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Book Review   |    
Matthew Kleban
Psychiatric Services 2007; doi: 10.1176/appi.ps.58.5.719
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edited by Theodore A. Petti, M.D., M.P.H., and Carlos Salguero, M.D., M.P.H.; Arlington, Virginia, American Psychiatric Publishing, Inc., 2006, 320 pages, $34.95

Dr. Kleban is a staff psychiatrist in the Community Day Hospital, Bronx Children's Psychiatric Center, New York City.

Community child and adolescent psychiatry is rife with challenges. Not only are there innumerable agencies and services, each having unique characteristics and cultures, but one's role within any given agency is often not clearly defined. Administrative and clinical responsibilities may overlap, and professional standards may yield to the financial restrictions of the public sector. Whether providing direct services or a consultation, it is imperative for the clinician to have a clear understanding of the system in which he or she operates. With these general principles in mind, Theodore Petti and Carlos Salguero have assembled a multiauthored text to enable clinicians to navigate these complexities.

The book is divided into four sections. After an introductory section, the book moves from principles to practice, offering a series of chapters that describe members of an interdisciplinary team. These appropriately credentialed individuals write the corresponding chapters. After outlining their educational background, the authors of these chapters provide information ranging from their theoretical perspectives to their more quotidian functions. As one author advises, the role of the social worker is to "support the parent's caregiving role, not supplant it." Another author cautions psychiatrists about signing documents that are prepared by members of other disciplines.

The third section discusses the many types of agencies serving this population: community mental health centers, schools, school-based health centers, foster care programs, child care settings, day treatment centers, chemical dependence programs, residential care programs, and advocacy groups. Some chapters describe administrative and organizational structures, including configurations of governance from director to frontline staff. Other chapters describe operational nuts and bolts, such as developing services and assessing outcomes. This section also includes historical and political background, pertinent legal and ethical issues, and tips on maintaining financial viability in the current mental health care environment. There is some thoughtful emphasis on the need to avoid burnout.

The chapter on schools provides a thorough discussion on consultation issues. It addresses how to gain access to local schools and maintain relations with educational staff, and it revisits the pervasive issue of role confusion. As one author articulates, "the goal of the consultative relationship should be to increase the school's autonomy in managing mental health problems and not to increase the school's dependency."

Although the book is largely focused on organizational matters, it includes some useful clinical pearls. In the challenging milieu of day treatment, flexibility is stressed. In lieu of traditional individual therapy, observing a child's interactions and implementation of coping strategies in the various group settings may prove to be more illuminating. The chapter on foster care highlights the clinician's need to balance the foster child's attachment difficulties with the foster parents' countertransference-like reactions toward the child.

The final section delineates innovative programs and future trends. For instance, it describes how Virginia and Illinois have dealt with the closing of inpatient state-operated facilities, namely by establishing more community-based treatments and shifting care to the private sector. Promising advances include the proliferation of wraparound services and multisystemic therapy, as well as the application of ongoing technological improvements.

One could argue that although the title implies a target audience of clinicians already identified as part of the community sector, the true beneficiaries include all mental health professionals working with children and adolescents. Another limitation is that, as with most multiauthored books, there is some inevitable redundancy. Perhaps a few of the chapters are overly theoretical, appealing mainly to those who, like the editors, have backgrounds in public health. Although there is one chapter broadly discussing forensic issues, there is no mention of the juvenile justice system, a notable omission given how closely linked these systems often are. For the most part, however, this book succeeds in providing concise, eminently readable, and clinically useful information about working with children in these various community settings.

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