BOOK REVIEWS
Injury in Children: The Need for Parental Involvement”; and
“Elimination Disorders in Children.” The chapter titles alone
alert the varied professionals who might find the information
relevant. For example, the chapters addressing elimination
disorders and sleep problems are likely to be very useful to
child and adolescent psychiatrists. The chapter addressing
abuse and neglect would be useful for clinicians providing
evaluation and treatment services for child protective agencies.
Section IV, titled “Medical/Pediatric Problems,” provides a
framework for designing a child behavior therapy plan that
would be a welcome addition to a multidisciplinary-team
approach to the treatment of problems such as the sequelae of
traumatic brain injury. While still bent toward providing
treatment from a behavior therapy-based approach, this book
does remind readers that collaboration with a physician may
be indicated, for example when ruling out organic pathology
as the etiology of chronic pain. Also, Table 1 in chapter 14
provides “Red Flag Symptoms Indicative of Organic Path-
ology” as possible indications for behavioral therapists to rein-
volve physicians when managing chronic pain.
The final section is devoted to behavior problems that occur
in multiple settings and topics such as treatment of tics, self-
injury, anxiety, and depression and social skills training. Al-
though this section is well-written and informative, many of
the problems included are often managed with medications by
child and adolescent psychiatrists. Hence the information
presented would be most useful when child and adolescent
psychiatrists are working conjointly with behavior therapists.
In summary, this book is an excellent comprehensive resource
for the traditionally trained behavior therapist in treating a
myriad of problems. It is useful to child and adolescent psy-
chiatrists in addressing some specific behavior problems, as
well as providing a more detailed understanding of the treat-
ment of patients who may be receiving behavior therapy.
Since this book emphasizes the designing of a treatment plan
specific to an identified problem and the evaluation of data to
ascertain whether or not the treatment is effective, it is espe-
cially useful in a managed care environment for clinicians
attempting to quantify improvement.
Robin D. Mallett, M.D.
Assistant Professor
Department of Psychiatry and Behavioral Sciences
University of Texas Medical Branch, Galveston
Lost Childhoods: The Plight of the Parentified Child. By
Gregory /. jurkovic, Ph.D.New York: Brunner Mazel, 1937,
252pp., $34.95 (hardcover).
When I received this book I was reminded of the hot-and-
heavy debate during my training years at Georgetown Uni-
J . A M . ACAD. C H I L D A D O L E S C . PSYCHIATRY, 3 7 : 8 , A U G U S T 1998
versity between the Bowen family therapy group and the
child and adolescent psychiatry group who were attempting
to integrate into child training a therapeutic and theoretical
model less rigid than the Bowen model. That debate con-
tinued for years. Sadly, the program ended last year because of
budget constraints and managed care. Sadly, because at its
end, family approaches had been well integrated into the
Georgetown program by such leaders as Henry Work, Wells
Goodrich, the Scharff‘s, Ted Beale, Kent Ravenscroft, Larry
Silver, and many others. As I reviewed this book, memories of
family training issues flashed through my mind.
This book presents a theoretical and treatment model with
an important focus: the parentified child. It may be an inter-
esting and important factor in diagnosis and treatment, but I
believe the author has overemphasized its importance, at least
for child and adolescent psychiatrists.
The book first presents the theory (part I, “Understand-
ing”) and then the practice (part 11, “Treatment and Preven-
tion”). Jurkovic reviews relevant literature, but much of his
theory is based on case vignettes, collected clinical material,
and other authors’ cases. Here I find a major fault with the
book. The theory seems based on rather weak studies of the
parentified child (no controls, no double-blind, no normal
comparison groups, etc.). Then the author takes an important
concept and expands it into a proposed model of treatment
and prevention. The importance of the concept seems valid,
but the overemphasis on the model does not.
The book is clearly written except for some confusion
about the wordparentification. (Is identifying with and mod-
eling positive parental traits a parentifiation? When I hear
the word parentifcation, I usually think of something neg-
ative.) Another strength of the book is a systems approach to
cases. Jurkovic encourages us when looking at a patient who
is a juvenile delinquent to look also at the system: child,
parents, extended family, courts, probation officers, church,
Big Brothers, etc. This emphasis is excellent. The parentifi-
cation concept is important, but Jurkovic seems to make it
the keystone of our understanding children. He hedges by
putting forward a disclaimer, conceding we can never really
prove cause and effect and need more studies.
In the IDC model (identify, describe, and contextualize)
presented in part I1 (p. 73),Jurkovic points out that parentified
children may be underidentified because they are frequently
overcompliant and may not cause problems. Destructive par-
entification may lead to acting-out behavior. Aren’t both of
these parentifications equally destructive in different ways? Is
this distinction useful? Jurkovic points out that this concept
may be helpful in understanding child abuse and neglect. He
encourages researchers to broaden their studies of child abuse
to include parentifiation and other systems issues.
The case examples in the book are excellent, and the multi-
level system approach is deep and helpful. Chapter 6, “Break-
895
BOOK REVIEWS
ing the Deadlock: The Case of Jamie,” is a superb example of
a systems approach to a case the author believes is one of the
most difficult examples of parentification he has seen. This
case demonstrates how all involved with this patient got into
the parentification mode. However, the old ideas of trans-
ference and countertransference may be equally useful concepts
to understand the case. “Jamie’s initial resistance appeared to
soften with each expression of concern” (p. 136).This empha-
sizes Jurkovic’s point that healers need to have hope, confront
people’s denial of severe situations, and be able to get every-
one involved to look at the system and not just the patient. Is
this the old psycho-social-biological model? Do we need a
new word that overemphasizes the parentification part of the
picture?
In chapter 8, “Wounded Healer: From Parentified Child to
Helping Professional,” the author discusses how the par-
entified child can grow up to be a somewhat wounded healer
who brings hidher own not-so-helpful countertransference
(my word) to the therapeutic relationship. Do we need the
narrow parentified child concept to explain countertransfer-
ence, modeling behavior, empathy, interpersonal psychiatry,
etc., when looking at wounded healers? Maybe not. Jurkovic
also touts the importance of his model for supervision, train-
ing, and screening applicants for mental health professional
training programs. Helpful, but maybe a stretch in terms of
its importance.
In “Transforming Experiments,” a subsection of chapter
9, the author describes a very interesting study of program
intervention in New York that tried to decrease child abuse
and neglect and improve child-parent relationships and out-
come. Some controls were used. Having a nurse in the home
(the most intensive intervention) who could educate, model,
get friends and family to help, and connect parents with com-
munity resources seemed to prevent child abuse and neglect
and other caregiver problems. The program was cost-effective
by decreasing emergency room visits, hospitalization time,
and Child Protective Services time. It also seemed to be most
helpful for those most at risk. Jurkovic reports that the degree
896
of parentification was not assessed. So, again my question:
This is an important and significant study, but is the concept
of parentification key to understanding the result?
Appendix A is an interesting compendium of theoretical
concepts that touch on parentification (“Constructs Related
to the Parentification of Children”). Jurkovic defines related
concepts from individual and family dynamics, family
systems, sociological, anthropological, addiction (e.g., code-
pendence), and developmental perspectives (e.g., Elkind’s
hurried child). The Appendix shows the varied systems and
theories that are related to parentification. In a way the Appen-
dix broadens the concept and shows other issues crucial to diag-
nosis and treatment beyond parentification.
In summary, this book presents interesting case material
that demonstrates an important issue. However, I do not
believe this book belongs on every child and adolescent psy-
chiatrist’s bookshelf or is a core book for our training pro-
grams. The author presents good vignettes and examples but
elevates an important theoretical concept to what seems to be
the key theoretical concept for diagnosis and treatment. I do
not believe this is appropriate. I am grateful to all my teachers
and colleagues who helped me understand family issues and
integrate them into my diagnostic and therapeutic sty!e. They
taught me a broad, eclectic approach. Thus, I was somewhat
disappointed in this author’s narrow focus. The Georgetown
program is gone, but it lives on through its graduates who use
a broad family approach integrated with the other major
elements of modern-day child and adolescent psychiatry.
Parentification, plus much more.
William L. Licamele, M.D.
Clinical Professor in Psychiatry and Pediatrics
Georgetown University Medical School
Washington, D C
Note to Publishers: Booksfor review should be sent to Dean X . Parmelee, M.D.,
Division of Child &Adolescent I’sychiaty, PO. Box 980489, Richmond, VA
23298-0489.
J . A M . ACAD. C H I L D A D O L E S C . PSYCHIATRY, 37:8, A U G U S T 1998