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Pediatric and Adolescent Psychopharmacology: A Practical Manual for Pediatricians.
Donald Greydanus , Joseph L Calles, Jr . & Dilip Patel . Cambridge University Press: New York, NY, 2008. 301 pages. CDN $70.00.
The premise of this information-packed book is indisputable – namely that there is an inadequate supply of child and adolescent psychiatrists and that the burden of care for behaviourally challenged children falls on the shoulders of other clinicians. Paediatricians, the authors argue, are not as a rule adequately exposed to child psychiatry during their training and may be faced with patients already taking unfamiliar psychopharmacological agents or may have to implement new drug treatment themselves. Notably, of the seven authors of this text, only one is a psychiatrist.
To what extent does access to this book assist a paediatrician in fulfilling the proposed role as mental health clinician? Does it provide information that cannot be easily or better obtained from standard works on child and adolescent psychiatry? The very nature and target audience of this book also raises interesting boundary issues. To what extent should the absence of psychiatrists encourage others to assume their role?
The early chapters of the book summarize various types of psychological management, as well as pharmacological and prescribing principles. The remainder is given to specific problems including Attention Deficit-Hyperactivity Disorder (ADHD), anxiety, depression, autism, disruptive behaviour, cognitive-adaptive disabilities, sleep disorders, tic disorders, schizophrenia and drug dependency.
Each chapter provides a short introduction to its subject, a differential diagnosis (sometimes unnecessarily long), and a comprehensive list of medications which can or have been used, including compounds which are no longer available or are out of favour (e.g. pemoline). Flow charts of management are appended to some chapters. In a flow chart for Bipolar Disorder “referral to psychiatry if not done before,” appears as an afterthought, the very last comment on the algorithm. Given the controversy surrounding the issue and the complexity of making a diagnosis, I found this surprising.
While this book provides much information on psychopharmacology, it could do better in distinguishing between those problems in which the support of a child and adolescent psychiatrist is essential and those that can be adequately managed by a paediatrician. There is a clear difference in this regard, for instance, between ADHD, where the bulk of management is already performed by paediatricians, and psychotic disorders, which are appropriately the primary aegis of the psychiatrist.
As a paediatrician who practices primarily in the field of mental health, I have found existing textbooks and journals essential in increasing my knowledge. However, they can only take one a small distance in making the transition from the practice of “organic” to psychological medicine. The training and guidance I have received from my psychiatrist colleagues and other mental health professionals have been indispensable. No book could have fulfilled this role.
If one were a paediatrician making therapeutic choices based on the contents of this source alone, without guidance from others, one could imagine that a sense of confusion might arise from a tyranny of choice with no clear direction as to what might work best in difficult circumstances. The information provided lacks context. The descriptions of the disorders in question are too brief and the writing style too concrete for the reader to readily grasp how any particular disorder will be experienced by the patient, the family, or the therapist. Some illustrative case studies might have been helpful but would have taken the text even further from its primary mandate.
In the end, while informed paediatricians are an asset to the mental health community, they cannot be expected to function as a thing apart. Only by working hand in glove with trained specialists in mental health will they find an appropriate niche in the mental health field. Without expert and diverse input there is a significant risk of the profession developing in ways that are inappropriate and unchecked. If all this means we need more child and adolescent psychiatrists – so be it. This book therefore cannot be recommended as an introductory text on child psychiatry for paediatricians. By extending its mandate to diagnostic issues it has weakened its main value as a resource on psychopharmacology.