Academic Psychiatry 22:59-63, March 1998
© 1998 Academic Psychiatry
Textbook of Child and Adolescent Psychiatry, Second Edition
Edited by Jerry Weiner, M.D. Washington, DC, American Psychiatric Press, Inc., and the American Academy of Child and Adolescent Psychiatry, 1997, 940 pages, ISBN 1–882103–03–3, $140.00
Jarrett Barnhill, M.D.
Key Words: Book Review • Child and Adolescent Psychiatry • Children • Adolenscent • Book Review • Psychotherapy • Supervision
The Textbook of Child and Adolescent Psychiatry is an update of an earlier edition based on a DSM-IV format. This text is also designed to incorporate recent research in neurobiology and neuropharmacology. The need for updates is driven by the population explosion of clinical neuroscientists in child psychiatry. Since Dr. Wiener vows to preserve and reformulate psychodynamic origins, each chapter blends the knowledge of experienced clinicians with those of younger researchers. This approach accommodates the ongoing dialectic process in child psychiatry. This second edition brings these often divergent views into a single formulation. Thus, each chapter is a microcosm of the ongoing processes in the development of child psychiatry for the twenty-first century.
The textbook is divided into 11 sections. The first addresses the historical roots of our specialty against the backdrop of social and cultural change. There is an interesting section on the emergence of diagnostic classifications within historical context. This series of diagnostic nomenclatures has provided a glimpse in the history of ideas, ranging from earlier psychodynamic formulations to current phenomenology. Our newer classification schemes limit dynamic formulation while honing in on phenomenology. These chapters address the broad strokes of social history that led to the birth and nurturing of child and adolescent psychiatry.
Section 2 presents a collection of assessment and diagnostic issues. This section brings the voices of experienced clinicians to the forefront. The chapters include a synthesis of diagnostic formulation as well as classification based on DSM-IV. Subsequent chapters follow assessment through a developmental course and culminate with parental and family systems as crucial variables in this developmental flowering. There are chapters on rating scales, neuropsychological testing, and the use of the laboratory as an aid in differential diagnosis and eventual treatment planning. These chapters add a scientific flavor and reflect attempts to increase the scientific rigor of our specialty. This section closes with formulation and presentation, and hopefully can preserve this vanishing art form. Today, the ability to weave a narrative that integrates each facet of child development receives less emphasis. The chapters by Drs. Shapiro and Byrd will remind us that formulation and presentation, as well as diagnostic criteria, are invaluable in the art of communication with fellow clinicians.
The next sections focuses on specific disorders. In this segment, the authors have stayed close to the format outlined by Dr. Wiener. Each chapter includes presentation of clinical findings, differential diagnosis, proposed etiopathogenesis, associated epidemiologic studies, clinical course, treatment approaches, prognosis, and arenas for future research. Section 3 addresses developmental disorders. Chapters on mental retardation focus on the relationship between adaptive behavior, tested intelligence, and risk for psychopathology. There is a discussion of the risk for psychiatric disorders among the developmentally disabled, related to not only psychosocial stressors, but also biological and syndrome specific features of certain mental retardation syndromes. Autistic disorders are discussed against the broad backdrop of other serious developmental disorders. Autism remains the most enigmatic of childhood disorders but has experienced an explosion of neuroscientific studies. This section is an update on many approaches to understanding the etiology of this brain disorder. The chapter on other pervasive developmental disorders encompasses the autistic spectrum as well as a variety of neurodegenerative disorders. In many respects, these pervasive disorders represent a final common pathway between brain dysfunction and associated neurobehavioral disorders. The last section focuses on Axis II specific disorders, providing an overview of motor, communication, and other learning difficulties.
Section 4 covers schizophrenia, psychosis, and severe mood disorders. The opening chapter reviews schizophrenia and associated psychotic disorders. Very early- onset schizophrenia is a rare disorder in childhood, with strong genetic linkages to late-onset schizophrenias. The notion of the schizophrenogenic mother has now been replaced with a neurodevelopmental paradigm that requires careful differential diagnosis and longitudinal follow-up. The section on mood disorders is capturing the growing interest in our specialty. In less than 20 years, we have evolved from a specialty that argued against the existence of affective illness, to one dominated by an explosion of both research and treatment for depression and bipolar disorder. It has become increasingly apparent that comorbidity, developmental variations in clinical presentation, and significant derailment of long-term adjustment and prognosis need continued study. The effects of puberty on clinical presentation, gender distribution, and treatment response are well described.
Section 5 focuses on attention-deficit and disruptive behavior disorders. The section weaves a tale of behavioral disruption as an outgrowth of temperamental variation and transactions with existing social environments. The opening chapter is a comprehensive review of an update on attention-deficit disorders. This disruptive behavior disorder has been the subject of intense study for nearly 50 years. Several newer issues have evolved, especially the neurobiology of attention, impulse control, intention and motivation, and the relationship to other psychiatric disorders. Attention-deficit hyperactivity disorder (ADHD) is becoming a disorder in which comorbidity is the rule rather than the exception, and the subcategorization of this disorder is becoming a treatment consideration. As a result, the treatment of ADHD has evolved from a simple one stimulant-one child approach, to a comprehensive approach accommodating comorbidity. Unfortunately in some situations, uncontrolled polypharmacy is the result. The second chapter traces the formation of conduct disorder from emerging disregard for the needs of others and social rules. In this context, temperamental and neurobiologic variables affect social and cultural factors. It appears that conduct disorders represent the confluence of developmental processes, shaped by family disruption, psychopathology, and pervasiveness of disruptive symptoms. Other sections review conduct disorder in childhood as an evolving process, related to both temperamental and perhaps neurobiological factors. Oppositional defiant disorder and conduct disorder may represent a spectrum or continuum of behavioral disruption. There is an excellent review by Dr. Lewis of conduct and antisocial disorders in adolescents, reflecting this synthesis of neuroscience and social theory.
Section 6 turns to anxiety disorders, focusing on separation anxiety, obsessive-compulsive disorder (OCD), phobia and panic, and posttraumatic stress disorders (PTSD). This is a well-written section that reviews some of the oldest and also the hottest areas of interest in child psychiatry. Separation and generalized anxiety disorders have been described for some time, with excellent dynamic formulations. Over the last several years, the research into the neurobiology of anxiety has expanded. The notions of behavioral inhibition and avoidant behaviors is becoming an area of increasing clinical interest. OCD has become the darling of child psychiatry. Once considered rare, this disorder may be quite common. As the neurobiology of OCD unfolds, the close relationship to tic disorders becomes apparent. In contrast to obsessive-compulsive symptoms in tic disorders, OCD as an anxiety disorder shows variable comorbidity with other anxiety and affective disorders. Phobia and panic disorder may represent phasic hyperarousal phenomena that share neurobiological underpinnings with PTSD. Both disorders seem to represent an adrenergically driven arousal-fear system run amok. Panic disorder appears spontaneous, with associated variations in avoidant learning and anticipatory anxiety. The section on PTSD addresses this significant problem from both a social and a neurobiological framework. The vulnerability to trauma, desensitization, and age-related factors play a significant role in this disorder. Insights into the neurobiology of PTSD and the emergence of cognitive-behavioral and acute pharmacological interventions have been encouraging. The distinctions between acute and chronic long-standing trauma remains crucial to planning treatment interventions and pharmacologic protocols.
Section 7 deals with eating disorders. There is an excellent review of feeding and eating disorders related to new classifications in infant psychiatry. These relate not only to arousal and attachment, but also to emerging separation/ individuation issues as well. Other sections focus on anorexia nervosa, the enigmatic disorder of self-starvation, and obsessive preoccupation with distorted body image. Long-term prognosis for anorexia had been relatively neglected but is drawing increasing interest. Bulimia nervosa is also addressed, in the context of the relationship with possible addiction and disruptive disorders. The overall treatment programs for both are well addressed and focus on a mixture of family, individual, and pharmacotherapies. The final section on obesity is of particular interest, especially in light of the "fattening" of America. The availability of high-calorie food, limitations on exercise, and an increasing generation bound by umbilical cords to television or computer screens makes this a particularly relevant issue. In spite of the years of research, and the promising genetic links to obesity, this issue remains a primary problem that requires life-long adjustment. Pharmacotherapies, although helpful as adjuncts, might have serious limitations in altering life-style.
Section 8 focuses on tic and stereotypical movement disorders. Tic disorders provide a glimpse into the basal ganglia, richly interconnected brain function. The link between "unconscious" and "involuntary" movements is a fascinating area. It appears that tic disorders represent an interface between dynamic theories of the unconscious energy and intrusive symptoms from dysfunctional sensory filters in the basal ganglia. The chapter provides an update on the spectrum of tic disorder and their complex relationship to obsessive-compulsive spectrum disorders. There is a brief discussion of the growing neurobiological interest in the psychiatric comorbidity within this family of movement disorders. The chapter reviews basic treatment and protocols, and as a model improvises a good framework for the practicing clinician.
Section 9 focuses on disorders of somatic function. This includes disorders of elimination, traditional psychosomatic disorders, and sleep disorders. The scientific study of sleep disorders have drawn increasing attention. The linkage between attention-deficit disorders, restless leg syndromes, and other arousal phenomena in sleep is well described. Likewise, the emergence of disorders such as narcolepsy has been of great interest in attempts to understand the evolution of these complex arousal disorders. The discussion of disorders of elimination provides a review of these age-old problems in both development and family transactions. Often, referrals to child psychiatrists for children with elimination disorders represents a systemic dysfunction. Most elimination disorders are identified by pediatricians and behaviorists, leaving a group of resistant patients who require careful analysis of dynamic and biological factors. The psychosomatic disorders represent another burgeoning arena. As we understand the relationship between the frontal cortex, limbic, and hypothalamic regions, and their input into functioning of the "lower organ," the boundary between psychic and somatic becomes increasingly blurred. This new research lays bare Rene Decartes notion of separation between body and mind. Unfortunately, American medicine has been plagued by this dualism, and this chapter restates the importance of a unitarian or transactional model.
Section 10 deals with a variety of special issues. There is a chapter on substance abuse that looks at both the epidemiology as well as the emerging neurobiological research in this field. Gender-identity disorders are looked at in terms of the evolution of attachment, separation/individuation, neurohormonal and prenatal influences, as well as genetic vulnerability in the evolution of these complex disorders. Adjustment disorders are reviewed. Some years ago, the overuse of adjustment disorders seemed to limit their usefulness. On the other hand, a well-defined psychobiologic model was used; these can become increasingly important in helping us understand the underpinnings of all psychopathology. Subsequent chapters on physical and sexual abuse are well written and incorporate much of the newer findings in this unfortunate and tragic chapter in our social history. Acquired immunodeficiency syndrome (AIDS) is reviewed from both a medical and psychological framework. The risk factors for becoming infected with the human immunodeficiency virus (HIV) in adolescence are discussed as well as the neuropsychiatric impact of this devastating immune disorder. Suicide and suicidality are addressed by Dr. Pfeiffer. In her usual succinct and comprehensive fashion, she has provided an update in current thinking on diagnosis and intervention. Sections on personality disorders describe the relationship between temperamental variables, life experience, and personality dysfunction. Likewise, the relationship to primary psychopathology at either subclinical or chronic forms is addressed. The final section on forensic psychiatry provides an excellent update of this often confusing world of legal medicine. Many clinicians often fail to even understand the questions they are asked in the demands of a courtroom setting, so unfortunately they shy away from this venue.
Section 11 provides an overview of treatment. The psychopharmacology section provides a basic review of psychopharmacology with a strong eye on clinical practice. There are many practical suggestions in this chapter, and the issues of drug selection, drug interactions, therapeutic drug monitoring, and clinical efficacy are reviewed. The chapter is comprehensive and offers a middle-of-the-road approach to the introduction of novel therapies. The section on psychoanalysis and psychodynamic therapy is refreshing. It has been fascinating to see psychoanalytic theory modify through time and evolve to adapt to the cultural matrix of our era. In our time of managed care, there is a danger that this time-honored treatment will be seriously curtailed. As the social warfare for the soul of America continues, other modifications in therapeutic technique will be essential. A section on shorter term therapies looks at crisis, dysequilibrium, and attempts at restoration as a process inherent in all forms of therapy. Patient selection is as crucial as clinician training. The section on behavior modification provides an overview of learning theory, with application of learning principles to clinical practice. Many clinicians use "behavior mod" techniques without adequate behavioral analysis, and failures often emerge from this practice. Family therapy is reviewed, offering a panorama of both theory and intervention strategies. Family therapy has now moved into its middle years with a growing sense of clinical wisdom and humility. Group therapy and hypnosis round out the section. Hypnosis remains an interesting intervention that remains controversial in some areas of forensic and clinical practice. Its value, however, may be limited by developmental and personality issues. On the other hand, it has proven to be an interesting technique, especially in terms of hyperarousal disorders.
Dr. Wiener has collected a distinguished group of clinician-scientists and veterans from the child psychiatry wars. His text is well written and imminently readable. The chapters are well organized and provide a quick glimpse at research and clinical practice in the mid-1990s. As with any multi-authored text, there is variability among the chapters, but most are solid overviews that keep the practicing clinician abreast of our rapidly expanding field. Dr. Wiener has met his original goals, and I think he has contributed to the ongoing dialectic process between the neurobiologic and the psychodynamic-psychosocial understanding of childhood psychopathology. This text is a reference for clinicians, and it is limited with respect to more highly focused researchers. On the other hand, with increasing specialization and microanalysis of neurobiology, an overview seems crucial to maintain balance. The reductionist view of the universe will continue to dissect human experience to the level of neurotransmitter, electrical impulse, and ultimate atomic structure. Unfortunately, reductionists will continually bump the trees as they sprint scientifically through the forest of our specialty. Dr. Wiener and the associated authors have widened our field of vision and reminded us that both the forest and the trees are equally important.
FOOTNOTES
Dr. Barnhill is clinical associate professor and director, Developmental Neuropharmacology Clinic, University of North Carolina School of Medicine atChapel Hill.
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