The last two decades have seen a geometric increase in the number of compounds available to treat mental illnesses, but not a single one was designed or rigorously tested in the care of children.  Patients and physicians therefore navigate a landscape characterized by both risk and opportunity.  The use of psychotropic medications in the young has grown rapidly, with correspondingly expanding societal concern over its implications.  There is, at the very least, a demand for greater understanding of normal and abnormal processes of child development to guide clinicians in this area.  Joan Luby has edited a compact and accessible text entitled Handbook of Preschool Mental Health: Development, Disorders, and Treatment, that helps to address the need.  For the trainee, it provides a framework; for the advanced clinician, it provokes important questions.

The subtitle of the book outlines its overall organization.  Social, emotional, and cognitive development in the preschool years of a normal child are taken up in the first section.  Illustrative examples and landmark studies are chosen well to highlight what is known and can be observed about the mental lives of children.  The perspective is decidedly Western, with a focus on the development of the self as a process of differentiation guided by interactions with parents and peers.  Development as a trajectory toward the establishment of meaningful relationships and healthy interpersonal systems not emphasized.  While it lies beyond the formal scope of the book, astute readers will benefit from how this survey of normal individuation informs modern psychiatric impressions of parents of child patients and adult patients in addition to the young.

The largest middle section of the book surveys the major categories of mental disorder that become apparent during the preschool period.  The seemingly ubiquitous phenomenon of attention deficit is given first consideration.  The authors point out historical and cultural trends that affect its prevalence and meaning.  Despite the widespread use of stimulants to address symptoms of attentional and behavioral disorders, there is a relative absence of discussion of the neurobiology of ADHD.  The chapter on oppositional defiant disorder is quite good.  It highlights confounding factors in understanding this controversial entity with a careful, thorough discussion of comorbidity.  There is even a well-organized attempt to understand different factors in the etiology of oppositionality.

Anorexia and bulimia nervosa are the conditions that usually come to mind when we speak of eating disorders.  A nice survey chapter in this text serves as a reminder that there are many ways younger children can manifest unhealthy relationships with food.  The PTSD section emphasizes a need to understand what trauma reactions look like in children, and its author suggests a rationale for revised diagnostic criteria and research that might help to advance the clinical science.  The sleep disorders chapter is at least as useful for its review of normal sleep development as it is for its outline of the different pathologies.  Although helpful discussions of the DSM entities, the chapters on attachment disorders and autism were somewhat disappointing.  With a narrowed focus on diagnosable conditions, the question of how attachment problems affect mental health presentations and symptomatology, in general, went unaddressed.  Similarly, autism was discussed from the perspective of the boundaries of diagnostic categories and associated comorbidity, rather than with a focus on autistic phenomena or their etiologies.  The controversial question of psychosis in preschool children is not addressed, and seems worthy of comment in this kind of text.

Conversely, mood disorders are discussed by the book's editor in some detail.  Dr. Luby displays extensive expertise in practical and theoretical understanding of the meaning and development of mood in preschoolers.  She proposes an emotional reactivity model that integrates developmental research and diagnostic principles.  While it may be challenging for her readers to apply her framework to individual clinical situations, the final section of the Handbook on assessment and treatment suggests practical validity to her way of thinking about patients.

Psychological testing receives a fair bit of attention, and the outline of what such assessment can and should provide is informative.  Pharmacotherapeutics are reviewed in good detail with attention to balancing concerns about the developing brain and the benefit of relieving symptoms in states of significant pathology.  Helpful guidelines and illustrative cases make for good chapters on play therapies.  An entire section devoted to early intervention strategies in autism is particularly helpful for providers to appreciate the importance of treatments that are delivered outside the clinic and hospital setting this challenging set of disorders.

We found the Handbook of Preschool Mental Health: Development, Disorders, and Treatment an enjoyable, informative, well-crafted read.  Consistencies of content are difficult to maintain in any edited textbook, but the overall structure of the work succeeds in minimizing problems with conflicting perspectives and organizing principles between and among the different sections.  It comes recommended as a valuable collection of first reference reviews in the care of the mental health of some of our field's youngest patients.

© 2007 J.J. Rasimas and Lloyd A. Wells

J.J. Rasimas, M.D., Ph.D. & Lloyd A. Wells, Ph.D., M.D., Mayo Clinic, Department of Psychiatry and Psychology, Rochester, MN 

Categories: ChildhoodDisorders