Abstract
PEDIATRIC AND ADOLESCENT PSYCHOPHARMACOLOGY: A PRACTICAL MANUAL FOR PEDIATRICIANS by Donald E. Greydanus, Joseph L. Calles, and Dilip R. Patel. 2008. Cambridge University Press, Cambridge, England. 277 pages.
The authors state at the beginning that their goal it to provide information about psychiatric medication use in children for pediatricians, nurses, and nurse practitioners, and they attempt this feat via a volume consisting of thirteen chapters. Some of the chapters are written by various combinations of these contributors; however nine of the chapters do not indicate an author suggesting that they were written as a part of a group effort.
The first three chapters focus on the basics: the principals of psychological management, basic neurochemistry, neuroanatomy and neurotransmission, and the third on the fundamentals of prescribing psychotropic medication. Chapter one is written by the psychologist of the group and briefly outlines the types of psychological treatments used to treat children with a variety of psychiatric problems. Descriptions of standard treatments used in psychiatry are followed by more specific indications of which treatments would be most commonly used in children and adolescents. This is followed by more detailed depictions of the types of treatments used with the more common types of psychiatric disorders or symptoms (e.g., anxiety disorders, attention-deficit/hyperactivity disorder (ADHD), sleep problems). Of note, at the end of this chapter there is a comprehensive table outlining evidenced treatments for anxiety disorders. Chapter two covers pharmacokinetics and basic neurochemistry including descriptions of the major neurotransmitter systems. It is brief and nicely written but has limited information on the known differences between children, adolescents, and adults.
Chapter three covers the basics of prescribing psychopharmacologic agents. It addresses the role of the Federal Drug Administration (FDA) and gives examples of recent warnings. The need for proper diagnosis, obtaining a good history and psychosocial assessment, and reviewing product information, the role of nonpsychopharmacological treatments, informed consents and patient and family education form the foundation of this chapter. There are also brief descriptions of switching, augmentation, discontinuation, and monitoring of psychotropic medications. The authors include an extensive table of the medications used to treat psychiatric problems in children that includes the uses and approved ages for each medication. At the end of this chapter is a useful table for caregivers about monitoring for suicide when a child is prescribed antidepressants.
Each of the next nine chapters covers the use of psychiatric medications in a particular psychiatric disorder or symptom. Most follow the same basic format: epidemiology and diagnosis/differential diagnosis/comorbid disorders, medications used, dosing strategies, FDA approved indications and ages, side effects, drug/drug interactions, contraindications, and monitoring.
The chapter on anxiety disorders describes a host of possible medications for the treatment of anxiety in children. The serotonin selective reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), buspirone, mirtazepine, propranolol, and benzodiazepines make up the bulk of this chapter. The chapter on ADHD is particularly well written, with two excellent tables: “Principles of psychopharmacological management of ADHD” and a psychostimulant medication table with brand name, dosage forms (including whether pills are scored or a liquid form is available), dose sizes, initial doses, titration and typical maximum doses, and duration of effect. Other medications such as atomoxetine, bupropion, tricyclic antidepressants, clonidine, guanfacine, venlafaxine, and modafinil are described later in the chapter. Of note, these nonstimulant medications are not described in as great detail as the psychostimulants. However, this may be understandable given the fact that they tend to be used when the often successful psychostimulants have failed or have a poor side effect profile or are contraindicated in a given patient. However, although the authors are careful to point out the need for cardiac monitoring, they do not refer to the sudden deaths published in relation to TCAs or the psychostimulant/clonidine combination use in children. In addition there is no algorithm or suggested guidelines describing under which circumstances these nonstimulants should be used.
The chapter on depression in children and adolescents makes the excellent (and practical) point that a lot of the dosing regimens used in children and adolescents are extrapolations of those used in adults. The authors discuss all of the available marketed antidepressants, mood stabilizers such as lithium, valproic acid, carbamazepine, lamotrigene and oxcarbazepine, and the anitpsychotics quetiapine and olanzapine. There is a table that describes the daily doses and the age of approval for either depression or bipolar disorder (although the table does not indicate for which disorder the age is indicated) and finally the chapter ends with two algorithms: one for major depression without psychosis and the other for bipolar depression. These are excellent; however, they appear more geared towards adults and perhaps adolescents than children.
The next chapter covers the infamous disruptive behaviors. Its strengths lie in the two excellent tables of disorders associated with disruptive behaviors and aggression and recommended pharmacologic strategies for certain psychiatric disorders associated with aggressive or violent behaviors. The chapter on schizophrenia in childhood and adolescence covers many of the medications used to treat schizophrenia and has a medication treatment algorithm at the end of the chapter; however, this chapter seems to be geared towards the treatment of adolescents and adults rather than children. The chapter on the treatment of autism spectrum disorders is brief and to the point; it is interesting that no comments on the use of other medications such as naltrexone or secretin are included as these are treatments of which a pediatrician may not be aware.
The chapter on medication use in children with cognitive-adaptive disabilities does an excellent job of describing not only the causes of mental retardation but also the various psychiatric disorders that may be co-morbid with mental retardation. The authors then go on to describe all of the psychotropic medications that have potential use in these individuals. The highlight of this chapter is the section on “How to use the medications: problem-oriented approaches” in which they describe for which type of behavioral problem each medication might be used. The authors then further define this by listing the specific syndromes associated with a particular symptom/problem (i.e., obsessions/compulsions in Prader-Willi syndrome, Fragile X syndrome, Down's syndrome, autism spectrum disorders, velocardiofacial syndrome and Williams' syndrome). There is also a summary table of first, second, and third choice medication recommendations for each of these symptoms/problems.
A welcome addition (one that can often be forgotten) is a chapter on sleep disorders. In this chapter the authors describe the types of sleep disorders, disorders associated with increased incidence of sleep disorders, and also include a list of the medications that interfere with normal sleep patterns. They make a point of including less common sleep disorders such as narcolepsy, restless legs syndrome, parasomnias, and it is here where primary nocturnal enuresis is discussed. There are detailed tables on the psychopharmacological treatment of these disorders, but less so for primary insomnia, although there is a table of potential medications used to treat insomnia associated with ADHD. Of note this table contains medications that have not been systematically studied in children (i.e., mirtazepine).
The chapter on tic disorders and Tourette's syndrome (TS) does a good job of describing the types of tics associated with these disorders, co-morbid conditions associated with TS, and includes a table of psychotropic medication used to treat TS (subdividing them into A, B or C as recommendation choices). Doses are discussed as well as side effects. The chapter ends with a treatment algorithm for TS with and without ADHD.
The final chapter is also one sometimes omitted from books on pediatric psychopharmacology and covers substance abuse in children and adolescents. There are tables on the risk factors for substance abuse as well as nonspecific indicators of substance abuse in adolescents. The authors cover the treatment of alcohol abuse/dependence as well as nicotine use in detail and are careful to include the fact that the current treatments are approved only for adults. There is a very well written table on nicotine replacement therapy formulations. The other drugs of abuse (marijuana, amphetamines, cocaine, opioids, hallucinogenic drugs and ecstasy) have brief but informative descriptions of the symptoms that can occur and offer some management strategies; for the opioids (heroin) there is an excellent table out lining the FDA approved medications used for heroin dependence treatment.
As stated previously, the goal of this volume is to provide information about psychiatric medication use in children for pediatricians, nurses, and nurse practitioners. And in many ways the authors do provide a basic springboard from which the non-child psychiatrist can take a plunge. The book is particularly good in describing the various psychiatric disorders seen in children and adolescents as well as co-morbidities and the types of treatments available. Their management strategies, especially in terms of monitoring medication are sensible and practical. They include much information about the specific psychotropic medications and their side effects and have many tables of medication choices, dosing and ages in which particular medications are approved or appropriate. Despite the fact that so many authors are involved, the style is consistent throughout, making the reading of this book easy and pleasant.
However, there are a few weaknesses that should be briefly mentioned. The first is the fact that, except for the chapters on ADHD, autism spectrum disorders, TS and tic disorders, and perhaps mental retardation, one gets the sense that the recommendations are adaptations from the adult literature rather than from the child and adolescent psychiatry literature. This is particularly true for some of the treatment algorithms. Unfortunately there are no clear references in order to assure that these algorithms are specifically for children. And this leads to the second weakness and that is the limited number of references. The authors include very helpful tables such as rate of seizures associated with developmental syndromes; they include treatment algorithms and suggested medication choices for different types of depression or for those with co-morbidities with certain diagnosis(es) but there are no indications of from where this information came. Although there are selected references at the end of each chapter, for these types of tables or recommendations it might be more helpful to include the source as a part of the caption of the table/algorithm. Another weak spot is that in some of the chapters the tables that list the different drugs and the FDA approved ages are a bit misleading. For instance, a table may indicate that a particular anticonvulsant is used in the treatment of a specific behavior and then add that the approved age is two years and up. However, in fact, the approval for this age is for the treatment of epilepsy, not that specific behavior. And finally there are some more minor inconsistencies, i.e., the authors state that atomoxetine is “black boxed” for liver toxicity (the black box is for suicidality; the liver toxicity is only a warning) and nefazadone is described in the treatment of depression in children, which is curious since it has not been available in the United States and Canada since 2004. Certainly, some of these perceived “weaknesses” may be possibly explained by the fact that several of the contributors are not from the United States. It is easy to assume that the way that it is done in the United States is the only way to prescribe medication; however, other countries do have their own preferences and standards.
It does seem a little unusual that a group of mostly pediatricians would write a book on pediatric psychopharmacology (granted there is one child psychiatrist but he is greatly outnumbered). After all, child psychiatrists have been extensively trained in the use of these medications and most of the available research in this field is derived from the work of child psychiatrists; it would therefore seem that such a book would be more appropriately written by them. One might argue that this is situation might be compared to a gastroenterologist writing a book about the treatment of asthma or heart disease. However, the fact remains that there are many children in need of psychiatric treatment and, compared to pediatricians, there are many fewer child psychiatrists available to treat these children. The fact that pediatricians are willing to step up to the plate to offer treatment obviates the need for many children and adolescents with psychiatric problems to go untreated. And one can also argue that it might be easier and more encouraging reading a book written by someone within their own discipline.
This book does play a role in educating pediatricians, nurses, and nurse practitioners to provide such treatment. However its limitations at this time make it more of a starting point rather than a primary resource. With some revisions and shoring up of these limitations, however, it has the potential to make a very helpful resource for pediatricians, nurses, and nurse practitioners who work with children and adolescents that have psychiatric disabilities.