Abstract
This reviewer has upset some colleagues in recent years by arguing that the patient assessment process should be concluded in under two hours, with a diagnosis and formulation made and an initial individualised service plan agreed. This is consistent with my UK experience. In the past, Victorian teaching has used a four session assessment and feedback format and was influenced by North American practice. An open trial of two teaching models is now underway, attempting to better understand the strengths and weaknesses of traditional and modern semi-structured approaches. It was interesting to review this book against that background.
The book aims to present a systemic model for child and family assessment in child and adolescent mental health. The first part of the book outlines the theoretical framework used and reconciles issues of individual psychological development with the process of human socialisation in families. It draws upon attachment theory to explain how individual psychological development is influenced by the relationship patterns experienced in the family. The author justifies contemporary multi-axial classifications of individual psychopathology for the unconverted, and summarises major models of psychotherapy and behaviour change with individuals and families. Three other models of family assessment are discussed, from the London Family Studies group (Family Task Interview), the McMaster group (Family Assessment Device) and the Timber-lawn group (Beavers Interactional Scale). The author then offers several principles for clinical family assessment as an introduction to his own approach which evolved between 1983 and 1993. The framework of the Darlington Family Assessment Scale (DFAS) is then described in part three.
The DFAS has four dimensions of child's health and developmental status, parent-centred problems, parent-child interactions (parenting style) and whole family functioning. The author provides examples of the relationship between the severity of family developmental deficits and the difficulties encountered in treatment of the presenting problem. He describes the process of engagement with family members, establishing working alliances and defining the position of the patient in relation to the presenting problem. This owes a lot to the text The Tactics of Change: Doing Therapy Briefly by Fisch, Weakland and Segal [1], which introduced the metaphors of ‘customers’ and ‘bystanders’, that were further developed by Berg and others. It also provides tips for engaging family members, for managing issues of individual confidentiality, and for avoiding potential pitfalls that lie in wait for the inexperienced family therapist. Chapter seven suggests general guidelines for the interviewer's behaviour and presents a ‘script’ for the interviewer, which takes the assessment through the several stages of the DFAS. The Darlington Family Interview Schedule and the Darlington Family Rating Scale are then finally revealed.
In practice, the DFAS is used in conjunction with other assessment instruments, and the entire package is completed in two clinic visits. Studies conducted in the early 1990s showed that it differentiated dysfunctional families, clarified differences in view between family members and helped in evaluating outcome. It also proved time consuming to administer, and its breadth meant that much of the content was irrelevant for some families. The DFAS is currently used more flexibly. At the end of this chapter is a section on communicating with children and on several child-centred assessment tools, which are each discussed. Chapter nine attempts to show how the data is integrated and used to design an appropriate method of intervention. I was surprised here to see no mention of Nurcombe's goal-orientated treatment planning, as this would have enhanced the general approach described. The author recommends providing clients with written reports, which I too have come to believe is good practice. The book concludes with an outline of how the DFAS may be used in training, gives some evidence for its effectiveness and proposes clinical guidelines for child and family assessment in un-screened populations presenting to child and adolescent mental health services.
The approach described here is very different to the assessment approach currently taught in Melbourne. Wilkinson's approach includes no specific questions which cover pregnancy, infancy, preschool activity or school entry, although it does inquire about areas of development. It does not ask about strengths of children, and does not include a child mental state examination, which in the opinion of many is essential for a valid diagnosis. However, there are many elements in common with child psychiatry assessment as taught in Melbourne. This book presents a ‘family-orientated approach to assessment in child and adolescent mental health’. I do not believe that it provides the optimal framework for assessing children and adolescents, although it is strong on family assessment. It is too weak on recognising individual differences and in acknowledging how these are influenced by many factors in addition to family variables. However, this is a valuable book and contains much useful information for child and adolescent mental health professionals with an interest in assessment, especially for those who have to design or conduct training in this area. It raises many questions, offers a broad basis for family assessment in child psychiatry, and has been found to be a useful teaching tool by the author. Many elements can be borrowed and incorporated into the tool kits of those who see children where family-based variables are thought to be maintaining problems or preventing their resolution.