Abstract
H
The idea of a Merck Manual style of understanding which forms of psychopathology specific symptoms and signs might be linked to is in itself a welcomed addition to the child and adolescent psychiatry library. This practical volume is divided into a brief introductory section, a large section on problem behaviors that forms the meat of the book, and 250 out of the 616 pages of the book that are devoted to eight helpful appendices, a glossary and index, and references. It is a very dense paperback that has a lot of fine print, many useful tables and charts, citation of measures, laboratory tests with standard normal values, and more, which obsessional clinicians can sink our teeth into.
The introductory section states that this book will list individual symptoms and behaviors that are most commonly the focus of complaint, and will also list the factors that can contribute to or cause them. The book is designed “to help readers decide if symptoms merit clinical attention or not and what further assessment is indicated.” The level of the text and the content are particularly well pitched to students, interns, residents, and beginning mental health practitioners. The volume contains useful discussions such as “the meaning of tears,” stating that tears are an invitation to meet the patient “with sympathy and encouragement,” and then offers some model phrases of encouragement. Another passage asks “When is intuition useful?” and yet another recommends giving feedback during and after assessment, always starting with the child's and parent's points of view in mind.
Following the introductory section, the book launches into the various developmental and psychological domains in which symptoms arise, and then lists those symptoms. Although not overtly remaining wedded to any particular school of thought or theory at first glance, a more careful reading suggests that the authors have a somewhat cognitive-behavioral bent, and that, therefore, cognition is the first domain in a guide meant for psychologists and psychiatrists, followed by motor, sensory, communication, and social. Thereafter, one notes categories such as “breaking rules, anger, anxiety, negativeness, and languor,” in place of a singular “emotional” or “affective” domain. And finally, there are the domains named “digestive/excretory”, and “bizarre experiences and ideas” related to more specific forms of psychopathology, such as psychotic disorders.
The very first behavior and related “Causelist” in the book is “Poor results in school or testing.” The authors state that this “has first place in the book because it needs to be considered in every child, even when it is not the presenting complaint.” Therefore, one immediately finds the focus of this volume on school-age children and academic performance to be a primary indicator of functioning, which is in contrast to social-emotional functioning, which might be listed as “first place” in other child mental health handbooks. The Causelist itself starts with the rubric “Not actually poor performance” but believed to be so because the child is “Not living up to parents' expectations…High-achieving family” and then moves to “Can't learn well” as related to “Intellectual disability (low intelligence)…Uncomplicated delay…Specific learning disability.” The lists throughout the book are similarly useful in logically breaking down possibilities that might relate to the cause of a given symptom or behavior and that theoretical bias might not help us see, particularly when starting out in our professional life.
Although the book is clearly useful for novice clinicians, it contains sections labeled as “Conundrums” that are appealing even to the most seasoned child and adolescent mental health professional. Topics such as “OCD within autism” or “selective mutism with autism” offer insight into these particular comorbidities. There are actually many references to autism, perhaps even in excess of those in relation to other forms of psychopathology. One important clinically and ethically intriguing “Special Topics” entry is entitled “Would an autism-related diagnosis help the child?” Another topic is that of “hatred” and “parental alienation syndrome.”
Books such as this one that try to organize complex human behaviors into lists do inevitably run into some rather odd and arbitrary-seeming associations, which can confuse the very readership to whom the book most appeals, namely younger clinicians and those in training. One such example is found in Causelist 11 (p. 71), entitled “Brief overwhelming states.” A perfectly reasonable list including “Tantrums, Rage, Breathholding Spells, Hyperventilation, Panics, Shuddering Attacks …” is then followed by “Orgasm” (which I can see as a brief “overwhelming” state – perhaps), but then is followed by “Autism”…and later “Pheochromocytoma.” How are these very disparate and unrelated forms of pathology, which can be anything but “brief” in their overwhelmingness, be considered as “brief overwhelming states”?
Another aspect of this book that is problematic is its representation of child–parent attachment and parental mental illness. The authors write, “usually children's level of [mental health] disturbance does not fluctuate with their parents' episodes of mental illness.” A citation is provided for this quote, which is not placed in an understandable clinical context, and was written by none less than Rutter and Quinton, but was from their article dated 1984 (Rutter and Quinton 1984). More recent research (Hobson et al. 2009; Schechter et al. 2010) clearly shows that parental mental illness and its exacerbation has effects on maternal–child interactions that do augment child distress and potentially lead to greater child mental health disturbance. Similarly, in the list that focuses on the behavior “behaving better with dad than with mum,” the possibility of a differing pattern of individual attachment with each parent is not considered, when this differing pattern would be considered highly salient in a diagnostic coding system such as Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood-Revised (ZERO TO THREE, 2005).
The aim of this book is noble and very important, and is a tall order for anyone to produce with more aplomb than the authors here have managed. All readers will find something useful clinically here. However, what this reviewer finds in need of greater clarity, and which is done better in some places in the book than in others is the integration of the developmental and relational context for many of the symptoms and behaviors listed. It is these two contexts in which clinicians often interpret symptoms and behaviors of children and adolescents. As this is a phenomenologically based book, the model is more traditionally medicopsychiatric, and many lists mix signs and symptoms regardless of the typicality of them at a given age or within a given relational or social setting. An example of when the book works well is in “Causelist 103: Crying” in which a table divides up what might cause crying at different stages of development: “Babies…Toddlers…Older…Any Age…In the parent …”
However, when looking at “Causelist 95: ANGER—Tantrums,” the place of developmental and relational context is less clear. The first entry in the list “Normal” suggests that children (without age or developmental stage) typically can manifest “Up to 10–15 minutes, 1–2 times a day of tantrums.” Causes are listed as “Discipline inadequate” and “Discipline inconsistent;” however, tantrums at certain ages and beyond given developmental delays are typically more frequent and unrelated to a problem with discipline. Tantrums may occur in one relational context subsequently but not in another. Research data to support the difference between “normal” and “pathological” tantrums within the preschool period show that the ability to resolve a tantrum is often a differentiating factor (Belden et al. 2008).
Following all of the lists, conundrums, and special topics, this volume provides clinically pertinent appendices such as “Functional analysis” with an eye toward behavioral experience, and “Further investigations/assessments.” Appendix F includes a Child and Adolescent Mental Health Assessment that students and clinicians can print out and use as a guide that links back to the reference book. The final appendix is devoted to important issues of patient confidentiality.
In summary, this handbook represents an important effort to catalog an A to Z of child symptoms and behaviors and their causes, mixed with practical assessment and diagnostic advice along the way. As an experienced clinician, I found it fun to leaf through, and think about how many different “causes” we can think of for a given behavior or symptom; for example, “Causes of difficulty changing what he's (child's) doing …”. He might like what he's doing now. He might not like what is offered to do next. He might dislike something that accompanies the change. He might be trying to assert his status or be oppositional. He might be inflexible because he's anxious. Or he might just be stuck and perseverative. Or might it be more of a mix? I guess ultimately breaking down the complexity of human behavior into lists with great care – care bordering on obsessiveness – sheds light not only on what is in the list but also on what we miss in so doing.
Footnotes
Disclosures
No competing financial interests exist.