Media watch

Duncan B Double

Lawrence H Diller

Basic Books, 2002

$25, 256 pp

ISBN 0 465 01645 6

Lawrence Diller, a behavioural paediatrician working in San Francisco, follows up his previous book Running on Ritalin with a guide for parents on psychotropic drugs for children. Wisely, he avoids the polarisation of the debate about the use of such drugs in children.

Diller is trained in family therapy and regards behavioural approaches as more effective than Freudian approaches. Complete ethical assessment of problems is required, and enlisting the help of teachers and considering educational options are essential parts of this process. Psychological methods advocated include increasing parental confidence through behavioural management techniques, such as time-out and reward systems, and increasing the child's sense of accomplishment through a cognitive-behavioural approach that involves naming and externalising maladaptive behaviour.

Diller's pragmatic, commonsense approach may have merits, although he does not always maintain a thorough critical perspective. Diller notes the striking increase in prescriptions for children in the USA: production of Ritalin (methylphenidate hydrochloride) increased by 700% between 1990 and 1998. He does speak out against the larger social and economic pressures, but he continues to medicate, particularly if a child's problems are severe and unresponsive to behavioural interventions.

In the more conservative UK, medication has had a “very limited” place in the treatment of the psychiatric disorders of childhood and adolescence. This is what the second edition of the textbook Child Psychiatry: A Developmental Approach by Philip Graham stated in 1991. By the third edition in 1999, medication was stated to have a “limited [the ‘very’ had been dropped] but increasing role”.

The data on methylphenidate is now regarded as testimony to its benefits. Clinical trials have shown the effectiveness of fluoxetine in the acute phase of non-psychotic major depressive disorder and obsessive–compulsive disorder, whereas drug trials on older antidepressants are less convincing.

The increased prescription could be because of a better evidence base. However, it cannot be the whole story because much prescription exceeds the agreed evidence, as Diller himself points out. The increase in classes of antidepressants, mood stabilisers, and neuroleptics must have had an effect.

Diller's book is well written and “parent-friendly”; it avoids the excesses of “biomedicalisation” of children's problems, and introduces the subtleties of the arguments. You may recommend it to parents if this is the level of information you think they want. However, I am sure that public debate needs to reach a higher level about whether drugs for children are better than placebos.