Primary Prevention of Mental, Neurological and Psychosocial Disorders JM Bartlett Primary Prevention of Mental, Neurological and Psychosocial Disorders World Health Organization 110pp £22 924-1545-16-X 924154516X.

This book offers practical Suggestions for the primary prevention of several mental, neurological and psychosocial disorders.

The book consists of a series of documents prepared by the World Health Organization in response to a call for detailed guidelines on the primary prevention of certain forms of mental or neurological disorder.It is mainly aimed at medical and other policy makers and professionals.The groups of disorders considered were mental retardation, epilepsy, suicide, and burn-out in health professionals.The subgroups selected to represent the broad group of mental retardation comprised Down syndrome, iodine deficiency, fetal alcohol syndrome, and phenylketonuria.These apparently disparate groups and subgroups were chosen because of their importance, and also to serve as a model for interventions which might prevent other mental or neurological disorders.
Perhaps because of the wide-ranging terms of reference, and the many different types of professionals to whom the book is aimed, the scientific level of the chapters varies.The strongest sections are those describing the nature and effectiveness of possible preventive measures for the conditions chosen, particularly the chapter on principles of primary prevention.The complexity of causation of most disorders is now better understood, and thus this term is used less now than it used to be.However, its message remains clear.In the words of the first chapter of this book it aims to 'intercept causes before they affect people, and [causes] should be differentiated not only from treatment and rehabilitation, but also from health promotion.' Within the same sociocultural context, different conditions may share the same predisposing characteristics.This means that relatively simple and inexpensive measures may have wider benefits than those specifically targeted, providing that account is taken of individual behaviour.The best examples of these principles are in the chapter on suicide.The recommended primary preventive actions include legislative as well as medical measures.They comprise the identification and treatment of depression, restriction of access to guns, detoxification of gas and car emissions, control of availability of toxic substances and medicines, 'deglamourizing' media reports of suicide, and erecting barriers to discourage jumping from high places.
The section on iodine deficiency is outstanding.This is among the most common causes of mental retardation worldwide and, at least in theory, is probably one of the easiest to prevent.The section includes a clear account of its effects, prevalence, methods of prevention and treatment, and their cost.It seems that many programmes to introduce iodine supplementation measures have failed because the need for educating the target groups, or involving local politicians or health workers has been neglected.Those in the salt industry also need to be involved, and whatever approach is used has to be adapted to local circumstances.
The inclusion of a chapter on 'staff burn-out' in mental health workers, including family members is initially surprising, but it is clearly important.The recommendations for preventive action, if not original, are sensible and helpful.These include the need for participation in decisions, support groups, more part-time employment, and training caregivers in time management and relaxation techniques.
For obvious reasons the chapter on epilepsy focuses on causes which are known to be preventable, but this gives a slightly unusual slant to this problem, with febrile convulsions and other infective causes given a high profile.Preventable causes include cysticercosis in many parts of the world, malaria as a cause of childhood fits, and head injury, particularly due to traffic accidents.However, I have doubts about the appropriateness of laying so much emphasis on febrile convulsions in this chapter without giving any clear picture of their short-and long-term consequences, compared with other forms of epilepsy.
Other less satisfactory sections include one on Down syndrome, which unfortunately refers to a drop in incidence due to the decreasing proportion of births to elderly mothers, a trend which has now been reversed in the United Kingdom and several other countries.Also unproven are the observations that risk is higher than normal in mothers below 16 years of age or where the father is 50 years of age or more, or that in as many as 25% the extra chromosome is paternal in origin.
In summary, this readable (but rather expensive) short book lays out clear possibilities for primary prevention which exist for the important conditions described.It spells out the necessity of involving those outside the health sector in devising and implementing preventive policies, and stresses the need to allow for the cultural and behavioural context in which these disorders occur, as well as having the knowledge of the pathology and causes of the specific disorders.For readers of this journal it can be recommended as providing a balance to the more familiar medical model of prevention.

Eva Alberman
ADHD in Adulthood: A Guide to Current Theory, Diagnosis, and Treatment By Margaret Weiss, Lily Trokenberg Hechtman, Gabrielle Weiss Baltimore and London: The Johns Hopkins University Press, 1999, pp 357, £41.50 hardcover ISBN 0-8018-6141-1 The adult form of attention-deficit-hyperactivity disorder (ADHD) is now recognized as an 'official' diagnosis in the United States, with the diagnostic criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV), published by the American Psychiatric Association.American clinicians have generally accepted the validity of this diagnosis, and it is not unusual for the diagnostic assessment of a child with ADHD to reveal that his father also has had enduring symptoms of inattention, distractibility, impulsivity, and disorganization, but has never been evaluated or treated for ADHD.
The authors of this volume, drawing on their pioneering Canadian long-term follow-up study of children with ADHD into adulthood, have written a comprehensive and lucid account of adult ADHD and its impact on self-esteem, educational achievement, work, and family.Possible etiologies, assessment tools, and comorbidities with other disorders are thoroughly described.Regarding the current controversy about whether any significant comorbidity occurs between ADHD and bipolar illness, they sensibly note that 'both ADHD and bipolar disorder are well-validated disorders that are not typically difficult to differentiate, and also not typically found together' (p 79).
The chapter on environmental restructuring gives practical advice about life adaptations to ADHD, including measures which will assist school and work performance.The reviews of psychological and pharmacological therapies are generally well-balanced and reflect contemporary research.However, the recommended dosages of methylphenidate (Ritalin), up to a maximum of 100 mg or 1 mg/kg/day, and dextroamphetamine (Dexedrine), up to a maximum of 50 mg or 0.5 mg/kg/day appear to be excessive for clinical practice with adults, especially given the risks of abuse.The personal statements and family vignettes in the chapter on living with ADHD vividly detail the obstacles that ADHD imposes on everyday life, but also remind us that the high energy level of persons with ADHD, when combined with good and effective treatment, can lead to successful outcomes.
ADHD in Adulthood is written for a wide audience, including family physicians, neurologists, psychiatrists, psychologists, social workers, and occupational therapists.The originally differing views of childhood ADHD among clinicians in North America, the United Kingdom, and the European continent have become more reconciled over time.It will be interesting to note whether the acceptance of adult ADHD follows a similar path.The first edition of Peripheral Neuropathy in Childhood was a much-needed contribution to the literature on this relatively rare, but important, group of conditions.In the past 9 years, there has been an explosion in the understanding of the molecular genetics and pathophysiology of the disorders affecting the peripheral nervous system.Ouvrier and his colleagues have risen to the challenge of up-dating their original text in a splendidly thorough manner.The result is a reliable and informative source of help for the child neurologist confronted by a condition which either primarily affects the peripheral nerves, or could be an abnormal response to infection, or is but one aspect of a more generalized disorder.

Mac Keith Press Publication
Advances in molecular biology are placed, firstly, in the chapter on historical perspectives, giving them a context in time which is, perhaps, predictive.They are further expanded throughout all considerations of hereditary disorders.Information on the peroneal muscular atrophy syndrome is particularly well endowed with references to recent understanding of clinical variants related to specific gene alterations.When Tooth described a peroneal type of progressive muscular atrophy in 1886, it is inconceivable that he would have anticipated that multiple distinct variants would be identified in the next 110 years.The present authors describe the seven main types of hereditary motor and sensory neuropathy (HMSN) with reference to clinical, neurophysiological, and genetic findings.They highlight the problems of making diagnoses of these conditions in early childhood, when the clinical pictures are far from being fully developed.Specific associations with optic atrophy and deafness, X-linked forms of HMSN, and other less common accompanying features are considered.One strength of this chapter on HMSN is the information on age at onset, which gives the reader a perspective on which of this group of disorders might be encountered in early childhood.
In the section of the Guillain-Barré syndrome, the parts on the clinical features and pathogenesis have been revised considerably, with particular reference to the recent appreciation of the role of campylobacter infections.There are additions to the chapter on chronic inflammatory demyelinating polyneuropathy in relation to preceding infections; clinical features; ancillary investigations; pathogenesis, where genetic factors, humeral immune mechanisms, and cellular immunity are considered; differential diagnosis; and treatment.There are comments on chronic relapsing axonal neuropathy.Peripheral nerve disorders which occur as part of infectious disease, for example, facial palsy in Lyme disease, rabies, and leprosy are reviewed in a chapter on miscellaneous neuropathies.Neuropathies in metabolic and degenerative disorders, those associated with toxins and those which occur as part of systemic diseases are given attention.Many useful tables and illustrative case reports enhance the text.There are chapters on ataxic neuropathies, sensory neuropathies, hereditary neuropathy with liability to pressure palsies, and focal lesions of the peripheral nerves.
Details of the investigation of a peripheral neuropathy are expanded.Helpful tables relate to the aetiological possibilities and the clinical types.The importance of considering whether the condition is symptomatic of a more generalized disorder is emphasized.Useful normal values for nerve conduction velocities at different ages are given.Undoubtedly, this is a book for the practising clinician.For most conditions described, the section starts with a list of the cardinal features.There are well over a thousand references, which in this edition are grouped together at the end of the text.No paediatric neurologist should be without a personal copy.

Sheila J Wallace
Book Reviews 71