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Child Maltreatment: A Handbook for Mental Health and Child Care Professionals
308
BOOK REVIEWS
tration camp experiences. These experiences appeared particularly to sensitize the parents to nutritional problems in their children. Both fathers and mothers, in Dr. Rahamimoff's experience, appeared overly concerned about whether their children would get enough food to eat. Overconcern often led to feeding practices which, rather than encouraging the children's eating, tended to set up negative patterns in which the children ate poorly. Dr. Rahamimoff discusses the parental behavior and its effect on the children almost entirely within the framework of classical conditioning, and it should be of interest to many child psychiatrists to read this discussion which is markedly different from our usual psychodynamic formulations. There is a long section in the book discussing cellular physiology and its possible links to the conditioned reflexes leading to the feeding problems. The review of neuronal physiology is well written. However, the hypothetical linkage proposed by Dr. Rahamimoff between the cellular physiology and the complex activities seen in the eating disorders is highly theoretical and not convincing. The book is illustrated with anecdotal material which provides an interesting background for the points which the author makes. Dr. Rahamimoff gives very specific recommendations for handling eating disorders in infants and young children where these disorders are brought about by the overprotective attitudes of the parents regarding eating behavior in their children. Among these is an excellent section on prophylaxis in which he points out that force should never be a part of the feeding process. He recommends a diversity of foods with earlier introduction of solid foods than is currently advocated by most pediatricians in the United States. He describes treatment by disinhibition and by creating new conditioned reflexes. He has found two types of medication for the children to be helpful: (1) cyproheptadine (Periactin®) and (2) neuroleptics (e.g., thioridazine). He points out that psychotherapy for the mother is an important part of therapy. Overall, this is a short book which should be of interest to child psychiatrists, particularly those who are involved in treatment of appetite disorders. The first 52 pages and the last 38 pages of the book are of most interest to child psychiatrists. The middle portion which deals heavily with neurophysiology could be quickly scanned by child psychiatrists without seriously hampering the overall understanding.
The Unexpected Minority: Handicapped Children in America. By John Gliedman, and Roth William. New York: Harcourt Brace Jovanovich, 1980, 525 pp., $17.95
Reviewed by Ira S. Lourie, M.D. * This fifth and final volume from the Carnegie Council on Children is an excellent addition to an already illuminating series of sociological studies of children and families in our society. In The Unexpected Minority a bold new social theory is presented pertaining to the role society ascribes to physically and cognitively handicapped individuals. The authors describe a "social pathology" model, and theorize how it leads to biases toward the handicapped, effects their development, and diminishes the value of available services. The social theory, as reflected in the title of the book, presents handicapped individuals as a subpopulation with a minority status, determined on the basis of biases and prejudice. The handicapped are discriminated against on the the basis of their appearance and because of a special pathological social role given to them. These biases society has toward this minority are enhanced by what the authors describe as "tolerance of deviance." While this tolerance is a reflection of our view of handicap as a pathological state, both medically and socially, it works to peoples' advantage in some ways by protecting them, but it also acts as a disadvantage when that same tolerance (of pathology) is used as an excuse for exclusion from normality. The authors also propose that we have used the medical model to view handicap, and as a result we see it as a sickness. Since our model of sickness is one of a temporary condition, it naturally follows that tolerance is similarly temporary. Therefore, those who
remain sick are seen as "moral failures" who assume a "permanently sick" role. The handicapped, who cannot avoid chronic disability, are then assigned a pathological societal role. There is a strong indictment of the medical model implicit in this section. In the second section of the book the authors propose the need for a social developmental framework in which the development of handicapped individuals can be viewed. This theory should be based on the concept that the handicapped live and grow within a milieu in which they must deal with both the limitations of their handicap and the biases of society. A cogent argument is then made that this social development effects development in other spheres; namely, psychological, intellectual, and moral. The authors surmise that to look at the development of a handicapped child within the framework of the non-handicapped places a burden on the child that cannot be met. They question the concept that the "rungs of the developmental ladder always must go in the same * Dr. Lourie is Assistant Director for Children's Mental Health Services, Division of Mental Health Service Programs, National Institute of Mental Health.
BOOK REVIEWS
order," why they might not be ordered differently for the handicapped? If true, it would be unfair to measure the development of a normal and handicapped child, using the same age-level criteria. Therefore, in each developmental area, a new handicapped-based developmental "ladder" must be created to reflect the exceptional nature and needs of the handicapped child's world. In the third and fourth sections of the volume, which focus on the impact of service delivery systems and employment policies, the authors become socio-political. In the section on Services, they indict school and medical professionals for undermining the parental role in the care and planning for their handicapped children and for invoking the social pathology model which undermines the full-growth potential of the individual and usefulness of any service provided. The authors plead for all professionals to use a more humanistic approach in dealing with the handicapped. The last section of the book focuses on the future employment outlook for the handicapped child in which the biases derived from the social pathology model are applied to the work force. Finally, the book has several appendices of background papers, including a section of well-known papers on the psychological aspects of handicap. There is also a section of chapter reference notes which are encyclopedic in nature and suffer only in that they are presented as true footnotes to the text and are difficult to use as an independent source of bibliographical and background information. Anyone who treats or is called on to evaluate a handicapped adult or child should read this volume. Whether or not one agrees with the logic and the need for new development schemata, the questions presented should be raised and deeply considered by every child mental health professional. Readers who are interested in the needs of psychologically and emotionally handicapped children will be disappointed as these groups are not discussed. In excluding these groups without explanation, the authors have committed a serious oversight which suggests further societal biases toward mental illness, present even among the most enlightened observers. In view of the recent interest in chronically mentally ill children, the application of the concepts in this work to the emotionally disturbed would be of great value.
Child Maltreatment: A Handbook for Mental Health and Child Care Professionals. By Arthur H. Green. New York: Jason Aronson, 1980,314 pp., $25.00 Father-Daughter Incest. By Judith Lewis Herman. Cambridge: Harvard University Press, 1981,282 pp., $15.95
309
Reviewed by Alayne Yates, M.D. * Each of these volumes is concerned with child abuse; each provides an extensive review of relevant research and each makes a plea for rapid and effective intervention. Child Maltreatment employs the data objectively in a considered multimodal approach to an enormously complex problem while Father-Daughter Incest molds the data to suit a political statement against the evils of male exploitation. Child Maltreatment is a long awaited volume which applies psychoanalytic theory to the understanding and treatment of abusive parents and abused children. Many of the conclusions are based upon investigations conducted by the author and his associates at the Downstate Medical Center in Brooklyn, New York. The presentation is lucid and certainly helpful to a variety of disciplines. The practical strategies for prevention as well as intervention are based upon sound therapeutic principles. The author clearly delineates the role of the child psychiatrist within the multidisciplinary team and stresses the need for reconstructive therapy for the abused child. The author reviews attachment theory, factors which mediate against successful bonding, the characteristics of the abuser and the abused, and the nature of the relationship between abuse life stress. He differentiates among violent abuse, sexual abuse, neglect, and failure to thrive. Other sections are devoted to interventions, service delivery prevention, current research, and legal issues. The presentation of abuse within a developmental frame is especially valuable: abuse occurs in response to phase specific stressors which occur predictably at each successive stage of the child's growth. Infants are abused when the parent is unable to tolerate the child's helplessness because it evokes memories of the parent's own early, unresolved frustration; parents abuse toddlers because of conflicts over autonomy and control. The preschool youngster may be beaten for masturbating or for acting seductively toward a parent; the grade school child may be struck by a paranoid, narcissistic, or controlling parent who interprets his interest in peers or adults at school as a traitorous act. Abused children may suffer from psychopathology which is similar to that described by Freud in his concept of the traumatic neurosis. The severe panic associated with the breaching of the stimulus barrier would explain the paralysis of ego functions and psychotic behavior which these children often exhibit at * Alayne Yates, M.D., is Chief of Child Psychi.atry ~nd Ass?ciate Professor of Psychiatry and Pediatrics at The University of Arizona, Tucson, Arizona.
BOOK REVIEWS
tration camp experiences. These experiences appeared particularly to sensitize the parents to nutritional problems in their children. Both fathers and mothers, in Dr. Rahamimoff's experience, appeared overly concerned about whether their children would get enough food to eat. Overconcern often led to feeding practices which, rather than encouraging the children's eating, tended to set up negative patterns in which the children ate poorly. Dr. Rahamimoff discusses the parental behavior and its effect on the children almost entirely within the framework of classical conditioning, and it should be of interest to many child psychiatrists to read this discussion which is markedly different from our usual psychodynamic formulations. There is a long section in the book discussing cellular physiology and its possible links to the conditioned reflexes leading to the feeding problems. The review of neuronal physiology is well written. However, the hypothetical linkage proposed by Dr. Rahamimoff between the cellular physiology and the complex activities seen in the eating disorders is highly theoretical and not convincing. The book is illustrated with anecdotal material which provides an interesting background for the points which the author makes. Dr. Rahamimoff gives very specific recommendations for handling eating disorders in infants and young children where these disorders are brought about by the overprotective attitudes of the parents regarding eating behavior in their children. Among these is an excellent section on prophylaxis in which he points out that force should never be a part of the feeding process. He recommends a diversity of foods with earlier introduction of solid foods than is currently advocated by most pediatricians in the United States. He describes treatment by disinhibition and by creating new conditioned reflexes. He has found two types of medication for the children to be helpful: (1) cyproheptadine (Periactin®) and (2) neuroleptics (e.g., thioridazine). He points out that psychotherapy for the mother is an important part of therapy. Overall, this is a short book which should be of interest to child psychiatrists, particularly those who are involved in treatment of appetite disorders. The first 52 pages and the last 38 pages of the book are of most interest to child psychiatrists. The middle portion which deals heavily with neurophysiology could be quickly scanned by child psychiatrists without seriously hampering the overall understanding.
The Unexpected Minority: Handicapped Children in America. By John Gliedman, and Roth William. New York: Harcourt Brace Jovanovich, 1980, 525 pp., $17.95
Reviewed by Ira S. Lourie, M.D. * This fifth and final volume from the Carnegie Council on Children is an excellent addition to an already illuminating series of sociological studies of children and families in our society. In The Unexpected Minority a bold new social theory is presented pertaining to the role society ascribes to physically and cognitively handicapped individuals. The authors describe a "social pathology" model, and theorize how it leads to biases toward the handicapped, effects their development, and diminishes the value of available services. The social theory, as reflected in the title of the book, presents handicapped individuals as a subpopulation with a minority status, determined on the basis of biases and prejudice. The handicapped are discriminated against on the the basis of their appearance and because of a special pathological social role given to them. These biases society has toward this minority are enhanced by what the authors describe as "tolerance of deviance." While this tolerance is a reflection of our view of handicap as a pathological state, both medically and socially, it works to peoples' advantage in some ways by protecting them, but it also acts as a disadvantage when that same tolerance (of pathology) is used as an excuse for exclusion from normality. The authors also propose that we have used the medical model to view handicap, and as a result we see it as a sickness. Since our model of sickness is one of a temporary condition, it naturally follows that tolerance is similarly temporary. Therefore, those who
remain sick are seen as "moral failures" who assume a "permanently sick" role. The handicapped, who cannot avoid chronic disability, are then assigned a pathological societal role. There is a strong indictment of the medical model implicit in this section. In the second section of the book the authors propose the need for a social developmental framework in which the development of handicapped individuals can be viewed. This theory should be based on the concept that the handicapped live and grow within a milieu in which they must deal with both the limitations of their handicap and the biases of society. A cogent argument is then made that this social development effects development in other spheres; namely, psychological, intellectual, and moral. The authors surmise that to look at the development of a handicapped child within the framework of the non-handicapped places a burden on the child that cannot be met. They question the concept that the "rungs of the developmental ladder always must go in the same * Dr. Lourie is Assistant Director for Children's Mental Health Services, Division of Mental Health Service Programs, National Institute of Mental Health.
BOOK REVIEWS
order," why they might not be ordered differently for the handicapped? If true, it would be unfair to measure the development of a normal and handicapped child, using the same age-level criteria. Therefore, in each developmental area, a new handicapped-based developmental "ladder" must be created to reflect the exceptional nature and needs of the handicapped child's world. In the third and fourth sections of the volume, which focus on the impact of service delivery systems and employment policies, the authors become socio-political. In the section on Services, they indict school and medical professionals for undermining the parental role in the care and planning for their handicapped children and for invoking the social pathology model which undermines the full-growth potential of the individual and usefulness of any service provided. The authors plead for all professionals to use a more humanistic approach in dealing with the handicapped. The last section of the book focuses on the future employment outlook for the handicapped child in which the biases derived from the social pathology model are applied to the work force. Finally, the book has several appendices of background papers, including a section of well-known papers on the psychological aspects of handicap. There is also a section of chapter reference notes which are encyclopedic in nature and suffer only in that they are presented as true footnotes to the text and are difficult to use as an independent source of bibliographical and background information. Anyone who treats or is called on to evaluate a handicapped adult or child should read this volume. Whether or not one agrees with the logic and the need for new development schemata, the questions presented should be raised and deeply considered by every child mental health professional. Readers who are interested in the needs of psychologically and emotionally handicapped children will be disappointed as these groups are not discussed. In excluding these groups without explanation, the authors have committed a serious oversight which suggests further societal biases toward mental illness, present even among the most enlightened observers. In view of the recent interest in chronically mentally ill children, the application of the concepts in this work to the emotionally disturbed would be of great value.
Child Maltreatment: A Handbook for Mental Health and Child Care Professionals. By Arthur H. Green. New York: Jason Aronson, 1980,314 pp., $25.00 Father-Daughter Incest. By Judith Lewis Herman. Cambridge: Harvard University Press, 1981,282 pp., $15.95
309
Reviewed by Alayne Yates, M.D. * Each of these volumes is concerned with child abuse; each provides an extensive review of relevant research and each makes a plea for rapid and effective intervention. Child Maltreatment employs the data objectively in a considered multimodal approach to an enormously complex problem while Father-Daughter Incest molds the data to suit a political statement against the evils of male exploitation. Child Maltreatment is a long awaited volume which applies psychoanalytic theory to the understanding and treatment of abusive parents and abused children. Many of the conclusions are based upon investigations conducted by the author and his associates at the Downstate Medical Center in Brooklyn, New York. The presentation is lucid and certainly helpful to a variety of disciplines. The practical strategies for prevention as well as intervention are based upon sound therapeutic principles. The author clearly delineates the role of the child psychiatrist within the multidisciplinary team and stresses the need for reconstructive therapy for the abused child. The author reviews attachment theory, factors which mediate against successful bonding, the characteristics of the abuser and the abused, and the nature of the relationship between abuse life stress. He differentiates among violent abuse, sexual abuse, neglect, and failure to thrive. Other sections are devoted to interventions, service delivery prevention, current research, and legal issues. The presentation of abuse within a developmental frame is especially valuable: abuse occurs in response to phase specific stressors which occur predictably at each successive stage of the child's growth. Infants are abused when the parent is unable to tolerate the child's helplessness because it evokes memories of the parent's own early, unresolved frustration; parents abuse toddlers because of conflicts over autonomy and control. The preschool youngster may be beaten for masturbating or for acting seductively toward a parent; the grade school child may be struck by a paranoid, narcissistic, or controlling parent who interprets his interest in peers or adults at school as a traitorous act. Abused children may suffer from psychopathology which is similar to that described by Freud in his concept of the traumatic neurosis. The severe panic associated with the breaching of the stimulus barrier would explain the paralysis of ego functions and psychotic behavior which these children often exhibit at * Alayne Yates, M.D., is Chief of Child Psychi.atry ~nd Ass?ciate Professor of Psychiatry and Pediatrics at The University of Arizona, Tucson, Arizona.