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Empirically Based Assessment of Child and Adolescent Psychopathology: Practical Applications, Second Edition
BOOK REVI EW S
on the incidence of childhood obsessive-compulsive disorder.) Clustering child psychopathology into eight syndromes limits the likelihood that more specific or subtle mood and anxiety disorders such as bipolar disorder, separation anxiety disorder. or the pervasive developmental disorders would be considered and treated . The very first case presentation (described in chapters 1 and 6) is of a 12-yearold boy who displays a complex array of symptoms including aggressive behavior. thought problems . and affective volatility. His condition is ultimately diagnosed as conduct disorder. When he is reevaluated 3 years later, he continues to have significant problems in behavior and thinking despite behavioral therapy at home and at school and "cognitive behavioral therapy to improve reality testing." The premise of diagnosing onl y by syndrome, while appealing when examining longer-term group outcomes, is problematic when treatment (especiall y psychopharmacological intervention) is best determined by specific symptoms and diagnoses already well documented in the behavioral science literature. The authors are critical of the DSM for excluding children (especially girls with symptoms of inattention) who do not meet exact criteria in order to make a diagnosis and are also concerned that the DSM-IV criteria for ADHD are overly inclusive. The empiric assessment system itself can be used erroneously. when "cutoff points" on the T scores or standard scores are chosen, below which the patient's problems are considered clinically insignificant . Most clinicians recognize that both systems are imperfect and in the process of continued evolution. and they use them in complementary ways for the benefit of the pat ient. The empirically based system has other limitations described by the authors. For example, some of the measures are variably time-sensitive and therefore may not be applicable to describe certain brief-treatment outcomes. Some of the material is not yet normed for a multicultural population. However. the instruments are publi shed in 50 different languages. One apparently keeps up on the application advances by purchasing the Bibliography ofPublished Studies Using the Child Behavior Checklist and Related Materials. The 1996 edition is publi shed by the University of Vermont Department of Psychiatry. The book falls short in its discussion of applications of the system in particular contexts, such as managed care (only four paragraphs), mental health carve-outs, fee-for-service settings, schools, and forensic appli cations. These are all covered in only seven pages. Furthermore, the case illustrations provided in chapters 5. 6. and 7 on how to use the empirically based evaluation system are very similar to what most clinicians already do in their practices. I would prefer to read about how to measure statistically significant change for large and diverse patient groups. or how the instruments might be used in prospective clinical research.
Empirically Based Assessment of Child and Adolescent Psychopathology: Practical Applications. Second Edition.
By Thomas M. Achenbach and Stephanie H. McConaughy. Volume 13. Developmental ClinicalPsychology and Psychiatry Series. Thousand Oaks, CA: Sage Publications. Inc.. 1997. 226 pp., $18.95 (soficouer). The objective of thi s book is to update the reader on advances in the empirically based assessment system . best known for the Child Behavior Checkli st (CBCL) . Its stated goal is to demonstrate how the system can be used by practitioners in managed care settings to "facilitate cost-effective assessment. planning, intervention, and outcome evaluation in health. education, and other services that deal with maladaptive behavior among the young" (chapter I, p. I). In addition to the CBCL/2-3, CBCL/4-18 , and the Teacher's Report Form (TRF), other instruments added to the system include the Teacher/Caregiver Report Form for Ages 2-5, Direct Observation Form. Young Adult Behavior Checklist (YABCL), Young Adult Self-Report (YASR), and Semistructured Clinical Interview for Children a nd Adolescents. The YABCL and YASR have an age range from 19 to 30; one of the syndromes described is really titled "Showing Off." This superficial name detracts from a valid concern the authors raise about eliminating the distinct ion between aggressive and non aggressive form s of conduct disorder . None of the instruments are keyed to the DSM; th e authors repeatedly point out that there are no publi shed studies yet evaluating the correlation of the emp iric syndromes to DSM-IV. The chapters vary in the complexity of the material presented. Some (chapters 1, 2, and 4) are largely review mater ial for most child psychologi sts or psychiatrists. This material may be helpful for those who are unfamiliar with the CBCL principles and who need to design and/or evaluate clinical operations within a managed care or other institutional setting. Chapter 3, "T he Nature and Correlates of Empirically Based Syndromes," was the most interesting to me. The authors discuss eight cross-informant syndromes derived by factor analysis using the CBCL/4-18 , Youth Self-Report, and TRF. These syndromes seem most useful for the externalizing disorders and attention-deficit/hyperactivity disorder (ADHD) . The externalizing syndromes include the Aggressive Behavior syndrome and the Delinquent Behavior syndrome. The internalizing synd ro mes are the Anxious/ Depressed , Somatic Complaints. and Withdrawn syndromes. The three remaining syndromes are the Attention Problems syndrome. the Social Problem s syndrome, and the Thought Problem syndromes. which includes psychoti c. "strange." and obsessive symptoms. (Th e latter diagnoses are described as "rare in children," contradicting recent epidemiological data
336
J.
AM. ACA D . C H I L D ADO L ESC. PSYCHIATRY. .H : 3. MARCH 19 98
BOOK REVIEWS
Helpful additions to the book would include information on the price of the components of the system and what an assessment package would cost for a medium-sized clinic to sample 100 new patients. The authors note that the data can be scored by hand, entered directly on computer by the reporter, or scanned by paraprofessionals. A busy clinic (or other treatment setting) would need to consider how the data would be incorporated into patient charts , organized, and then stored separately before instituting their use systematically. Also, a chapter devoted to issues concerning a criteriabased approach versus the empirically based approach could raise important discussion leading to future directions for research in how we are to diagnose psychopathology in children . This book provides an adequate conceptual overview of the instruments and some of their potential uses. It does not meet stated goals in that the instruments were not developed for all of the uses encouraged, and data concerning these uses are only beginning to be published. Those interested in planning to use the empirically based standardized assessment system in broad clinical operation need to purchase and review the individual instruments and their user manuals as well as other references. Barbara L. Gracious, M.D. Division Director, Child and Adolescent Mental Health Scott & White Clinic, Temple, TX Assistant Professor of Psychiatry and Pediatrics Texas A & M University, College Station
Gender Identity Disorder and Psychosexual Problems in Children and Adults. By Kenneth j. Zucker, Ph.D., and Susan j. Bradley, M.D. New York: The Guilford Press, 1995,440 pp., $46.00 (hardcover). Who am I? Am I a boy or a girl? Questions about sexual identity are fundamental to a sense of self, and they are asked by children at a very early age. In the overwhelming majority of cases, the child's perception agrees with her or his biological sex. The little boy self-identifies as a boy, and the little girl self-identifies as a girl. What happens in the rare cases when there is disagreement-when the little boy stoutly maintains that he is, or should be, a girl or vice versa-is the subject of this new book on gender identity disorder in children. The authors deal forthrightly with two potentially troublesome issues concerning the diagnosis. The first is whether strong and persistent cross-gender identification in children should be considered a disorder at all. Adolescents and adults who wish to be the opposite sex may be depressed and suicidal; often , they request referral to a clinic for sex reassignment. They clearly meet the criterion of displaying a major impairment in functioning. Zucker and Bradley argue that children who want to be the opposite sex meet the same
J.
AM . A C AD . C H I L D A D O LE SC. PSYCHIATRY . .H: .~ . MAR CH 1') 9R
criterion. These children cross-dress, fantasize about being the opposite sex, play primarily with members of the opposite sex, and are uncomfortable with members of their own sex. They are very unhappy, as are their families. The second potentially troublesome issue is the relationship between gender identity disorder (who am I?), a psychiatric entity, and homosexuality (whom do I prefer sexually?), which is no longer considered to be a psychiatric disorder. Since many children with gender identity disorder become homosexuals as adolescents or young adults, the question naturally arises as to whether gender identity disorder is not simply an early manifestation of homosexuality. Zucker and Bradley argue against that interpretation, on the grounds that although many individuals with the disorder become homosexuals later on, the reverse is not true; the majority of homosexuals do not recall having had gender identity problems in childhood. Zucker and Bradley suggest that the child with gender identity disorder identifies with the opposite sex because that sex is viewed as safer, more secure, or more valued. The crossgender behaviors and attitudes are defensive measures to reduce anxiety. The model presented by the authors is one in which the etiology of the disorder is explained on the basis of a combination of factors that involve the child, the parents, and the family system. All of the relevant factors must be present at a sensitive period when the child develops a sense of identity as a male or female. The book has a number of strengths. Zucker and Bradley bring together and critique the literature, both theoretical and empirical, on the etiology, assessment, and treatment of gender identity disorder in children and adolescents. The book is comprehensive, with an impressive number of studies cited and discussed. Particularly useful are the summary charts showing all of the studies on a particular topic, along with such crucial information as whether a control group was included and the measures used. The authors are remarkably even-handed in their approach. There are some weaknesses. One is that, although many research studies are cited, few-as the authors themselves point out-meet the criteria for good research (e.g., they lack control groups , report findings for only a small number of participants, and/or involve the use of subjective measures). It is not surprising that the findings often are contradictory or ambiguous. Amid the welter of information, the reader is left, at times, wondering what it all means. While Zucker and Bradley cannot be faulted for the current state of ignorance and confusion in their field, the reader nevertheless expects that, once all the studies on some topic have been presented, it will be possible to achieve some sense of closure, but this does not always happen. The authors have provided sections in which they summarize and purportedly offer conclusions, but these sections are the vaguest and least satisfying portions of the book .
337
on the incidence of childhood obsessive-compulsive disorder.) Clustering child psychopathology into eight syndromes limits the likelihood that more specific or subtle mood and anxiety disorders such as bipolar disorder, separation anxiety disorder. or the pervasive developmental disorders would be considered and treated . The very first case presentation (described in chapters 1 and 6) is of a 12-yearold boy who displays a complex array of symptoms including aggressive behavior. thought problems . and affective volatility. His condition is ultimately diagnosed as conduct disorder. When he is reevaluated 3 years later, he continues to have significant problems in behavior and thinking despite behavioral therapy at home and at school and "cognitive behavioral therapy to improve reality testing." The premise of diagnosing onl y by syndrome, while appealing when examining longer-term group outcomes, is problematic when treatment (especiall y psychopharmacological intervention) is best determined by specific symptoms and diagnoses already well documented in the behavioral science literature. The authors are critical of the DSM for excluding children (especially girls with symptoms of inattention) who do not meet exact criteria in order to make a diagnosis and are also concerned that the DSM-IV criteria for ADHD are overly inclusive. The empiric assessment system itself can be used erroneously. when "cutoff points" on the T scores or standard scores are chosen, below which the patient's problems are considered clinically insignificant . Most clinicians recognize that both systems are imperfect and in the process of continued evolution. and they use them in complementary ways for the benefit of the pat ient. The empirically based system has other limitations described by the authors. For example, some of the measures are variably time-sensitive and therefore may not be applicable to describe certain brief-treatment outcomes. Some of the material is not yet normed for a multicultural population. However. the instruments are publi shed in 50 different languages. One apparently keeps up on the application advances by purchasing the Bibliography ofPublished Studies Using the Child Behavior Checklist and Related Materials. The 1996 edition is publi shed by the University of Vermont Department of Psychiatry. The book falls short in its discussion of applications of the system in particular contexts, such as managed care (only four paragraphs), mental health carve-outs, fee-for-service settings, schools, and forensic appli cations. These are all covered in only seven pages. Furthermore, the case illustrations provided in chapters 5. 6. and 7 on how to use the empirically based evaluation system are very similar to what most clinicians already do in their practices. I would prefer to read about how to measure statistically significant change for large and diverse patient groups. or how the instruments might be used in prospective clinical research.
Empirically Based Assessment of Child and Adolescent Psychopathology: Practical Applications. Second Edition.
By Thomas M. Achenbach and Stephanie H. McConaughy. Volume 13. Developmental ClinicalPsychology and Psychiatry Series. Thousand Oaks, CA: Sage Publications. Inc.. 1997. 226 pp., $18.95 (soficouer). The objective of thi s book is to update the reader on advances in the empirically based assessment system . best known for the Child Behavior Checkli st (CBCL) . Its stated goal is to demonstrate how the system can be used by practitioners in managed care settings to "facilitate cost-effective assessment. planning, intervention, and outcome evaluation in health. education, and other services that deal with maladaptive behavior among the young" (chapter I, p. I). In addition to the CBCL/2-3, CBCL/4-18 , and the Teacher's Report Form (TRF), other instruments added to the system include the Teacher/Caregiver Report Form for Ages 2-5, Direct Observation Form. Young Adult Behavior Checklist (YABCL), Young Adult Self-Report (YASR), and Semistructured Clinical Interview for Children a nd Adolescents. The YABCL and YASR have an age range from 19 to 30; one of the syndromes described is really titled "Showing Off." This superficial name detracts from a valid concern the authors raise about eliminating the distinct ion between aggressive and non aggressive form s of conduct disorder . None of the instruments are keyed to the DSM; th e authors repeatedly point out that there are no publi shed studies yet evaluating the correlation of the emp iric syndromes to DSM-IV. The chapters vary in the complexity of the material presented. Some (chapters 1, 2, and 4) are largely review mater ial for most child psychologi sts or psychiatrists. This material may be helpful for those who are unfamiliar with the CBCL principles and who need to design and/or evaluate clinical operations within a managed care or other institutional setting. Chapter 3, "T he Nature and Correlates of Empirically Based Syndromes," was the most interesting to me. The authors discuss eight cross-informant syndromes derived by factor analysis using the CBCL/4-18 , Youth Self-Report, and TRF. These syndromes seem most useful for the externalizing disorders and attention-deficit/hyperactivity disorder (ADHD) . The externalizing syndromes include the Aggressive Behavior syndrome and the Delinquent Behavior syndrome. The internalizing synd ro mes are the Anxious/ Depressed , Somatic Complaints. and Withdrawn syndromes. The three remaining syndromes are the Attention Problems syndrome. the Social Problem s syndrome, and the Thought Problem syndromes. which includes psychoti c. "strange." and obsessive symptoms. (Th e latter diagnoses are described as "rare in children," contradicting recent epidemiological data
336
J.
AM. ACA D . C H I L D ADO L ESC. PSYCHIATRY. .H : 3. MARCH 19 98
BOOK REVIEWS
Helpful additions to the book would include information on the price of the components of the system and what an assessment package would cost for a medium-sized clinic to sample 100 new patients. The authors note that the data can be scored by hand, entered directly on computer by the reporter, or scanned by paraprofessionals. A busy clinic (or other treatment setting) would need to consider how the data would be incorporated into patient charts , organized, and then stored separately before instituting their use systematically. Also, a chapter devoted to issues concerning a criteriabased approach versus the empirically based approach could raise important discussion leading to future directions for research in how we are to diagnose psychopathology in children . This book provides an adequate conceptual overview of the instruments and some of their potential uses. It does not meet stated goals in that the instruments were not developed for all of the uses encouraged, and data concerning these uses are only beginning to be published. Those interested in planning to use the empirically based standardized assessment system in broad clinical operation need to purchase and review the individual instruments and their user manuals as well as other references. Barbara L. Gracious, M.D. Division Director, Child and Adolescent Mental Health Scott & White Clinic, Temple, TX Assistant Professor of Psychiatry and Pediatrics Texas A & M University, College Station
Gender Identity Disorder and Psychosexual Problems in Children and Adults. By Kenneth j. Zucker, Ph.D., and Susan j. Bradley, M.D. New York: The Guilford Press, 1995,440 pp., $46.00 (hardcover). Who am I? Am I a boy or a girl? Questions about sexual identity are fundamental to a sense of self, and they are asked by children at a very early age. In the overwhelming majority of cases, the child's perception agrees with her or his biological sex. The little boy self-identifies as a boy, and the little girl self-identifies as a girl. What happens in the rare cases when there is disagreement-when the little boy stoutly maintains that he is, or should be, a girl or vice versa-is the subject of this new book on gender identity disorder in children. The authors deal forthrightly with two potentially troublesome issues concerning the diagnosis. The first is whether strong and persistent cross-gender identification in children should be considered a disorder at all. Adolescents and adults who wish to be the opposite sex may be depressed and suicidal; often , they request referral to a clinic for sex reassignment. They clearly meet the criterion of displaying a major impairment in functioning. Zucker and Bradley argue that children who want to be the opposite sex meet the same
J.
AM . A C AD . C H I L D A D O LE SC. PSYCHIATRY . .H: .~ . MAR CH 1') 9R
criterion. These children cross-dress, fantasize about being the opposite sex, play primarily with members of the opposite sex, and are uncomfortable with members of their own sex. They are very unhappy, as are their families. The second potentially troublesome issue is the relationship between gender identity disorder (who am I?), a psychiatric entity, and homosexuality (whom do I prefer sexually?), which is no longer considered to be a psychiatric disorder. Since many children with gender identity disorder become homosexuals as adolescents or young adults, the question naturally arises as to whether gender identity disorder is not simply an early manifestation of homosexuality. Zucker and Bradley argue against that interpretation, on the grounds that although many individuals with the disorder become homosexuals later on, the reverse is not true; the majority of homosexuals do not recall having had gender identity problems in childhood. Zucker and Bradley suggest that the child with gender identity disorder identifies with the opposite sex because that sex is viewed as safer, more secure, or more valued. The crossgender behaviors and attitudes are defensive measures to reduce anxiety. The model presented by the authors is one in which the etiology of the disorder is explained on the basis of a combination of factors that involve the child, the parents, and the family system. All of the relevant factors must be present at a sensitive period when the child develops a sense of identity as a male or female. The book has a number of strengths. Zucker and Bradley bring together and critique the literature, both theoretical and empirical, on the etiology, assessment, and treatment of gender identity disorder in children and adolescents. The book is comprehensive, with an impressive number of studies cited and discussed. Particularly useful are the summary charts showing all of the studies on a particular topic, along with such crucial information as whether a control group was included and the measures used. The authors are remarkably even-handed in their approach. There are some weaknesses. One is that, although many research studies are cited, few-as the authors themselves point out-meet the criteria for good research (e.g., they lack control groups , report findings for only a small number of participants, and/or involve the use of subjective measures). It is not surprising that the findings often are contradictory or ambiguous. Amid the welter of information, the reader is left, at times, wondering what it all means. While Zucker and Bradley cannot be faulted for the current state of ignorance and confusion in their field, the reader nevertheless expects that, once all the studies on some topic have been presented, it will be possible to achieve some sense of closure, but this does not always happen. The authors have provided sections in which they summarize and purportedly offer conclusions, but these sections are the vaguest and least satisfying portions of the book .
337