Child and Adolescent Psychopharmacology

Reading a psychopharmacology text, although illuminating, can prove to be an alienating experience. Patients seem rapidly distilled into minimalist diagnostic labels, complex disorders become ill-wired neural circuitry or the byproduct of misbehaved genetic turmoil, and the task at hand can appear as no more than glorified matchmaking between molecules and receptors, with constant avoidance of the story’s ever-present bad guys: side effects and drug interactions. Pediatric psychopharmacology, that budding field rapidly coming of age, has been no exception to the rule. Children and adolescents who are textured and alive rather than neurochemically and comorbidly abstract—kids, in other words—have been notoriously underdosed in the few pediatric psychopharmacology textbooks that are out there. It is not the inner-life-meets-big-science that I am advocating for here, nor the softening and heartening of what little hard science we have available, but, rather, for a book capable of recalibrating the focus of our scientifically fast-paced days. A book written from regular action at the office or the bedside, rather than from machinations in the library or the wet lab, or from keyboard virtuosity at MEDLINE’s feet.

Stanley Kutcher has written just such a book, one that is refreshingly full of kids depicted through clinical vignettes that ring true with familiarity. There are those who refuse medication, those who can’t get enough, and those who punish their parents through their noncompliance. There are the ones who get better, and the many who don’t; those who magically turn around on a stimulant, and those who are chugging along through an umpteenth medication cocktail. There is throughout the book an understanding of the battleground that the prescription of medication can become for adolescents, and of the subtleties involved in dealing with troubled families, with complex systems, and with the many players involved in a child’s care. This, in brief, is a book reflecting a wealth of clinical experience and written with rolled-up sleeves from well within the trenches of everyday clinical practice.

The book’s many strengths clearly lie within the clinical domain. In fact, a “Clinical” prefix or an “in Clinical Practice” suffix would have done justice to its title and served to reflect more accurately its content and aims. Despite a long introduction highlighting the scientific underpinnings of pediatric psychopharmacology and the discipline’s increasingly evidence-based foundations, the book is at times thin with data on which to claim solid ground. The landscape is especially barren when outright downward extrapolations from the adult literature that have not been adequately studied in minors are debited against the book’s overall balance.

With such caveats in mind, the tone set at the outset comes across as overly enthusiastic, making me unable to backslap and high-five in the name of the field’s scientific good standing. For example, an early chapter on panic disorder, while useful and concise, seems prematurely authoritative, given the minuscule literature specifically about juveniles with this disorder, the fact that little developmental consideration has been given to its nosology and natural course, or that extensive pharmacological recommendations are endorsed with scant or absent empirical support. Similar limitations color the approach suggested for treatment-resistant depression, for the use of novel antidepressants in an array of disorders, or for the long-term management of youngsters with schizophrenia, to name a few. For readers not entirely familiar with the field, it can prove challenging to disentangle what in the end is but a single individual’s recommendations (even if that individual is one as experienced as Dr. Kutcher) from what is based on published studies in which the data are critically reviewed. The ambiguity is also palpable in the many footnotes to otherwise excellent tables, which suggest that information has been partly compiled from the author’s own clinical experience. The fact that each chapter ends with a small list of “suggested readings” (a series of review papers and other books), rather than the more formal “references,” “bibliography,” or “literature cited,” further contributes to the difficulty in telling excitement and experience from supporting evidence.

Dr. Kutcher’s book succeeds in accurately reflecting the status of North American pediatric psychopharmacology. It puts its finger on a very real pulse—one in which a paucity of data is balanced against the legitimate wish to treat with ever more powerful compounds, and in which psychosocial and pharmacological interventions are not as cozy with each other as one would hope. As such, the limitations and shortcomings of the book are in no small measure those of the field more generally. By including 130 pages of appendixes culling together an array of rating scales, Dr. Kutcher has made a serious attempt (and an unspoken invitation) to bring legitimate metrification into the practicing clinician’s regular job description. Bearing this important effort in mind, the reader can view the introduction as praying for scientific validation rather than preaching many such spoils.

Child and adolescent psychiatrists are faced with the daily challenge of helping youngsters with severe, chronic, and incapacitating conditions that have not escaped the additional yoke of public stigmatization. There is much that can be hoped for realistically in the future pharmacological treatment of neuropsychiatric conditions of youth, but practitioners today can hardly be paralyzed in inaction while waiting for the development of full scientific clarity. The rigors of clinical trials methodology are especially time-consuming and slow in gestation. Dr. Kutcher has taken a frank stab at instrumentalizing the myriad treatment options available today and in leading the way along a rational path of psychopharmacological intervention with children and adolescents. If, in Dr. William Osler’s famous words (borrowed from the book’s first line), “medicine is a science, the practice of which is an art,” it may be said of pediatric psychopharmacology that it too is a science—one in its tender infancy, and whose art has to be practiced with maturity well beyond its years.