Editors’ Best of 2025

Abstract

In its third year, JAACAP Open is now indexed in PubMed Central (PMC) and the Directory of Open Access Journals (DOAJ), accepted into the Web of Science Emerging Sources Citation Index (ESCI), and will have an impact factor beginning in June 2026. We are proud to support the dissemination of some of the highest-quality research being conducted in our field. Choosing the “best” among already high-quality submissions is always a tall order and most certainly misses the many ways in which articles make an impact: is the “best” the most interesting, the most surprising, the most educational, the most impactful, the most provocative, or the most enjoyable? How do we decide? Our team selected some articles that have the potential for high impact based on their methodological novelty, attunement to the complexity of development in the context of a variety of different sociocultural settings, focus on understudied populations, and ability to inform clinical practice today. With a special issue featuring scholarly work focused on suicide, it should be no surprise that some of our picks came from that issue. It is our pleasure to give a special “hats off” to the 2025 articles that we think deserve your attention, or at least a second read!

In its third year, JAACAP Open is now indexed in PubMed Central (PMC) and the Directory of Open Access Journals (DOAJ), accepted into the Web of Science Emerging Sources Citation Index (ESCI), and will have an impact factor beginning in June 2026. We are proud to support the dissemination of some of the highest-quality research being conducted in our field. Choosing the “best” among already high-quality submissions is always a tall order and most certainly misses the many ways in which articles make an impact: is the “best” the most interesting, the most surprising, the most educational, the most impactful, the most provocative, or the most enjoyable? How do we decide? Our team selected some articles that have the potential for high impact based on their methodological novelty, attunement to the complexity of development in the context of a variety of different sociocultural settings, focus on understudied populations, and ability to inform clinical practice today. With a special issue featuring scholarly work focused on suicide, it should be no surprise that some of our picks came from that issue. It is our pleasure to give a special “hats off” to the 2025 articles that we think deserve your attention, or at least a second read!

Scoping Review: Perceived Needs, Barriers, Facilitators, and Satisfaction With Access and Utilization of Mental Health Services Among Rural Adolescents and Parents in the United States, Gunlicks-Stoessel et al.

How can child and adolescent psychiatry best respond to the high rates of morbidity and mortality caused by mental health problems among youth? Answering this question involves knowledge of epidemiologic patterns of disparity in these problems. The ecosocial theory of disease distribution holds that social factors influence patterns of disparity and provide opportunities for amending them to ensure equitable distribution of health resources among populations.¹

At a time when mental health parity is being debated, these disparities especially affect youth living in rural areas in the United States due to multiple factors. There is an epidemic in mortality due to substance use and suicide among rural communities experiencing economic and social dislocation in the United States.² This problem is compounded by a lack of sufficient child and adolescent psychiatrists and youth mental health resources in rural communities. As a result, rural youth face multiple barriers to care including a dearth of services, while social and economic factors contribute to deaths of despair in rural communities.

In a scoping review of 70 studies of mental health service use satisfaction among rural youth and parents, Gunlicks-Stoessel and colleagues³ summarize important knowledge about these disparities and highlight several areas of need. In doing so, they help keep the needs of rural youth visible. These include service components and barriers; a desire for telehealth and prevention services; and a perceived need to address depression, anxiety, parenting support, and substance use interventions. Their research both contributes important knowledge to addressing the needs of rural adolescents while highlighting that understanding and amending mental health inequity is an ethical imperative for groups at risk in all regions of the United States. In doing so, this article serves to remind us of the importance of working toward improving access to high-quality mental health care for youth in rural America.

Stewart L. Adelson, MD

Navigating Funding Cliffs: An Exploration of the Dynamic Contextual Factors That Influence Evidence-Based Practice Sustainment, Lindquist et al.

Community-based health care centers often serve under-resourced communities; providing access to mental health treatment for youth who may otherwise not be able to access treatment. Community-based health centers also provide integrated services, reducing fragmentation of treatment and clinical and social services, and improving care coordination between providers. Integrated treatment that is culturally responsive is associated with better mental health and substance use outcomes as well as function outcomes.⁴

Funding from grants such as those from the Substance Abuse and Mental Health Service Administration (SAMHSA) provide resources to implement, disseminate, and scale evidence-based practices (EBPs) in centers that may not have the financial or personnel resources for comprehensive psychiatric and mental health treatment. Lack of resources in these environments may manifest as fewer clinicians trained in EBPs, lack of financial resources to train clinicians in EBPs (training tools, facilitators, and facilities), high turnover among clinicians, lower ability to obtain funding for sustainability initiatives, poor adaptability of interventions to community-specific factors (ie, difficulties of translating EBPs to non-academic clinical settings), and insufficient buy-in from administrators, clinicians, and others.

Lindquist and colleagues⁵ use qualitative methodology in “Navigating Funding Cliffs: An Exploration of the Dynamic Contextual Factors That Influence Evidence-Based Practice Sustainment” to examine factors that may contribute to sustainability of the Adolescent Community Reinforcement Approach (A-CRA) for youth with substance use disorders (SUDs) who are engaged in care in community-based clinics. The authors queried clinicians and supervisors at 51 organizations providing SUD services across 27 states that received SAMHSA Center for Substance Abuse Treatment (CSAT) grants between 2006 and 2012. Key themes that emerged from their qualitative analyses about the organization’s A-CRA sustainment trajectory were categorized as pivotal moments (eg, loss of funding resulting in inability to engage in community outreach or purchase of motivational incentives, A-CRA services no longer being billable, the need to obtain other sources of funding), transitions and driving forces (eg, corporate restructuring, staff turnover, and leadership change), and “slow burn processes” (eg, differing treatment priorities between A-CRA and treatment organizations). The main differentiating factor for those organizations able to sustain A-CRA (vs those that were not) was continuous optimization of the fit between A-CRA and their organization, within an organization that was invested in obtaining the resources that allowed them to do so. Additional challenges, barriers, and opportunities experienced during and after the grant periods are discussed in the article in context of A-CRA sustainment. This paper highlights the challenges of “funding cliffs” that treatment organizations face in sustaining EBPs for adolescents with SUDs. This builds and expands on the implementation literature in identifying internal, external, and individual factors that contribute to, and present barriers to, sustainability. A major challenge is the lack of permanency of reimbursement for programs that are rooted in science and that can be performed with fidelity but require costs above and beyond standard practice. Collaborative approaches may help bridge the divide in funding cliffs and improve sustainability of EBPs in community settings. Adoption of community-based participatory research approaches whereby partnerships between academic clinicians and community organizations may help address longitudinal funding issues and reduce the resource burden of providing evidence-based care in communities.⁶ Partnerships between community clinics and school-based clinics may also be effective in increasing accessibility, and diversifying funding sources.⁷ Importantly, navigating funding cliffs in communities’ health centers requires organizational structures with leadership whose priorities are aligned with the priorities of the clinicians and communities they serve. There is a need to develop more EBPs that are measurement informed, to guide more effective interventions. Finally, the field needs the leadership of individuals who have experience with and investment in provision of EBPs that are funded through multiple and varied sources. With stable funding, the field can make meaningful strides in adopting a culture of care, collaboration, and consistency for those residing in low-resourced communities.

Kara S. Bagot, MD

Exposure-Focused Cognitive–Behavioral Therapy for Youth Anxiety Disorders: Superiority Over Relaxation-Based Comparator and Predictors of Response, Bilek et al.

Compared to pharmacotherapeutic and even surgical treatments, establishing the efficacy of psychosocial treatments poses special difficulties. When placebo and sham-procedure controls are combined with randomization and blinding of study participants and the investigative team, clinical trials enable robust inferences about the benefits and harms of interventions because they provide strong protection from bias and confounding.

In the evaluation of psychotherapies, however, randomization to treatments is easy enough, but devising credible comparator treatments and blinding has been controversial and tricky to implement. Considerations often include creating equivalence between treatment groups for the amount and frequency of therapist contact, comparable commitment by study therapists to the comparator treatments, and overall credibility to participants so they have roughly the same outcome expectations across groups, among other things. However, for decades the most common approach in psychotherapy research was to compare a rigorous manualized treatment (which investigators often have motivation to see validated) with rather unconvincing comparators. These include wait-list controls (randomizing patients to receive the study treatment later while they first participate in the evaluation regimen and receive no care); treatment-as-usual (whereby patients go about obtaining routine community services not necessarily at the study site, sometimes with enhanced clinical monitoring by the study team); and attention-controls (whereby patients are seen for comparable time by study clinicians, but treatment is fairly unstructured except for avoiding components of the “active” therapy under study). In the early years, these approaches were justified by assertions such as, “We have to start somewhere, and if our treatments really aren’t better than nothing, we should know that first” and “At least we are empirically validating what we’re doing rather than the who-knows-what’s-going-on in routine care psychotherapy.”

Now, of course, our field has outgrown its youth and is at least well into young adulthood. That means greater responsibility and accountability. Bilek and colleagues⁸ provide a trial framework for anxiety disorders in youth 7 to 17 years of age that demonstrates the new level of methodological sophistication that should now be expected.

The authors point out that the studies evaluating cognitive–behavioral therapy (CBT) for this patient group yielded much larger effect sizes when the comparator condition was a waitlist or similar non-active or “token” treatment (28 studies) than did trials with active-treatment comparators (of which there are only 4). Bilek et al.’s contribution here is to compare 12 weeks of exposure-focused CBT (EF-CBT) with a highly credible comparator, relaxation, and mentorship training. They controlled effectively for clinical contact time, ensured high fidelity for both structured treatments, and measured credibility with a standardized rating scale that showed both interventions to be highly credible to participants. Their findings, which update an earlier interim report, show both groups initially improving with separation favoring EF-CBT by the trial’s conclusion.

I hope this type of design provides a new standard for evaluating psychosocial treatments. However, research in this area will continue to confront challenges in maintaining rigorous implementation and in cost. Studies of this type will probably never be as well resourced as placebo-controlled medication trials, which frequently have industry funding or partial in-kind support such as drug and matching placebos. However, our field is yearning for exactly this sort of guidance from clinical research.

Joseph Blader, PhD

Data-Driven Identification of Brain–Behavioral and Sociodemographic Predictors of Anxiety Severity in Children Using Machine Learning, Iturra-Mena et al.

Iturra-Mena and colleagues’⁹ article illustrates an important area of emerging neuropsychological research, focused on integrating basic neuroscience with clinical observations. Three innovative aspects are worth mentioning. First, the study used cutting-edge machine learning statistical methods that are designed to investigate large datasets without a priori hypotheses. Second, the research examined brain markers of cognition (electroencephalographic [EEG]/electrophysiologic signals) in the context of a behavioral task (Go–No Go task measuring response inhibition) alongside sociodemographic variables associated with anxiety in children recruited from the community. Third, the authors applied the Research Domain Criteria (RDoC) framework¹⁰ launched by the National Institute of Mental Health to use neurobiological measures and observable behaviors to understand clinical phenomena. The aspiration is to use evidence from neuroscience as the foundation for updating mental health diagnoses and to improve upon the nosology as currently described in DSM-5¹¹ and ICD-11.¹²

Iturra-Mena et al. applied machine learning methods to examine large data sets from electrophysiological recordings and response inhibition measures to investigate dimensions of cognition and behavior associated with anxiety in 181 children, 4 to 10 years of age, from 3 previous studies. Machine learning methods analyzed all data points without prespecified research questions. The objective here was to identify the variables most highly associated with childhood anxiety. In addition, the statistical techniques investigated how the neurobiological variables fit together. EEG signals measured cognitive processes such as error identification and attention, whereas the behavioral task measured response to errors. The authors also included sociodemographic and clinical indicators, such as single-parent status and maternal depression scores, which are known risk factors for childhood anxiety. The relative salience of these clinical, cognitive, and behavioral indicators was examined simultaneously. As a child psychiatrist, I am familiar with sociodemographic risk factors for childhood anxiety, such as maternal mental health, single-parent family, child age and sex, and comorbid diagnoses; but I am rarely presented with electrophysiological recordings representing cortical activity in real time during a behavioral task, in this case, response inhibition. These dimensional indicators from preclinical neuroscience represent specific cognitive and behavioral domains that vary among individuals and cut across clinical presentations regardless of specific diagnoses. Examination of such dimensional endophenotypes provides a prime example of how the Research Domain Criteria (RDoC) framework¹⁰ can be applied to provide biological evidence for brain processes related to mental health. The current study identifies that error recognition (hypervigilance) is followed by heightened inhibition of responses (slowed response time) in anxious children, especially when they also exhibit poor attention. These cognitive–behavioral relationships are intensified among children of single mothers. The juxtaposition of these 3 domains—cognitive, behavioral, and sociodemographic—provided a eureka moment for me as a clinician. Anxious people are on the lookout for errors, avoid making them when possible, and with poor focus are even more anxious. Not uncommonly, anxious children cling to their single parent. Many clinicians already identify patterns of cognitions, behaviors, and family relationships, and choose intervention targets based on their observations. Iturra-Mena et al.’s study has elegantly captured a neurobiological picture of these patterns, one that can inform future standards for how to describe a child with symptoms of anxiety. Although it is still in the early days, neurobiological research based on the RDoC framework promises to make clinical categories more precise and to provide more accurate intervention targets for each individual child.

Alice Charach, MD, MSc, FRCPC

Predictive Validity of the e-Connect Suicide Risk Classification Algorithm in Youth on Probation, Sarapas et al.

Despite our best clinical diagnostic and treatment approaches, suicide remains the second leading cause of death from age 10 to age 34 years. Death by suicide is the tip of the iceberg, and the Center for Disease Control and Prevention’s Youth Risk Behavior Surveillance (YRBS) shows, annually among US high school students, that approximately 20% seriously contemplated ending their life (aka “suicidal ideation”) at least once, 16% made a suicide plan at least once, and 9% intentionally tried to end their life (aka “suicide attempt”) at least once; and we mostly talk about the 2% who made a suicide attempt and sought medical care—at least once.¹³

No single effort will solve this problem. There is an urgent need for more research on suicide and self-injury among children and adolescents—every aspect from underlying neurobiological mechanisms; risk and resilience factors including social determinants of health; novel treatments including medications, therapies, and potential digital interventions; and public health and education detection and prevention efforts.

Sarapas and colleagues¹⁴ address this need in an important population—youth on juvenile probation. They sought to test the e-Connect suicidal thoughts and behaviors risk classification system using data from 4,344 youth on probation examined at baseline and up to 4 additional follow-up assessments. Their logistic regressions assessed the relationship between baseline risk class for suicidal ideation, planning, gathering lethal means, and attempts over 12 months. Their primary finding was that baseline risk class predicted the likelihood of all 4 STBs over 12 months, even after adjusting for baseline history of STBs. From this, the authors conclude the tiered risk classification algorithm supports its use in probation settings for triage and treatment considerations. Moreover, such work hopefully inspires others to improve upon our evidence-based approaches for evaluation of suicide risk and guiding appropriate intervention.

Daniel P. Dickstein, MD, FAAP

Clinical Profiles Associated With Deliberate Self-Harm in Preadolescent Children, Thompson et al.

There is a paucity of data about the clinical characteristics of preadolescent children who harm themselves. This is particularly unfortunate, as preadolescent children who deliberately harm themselves are at increased risk for subsequently attempting suicide. A delineation of the characteristics of children who intentionally self-harm could lead to the development of scientifically informed self-harm and suicide prevention initiatives.

Besides describing the features of school-aged children who deliberately harmed themselves, Thompson and colleagues¹⁵ worked to identify which of these children were most at risk for having another self-harm act within the year following their initial incident of self-harm. The authors’ approach consisted of a retrospective cohort design that included children 5 to 11 years of age (inclusive). They focused their study between the years 2010 to 2020 in a Medicaid-enrolled group. This resulted in a cohort of 878 children with a mean age of 9.67 years at the time of the first incidence of self-harm.

The investigators found that 13% of the children who initially self-harmed harmed themselves again within the subsequent year. Using latent class profile methodology applied to the data from children who initially self-harmed, the authors identified 3 distinct patient profiles. The authors found that 2 of the latent profiles were each at greater risk for self- harm when compared to the third group of patients. This third group that were found to be at lower risk for repeated self-harm were younger, had fewer identified psychiatric conditions, and were from non-metropolitan communities.

This paper provides an initial description regarding the clinical profiles of preadolescent children who deliberately harm themselves. In addition, this work describes children who are at increased risk for harming themselves again.

Suicide is a leading cause of death in adolescents. Sadly, suicide has become a leading cause of death in preadolescent, school-aged children. Now, more than ever, we need papers like this to focus work on a topic that has become ever more salient.

Robert L. Findling, MD, MBA

Characterizing Silence: Adolescents’ Nondisclosure of Their Suicidal Thoughts and Behaviors to Their Family and Peers, Spears et al.

How do we prevent suicide in youth who keep their suicidal thoughts and plans to themselves? Many clinicians working with suicide attempt survivors know it is not uncommon for families and caregivers to be unaware that their child was wrestling with these challenges. Not disclosing suicidal thoughts to family hampers the ability of youth to access care and has been linked to future suicidal thoughts and behaviors.16, 17, 18 Recent reports suggest that 3 of every 5 youth dying by suicide in the United States lacks a psychiatric diagnosis.¹⁹ Indeed, for many youth, their first suicide attempt coming to medical attention may be their first interaction with psychiatric care and, furthermore, almost three-fourths of those dying do so on their first attempt, precluding any future intervention.²⁰ The consequences of families and caregivers not knowing about their child’s suicidal thoughts could not be higher. It is therefore imperative for clinicians to better understand the motivations of youth who choose not to involve those people in their personal lives with their suicidal struggles.

In the article “Characterizing Silence: Adolescents’ Nondisclosure of Their Suicidal Thoughts and Behaviors to Their Family and Peers,” authors Spears, Shin and Cha study this oft-neglected group.²¹ Crucially, in exploring thoughts and behaviors that adolescents are reticent to share, the study had to be anonymous. In what is uncommon in adolescent research but necessary to create the space to study this group, parental consent was waived, ensuring anonymity and thereby allowing the authors to remove barriers to participation that might have infringed on the comfort of these youth, thereby limiting both participation and information shared.

Using Instagram, Spears et al. recruited 154 youth 13 to 17 years of age (92.21% female, 72.08% White) from across the United States who had a history of suicidal thoughts and/or behaviors (STBs). This group then participated in a Web-based survey regarding lifetime history of STBs and their nondisclosure of these experiences to caregivers. Most adolescents (69.46%) identified a family member as their primary confidant, with a slight preference for nonparental family members over parents (35.06% vs 34.42%). Almost a third did not disclose any of their STBs to anyone in their lives, becoming what the authors label as perpetual nondisclosers. Selective nondisclosers, the majority of the sample (72.08%), had disclosed to a confidant but had at least one social contact from whom they withheld information. The authors identified that fear of negative reactions, resistance to intervention, concern for dismissal of suicidality, and self-reliance were the main factors behind nondisclosure. Compared to those individuals who selectively nondisclosed, perpetual nondisclosers were more likely to identify self-reliance and concern about dismissal of suicidality as their main reasons for not disclosing to their primary confidant. Although the occurrence of making suicidal plans and history of suicide attempts did not differ between these 2 groups, perpetual nondisclosers reported significantly more frequent suicidal thoughts.

What does this portend for mental health professionals working with suicidal patients and their families? Families will struggle to help their children if they are unaware of their plight. Spears et al.’s study nonjudgmentally examines nondisclosure of STB in youth, helpfully seeking to understand the complicated reasons behind this nondisclosure while recognizing the purpose that nondisclosures might serve. Understanding the complexity behind adolescents’ unwillingness to share their suicidal thoughts, plans, and behaviors with those caring for them most might start to help us, as a field, to think of new and creative ways of working with families and engaging youth who might be at risk for death by suicide. The authors’ initiative to study this neglected group and the potential that better understanding these adolescents has for engaging and addressing suicide risk propels this paper to one of our “Best of 2025.”

Alastair J. S. McKean, MD

Vortioxetine for Major Depressive Disorder in Children: 12-Week Randomized, Placebo-Controlled Study, Huss et al.

In the year’s Best of JAACAP Open, the article by Huss and colleagues²² is highlighted for reporting on the safety and efficacy of vortioxetine in youth with major depressive disorder between the ages of 7 and 11 years. Vortioxetine did not separate from placebo on efficacy (p <.09), and nausea was the most common adverse event (11.1%-12.6%). This article is featured because it generates evidence for safety despite lack of efficacy of vortioxetine for depression in children between the ages of 7 and 11 years. Few prior clinical trials have focused on testing treatment efficacy in children with depression in this age range. Furthermore, double-blind randomized controlled clinical trials (RCTs) provide the strongest level of evidence on which to base our clinical practice, and are essential to the field of child and adolescent psychiatry. All outcomes from well-designed clinical trials, either positive or negative, can inform clinical practice, and it is helpful to pay attention to how researchers reporting clinical trial outcomes prioritize primary and secondary outcomes, and to appreciate what we can learn from them, respectively.

Mechanistically, vortioxetine is reported to increase serotonin levels in the brain by inhibiting its reuptake, which in turn modulates and stimulates various serotonin receptors contributing to an antidepressant effect. We have observed many depression trials of medications with a variety of different mechanisms fail to separate from placebo.²³ It is unclear why the slight improvement in depression severity with vortioxetine compared to placebo was not significant. Was a baseline severity score of 40 or more on the Children’s Depression Rating Scale insufficient? Were there too many sites or too many arms?

Because the ways in which a positive trial outcome informs clinical practice are self-evident, here are a few ways in which negative randomized controlled trial outcomes are essential for progress in the field of child and adolescent psychiatry. First, negative RCT results provide an essential counterbalance in child and adolescent psychiatry by defining the limits of efficacy, preventing premature uptake of unproven treatments, and ensuring that clinical practice remains evidence based. For instance, several pediatric depression trials of paroxetine and citalopram demonstrated no superiority to placebo and raised concerns about increased suicidality, prompting black-box warnings and positioning other antidepressants such as fluoxetine, and later escitalopram, with more reliable evidence to be Food and Drug Administration approved in youth for depression. Beyond efficacy, negative RCT results contribute critical safety data and demonstrate large placebo and nonspecific treatment effects, possibly redirecting research toward novel pharmacologic strategies or psychosocial models of care. Taken together, negative trial results act as evidence-based safeguards, ensuring that vulnerable youth are protected from ineffective or harmful interventions, while sharpening guidelines and resource allocation in psychiatric practice. Thus, data-informed clinical decision making can be enabled by negative trial results to better optimize and personalize treatment based on reported adverse events and secondary outcome analyses.

Manpreet K. Singh, MD, MS