, neglect, and untreated mental disorders, recent studies show that the persistent use of cannabis before the age of 18 years has a real risk of reducing IQ by an average of 8 points, according to Meier and colleagues.1

This is thought to occur through interference of specific white matter tract development,2 raising the issue of how to address the increasingly assumed “safety” of cannabis, now that there is a ground swell of support in favor of its legalization, a phenomenon that is bound to abet increased use in children or adolescents. They might reason that, after all, it’s a “natural substance,” not a “drug,” shouldn’t this research data be transmitted to young people as it develops?

All of these conditions, from bullying to drug use, present the possibility of later effects that can profoundly affect the trajectory of an adult’s life. The opportunity for harm reduction and damage prevention is great, but we need to be current in reviewing the potential damages to make prevention an adequate priority in the context of our usual role — being called upon to respond to crises (often a result of earlier damages) in day-to-day practice.

We all know that prevention is more powerful than responding to a crisis, but prevention is hard to prove, it takes time to see the outcome, it’s “iffy.” Meanwhile, reversing a crisis is definite — it’s “real” — you know you’ve helped (even if you’ve helped much less than if you could have prevented the crisis in the first place). That’s a conundrum for medicine.

Virtual Reality

This month’s feature in our ongoing series of articles exploring how the military is exploring new ways to treat posttraumatic stress disorder (PTSD) is written by Albert “Skip” Rizzo, PhD, an expert in the use of virtual reality technology in mental health applications and on cognition, and a member of the Institute of Medicine’s committee to study how PTSD is being addressed by the Department of Veterans Affairs. Some of you might have seen Dr. Rizzo’s work using video games to help PTSD-affected soldiers, addressed in this issue, profiled on Sanjay Gupta, MD’s, CNN program, “The Next List.” It’s another way we are able to challenge ourselves as clinicians to think beyond what we know is “real” in search of solutions for intractable problems facing our patients.

Off-Label Use of Zolpidem

This month’s Case Challenge is really more of an observation that led to an innovative off-label use of a common sleep-aid to help calm a woman who is bipolar with sleep disturbances.

Because as clinicians part of our job is always to bring comfort to our patients, I thought this case was worth publishing.



  1. Meier MH, Caspi A, Ambler A, et al. Persistent cannabis users show neuro-psychological decline from childhood to midlife. Proc Natl Acad Sci U S A. 2012;109(40):E3657–E2664 doi:10.1073/pnas.1206820109 [CrossRef]
  2. Zalesky A, Solowij N, Yucel M, et al. Effect of long-term cannabis use on axonal connectivity. Brain. 2012;135:2245–2255 doi:10.1093/brain/aws136 [CrossRef] .

Jan Fawcett, MD, a graduate of Yale University School of Medicine, is a Professor with the Department of Psychiatry at the University of New Mexico School of Medicine. Prior to that, he served 30 years as the Stanley Harris, Sr. Chairman of the Department of Psychiatry at Rush Medical College in Chicago. He is a co-author of the American Psychiatric Association’s Practice Guidelines Committee on the assessment and management of suicidal patients and was chairperson of the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, (DSM-5) Mood Disorders Task Force. Dr. Fawcett maintains an active clinical practice focusing on patients with treatment-resistant major affective disorders. He  is the recipient of many awards, including the 2000 Menninger Award for research in mental health, and the Falcone Prize for affective disorders research.

Contact Dr. Fawcett via email:


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