From Child Sexual Abuse to Adult Sexual Risk Trauma

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our knowledge and understanding of pediatric psycho-                It would be a very useful and well-appreciated reference vol-
pharmacology.                                                       ume for anybody treating children and adolescents.
   The book is divided into four major sections. The first,                                                   RICHARD BALON, M.D.
Biological Bases of Pediatric Psychopharmacology, provides                                                           Detroit, Mich.
“a foundation of neurobiology upon which the rest of the
volume is built.” This section consists of three subsections—       From Child Sexual Abuse to Adult Sexual Risk: Trauma,
Developmental Principles of Neurobiology and Psychophar-            Revictimization, and Intervention, e d i t e d by Li n d a J .
macology, Genetic Principles, and Developmental Psychopa-           Koenig, Ph.D., Lynda S. Doll, Ph.D., Ann O’Leary, Ph.D., and
thology. The second section, Somatic Interventions, reviews         Willo Pequegnat, Ph.D. Washington, D.C., American Psycho-
psychotropic agents used in pediatric psychopharmacology            logical Association, 2004, 346 pp., $49.95.
as well as other somatic treatments, such as complementary
                                                                       From clinical forensic experience, I have found that indi-
and alternative medicine approaches, ECT, and transcranial
                                                                    viduals, especially females, who report sexual abuse as chil-
magnetic stimulation. The third section, Assessment and
                                                                    dren are at higher risk for rape and other sexual assaults as
Treatment, begins with general principles such as clinical as-
                                                                    adults. I have also found that most of the men whom I have
sessment, clinical instruments and scales, the psychology of
                                                                    examined who have been convicted of mass murder or as se-
prescribing, and combining pharmacotherapy and psycho-
                                                                    rial killers have a history of sexual abuse as children. Thus,
therapy. It continues with a focus on treatment of specific dis-    child sexual abuse is a most important factor in the psychiat-
orders and syndromes and discussions of special clinical pop-       ric history of patients who have been victimized and defen-
ulations such as substance-abusing youth, individuals with          dants who have been charged with violent crimes.
mental retardation, medically ill children and adolescents,            This book focuses not only on the clinical aspects of child
and preschoolers. The section closes with a focus on other ar-      sexual abuse but also on the research data supporting the
eas of clinical concern such as aggression, agitation, and          finding that individuals who have been abused as children are
elimination disorders. The last section, Epidemiological, Re-       at a higher risk for adult sexual assault or adult sexual behav-
search, and Methodological Considerations, reviews issues           ior that may lead to sexually transmitted diseases, especially
such as the methodology and design of clinical trials, regula-      HIV.
tory issues, ethical issues in research, and international per-        It is no surprise to learn that three of the editors are with the
spectives. An appendix titled Pediatric Psychopharmacology          Centers for Disease Control and that two of them specialize in
at a Glance provides a summary table of medications used in         research on HIV/AIDS. The fourth editor is with the Center for
pediatric psychopharmacology.                                       Mental Health Research on AIDS at the National Institute of
                                                                    Mental Health.
   The general approach to treating children and adolescents
                                                                       The book is divided into four sections. The first is an intro-
proposed in this book is developmental and integrative,
                                                                    duction asking the question about the link between child sex-
which the editors point out is the legacy of the late Donald
                                                                    ual abuse and adult sexual risk. This lays the foundation for
Cohen, to whom the book is dedicated. Psychopharmacology
                                                                    the rest of the text. Section 2 develops the clinical aspects of
is not seen in vacuum but as “one (albeit a powerful one)           child sexual abuse and adult sexual risk, including relation-
among the many tools available for the treatment of psychiat-       ships, revictimization, and HIV. The authors discuss the im-
rically ill children and adolescents.” The book is well ar-         plications for boys as well as girls who have been sexually
ranged, well organized, and easy to read (with the exception        abused.
of the first section, which most of the clinicians who are a few       Section 3 discusses the theoretical bases for adult risk in
years out of training may have to read with a lot of effort).       revictimization, including cognitive, social, and behavioral
   Any deficits? As with any volume of this scope, there are        mediators. For example, several chapters include attitudinal
some. I understand that any book will be at least 2–3 years be-     paths for the link between childhood trauma and adult HIV
hind the current state of knowledge. Nevertheless, I missed         risk and the link between child sexual abuse and risky sexual
some discussion and warning regarding the use of atypical           behavior. One chapter discusses the role of dissociative ten-
antipsychotics and the possible development of diabetes             dencies, a controversial area in the field of sexual trauma and
mellitus. This is an important and troublesome issue in this        memory recovery. The important issue appears to be the link
population, and the first reports appeared almost 5 years ago.      between victims of child sexual abuse who later become re-
                                                                    victimized as adults.
For obvious reasons, the latest controversy regarding selective
                                                                       The final section discusses interventions to promote health-
serotonin reuptake inhibitors and suicidality could not be ad-
                                                                    ier sexual outcomes among the survivors of child sexual abuse.
dressed either. There are occasional misquotes. I also think
                                                                    The hopeful notion of the book is that it does not have to be in-
that the readers would welcome some specific guidelines or a
                                                                    evitable that people who were sexually abused as children will
brief outline for the treatment of each disorder at the end of      be victimized again as adults. The chapters in this section dis-
each chapter on a specific disorder. Thus, my initial overen-       cuss interventions to prevent further abuse, risk-reduction ap-
thusiasm was a bit tempered at the end of the day. Neverthe-        proaches, group therapy for victims of child sexual abuse, and
less, these small issues would be easily correctable in another     effective risk-reduction programs.
edition and take away nothing from the usefulness and com-             Most of the authors of the chapters are psychologists and
prehensiveness of this excellent book. It is a well-edited, well-   researchers. David Spiegel is the only M.D., and his work with
referenced, fairly user-friendly (in spite of its weight!), ency-   hypnosis and memory retrieval is well-known. The book is
clopedic volume that will be appreciated by many in the field.      well written, well edited, and well referenced. For the re-

1142            http://ajp.psychiatryonline.org                                                    Am J Psychiatry 161:6, June 2004
                                                                                                                         BOOK FORUM


searcher, the current notions of the effect of childhood sexual       may lessen tensions and trepidations abounding at the inter-
abuse on adults are evident, but the issues raised suggest that       face of law and clinical practice. For clinicians and therapists
further research is needed. For the clinician, the book is espe-      seeking relief from law-related anxiety, this text may well
cially helpful in understanding the motivation, behavior, and         prove to be an antidote.
attitude of victims of child sexual abuse who come for help              Barsky and Gould adopt an absorbingly didactic approach
with psychological problems as adults. Only by understand-            to elucidating the vastly complex corpus of the law. Their art-
ing the linkages between child sexual abuse and risky adult           ful examination is both insightful and practical. The glossary
sexual behavior can therapists institute intervention and risk        of briefly annotated law-related terms, the appendixes con-
prevention.                                                           sisting of samples of instructive documents, and the many
   Because of the importance of the effect of child sexual            references are useful.
abuse on victims and on others who may be victimized by                  The range of topics is necessarily delimited. The volume fo-
men who have been abused as children, we need to study this           cuses on practical strategies, potentially quite helpful to the
process more intensely and try to prevent the damage that oc-         clinician professionally enmeshed in the adversarial web of
curs later as a result of the trauma to these children. It is in-     the law. Particularly, the many interlacing strands of law per-
deed a monumental challenge, especially in a free society.            tinent to the role of a witness in the legal context are assidu-
The authors indicate that they wrote this book following              ously unraveled. Selected topics include 1) clinician-witness
heated discussions among themselves and their colleagues              preparation for legal proceedings, 2) the core mechanics of a
with the intent of preventing further childhood sexual abuse          legal hearing, 3) judicious maintenance of clinical records
as much as possible and protecting future generations of chil-        that potentially may become embroiled in litigious circum-
dren. It is not only a noble goal but a necessary one that clini-     stances, 4) the prospective role of clinicians in law-rooted al-
cians who understand the process and the linkages can help            ternative forums to adjudication, 5) enthralling commentary
achieve. It is also essential for researchers to continue their ef-   regarding expert-witness-related topics, 6) a terse overview of
forts to shed more light on this murky area. This book is an          documentary evidence, and 7) challenges and concerns for
important beginning of that process. It gives the foundation          the clinician ensnared in a malpractice action.
of knowledge and experience that we have today based on                  Prospective readers should understand that fully decipher-
past experience, leading to future progress.                          ing the innumerable strands forming the fabric of the law is
                                       ROBERT L. SADOFF, M.D.         likely a Sisyphean task. Attendant difficulties are com-
                                             Philadelphia, Pa.        pounded by the ever-shifting nature of the law. Moreover, this
                                                                      volume, although written superbly, is plainly not a suitable
                                                                      surrogate for the finely honed counsel of legal professionals,
                                                                      applied with precision to individual, real-life cases.
                 FORENSIC PSYCHIATRY                                     In choosing to write about law for nonlawyers, Barsky and
                                                                      Gould have taken on the daunting task of safely traversing a
                                                                      course between the Scylla of writing in a too legally compli-
Clinicians in Court: A Guide to Subpoenas, Depositions,               cated manner for nonlawyer readers and the Charybdis of
Testifying, and Everything Else You Need to Know,                     overdiluting the material presented to the point of unwit-
by Allan E. Barsky, J.D., M.S.W., Ph.D., and Jonathan W. Gould,       tingly engendering a literary brew that is misleading in its
Ph.D. New York, Guilford Publications, 2002, 256 pp., $36.00;         simplicity. Happily, Barsky and Gould have brewed an excel-
$24.00 (paper).                                                       lent witness-preparation resource that should prove to be
                                                                      quite intellectually nourishing to a legion of readers who may
   Nonlawyer clinicians and therapists ensconced in any of            choose to imbibe its edifying contents, including mental
the variant substrata that, broadly and collectively, constitute      health and human services professionals as well as clinicians
medicine and human services may be tempted to look warily             and therapists drawn from disparate professional back-
askance at the legal system as an inscrutable and potentially         grounds but potentially tethered to the law.
disquieting realm. Indeed, whereas clinicians are accustomed
                                                                                                              LEO UZYCH, J.D., M.P.H.
to working therapeutically and collaboratively, the bedrock of
                                                                                                                    Wallingford, Pa.
the legal infrastructure is unabashedly adversarial in nature.
In this vein, the masterful book Clinicians in Court should be
a great practical boon to nonlawyers who desire some basic            Principles and Practice of Forensic Psychiatry, 2nd
understanding of the unfamiliar province of law.                      ed., edited by Richard Rosner. London, Arnold, 2003, 906 pp.,
   This well-sculpted vade mecum for clinicians and thera-            $149.50.
pists has been crafted, in a lucid and highly practical fashion,
by two authors having distinguished academic and profes-                 This is a weighty volume literally and figuratively (it weighs
sional pedigrees encompassing law, social work, and psychol-          more than 5 lb). When the first edition appeared in 1994, it
ogy. Guided by the overarching concern of providing the               paralleled the belated recognition of forensic psychiatry as a
treating clinician or therapist with some at-least-rudimentary        psychiatric subspecialty (1). When the American Board of Fo-
measure of understanding of the legal system, Barsky and              rensic Psychiatry (now disbanded) was formed in the 1970s to
Gould have succeeded in providing a sound road map, well-             give recognition to the field, the American Board of Psychiatry
designed to guide clinicians obliged to traverse the vexing           and Neurology did not give its imprimatur by way of recogni-
labyrinth of law. By helpfully demystifying some of the tools         tion and examination. The “Added Qualification in Forensic
and armaments of law and litigation, the volume’s contents            Psychiatry” was not made available until 1994.

Am J Psychiatry 161:6, June 2004                                                       http://ajp.psychiatryonline.org         1143