- Email: [email protected]
Robin: Comprehensive treatment of a vulnerable adoloscent
1934
Book Reviews
life, the prevention of ill health and the restoration of a ‘caring community’, suggests implementation strategies and describes the benefits to be gained from their success. He offers examples from both the developed and the less developed countries within the European Region indicating changes required at a variety of levels, including individual health consumers, health providers and politicians. The illustrations emphasize the importance of lay care within the context of both the family and the larger community, equality of access to quality primary care, effective and appropriate technology, the use of mid-level health professionals and the importance of women as traditional providers of care and as sources of information for future planning. The shortest and least effective portion of the book covers implementation strategies. O’Neill summarizes the problems as follows: The political implications of the Strategy are farreaching. They include a fundamental shift in social attitudes, an important change in relationships inside the medical profession, and the reallocation of resources: people, money and equipment. The Strategy represents a challenge, however, not a threat. By definition, community care is a people’s movement, established not on a narrow but on the broadest of political bases. He goes on to describe a popular movement which would link health and social organizations, labor unions, and pressure groups, as well as professionals in an effort to enact legislation necessary for the changes he advocates. Although Q’Neill provides several examples of effective legislative efforts, he glosses over the very difficulties that he has identified. Numerous examples can be given of the problems he overlooks or optimistically oversimplifies. For example, he notes the expense associated with implementing the proposed changes. From where are the funds to come? The author suggests that they will be made available as a result of substantial reductions in defense spending by all countries in the region, although he offers no explanation as to how this change will be accomplished. He advocates major changes in the medical profession with the shifting of responsibility from physicians to lower-level providers or to lay people. Again, little information is provided as to how this will be implemented. If the current struggles on the part of nurse practitioners in the United States to expand their autonomy are generalizable, these changes will not be easily achieved. Although Q’Neill emphasizes the major role to be played by consumer/citizen groups in the implementation process, he never addresses problems that have been encountered in the past (e.g. selecting representative groups and avoiding control of these groups by professionals). Finally, and most importantly, Q’Neill provides no explanation as to how politicans will develop the political will necessary to implement decisions unpopular with powerful interest groups in the medical-industrial complex. Although he advocates stricter regulation of procedures of ‘risk-creating’ products (e.g. tobacco, alcohol) and more exacting evaluation of new medical technology, O’Neill does not indicate either how citizen groups will effectively oppose these powerful interest groups or how politicians will be persuaded to regulate them. In spite of these drawbacks, Health Crisis 2000 will be of use with many groups, especially those indicated at the beginning of this review. The value of this book lies in its ability to inform a larger segment of the population of the issues and to encourage active participation in efforts to shift the health care system away from the disastrous course on which we now find ourselves and to work to develop new health care systems with the potential to promote health for all by the year 2000. American Institutes for Research Cambridge, MA, U.S.A.
SUSAN E. JENNINGS
Dimbility in Adolescence, by ELIZABETH M. ANDERWN and LYNDACLARKE.Methuen, London, 1982. 380 pp. This book is the report of a study of 119 adolescents between the ages of 15 and 19 with either cerebral palsy or spina bifida plus hydrocephalus (individuals with an I.Q. below 70 were, however, excluded), and a smaller control sample, all living in a defined geographical area (the North-West Thames Health Region in England). Its purpose was to assess the nature of psychological problems found in these disabled adolescents, the quality of their social life and the adequacy of resources available to them, using structured interviews with the teenagers themselves, questionnaires and interviews with parents and school personnel. There was a follow-up study of about half of the adolescents a year later, after they had left school. Clearly the group is one of adolescents with fairly severe and complicated disability, not simply of locomotor handicaps but also speech difficulties (in cerebal palsy), incontinence, infections (in spina bifida), epilepsy and organic brain deficit. Not surprisingly, there was a high incidence of psychological problems-depression, anxiety, lack of self-confidence, low self-esteem, fearfulness and social isolation. On the other hand, it was equally notable that about half of the adolescents did not have-such psychological difficulties. Problems were more likely to be found in the teenagers with more severe handicaps; particularly in those with epilepsy, lower 1.Q.s (below 85), and with urinary appliances, and in those whose mothers had emotional problems themselves. One of the authors’ findings which seems of importance was that although many of the adolescents had difficulty with self-care and in achieving independence and self-sufficiency, most of them wanted and were capable of greater independence, and that to a significant extent parents, schools and medical staff had failed to encourage and assist them in this direction. Many of the adolescents were extraordinarily ill-informed about their disability (e.g. over half the ones with cerebral palsy did not even know the name of their condition) and about resources available to them. As the authors remark, “It is impossible to imagine how the disabled person is to avoid feelings of helplessness if he is not given the basic information to enable him to understand or account for his handicap”. They go on, “On the evidence available, one must conclude that a major problem with current service provision is the failure to recognize the importance of cultivating independence and the capacity for decision making among handicapped young people, both as a way of ensuring they are enabled to lead fuller lives, and as a way of enhancing self-esteem and feelings of worth”. A further conclusion was that social isolation caused more distress in this group than any other factor; this was a particular problem after they left school and could not find employment. While this study deals with a rather special group, its findings probably have a more general application, and even though the specific resources in Britain are different than elsewhere, the problems are universal, and this book should be of value to anyone working with disabled adolescents. Massachusetts General Hospital Boston, MA, U.S.A.
JOHN H. LAMONT
ROBIN: Comprehensive Treatment of a Vulnerable Adohcent, by Lors BARCLAY MURPHY and J. COTIXR HtaSCHBERG.Basic
Books, New York, 1982. 362 pp. 320.95.
AS our society becomes increasingly more complex thereby demanding exceptionally well trained, technically competent young adults, it is imperative we understand and utilize all the knowledge available on the subject of
Book Reviews adolescent growth and development. In compelling prose, Dr Murphy records her therapeutic alliance with Robin, who came to her as a 12-year-old girl with brain damage, learning problems and rather severe behavioral difficulties. How Dr Murphy met the challenge over a 3 year period is the focus of this book. Robin was the third child in the family and was supposed to be a boy. Her two sisters were 5 and 2 years older, both reported to be normal healthy children. Robin was described as unresponsive at birth, and difficult to manage by an anxious, unhappy mother. The infant’s deformaties were asymmetrical skull, asymmetrical ear placement, primitive ear formation, all of which were described as mild. Radiation therapy for skin hemangiomata during early infancy left some scars. Two years-after-Robin was born, the mother delivered a healthv bov. the final child in the familv. The reader will be correct in assuming that the brother’s arrival posed an immediate acceleration of Robin’s insecurity and indeed this was the situation. Robin’s motor skills were noted, early on, to be sluggish. She was clumsy and frustrated daily with inability to keep up with other children. Learning in school was nearly impossible for her. She developed a tremor in her right hand, her dominant hand, and so her ability to write was compromised. The parents made an heroic decision when they moved from Nebraska to Topeka, specifically to get help for Robin in the Menninger Foundation. The Menninger evaluation pronounced Robin a poor therapy risk, probably because she was already achieving maximum secondary gain from her disabilities. However, when asked whether or not she would consider taking Robin on as a patient, Dr Murphy accepted the challenge. She did so with the understanding that Robin would also be enrolled as a day patient in the Children’s Hospital of the Menninger Foundation, a unit with a school for children of comparable age and who were also experiencing difficulties at home and at school. Dr Murphy insisted upon a therapeutic approach with social, school and medical support. With this program agreed to and in place, the story of Robin and Dr Murphy unfolds. The panorama of early adolescence is the theme of Robin. Although Robin does have physical handicaps and neurological dysfunction, her struggle to become an adult person is as touching and timeless as it is for every young adolescent. Time and again Robin refers to the need for someone to ‘push me’. Dr Murphy does the pushing, to be sure, but always with love and respect for Robin the individual, not Robin the handicapped. Dr Murphy wonders, as we all do who work with young people at “the healina newer of corrective love and SUDDOI?". -As a therapist, Dr Murphy mar& at the “islands of creativitv” in Robin’s brain. With Dr Murohv’s heto. Robin learns about sex, separation and control;she reach& out to other people and is ready and able to give herself to those whose needs are greater than hers. Robin’s family was in serious turmoil during the 3 years of Robin’s therapy. Eve, the sister who was 2 years older had a breakdown which required admission to the Children’s Hospital at Menninger. Her brother Jim had major school problems. And yet Robin managed to work through her own set of problems with appropriate and thoughtful empathy for her siblings. Parents and professionals who wish to know more about adolescent feelings and behavior can only benefit by reading this splendid book. For medical students who are contemplating a career either in Pediatrics or Child Psychiatry, this is a book which must be on the required reading list.
The Children’s Hospitul Haroard Medical School Boston, MA, U.S.A. S.S.M.,7,*3--H
ROBERTP. MASLAND JR
1935
Lead Versus Heah Sources and Elk&s of Low Level Lead Exposure, edited by M. RIJ?TERand R. R. JONES.Wiley,
Chichester, 1983 This book gathers together the edited papers presented at
an international symposium held in London in May 1982. The symposium was organ&d by a food company and by the CLEAR Charitable Trust. Since the CLEAR organisation was founded as a pressure group with the laudable object of increasing public and political awareness of the public health hazard posed by lead pollution in general, and by lead petrol additives in particular, it might have been suspected that both the symposium and the publication under review would have a predominantly partisan character. This is not the case. The selection of Professor Rutter as symposium chairman and joint editor bears witness. Rutter had been a member of the government Working Party that in 1980 produced the highly controversial Lawther Report with its dismissal of petrol lead as a major contributor to human lead burdens and its professed scepticism concerning the numerous reports associating ‘low level’ lead with adverse effects on the mental development of children. Rutter’s scholarly concluding article (Chap. 17) makes clear that he has now reassessed his views, largely, it would appear, on the basis of the new studies reported and now published in the present book. Two of the papers presented at the symposium are not included in the present volume. As these omitted papers covered the important topics of lead and abnormal births and environmental sources of lead exposure respectively, it is fortunate that excellent reviews of these same topics have been provided by Silbergeld, Jones and Stephens respectively. Additional papers by Duggan on leadcontaminated dust as a source of lead exposure for children and by Otto on neuroelectrical changes in the child brain associated with lead exposure further broaden the scope of the book beyond that of the symposium. Although it should not be regarded as a textbook, the present volume, unlike many books based on symposium proceedings, does provide a broadly based review of present knowledge in an important and developing field with implications extending well beyond the conventional frontiers of science and medicine. For example, the effects of lead on intelligence and behaviour of children take one into the fields of education and sociology, while the question whether lead-free petrol will be made available can take one into the fields of automobile engineering, refining technology and industrial politics. The book falls into 3 main sections. The first is concerned with sources of environmental lead. Appropriately enough, it starts off with a paper by Patterson, widely regarded as the founding father of modem studies of environmental lead. His chapter reviews the evidence that present body burdens of lead are some 50~1000 times greater than those in the bodies of our prehistoric ancestors. However, the grossly un-natural nature of the present levels, now regarded as ‘normal’, suggests that the term ‘low level’ is a potentially misleading example of the unqualified comparative. Other interesting papers in this section are concerned with the declining blood lead levels in the U.S. population which appear to correlate quite closely with the declining usage of lead petrol additives (Annest, Billick), the problem of plumbosolvent water (Moore) and the above-mentioned reviews by Duggan on the hazard to children posed by high levels of lead in dust, and by Jones and Stephens on the question of petrol lead contributing to lead in man. On this last topic, they make the important point largely overlooked in the Lawther Report that fall-out of airborne lead (which comes mainly from petrol) causes massive and widespread contamination of foodcrops and is therefore an important source of dietary lead. This contamination bypasses the natural barriers in root systems to the translocation of lead from the soil to edible parts of plants.
Book Reviews
life, the prevention of ill health and the restoration of a ‘caring community’, suggests implementation strategies and describes the benefits to be gained from their success. He offers examples from both the developed and the less developed countries within the European Region indicating changes required at a variety of levels, including individual health consumers, health providers and politicians. The illustrations emphasize the importance of lay care within the context of both the family and the larger community, equality of access to quality primary care, effective and appropriate technology, the use of mid-level health professionals and the importance of women as traditional providers of care and as sources of information for future planning. The shortest and least effective portion of the book covers implementation strategies. O’Neill summarizes the problems as follows: The political implications of the Strategy are farreaching. They include a fundamental shift in social attitudes, an important change in relationships inside the medical profession, and the reallocation of resources: people, money and equipment. The Strategy represents a challenge, however, not a threat. By definition, community care is a people’s movement, established not on a narrow but on the broadest of political bases. He goes on to describe a popular movement which would link health and social organizations, labor unions, and pressure groups, as well as professionals in an effort to enact legislation necessary for the changes he advocates. Although Q’Neill provides several examples of effective legislative efforts, he glosses over the very difficulties that he has identified. Numerous examples can be given of the problems he overlooks or optimistically oversimplifies. For example, he notes the expense associated with implementing the proposed changes. From where are the funds to come? The author suggests that they will be made available as a result of substantial reductions in defense spending by all countries in the region, although he offers no explanation as to how this change will be accomplished. He advocates major changes in the medical profession with the shifting of responsibility from physicians to lower-level providers or to lay people. Again, little information is provided as to how this will be implemented. If the current struggles on the part of nurse practitioners in the United States to expand their autonomy are generalizable, these changes will not be easily achieved. Although Q’Neill emphasizes the major role to be played by consumer/citizen groups in the implementation process, he never addresses problems that have been encountered in the past (e.g. selecting representative groups and avoiding control of these groups by professionals). Finally, and most importantly, Q’Neill provides no explanation as to how politicans will develop the political will necessary to implement decisions unpopular with powerful interest groups in the medical-industrial complex. Although he advocates stricter regulation of procedures of ‘risk-creating’ products (e.g. tobacco, alcohol) and more exacting evaluation of new medical technology, O’Neill does not indicate either how citizen groups will effectively oppose these powerful interest groups or how politicians will be persuaded to regulate them. In spite of these drawbacks, Health Crisis 2000 will be of use with many groups, especially those indicated at the beginning of this review. The value of this book lies in its ability to inform a larger segment of the population of the issues and to encourage active participation in efforts to shift the health care system away from the disastrous course on which we now find ourselves and to work to develop new health care systems with the potential to promote health for all by the year 2000. American Institutes for Research Cambridge, MA, U.S.A.
SUSAN E. JENNINGS
Dimbility in Adolescence, by ELIZABETH M. ANDERWN and LYNDACLARKE.Methuen, London, 1982. 380 pp. This book is the report of a study of 119 adolescents between the ages of 15 and 19 with either cerebral palsy or spina bifida plus hydrocephalus (individuals with an I.Q. below 70 were, however, excluded), and a smaller control sample, all living in a defined geographical area (the North-West Thames Health Region in England). Its purpose was to assess the nature of psychological problems found in these disabled adolescents, the quality of their social life and the adequacy of resources available to them, using structured interviews with the teenagers themselves, questionnaires and interviews with parents and school personnel. There was a follow-up study of about half of the adolescents a year later, after they had left school. Clearly the group is one of adolescents with fairly severe and complicated disability, not simply of locomotor handicaps but also speech difficulties (in cerebal palsy), incontinence, infections (in spina bifida), epilepsy and organic brain deficit. Not surprisingly, there was a high incidence of psychological problems-depression, anxiety, lack of self-confidence, low self-esteem, fearfulness and social isolation. On the other hand, it was equally notable that about half of the adolescents did not have-such psychological difficulties. Problems were more likely to be found in the teenagers with more severe handicaps; particularly in those with epilepsy, lower 1.Q.s (below 85), and with urinary appliances, and in those whose mothers had emotional problems themselves. One of the authors’ findings which seems of importance was that although many of the adolescents had difficulty with self-care and in achieving independence and self-sufficiency, most of them wanted and were capable of greater independence, and that to a significant extent parents, schools and medical staff had failed to encourage and assist them in this direction. Many of the adolescents were extraordinarily ill-informed about their disability (e.g. over half the ones with cerebral palsy did not even know the name of their condition) and about resources available to them. As the authors remark, “It is impossible to imagine how the disabled person is to avoid feelings of helplessness if he is not given the basic information to enable him to understand or account for his handicap”. They go on, “On the evidence available, one must conclude that a major problem with current service provision is the failure to recognize the importance of cultivating independence and the capacity for decision making among handicapped young people, both as a way of ensuring they are enabled to lead fuller lives, and as a way of enhancing self-esteem and feelings of worth”. A further conclusion was that social isolation caused more distress in this group than any other factor; this was a particular problem after they left school and could not find employment. While this study deals with a rather special group, its findings probably have a more general application, and even though the specific resources in Britain are different than elsewhere, the problems are universal, and this book should be of value to anyone working with disabled adolescents. Massachusetts General Hospital Boston, MA, U.S.A.
JOHN H. LAMONT
ROBIN: Comprehensive Treatment of a Vulnerable Adohcent, by Lors BARCLAY MURPHY and J. COTIXR HtaSCHBERG.Basic
Books, New York, 1982. 362 pp. 320.95.
AS our society becomes increasingly more complex thereby demanding exceptionally well trained, technically competent young adults, it is imperative we understand and utilize all the knowledge available on the subject of
Book Reviews adolescent growth and development. In compelling prose, Dr Murphy records her therapeutic alliance with Robin, who came to her as a 12-year-old girl with brain damage, learning problems and rather severe behavioral difficulties. How Dr Murphy met the challenge over a 3 year period is the focus of this book. Robin was the third child in the family and was supposed to be a boy. Her two sisters were 5 and 2 years older, both reported to be normal healthy children. Robin was described as unresponsive at birth, and difficult to manage by an anxious, unhappy mother. The infant’s deformaties were asymmetrical skull, asymmetrical ear placement, primitive ear formation, all of which were described as mild. Radiation therapy for skin hemangiomata during early infancy left some scars. Two years-after-Robin was born, the mother delivered a healthv bov. the final child in the familv. The reader will be correct in assuming that the brother’s arrival posed an immediate acceleration of Robin’s insecurity and indeed this was the situation. Robin’s motor skills were noted, early on, to be sluggish. She was clumsy and frustrated daily with inability to keep up with other children. Learning in school was nearly impossible for her. She developed a tremor in her right hand, her dominant hand, and so her ability to write was compromised. The parents made an heroic decision when they moved from Nebraska to Topeka, specifically to get help for Robin in the Menninger Foundation. The Menninger evaluation pronounced Robin a poor therapy risk, probably because she was already achieving maximum secondary gain from her disabilities. However, when asked whether or not she would consider taking Robin on as a patient, Dr Murphy accepted the challenge. She did so with the understanding that Robin would also be enrolled as a day patient in the Children’s Hospital of the Menninger Foundation, a unit with a school for children of comparable age and who were also experiencing difficulties at home and at school. Dr Murphy insisted upon a therapeutic approach with social, school and medical support. With this program agreed to and in place, the story of Robin and Dr Murphy unfolds. The panorama of early adolescence is the theme of Robin. Although Robin does have physical handicaps and neurological dysfunction, her struggle to become an adult person is as touching and timeless as it is for every young adolescent. Time and again Robin refers to the need for someone to ‘push me’. Dr Murphy does the pushing, to be sure, but always with love and respect for Robin the individual, not Robin the handicapped. Dr Murphy wonders, as we all do who work with young people at “the healina newer of corrective love and SUDDOI?". -As a therapist, Dr Murphy mar& at the “islands of creativitv” in Robin’s brain. With Dr Murohv’s heto. Robin learns about sex, separation and control;she reach& out to other people and is ready and able to give herself to those whose needs are greater than hers. Robin’s family was in serious turmoil during the 3 years of Robin’s therapy. Eve, the sister who was 2 years older had a breakdown which required admission to the Children’s Hospital at Menninger. Her brother Jim had major school problems. And yet Robin managed to work through her own set of problems with appropriate and thoughtful empathy for her siblings. Parents and professionals who wish to know more about adolescent feelings and behavior can only benefit by reading this splendid book. For medical students who are contemplating a career either in Pediatrics or Child Psychiatry, this is a book which must be on the required reading list.
The Children’s Hospitul Haroard Medical School Boston, MA, U.S.A. S.S.M.,7,*3--H
ROBERTP. MASLAND JR
1935
Lead Versus Heah Sources and Elk&s of Low Level Lead Exposure, edited by M. RIJ?TERand R. R. JONES.Wiley,
Chichester, 1983 This book gathers together the edited papers presented at
an international symposium held in London in May 1982. The symposium was organ&d by a food company and by the CLEAR Charitable Trust. Since the CLEAR organisation was founded as a pressure group with the laudable object of increasing public and political awareness of the public health hazard posed by lead pollution in general, and by lead petrol additives in particular, it might have been suspected that both the symposium and the publication under review would have a predominantly partisan character. This is not the case. The selection of Professor Rutter as symposium chairman and joint editor bears witness. Rutter had been a member of the government Working Party that in 1980 produced the highly controversial Lawther Report with its dismissal of petrol lead as a major contributor to human lead burdens and its professed scepticism concerning the numerous reports associating ‘low level’ lead with adverse effects on the mental development of children. Rutter’s scholarly concluding article (Chap. 17) makes clear that he has now reassessed his views, largely, it would appear, on the basis of the new studies reported and now published in the present book. Two of the papers presented at the symposium are not included in the present volume. As these omitted papers covered the important topics of lead and abnormal births and environmental sources of lead exposure respectively, it is fortunate that excellent reviews of these same topics have been provided by Silbergeld, Jones and Stephens respectively. Additional papers by Duggan on leadcontaminated dust as a source of lead exposure for children and by Otto on neuroelectrical changes in the child brain associated with lead exposure further broaden the scope of the book beyond that of the symposium. Although it should not be regarded as a textbook, the present volume, unlike many books based on symposium proceedings, does provide a broadly based review of present knowledge in an important and developing field with implications extending well beyond the conventional frontiers of science and medicine. For example, the effects of lead on intelligence and behaviour of children take one into the fields of education and sociology, while the question whether lead-free petrol will be made available can take one into the fields of automobile engineering, refining technology and industrial politics. The book falls into 3 main sections. The first is concerned with sources of environmental lead. Appropriately enough, it starts off with a paper by Patterson, widely regarded as the founding father of modem studies of environmental lead. His chapter reviews the evidence that present body burdens of lead are some 50~1000 times greater than those in the bodies of our prehistoric ancestors. However, the grossly un-natural nature of the present levels, now regarded as ‘normal’, suggests that the term ‘low level’ is a potentially misleading example of the unqualified comparative. Other interesting papers in this section are concerned with the declining blood lead levels in the U.S. population which appear to correlate quite closely with the declining usage of lead petrol additives (Annest, Billick), the problem of plumbosolvent water (Moore) and the above-mentioned reviews by Duggan on the hazard to children posed by high levels of lead in dust, and by Jones and Stephens on the question of petrol lead contributing to lead in man. On this last topic, they make the important point largely overlooked in the Lawther Report that fall-out of airborne lead (which comes mainly from petrol) causes massive and widespread contamination of foodcrops and is therefore an important source of dietary lead. This contamination bypasses the natural barriers in root systems to the translocation of lead from the soil to edible parts of plants.