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Child Psychiatry.
  1. ANTHONY COX, Professor of Child and Adolescent Psychiatry

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    Child Psychiatry. By Robert Goodman, Stephen Scott. (Pp 328 paperback; £18.99.) Blackwell Science, 1997. ISBN 0-63203885-3.

    There is a continuing need for a book of manageable size that can be used as an introduction and resource by trainees and professionals whose work brings them into contact with issues concerned with child mental health. Most texts in English that aim to perform this function are out of print so there is an important gap to be filled. Although Goodman and Scott have gone a long way to achieve their goal there are a number of deficiencies and disappointments.

    The audience explicitly includes a wide range of disciplines from education, social work, nursing, and psychology to paediatrics, psychiatry, and general practice, yet there is remarkably little mention of the contributions of disciplines other than child psychiatry to the assessment and treatment of children with psychological and psychiatric disorders. For example, there is no significant account of psychological assessment nor the manner in which teachers can be included in treatment programmes.

    The ordering of certain chapters and sections seems unsatisfactory so that assessment precedes classification and epidemiology, and risk factors follow detailed accounts of a range of specific disorders. Incidentally, maltreatment of children is included as a specific disorder or presentation when strictly it is a risk factor.

    There is more emphasis on factors than processes with one or two notable exceptions—for example, in the section on psychosomatics, and although there are chapters on preschool problems and disorders of adolescence, a developmental perspective is not strongly represented.

    Assessment is not put in context so that how different components of assessment fit together is not discussed. There appears to be a misunderstanding about what constitutes good semistructured interviewing, and the suggested scheme for history taking is full of closed questions. There is a notable weakness in proposed methods of learning about relationships. Formulation is referred to much later in the book but is not developed either in the assessment or classification chapters. The manner in which the chapters on specific disorders and presentations relates to classification is not explained, and there is considerable variation in their organisation. One consequence is that information is not systematic about all disorders—for example, there is nothing on the treatment of substance use and abuse.

    Comorbidity is barely discussed. This is an important issue because the authors raise the question of whether conduct disorders are appropriately dealt with by child psychiatric services when those disorders are “clearly, socially determined”. As the authors demonstrate, there are a wide range of factors and other disorders that are commonly associated with conduct disorders. These factors and their attendant processes are often missed in assessment, pointing to the need for medical and psychological input. Related to this, only school refusal is given a chapter, not truancy or the wider range of school attendance difficulties.

    Related to the last point there is a tendency to give less weight to the contribution of social factors; this is exemplified in the discussion of models for the link between mental retardation and psychiatric disorders. The model of a common genesis of low IQ and psychiatric problems from social factors is dismissed, yet four pages later when considering brain disorders it is acknowledged that there is at least continuing controversy as to whether children with brain disorders are “more vulnerable to ordinary risk factors or simply as vulnerable”. In other words the notion that there can be an interaction between brain dysfunction and social factors just as there could be between social factors and IQ in generating psychiatric problems, is overlooked under mental retardation.

    Parenting skills gets a good deal of mention but parent–child relationships very little. There is a chapter on attachment in the risk factors section but no full discussion of parenting and the parent–child relationship in other respects.

    The chapter on preschool problems is particularly disappointing with little acknowledgement of the importance of prevention.

    The lack of emphasis on broader social factors is sustained in that these are not included in the risk factors section even though there is good evidence for the impact of wider social factors, such as community and housing, both by their effect on parenting and more directly on the older child. Incidentally only peer popularity and unpopularity are referred to and not other peer influences.

    The treatment section understandably gives greater weight to evaluated treatments but this leads to what appears to be a relatively positive account of behavioural approaches, although the quoted outcome studies have only palpable effect sizes for problems, many of which the authors suggest fall outside the domain of child psychiatry, such as antisocial behaviour in pubertal children, and wetting. There is nothing on inpatient treatment and no section on broader aspects of management such as working with other agencies including schools.

    Finally the different sections are not clearly related to each other so that it becomes a little strange to see that there is more on treatment of enuresis than of almost any other condition in the specific disorders section. This becomes understandable when it is appreciated that the treatment section aims to address treatment issues related to a number of different conditions.

    Despite the criticisms there is much to commend the authors’ achievement in succinctly summarising so much information in a readable fashion, although there are occasions when terms are used without adequate explanation at the first usage. For example, the reference to attachment relationships on page 6 when the attachment chapter starts on page 199, and the undefined reference to significant harm on page 166 in the maltreatment chapter.

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