ENHANCED MONITORINGof Psychosocial Needs in Patients with Genetic Conditions: A CloserLook at the PKU ClinicHAZEL VESPA, LCSW • LAUREN LEVITON, LCSW

Social workers have important contributions to make in working with people coping with geneticconditions. The rapid pace of medical advances and increased treatment options for phenylketonuria(PKU), for example, have challenged the clinical interdisciplinary team to offer more comprehensiveassessments and further program development. In addition to the metabolic abnormality, manypsychosocial concerns are visible in this patient population and have often required further evaluationand referral to a mental health specialist. Unfortunately, comprehensive mental health screeningstargeting emotional and behavioral concerns are not routinely implemented during outpatientappointments within our metabolic genetic population. In this report we illustrate the integral role thatsocial work provided in the introduction and implementation of mental health screening questionnaires inthe PKU Clinic at Children’s Memorial Hospital.

People with PKU have a form of hyperphenylalaninemia, a rare inherited metabolic disorder. PKU iscaused by a mutation in the gene coding for phenylalanine hydroxylase (PAH), a liver enzyme, leadingto elevated levels of the amino acid phenylalanine (Phe). Individuals with severe forms of PKU have acomplete absence or profound deficiency of PAH enzyme activity and typically have very high Phe levels(> 1200 mol/L or > 20 mg/dL). A partial PAH deficiency results in a lower degree of blood Pheelevation (Hoeks & Janssens, 2009). A normal Phe level is 60 to 120 mol/L or 1 to 2 mg/dL. If thisproblem is not found and treated early in infancy, PKU can cause severe developmental delays, includingmental retardation, microcephaly, delayed speech, seizures, and behavioral abnormalities.

Newborn screening for PKU began in the early 1960s and became the prototype for identifying similargenetic conditions that require early treatment. Screening infants shortly after birth helped to prevent thesevere cognitive and developmental impairments that resulted from not being diagnosed. Whenidentified at birth, PKU is treated with Phe-free, protein supplemental medical foods, and a Phe-restricteddiet to avert severe brain damage and developmental delays. Foods high in protein, such as meat,poultry, fish, dairy products, eggs, beans, and nuts, are eliminated. A prescription medicine for PKUcalled Kuvan® (sapropterin dihydrochloride) received Food and Drug Administration approval in 2007)

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NASW Practice & ProfessionalDevelopment BlogWhere can you find the latestinformation posting about socialwork practice? Visit the NASWPractice and ProfessionalDevelopment Blog. Designed forNASW Section members and socialworkers in practice, it offers trendingtopics, valuable resources, andprofessional developmentopportunities. Learn more atwww.socialworkblog.org/practice-and-professional-development/.

IT’S A FACT: To protect confidentiality of HIV status,

Elizabeth H. Fung, PhD, ACSW ChairWendy Auslander, PhD, LCSWJacquelyn J. Nash, MSW, LCSWThomas W. Sedgwick, LCSW, ACSW, CCMKelly Ann Spangler, MSW, MPA LCSW

HealthCommitteeMembers

can be used to lower Phe levels in combinationwith a Phe-restricted diet.It may also lead to

improvement in theneurocognitive symptoms of PKU.

RATIONALEA Phe-restricted dietary regimenhas prevented severeneurological injury in manypatients with PKU. However,studies have shown thatchildren with PKU may be atincreased risk for schoolproblems and attentionaldisorders. Recent researchconducted by Anastasoaie etal., (2008) revealed thatpatients whose disease istreated from early infancy withor without diet may still bevulnerable and experienceneurocognitive, behavioral,and psychosocial challenges.Adults may experienceproblems with concentration,

organization, and moodiness,which are components ofexecutive function (EF) (Hoeks,den Heijer, & Janseen, 2009).Additional EF domains includeplanning, inhibitory control,attentional flexibility, andworking memory (Anderson etal., 2002). These processesaffect goal setting, problemsolving, and skills needed tolive independently and tomanage a Phe-restricted diet.

In the early years of PKUtherapy, treatment was typicallydiscontinued around age sixand patients were allowed toreturn to an unrestricted diet.Years later, when the datarevealed declining IQs andother neurocognitive sequelaein patients off diet, mostphysicians advised patients thatit would be in their best interestto return to a Phe-restricted diet.However, some patients chose

not to, or were unable to do so.For the past two decades,physicians have agreed thatblood Phe levels need to becontrolled throughout thelifetime of patients with PKU.

Despite recommendations tocontinue the PKU diet for life,however, compliance withtreatment continues to be aproblem. As patients get older,an increasing numberexperience difficulty maintainingthe Phe-restricted diet andeventually lose contact with thePKU clinic. These patients maygradually develop behavioral,emotional, and executivefunctioning difficulties. Overallfindings from a collaborativestudy on PKU in adulthoodcorrelated high Phe levels afterage 6 with abnormalities inpsychological, educational,and occupational performance(Koch et al., 2002).

In response to these concerns,the clinical team working withthe PKU population introduced aquality improvement initiative.A Diversified Approach to PKUTreatment (ADAPT) wasintegrated into the PKU clinicprogram. This program wasplanned and designed incollaboration with two otherPKU centers. ADAPT isdesigned to identify these issuesin patients with PKU moreproactively and systematicallyby incorporating screening for executive function andpsychiatric distress (Leviton,Vespa, & Burton, 2011).

METHOD Social workers, in coordinationwith the rest of the clinicalteam, implemented andexecuted the screening tests. Anintroductory letter, sent to allactive patients and/or parents,explained the rationale and

NASW PRESIDENTJeane W. Anastas, PhD, LMSW

EXECUTIVE DIRECTORElizabeth J. Clark, PhD, ACSW, MPH

NASW STAFFDirector, Center for WorkforceStudies & Social Work PracticeTracy Whitaker, DSW, ACSW

Specialty Practice Section ManagerYvette Mulkey, BA

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and Macro Specialty, ACSWBekki Ow-Ärhus, ACSW, DCSW,

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all states apply confidentiality laws to HIV test results.

plan for implementation ofADAPT in order to engage themas working partners. Familieswere encouraged to share theirquestions and concerns tofurther support this initiative.Patients with a diagnosis ofPKU who are age 5 or older,presenting for a regular clinicvisit, are screened for potentialareas of vulnerability that canbe associated with PKU. Thequestionnaires specificallyaddressed areas of EF andpsychiatric distress usingvalidated self or parent reportinstruments. Questionnairesused to address psychiatricconcerns include the PediatricSymptom Checklist in childrenand the Brief SymptomInventory in adults. Executivefunctioning impairment isidentified via the BehaviorRating Inventory of ExecutiveFunction. Patients who screenpositive on either tool arereferred to local mental healthcare professionals for furtherassessment and evaluation.Screenings were completedduring a patient’s routine PKUappointment; questionnairestook approximately 15 to 20minutes to complete andintegrated well into the courseof the clinic visit.

SUMMARY ANDIMPLICATIONS FOR PRACTICESocial workers, in coordinationwith the clinical team, wereintegral in initiating screeningfor EF and psychiatric distressin the PKU clinic.• Social workers introduced

questionnaires to patientsand their parents at theirannual appointment.

• Social workers scored thequestionnaires and conveyedresults to patients or parents.

• Social workers made asignificant effort to identifymental health providers for

further evaluation andtreatment recommendations.Providers includedcommunity-basedpsychologists, psychiatrists,neuropsychologists, andschool-based personnel.

• Motivational interviewingtechniques were used whendiscussing feedback andambivalence whenintegrating mental healthservices into the treatmentplan.

Patients and families werereceptive to mental healthscreening and, whenappropriate, referral to acommunity-based mental healthprovider became part of theoverall PKU treatment plan.Patients cited the followingreasons for refusing a referralto a mental health provider:financial concerns, disbeliefthat a problem existed, timecommitments, or currently inmental health treatment.Screening serves as a catalystto identify more subtle problemsin individuals living with PKU thathave affected their self-esteemand ability to self-monitor.

This quality improvementinitiative has also enhancedcommunication and goal settingamong the interdisciplinaryclinic team and allowed us todevelop additional educationalservices. An example is a staff-led “Boot Camp” for adultpatients who could benefit frompeer support and groupeducation around theirdiagnosis of PKU. This initiativeemphasized the importance ofworking with preadolescentand adolescent patients onfostering independence andself-management of PKUtreatment. Recognition andtreatment of psychiatric distressand cognitive impairment have

the potential to improvepatients’ ability to adhere toPKU treatment plans, as well astheir overall quality of life.Social workers played a criticalrole in the implementation andexecution of this screeningprocess in this clinic.

Lauren Leviton, LCSW, is a clinicalsocial worker, Division of Genetics,Birth Defects, and Metabolism,Children’s Memorial Hospital, Chicago,IL. She can be contacted atlleviton@childrensmemorial.org.

Hazel Vespa, LCSW, is a clinical socialworker, Division of Genetics, BirthDefects, and Metabolism, Children’sMemorial Hospital, Chicago, IL. She can be contacted athvespa@childrensmemorial.org.

REFERENCESAnderson, V., Anderson, P.,

Northam, E., Jacobs, R., &Mikiewicz, O. (2002).Relationships betweencognitive and behavioralmeasures of executive functionin children with brain disease.Child Neuropsychology, 8,231-240.

Anastasoaie, V., Kurzius, L.,Forbes, P., Waisbren, S.(2008). Stability of bloodphenylalanine levels and IQ in children withphenylketonuria. MolecularGenetics and Metabolism,95, 17-20.

Hoeks, M.P., den Heijer, M., &Janseen, M.C. (2009). Adultissues in phenylketonuria.Netherlands Journal ofMedicine, 67(1), 2-7.

Koch, R., Burton, B.,Hoganson, G., Peterson, R.,Read, W., Rouse, B., et al.(2002). Phenylketonuria inadulthood: A collaborativestudy. Journal of InheritedMetabolic Disease, 25, 333-346.

Leviton L., Vespa H., & BurtonB. (2011, March). Mentalhealth screening in thePhenylketonuria (PKU) Clinic.Poster session presented atthe Annual Clinic GeneticsMeeting, Vancouver, BC,Canada. Retrieved fromhttp://submissions.miracd.com/SecureView/ACMG/62opgsiqhxj3xej18fta.pdf

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Knowledge of an arrayof modalities is essentialfor social workproviders. Likely,

treatment teams inclusive of theclient or the client’srepresentative are involved andcommitted to the modality ofchoice that is in the best interestof the client. Whether deliveredsolely or in combination,treatment modalityimplementation usually occursafter a series of assessments anddiagnosis. Prior to determinationof the modality of choice, clientmental and physical healthstability are paramount. Thepresence of substance usedisorders can mimic psychiatricdiagnosis. Hence, beforetreatment is implemented,clients must demonstratereadiness for treatment. Alltreatment modalities havebenefits and challenges.

Myriad issues influence thesocial work provider’s decisionmaking with respect to the besttreatment approach for clients.At the outset, it is essential thatclinicians inquire about theirclient’s reason for presentation.Essentially, what is theprecipitating event motivating

the client’s presentation? Thisincludes whether the client isself-referred, court ordered, orotherwise motivated fortreatment. The reason fortreatment provides some insightinto the client’s willingness toengage in a therapeutic alliancewith the clinician. Furthermore,it is reasonable to inquire aboutwhat the client hopes toachieve by participating intreatment. Hence, from theinitial moments of meeting aclient, the social work providerbegins gathering informationthat will culminate in the choiceof a treatment approach.

CLINICAL ASSESSMENTThe clinical assessment has beenreferred to by many names,among them (1) social workassessment, (2) bio-psychosocialassessment, and (3) behavioralhealth assessment. Regardlessof semantics, it is vital thatclinicians complete anassessment that includes but isnot limited to (1) demographics,(2) health status (history ofinpatient and outpatienthospitalizations), (3) socialsupports, (4) income, (5)employment, (6) mental health(medications, benefit, and

outcomes), (7) substance abusehistory (drug of choice,frequency, amount, treatmenthistory, and completion), (8)trauma history, (9) education,(10) criminal history, (11) diet,(12) spirituality, (13) otherpsychosocial issues(bereavement, housing,relationships, poverty, anddomestic violence), (14)behavior across the life span,and (15) goals for treatment.Clinical assessments need to beuser friendly, relevant to thepopulation assessed, and easilytranslated from identified needsinto services delivered (Leon &Armantrout, 2007). At thecompletion of the assessment,clinicians are encouraged toobtain signed consents forrelease of information.Information obtained duringcompletion of the clinicalassessment assists clinicianswith formulation of the besttreatment modality for clients.

Physical health. Before initiatingany type of treatment modality,it is important to verify theclient’s health status. Behavioralhealth social work providersneed to know the date of theclient’s most recent health

exam. If the client has not hada physical exam in more than ayear, it is recommended that theclient be referred for an exam.In some instances, it isbeneficial for behavioral healthsocial work providers to providereferral sources commensuratewith the client’s income andneeds, should the client havelimited or no health insurancebenefits. A client’s health statusprovides a wealth of knowledgeabout mobility, availability, andother barriers to treatment.

Mental health/suicidal ideation.During clinical assessment, it isvital that clinicians identifypsychosis, any previous historyof suicidal ideas or gestures,and medication use (dosage,duration of use, compliance,benefits, or concerns). Inaddition, behavioral healthsocial work providers areencouraged to identify self-injurious behaviors (cutting,binging, or purging) thatsuggest elevated risk as aprelude to treatment. It is usefulto recognize any recenthospital admissions to inpatientpsychiatric units or outpatientmedical services (location,duration, interventions, and

TREATMENTMODALITIESPsychopharmacology,Therapy Only, orBoth, and Why?VIRGINIA HINES, PHD, LCSW

outcomes). If any of these issuesare present, it is necessary toassess the client’s mentalstability before beginning anytreatment intervention/modality. Identification ofmental instability prior tobeginning a new treatmentintervention allows behavioralhealth social work providers todemonstrate concern for clientsby making referrals to hospitalsor other needed services.

Substance use disorders.Social work providers areencouraged to inquire aboutactive substance use disordersby asking clients about the lastuse of drugs, frequency of use,duration of use, treatmentepisodes, completion oftreatment, and actions taken tomaintain abstinence. Clientsdiagnosed with mental illnessoften have or are at risk ofdeveloping a substance usedisorder. When mental illnessor physical illness occurssimultaneously with a substanceuse disorder, it is referred to ascomorbid or dual diagnosis(National Institute of Drug

Abuse, 2009). Clients areencouraged to report substanceuse disorders and avoid usingnonprescription drugs concurrentwith psychotropic medicationsto avoid continuing or worseningsymptoms. Some mental healthdisorders and substance usedisorders have similarsymptoms. Before a definitivemental health diagnosis can bemade, clients may requirehospitalization in a safeenvironment where symptomscan be identified and managedwith medications by a trainedpsychiatrist and treatment team.Clients prescribed psychotropicmedications should avoid usingnonprescription drugs owing tothe increased risk of self-harm.

Psychosocial issues. Clients facemany issues endemic to thecurrent financial crisis,including employment loss,housing loss, domestic issues,budgeting, adult childrenreturning home, homelessness,and child placement in the childwelfare system. When issuesarise that are outside of thesocial work provider’s scope of

practice, clients should bereferred to competent serviceproviders who are able to meetclients’ needs. Social workproviders are also encouragedto consult with colleagues andengage in continuingeducation.

Client readiness for treatment.Clients can provide insight intotheir readiness to develop atherapeutic alliance withclinicians by demonstratingwillingness to schedule sessionsand complying withappointment times. Otherindications of motivation fortreatment include contractingfor safety, signing all releases,adhering to payment schedules,rescheduling appointments in atimely manner in the event ofemergencies, communicatingeffectively regarding goals andprogress in therapy, andcompleting any homeworkassignments. Clients provideverbal and behavioral cuessuggestive of treatmentapproaches that might becongruent with their needs.

Previous treatment experiences.Insight into a client’sexperiences with and reactionsto previous treatmentapproaches can be gleanedduring the assessment period.Many clients are educatedconsumers and are Internetsavvy, so they may know abouttheir diagnosis and be willingto provide what medicationshave been most effective forthem. Social work providers areencouraged to gauge clientreports of previous experienceswhen determining futuretreatment approaches.

TREATMENT APPROACHESPHARMACOLOGY-ONLYAPPROACHOften clients are resistant toindividual therapy, grouptherapy, or pharmacologicalinterventions. The availability ofa wide range of psychotropicmedications creates a plethoraof opportunities for clients toreceive medications that areless toxic and have fewer sideeffects than thosepreviouslyavailable. New

psychotropic medicationsprovide multiple opportunitiesfor clients to work with theirphysicians to find the mosteffective medication(s) tocontrol unwanted symptoms andside effects (e.g., dry mouth,weight gain, delusions, andnightmares). Pharmacology-only interventions may beconsistent with the client’swishes but trigger lasting ortemporary side effects (Bolton,Sareen, & Reiss, 2006). Clientsseeking pharmacologicalinterventions should beeducated about these sideeffects so that they can make aninformed decision relative tothe risks and the benefits ofpharmacological interventions.

Special concerns. Children ages12 to 20 who are linked to thejuvenile justice (JJ) and childwelfare (CW) systems presentspecial concerns. Moses(2008) reported that users ofpsychotropic medication withinthese populations are moresusceptible to drug treatmentmisuse (antipsychotics, moodstabilizers, and multiple drugs).Drug treatment misuse is oftenattributed to the absence ofadvocates focused on the bestinterest of the child and limitedoversight. Furthermore, the JJand CW systems have fewerstaff, which may increase thelikelihood of coercive,excessive, or inappropriatetreatments. Other concernsinclude the tendency of AfricanAmerican and Latino youths tonot see the need formedications and to avoid usingthem, and their desire to workproblems out on their own(Leslie et al., 2003).

Challenges when usingpharmacology-only therapies.Pharmacology-onlyinterventions likely requireperiodic lab tests to verifymedication compliance andassess toxicity in the client’ssystem. Pharmacology-onlyinterventions require clients tobe responsible for obtainingtheir prescriptions in a timelymanner and reportingproblematic or unwantedeffects. Pharmacologyeffectiveness varies amongdiverse populations. Whatworks effectively in AfricanAmerican clients may beineffective in Asian populations.Clients are encouraged toeducate themselves aboutmedication side effects prior touse and to comply withmedication directions. Theyshould note and communicatetheir level of satisfaction withpsychotropic medications to theprescriber. Any unwantedeffects of medications should bepromptly reported to theprescriber.

Clients are encouraged to bepersistent with providers whentrying to find the bestmedication, as there are manypsychotropic medications. Theyshould also avoid discontinuingmedications without discussingit with their physicians, as somemedications may cause adversewithdrawal effects whendiscontinued abruptly (Potentialadverse effects, 2010). Otherbarriers to use of psychotropicmedications may include clientsforgetting to take medicationsand being prescribed multiplemedications. Hence,pharmacology-onlyinterventions are viabletreatment alternatives, but oftenrequire joint efforts of the client(or client’s representative),

prescriber, and behavioralhealth social work provider.Clients often report negativeside effects of medications totheir therapist. Clients may feelmore comfortable reportingundesirable side effects to theirbehavioral health social workprovider rather than theirprescriber. Therefore,behavioral health social workproviders often mediate forclients and facilitate qualitybehavioral health servicedelivery to clients.

THERAPY-ONLY APPROACH When clients report (1)aberrations with respect tomedication side effects and (2)stigma associated with takingpsychotropic medications,therapy-only interventions maybe in their best interests.However, many clients may notbe appropriate for therapy.Alternatives to therapy arerequisite when a client has ahistory of acting out in therapysettings or has a psychoticdisorder, which might inhibitthe client’s ability to participatein a session or create a dangerto self or others. The role of thesocial work provider alwaysencompasses educating clientsand directing them to the mostappropriate treatment modality.Other factors that can affecttreatment modalities employedinclude but are not limited tothe cost of the modality,availability of the modality, andtherapist availability andspecialization.

When there are no psychiatricsymptoms warrantingpsychotropic medication use,the client has been concernedabout the presenting issue for alimited time, and the issue is notsevere, therapy only might bethe best modality. For instance,

clients presenting for problemsolving or assistance withconcrete issues might requirebrief interventions.Motivational, problem-focused,and cognitive behavioraltherapies are considered brieftherapies. In contrast toproblem solving, clientspresenting with trauma issuesmay require exposure therapythat warrants protractedtherapy sessions, includingextensive assessment,education, cognitiverestructuring, development ofnew coping styles, limit setting,anger management, and safetyplanning. When clients requesttherapy, meet the timeconstraints for therapy, andhave prior experience withtherapy, they may be bestserved through therapeuticinterventions. Some of the morepopular therapeuticinterventions include cognitivebehavioral therapy, dialecticalbehavioral therapy, exposuretherapy, eye movementdesensitization, andreprocessing therapy.

Benefits of therapy. Therapy,whether provided individuallyor in group format, provides theopportunity for clients to obtaina diverse perspective withregard to problem identificationand resolution. Therapeuticgroup members likelyencapsulate myriad lifeexperiences, knowledge, andopinions that can enhancelearning and perspective forclients. Groups also fosteropportunities for reflectionthrough the reports of groupmembers, as well aspossibilities for socializationpost group. Of even greatersignificance is the opportunityfor normalization of an issuethat was experienced in

isolation to be re-experiencedin a way that makes itmanageable. Therapeuticindividual or group sessionscan be beneficial andrewarding for behavioral healthclients.

Challenges in the use oftherapy. In general, social workproviders are responsible forguiding individual and groupsessions. Often clients engagein testing or challengingboundaries established by thebehavioral health social workprovider or group facilitator.Before they begin group orindividual therapy sessions,clients need to be educated.Education should include theopportunity for clients to signcontracts and release ofinformation forms, and tounderstand group rules andprocesses that can beanticipated in group orindividual sessions. Therapyparticipants may haveidiosyncrasies that they want tohave acknowledged. They alsoneed to be permitted to expresstheir expectations for treatment.In short, some clients maybenefit more from individualsessions versus group sessionsor vice versa. Behavioral healthsocial work providers can usediagnosis to gauge how clientsmight be best served. Thebehavioral health social workprovider or facilitator inconjunction with the groupmembers reserves the right toask someone who does notcomply with the rules to leavethe session. Either clients orbehavioral health social workproviders determine whenclients have obtained maximumbenefit from treatment.

COMBINATION APPROACHClients may need to takepsychotropic medications whenexperiencing symptoms thatinhibit their functioning athome, work, or in socialsettings. However, oncesymptoms are stabilized, it isoften beneficial for clients toparticipate in therapy that willpermit them to receivefeedback, education, insight,nonthreatening confrontation,and an opportunity toexperience new ways oflearning, thinking, behaving,and socializing. Grouptherapies should not beexcluded as effective modalitiesfor clients.

SUMMARYSocial work providers areintrinsically involved withtreatment delivery. Theyadminister clinical services andmay participate as members ofteams that work in tandem inbehavioral health deliverysystems. Clients are likely toreport pharmacological issuesand other complications oftreatment interventions to theirsocial work providers. In turn,social work providers need toeducate clients about theirrights and the role of providers,and be instrumental inreporting pharmacologicalunder- or overuse whenapplicable. Behavioral healthand health encompasses theassessment, treatment, andevaluation of service provisionto clients presenting with co-occurring disorders. Duringassessment and interaction withclients, social work providersmust listen for vital informationthat they can use to gauge themost effective approach intreating clients.

Pharmacological treatmentsand best practice therapeuticinterventions can be used aloneor in combination to facilitatechange in client populations.Clients are encouraged toeducate themselves about thevarious therapies available tothem and to actively participatein the chosen intervention byreporting problems and benefitsthroughout treatment. Clientsincapable of informed consentrequire oversight by aninterested party in efforts topreempt over- or undertreatment.It is imperative that clientscommunicate with theirprescriber and other members oftheir treatment team with a goalof enhanced behavioral health.

Virginia A. Hines, PhD, LCSW, is areentry specialist employed with theVeterans Health Administration (VHA)of Southern Nevada. Dr. Hines’ 19-year employment history withVHA has been in the areas ofinpatient medicine, intensive care,psychiatry, long-term care, contractnursing home, addictions, womenveterans’ issues, and reentry.

REFERENCESBolton, J.M., Sareen, J., &

Reiss, J.P. (2006). Genitalanesthesia persisting for sixyears after sertralinediscontinuations. Journal ofSex & Marital Therapy,32(4), 327-330.

Howard, R.H. (2010). Potential adverse effects ofdiscontinuing psychotropicdrugs; Part 4:Benzodiazepine, glutamate,opioid, and stimulant drugs.Journal of PsychologicalNursing & Mental healthservices, 48(9), 11-14.

Leon, A.M., & Armantrout, E.(2007). Assessing familiesand other client systems incommunity-basedprogrammes: Development of the CALF. Child & FamilySocial Work, 12(2), 123-132.

Leslie, L., Weckerly, J.,Landsverk, J., Hough, R.L.,Hurlburt, M.S., & Wood, P.(2003). Racial/ethnicdifferences in the use ofpsychotropic medication inhigh-risk children andadolescents. Journal ofAmerican Academy of Child& Adolescent Psychiatry,42(12), 1433-1442.

National Institute of DrugAbuse. (2009). NIDAinfofacts: Comorbidity:Addiction and other mentaldisorders. Retrieved fromwww.drugabuse.gov/infofacts/comorbidity.html

Moses, T. (2008). Psychotropicmedication practices foryouth in systems of care.Journal of Child & FamilyStudies, 17(4), 567-581.

Clinical social workers interestedin learning more about treatinganorexia nervosa will find thisbook useful. It reflects anapplied approach to anorexianervosa utilizing the social workprofession’s general perspectiveof person in environment.Written by seasoned clinicalsocial worker Dr. Maria Baratta,the book views the disease andits treatment through anadditional lens, the feministsociobehavioral perspective.

Dr. Baratta examines theindividual and societal aspectsof the eating disorder. The bookbegins with an overview ofanorexia nervosa, includingdiagnostic features andcomorbid disorders accordingto the DSM-IV-TR. The text alsoexplores the historical

development of anorexianervosa, including a discussionof the cultural elements of thedisease (religion and class).Nonpsychiatric explanations arediscussed as well, providing thereader with multiple vantagepoints to evaluate the eatingdisorder and information toincorporate into clinical judgmentand therapeutic process.

Clinical social workers willappreciate the pragmatism withwhich therapeutic and treatmentmodels are addressed. Thetopics are covered in a structureintuitive to the therapeuticprocess, with the brevity oftenneeded in the practice setting.Case studies are included andprovide examples of the author’suse of clinical interventions andtheory. Guidelines for weight

management and self-care arethe final portion of the book,highlighting concrete andphilosophical shifts salient tohealthy eating. This informationserves as a readily accessiblereference for the practitioner.

Dr. Barrata acknowledges in thetext’s introduction that the focusis the female population. So, toensure cultural competence,practitioners interested inworking with men with anorexianervosa will need to seek outadditional information andresources on how the diseaserelates specifically to men. It isalso helpful to know that thefeminist exploration does notexplicitly account for a broadvariance of racial and ethnicminority women’s experiencewith anorexia nervosa or

eating disorders. Practitionersworking with racial and ethnicminority girls and women willalso need to seek out additionalinformation on how anorexianervosa affects these womenuniquely.

For more information aboutSkinny Revisited: RethinkingAnorexia Nervosa and ItsTreatment and other bookspublished by the NASW Press,please visitwww.naswpress.org.

Reviewed by Kamilah S. Omari,LLMSW, ACSW, senior practiceassociate, Professional DevelopmentDivision-National Association of SocialWorkers National Office, can becontacted at komari@naswdc.org.

BOOK REVIEW:Skinny Revisited: Rethinking Anorexia Nervosa and Its TreatmentAuthored by Maria Baratta

ISBN: 978-0-87101-407-8. 2011. Item #4078. 120 pages.

BOOK REVIEW BY KAMILAH S. OMARI, LLMSW, ACSW

750 FIRST STREET NE, SUITE 700WASHINGTON, DC 20002

For more information, visitSocialWorkers.org/Sections

Did You KnowThe U.S. Dept. of Human Services(HHS) Office of Civil Rights (OCR) is piloting a program to perform 150 audits of health care entities toassess compliance with HIPAAPrivacy and Security Rules andBreach Notification standards fromNovember 2011 to December 2012.

For more details visit:www.hhs.gov/ocr/privacy/hipaa/enforcement/audit/index.htmlwww.socialworkers.org/hipaa

Call for Social Work Practitioner Submissions

NASW invites current social work practitioners to submit brief articles for our specialty practice publications. Topics must be relevant to one or more of the following specialized areas:

For submission details and author guidelines, go toSocialWorkers.org/Sections. If you need more information, email sections@naswdc.org.

• Administration/Supervision• Aging• Alcohol, Tobacco, and

Other Drugs• Child Welfare• Children, Adolescents,

and Young Adults

• Health• Mental Health• Private Practice• School Social Work• Social and Economic

Justice & Peace• Social Work and the Courts