Leo Kanner’s Call for a Pediatric-Psychiatric Alliance Marga Vicedo, PhD, Juan Ilerbaig, PhD

The “Menace of .”1 The the Division of Child and title of pediatrician Joseph Adolescent Psychiatry at the Johns Brennemann’s 1931 article was Hopkins University (JHU) School of inflammatory, and it was meant to Medicine, called for an alliance be. Brennemann voiced concerns between child psychiatry and about psychiatry that many . Here, we examine how contemporary pediatricians shared Kanner came to that conviction at the time.2,3 Under “psychiatry” through the influence of he included the work of an array of Adolf Meyer and pediatrician professionals in , child Edwards A. Park and argue that development, and child guidance pediatrics deeply shaped Kanner’s who, in his opinion, were work in child psychiatry. negatively influencing parents’ attitudes toward their children’s Meyer, the director of JHU’s Henry health. These professionals, who Phipps Psychiatric Clinic, saw the were trained in psychoanalysis, roots of mental disorders in the mental testing, or the behaviorist behavioral habits that people psychology of John B. Watson, develop as defenses against Institute for the History and Philosophy of Science and Technology, 7 University of Toronto, Toronto, Canada popularized standards, techniques, environmental stress. and theories that parents could not Psychobiology, as he called his Drs Vicedo and Ilerbaig conceptualized and designed the study, fully understand. In addition, they approach, required a careful conducted the research on the primary and secondary sources, drafted the initial manuscript, and reviewed and led parents to see any variation examination of the individual’s revised the manuscript; and both authors approved the final fi fi development to identify the causes from a scienti cally de ned ideal of manuscript as submitted and agree to be accountable for all health as a problem. of his or her mental condition. aspects of the work. Biographical data and information DOI: https://doi.org/10.1542/peds.2019-4047 Brennemann argued that only about the family history and pediatricians had sufficient environment were as important as Accepted for publication Mar 10, 2020 knowledge of the specific and physical, mental, and laboratory Address correspondence to Marga Vicedo, Institute for the normal conditions of children’s examinations; all contributed to the History and Philosophy of Science and Technology, University ’ of Toronto, Victoria College, Room 316, 91 Charles St W, lives to understand each child as an patient s case history, which was Toronto, ON M5S 1K7, Canada. E-mail: marga.vicedo@ individual and to diagnose the standardized unit of study for utoronto.ca ’ pathologic deviations. Yet, lacking the psychiatrist. A person s PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098- the elaborate jargon of the childhood became an important 4275). ’ psychoanalysts or the prestige of part of the patient s clinical history. Copyright © 2020 by the American Academy of Pediatrics the behaviorists’ laboratory In the case of children, the early FINANCIAL DISCLOSURE: The authors have indicated they have methods, pediatricians appeared to years of development were crucial. no financial relationships relevant to this article to disclose. be losing the ongoing debate over FUNDING: No external funding. a fundamental question: who is the The head of JHU’s pediatric clinic, POTENTIAL CONFLICT OF INTEREST: expert on the mental health of Edwards A. Park, helped give The authors have indicated they have no potential conflicts of interest to disclose. children?4 Kanner an institutional home. The clinic, founded in 1912 as the Recognizing the validity of Harriet Lane Home for Invalid To cite: Vicedo M and Ilerbaig J. Leo Kanner’s Call for Brennemann’s concerns, Children, was the nation’s first a Pediatric-Psychiatric Alliance. Pediatrics. 2020;145(6): e20194047 psychiatrist Leo Kanner,5,6 head of pediatric clinic affiliated with

Downloaded from www.aappublications.org/news by guest on September 28, 2021 PEDIATRICS Volume 145, number 6, June 2020:e20194047 MONTHLY FEATURE a university.8 After becoming its and pediatric specialists as one of personalities led Kanner19 to study pediatrician-in-chief in 1927, Park “mutual give-and-take collaboration.” “types of psychopathologic problems opened several specialist clinics and that are not taken directly to At the Harriet Lane Home for Invalid subdepartments.9,10 Joining forces to and not commonly seen Children, Kanner facilitated better understand and treat children’s in child guidance clinics.” collaboration in casework. He conditions, Meyer and Park expanded the role of pediatricians in Third, pediatrics also deepened inaugurated a child psychiatry unit the psychiatric unit, asking them to Kanner’s appreciation for the within the Harriet Lane Home in 1930. include in their referral slips their significance of infancy. Classifications Park and Meyer shared a deep own descriptions of problems and of childhood mental disorders dissatisfaction with the approach to possible causes. The avoidance of compiled in the context of mental children’s health in child guidance diagnostic terminology in referral hygiene clinics, Kanner noted, tended clinics. An early champion of the slips and medical record notes to neglect “disorders occurring in mental hygiene movement, Meyer empowered pediatricians to deal with early infancy.” Those disorders were became frustrated because child personality problems on their rarely seen in mental hygiene clinics, guidance clinics were not tied to own terms. but “one working directly with a Pediatric Hospital certainly sees hospitals or universities and thus How did the close work with fi 11 a sufficient[ly] great number of these lacked a solid scienti c foundation. pediatricians affect Kanner’s outlook disorders to wish to have them Other academic psychiatrists also on child psychiatry? His view of ’ included in an adequate disapproved of the clinics lack of mental problems broadened in classification.”20 Queries from the connection to teaching hospitals and several respects. their increasing adherence to pediatricians at Harriet Lane shaped 21 psychoanalytic views instead of First, Kanner’s interactions with Kanner’s own grouping of the taking a “medical approach.”12,13 pediatricians made him aware that disorders of infancy and early psychiatrists needed to better childhood, which had been “the no As a pediatrician, Park shared understand both the children’s man’s land of child psychiatry.” Brennemann’s concern that many normal development and their unique Furthermore, the insights Kanner self-described experts in children’s problems. Kanner thought that gleaned from pediatrics left their mental health knew little about real examining children’s behavioral imprint on his 2 major professional children. Park also worried that child issues through the looking glass of contributions: his 1935 manual of guidance clinics were undermining adult mental problems hindered child child psychiatry and his proposal of the influence of pediatricians. These psychiatry. “Behavior disorders of infantile as a psychiatric clinics had built their expertise on the children,” he noted, had “interested condition. psychiatrist–psychologist–psychiatric the psychiatrists only as they seemed social worker triad, leaving to fit into diagnoses in accordance In Child Psychiatry, the first English pediatricians as outsiders, as another with classifications devised for textbook on this subject, Kanner22 leading pediatrician, Bronson adults.” But child psychiatry required integrated pediatric knowledge into 14,15 Crothers, complained. Park and that “the common behaviour child psychiatry. As Park’s23 preface Meyer agreed on the need for problems of boys and girls” take noted, this book offered a pediatric- collaboration and asked Kanner to center stage, displacing attention centered perspective. It was “not head their pioneering project for child from the “extremes and end-products based on imaginary children” but on psychiatry within a pediatric unit. of mental aberrations.”17 the study of actual children from the Harriet Lane clinic. The book shifted Excited about this landmark Second, working with pediatricians, the focus of child psychiatry toward institutional initiative, Kanner Kanner became more aware of the the “common behavior disturbances devoted most of his publications in interactions between physical and of children” and assumed that the the 1930s to fleshing out the mental health problems in childhood. “pediatrically trained mind” could connection between psychiatry and He encountered problems connected – “recognize” them early on and pediatrics. Kanner16 18 argued that to hospitalization and developed “prevent their development.” psychiatric diagnosis and treatment a better knowledge of acute and Reviewers fully agreed.24 of childhood behavioral problems chronic illnesses. He was also able to should become “the joint concern of follow the personality development of Kanner’s views on autism are also the psychiatrist and the pediatrician.” children who had visited the pediatric better understood by seeing them He called for a pediatric-psychiatric clinic as premature or malnourished within this pediatric context. One can alliance and described the proper infants. This work with real children spot the germ of Kanner’s view of relationship between psychiatrists and exposure to a wide variety of autism as an “early infantile”

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