Child and Adolescent Neurology for Psychiatrists

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regard ing this top ic. (May we never view another T V movie on the subject of stranger abdu cti on again l) Th e text is full of relevant information on such topic s as the difficulty of defining the nature and scope of the problem of missing children , the history of the fede ral and state legislation regarding child wel fare laws and missin g ch ildren , and how local law en forcement personn el thin k and opera te in handling the various kinds of missin g children rep orts present ed to them (from toddl er missin g near a river at du sk to a teen with a history of rep eated runnings). Th e authors begin by first addressing the confusi ng usage s of " miss ing child" by va rious person s. As a res ult, most of us have been " missing" by one definition or another at sometime in our childhood. (Our parents were never always certain where we played, and we were sometimes late for supper.) But, at least in my ca se, neither my friends nor myself ju st simply disappeared nor were abducted by strangers, non e of us were kick ed out and told never to return (the autho rs name these " the thro waways" ). None ran aw ay fro m home for more than 24 hours. What abo ut children abducted by stra nge rs? It is exceed ingly rare . By one study of child kidnapping, the estimates are 200 to 300 stranger kidn app ings in the Un ited States yea rly (this is abo ut 3% of all child abductions.) The auth ors co mpa re this with 20,0 00 hom icides, 90,000 reported rap es, 500,000 repo rted robberies, and 900,000 reported aggravated assaults annually. So wh y has this rare event received such prominent attention by medi a and po sturing politicians? It is a fasc inating story. Oth er findings? First, some goo d news: of those ch ildren and teens reported " missing " (who are either los t or have " ru n away") the vas t majority return hom e or are found within 24 hours unh armed . Now for the bad news: becau se divorce is so prevalent, many missing childre n are "missing" as the result of parental abductions du ring a custody dispute. (Family abductions, th at is, when the child is taken by a fa mily member, were estimated at 163,000 in 1988. ) Although some children are abdu cted out of con cern by the noncustodial parent that the child had been abu sed (in one study, less than 1% were actually sex ually abu sed ), more often it see ms the abduction is don e out of spite. The authors point out that the ch ild ' s best interest ofte n is not a priorit y either for the se parents or for the co urts, which ofte n would prefer to lea ve cu stody decrees so vag ue and' 'flex ible" that the y make it ne arly impossibl e for local law enforce ment officials to determine whether the custody agreement has, in fact, been violated. To address the problem of missing children adequately, the issue s associated with parent al discord and divorce and their dev astating effects on children need to be adequately addressed. The authors then describe, in suffici ent det ail , the past well-meaning but unsuccessful attempts to add ress this significa nt soci al problem . Here is more bad news (aga in, not new to many of us in the child/teen ment al health field): a much smaller percentage of run awa ys and throwaways (but an increasi ng ly growing abso lute number of chi ldren and teen s) don 't return home at all. These are the Huckleberry Finn s who prefer enduring the trauma of living on the stree ts, suffering the ph ysic al assaults, rape, drug abu se, pro stitution and medi cal illn esses to the greater misery that would result in returning J. Am.Aca d. Child Ado/esc. Psychiatry, 32:5. September 1993

hom e. (Did you remember that Huck left hom e to avoid the brutal beatings fro m his alco ho lic fath er?) In 198 8, an estimated 133,500 children ran away without a place to stay (the majority were juveniles running from group homes) . Now reflect on the following: the 2.5 million reported cases of child abu se in 1989 , the estimated 1.2 milli on children who have at some time in their lives been attacke d by parents with a leth al wea pon, the conse rva tive estimate of 1,225 children killed at the hand s of their parents or parent surro ga tes yearly, and the estimated 16,000 daught ers aged 5 to 17 yea rs old who have sexual activity wi th their fathers yea rly . Th e readers " take-home " message regarding the vast majority of missing childre n cases who stay missing is: " the bogey man lives at hom e." Now for the worst of the bad news: given the current political and social climate, as well as current governmental spendi ng cuts and prior itie s (as usual in go vernment , child and fa mily we ll-bei ng make for gre at speec hes but are give n a low funding priority), it wi ll be exceedingly difficult to find acceptable solutions to the massive social and legal probl em s associ ated with severely distre ssed families and the resulting missin g children. In the authors ' wo rds: Doi ng anything significant or long lasting about missing children means improving some of the basic social institutions that affect the immediate and long-term welfare of all children-the family, the school system, and the neighborhood.

I have one co mplai nt: given that this book is advertised as the first book to adequately address the sco pe and co mple xity of issues and challenge s that missin g childre n pose, there is ab solut ely no menti on of psychi atr ists ! I wo uld have tho ught some men tion wo uld have been made of our role in the arena of child/teen/family evaluation, treatm ent , and public poli cy advocacy . Neverth el e ss, I rec ommend thi s book to any mental health worker treating children , adolescents, and their fa milies for the historical, soc ial, and political perspective the authors pro vide. This book is especially addressed to pub lic policy makers and their con stituents. As such, it pro vide s much useful "ammunition" that we in the mental health field ca n use to advocate more effec tive ly for more s uppo rt in identifyin g, assessing, and tr eating distr e ssed children and their fam il ies before they be come " miss ing" or wo rse . DALE MORTIMER , M.D . :

Vancouver. Washington

Child and Adolescent Neurology for Psychiatrists. Edited by David M yl and Kau fm an , M .D ., Gail E . Sol omon , M.D ., and Cynthia R. Pfeffer, M.D. Baltimore, MD: Wil liam s and Wi lkins, 1992, 269 pp ., $52 (ha rdcover) . In the Preface , the editors' 'offer thi s book , expressly written for psychi atri sts, as an overview of impo rta nt neurological disord ers that occ ur in children and ado lesc ents ." Th ey also intend to enhance the clinical co llaboration betw een the psychiatrist who has gained kn owl edge from the book and J085

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his or her colleagues in neurology. The editors draw inspiration from the proclaimed' 'Decade of the Brain," hoping to prepare the reader for this decade. Coincidentally, with its grey cover and white pages, one could easily surmise that a cross section of the book would contain both grey and white matter. The book certainly seems successful in presenting an overview of pediatric neurological disorders. The 28 contributors have loaded it with facts, and I found myself underlining them as if I was planning to check out my shortterm memory as I did many years ago in medical school. Thus anyone needing access to the general framework of knowledge in this area should find this book very useful. The chapters, for the most part, are arranged by groups of related disorders with the emphasis on clinical description and not treatment. The chapters are well referenced, and the index seems comprehensive so as to give the book good utility as a text and reference book. Some chapters relate rather classic neurological disorders such as those on movement disorders or neuromuscular diseases or brain tumors in children. Others update the current terminology for familiar disorders such as those on epilepsy and on headaches in children (neurologist too can reclassify). The chapter on neuroradiologic imaging in children and the one on HIV-I and the central nervous system are a part of the new frontier in our developmental knowledge. They are both excellent. Some chapters are truly common ground for both psychiatry and neurology such as those on attention deficit hyperactive disorders, pervasive developmental disorders, Tourette's syndrome and other tic disorders, mental retardation, and sleep disorders. Sometimes it was a bit strange seeing these as "neurologic disorders" for child and adolescent psychiatrists. This leads to my critical questions about this book. Was it expressly written with the psychiatrist in mind, or is this mainly a collection of down-weighted papers covering various areas in pediatric neurology with occasional clinical relevancy for psychiatrists? I have little doubt about good intentions, and there are chapters such as the one dealing with the psychiatrist's role in the emergency room treating neurologic emergencies, which clearly capture relevancy for psychiatrists. However, there did not appear to be any consistent focus or process that maintained a theme of "expressly for psychiatrists." In at least two of the chapters, the authors acknowledge adapting them from previously published articles. No doubt it is difficult to orchestrate a sizable number of contributors, mostly neurologists, into this type of movement. Yet a stronger integration of the chapters into this theme would have been helpful for the reader. The chapter on psychiatric symptoms in the progressive metabolic, degenerative, and infectious disorders of the nervous system is exceptionally well written and seemed to have captured some of the essence of the often difficult differential diagnostic process. The attunement of the psychiatrist to the clinical symptoms of neurodegenerative disorders as well as a definition of his or her role in 1086

management was accomplished clearly. This chapter incorporates a large body of factual neurology into a very palatable capsular review obviously designed for psychiatrists. Finally, will this book promote improved collaboration among the two doctoring specialists? If factual pediatric neurology were the common denominator, then, yes, it would. However, few psychiatrist ever will carry much of this body of knowledge farther than the board exams without some constancy of clinical exposure. What is needed is the experience of a pediatric neurologist and a child psychiatrist who have worked closely over time. The shared collaborative experiences could wisely define the interdigitated clinical areas for both psychiatrists and neurologists who treat children. However, this volume isa good beginning to such a shared relationship with colleagues in child neurology, for it makes readily available a body of knowledge that may enable the psychiatrist to better communicate with the neurologist. Books written expressly for readers who by nature are not attracted to the subject must address a certain amount of resistance. It does not need to be sugar coated, but a little honey goes a long way. The reviewed book, however, lacked a "soft sell" for me as a child and adolescent psychiatrist. It does have true merit in its straightforward factual approach, and I can recommend it for its knowledge base and as an important new reference text for psychiatrists. The book should be useful in preparing for board examinations and also could be, in part, incorporated into the teaching curriculum in the residency programs in psychiatry. However, I doubt it will have much impact on the state of interdisciplinary relationships. ROBERT H. BEASLEY, JR., M.D. Associate Professor of Psychiatry University of Oklahoma Health Sciences Center

Women, Girls and Psychotherapy-Reframing Resistance. Edited by Carol Gilligan, Annie Rogers, and Deborah Tolman. New York: Harrington Park Press, 1991,272 pp., $14.95 (softcover). The authors set out to fill the gaps in "feminist clinical literature" on adolescent psychology and to clarify their position in defining resistance as a health-sustaining process rather than "as a impediment to the creation of a working therapeutic relationship." The book is organized into four sections: In Section I, Ms. Gilligan presents relationships in adolescent girls as central to the development of an identity, and "security" in the process of becoming integrated into society. Girls are described as experiencing and offering' 'a healthy resistance to disconnections" in the struggle to establish their separate identities. Separation as essential to development is perceived as a threat and therefore resisted. Ms. Rogers eloquently describes the struggle involved in the establishment of the identity of the female psychotherapist. The battle to permit identification of the adolescent girl with the psychotherapist, in contradiction to and in defiance J. Am. Acad. Child Adolesc. Psychiatry, 32:5, September 1993