Chronic Mental Illness in Children and Adolescents

Chronic Mental Illness in Children and Adolescents

Edited by John G. Looney

Washington, American Psychiatric Press, Inc., 1988. 267 pp.

For many, the notion of chronic mental illness in children is hard to accept. Children, even emotionally disturbed children, usually engender a sense of optimism and hope in the future. For those who work in the fields of child welfare and child psychiatry, however, it is well known that there exists a fraction of children and adolescents whose disturbance is both severe and enduring. This book focuses on severely disturbed youngsters, describes these children, and illuminates their needs.

The book, with fifteen contributors, is an outgrowth of a national conference held in 1985 aimed at this same population. There are four major sections in the book and a total of thirteen chapters; each of the major sections addresses a particular aspect of the larger picture of child mental health services. Although the volume evidences some repetition, it is well organized; each chapter builds on previous chapters.

The first section deals with the nature and scope of the problem and moves nicely from the case examples of Chapter 1 to Chapter 2’s discussion of these children in the aggregate. Some readers may find the methods used in Chapter 3 to estimate the prevalence of severely emotionally disturbed children and adolescents from existing data a bit facile, but, given the state of the art of child psychiatric epidemiology, the estimates offered may not be far out of line. Another chapter in this section, written by Jane Knitzer, provides a lucid review of recent policy concerning this population and offers some ideas regarding pressing policy questions. The major theme of this section is that, as a group, severely emotionally disturbed children have needs that require careful treatment and planning.

Section two considers the role of the public and private sectors in the treatment and programmatic planning for severely disturbed children and adolescents. Two of the chapters in this section point out the continuity of care problem, which is compounded by the fragmented service system and the multiple treatment needs of these youngsters. The problem is described in Chapter 5, and a model for solving the problem is outlined in the last chapter of this section. Included in this section is an essay on private inpatient care. Unfortunately, this chapter describes long-term treatment of children and adolescents in a private psychiatric hospital, in contrast to the current trend, driven to a great extent by economic pressures, which is clearly toward brief hospitalization.

In the third section, special issues such as the training needs of mental health professionals, the value of family treatment with this population, and the importance of evaluative research to assess the effectiveness of various treatment programs are considered. Although the chapters in this section are not as unified as those in other sections of the book, each of these chapters is particularly strong.

The last section considers the policy and funding issues that require resolution in order to confront the needs of these children and adolescents. The first of the two chapters reiterates the need for a high degree of cooperation between public and private agencies to build an integrated system of care. The author, Donald Gair, returns to the notion of chronicity and cautions against building a system of care for these children. He warns that the definition of chronicity may result in the exclusion of troubled children from services. Rather than being exclusionary, the service system should focus on the tasks of childhood and provide interventions that are commensurate with developmental needs. In such a child development model, public schools would form the foundation of the service system, and psychiatry would have to relinquish the medical model to some extent. The final chapter outlines a strategy for constructing an organized system of care for children; here, John Looney, also the book’s editor, carefully maps out the barriers to building such a system and provides an agenda for further discussion and planning. This chapter could stand as a summary of the entire book.

This volume was intended for mental health professionals, though others interested in child development and public policy for children will also find the book worth reading. It does not consider in any detail the effect of current economic pressures on child psychiatric services — especially on inpatient services, which is an unfortunate omission because as inpatient stays decrease, there may well be an increase in referrals of more acutely disturbed children to residential and public facilities. Hence there is an urgent need to achieve coordination between public and private service sectors. The book effectively describes the difficulties confronting severely emotionally disturbed children and their families in human terms. The magnitude of the problem is estimated, and possible solutions are described — perhaps the major contribution of the volume. It goes beyond mere complaining about the fragmented service system that currently exists and offers an agenda for further discussion of this problem and its solution.