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Ordinary Families, Special Children: A Systems Approach to Childhood Disability
BOOK REVIEW
The Introduction and first three chapters present the goal of the text, review the theories of the two often divergent views, render a model of classification ofleaming disorders , and critique the literature on the neuropsychological versus psychodynamic controversy. I frequently had to force myself to plow ahead because it is not easy reading and much could be stated more succinctly. The Critique of the Literature chapter could easily be in a doctoral dissertation : thorough, references on every line , dull. Early on, some case vignettes are given to highlight how an open-minded approach may help, tantalizing the reader to read on for the results. However, it is a long way to Chapter 5 which elaborates on the cases with the results of psychological and neuropsychological testing and happenings in treatment. I was surprised to find that the authors never mention the usefulness of a child psychiatrist in their deliberations and recommendations on the cases. In fact, for one case, they recommended a "neurological consultation to explore more specifically the nature and possible psychopharmacological controls of her attention/mood disturbance." Similarly, in Chapter 4, Diagnostic Principles and Process, the authors state that a reason for neurological evaluation is " hyperactivity and/or distractibility" for which amphetamines can be prescribed. They do note an exception, namely, the situation wherein the therapist is a "psychiatrist," in which case the psychiatrist can provide the medication. No mention is made of the value of other medications and the importance of child psychiatric consultation for many of these children with learning disorders and behavioral/emotional problems. Also, in this chapter they omit a discussion of the value of a careful psychiatric-genetic history when performing an evaluation. Chapter 6 is a brief review of Common Neuropsychological Disorders such as Visual Perceptual Disorders , Gerstmann Syndrome , Dyslexia , and Chapter 7 presents considerable detail on the techniques of treatment integrating neuropsychological remediation and standard psychotherapy, again stressing the importance of their integration in a treatment plan. I do not recommend this book as an introductory text , however appealing the title may be to those in our field who grapple daily with the complexities of the comprehensive diagnostic process. DEAN X. PARMELEE, M.D. Chairman of the Division of Child Psychiatry Medical College of Virginia
Ordinary Families, Special Children: A Systems Approach to Childhood Disability. By Milton Seligman and Rosalyn Benjamin Darling. New York: The Guilford Press, 1989,272 pp. , $30.00 (hardcover) . Every family, no matter how rich, talented , or educated has the potential for having a child with a disability. The disability can affect the cognitive functions alone (mental retardation), the physical aspects ofthe child (cerebral palsy), J.Am .Acad. Child Adolesc.Psychiatry , 29:4, July 1990
or a combination of both. Yet, no matter what the disability , it has a profound impact not only on the child himself but also on the parents, siblings, and extended family. As the authors point out, childhood disability makes demands on families in terms of time, social stigma, psychological well-being , family relationships, economic resources, and freedom of movement. Yet, American society does not always provide sufficient support to allow these families to maintain their usual way of life. Sometimes, the families do find the necessary supports through their own family or community. The success or failure of the ordinary family in dealing with the special child is dependent on the social world around them as well as the resources within the family. The authors begin the book by introducing the conceptual framework of social systems and family systems. They then go on to describe the birth and growth to adulthood of the disabled child, and how this child affects the family . The family is studied not only as a unit, but also as individuals (siblings, mothers, fathers, and grandparents) . How the family's culture and subculture affect its coping is discussed. The authors then end by discussing how the professional can help the family by identifying the family's strengths and giving aid to overcome its weaknesses. The professional-family interaction is examined with specific suggestions made on how to interact as well as what types of communication (or lack of communication) should be avoided. The authors garnered their information for this book from both empirical investigations and by interviewing family members directly. The extensive bibliography at the end of each chapter testifies to the thoroughness with which the authors studied the literature . The personal anecdotes throughout the book give a human quality and let the reader identify the anguish these families feel as well as the constraints our society puts on these already suffering people. This is truly necessary reading for any person dealing with families with a special-needs child . The parents themselves might find comfort in reading this book since they can better understand the emotional turmoil they have been or are going through. After reading the book, one of the major questions haunting me, as it should every reader of Ordinary Families, Special Children, is why do we, as a society, make it so hard for these families to be completely integrated. The authors point out that there are cultures in which the handicapped child is truly accepted, where the community as a whole supports the family . It is as if the motive to be successful , as defined by our culture (being rich , powerful, materialistically successful), precludes the incorporation of the less able into our society, and thereby ostrasizes their families for producing these "imperfect" beings . Because an individual can only do menial chores under supervision, does that make that being any less of a person than the college professor? Does success at that kind of job make his family any less proud of his accomplishments? We, as professional s, have to teach our society to accept what every person can contribute and not judge others by their deficits. Perhaps, someday, a book can be written 673
BOOK REVIEW
entitled Ordinary Families, Ordinary Children, regardless of the limitations of the child. ABBY L. WASSERMAN, M.D . Director of the Division of Child and Adolescent Psychiatry St. Luke's Hospital
Videotape:Why Won't My Child Pay Attention? 1989, 76 minutes; color . Format : W' videotape, $29.95 . Lecturer: Sam Goldstein, Ph.D. Produced by Neurology Learning and Behavior Center, 679 East 3900 South, Suite 100, Salt Lake City, Utah 84107-1973. This videotape is aimed at educating and guiding parents of children or adolescents with attention-deficit hyperactivity disorder (ADHD). Even though the quality of the pr~ duction (including lighting , setting , and camera work) IS quite good, the format is a somewhat limited one; essenti ~lly a lecture given by Dr. Goldstein to a group of parents in a studio. The viewer's attention is held by the lecturer's animated and somewhat aggressive style of delivery and also by the judicious insertion of graphics . Even in a well-staged lecture such as this, a certain amount of viewer monotony would have ensued were it not for the inclusion at appropriate points in the lecture of excerpts of comments from an interview with five members of a family in which two teenage sons have had attention-deficit disorder. The remarks of the parents , the sons, and their adolescent sister provide enriching and easily understandable interludes, a welcome change of pace form the lecturer 's (admittedly) kinetic delivery. This reviewer would have liked to have seen scenes of these or other patients in home, school , or community settings where examples of their behaviors, or of the management techniques suggested, could have been better demonstrated. At the end of the lecture, a brief question and answer period between the audience and lecturer is included. The content is basically sound but is limited by the fact that a lecturer must generalize about each topic of the subject at hand. Individual parents may thus find portions of the tape irrelevant , or, worse , may be misled to apply some of the conclusions or recommendations inappropriately to their particular situation . The lecturer does try to ~o~e~ this b.y suggesting at several points how complex an mdlvld~a~ diagnostic or treatment process can become. Notably missmg, however, is any suggestion that a child or adolescent psychiatrist might be one of the useful clinicians to tum to at those times. The latter part of the lecture is devoted to a description of the treatment and management approaches. There is a heavy (and appropriate ) emphasis in this section on under-
674
standing the nature of the impulsivity and the difficulties in concentration which create frustrations in dealing with a child or adolescent with ADHD. The lecturer advises that if a child is showing unacceptable behavior the parent should first make a judgment as to whether the behavior is an example of " incompetence" (i.e. , the child has acted impulsively and without thinking) or an example of "non. compliance" (i.e., a more willful decision to misbehave ). If it is the former, then the positive reinforcement approach should be used . If the parent feels the child is willfully misbehaving , then a more punitive approach is needed . Dr. Goldstein goes into some detail about management techniques. Unfortunately, the lecture format cannot do much more than introduce parents to the above issues, and it does begin to try to help them to understand the unusual subjective states, motivation , and behaviors of the children who have this disorder. One potentially troubling aspect of the presentation is the lecturer ' s discussion of the role of medication in treating ADHD patients . Dr. Goldstein implies that he " saves" the consideration of medication until after he has tried other methods of treatment. In this reviewer' s opinion, this approach may unnecessarily alarm some parents about the legitimate role medication plays in management. Such an approach to medication may have equally unfo~un.ate consequences as the opposite philoso~hy t~a~ medlca~l~n alone is all that is needed. The lecturer s position on this IS controverted later in the tape itself by the family members interviewed, who comment on the dramatic improvement brought about by the use of medication. . . The several questions asked by the parents in the audience open up areas that many famili~s are co?cerned.about: : ' Ca,~ the condition be used as an excuse for misbehavior? " How do you answer criticism of others that you are
~ot
being a good parent?" "Should we expect an :'-D.HI? child to have the same responsibilities at home as hIS siblings?' "How can parents who are 'worn out' learn to be 'calm' with their ADHD child?" "Would Boy Scouts be a good activity group for my son to join ?" . In summary, a clinician who would like to use this tape to help parents learn more about this disorder would do well to alert them to the generalizations involved and to suggest that they should additionally explore their indi~idual concerns and questions with an appropriate professional . They should be advised that the tape deserves more than one viewing because it presents a complicate~ networ~ of interwoven factors which must be looked for m any child who has the ADHD. PAUL N. GRAFFAGNINO , M.D. Clinical Professor of Psychiatry Associate Clinical Professor of Pediatrics University of Connecticut School of Medicine
l .Am.Acad. Child Adoles c.Psychiatry, 29:4, luly 1990
The Introduction and first three chapters present the goal of the text, review the theories of the two often divergent views, render a model of classification ofleaming disorders , and critique the literature on the neuropsychological versus psychodynamic controversy. I frequently had to force myself to plow ahead because it is not easy reading and much could be stated more succinctly. The Critique of the Literature chapter could easily be in a doctoral dissertation : thorough, references on every line , dull. Early on, some case vignettes are given to highlight how an open-minded approach may help, tantalizing the reader to read on for the results. However, it is a long way to Chapter 5 which elaborates on the cases with the results of psychological and neuropsychological testing and happenings in treatment. I was surprised to find that the authors never mention the usefulness of a child psychiatrist in their deliberations and recommendations on the cases. In fact, for one case, they recommended a "neurological consultation to explore more specifically the nature and possible psychopharmacological controls of her attention/mood disturbance." Similarly, in Chapter 4, Diagnostic Principles and Process, the authors state that a reason for neurological evaluation is " hyperactivity and/or distractibility" for which amphetamines can be prescribed. They do note an exception, namely, the situation wherein the therapist is a "psychiatrist," in which case the psychiatrist can provide the medication. No mention is made of the value of other medications and the importance of child psychiatric consultation for many of these children with learning disorders and behavioral/emotional problems. Also, in this chapter they omit a discussion of the value of a careful psychiatric-genetic history when performing an evaluation. Chapter 6 is a brief review of Common Neuropsychological Disorders such as Visual Perceptual Disorders , Gerstmann Syndrome , Dyslexia , and Chapter 7 presents considerable detail on the techniques of treatment integrating neuropsychological remediation and standard psychotherapy, again stressing the importance of their integration in a treatment plan. I do not recommend this book as an introductory text , however appealing the title may be to those in our field who grapple daily with the complexities of the comprehensive diagnostic process. DEAN X. PARMELEE, M.D. Chairman of the Division of Child Psychiatry Medical College of Virginia
Ordinary Families, Special Children: A Systems Approach to Childhood Disability. By Milton Seligman and Rosalyn Benjamin Darling. New York: The Guilford Press, 1989,272 pp. , $30.00 (hardcover) . Every family, no matter how rich, talented , or educated has the potential for having a child with a disability. The disability can affect the cognitive functions alone (mental retardation), the physical aspects ofthe child (cerebral palsy), J.Am .Acad. Child Adolesc.Psychiatry , 29:4, July 1990
or a combination of both. Yet, no matter what the disability , it has a profound impact not only on the child himself but also on the parents, siblings, and extended family. As the authors point out, childhood disability makes demands on families in terms of time, social stigma, psychological well-being , family relationships, economic resources, and freedom of movement. Yet, American society does not always provide sufficient support to allow these families to maintain their usual way of life. Sometimes, the families do find the necessary supports through their own family or community. The success or failure of the ordinary family in dealing with the special child is dependent on the social world around them as well as the resources within the family. The authors begin the book by introducing the conceptual framework of social systems and family systems. They then go on to describe the birth and growth to adulthood of the disabled child, and how this child affects the family . The family is studied not only as a unit, but also as individuals (siblings, mothers, fathers, and grandparents) . How the family's culture and subculture affect its coping is discussed. The authors then end by discussing how the professional can help the family by identifying the family's strengths and giving aid to overcome its weaknesses. The professional-family interaction is examined with specific suggestions made on how to interact as well as what types of communication (or lack of communication) should be avoided. The authors garnered their information for this book from both empirical investigations and by interviewing family members directly. The extensive bibliography at the end of each chapter testifies to the thoroughness with which the authors studied the literature . The personal anecdotes throughout the book give a human quality and let the reader identify the anguish these families feel as well as the constraints our society puts on these already suffering people. This is truly necessary reading for any person dealing with families with a special-needs child . The parents themselves might find comfort in reading this book since they can better understand the emotional turmoil they have been or are going through. After reading the book, one of the major questions haunting me, as it should every reader of Ordinary Families, Special Children, is why do we, as a society, make it so hard for these families to be completely integrated. The authors point out that there are cultures in which the handicapped child is truly accepted, where the community as a whole supports the family . It is as if the motive to be successful , as defined by our culture (being rich , powerful, materialistically successful), precludes the incorporation of the less able into our society, and thereby ostrasizes their families for producing these "imperfect" beings . Because an individual can only do menial chores under supervision, does that make that being any less of a person than the college professor? Does success at that kind of job make his family any less proud of his accomplishments? We, as professional s, have to teach our society to accept what every person can contribute and not judge others by their deficits. Perhaps, someday, a book can be written 673
BOOK REVIEW
entitled Ordinary Families, Ordinary Children, regardless of the limitations of the child. ABBY L. WASSERMAN, M.D . Director of the Division of Child and Adolescent Psychiatry St. Luke's Hospital
Videotape:Why Won't My Child Pay Attention? 1989, 76 minutes; color . Format : W' videotape, $29.95 . Lecturer: Sam Goldstein, Ph.D. Produced by Neurology Learning and Behavior Center, 679 East 3900 South, Suite 100, Salt Lake City, Utah 84107-1973. This videotape is aimed at educating and guiding parents of children or adolescents with attention-deficit hyperactivity disorder (ADHD). Even though the quality of the pr~ duction (including lighting , setting , and camera work) IS quite good, the format is a somewhat limited one; essenti ~lly a lecture given by Dr. Goldstein to a group of parents in a studio. The viewer's attention is held by the lecturer's animated and somewhat aggressive style of delivery and also by the judicious insertion of graphics . Even in a well-staged lecture such as this, a certain amount of viewer monotony would have ensued were it not for the inclusion at appropriate points in the lecture of excerpts of comments from an interview with five members of a family in which two teenage sons have had attention-deficit disorder. The remarks of the parents , the sons, and their adolescent sister provide enriching and easily understandable interludes, a welcome change of pace form the lecturer 's (admittedly) kinetic delivery. This reviewer would have liked to have seen scenes of these or other patients in home, school , or community settings where examples of their behaviors, or of the management techniques suggested, could have been better demonstrated. At the end of the lecture, a brief question and answer period between the audience and lecturer is included. The content is basically sound but is limited by the fact that a lecturer must generalize about each topic of the subject at hand. Individual parents may thus find portions of the tape irrelevant , or, worse , may be misled to apply some of the conclusions or recommendations inappropriately to their particular situation . The lecturer does try to ~o~e~ this b.y suggesting at several points how complex an mdlvld~a~ diagnostic or treatment process can become. Notably missmg, however, is any suggestion that a child or adolescent psychiatrist might be one of the useful clinicians to tum to at those times. The latter part of the lecture is devoted to a description of the treatment and management approaches. There is a heavy (and appropriate ) emphasis in this section on under-
674
standing the nature of the impulsivity and the difficulties in concentration which create frustrations in dealing with a child or adolescent with ADHD. The lecturer advises that if a child is showing unacceptable behavior the parent should first make a judgment as to whether the behavior is an example of " incompetence" (i.e. , the child has acted impulsively and without thinking) or an example of "non. compliance" (i.e., a more willful decision to misbehave ). If it is the former, then the positive reinforcement approach should be used . If the parent feels the child is willfully misbehaving , then a more punitive approach is needed . Dr. Goldstein goes into some detail about management techniques. Unfortunately, the lecture format cannot do much more than introduce parents to the above issues, and it does begin to try to help them to understand the unusual subjective states, motivation , and behaviors of the children who have this disorder. One potentially troubling aspect of the presentation is the lecturer ' s discussion of the role of medication in treating ADHD patients . Dr. Goldstein implies that he " saves" the consideration of medication until after he has tried other methods of treatment. In this reviewer' s opinion, this approach may unnecessarily alarm some parents about the legitimate role medication plays in management. Such an approach to medication may have equally unfo~un.ate consequences as the opposite philoso~hy t~a~ medlca~l~n alone is all that is needed. The lecturer s position on this IS controverted later in the tape itself by the family members interviewed, who comment on the dramatic improvement brought about by the use of medication. . . The several questions asked by the parents in the audience open up areas that many famili~s are co?cerned.about: : ' Ca,~ the condition be used as an excuse for misbehavior? " How do you answer criticism of others that you are
~ot
being a good parent?" "Should we expect an :'-D.HI? child to have the same responsibilities at home as hIS siblings?' "How can parents who are 'worn out' learn to be 'calm' with their ADHD child?" "Would Boy Scouts be a good activity group for my son to join ?" . In summary, a clinician who would like to use this tape to help parents learn more about this disorder would do well to alert them to the generalizations involved and to suggest that they should additionally explore their indi~idual concerns and questions with an appropriate professional . They should be advised that the tape deserves more than one viewing because it presents a complicate~ networ~ of interwoven factors which must be looked for m any child who has the ADHD. PAUL N. GRAFFAGNINO , M.D. Clinical Professor of Psychiatry Associate Clinical Professor of Pediatrics University of Connecticut School of Medicine
l .Am.Acad. Child Adoles c.Psychiatry, 29:4, luly 1990