Clinical Child Neuropsychiatry

Clinical Child Neuropsychiatry

C Gillberg

New York: Cambridge University Press; 1995. 368 p

This reviewer was privileged to hear a remarkable presentation by Dr Christopher Gillberg, a Swedish child psychiatrist, in Australia in 1992. He was one of the invited plenary speakers at the International Association for the Scientific Study of Mental Deficiency at the Gold Coast Conference in 1992. He spoke clearly and precisely as he related a wealth of personal research about the underlying medical conditions leading to the autistic disorders. During the past 10 years, Dr Gillberg has become a preeminent world authority in the field of mental retardation and psychiatric disorder. This textbook confirms that his writing matches his memorable presentation in Australia. It is an encyclopedic distillation of not only the psychiatric aspects of mental retardation but also the organic factors involved in obsessional disorders, attentional disorders, language disorders, sleep and elimination disorders, and more. Even more surprising is his compilation of the existing knowledge on behavioral and physical phenotypes, which he correlates with genetic findings, a task not previously attempted to this reviewer’s knowledge.

With Gillberg’s inclusion of the psychiatric sequelae of traumatic brain injury in children, epilepsy, cerebral palsy, and brain tumors, along with their neurodevelopmental, neuropsychological, and laboratory workups, directors of child and adolescent psychiatry education, after reading this textbook, will likely have to insist on the inclusion of 6 months to a year of developmental pediatric and pediatric neurology in child psychiatry training in order to allow themselves to be called “Complete Child Psychiatrists”!

Although the Ontario Health Study indicates that the percentage prevalence of emotional and behavioral disorders in children and adolescents is in the double figures, Gillberg, in his chapter on epidemiology, states that up to 10% of children have neuropsychiatric disorders(the bulk of which manifest as attention deficit disorders). The importance of workup and diagnosis by trained clinical child psychiatrists is emphasized by such figures.

In this textbook, we are brought up to date with molecular genetics in diagnosing such conditions as fragile X syndrome, Prader-Willi syndrome, Angelman’s syndrome, neuroflbromatoses, Duchenne muscular dystrophy, and possibly Williams syndrome. Other background factors, such as temperament, prenatal, sociocultural, and familial factors are noted, and an excellent bibliography is provided for more detailed reviews.

A brief but significant chapter on normal development includes not only a practical table of milestones (useful for clinical inventory) but also a clear exposition of Baron-Cohen’s “Theory of Mind” and subsequent development of complex social interaction and empathy.

As would be expected from one of Gillberg’s primary areas of interest, the chapter on autism and “autism spectrum” disorders is excellent. It not only brings us up to date with DSM-IV definitions, but also it supports Lorna Wing’s thesis that there is doubtful specificity of “pure” Kanner autism. Instead, Gillberg proposes that there are a number of conditions that result in disorders of “empathy.” He makes a compelling argument against the current classification of pervasive developmental disorders. This is particularly supported when he lists 17 organic conditions that have been confirmed as producing the autism spectrum. The standardized neuropsychiatric assessment and relevant laboratory workups to detect these 17 conditions are outlined. Of particular importance and interest to child psychiatrists is his detailed review of the current state of knowledge of Asperger’s syndrome, including an outline of the controversy over classification and the long-term outcome for those suffering from this condition.

There is a surprising inclusion of anorexia nervosa in the chapter, which also links obsessive-compulsive disorders with tic disorders and Tourette’s syndrome. He outlines the hypothesis that anorexia nervosa is a final common pathway disorder including psychosocial, neurochemical, and local gastric factors with a minimal relationship to family dysfunction.

Gillberg makes a significant contribution to clinical diagnosis and treatment as well as future research potential by introducing the term “DAMP” disorders. This new umbrella term covering “Deficits in Attention, Motor Control and Perception” is much clearer than the alternative phrase, “Minimal Brain Dysfunction.” It was coined by Gillberg in 1983 and is now accepted by the Nordic consortium of child psychiatry. Given that attentional disorders, motor control disorders, hyperkinetic disorders, perceptual (reading and writing) disorders, and speech and language disorders overlap, this is a much-needed classification that is worthy of considerable scrutiny by the American Psychiatric Association and World Health Organization.

Another new term for this reviewer is “Jactatio capitis.” No, it is not a new paraphilia, but it has implications for those clinicians working with tic disorders and other repetitive rhythmic disorders. (To find out more, the reader is referred to Chapter 9.)

The longest chapter (70 pages) and the one filled with the most “meat” is entitled “Specific Syndromes Not Otherwise Referred To.” Here, Gillberg is at his most-knowledgeable best, compiling the prevalence, sex ratios, behavioral phenotypes, pathogenesis, diagnosis, workup, treatment, and outcome of congenital developmental syndromes. My only criticism of this chapter, and it is rather muted, is that the chapter could have included more pictures of the dysmorphic features of some of the syndromes. I suppose, however, that the knowledgeable reader should have a companion volume such as the Nyhan and Sakatis textbook, Diagnostic Recognition of Genetic Disease, on the shelf.

The psychopharmacology of child neuropsychiatric syndromes is complete, succinct, and up to date and draws heavily on the author’s former working relationship with Magda Campbell.

For his next edition (hopefully because of the importance of this textbook there will be many future editions), this reviewer would like to see expansion in the size of the specific syndrome chapter as well as an expansion on the psychiatric sequelae of and psychosocial intervention with traumatic brain injury, cerebral palsy, and epilepsy.

The textbook gains tremendous consistency from its single authorship. It is a major textbook, more comprehensive, detailed, and current than any other on developmental psychiatry. It, along with Levine and others’ 1983 textbook, Developmental-Behavioural Pediatrics, should be on the shelf of every child psychiatry resident, notwithstanding its price. It has fulfilled Gillberg’s goal of being “the first such compilation on clinical child neuropsychiatry, in which all the infancy, childhood or adolescent onset disorders in which mental, emotional and behavioural problems predominate . . . and for which biological factors . . . play a major . . . role are included.” Congratulations, Dr Gillberg!