BOOK REVIEWS

The Child With Special Needs: Encouraging Intellectualand Emotional Growth. By Stanley I Greenspan and SerenaWieder, with Robin Simons. Reading, .MA: Perseus Books, 1998,496pp., $26.00 (hardcover).

We know how devastating it is when we first tell parentsthat we believe their young child has a developmental disorderor other disability. Regardless of the words we use, parentscannot help but feel a great sense of loss. They may feel con­fused about the implications of what they have heard; theymay also feel frightened and overwhelmed, angry and guilty.These are of course normal reactions, but this book addresses .itself to the most dangerous response a caregiver may have­hopelessness and resignation.

The authors' premise is simple. Some children with specialneeds (defined broadly to include developmental disorderssuch as autism and pervasive developmental disorders, mentalretardation, language and speech problems, cerebral palsy,attention deficit disorders, genetic syndromes, and other phys­ical challenges) do better than others. As experience can impactbrain development, the most helpful intervention will identifyeach child's specific strengths and ~eaknesses and then system­atically guide the child through the development of basic func­tional skills. In this context, the authors believe that DSMdiagnosis, with its emphasis on grouping by pathology, is oftenmisleading. Instead, they focus on a functional assessment ofeach child's biological challenges and strengths organizedaround differences in sensory reactivity, cognitive and emo­tional processing, motor tone, and planning. Next, the child'smastery of what the authors define as the 6 functional mile­stones (emotional skills) is facilitated by intensive interactioncalled "floor time." While other professionals will work withthe child, this intervention requires that the parents are trainedto use these techniques in multiple daily floor time sessions.

The book is divided into 3 sections. Part 1 introduces thephilosophy of this program and explains how parents canobserve their child's biologically determined strengths andchallenges, the child's interactive patterns, and their own fam­ily's interactive patterns and the way that these may impact thechild with special needs. Here the authors emphasize the keyrole that emotion plays in learning. Emotion (affect) is whatallows the mind to identify which aspects of experience areimportant and meaningful. The ability to connect this emo­tional information to perceptions, then behavior, and ulti­mately to words is identified as the critical task for all children,but especially for children with autistic problems, who theauthors see as having a core deficit in this capacity. An appre-

]. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 38:8, AUGUST 1999

Assistant Editor: Dean X Parmelee, MD.

ciation of the importance of emotion informs the view thatearly developmental milestones are achieved through emo­tional interactions. In this way children learn to balance theirinterest in the world with the ability to self-regulate; they learnto pay attention to their parents and then to respond to themwith gestures. This leads to increasingly complex communica­tion between caregivers and children and to the developmentof imaginative and creative play with things, ideas, and words.The authors argue that while typical children often masterthese skills easily, children with special needs will need help.

The second part of the book details the therapeutic inter­vention between caregivers and child that is defined as floortime. The twin principles that are emphasized here are thatwhen engaged in this kind of play time with their children,parents must both capture the child's interest and encourage in­teraction. More specific guidelines are presented, and detailedexamples demonstrate how to work with children to helpthem develop the emotional skills described above. Here, as inthe rest of the book, clinical examples are used effectively todemonstrate not only specific techniques but more impor­tantly the entire process of working this way with children;the inevitable frustrations are noted, as are the ways in whichinteractions can be subsequently adapted as the child and par­ents encounter both difficulties and success. Some recommen­dations for applying this model to organize the child's treatmentteam and school interventions are touched on in the third andlast section of the book. In this section the focus is on howthese interventions would ideally work, with relatively lessfocus on the real difficulties that parents often have in findingintegrated systems of care.

This, I think, is perhaps the only major shortcoming of thisbook: that it assumes accurate diagnosis; a detailed assessmentof sensory and processing abilities; a team coordinator with anappreciation of early emotional and developmental skills; atherapist with patience and experience in the techniques offloor time; access to regular physical, occupational, and speechtherapy; and motivated and capable parents with enoughfinancial, emotional, and time resources to commit to alengthy and intensive treatment. While these resources may beideal, they are frequently not readily available, and there is notenough emphasis on how families may go about finding them.Similarly, although this book purports to be intended for bothparents and professionals, it gives little specific attention tohow therapists, educators, psychologists, and psychiatristsmight best integrate this approach with their existing skillsand resources.

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BOOK REVIEWS

Still, this book is an important one for both families of chil­dren with special needs and the professionals who work withthese children. Its emphasis on intervention, on the active roleof the parent, and on the need for attunement to the emo­tional development of the child motivates us to reexamine ourtypical reactions of hopelessness and resignation when facedwith a child with a severe developmental disability. Traineeswho read this book will be encouraged that there are real skillsthey can impart to the families of these children, and profes­sionals who have long worked with children with specialneeds and their parents will benefit from the detailed clinicalexamples and the fresh theoretical perspectives so well pre­sented here.

Shannon S. Croft, M.D.Assistant Professor

Sandra Sexson, M.D.Chief, Child and Adolescent Psychiatry

Department of Psychiatry and Behavioral SciencesEmory University School of Medicine, Atlanta

Cutting: Understanding and Overcoming Self-Mutilation.By Steven Levenkron. New York: WW Norton & Company,Inc., 1998,269pp., $25.00 (hardcover).

For most people, the idea of using self-mutilation to copewith painful emotions seems illogical at best. Cutting waswritten by a therapist who has treated many patients who self­mutilate. The author's goal is to help readers develop someunderstanding of this unusual symptom. His target audienceincludes people who discover that someone close to them usesself-mutilation, people who are horrified or curious about thebehavior (including therapists), and people who want tobetter understand their own cutting behavior. The book iswritten from his own practice; it is not a review of the litera­ture. It also is not a treatment manual, although he does giveexamples of techniques that he believes have been useful.

Throughout the book, the author offers vignettes to helpthe reader understand why people may cut themselves.During the first 3 chapters, he explores some ways that hispatients have described experiencing self-mutilation. Onepatient, Annika, reported that she experienced cutting as "aninjection of Novocaine" (p. 27). Another patient, Juanita, isquoted as saying, "It's never about liking the pain. If I likedthe pain, then it wouldn't help. I hate it. That's why it helps"(p. 38). These chapters offer insight for readers into whatsome people gain from cutting. The examples and discussionstry to reframe cutting as a solution to a difficult problem,albeit one with long-term negative consequences.

The author comes closest to revealing his theoretical perspec­tive in chapter 5, "HowThe Disorder Takes Shape." He appears

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to borrow from a number of theoretical frameworks but doesnot offer any specific psychodynamic, cognitive, or behavioraltheory as the basis for his interpretations. His clinical examplesand explanations offer the reader a possible understanding ofthis bizarre behavior in a way that seems reasonable, whether ornot his explanation is correct. He appears to incorporate learn­ing theory in some cases and a more psychodynamic approachin others. For example, he describes a cycle in which peoplelearn that the tactile and visual experience of cutting can neu­tralize feelings of rage, self-hatred, and fear of personality dis­integration. Once someone learns that cutting works, he or shemay begin to use the technique in anticipation of negative feel­ings. A more psychodynamic explanation appears in a vignetteabout Tracey (pp. 73-76), who respected her father and worriedabout the ill effects his drinking was having on his healthdespite his frequent beatings of her with a belt buckle. One day,when she was feeling disconnected from her father, Tracey cutherself with the belt buckle. Levenkron explains this behaviorby writing, "Tracey had fused attachment with pain" (p. 75).His description and interpretation of self-mutilating behavioroffer the reader some ways to make sense of it, which may ena­ble the reader to become more empathetic and less judgmentaltoward people who cut themselves. It does not, however, offerthe clinician a comprehensive framework within which this andother behaviors might be understood.

Although the DSM considers self-mutilation as a symptomthat can occur in a variety of psychiatric illnesses, Levenkronpresents self-mutilation as a disorder. If a patient with anobvious psychiatric illness occasionally curs, he refers to thecutting as a feature of that patient's illness. However, hedefines self-mutilation as a distinct disorder when it becomesthe most prominent symptom. When he uses the term "dualdiagnosis," he refers to people with self-mutilation and anotherdisorder such as borderline personality disorder, depression, oran eating disorder. He does not mention that his definitionsdiffer from conventional psychiatry. While there may be somebenefits to using Levenkron's definitions, he does not offer anyarguments to support such a change. These new definitionsmay confuse patients who are seeking treatment from clini­cians who use conventional definitions.

A variety of reactions toward cutting is the topic of chapter 4,"The Reactions of Others." The author notes that the publicofren describes CUtting as disgusting, despite the frequent expo­sure to violence in the media. Parents may be caught up in theirown guilt; they may perceive their child's cutting as an attackagainst them and may say things such as "How ungrateful ofyou!" Mental health professionals may react with "fear, anger,disgust, and revulsion" (p. 60). As I carried this book around thehospital, I encountered many similar reactions from child psy­chiatrists and pediatricians. I heard comments such as "thosepeople are really sick" and ''I'm glad somebody wants to treat

]. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 38:8, AUGUST 1999