Pediatric Psychopharmacology

            Pediatric Psychopharmacology: Combining Medical and Psychosocial Interventions is written by three psychologists to “inform nonphysician practitioners” regarding the psychopharmacologic treatment of the pediatric population as well as the “collaborative options” in such treatment (p.3).  In this age of cooperative treatment between physicians (psychiatrists as well as primary care specialists) and nonphysician mental health care providers, the book’s goals are timely and appropriate.   The book contains 10 chapters.  The first three chapters include an overview of collaborative practices, methods for monitoring medication treatment, and addressing barriers to treatment.  The last seven chapters cover specific mental illnesses and their treatment with both psychopharmacologic and psychosocial interventions. 

            As I began reading the book, I was struck by a paradox.  Though the authors advise and recommend collaborative efforts with prescribing physicians, they did not follow their own advice.  Rather than joining in their writing efforts with a child psychiatrist experienced in psychopharmacology, they chose not to collaborate and instead wrote this book based on their own experience and knowledge as nonphysician professionals.  The effects of this choice echo through the book, as it reads as though it were written based on books and papers, and lacks an appreciation for the complexity and ambiguity of medication treatment for individual children with mental illness.   For example, the first chapter includes a section on the importance of identifying “intervention goals” in treatment.  The scenario illustrating this involves a child with oppositional defiant disorder and generalized anxiety disorder.  In this case the authors state, “the intervention will very greatly depending on whether the primary goals of treatment pertain to the alleviation of oppositional behavior or to the symptoms of anxiety” (p. 7).  This example and statement imply that oppositional defiant disorder and generalized anxiety disorder are separate and distinct disorders that can be addressed independently of each other.   Is this true?  Or are these two disorders often intertwined in an individual patient, such that the symptoms of both are due to common underlying causes?  In my experience, making environmental modifications to reduce oppositional behavior frequently reduces anxiety, and pharmacological treatment of anxiety often reduces oppositional symptoms.  

            Chapter 1 also includes a review of the arguments for and against prescribing privileges for psychologists.  This section is particularly interesting to read given recent events in New Mexico, where prescribing privileges for psychologists were recently signed into law.  However, it is unclear why a book dedicated to teaching pediatric psychopharmacology devotes significant space to this highly politicized issue.

            The second chapter presents various rating instruments for monitoring treatment outcomes, appropriately emphasizing the need for target symptoms.  It is not clear whether the authors are recommending the use of these instruments in all clinical situations, or only in select situations (such as a research environment).  If the former is the case, they present a rather cumbersome system for the ongoing assessment of patients and monitoring treatment outcomes.  Many children have several overlapping conditions, and would need to be tested repeatedly with multiple devices.   This would require time to administer, score, interpret, and communicate the results of such tests.  Who would pay for this time?  Would it be taken from time otherwise dedicated to the face-to-face interactions crucial to building rapport?  Is there conclusive evidence that rating instruments lead to more effective treatment than treatment that identifies specific treatment goals without such instruments?  In the same chapter, the authors recommend placebo controlled single subject procedures in treating children (p. 36).  What are the ethical issues involved in such trials?  What are the implications of treating an individual with a placebo when that individual has a condition for which medication has been proven effective?  These important questions are not addressed.

            At times the writers take a paternalistic attitude towards treatment methodology.  For example, in Chapter 8, “Mood Disorders”, they recommend primarily psychotherapeutic treatment of depression.  “It is advised, therefore, that treatment of pediatric depressive disorders always incorporate psychological (e.g. cognitive-behavioral and interpersonal) intervention components and that medication be viewed as a possible augmentation” (p. 166).  In my opinion, there are two problems with this position.  First, it discounts the results of recent placebo controlled randomized clinical trials on the treatment of pediatric depression, which show that medications are well tolerated and effective in the treatment of pediatric depression independent of psychotherapy.  The efficacy of both fluoxetine (Prozac) and paroxetine (Paxil) have been validated through this research (Keller 2001, Emslie 1997).   Second, the authors’ statement neglects the ethical principle of autonomy,  that is the right of patients (or in the case of minors, their parents) to choose among treatment options for themselves, rather than the health care provider choosing for them.  Medications are a reasonably safe and effective treatment for depression.  Patients and their families should be informed of this, and should they choose this option, treatment with medication should be facilitated in an appropriate environment.  To relegate psychopharmacologic interventions to an adjunctive role to therapy fails to take into account the scientific support for medication treatment, and denies patients the right to choose for themselves the method(s) of treatment with which they are most comfortable.

            Parts of the book revealed a surprising number of errors, some of which were merely annoying and others that were frankly misleading.  There are multiple incidences of medication names or trade names being misspelled.  Some examples include “Dexadrine” instead of Dexedrine (p. 110), “Resperidone” instead of risperidone on three occasions (p. 115), and “olanazapine” instead of olanzapine (p. 139).   More concerning is a chart summarizing medications for ADHD where the authors list appetite suppression as an adverse effect of dextroamphetamine and methylphenidate (p.111).  However, in the same chart they do not list appetite suppression as a side effect of Adderall (a combination of dextroamphetamine and racemic amphetamine).  This error could easily lead a reader to falsely believe that Adderall does not suppress appetite, even though this is a well-known and common side effect.  Finally, errors in a chart summarizing medications used for treating tics are potentially dangerous (p.212).  There, medication doses are wrongly listed as mg/kg/day, when they should have been listed as mg/day.  As some of these medications have serious cardiovascular effects, children could be gravely harmed if a physician or other practitioner unfamiliar with these medications were to use this chart as a reference in prescribing or administering them.  The difference between treating a 20 kg child with 0.3 mg/day of clonidine as opposed to 0.3 mg/kg/day (a dose of 6 mg/day) is potentially life threatening.  Whether these errors are due to careless proofreading or to a lack of experience and knowledge of the subject, they are misleading and possibly dangerous.

            This book has areas of strength.  It is well referenced, with citations listed at the end of each chapter.  Chapter Three includes an excellent section on overcoming barriers to treatment via education, support, collaboration, and community based services.  The use of Prochaska’s five stages of change is a useful way to conceptualize and understand how patients and their families come to accept, learn about, and eventually engage in treatment of mental illness (p. 49).  Furthermore, the discussion of social validity as a potential obstacle to treatment captures the importance of recognizing how cultural factors can influence treatment on an individual or family level.  Unfortunately, these strengths are overshadowed by the text’s weaknesses.

            Mental health professionals need to collaborate to increase the awareness of mental illnesses as treatable conditions, improve the quality of treatments available, and conduct research to develop new treatment options.  This book offers useful information about how to collaborate as well as ways to use rating instruments in the treatment process.  But it lacks the very collaborative attitude it recommends to others, and contains numerous and significant errors.  Other books on pediatric psychopharmacology are more comprehensive and more factually accurate, including Practitioner’s Guide to Psychoactive Drugs for Children and Adolescents by Werry and Aman.   For nonphysician practitioners seeking more information on this subject, close collaboration with physicians and/or pharmacologists is vital adjunct to any text.

References:

Emslie GJ, Rush AJ, Weinberg WA, Kowatch RA, Hughes CW, Carmody T, Rintelmann J. A double-blind, randomized, placebo-controlled trial of fluoxetine in children and adolescents with depression. Archives of General Psychiatry, Nov 1997, 54(11): 1031-7.

Keller MB, Ryan ND, Strober M, Klein RG, Kutcher SP, Birmaher B, Hagino OR, Koplewicz H, Carlson GA, Clarke GN, Emslie GJ, Feinberg D, Geller B, Kusumakar V, Papatheodorou G, Sack WH, Sweeney M, Wagner KD, Weller EB, Winters NC, Oakes R, McCafferty JP.  Efficacy of Paroxetine in the Treatment of Adolescent Major Depression: A Randomized, Controlled Trial.  Journal of the American Academy of Child and Adolescent Psychiatry, July 2001, 40(7): 762-772.

Werry JS, Aman MG. Practitioner’s Guide to Psychoactive Drugs for Children and Adolescents, 2^nd Edition.  Plenum Publishing Corporation, New York, NY, 1999.

© 2002 Christopher A. Lamps

Christopher A. Lamps, M.D., Instructor, ACH Pediatric Psychiatry, and Medical Director, Child Study Center, University of Arkansas for Medical Sciences