Book Review

Pediatric Psychopharmacology: Principles and Practice

N Engl J Med 2003; 349:1194-1195September 18, 2003

Article

Pediatric Psychopharmacology: Principles and Practice
Edited by Andrés Martin, Lawrence Scahill, Dennis S. Charney, and James F. Leckman. 791 pp., illustrated. New York, Oxford University Press, 2003. $129.95. ISBN: 0-19-514173-3

It was six men of Indostan

To learning much inclined,

Who went to see the Elephant

(Though all of them were blind),

That each by observation

Might satisfy his mind.

John Godfrey Saxe (1816-1887)

Pediatric psychopharmacology has been a much maligned and often misunderstood form of treatment for children with clinically significant psychiatric and behavioral disturbances. This legacy is largely attributable to the same ignorance that plagued the blind men. Critics and faux scientists have all grabbed a portion of the problem for their own purposes or polemics, rather than appreciating the large and complex nature of the problems involved in the diagnosis and treatment of children and adolescents with psychiatric illness. This is a particularly sad state of affairs, since the estimated prevalence of such disorders is approximately 20 percent. It would appear that less than 50 percent of affected children are ever evaluated; still fewer receive any semblance of treatment. This lack of attention is particularly unfortunate because there are many safe and effective treatments (both somatic and psychosocial) for this group of patients.

In the Saxe poem based on the Indian fable, we learn of a nearly futile search by the curious yet unseeing. In some ways, this has been the history of the study of pediatric psychopharmacology. However, much has changed in the past two decades, as we have begun to move out of the darkness toward a systematic approach to this vitally important area of investigation and treatment. Led by the spirit and wisdom of their mentor and colleague, Donald J. Cohen (1940–2001), the editors have assembled an extraordinary international team of more than 100 investigators and clinicians to grapple with the complexities of pediatric psychopharmacology. Like the fabled blind men, the authors have approached complex issues from many perspectives, but rather than stumble around haphazardly and arrive at snap conclusions, the editors have carefully organized the scientific knowledge into four distinct sections. Most important, each chapter of this well-edited book maintains the essential developmental perspective on symptoms and treatments relevant to children and adolescents.

The first section, “Biological Bases of Pediatric Psychopharmacology,” includes detailed discussions of developmental neurophysiology, pharmacokinetics, psychopathology, and genetics, followed by a discussion of the neurobiology of specific disorders. “Somatic Interventions” focuses on the first of two distinctly different approaches to neuropharmacology, carefully reviewing the function and use of psychopharmacologic agents according to class.

One legitimate criticism of the use of psychotropic medications in young people is that many practitioners, when faced with behavioral problems, simply “give the medicine a try.” To counter this trend, “Assessment and Treatment” provides a resource for the evaluation of children with specific symptoms and disorders, including a guide to diagnostic instruments and rating scales for monitoring the well-described treatments. The authors recognize that the general rules of practice may not apply neatly to special populations, such as patients with mental retardation or preschoolers. “Epidemiological, Research, and Methodological Considerations,” the fourth section, covers the context in which the treatments are developed and used, including the research methods, the relevant ethical considerations, the evidence-based approach to the use of medications with psychotherapy, and regulatory issues.

If there is so much knowledge regarding this topic, why has a comprehensive book of this quality been so long in coming? Perhaps it is because, as Klin and Cohen have suggested, any indication for the use of drugs in childhood “is often considered an `orphan' indication, as if childhood was an anomalous and rare state of being and the diseases of childhood were of secondary importance” (“Theoretical Perspectives on Autism.” Signal [World Association of Mental Health] 1994;2(2):7-12.). I hope that Pediatric Psychopharmacology and the work that it represents will allow for the thoughtful, scientific adoption of pediatric psychopharmacology, rather than leave it in the nether lands of clinical science. It may even lead to an end to some of the controversies, ambivalence, pseudoscience, and false beliefs about treating children and adolescents who have serious psychiatric illnesses. Pediatricians, psychiatrists, family practitioners, neurologists, and other practitioners who use this book for primary learning as well as for reference may be able to avoid the fate of the blind men:

So oft in theologic wars,

The disputants, I ween

Rail on in utter ignorance

Of what each other mean

And prate about an Elephant

Not one of them has seen!

Bennett L. Leventhal, M.D.
University of Chicago, Chicago, IL 60637
bleventhal@uchicago.edu