BOOK AND MEDIA REVIEW 969

tions for adolescent and adult development. There is consid­erable redundancy in the articles in terms of reviewing theissues and existing research. Nonetheless, it is intriguing tofind the various contributors arriving at similar findings par­ticularly regarding sex differences in moral development.Females consistently show a care focus in their moral reason­ing whereas males are more oriented toward justice consid­erations. Developmental factors that may account for thesedifferences are discussed, including inequality and the tend­ency of females to be more relationship focused than males.The authors do not consider whether there might also beanatomical basis for this difference in terms of right brainversus left brain functions and recent evidence that suggestanatomical differences (specifically, a wider corpus callosum)in female brains compared to male brains. Regarding sepa­ration-individuation in adolescent females, Gilligan notes (p.146) "... adolescent girls who demonstrate a reluctance toexit may articulate a different voice-a voice which speaks toloyalty to persons and identifies detachment as morally prob­lematic."

Of particular interest was the chapter "Urban Adolescents'Concepts of Violence" by Ward. She notes the high frequencyof references to violence in the 51 urban adolescents that shestudied and that many of these teens shared a perspective ofretributive justice. She found that while these teens did notnecessarily espouse a subculture of violence, that "It is theavailability and abundance of weapons that in many waysforces the response of violence as a necessary defense" (p.197). She also discusses the role models set by mothers whosubmit to violence, in essence conveying to their children thateither the abuse is not really violent or that she is powerlessto do anything about it.

The chapters on "The Vulnerable and Invulnerable Physi­cian" and "Women Lawyers: Archetypes and Alternatives"should be of particular interest to the child psychiatrist on apersonal level. In the first chapter, Gilligan and Pollak notethe vulnerabilities of physicians in maintaining the delicatebalance between intimacy and distance and the dangers thatexist at either extreme. They review studies showing thatmales project more danger into situations of close personalaffiliation than into achievement situations and that the op­posite is true for women. In their study of TATs of medicalstudents, these authors found themes of abandonment andisolation to predominate for women. In contrast, the malestudents wrote more violent stories and tended to see dangerattached with intimacy. They conclude that the entry of anincreasing number of women into medicine may have asalutary effect. They suggest that, like the canaries taken intomines, women may serve as a barometer to "reveal places inmedical training and practice where human connection hasbecome dangerously thin" (p. 262). However, paradoxically,they note that because of their fear of disconnection, womenmay be hesitant to initiate conflict and change into the wayin which medicine is practiced.

The chapter on "Woman Lawyers" by Jack and Jack ex­plores the balance between being caring and uncaring and theproblems of finding workable boundaries. Lessons can belearned in this chapter regarding the need not to forsake theself.

This book raises provocative questions such as "how to

encourage human responsiveness within a framework of acompetitive, individualistic culture?" (p. 291) and underscoresthe need for more studies on adolescent female development.Unfortunately, it does not provide the reader with readyanswers but does stimulate one's thinking in these areas.

DIANE H. SCHETKY, M.D.Private Practice

Rockport. Maine

Giving Children a Chance: The Case for More EffectiveNational Policies. Edited by George Miller. Washington,DC: Center for National Policy Press, 1989, 231 pp. (pa­perback).

This is a book of nine essays, primarily about programs tohelp disadvantaged young children, written by authors fromvarious disciplines who share a homogeneous if indeed nothomogenous point of view. In the preface, former Senatorand vice-presidential candidate Edmund Muskie states thatthe purpose of this collection is to provide information to ournation's "younger leaders" who have a "high degree of con­cern" but are found to be uninformed about the effectivenessof early intervention programs.

In the Introduction to these essays, U.S. RepresentativeGeorge Miller writes as a devoted and staunch advocate forchildren and as Chairman of the House Select Committee onChildren, Youth and Families. He wishes to develop a na­tional strategy for children which would take advantage oftwo resources: one, the increasing concern of our businesscommunity about an inadequately educated labor force forindustry's needs in the future; and second, an existing bodyof data that document both the need for and the effectivenessof early intervention programs. In his comments, Mr. Millerasserts that we have programs that work (e.g., Head Start;prenatal care) and that "... We must not allow the federalbudget deficit or lingering inaccurate views about social pro­grams to deter us from investing in comprehensive health andeducation services for young children in every communityand at every income level. ... It is our duty to help America'schildren get a strong start in life." These are admirable senti­ments which have about them a familiar ring stretching backat least to the 1960s, when we as a society believed thatspending more money on federally administered social welfareprograms would eliminate poverty. Mr. Miller is correct; wedo have programs which can be helpful and should be sup­ported, but at the same time we must be careful to avoid"deja vu all over again" in springing back to the rhetoric,rationale, and solutions of a generation ago.

Why is this a concern in regard to this volume? In the firstchapter, by Weissbroud and Emig on Early Childhood Pro­grams for Children in Poverty, they identify that politiciansand business leaders both are expressing concerns aboutpoor children who are not receiving an education. Theauthors advocate eradicating poverty by policies which "pro­mote full employment, safe and affordable housing, adequatehealth care ...." with a special focus on early childhoodeducation. They also advocate expanded prenatal care, nutri-

970 BOOK AND MEDIA REVIEW

tion programs. preschool programs and preschool child care;i.e., "... every poor child (should) receive every service he orshe needs to prevent long term problems from developing." Ican 't disagree with any of this-I can only bemoan anddespair that there is not a single mention anywhere that theparents of these children should bear an y responsibility oraccountability for the care of the ir children or how to addressthat critically missing ingredient.

In the next chapter, James Garbarino (President, The Er­ikson Institute in Chicago) proposes early stimulation ofcognitive development as a strategy for reducing poverty. Theauthor first discusses three "types" of intelligence-"compo­nential" (the most familiar type), "experiental" (figuringthings out), and "contextual" (I interpret this to be similar to"street smarts"). Garbarino then leads us through a review ofPiagetian and Eriksonian stages, indulges in a surprisinglyoversimplified discussion of genetics versus learning, andmakes a case for the value of total early intervention programswhich promote all three types of intelligence in the earl yprevention of the effects of poverty. Again , the overwhelmingrealities in the lives of many of these children-abuse, poorhousing, violence, drugs, neglect-are barely mentioned orignored altogether.

The next chapter. by Eleanor S. Szanton (The NationalCenter for Clinical Infant Programs in Washington. D.C.). isa valuable compilation of almost all the statistics anyonewould need to understand the dimensions of the problem ofchildren of poverty. This chapter should have been the firstin the book-it is full of dispassionately presented but fasci­nating and important data in the form of tables . graphs, charts.narrative, and an excellent bibliography.

Sara Rosenbaum (The Children's Defense Fund) addresseshealth status, insurance coverage. and trends in public healthpolicy in children of poverty. This article tends to be repeti­tious of what we already know : poor children are terriblydisadvantaged, they are worse off in the United States than inmost other Western countries. and that those not covered byhealth insurance are the worst off. The discussion of healthinsurance is knowledgeable and helpful. but much of thisessay has a sort of scolding and blaming quality. The solutionsonce again call for more money for health coverage. more"health providers" for underserved communities. more fund­ing for maternal and pediatric services, etc.

The remaining chapters include: Poverty. Family and TheBlack Experience by James Comer (The Yale Child StudyCenter); Preventive Services for Children in a Multi-RiskEnvironment by Stanley Greenspan (The George WashingtonUniversity Medical school); Lisbeth Schorr's (Harvard) essayon Breaking the Cycle of Disadvantage: New Knowledge.New Tools. New Urgency; a chapter on community-basedparenting interventions by Judith Mus ick and Rogert Halpern(both from the Erikson Institute in Chicago); and at the end.an Appendix, which is the report of a study conducted byPeter D. Hart. This report is in essence the summary of aseries of focus groups involving 40 young. but "high levelbusiness executives." I found this last chapter-the Appen­dix-the most superficial chapter of all: it assures us that ouryoung business leaders have a deep concern for the future ofthe country (in particular, of course, the economy). they arepoorly informed about poverty and poverty programs (having

never had much contact with poverty), but that they arecapable of developing a concern about poverty, that theyfavor well-managed government programs, and that theybelieve education is worthwhile. No, I am not kidding, that'sthe content.

The other chapters mentioned above, happily, do havemore substance. but of varying degrees . Comer's thesis issimplistic sociology but a valuable presentation of the im­pressive public school intervention program he developed inNew Haven.

Greenspan reminds us of the enormous potential in infantsfor active learning. reviews his classification of severely im­paired "multi-risk" families. and describes the model infantintervention programs developed under his leadership in theClinical Infant Development Program. Here you have a fullappreciation of the extent and degrees of parent and familyimpairment which must be confronted for any hope of successin early intervention.

Finall y. Schorr's article also is a valuable contribution. Sheidentifies all the high-risk factors and makes a strong case forthe expanded support of programs that have demonstratedthe ir effectiveness (although almost without exception theseprograms have never been tested for success either beyondtheir original site or with new leadership). She describesseveral such programs of intensive. family-centered outreachservices, identifies the attributes of successful programs, andunderscores the financial commitments that must be made tosupport successful intervention.

One serious limitation throughout these essays has beenalluded to-that is the absence of any attention to the earlydevelopmental, emotional, and mental disorders affectingchildren of poverty. There is a high incidence of attentiondefic it disorders, learn ing disabil ity, depression, and conductdisorders in these children, anyone or combination of whichwill seriously interfere with any educational program. Takentogether, and combined with other disorders, perhaps 30% ormore of children of poverty are affected and will require evenmore special resources. This issue should not be overlookedin a book addressing national policy for children of poverty.

Overall. the value systems, social philosophies, and attitudesexpressed in these chapters are familiar to and compatiblewith those of child and adolescent psychiatrists, and for ourmembership the book tends to preach to the converted, albeitwith much data to support its concerns for the children ofpoverty. What I consider the book's most persistent andserious flaw is that while it consistently supports greaterfinancial and political support for earl y intervention for in­fants and children of povert y. almost nowhere is there anyserious consideration of including any requirements or expec­tations of the parent(s) or adult en vironment that producesand neglects these ch ildren. Without taking this issue head ­on . I am concerned. if not convinced . that we will neversignificantly improve the outcome for these children, and wewill never provide them the opportunity they need.

JERRY M. WIENER, M.D.Leon Yochelson Professor and Chairman

Department ofPsychiatry and Behavioral ScienceThe George Washington University School ofMedicine