The book is aimed at practitioners and researchers, but fewpractitioners would find this scholarly but rather dense bookuseful except as a reference source. But as a reference text onADHD, this is one of the best available at the moment andquite complementary to others now available in that, aswould be expected, it offers somewhat different coverage,emphasis, and style-a must for every library and for seriousstudents of ADHD and a blow for the universality of scienceover nationalism and narcissism!

John S. Werry, M.D.Emeritus Professor of Psychiatry

University of Auckland, New Zealand

Growing Up Sad: Childhood Depression and Its Treatment.By Leon Cytryn , M.D., and Donald McKnew, M .D. New Yorkand London: U%'U%' Norton & Co. , 1996. 216 pp.• $25.00(hardcover).

Growing Up Sad: Childhood Depression and Its Treatment,an updated expansion of the 1983 edition, Why Isn'tJohnnyCrying? is a truly ground-breaking, state-of-the-art book. Itmasterfully integrates the authors' own research and clinicalexpertise with earlier theories and findings of child devel­opment and the cutting edge of neurobiology research toenhance the understanding of childhood depression , its pre­vention , and its treatment.

Four major advances in the field are identified by theauthors as "changing the face of child psychology": (1)research showing that early-onset depression "may be a fore­runner of later major depression or bipolar disorder"; (2)developmental psychopathology showing various manifesta­tions of mood and mood disorders from infancy to adult­hood; (3) discovery of new antidepressants that "haveextended the limits of pharmacological treatments"; and (4)epidemiological research that unravels the issue of cornorbid­iryof depression with other mental disorders.

These advances are integrated into a meaningful biopsy­chosocial synthesis. In deceptively simple and clear language,the authors brighten up research data with lively case vig­nettes, making the book very readable for both mental healthprofessionals and parents .

In step with the spirit of integration, fairness and balancepermeate throughout the 11 chapters of the book. Over­whelming statistics showing genetic risks in the offspring ofdepressed parents are counterbalanced by the emphasis onth e fact that 70% of these offspring are disease-free .Interpretation of the twin and adoption studies equallyemphasizes inheritability and the child's identification process

BOOK REVIEWS

with the depressed parent. While statistics report scarcity ofsuicide attempts in the very young, compelling case vignettesare powerful reminders of their existence and seriousness .Easily identifiable DSM-IV descriptive criteria of childhooddepression are deepened and broadened by a peek into theunconscious nature of the depression process and the push ofmaturation. Interpretation of the pathological findings in theyoung offspring of parents with unipolar and bipolar depres­sion takes on a special meaning when referenced against thebackdrop of theories and findings of child development anddevelopmental psychopathology.

A well-balanced overview of psychosocial therapiesincludes not only types of therapy but also therapeutic proc­esses. Of particular relevance is the emphasis on the contrastbetween virtually limitless potentials of psychotherapy andits "real-life" limitations, e.g., rationed health care. As sea­soned clinicians, the authors also remind the reader about thenecessity of complementing conventional therapy with cru­cial community interventions, e.g., school, juvenile court, etc.

In the area of psychopharmacology research of childhooddepression, the authors place its negative findings into per­spective by highlighting theories that might explain these dis­appointing results. While encouraged by the reported efficacyof lithium in a study of childhood bipolar disorder, they cau­tiously remind the reader about the lack of safety and long­term follow-up studies.

In the area of prevention, the authors laud the nationalincentive aimed at increasing public awareness of depressionand at promoting early intervention programs targeting chil­dren of depressed parents . However, they contend that muchmore work is needed to achieve "emotional immunization"against childhood depression. To reconciliate the "nature"with "nurture" facets of risk prevention, the authors delveinto the potentials of genetic counseling as well as those ofpsychosocial prevention such as divorce counseling, griefcounseling, trauma counseling, etc.

Finally, moving onto the cutting edge, the authors give cre­dence to the national emphasis on "the decade of the brain"by citing M. George and colleagues' 1995 landmark studyshowing changes in regional cerebral blood flow associatedwith the experimentally evoked transient sadness and happi­ness. However, they equally stress the role of the mind byreporting Baxter and colleagues' 1992 study showing caudateglucose metabolic normalization by either active drugs orbehavior therapy in obsessive-compulsive disorder.

In the epilogue, the authors' emphasis on "the necessaryremedicalization of psychiatry, while preventing its dehuman­ization" summarizes well their biopsychosocial stance. Dis­passionate on every controversial issue, they conclude thebook with a passionate call for "early detection and treatmentof depressed children, before the depression becomes a way oflife. . . . Given timely and appropriate help, most depressed

) . AM . ACAD . CHILD ADOL ESC. PSYCHIATRY, 36:9. SEPT EMB ER 19 9 7 1305

BOOK REVIEWS

children can be helped to lead a normal and productive life(p. 186)."

A "must" on the bookshelf of every professional workingwith depressed children, Growing Up Sad: ChildhoodDepression and Its Treatment is also an invaluable resourcebook for families with depressed youth.

Nga Nguyen, M.D.Associate Professor

Department of Psychiatry and Behavioral SciencesMedical Director

Division of Child and Adolescent Outpatient ClinicsUniversiry of Texas Medical Branch at Galveston

How to Partner with Managed Care: A "Do-It-Yourself Kit"for Building Working Relationships and Getting SteadyReferrals. By Charles H. Browning, Ph.D., and Beverly j.Browning, Ph.D. New York: John Wiley 6- Sons, Inc., 1996,366pp., $39.95 (hardcover).

This book was written by two very experienced clinicalpsychologists from California who have successfully changedtheir practice to accommodate what they label the "ManagedCare Giants." It is primarily directed at psychotherapists inprivate practice who are not psychiatrists, as a "SurvivalGuide." The authors previously wrote the Private PracticeHandbook, now in its fourth edition.

This is a book that some child psychiatrists should con­sider reading, while others should definitely not. For thosewho consider managed care in all of its forms an evil thatmust be fought at all costs, this is not a book to consider. Youwill most likely be offended, as I was at times, and even out­raged by the assertion that managed care, in its most intrusiveform, is inevitable and must be given in to. It goes into greatdetail about what case managers want and how to accommo­date them-how to "prove" yourself worthy of their referrals.Also, if you do dynamically oriented psychotherapy andbelieve that short-term, symptom-focused therapy compro­mises your professional integriry, then this is not a book foryou, either.

Child psychiatrists who view psychotherapy as being anintegral and essential part of good treatment should considerreading selected parts of this book, which are excellent.Thosechild psychiatrists who are currently part of a group or net­work or are considering forming or joining a network shouldgive serious consideration to selected parts of this book,particularly if the group is considering accepting risk. As apart of a risk-sharing network, it is likely that you will findyourself reviewing the utilization of your colleagues, decidingwhat type of and how much psychotherapy is medically

appropriate and/or necessary for a particular patient. In thisrole you will be confronted with some very difficult and"sticky" issuesand may find that sometimes "the enemy is us."

If one believes that professionals, not businessmen, shoulddecide how limited health resources should be allocated,then it is quite possible you will be faced with the questionof deciding how much therapy is "medically necessary."This is the position I found myself in recently, as the psy­chiatric consultant to our state's Medicaid program. One ofmy responsibilities has been making utilization decisionsabout requests for "extended" (i.e., long-term) psy­chotherapy. I became acutely aware of the extremely widerange of approaches being used in practice for similar dis­orders and how little we knew about what was effective,particularly regarding "dosage." When does weekly psy­chotherapy produce better results than bimonthly psy­chotherapy? More is not particularly better. In addition, theability of clinicians to articulate clear and measurable goals(outcomes) is at best problematic.

The book has 11 chapters and 5 appendices. Examples are"On Adjusting Attitudes and Taming Giants," "PartneringWith Managed Care: Building the Future Referral Base forYour Practice by Cooperating with Case Managers," and"Automating Your Practice to Make It Managed Care Efficientand Successful: Practical Advice From Four Consultants."

For psychiatrists, the strength of this book is the chaptersthat deal with clinical issues. While written as part of a bookabout managed care, these chapters could stand alone and areworth reading because they skillfully address a number ofissues that every clinician treating patients with psychiatricdisorders is, or should be, concerned about. These chaptersaddress the issue of being accountable for what we do asclinicians/psychotherapists.

There are four chapters devoted to clinical issues. Thelongest of these is on "Brief Therapy." This is primarily adescription of strategies and techniques. While some of theideas presented might be considered controversial, I foundthe majority of the authors' approaches insightful and useful.For example, they discuss the concept of treatment targetedimpairments (T'Tls), which they define as the "outwardexpression" of certain DSM-IV diagnoses. While not dissim­ilar to the concept of symptoms, 'TTls as they describe themhave the potential of more clearly defining what is targeted intreatment and thus help measure progress. The authors thenproceed to discuss in the following sections areas such as thenecessity of prioritizing impairments according to their pre­dicted responsiveness to interventions, getting the patient tocommit to impairments to be eliminated or changed, how todefine precipitating events or "triggers," along with a host ofother specific techniques.

A second clinical chapter is devoted to assessingT'I'Is, Tenspecificareas are discussed in detail. While most of these areas

1306 ]. AM. ACAD. CHILD ADOLESC. PSYCHIATRY. 36:9. SEPTEMBER 1997