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Book Forum: Childhood and Adolescence Issues   |    
Psychotherapy for Children and Adolescents: Evidence-Based Treatments and Case Examples
LAWRENCE HARTMANN, M.D.
Am J Psychiatry 2005;162:1231-1232. doi:10.1176/appi.ajp.162.6.1231
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By John R. Weisz. Cambridge, U.K., Cambridge University Press, 2004, 528 pp., $95.00; $36.99 (paper).

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This book reviews a good many recently published so-called evidence-based studies of several common and troublesome childhood psychiatric disorders. It leaves out a great deal about child and adolescent psychiatry and psychotherapy. Within some rather severe limits, however, which could have been acknowledged and discussed more prominently and thoroughly by the author, this is an unusually tidy and in many ways modestly useful book. Each of the four long main sections of the book is preceded by a brief introduction and followed by an even briefer conclusion, but given the vast areas of child psychiatric issues left out or slighted, one wishes that the contextualizing and, here and there, properly skeptical thinking of the introduction and summary chapters had been rather longer and more probing.

This book might, for example, have provided an excellent opportunity to discuss the many limitations of the phrase "evidence-based," which is currently fashionable and seemingly above reproach (but actually often somewhat smug, narrowly understood, and propagandistic). What is easiest to measure in child psychiatry tends to get measured and quantified and called real; what is harder or takes longer to measure gets implicitly brushed aside. Psychiatric research, whose fields are often quite complex, has too often simplified the real questions of What is evidence? and What is science? Related to this problem, the book might also have provided or at least indicated a far larger and subtler series of discussions of the large, and often understandable, gaps between clinicians and researchers. Clinicians actually do have a good bit of evidence. Insofar as the book discusses the gap, it seems to assume that the so-called evidence-based researchers, who give shape to this volume, are simply right and that the clinicians—and often perhaps patients—are wrong. I think that is a downright dangerous error.

The four main sections, labeled B through E, are Treatments for Fears and Anxiety, Treatments for Depression, Treatments for Attention Deficit/Hyperactivity Disorder, and Treatments for Conduct Problems and Conduct Disorders. Each begins with an appealing page-or-two case example, which seems to me a useful and welcoming introduction, but the case examples chosen seem, in both their presentation and their perhaps real or hypothetical or even wishful responses to treatments, to bear signs of being (it remains hard to tell) in an odd limbo between real cases and pasted together prototypical cases: Sean, Megan, Kevin, and Sal.

In section B, after a few very brief introductory comments on fears and anxiety, we are given a chapter titled "Four Classic Treatments for Fears: Modeling, Systemic Desensitization, Reinforced Exposure, and Self-Talk." These are important, and clearly presented. Like most of the other chapters, this one has a potentially useful ending, consisting of a brief and narrowly defined page on how to find out more about the four treatments just discussed. The author’s freedom with the word "classic" here and in similar places when discussing what he has just discussed may be a bit less than reassuring to some readers, but that is not a major cavil. In the following chapter, titled "Therapies for Anxiety Disorders: Coping Cat, Coping Koala, and Family Anxiety Management," protocols and definitions of cogent clinical factors are often given, and this is very welcome. On the whole, these are fairly clean reviews of some studies that meet the author’s definition of evidence, or wish for relative neatness and quantifiability, and have been published in the past decade or so. As such they are quite welcome, and it is useful to have them summarized in one place.

Sections C, on depression, and D, on attention deficit hyperactivity disorder (ADHD), are also neatly organized, and Section E, on conduct, is nearly as neat, although it necessarily brings in multisystemic treatment and, to some extent although less than one would wish, the necessary if messy area of families. In C, D, and E, as in B, the treatments are nearly entirely cognitive-behavioral. Fair enough, given the focus of the book, but not entirely fair, and not entirely realistic or useful. Not only is pharmacology hardly discussed at all, even in the treatment of childhood ADHD, but even combined pharmacotherapy plus psychotherapy is hardly mentioned—and that seems to me, in this day and age, odd, and a major opportunity lost.

A young or relatively naive reader of this book, impressed by the book’s title and seeming neatness and adequacy, may hope that the book is a general text about child and adolescent psychotherapy, or about good child and adolescent psychotherapy. As one older clinician and reader, let me build on that last point to list a few of the vital areas in child psychiatry and psychotherapy beyond the scope of, not covered, or not adequately acknowledged in this book:

It avoids biological psychiatry. It nearly wholly avoids not only dynamic psychiatry and the unconscious but also meanings, psychological understanding of feelings, relationships, conflicts, defenses, anger, pain, shame, guilt, and self-deception. It has a rather narrow view of human adaptation. It has nearly nothing to say about the nature of the therapist, and the patient’s relationship with him or her. It says little about the difficulties of listening, to oneself and to others. It nearly wholly avoids the family. It nearly wholly avoids social psychiatry: society, culture, race, class, prejudice, poverty, ethnicity, schools, religions, public economic institutions and arrangements, etc. It tends to avoid development. It accepts 6 months as an adequate follow-up in child studies. It tends to avoid causality. It nearly wholly avoids prevention. It avoids severe illness, such as autism, pervasive developmental disorder, schizophrenia, bipolar disorder, severe depression, and major substance abuse. It evades intelligence, learning disorders, psychosomatic disorders, parental illness or absence or death, other lack of good enough parenting, neurological and other physical illness, divorce, many problems with sex and aggression, abuse and neglect, loss, trauma, and posttraumatic stress disorder.

This is a long list, but all this does not mean it is a bad book. The author clearly tried to set some limits, in a partly postpsychoanalytical field still rather heavy with anecdote and unreliable clinical reports. Although the book might have explained its limits more clearly, it still helps us rather efficiently to review a good many recent studies in "evidence-based" psychotherapies for, mostly, mild to moderately disturbed children and adolescents. It also helps to clarify the still rather narrow world of so-called evidence-based psychotherapies for those youngsters. It will, one hopes, serve as part of a necessary era of serving the mental health of children by trying better to define what we know, and by listening to and noticing not just patients, and not just societal neglect, but also both researchers and clinicians.

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