Linda S. Grossman

OBJECTIVE: A subpopulation of chronically mentally ill patients, sometimes referred to as "revolving door" patients, are frequently readmitted to psychiatric units. This study examined the relationships among demographic features, diagnostic characteristics, and frequency of hospitalization of patients from four state hospitals. METHOD: Two semistructured, standardized instruments, the Schedule for Affective Disorders and Schizophrenia and a life events history, were administered to 135 inpatients who met the Research Diagnostic Criteria for schizophrenia (N = 56), schizoaffective disorder (N = 33), unipolar major depressive disorder (N = 23), and bipolar disorder (N = 23). Criminal history was assessed by arrest records. The main outcome measure was the number of hospitalizations. RESULTS: Chi-square and trend test analyses indicated that substance abuse and noncompliance with medication regimens were significantly associated with higher frequencies of hospitalization. A multiple regression model, which included alcohol/drug problems, medication noncompliance, and six sociodemographic and diagnostic variables (age, gender, race, marital status, years of education, and diagnosis) accounted for a significant proportion of the ability to predict frequency of hospitalization. Half of this predictability was due to the relationship of substance abuse and medication noncompliance with number of hospitalizations. CONCLUSIONS: Alcohol/drug problems and noncompliance with medication were the most important factors related to frequency of hospitalization. Preventing these behaviors through patient education may reduce rehospitalization rates.

Eager to Learn: Educating Our Preschoolers, edited by Barbara T. Bowman, M. Suzanne Donovan, and M. Susan Burns of the National Research Council, Committee on Early Childhood Pedagogy, Commission on Behavioral and Social Sciences and Education, Washington, DC, National Academy Press, 2001, 443 pp, $34.95. In the Preface, the editors state that this book is intended to be a first attempt at a comprehensive, cross-disciplinary synthesis of the theory, research, and evaluation of the literature relevant to early childhood education. It is the product of a 3-year effort by a committee appointed by the National Research Council to provide recommendations regarding policies and best practices for the education for preschoolers. The book begins with the Executive Summary of the committee's work and then proceeds to provide extensive documentation to support the committee's recommendations. This documentation includes a detailed description of the science of learning as applied to preschoolers, including theories of cognitive development, the importance of relationships in developing both the social and emotional aspects of the child and also in facilitating and fostering cognitive development, and the current knowledge regarding the development of the brain in preschool-age children. The next chapter focuses on the importance of cultural and individual variations in the development of cognitive skills, in social and emotional development, and in physical and motor development. It includes a short discussion of the impact of disabilities on development and the importance of including children with disabilities in regular preschool settings, both for the optimal development of the child with disabilities and to help develop empathy and an appreciation of differences in the other children enrolled in the program. Much of this chapter is devoted to reporting the results of a study of children enrolled in kindergarten who vary widely in age and backgrounds and to comparing the children's skill levels in a variety of areas, with factors such as the child's chronological age and cultural and socioeconomic background taken into consideration. The fourth chapter discusses research regarding program quality, early education approaches most commonly employed, and the short- and long-term outcomes for these differing approaches. Programs in the United States also are compared with those of other countries. All of this logically leads into a discussion of curriculum and pedagogy, including goals, content, and teaching strategies. Additional chapters cover questions regarding the assessment of early childhood education, including a discussion of the assessment of the different components of the program and the role of assessment in making policy decisions. Equally important is the chapter on appropriate preparation for early childhood professionals and the one on program and practice standards. The book ends with a short section devoted to the conclusions and recommendations of the Committee on Early Childhood Pedagogy, an extensive appendix, and a list of references. This book clearly represents a great deal of work on the part of this committee. They have made extensive efforts to back up their recommendations with as much scientific evidence and outcome data as possible. This is not an easy task, given the limited amount of good research in this area and the difficulties in comparing programs that may serve quite different youngsters. Their thorough and comprehensive approach makes this book important reading for professionals who find themselves in the role of advising individual families and, even more importantly, larger groups, such as schools or state agencies, regarding curriculum, policies, and priorities for preschool education. The editors have done an excellent job of describing what work has been done so far and why the expert panel is making these specific recommendations. The editors also skillfully balance the different factors that play a role in early childhood education, especially the sometimes conflicting demands of fostering cognitive development while encouraging social and emotional growth and, at the same time, accommodating individual differences in both cognitive level and temperamental style. For some readers, the recommendations of the expert committee will be the most important part. Other readers will appreciate the detailed summary of present knowledge, and still others may find the extensive references to be the most helpful part of the book as they grapple with their own views about this complex topic with limited research to guide us. Linda S. Grossman, M.D. Division of Behavioral and Developmental Pediatrics; University of Maryland School of Medicine; Baltimore, Maryland

BACKGROUND: It is unclear whether outcome in schizoaffective disorders is more similar to schizophrenia or affective disorders. AIMS: To provide longitudinal data on clinical course and outcome in schizoaffective disorders versus schizophrenia and affective disorders, and determine whether mood-incongruent psychotic symptoms have negative prognostic implications. METHOD: A total of 210 patients with schizoaffective disorders, schizophrenia, bipolar manic disorders and depression were assessed at hospitalisation and then followed up four times over 10 years. RESULTS: At all four follow-ups, fewer patients with schizoaffective disorders than with schizophrenia showed uniformly poor outcome. Patients with mood-incongruent psychotic symptoms during index hospitalisation showed significantly poorer subsequent outcome (P < 0.05). CONCLUSIONS: Schizoaffective outcome was better than schizophrenic outcome and poorer than outcome for psychotic affective disorders. Mood-incongruent psychotic symptoms have negative prognostic implications. The results could fit a symptom dimension view of schizoaffective course.

OBJECTIVE: Recent legislation in several states providing for civil commitment and preventive detention of sexually violent persons has stirred legal, clinical, and public policy controversies. The mandate for psychiatric evaluation and treatment has an impact on public mental health systems, requiring clinicians and public administrators to direct attention to treatment options. It is a common view that no treatments work for disorders involving sexual aggression. The authors examine this assumption by reviewing research on the effectiveness of treatment for adult male sex offenders. METHODS: MEDLINE was searched for key reviews and papers published during the years 1970 through 1998 that presented outcome data for sex offenders in treatment programs, individual case reports, and other clinically and theoretically important information. RESULTS: Although rigorous research designs are difficult to achieve, studies comparing treated and untreated sex offenders have been done. Measurement of outcome is flawed, with recidivism rates underestimating actual recurrence of the pathological behavior. Outcome research suggests a reduction in recidivism of 30 percent over seven years, with comparable effectiveness for hormonal and cognitive-behavioral treatments. Institutionally based treatment is associated with poorer outcome than outpatient treatment, and the nature of the offender's criminal record is an important prognostic factor. CONCLUSIONS: Although treatment does not eliminate sexual crime, research supports the view that treatment can decrease sex offense and protect potential victims. However, given the limitations in scientific knowledge and accuracy of outcome data, as well as the potential high human costs of prognostic uncertainty, any commitment to a social project substituting treatment for imprisonment of sexual aggressors must be accompanied by vigorous research.