Book Review

Do They Grow Out of It? Long-term outcomes of childhood disorders

N Engl J Med 1996; 335:2004-2005December 26, 1996

Article

Do They Grow Out of It? Long-term outcomes of childhood disorders
Edited by Lily Hechtman. 287 pp. Washington, D.C., American Psychiatric Press, 1996. $40. ISBN: 0-88048-703-8

For many years, mental health professionals who work with children have been asked by parents, “Will my child grow out of it?” Those of us who have been careful to base our responses on the literature have had to reply in a way that undoubtedly seemed ambiguous to parents, often sounding as though we really didn't know. Now, in this book, we have the data, at least as they exist today. Clearly, as the number of investigations in this area grows, we will have answers that allow better prediction. However, we can now say that a large proportion of children with emotional or behavioral problems do not grow out of them. The actual proportions of complete cure or remission vary with the disorder, being lowest in the more severe disorders, such as the pervasive developmental disorders, and highest in the more traditionally “neurotic” disorders. However, even in the case of anxiety disorders, the evidence suggests that many children and adolescents continue to have difficulties. We have known for several years that children with severe behavioral problems are likely to continue having difficulties in adolescence and adulthood, but it is helpful to have this information pulled together and analyzed with regard to the factors that may contribute to such poor outcomes.

The authors of the various sections of the book are clear in pointing out the limitations of the literature. These include the methodologic problems of the earlier studies, changing diagnostic criteria, the drawing of conclusions from clinical samples, and the problem of attrition in follow-up studies. Some of these issues are being addressed in recent and ongoing studies that will result in clearer answers. The question of treatment and its effects is also addressed, although in this area the literature remains limited and points to the critical need for more studies.

Coexisting conditions emerge as a confounder in many studies, but also as a very important variable that usually affects outcome in a negative direction. We have been aware for a number of years that in adults coexisting personality disorders affect the outcome of affective disorders. In this book coexisting conduct disorder and substance abuse in young people appear to have a similar negative effect.

The editor has wisely chosen to include not only disorders defined in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, but also important behavioral problems, such as suicide, which is a concern for the families affected and also for society, given the dramatic increase in suicide among youths over the past three decades. The follow-up studies indicate that a substantial number of children and adolescents are continuing to struggle with suicidal ideation. The author of this chapter also highlights some of the factors related to successful suicide attempts, such as male sex, having or having had a depressive disorder, and past suicidal behavior, especially serious attempts at suicide. The lack of effectiveness of most efforts at prevention presents important challenges for the specialists in the field.

A related area is that of speech and language disorders in children. Again, the evidence is that children with more severe disorders are less likely to grow out of them. The connection with psychiatric disorders and learning disabilities is reviewed, because both of these are related to or affected by a history of speech and language disorders.

In this review I am focusing on the most striking findings. What this book provides, however, is a wealth of detail about the various studies in each area, with attention to factors that may affect outcome. The authors of each chapter are acknowledged experts in their areas, having all contributed to follow-up studies of children and adolescents with emotional and behavioral disorders.

Although the book will be of greatest interest to mental health professionals, it may also be useful to primary care physicians who counsel families with affected children. It is a must read for all child and adolescent mental health professionals.

Susan J. Bradley, M.D.
University of Toronto, Toronto, ON M5S 1A1, Canada