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Book Forum: Psychopharmacology   |    
Straight Talk About Psychiatric Medications for Kids
Am J Psychiatry 2000;157:145-145.
View Author and Article Information
Chicago, Ill.

by Timothy E. Wilens, M.D. New York, Guilford Publications, 1998, 320 pp., $29.95; $14.95 (paper).

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Dr. Wilens provides a clear, no-nonsense discussion of the role of drug treatment for psychiatric disorders in children and adolescents. He divides his work into three parts: what parents should know; the most common disorders in children; and a review of the different classes of psychotropic agents. In addition, the appendix includes tables containing pertinent information about the more commonly used drugs in each class, examples of medication logs that parents are encouraged to keep, and pertinent bibliographic and organizational resources that are available.

The author’s ability to write succinctly and at a level that is readily appreciated by nonprofessionals is the real strength of this work. He first covers and simplifies an enormous amount of material, including basic biological concepts, diagnosis, and, when appropriate, alternative approaches to medications. He highlights important terms and defines them in the context of the most frequently voiced concerns of parents. His step-by-step approach, emphasizing the critical role that parents play, provides a sense of empowerment necessary to achieve an optimal outcome. Dr. Wilens brings home the need for collaboration with physicians deftly and empathetically while addressing such sensitive issues as when and how to raise concerns, seeking a second opinion, and switching physicians. This section ends with a frank discussion of one of the most devastating and frightening experiences a child or parent may face: the need for hospitalization.

Unfortunately, the last two sections are less satisfying. Dr. Wilens covers the most common psychiatric conditions encountered in clinical practice, defining and discussing each disorder and a general treatment approach, as well as the role of medications. In the final section, he reviews each class of psychotropics, including their putative mechanism of action, common indications, typical dosing ranges, and adverse effects. Although there is a dearth of controlled trials in the area, one can extrapolate from the clinical trial experience in adults to provide at least some initial guidance. In this context, I found the discussions on the use of antipsychotic agents problematic, with a tilt toward the use of neuroleptics over the latest generation of novel agents. In particular, the timing and duration of treatment in this younger age group may substantially increase total drug exposure, resulting in an increased risk of adverse neurological events such as tardive dyskinesia. Indeed, this concern has fueled the shift to novel agents as first-line treatments in adults. More troubling is the recommendation that neuroleptics may be used in the management of conditions such as conduct disorder and oppositional defiant disorder (p. 143), dissociative episodes associated with posttraumatic stress disorder (pp. 164, 167), and more severe sleep disorders (p. 186). Surely, we can recommend less risky approaches.

There are also several errors that physicians may readily recognize but parents may not. Examples include listing doxepin as a serotonin reuptake inhibitor (p. 206), Vivactyl as a trade name for nortriptyline (p. 207), and perphenazine as the generic form of Prolixin (p. 234). Comments about the anticonvulsants also contain erroneous material, such as attributing clinically significant autometabolism to divalproex rather than carbamazepine (pp. 220, 221), and there is no discussion of carbamazepine’s clinically relevant capacity to accelerate the metabolism of co-prescribed drugs.

In summary, I believe the first section and other subsequent parts providing guidance to parents are well written, informative, and quite useful. Sections dealing with medication, however, are not as precise and could possibly create confusion for parents. If there are further printings, I would suggest careful editing of these errors.




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