DOCUMENT RESUME ED 027 951 PS 001 601 By-Eisenberg, Leon Child Psychiatry: The Past Quarter Century. Harvard Univ., Cambridge, Mass. MedicalSchool. Pub Date 3 Oct 68 Note- 29p.; Paper presented atTwenty-Fifth Anniverserary, Dept. of Psychiatry,McGill University, Montreal, Canada, October 3, 1968 EDRS Price MF-$0.25 HC-$1.55 Descriptors-*Child Development, *Child Psychology,Cultural Disadvantagement, Culture FreeTests, Economic Disadvantagement, Family Environment, Mental Health,Nutrition, Physical Development, PrenatalInfluences, *Psychiatry, Psychological Needs, Racism,*Research Needs, *Research Reviews(Publications), School Role, Social Environment, Test Interpretation The developments in child psychiatry inthe past 25 years have beenencouraging but represent only a prelude tothe significant work that mustbe done relatively soon to meet the needsof the contemporary child.Before 1940, the desirabilityof multidisciplinary study of the child hadbeen well established, andchild guidance clinics had appeared. Until the1960's, however, the focus was onthe clinical study of individual patients and families,rather than population studies,and generalizations were madefrom the former to the latter.Concern for the poor and theblack was dormant for too long in the past quartercentury; it is .in such areas aspoverty and racism that serious psychologicaland organic problems in children occur.Specifically, research inchild development must be concernedwith many important factors. including (1) the "test bias" ininterpreting results ofachievement tests; (2) the prenatal and paranatal factorsthat influence brain development;(3) nutritional factors, before and after birth;(4) the psychosocial environmentof the child, especially the family environment;(5) the. influence and role ofschool; and (6) the effects of racism. (WD) U. I. MIRIAM OP KAMVOCATION & WELFARE OFFICE OF EDUCATION FROM THE THIS DOCUMENT HAS BEEN REPRODUCEDEXACTLY AS RECEIVED POINTS OF VIEW OROPINIONS PERSON OR ORGANIZATION ORMINATING IT. EDUCATION STATED DO NOT NECESSARILY REPRESENTOFFICIAL OFFICE OF. IP tosinotiOR POUCY. CHILD PSYCHIATRY: THE PAST QUARTER CENTURY BY LEON EISENBERG, M.D. PROFESSOR OF PSYCHIATRY HARVARD MEDICAL SCHOOL AND CHIEF OF PSYCHIATRY MASSACHUSETTS GENERAL HOSPITAL Twenty-Fifth Anniversary, Departmentof Psychiatry, McGillUniversity Montreal, October 3, 1968 At the risk, inthis election year, ofsounding like a candidate of my pleasure at for office, I cannotforego public acknowledgement has been unusually being invited back toMontreal. Each of my visits here rewarding, both becauseof the beauty of this cityand fhe stimu2ation particularly provided by its intellectualenvironment. This occasion is a of an outstanding welcome ono, acknowledging asit does the 25th anniversary For a citizen of department of psychiatryand its distinguisheddhairman. with the tension between the United States,Montreal has especial meaning formerly oppressed language group its two c.ultuzes andthe struggle of a will provide a for its proper place inth sun. A constructive outcorhe communities, wracked asthey are model of :;reatsignificance to our awn then, I am grateful by internecineconflict. For these several reasons, be here. to ProfessorCleghorn for the opportunity to Ee has asked me to comment upon"developments in child psychiatry of research in the in the past quartercentury" and "to map out promises Historiography is a constant yearsahe'd." Neither task is an easy one. form from the groundsof logue between past andpresent; it takes new hence will almost the shifting present. The historian twenty-five years from certainly view our recentpast from perspectivesquite different distance from the our own, havingat his command newviewpoints and more will be on-troversies in which we arestill engaged. We can only hope he due respect for ourvenerability kind to thoseof usthen still alive, and for limiting my if not for ourperspicacity. I beg him to forgive me I know well survey mostly tothis continent, butthis is the only scene enough to dare these comments. take as its Fortunately, our assessmentof recent developments can Professor Kanner, point the insightful andbalanced comments of -2- delightfully literatepublications,(1-3), who, in a seriesof scholarly and of child psychiatry. The has attended thebirth and early childhood the mechanism ofsuperfecunda- paternity of thishybrid invites us to invoke the juvenile courtmovement, tion, involving as itdid general psychiatry, psychoanalysis, pediatricsand defectology, education,child development, concerned with the"mental diseases" child guidance. Although textbooks before the turn of the century, and "insanity" ofchildren had appeared of adult nosology upon they were primarilyexercises in the imposition 1926 that Homburger(4) wrote childhood disorders(2). It was not until of childhood that canbe said the first treatise onthe psychopathology child as a person andit was not until to be informedby a concern for the textbook with the title 1935 that Kanner (5)published the first American "Child Psychiatry". burgeoning feature of By the 1930's,child guidance clinics were a anderpsychiatrie had the North American scene. Tramer's Zeitschrift Rh- international congress inParis been founded, and Heuyerhad organized an The year that marksthe opening under the title"Psychiatrie infantile". the year in whichProfessor of our survey (1943),appropriately enough, was syndrome that has come tobe Kanner reported thepreviously undescribed instance of a psychotic known as early infantileautism (6), the first disorder peculiar to childhood. might To that point intime, the contributionsof child psychiatry be summarized in these terms. The desirability ofmultidisciplinary At an operational study of the child in hisfamily had been wellestablished. of the social worker, the level, this was reflectedin the collaboration guidance clinic and in the psychologist and thepsychiatrist in the child -3- eligibility of all three &coups formembership in the American Ortho- psychiatric Association (7). The first effective drugs, the amphetamines, had been introduced (8). The thesis that adult disorders haveantecedents in childhood experience had beenbroadly accepted; true, this idea had been introduced into psychiatry by Freudwithout the benefit of child study four decades earlier, but theaccumulating clinical reports of child psychiatrists had given it - or atleast appeared to have given it - empirical support. The enthusiasm for prevention, again adoctrine enunciated at the turn of the century in the mentalhygiene movement, had now become the province of children's clinics. In much the same spirit that Victor Hugo had proclaimed that the opening of each newschool meant the closing of a prison, the community was led to expect that each new child clinic made obsolete an adult mental hospital. However distant the day of its realization might seem, given the shortages offunding and manpower then as now, there was no lack ofconviction that the control of mental illness could be attained by a proper network of child guidanceclinics, training of school teachers, and education of paients.And this conviction was no mere matter of neve optimism onthe part of our professional forebears; the nature of their daily clinical workwith its high rates of symptomatic improvement in the children they cared for appeared toverify their beliefs. Yet for all the honor due to child psychiatryfor having pioneered a broader view of patient-family-communityinteraction than was then typical of adult psychiatry, our horizons were constrictedby our focus on the clinical study of the individual patients andfamilies who passed through our clinic doors. It is only in the last decade that wehave begun to recognize that population studies are essential(9) and that clinic intake 1, -4- has unintended as well asdeliberate bias built into it(10). Once appropriate controls for social class areintroduced, it becomes dif- ficult to verify the widespreadassumption that such variables as age 1 and method of weaning, toilettraining practices, sex education orthe parental attitudes measured bystandard inventories distinguish clinic patients from other children(11). Such factors do indeed vary signifi- cantly by social class but theyfail to predict patienthood. In contrast to such factors, whatdid discriminate patients from controls, in astudy of a sample of our clinicpopulation, was the experience of separation from parents by illness, death ordesertion and the occurrence of marital distress (11). Many of the formulations which seem tohave explanatory value when applied in retrospect topatient populations skewed in unknown fashion by gate keeping proceduresdisappear into insignificance when appropriate sampling and controltechniques are introduced. Such errors, in my estimation, have stemmed in partfrom the isolation of the child guidance clinic from medicine, on the onehand, and from child develop- ment on the other. No physiologist would describe anormal heart in terms derived solely from thestudy of a failing one; had he done so, Starling would have concluded thatventricular output decreases rather than increases in relation toventricular dilatation. Yet we have general- ized from our clinical work withtroubled families to theories of normal development. Freud's experience before the turn of the centuryshould have warned us of the unreliability of ourpatients' reconstructions of their past; what he first thought tobe historical events he later discovered to be fantasy. Yet he and we have perseveredin our