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Diagnosis and Psychopharmacology of Childhood and Adolescent Disorders
BOOK REVIEWS Book Review Editor: Kenneth S. Robson, M.D. Diagnosis and Psychopharmacology of Childhood and Adolescent Disorders. By Jerry M. Wiener. New York: John Wiley & Sons, 1985,373 pp., $34.95. Reviewed by Barbara J. Coffey, M.D.* Child and adult psychiatrists, residents and other mental health clinicians now have an up-to-date, comprehensive reference available to them in the form of this new Wiley Series book. A relatively short, small book, it is entirely readable throughout. The book neatly bridges a gap between Wiener’s earlier version, Psychopharmacology in Childhood and Adolescence in 1977, and the other comprehensive pediatric psychopharmacology references: Werry’s Pediatric Psychopharmacology: The Use of Behavior Modifying Drugs in Children (1978) and Klein and Gittleman’s Diagnosis and Drug Treatment of Psychiatric Disorders: Adults and Children (1980). The book is well organized and consistent in its format throughout. Twenty authors, many of whom are senior researchers, clinicians and educators, have contributed to the 12 chapters that have been divided into three sections. Although there is some variety in quality of written material, literature reviews and bibliographies from chapter to chapter, it is overall a highly readable, “easy access” reference that provides a thorough overview of each topic with appropriate detail, in most cases, where indicated. The first section is a general one, “Basic Issues,” meant to provide the reader with an introduction to the history of child psychopharmacology, the importance of development considerations, and methodology and assessment. Drs. Wiener and Jaffe discuss the historical development of pediatric psychopharmacology from the 1930s through the early to mid 1980s, and include some useful elaboration on key studies, such as Bradley’s original work with Benzedrine in institutionalized hyperactive children in 1937. The second chapter, on the interaction of drugs and development, includes such important concepts as medication’s role in enhancing/promoting optimal development, and the issue of the meaning of giving drugs to children. These are both essential issues that have not been adequately addressed in the scientific liter*Dr. Coffey is the Director of the General Child Psychiatry Clinic, Associate Director of the Division of Ambulatory Services, Assistant Professor of Tufts University School of Medicine and Director of Pediatric Psychopharmacology at New England Medical Center.
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ature. This chapter could have been improved somewhat by consolidation and abridgement of its length. Dr. Conners’ chapter on methodology and assessment is an excellent compilation,discussing drug studies designs, the current ascendancy of the use of structured interviews, and compliance issues (rarely addressed in chid psychopharmacology).Additionally, there are excellent tables on internal/external validity as related to therapy outcome research, and assessment instruments. A sole criticism of this introduction section would be to note the absence of a chapter, or section, on general principles of drug use in children and adolescents. For the practicing clinician, such issues as the role of parents, teachers, and child’s subjective reports; the need to use combined approaches taking into account diagnosis and target symptoms, and differences between children and adolescents with regard to pharmacokinetics would have been useful inclusions, to set a frame of reference for the clinical chapters. Section I1 is comprised of the “Clinical Disorders” including Psychoses, Affective Disorders, Attention Deficit Disorders, Anxiety Disorders, Tourette’s Syndrome/Tic Disorders, Conduct Disorders, Eating Disorders, and Enuresis/Sleep Disorders. Each chapter follows a similar format and discusses definitions, using DSM-I11 criteria, diagnostic considerations, drugs of choice and general guidelines as to clinical usage, untoward effects, assessment and a summary. There is some range of quality in the chapters, but in general, they are coherent, generally cogent, and relevant. Some authors, for example Dr. Magda Campbell in the chapter on Psychoses, include a scientific literature review, which is useful. Her discussion of untoward effects was helpful; the lack of inclusion of neuroleptic malignant syndrome as a rare but nevertheless possible untoward effect was perhaps an oversight. Puig Antich’s chapter on Affective Disorders was thorough and comprehensive. Particularly interesting was the discussion regarding the apparent high placebo response rate in depressed, hospitalized children. The ADD chapter is one of the shortest but is rather compact in that it contains the necessary information for the clinician. There is an excellent discussion on effects of stimulants, both psychological and behavioral; somewhat puzzling is the lack of a section on review of the literature of the stimulant studies, the
582
BOOK REVIEWS
most extensive in pediatric psychopharmacology. Perhaps the authors felt that the section on stimulants in the Introduction would suffice. The sections on Anxiety Disorders, Conduct Disorders and Eating Disorders were cogent and contained good reviews. There was no mention of thyroid complications of lithium use for aggressivity in the conduct disorders section, despite excellent coverage of other adverse effects of Lithium. The sections on Tourette’s Syndrome/Tics and Sleep Disorders/Enuresis were of outstanding quality and were distinguished by the discussion the authors gave to relevant, non-pharmacological intervention. The third and final section “Summary and Prospect” was the book’s weakest point. Dr. Wiener provides the reader with a “Summary of Chapters” 1 through 12 which appeared redundant and unnecessary in this context. Perhaps including these summary paragraphs as abstracts before each individual chapter would have performed the same function in a more useful place. One is more ready at the conclusion for prospects for the future, which might have been expanded. Another criticism, not so much of the authors or editor, is the apparent lack of proofreading-there were many typographical errors throughout the book, including six on page 209. Overall, this is a useful book for practicing clinicians in the child mental health field. It has many strengths, and its weaknesses are relative. Although it is not as comprehensiveor broad in scope as the Werry or Klein texts, it provides an improvement over the previous edition and other existing pediatric psychopharmacology texts. Its strengths are primarily in the “psychopharmacology” rather than “diagnosis” part of the title, but that is just what is needed.
The Interpersonal World of the Infant: A View from Psychoanalysis and Developmental Psychology. By Daniel L. Stern. New York Basic Books, 1985,304 pp., $22.95. Reviewed by Charles H. Zeanah, M.D.* There is a story about four medical students who watch in silence as a young woman with a protuberant abdomen walks past them. The first year student looks puzzled and says, “Iwonder what’s going on with her.” Immediately, the second year student answers, “She’s got an ovarian tumor, probably a serous cystadenocarcinoma.” The third year student glances disdainfully at the second year student and says, “No, no. She’s pregnant-about 24 weeks gestation, I’d say.” The * Dr. Zeanah is Assistant Professor of Psychiatry and Human Behavior, Brown University Program in Medicine, Providence, Rhode Island.
fourth year student, who continues to watch the woman walk away in the distance, says quietly, “I wonder what’s going on with her.” The problem of a little bit of knowledge on the one hand, but a pressing need to explain on the other, has hampered our theories of human development, as well. These theories are essential for organizing and systematizing observations, for rendering testable hypotheses, and for guiding our clinical efforts. Theories are also important because we tend to believe them. The problem, of course, is that what we “know” makes it hard for us to see anything else. Consider that a generation or two of child analysts, despite extraordinary clinical sensitivity and powers of observation, looked at young infants and saw them only as “autistic” and “narcissistically reactive.” Given the problem that the knowledge base for many of our theories of development has been either deficient or improperly derived from adult psychopathology, we have often speculated about infant experience as wildly but as assuredly as the second and third year students above. In his much anticipated new book, Daniel Stern takes a fresh look at “what’s going on” in the first 2 years of life. The first message from this work is that we know considerably more that we ever have before about infants, so that the theoretical model he develops is far better supported by scientifically sound research than those which have preceded it. Stern’s unique background as a psychoanalyst and as a basic researcher in developmental psychology has enabled him to address rich and pressing questions about human experience from psychoanalysis with the scientific rigor of academic psychology. He focuses on the vital but elusive construct of the sense of self as it forms during the first 2 years of life. Masterfully, he puts himself into the mind of the infant, and armed with all that we know about the infant’s developing cognitive, social, and linguistic capacities at different ages, he asks what the infant’s subjective experience of self, of other, and of self-with-other must be like. His conclusions, if borne out, must change our thinking about development, about psychopathology, and even about treatment. To describe the development of the infant’s sense of self, which is the major focus of the book, Stern first points to three periods which are characterized by dramatic changes in infant development: 2-3 months, 9-12 months, and 15-18 months. He contends each of these periods involve major changes in the infant’s subjective experience of self and the quality of his or her relatedness to others. He proposes that the sense of emergent self, which concerns “the coming into being of organization which is the basis of learning and creating,” forms during the first 2 months of life. The sense of core self, which is experienced as
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ature. This chapter could have been improved somewhat by consolidation and abridgement of its length. Dr. Conners’ chapter on methodology and assessment is an excellent compilation,discussing drug studies designs, the current ascendancy of the use of structured interviews, and compliance issues (rarely addressed in chid psychopharmacology).Additionally, there are excellent tables on internal/external validity as related to therapy outcome research, and assessment instruments. A sole criticism of this introduction section would be to note the absence of a chapter, or section, on general principles of drug use in children and adolescents. For the practicing clinician, such issues as the role of parents, teachers, and child’s subjective reports; the need to use combined approaches taking into account diagnosis and target symptoms, and differences between children and adolescents with regard to pharmacokinetics would have been useful inclusions, to set a frame of reference for the clinical chapters. Section I1 is comprised of the “Clinical Disorders” including Psychoses, Affective Disorders, Attention Deficit Disorders, Anxiety Disorders, Tourette’s Syndrome/Tic Disorders, Conduct Disorders, Eating Disorders, and Enuresis/Sleep Disorders. Each chapter follows a similar format and discusses definitions, using DSM-I11 criteria, diagnostic considerations, drugs of choice and general guidelines as to clinical usage, untoward effects, assessment and a summary. There is some range of quality in the chapters, but in general, they are coherent, generally cogent, and relevant. Some authors, for example Dr. Magda Campbell in the chapter on Psychoses, include a scientific literature review, which is useful. Her discussion of untoward effects was helpful; the lack of inclusion of neuroleptic malignant syndrome as a rare but nevertheless possible untoward effect was perhaps an oversight. Puig Antich’s chapter on Affective Disorders was thorough and comprehensive. Particularly interesting was the discussion regarding the apparent high placebo response rate in depressed, hospitalized children. The ADD chapter is one of the shortest but is rather compact in that it contains the necessary information for the clinician. There is an excellent discussion on effects of stimulants, both psychological and behavioral; somewhat puzzling is the lack of a section on review of the literature of the stimulant studies, the
582
BOOK REVIEWS
most extensive in pediatric psychopharmacology. Perhaps the authors felt that the section on stimulants in the Introduction would suffice. The sections on Anxiety Disorders, Conduct Disorders and Eating Disorders were cogent and contained good reviews. There was no mention of thyroid complications of lithium use for aggressivity in the conduct disorders section, despite excellent coverage of other adverse effects of Lithium. The sections on Tourette’s Syndrome/Tics and Sleep Disorders/Enuresis were of outstanding quality and were distinguished by the discussion the authors gave to relevant, non-pharmacological intervention. The third and final section “Summary and Prospect” was the book’s weakest point. Dr. Wiener provides the reader with a “Summary of Chapters” 1 through 12 which appeared redundant and unnecessary in this context. Perhaps including these summary paragraphs as abstracts before each individual chapter would have performed the same function in a more useful place. One is more ready at the conclusion for prospects for the future, which might have been expanded. Another criticism, not so much of the authors or editor, is the apparent lack of proofreading-there were many typographical errors throughout the book, including six on page 209. Overall, this is a useful book for practicing clinicians in the child mental health field. It has many strengths, and its weaknesses are relative. Although it is not as comprehensiveor broad in scope as the Werry or Klein texts, it provides an improvement over the previous edition and other existing pediatric psychopharmacology texts. Its strengths are primarily in the “psychopharmacology” rather than “diagnosis” part of the title, but that is just what is needed.
The Interpersonal World of the Infant: A View from Psychoanalysis and Developmental Psychology. By Daniel L. Stern. New York Basic Books, 1985,304 pp., $22.95. Reviewed by Charles H. Zeanah, M.D.* There is a story about four medical students who watch in silence as a young woman with a protuberant abdomen walks past them. The first year student looks puzzled and says, “Iwonder what’s going on with her.” Immediately, the second year student answers, “She’s got an ovarian tumor, probably a serous cystadenocarcinoma.” The third year student glances disdainfully at the second year student and says, “No, no. She’s pregnant-about 24 weeks gestation, I’d say.” The * Dr. Zeanah is Assistant Professor of Psychiatry and Human Behavior, Brown University Program in Medicine, Providence, Rhode Island.
fourth year student, who continues to watch the woman walk away in the distance, says quietly, “I wonder what’s going on with her.” The problem of a little bit of knowledge on the one hand, but a pressing need to explain on the other, has hampered our theories of human development, as well. These theories are essential for organizing and systematizing observations, for rendering testable hypotheses, and for guiding our clinical efforts. Theories are also important because we tend to believe them. The problem, of course, is that what we “know” makes it hard for us to see anything else. Consider that a generation or two of child analysts, despite extraordinary clinical sensitivity and powers of observation, looked at young infants and saw them only as “autistic” and “narcissistically reactive.” Given the problem that the knowledge base for many of our theories of development has been either deficient or improperly derived from adult psychopathology, we have often speculated about infant experience as wildly but as assuredly as the second and third year students above. In his much anticipated new book, Daniel Stern takes a fresh look at “what’s going on” in the first 2 years of life. The first message from this work is that we know considerably more that we ever have before about infants, so that the theoretical model he develops is far better supported by scientifically sound research than those which have preceded it. Stern’s unique background as a psychoanalyst and as a basic researcher in developmental psychology has enabled him to address rich and pressing questions about human experience from psychoanalysis with the scientific rigor of academic psychology. He focuses on the vital but elusive construct of the sense of self as it forms during the first 2 years of life. Masterfully, he puts himself into the mind of the infant, and armed with all that we know about the infant’s developing cognitive, social, and linguistic capacities at different ages, he asks what the infant’s subjective experience of self, of other, and of self-with-other must be like. His conclusions, if borne out, must change our thinking about development, about psychopathology, and even about treatment. To describe the development of the infant’s sense of self, which is the major focus of the book, Stern first points to three periods which are characterized by dramatic changes in infant development: 2-3 months, 9-12 months, and 15-18 months. He contends each of these periods involve major changes in the infant’s subjective experience of self and the quality of his or her relatedness to others. He proposes that the sense of emergent self, which concerns “the coming into being of organization which is the basis of learning and creating,” forms during the first 2 months of life. The sense of core self, which is experienced as