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Anxiety Disorders

Review of "Phobic and Anxiety Disorders in Children and Adolescents"

By Thomas H. Ollendick and John S. March (Editors)
Oxford University Press, 2004
Review by Roy Sugarman, Ph.D. on Oct 23rd 2005
Phobic and Anxiety Disorders in Children and Adolescents

As with so many recent works, these editors set out to "bridge the gap" between evidence based, scientific approaches, the academic royal road to expertise, and the pragmatic, most useful way of doing things from a clinician's perspective. Perhaps uniquely, these authors contrived to have at least a psychologist and psychiatrist write each chapter as a way of appearing multidisciplinary, to gain the perspective of each in each chapter, often with multiple authors.

In this way, the 19 chapters address the increasingly fragile population of modern children, but inevitably, still following the model that these children are possessed of some illness entity, some sickness, without really engaging in a meaningful discourse around the morbidity in social settings, and no mention of social capital and other epidemiological work is effectively entertained. Social phobia, yes, social capital no. If one becomes ill, this is internally systemic, and treated in this way. Miller and others (see the review of Facing Human Suffering) have a different slant on things in balancing, or at least confronting, the "bridge", as does Weisz, with a specific approach to children and adolescents (see the review of Psychotherapy for Children and Adolescents: Evidence-Based Treatments and Case Examples).

In this book, even Ferdinand et al's chapter 16, dealing with prevention and intervention, makes only passing reference to society, and its demands, by demonstrating primary intervention to be a form of preparation of schools and other settings to deal with vulnerable individuals. Vulnerable here then implies that there are those who will get ill, all things being equal, and those that will not.

A more modern approach perhaps, is that there are certainly vulnerable brains which will become ill in even normal settings, but that there are also normal brains which will become unsettled in extreme settings, and there is no shortage of this in today's world. And of course there are vulnerable brains in extreme settings too. There is also the question of the pressure of modern society representing a less than normal, more than extreme setting in everyday experience, and then of course there is the breakdown of family, decline in values that rely on religious opiates, and drugs, environmental toxins and so on, hence the rising rate of psychiatric conditions in each successive generation of children.

These Ch 16 authors do mention "interventions may aim to strengthen coping and problem solving strategies" but again, little mention of what may happen beyond the individual, and certainly another issue: for many Western countries in the world, smaller numbers of local medical and nursing graduates entering the postgraduate training programs. The nature of the work has changed, and shortages of mental health workers in the medical fields, if not psychology, are now common. Countries like Australia cannot meet their mental health nurses and psychiatry registrar quotas and must recruit far and wide. And then there is the recovery movement and its input on behalf of the philosophy of consumers of these services. Finally, many Western countries have a backward view of the value of psychological input and its burgeoning evidence base, and the most uncertain value medication in remission, versus improvement.

Controversies also abound with regard to ADHD and other contentious diagnostic and treatment entities, and other authors such as Scott Lilienfeld and colleagues have pointed out the thinness of the science which is overrepresented in this book as more competent than clinicians believe it to be (see the following books by Scott and others Rethinking ADHDand also Science and Pseudoscience in Clinical Psychology )

However, the book stays true to itself and its market in most competent ways, with three sections dedicated to Foundational issues, Assessment and treatment of specific disorders, and predictably, future directions for research and practice, without really doing much real "bridging" as the other books above may have done in a somewhat more direct and philosophical way.

Part one describes diagnostic issues, etiology of fear and panic, development and epidemiology of anxiety disorders, developmental issues, and comorbidity of childhood and adolescent anxiety disorders, from a prevalence point of view, finishing with a combined psychosocial and pharmacological approach, written by March and Ollendick themselves. This is the best chapter in the book, as the editors acknowledge:

In a perfectly evidence-based world, selecting an appropriate treatment from among the many possible options would be reasonably straightforward. However, in the complex world of clinical practice, choices are rarely so clear-cut ... expected outcomes vary by disorder, by treatment modality, and certainly by factors specific to the child, the clinician, and the setting(s) in which they live and work (p. 141).

A lessons from the clinic section follows in this chapter, emphasizing the importance of differential therapeutics, rating scales, the limits of tailoring treatments, dose-response and time-response issues, the monitoring of desirable and undesirable outcomes, emphasis on psychoeducation, all well done but far too brief. A huge decision tree is provided in the practice guidelines section for OCD as an example, very comprehensive, and this book would've been stronger with more of this discussion and integration.

Section II consists of chapters dedicated to phobia, social anxiety, school refusal, separation anxiety, child onset panic disorder, generalized anxiety disorder, OCD, PTSD and selective mutism. Again, unlike Weisz and others, the discussions are heavy on research, assessment, diagnosis, and light on how-to-do this and how to actually sit down and confront the issues, e.g. school refusal. Novice psychologists confronting the conditions for the first time would be hard-pressed to find the manual in the chapter, of lets say what to do on day one. These are academic chapter's hell bent on informing, and there really are lots of those around. Few are as integrated as they need to be, and all assume that the reader will receive training from somewhere else, a workshop, which will provide. They will tell us Kendall 1990 did something with this or that condition, and of course we might have to then seek out Kendall. What Kendall and colleagues produced is not discussed; there are no windows that set out in stepwise cookbook fashion what the approach was, or how it works.

Edited books like these, with around 140 references per chapter are great reference sources, but after reading, they go on the shelves with not much further need. Books such as Weisz's are likely to hardly rest there for many moments before being whipped out, heuristically useful as they are, with much more pragmatics, much less aesthetics, although they balance the divide better then edited books.

This is then for me the divide between the edited textbook-like March and Ollendick offering from Oxford, and the paperback I- wrote- it- all- myself work such as John Weisz's offering from Cambridge University Press: I know who wins the race in dealing with the same subject matter. In the editing, March and Ollendick's authors have trotted out the litany of things they must, but as Miller pointed out, the student will be left disappointed and not really informed or equipped. On the other hand, John Weisz wrote it all himself, structured and organized each chapter himself, and the result is an immediate reference guide for the serious clinician who wants to know the evidence base, and also, really accurately, what to then do with the results of those offerings, and not to have to go to Kendall and find out what the application really was.

Read both offerings, of similar lengths, and the Weisz offering is the most valuable in terms of bridging the gap between the evidence base and clinical practice, where children and adolescents are concerned.

This does not imply that the March/Ollendick offering is not a superior, competent work in itself: it just does not compare in what it says it sets out to do, comparing it to books of similar length, published in the same year, and setting out the same parameters and ambitions. Weisz's organization is also superior, given his control over all the chapters as writer, and his reference sections at the end are superior, breaking down authors and subjects into separate sections, and then by page numbers. Weisz also went wider, bringing in communications theory, from the sixties, existentialism from Buber and others, wide ranging far beyond the March/Ollendick parameters, and paying more than lip service to clinical applications, in detail.

Both books serve their purpose admirably: I know which one I would buy however, and which one will get used most often, with telling outcomes.



2005 Roy Sugarman


Roy Sugarman, Ph.D., Conjoint Senior Lecturer in Psychiatry, University of New South Wales, Australia


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