Practical Child and Adolescent Psychopharmacology

Child and adolescent psychopharmacology has definitely been coming of age. The field has been rapidly expanding as well-established and less well-established pharmacological treatments for different child and adolescent mental disorders become available. The demands for guidance through this new field have been growing. As a result, textbooks of child and adolescent psychopharmacology started to arrive.

The newest arrival, Practical Child and Adolescent Psychopharmacology, in the Cambridge Child and Adolescent Psychiatry Series, is edited by Stan Kutcher, a well-known child and adolescent psychopharmacologist. He assembled a team of 31 distinguished contributors from Canada, the United Kingdom, and the United States. The book consists of 15 chapters and could be divided into two parts: introduction plus general issues in child and adolescent psychopharmacology (chapters 1, 2, and 3) and psychopharmacology of specific disorders (the remaining 12 chapters). Let me summarize the contents of the book first and then evaluate it.

The first two chapters provide a social and developmental context of child and adolescent psychopharmacology. Chapter 1, “Child and Adolescent Psychopharmacology at the Turn of the Millennium,” briefly summarizes the history of the field and then discusses the changing prescribing philosophies, new trends in prescribing, setbacks, and rising expectations. Chapter 2, “Developmental Psychopharmacology,” deals with some important biological concepts, such as plasticity and sensitive periods in development, apoptosis, cellular migration and growth, coupling, the effects of stress and early experience on hippocampal neurogenesis, and pediatric pharmacogenetics. Chapter 3, “Clinical Aspects of Child and Adolescent Psychopharmacology,” is a thorough overview of basic clinical issues in prescribing psychotropic medications to children and adolescents. It discusses information gathering (structured and unstructured interviews, the parental interview), baseline assessment for psychopharmacological treatment (including a great mental status chart), psychoeducational aspects of prescribing, deciding which medication to use, and how long to treat. This chapter reminds the reader that 1) while the rest of medicine relies increasingly on procedures, tests, and the like to define diagnosis, psychiatry must still live by its wits and 2) child psychiatrists are referred the most diagnostically complicated, treatment-refractory children.

The rest of the book focuses on psychopharmacology of specific disorders. Chapter 4, “Depression,” is a short overview of psychopharmacology for depression with general guidelines for treatment of child depression. Chapter 5, “Bipolar Mood Disorders: Diagnosis, Etiology, and Treatment,” summarizes the diagnostic issues, biology, and treatment issues of bipolar disorders. Chapter 6, “Schizophrenia and Related Psychoses,” provides, among other material, guidance to the management of the acute phase of psychosis, intermediate and long-term management, and management of the side effects of neuroleptics. I was surprised by suggestions to start treatment with older, “typical” neuroleptics and that a combination of medium- and low-potency neuroleptics may be useful during the first week or two of acute management. Chapter 7, “Obsessive-Compulsive Disorder,” discusses the epidemiology, diagnosis, etiology, and treatment of obsessive-compulsive disorder (OCD). The lengthy discourse on etiology starts with the obvious—“The etiology of OCD is unknown.” Chapter 8, “Anxiety Disorders,” contains a well-organized and practical summary of psychopharmacology of anxiety disorders (e.g., a dosing table), but the discussion of CNS mechanisms for anxiety is superfluous. Chapter 9, “Attention-Deficit/Hyperactivity Disorder,” is a scholarly overview of the literature on the treatment of ADHD and future directions. Chapters 10, “Pervasive Developmental Disorder,” and 11, “Aggressive Behavior,” summarize the limited body of evidence on psychopharmacology of these groups of disorders or behaviors. Chapter 12, “Adolescent Substance Use Disorder,” is a lengthy discourse on etiology of substance use disorder and its treatment in adults but provides very little guidance on treatment of adolescent substance use disorder. Chapter 13, “Tic Disorders and Tourette Syndrome,” is a surprisingly lucid and informative summary of the treatment of tics. It emphasizes that most clinicians are shifting away from tic suppression and that comorbid conditions, more than tics, are the object of clinical attention lately—for any tic, including Tourette’s disorder. Chapter 14, “Eating Disorders and Related Disturbances,” gets quickly into the psychopharmacology of these disorders but provides little information on treatment of children and adolescents. The last chapter, “Medical Psychiatric Conditions,” reminds the reader of the association between medical and psychiatric illnesses such as epilepsy, headache, and asthma.

Although this book provide a wealth of information, I do not believe that it fulfills the goal set by its title. The book is informative but not “practical.” Some chapters are brief and shallow, and some contain lengthy and scholarly but not very useful discourses on etiology, but most of the chapters give us little practical guidance on the nuts and bolts of child and adolescent psychopharmacology. The book could also benefit from using more case vignettes. I was surprised by the lack of attention to detail on the part of the publishing house, demonstrated by typographical and factual errors (the brand name of citalopram is not Celebrex; brofaromine is not bufaramine). However, in all fairness, some chapters—the ones on clinical aspects of child and adolescent psychopharmacology, on anxiety disorders, and on tic disorders—are excellent, practical, and useful. The book is also well referenced.

I feel that this book will be appreciated by those preparing for a child and adolescent psychiatry examination or by academic child and adolescent psychopharmacologists. Those looking for quick and practical guidance, unfortunately, will be disappointed.