Handbook of Child and Adolescent Outpatient, Day Treatment, and Community Psychiatry

Dr. Ghuman and Dr. Sarles, the authors of this useful, up-to-date text, note that planning mental health programs for children and adolescents has become increasingly complex and difficult. They report that there has been a massive shift in health care in the 1990s, a shift that was observed first in adult patients and later in child and adolescent patients. Mental health service delivery has moved from long-term inpatient and residential care to care in the community and home. This change in service delivery has been touted as progress and in the best interests of children and families, but in reality it has been driven primarily by economic pressures to reduce costs. The stay in an inpatient setting has gotten shorter and shorter even if an appropriate treatment plan mandates a longer stay.

As the length of inpatient treatment has decreased, new programs have developed and are developing for outpatient and community care. A new lexicon of terminology has developed for child services in the home and community, including “family preservation initiatives,” “wraparound services,” “umbrella services,” and “in-home services.” The emphasis of all these programs is on treating children and adolescents in their home and community. The stated basis for this is to decrease a family’s dependence on others and to strengthen family bonds. However, there remains a cohort of chronically and severely disturbed children, adolescents, and their highly stressed parents, who do not respond to using less restrictive community approaches. Unfortunately, mental health planners and insurance agencies have neglected the care of these children.

This book was designed to describe emerging clinical services both in design (theory) and in practice (administration and staffing). The text, divided into six sections, deals primarily with day treatment and community psychiatry and only peripherally with inpatient services. The first section deals with general issues related to administration, staffing, training, and collaborative aspects of outpatient work. Section 2 addresses assessment aspects of outpatient work, including the assessment of infants, preschool children, school-age children, adolescents, and their families. In this section, chapter 8 addresses psychological evaluation and assessment. This chapter is one of the most comprehensive I have read on psychological evaluation and assessment. It lists all the currently available reliable and valid tests, describes them, and addresses their assets and liabilities. It is a useful reference chapter for residents, child fellows, and practicing child and adolescent psychiatrists.

Section 3 addresses the common disorders of childhood and adolescence, including affective disorder, obsessive-compulsive disorder, tics and Tourette’s disorder, separation anxiety disorder, attention deficit hyperactivity disorder, conduct and oppositional disorders, alcohol and substance abuse disorders, pervasive developmental disorder, and learning disorders. All of these clinical chapters are well written by experts in the field and adhere to criteria in DSM-IV. Section 4 describes therapeutic interventions; chapter 17 in this section is devoted to pharmacotherapy in children and adolescents. It is a comprehensive review of the medications that are approved or used off-label for children and adolescents. The author addresses psychopharmacology in young patients in a comprehensive fashion, including such issues as method of action of the medication, risks and benefits of the medication, dose schedule, and side effects. Obviously, much more could be said about each medication, but for a quick guide and reference, this chapter is useful.

Section 5 describes mental health services that are intermediate in level of intensity between inpatient and outpatient treatment. These include day hospital and day school. Each of these chapters addresses administrative structure, staffing ratios and physical facilities, and relationships to outside agencies. The last section, section 6, addresses different aspects of community-based programs, including mental health services in the schools, home- and community-based care, the therapeutic nursery, and foster care. Each of these chapters is written in an easy-to-understand, readable style.

This book would serve general psychiatrists well. The level of detail is inadequate for child psychiatry trainees, child psychiatrists, and child mental health personnel. Each chapter provides a detailed and comprehensive list of references and offers a pathway toward finding more information on a specific subject.

Our field is rapidly changing. Unfortunately, the pace of change is almost frenetic. By the time a book such as this, with a publication date of 1998, is in the hands of readers, much of the field will have changed. However, as much changes, much will remain the same. That is, chapters dealing with the diagnostic assessment of youth; principles of psychotherapy, cognitive therapy, and behavior therapy; and the different outpatient and community treatment programs are still current. The authors are to be congratulated in that they have managed to achieve a uniform style from a diverse and talented group of contributors. This makes this handbook a highly readable and useful reference text for general psychiatrists, psychologists, and other mental health clinicians.