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Pediatric PsychopharmacologyReview - Pediatric Psychopharmacology
Principles and Practice
by Andres Martin, Lawrence Scahill, Dennis S. Charney, James F. Leckman (Editors)
Oxford University Press, 2003
Review by Michael Brodsky, M.D.
Mar 25th 2004 (Volume 8, Issue 13)

A large body of research literature exists on the topic of treatments for adults with psychiatric disorders. Although this research does not always provide clear-cut answers to clinical questions, by and large one can find a published study or opinion on most topics and questions within adult psychiatry.

In the field of child psychiatry the scene is quite different. There are far fewer child psychiatrists overall, and child psychiatric researchers in particular, than there are adult psychiatrists and researchers. In adult psychiatry there are at least four major monthly journals devoted to publishing significant research findings; in child psychiatry there is one. Many basic questions pertaining to the psychiatric treatment of children and adolescents remain unanswered, or even unasked.

Thus, the editors of Pediatric Psychopharmacology faced a considerable challenge in assembling a compendium of the accumulated knowledge pertaining to the psychopharmacological treatment of children and adolescents. Three of the editors are on the faculty of the Yale Child Study Center, while the fourth is a senior scientist at the National Institute of Mental Health (NIMH). The volume is dedicated to the memory of Donald J. Cohen, the late chairman of child psychiatry at Yale, who was a major force behind the ascension of the neurobiological perspective in child psychiatry over the past three decades.

The volume is divided into for major sections: an introductory section on the neurobiological underpinnings of current understanding of both mental illness and drug effects in the central nervous system; a lengthy section on the classes of medications and other "somatic" interventions most commonly used in child psychiatry; a section on issues and recommendations in assessment and treatment of childhood mental disorders; and a concluding section on issues in research, ethics, and epidemiology that confront contemporary child psychiatrists. More than one hundred authors contribute to the volume's 56 chapters, and the table of contents contains a virtual Who's Who of American and international academic child psychiatry. Most of the authors are the preeminent authorities on their subject matter--again a reflection of the relatively small community that constitutes academic child psychiatry.

A formal review of child psychopharmacology forms only one quarter of the volume, and one wonders if a more descriptive title would have been The Biological Basis of Child Psychiatry. The book aspires to address nearly every aspect of child psychiatric practice, covering aspects of the topic well beyond the realm of medications and their use. The breadth and depth of coverage is quite remarkable, ranging from musings on the influence of pharmaceutical companies in a chapter on prescribing practices, to detailed description of the anatomy of the bladder in a chapter on enuresis, to detailed and highly technical descriptions of neuronal migration in the forebrain in a chapter on neurological development. Detail about each of the medications in the child psychiatrists' armamentarium is extensive without becoming overwhelming. The authors do a good job of highlighting controversies and pitfalls in the field, such as the reported association between valproic acid and polycystic ovary syndrome. At a hefty 791 pages, the book appears better suited for use as a reference text to be consulted selectively rather than an overview to be read cover-to-cover in a few sittings. Additionally, the book appears to be aimed squarely at psychiatrists and associated faculty in academic settings, as few clinicians in private practice will likely appreciate the extensive content on non-clinical, basic science aspects of psychopharmacology.

A particularly valuable and unexpected feature of the book is the inclusion of more "philosophical" chapters, which consider the context and larger meanings of psychiatric medications for children. In chapters with titles such as "Psychopharmacological Treatment of Preschoolers," "Thinking About Prescribing," "Who Is Prescribing? And for Whom, How, and Why?," the authors take a step back from the raw data of clinical trials and pharmacokinetic studies to consider what the use of psychotropic medications implies about child psychiatrists, the parents and children who seek treatment, and the role of medications in society.

As with all medical textbooks, there is a significant lag time between submission of the manuscript and appearance of the work in print. Most of the research papers cited were published during or before 2001, which is an impressive feat for a book published in 2003. However, some important issues that have emerged since 2001, including the FDA's recent precautions regarding SSRI's in children, and the withdrawal of nefazodone from European markets, are not addressed in this volume. The citations and bibliographies at the end of each chapter are extensive and up-to-date. An increasingly common practice in psychiatry texts is for the most important two or three references to be marked with an asterisk, and this would have improved the utility of the reference lists.

In summary, then, Pediatric Psychopharmacology provides a well-written and nearly comprehensive guide to the biology of mental illness in children and adolescents.

The editors manage to survey the broad and sometimes contradictory corpus of literature in the field and to organize current knowledge in a reader-friendly format and sequence. The authors for the most part write in crisp and engaging prose. One wishes that they could make more conclusive statements about clinical decision-making, but the relative paucity of research in the field preclude definitive treatment strategies for many conditions. Nevertheless, the book is likely to become a landmark in the field and to set a new standard for research-driven publications in child psychiatry.

 

© 2004 Michael Brodsky

 Michael Brodsky is a psychiatrist in training in Los Angeles, California, and an avid reader.


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