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Book Reviews   |    
Learning Disorders and Disorders of the Self in Children and Adolescents
Reviewed by Audrey R. Newell, M.D., M.S.
Psychiatric Services 2002; doi: 10.1176/appi.ps.53.7.908
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by Joseph Palombo; New York, W. W. Norton & Company, 2001, 332 pages, $32

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This book addresses an important topic—children with learning disorders or disorders of the self fill the offices of many mental health professionals.

The author notes that children with learning and behavior disorders evoke different kinds of responses from their parents, teachers, siblings, and classmates than other children do. These responses affect how the children develop socially, cognitively, and emotionally. The author describes the essential features of several types of disorders: dyslexia, attention-deficit hyperactivity disorder, executive function disorders, spatial cognition difficulties, nonverbal learning disabilities, and Asperger's disorder. He then describes the complex interaction between a disability and a child's environment, and how that shapes the child's developing sense of who he or she is and what he or she might become.

Children use their experiences to develop their identity and self-narratives. As children with learning disorders develop their identities, they ask questions such as "Why can't I read?" "Why are my parents always criticizing me?" and "Why don't I have any friends?" Good therapists can help children develop a rich and positive sense of self—a sense that includes their learning disorder but also includes many other elements.

This book is helpful in getting the reader to think about how children with learning and behavior disorders develop a sense of self. The author also presents some useful practical tips. For example, when conducting therapy with a child who has serious behavior problems, he helps the child overcome resistance to discussing his behaviors by calling the behaviors "experiments" and "focus[ing] on what could be learned from them." He presents applications of psychoanalytically oriented self psychology that will interest adherents of this approach.

Although the right questions are asked in this book, readers will still be left looking for answers. Most of the book is devoted to descriptions of the problems we know so well, rather than to practical solutions. Readers will still wonder, What can a parent do to help a child make friends? What extracurricular activities would be good for a child with spatial cognition difficulties? What should the school write into the individualized education plan for a child with an executive function disorder?

The numerous references to neuropsychological testing data may baffle readers who do not have an extensive background in this area. It would have been helpful for the author to have explained more fully just what these tests measure and how to apply the results during therapy with a child or a family.

Finally, the treatment of "Sam," a patient with executive function disorder, was singularly problematic. The author followed Sam from age 13 until his early twenties. He worked directly with Sam for a few years, but most of the time he provided guidance to Sam's mother. Despite a verbal IQ of 125 and good reading skills, Sam rarely did schoolwork, did no chores at home, and used drugs and alcohol heavily throughout the entire course of treatment. The author's main intervention strategy was to advise the parents to continue to provide emotional and financial support so as to maintain the parent-child relationship. By the time Sam was in his early twenties, he had finally passed his high school equivalency test. He had only once held a job, briefly, in his late teens, in a record store. He was using marijuana daily and visiting bars at night.

Since Sam's parents were able to afford any kind of treatment, readers will wonder why the author did not suggest long-term residential substance abuse treatment when it was clear that Sam had a serious problem in his early teens. In his late teens, Sam was arrested for possession of marijuana. The lawyer, prosecutor, and judge agreed that Sam would be released but did not impose any requirements for substance abuse treatment. Why were behavior modification techniques not tried? When reasonable target behaviors are selected, meaningful positive reinforcements given, and progress measured in small steps, kids take pleasure in their growing accomplishments. Medication can be helpful for some patients with executive function disorders; why was it never considered?

The author is clearly comfortable with psychoanalytically oriented self psychology. This is a beautiful form of therapy, and it produces wonderful results for some patients. I wish I could do it as well as the author can. However, all subspecialists need to know their limitations. The author should be able to tell the reader which patients do well with this form of therapy alone, when to call in consultants from other fields such as behavior modification, cognitive-behavioral therapy, substance abuse, and psychopharmacology, and what those specialists have to offer children and adolescents who need a multidisciplinary approach.

Dr. Newell is affiliated with the department of medical education at Oakwood Hospital in Dearborn, Michigan, and with the department of psychiatry at the University of Michigan in Ann Arbor.

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