Pediatric Psychopharmacology: Combining
Medical and Psychosocial Interventions is written by three psychologists to
inform nonphysician practitioners regarding the psychopharmacologic treatment
of the pediatric population as well as the collaborative options in such
treatment (p.3). In this age of
cooperative treatment between physicians (psychiatrists as well as primary care
specialists) and nonphysician mental health care providers, the books goals
are timely and appropriate. The book
contains 10 chapters. The first three
chapters include an overview of collaborative practices, methods for monitoring
medication treatment, and addressing barriers to treatment. The last seven chapters cover specific
mental illnesses and their treatment with both psychopharmacologic and
As I began reading the book, I was
struck by a paradox. Though the authors
advise and recommend collaborative efforts with prescribing physicians, they
did not follow their own advice. Rather
than joining in their writing efforts with a child psychiatrist experienced in
psychopharmacology, they chose not to collaborate and instead wrote this book
based on their own experience and knowledge as nonphysician professionals. The effects of this choice echo through the
book, as it reads as though it were written based on books and papers, and
lacks an appreciation for the complexity and ambiguity of medication treatment
for individual children with mental illness.
For example, the first chapter includes a section on the importance of
identifying intervention goals in treatment.
The scenario illustrating this involves a child with oppositional
defiant disorder and generalized anxiety disorder. In this case the authors state, the intervention will very
greatly depending on whether the primary goals of treatment pertain to the
alleviation of oppositional behavior or to the symptoms of anxiety (p.
7). This example and statement imply
that oppositional defiant disorder and generalized anxiety disorder are
separate and distinct disorders that can be addressed independently of each
other. Is this true? Or are these two disorders often intertwined
in an individual patient, such that the symptoms of both are due to common
underlying causes? In my experience,
making environmental modifications to reduce oppositional behavior frequently
reduces anxiety, and pharmacological treatment of anxiety often reduces
Chapter 1 also includes a review of
the arguments for and against prescribing privileges for psychologists. This section is particularly interesting to
read given recent events in New Mexico, where prescribing privileges for
psychologists were recently signed into law.
However, it is unclear why a book dedicated to teaching pediatric
psychopharmacology devotes significant space to this highly politicized issue.
The second chapter presents various
rating instruments for monitoring treatment outcomes, appropriately emphasizing
the need for target symptoms. It is not
clear whether the authors are recommending the use of these instruments in all
clinical situations, or only in select situations (such as a research
environment). If the former is the
case, they present a rather cumbersome system for the ongoing assessment of patients
and monitoring treatment outcomes. Many
children have several overlapping conditions, and would need to be tested
repeatedly with multiple devices. This
would require time to administer, score, interpret, and communicate the results
of such tests. Who would pay for this
time? Would it be taken from time
otherwise dedicated to the face-to-face interactions crucial to building
rapport? Is there conclusive evidence
that rating instruments lead to more effective treatment than treatment that
identifies specific treatment goals without such instruments? In the same chapter, the authors recommend
placebo controlled single subject procedures in treating children (p. 36). What are the ethical issues involved in such
trials? What are the implications of
treating an individual with a placebo when that individual has a condition for
which medication has been proven effective?
These important questions are not addressed.
At times the writers take a
paternalistic attitude towards treatment methodology. For example, in Chapter 8, Mood Disorders, they recommend
primarily psychotherapeutic treatment of depression. It is advised, therefore, that treatment of pediatric depressive
disorders always incorporate psychological (e.g. cognitive-behavioral and interpersonal)
intervention components and that medication be viewed as a possible
augmentation (p. 166). In my opinion,
there are two problems with this position.
First, it discounts the results of recent placebo controlled randomized
clinical trials on the treatment of pediatric depression, which show that
medications are well tolerated and effective in the treatment of pediatric
depression independent of psychotherapy.
The efficacy of both fluoxetine (Prozac) and paroxetine (Paxil) have
been validated through this research (Keller
2001, Emslie 1997). Second, the
authors statement neglects the ethical principle of autonomy, that is the right of patients (or in the
case of minors, their parents) to choose among treatment options for
themselves, rather than the health care provider choosing for them. Medications are a reasonably safe and
effective treatment for depression.
Patients and their families should be informed of this, and should they
choose this option, treatment with medication should be facilitated in an
appropriate environment. To relegate
psychopharmacologic interventions to an adjunctive role to therapy fails to
take into account the scientific support for medication treatment, and denies
patients the right to choose for themselves the method(s) of treatment with
which they are most comfortable.
Parts of the book revealed a
surprising number of errors, some of which were merely annoying and others that
were frankly misleading. There are
multiple incidences of medication names or trade names being misspelled. Some examples include Dexadrine instead of
Dexedrine (p. 110), Resperidone instead of risperidone on three occasions (p.
115), and olanazapine instead of olanzapine (p. 139). More concerning is a chart summarizing
medications for ADHD where the authors list appetite suppression as an adverse
effect of dextroamphetamine and methylphenidate (p.111). However, in the same chart they do not list
appetite suppression as a side effect of Adderall (a combination of
dextroamphetamine and racemic amphetamine).
This error could easily lead a reader to falsely believe that Adderall
does not suppress appetite, even though this is a well-known and common side
effect. Finally, errors in a chart
summarizing medications used for treating tics are potentially dangerous
(p.212). There, medication doses are
wrongly listed as mg/kg/day, when they should have been listed as mg/day. As some of these medications have serious
cardiovascular effects, children could be gravely harmed if a physician or
other practitioner unfamiliar with these medications were to use this chart as
a reference in prescribing or administering them. The difference between treating a 20 kg child with 0.3 mg/day of
clonidine as opposed to 0.3 mg/kg/day (a dose of 6 mg/day) is potentially life
threatening. Whether these errors are
due to careless proofreading or to a lack of experience and knowledge of the
subject, they are misleading and possibly dangerous.
This book has areas of
strength. It is well referenced, with
citations listed at the end of each chapter.
Chapter Three includes an excellent section on overcoming barriers to
treatment via education, support, collaboration, and community based
services. The use of Prochaskas five
stages of change is a useful way to conceptualize and understand how patients
and their families come to accept, learn about, and eventually engage in
treatment of mental illness (p. 49).
Furthermore, the discussion of social validity as a potential obstacle
to treatment captures the importance of recognizing how cultural factors can
influence treatment on an individual or family level. Unfortunately, these strengths are overshadowed by the texts
Mental health professionals need to
collaborate to increase the awareness of mental illnesses as treatable
conditions, improve the quality of treatments available, and conduct research
to develop new treatment options. This
book offers useful information about how to collaborate as well as ways to use
rating instruments in the treatment process.
But it lacks the very collaborative attitude it recommends to others,
and contains numerous and significant errors.
Other books on pediatric psychopharmacology are more comprehensive and
more factually accurate, including Practitioners Guide to Psychoactive
Drugs for Children and Adolescents by Werry and Aman. For nonphysician practitioners seeking more
information on this subject, close collaboration with physicians and/or
pharmacologists is vital adjunct to any text.
A double-blind, randomized, placebo-controlled trial of fluoxetine in children
and adolescents with depression. Archives of General Psychiatry, Nov 1997,
MB, Ryan ND, Strober M, Klein RG, Kutcher SP, Birmaher B, Hagino OR, Koplewicz
H, Carlson GA, Clarke GN, Emslie GJ, Feinberg D, Geller B, Kusumakar V,
Papatheodorou G, Sack WH, Sweeney M, Wagner KD, Weller EB, Winters NC, Oakes R,
McCafferty JP. Efficacy of Paroxetine
in the Treatment of Adolescent Major Depression: A Randomized, Controlled
Trial. Journal of the American Academy
of Child and Adolescent Psychiatry, July 2001, 40(7): 762-772.
JS, Aman MG. Practitioners Guide to Psychoactive Drugs for Children and
Adolescents, 2nd Edition.
Plenum Publishing Corporation, New York, NY, 1999.
2002 Christopher A. Lamps
A. Lamps, M.D., Instructor, ACH Pediatric Psychiatry, and Medical Director,
Child Study Center,
University of Arkansas for Medical Sciences