Child and Adolescent Psychopharmacology

Child and Adolescent Psychopharmacology

S.P. Kutcher

Philadelphia: WB Saunders; 1997. 509 pp. with index

ISBN 0-7216-5749-4

This book represents the state of the art in childhood psychopharmacology. Well written and capturing the highest level of existing evidence in the field, it serves as a reference text as well as an instructive how-to manual for those practising childhood psychopharmacology.

The text is organized into five sections. Section 1 is very brief and introduces the book by outlining the move toward empiricism in child and adolescent psychopharmacology, specifically, and childhood psychiatric disorders, generally. A broad clinical model is emphasized, to bring the science of the controlled experimental study into the realm of the clinical environment by combining medication with other empirical interventions.

Section 2 deals with baseline assessment before beginning psychopharmacological treatment. The section begins with general issues and then moves to more specific assessment, both in terms of rating scales for different disorders as well as more specialized ancillary assessments such as family, social and interpersonal, academic, speech and language and institutional assessments. The fourth chapter of the section covers baseline medical assessment for psychopharmacological treatment. Useful pointers in the medical history, exclusion of medical illness, baseline investigations and monitoring (including principles of therapeutic drug monitoring) are covered extensively.

Highlighted summaries allow quick rereading of a chapter. In addition, chapter 3, which deals with individual baseline psychiatric assessment for psychopharmacological treatment, has several useful tables with pointers to the psychiatric diagnosis. The reader is referred to relevant rating scales contained in the appendices. Of great use to the busy clinician is the visual analog scale, which allows for baseline rating and monitoring of specific target symptoms. Chapter 3 uses case examples and commentaries to illustrate points made in the text. These cases are relevant and reminiscent of my own day-to-day practice. Each raises important clinical examples and dilemmas. Rather than distracting from the text, in most cases they reinforce the text and make the book more readable. This excellent technique continues through the rest of the book.

Section 3 covers the planning, initiation and provision of psycho-pharmacological treatment. Although superficially this section seems to repeat some of the content of the previous section, it does in fact offer additional wisdom and deals with important practical issues in the treatment of children and adolescents generally and psychopharmacology more specifically. The principles of patient and family education are clearly articulated, as are the standards of informed consent. While legislation may vary in different jurisdictions, a useful set of guidelines is provided for obtaining informed consent from both the child and family, taking into account the developmental and cognitive status of the child. Throughout, the book adopts a respectful client-centred philosophy. This attitude is well reflected in the clinical case examples.

Section 4, appropriately the most dense segment of the book with 10 chapters, deals with the clinical practice of child and adolescent psychopharmacology. Each chapter outlines the treatment of a particular disorder, with 3 chapters devoted to the anxiety disorders; the first of these very briefly describes the general issues in the psychopharmacological treatment of the anxiety disorders, followed by a chapter devoted to the treatment of panic disorder and the third to other anxiety disorders. The author emphasizes the high morbidity of anxiety disorders beginning in childhood and suggests that evidence supporting the principle of least intrusive intervention first is lacking. Combined interventions (pharmacological and psychological) applied aggressively, especially when symptoms and functional impairment are significant, may lead to better outcomes. This principle is applied in the subsequent 2 chapters. In keeping with the format of the book, these 2 chapters guide the clinician — with the use of case material — through the management of these disorders, providing a framework for assessment and measurement of outcome, as well as the specifics of drug choice, augmentation techniques, dosage ranges and some principles for treatment duration.

Other chapters that are highly recommended are those on the treatment of depressive disorders and bipolar disorder. In chapter 11, the author takes the reader through the standard management of depressive disorders in childhood and adolescence using 2 case examples and commentaries, which highlight treatment issues. The text is written like an expanded step-wise treatment manual but remains interesting and readable. The chapter focus is on the use of selective serotonin reuptake inhibitors (SSRIs). While the author clearly outlines alternative and augmentative treatment strategies, he completely dismisses the use of tricyclic antidepressants (TCAs) as alternatives, although there may still be a role for these drugs — for example, the use of desipramine or nortriptyline to treat dysthymia in adolescents with comorbid attention deficit hyperactivity disorder. There is only a single line devoted to the newer-generation antidepressant venlafaxine, and this appears odd and out of context. Nefazodone is not mentioned at all, perhaps because of its novelty.

Chapter 12 is thorough in its review of the thymoleptics and ancillary treatments for bipolar disorder. A subsequent edition will likely review the use of the novel antipsychotics, especially risperidone and olanzapine in the treatment of bipolar disorder with psychosis. These drugs are not mentioned, perhaps as a result of the author’s use of the highest available level of evidence in outlining psychopharmacological treatment of children.

If this book has any drawbacks, it is a tendency to be long-winded and repetitive. For example, the last paragraphs of the 2 case commentaries in the chapter on acute schizophrenia (chapter 13) are almost identical. While each of these paragraphs (page 224 and page 225) “emphasize[s] the importance of using proper pharmacological treatment within the context of optimal and comprehensive care” “and keeping in mind the expected paradigm of chronic care with the goal of controlling acute symptoms, preventing relapse, and optimizing patient function,” a single statement would suffice. Occasionally, terminology is used loosely; for example, neuroleptic malignant syndrome is referred to as a “true psychiatric emergency” when it is better defined as a true medical emergency. The section describing “initiating and optimizing methylphenidate treatment” (on page 279 of chapter 15, “Psychopharmacologic Treatment of Attention-Deficit Hyper-activity Disorder”) is quite unclear: 2 potential strategies are outlined (1 and 2) and then strategy 3 (which appears to be strategy 1) is referred to in the case example. Furthermore, it is difficult to determine any real difference between strategies land 2.

There are 7 appendices, which provide an inclusive array of potential rating scales available for the use of psychopharmacologists treating children. The book is well indexed, and a useful reference list can be found at the conclusion of each chapter.

Overall, this book is a very useful addition to the growing library of texts on child and adolescent psychopharmacology. I strongly recommend it as a useful and practical guide for practitioners prescribing psychopharmacologic agents to children and adolescents. I look forward to an updated and perhaps more streamlined edition in a few years’ time.