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Prognosis in child psychiatry
BOOK
REVIEWS
fessional) argues for an emergency, it should be accepted as such, even though bility of manipulation by the patient may be part of the situation.
293 the possi-
There are many other administrative ideas scattered throughout the book. Although treatment is designed for the patient, careful attention to the treatment setting must be Dr. Hankoff suggests a balance between considered in order to provide effective service. appropriate administrative needs and flexibility in clinical decision making. His attention to telephone service, secretarial help and teaching opportunities as a basis for maintenance of staff morale is useful. These strengths of the book, I think, offset some of the weaknesses which crop up in the more direct clinical discussions. For instance, Dr. Hankoff correctly points out the possibility of excessive dependency development in the patient as a danger of energetic activity by the therapist, but he suggests this dependency can be readily altered by the therapist merely pointing out to the patient his excessive demands. This monograph, despite having only 86 pages of text, may provide some review of administrative problems or point out some previously overlooked details which might improve the function of a treatment service. The weaknesses lie in the brevity of coverage which limits the overall value of the monograph-W&r N. Stone, M.D., Cincinnati, Ohio.
PHO~NOSIS IN CHILD PSYCHIATRY. By Hilchen Sommerschild Sun&y, M.D., and Peter Christian Kreyherg, M.D. Baltimore, Xld., Williams and Wilkins, 1968, 117 pages, $18.56. In this study 285 children admitted for inpatient diagnostic evaluation to the newly formed Department of Child Psychiatry in Oslo from 1950 to 1954 were reevaluated some eleven to fifteen years after this admission. These children came from all over and except for the possible therapeutic Norway, were returned to their communities, impact of the diagnostic admission itself, they received essentially no psychiatric treatment. Of the 285 children admitted all except one were traced in the follow up study with a hundred and eighty four interviewed by the two authors and the others reassessed from reports by other psychiatrists and by the families. The goal of this Norwegian study was to assess the long range prognosis of the psychiatric conditions encountered in children. I found the book of interest hecause In many ways this study achieves its objectives. of the way it dealt with the problems of methodology and communication. This study dealt with observational and informational data derived from the original hospital chart and the later re-evaluations, and studies the relevance of these factors to prediction of outcome without treatment. While this limited the data which could be considered, clear communication about the data was possible. This concise monograph begins with an introduction to the study and contains a discussion of the methods used, a description of the patients at primary examination and at the follow up study and an account of the individual symptoms and groups of symptoms they regarded as relevant to the prognosis of the psychiatric condition. The hook ends with an excellent summary and general discussion. The authors divided their group of children into four main diagnostic categories, apparently using schema somewhat different from the diagnoses as listed on the charts initially. The categories used were neurosis, psychosis, oligophrenia and patient with a handicap (normal intelligence but neurological lesions or speech and hearing deficits ), with sub-divisions in each category. As the diagnostic category by itself would not necessarily reflect the severity of the illness, the authors have in addition classified the groups as healthy, moderate, or severe in impairment at the primary examination and compared this with current evaluations which stressed present performance in several areas of function easily observable or readily inferred. A number of representative case histories are given. Although quite spare, the case histories were adequate, yet I found myself wishing for more information in order to relate these cases to my own diagnostic approaches. One hopes that a broadly derived classification such as proposed in the C.A.P. Report 62 on Psychopathological Disorders in Childhood will be used in such studies in the future. If
294
BOOK
Wc can develop value. Special
a common
studies
such
as this will have
markedly
increased
to the neurotic group. At follow up 57% were regarded as endured their illness an average of six and a half years. Those who kept their symptoms after eighteen years of age, tended to change very little except that they no longer asked for psychiatric help. Of the patients who were evaluated, there were few patients, who, as adults, regarded the childhood admission into a hospital as having had any decisive effect on the course of the illness or their later adaptation. This group received very little treatment; as the groups with the worse outcome received the most treatment. The monograph implicitly raises question as to where treatment resources should best be expended in a setting where the demand for treatment is great and the resources limited.
healthy.
attention
language,
REVIEWS
was given
Those who got better
In the neurotic group, the clinical material was analyzed to see which of the variables studied together give the best prediction of outcome. Seven factors were found to have significance in predicting outcome. These were: emotional conditions in the home, emotional relations to others, volition, psychomotor hyperactivity, intelligence, capacity for play, and organic brain damage. Of these, emotional relationships to others, capacity for play, and organic brain disease were most useful with the prediction being made still more certain if the environment were assessed as well. Studies such as this, of central importance in elucidating the natural history of psychiatric disorders, with no necessity to test hypotheses or evaluate treatment methods, rest heavily on evaluative criteria clearly shared and understood by all. Thus there is merit in dealing with observational and informational data as most child psychiatrists would agree with the inferences to be drawn from these data. It has always been difficult to compare studies such as this with other studies because the population studied, the diagnostic categories, and the evaluative criteria all may be different. Long range assessment of outcome of psychiatric conditions encountered in children continues to be vital to our understanding of development and the deviations of illness and suffering. The method used in this study suggests that useful psychiatric information can be derived from a study of closed charts and that this information can be meaningfully compared to current follow up evaluations of children. Thus while we do not have a universal language common to all child psychiatrists, in use now and in the past, this study demonstrates that it is still possible both to look back in the past and to commuuicate with others currently. The authors are to be praised for making available data that is readily integrated by a child psychiatrist of any theoretical background. At the same time a child psychiatrist, no matter what his theoretical background, could fault the study for not including factors he would deem essential to an understanding of the child, a matter the authors have recognized. This lean import is a worthy addition to outcome studies in child psychiatry. While not a pioneering study, it is a worth while addition of interest to child psychiatrists interested in studying the natural history of childhood disorders and in the problem of finding ways of making use of information from the past and communicating this information to colleagues in the present. The price, $13.50, is hard to reconcile with the size of the book.-Israel Dizenhuz, M.D., Cincinnati, Ohio
REVIEWS
fessional) argues for an emergency, it should be accepted as such, even though bility of manipulation by the patient may be part of the situation.
293 the possi-
There are many other administrative ideas scattered throughout the book. Although treatment is designed for the patient, careful attention to the treatment setting must be Dr. Hankoff suggests a balance between considered in order to provide effective service. appropriate administrative needs and flexibility in clinical decision making. His attention to telephone service, secretarial help and teaching opportunities as a basis for maintenance of staff morale is useful. These strengths of the book, I think, offset some of the weaknesses which crop up in the more direct clinical discussions. For instance, Dr. Hankoff correctly points out the possibility of excessive dependency development in the patient as a danger of energetic activity by the therapist, but he suggests this dependency can be readily altered by the therapist merely pointing out to the patient his excessive demands. This monograph, despite having only 86 pages of text, may provide some review of administrative problems or point out some previously overlooked details which might improve the function of a treatment service. The weaknesses lie in the brevity of coverage which limits the overall value of the monograph-W&r N. Stone, M.D., Cincinnati, Ohio.
PHO~NOSIS IN CHILD PSYCHIATRY. By Hilchen Sommerschild Sun&y, M.D., and Peter Christian Kreyherg, M.D. Baltimore, Xld., Williams and Wilkins, 1968, 117 pages, $18.56. In this study 285 children admitted for inpatient diagnostic evaluation to the newly formed Department of Child Psychiatry in Oslo from 1950 to 1954 were reevaluated some eleven to fifteen years after this admission. These children came from all over and except for the possible therapeutic Norway, were returned to their communities, impact of the diagnostic admission itself, they received essentially no psychiatric treatment. Of the 285 children admitted all except one were traced in the follow up study with a hundred and eighty four interviewed by the two authors and the others reassessed from reports by other psychiatrists and by the families. The goal of this Norwegian study was to assess the long range prognosis of the psychiatric conditions encountered in children. I found the book of interest hecause In many ways this study achieves its objectives. of the way it dealt with the problems of methodology and communication. This study dealt with observational and informational data derived from the original hospital chart and the later re-evaluations, and studies the relevance of these factors to prediction of outcome without treatment. While this limited the data which could be considered, clear communication about the data was possible. This concise monograph begins with an introduction to the study and contains a discussion of the methods used, a description of the patients at primary examination and at the follow up study and an account of the individual symptoms and groups of symptoms they regarded as relevant to the prognosis of the psychiatric condition. The hook ends with an excellent summary and general discussion. The authors divided their group of children into four main diagnostic categories, apparently using schema somewhat different from the diagnoses as listed on the charts initially. The categories used were neurosis, psychosis, oligophrenia and patient with a handicap (normal intelligence but neurological lesions or speech and hearing deficits ), with sub-divisions in each category. As the diagnostic category by itself would not necessarily reflect the severity of the illness, the authors have in addition classified the groups as healthy, moderate, or severe in impairment at the primary examination and compared this with current evaluations which stressed present performance in several areas of function easily observable or readily inferred. A number of representative case histories are given. Although quite spare, the case histories were adequate, yet I found myself wishing for more information in order to relate these cases to my own diagnostic approaches. One hopes that a broadly derived classification such as proposed in the C.A.P. Report 62 on Psychopathological Disorders in Childhood will be used in such studies in the future. If
294
BOOK
Wc can develop value. Special
a common
studies
such
as this will have
markedly
increased
to the neurotic group. At follow up 57% were regarded as endured their illness an average of six and a half years. Those who kept their symptoms after eighteen years of age, tended to change very little except that they no longer asked for psychiatric help. Of the patients who were evaluated, there were few patients, who, as adults, regarded the childhood admission into a hospital as having had any decisive effect on the course of the illness or their later adaptation. This group received very little treatment; as the groups with the worse outcome received the most treatment. The monograph implicitly raises question as to where treatment resources should best be expended in a setting where the demand for treatment is great and the resources limited.
healthy.
attention
language,
REVIEWS
was given
Those who got better
In the neurotic group, the clinical material was analyzed to see which of the variables studied together give the best prediction of outcome. Seven factors were found to have significance in predicting outcome. These were: emotional conditions in the home, emotional relations to others, volition, psychomotor hyperactivity, intelligence, capacity for play, and organic brain damage. Of these, emotional relationships to others, capacity for play, and organic brain disease were most useful with the prediction being made still more certain if the environment were assessed as well. Studies such as this, of central importance in elucidating the natural history of psychiatric disorders, with no necessity to test hypotheses or evaluate treatment methods, rest heavily on evaluative criteria clearly shared and understood by all. Thus there is merit in dealing with observational and informational data as most child psychiatrists would agree with the inferences to be drawn from these data. It has always been difficult to compare studies such as this with other studies because the population studied, the diagnostic categories, and the evaluative criteria all may be different. Long range assessment of outcome of psychiatric conditions encountered in children continues to be vital to our understanding of development and the deviations of illness and suffering. The method used in this study suggests that useful psychiatric information can be derived from a study of closed charts and that this information can be meaningfully compared to current follow up evaluations of children. Thus while we do not have a universal language common to all child psychiatrists, in use now and in the past, this study demonstrates that it is still possible both to look back in the past and to commuuicate with others currently. The authors are to be praised for making available data that is readily integrated by a child psychiatrist of any theoretical background. At the same time a child psychiatrist, no matter what his theoretical background, could fault the study for not including factors he would deem essential to an understanding of the child, a matter the authors have recognized. This lean import is a worthy addition to outcome studies in child psychiatry. While not a pioneering study, it is a worth while addition of interest to child psychiatrists interested in studying the natural history of childhood disorders and in the problem of finding ways of making use of information from the past and communicating this information to colleagues in the present. The price, $13.50, is hard to reconcile with the size of the book.-Israel Dizenhuz, M.D., Cincinnati, Ohio