The Century of the Child

A survey of the field of child psychiatry: the advances, the popular fallacies, the need for new programs

THE scientific study of child development did not begin until the twentieth century, which has been called, among other things, the Century of the Child. If it is to live up to this label, we must make better use of the next forty years than we have of the past sixty. But the revolution in child psychiatry is still relatively young, and I will begin by trying to sketch the somewhat erratic course it has taken so far.

If I dwell on the thought and influence of Freud, it is because I speak as a child psychiatrist; but I do not wish to minimize the contribution which outstanding people in other disciplines have made to our understanding of childhood. Piaget and Sears in the field of psychology, Mead in anthropology, Lorenz in ethology, and the Russian Pavlovians are a few of the people that come readily to mind. Freud, however, was the first to attempt to give us a body of scientific knowledge that would lead to a general psychology of man. The anthropologists, applying this knowledge to the study of culture and society, found that child-rearing processes furnished illuminating clues to an understanding of people and their institutions. The pediatricians learned to connect physical growth with emotional development, and the way was paved for Dr. Spock to write his bible on the subject of infant care. Whichever way we turn, we detect the seminal influence of Freud's discoveries.

Freud's investigations into the neuroses of adults forced him to reconstruct their early childhoods and provided clinical support for the old belief that "The Child is the father of the Man." His findings led him to frame not only a psychology of man but also laws of human development, and his contributions have completely changed our image of childhood. Gone is the sentimental view that childhood is an era of innocence and the belief that an innate process of development continuously unfolds along more or less immutable lines. Freud suggested that, from birth on, the child's development proceeds in a succession of well-defined stages, each with its own distinctive psychic organization, and that at each stage environmental factors can foster health and achievement or bring about lasting retardation and pathology.

This realization has placed new and complex responsibilities on parents, teachers, and community services. Many parents are now well aware how much their presence or absence, their words, their actions, indeed, their whole emotional state affect their children. This is an important gain. Unfortunately, it must be added that Freud's theories have also been widely misunderstood. For one thing, they have often been taken to mean that discipline should be suspended, controls eliminated—in sum, that the child should be continuously gratified. Freud, on the contrary, pointed out that denial and conflict were as essential a part of the process of growth as gratification, and he never minimized the child's need for direction.

There are two main reasons why this aspect of Freudian doctrine has been so seriously misinterpreted. In the first place, his early studies of neurosis, made in the bourgeois culture of the late Victorian era, brought to light the damaging effects of authoritarian parental control, moral overrestriction, and stifling prudery; and it was no doubt inevitable that his emancipatory discoveries should have encouraged a concept of child rearing which went overboard on the side of permissiveness.

A second reason for the confusion which has arisen is to be found in the path followed by Freud's own thought. In the early years, he concentrated on those factors in neurosis which stemmed from abnormal repression of the instinctual drives, the forces of the id. It was not until the nineteen twenties that he shifted the main focus of his investigations from the id to the role of the ego —the managerial aspect of man's psychic structure which seeks to align his instinctual drives and moral imperatives with reality. Now, when Freud's doctrine began to be widely propagated in the nineteen twenties, its publicists and popularizers were, at best, familiar only with his early work. They were the spokesmen of a cultural revolt which sought to discredit the moral prohibitions of the past, and they presented an often garbled version of Freud's early findings as a scientific justification of the cult of uninhibited "self-expression." Even today, few laymen are well acquainted with Freud's ego psychology, which emphasizes the organizing and integrating aspects of the ego. These later theories are very important to our understanding of the child. They show that the ego is not self-formative, and they clearly imply that the answer to the crippling restrictiveness of the past is not its diametric opposite, unqualified license.

In fact, Freudian psychology does not, as some people apparently imagine, provide a set of ready-made prescriptions for the rearing of children. It has forced us to take into account not only what the mother or teacher does to a child, but also how it is done; not only whether the mother nurses the baby and spends much time with him, but also whether she is able to give him gratification and support his strivings for mastery. The complexity of the interactions between mother and child cannot be reduced to rigid formulas. Love and understanding cannot be prescribed, and if they are not genuinely manifested, the most enlightened efforts to do what is best for the child may not be effective.

It is certainly encouraging to see how eager are millions of parents today to learn how they can contribute most to the development of their children; the upsurge of interest in this field is nothing less than extraordinary. But a note of caution must be sounded. It is a mistake to look for clearcut, universal answers on such issues as schedule feeding versus demand feeding, imposed toilet training versus demand training, discipline versus self-regulation. In every case, individual factors are involved, and one needs to know the specific quality of the parent-child relationship before recommendations can safely be made. The newspaper or magazine columnists who impersonally dispense answers to their readers' queries are likely to oversimplify the problems, and their advice could readily be misleading. The whole of Freud's contribution points up the complexity of human nature and the intricacy of the laws which govern the early phases of development. Whoever has understood a single page of Freud knows that he never dealt in facile prescriptions.

IT is only in recent years that child psychiatry—the term was first used in 1935—has become recognized as a specialty in its own right. In the past, children were treated as though they were small adults. Their mental disorders were approached with the same criteria as those clinically applied to adults; it was not realized that the same disorder manifests itself differently in a child than in a grown-up person, because the child's organism is different. Thus, until two decades ago, no one diagnosed schizophrenia in childhood, owing to the fact that the expected symptoms were not encountered. But systematic observation of children from birth on has enlarged our understanding of child development, and one of the consequences of our new knowledge is the discovery of schizophrenia in childhood. Indeed, tremendous progress has been made in helping schizophrenic children, even though the precise cause of the disease remains obscure.

Twenty years ago, very little was known about the nature of mental deficiency; children suffering from a wide variety of ills were lumped together as "mentally defective." Now mental deficiency is in the foreground of investigation and has been broken down into at least fifty categories. We have discovered many of the specific biological disorders which underlie some of these categories, and this is a first step toward devising appropriate treatment. Character disorders and the forerunners of neurotic symptoms can now be detected in the first few years of life. We have understood that they are bound up with specific life situations to which a child is struggling to adjust, and we treat them with encouraging results. There have' been studies of normal children who have 'to make an adjustment to pathology in the family or to a pernicious environment; of children whose own weaknesses, coupled with bad environmental conditions, are leading them into emotional pathology; and of children who are deeply disturbed within a normal environment.

Many research studies are collecting data which will corroborate, modify, or put in question our theories. Most of the studies are based on few cases, but each child is explored as intensively as possible. We hope that these researches will teach us more about the nature of native endowment and thereby help us to understand why various children react so differently to the same environment. Already we have been able to make a beginning toward classifying different patterns of functioning. These delineations of various types of children, based on intensive study of their psychic biographies, should eventually lead to far-reaching changes in child rearing. We will not treat the child according to general principles of what is "good for children," but will pay far greater attention to the differing needs of children with different native endowments.

A good example of the high cost of failure in this sphere is the problem of juvenile delinquency, which underlines the urgency of applying on a larger scale our existing knowledge about the causes of antisocial behavior. We do not, to be sure, know all of the factors involved in such behavior. But it is well established that its main sources are a disrupted home and a bad environment, which combine to prevent normal integration. If we were to tackle individual and social pathology early enough, the incidence of juvenile delinquency could be substantially decreased. Unfortunately, the emergency programs that are currently being applied are not infrequently confused or inappropriate.

One trouble is that the term "juvenile delinquency" fails to differentiate between the various sources of antisocial behavior. The delinquent may be suffering from a neurotic conflict in which aggression is wildly mobilized against society; he may be a young psychopath who has never developed an adequate sense of right and wrong—in clinical terms, he has a deficient superego. He may be suffering from organic difficulties which make him a slavish follower who simply carries out actions planned and directed by others. He may be an adolescent whose behavior reflects the pathology of his environment rather than any defect in his own psychic structure. Clearly, for each of the cases enumerated, different measures are required. To lump a variety of quite different problems, individual and social, under an oversimplified heading and apply to them the same program is not a particularly promising line of attack.

I said at the outset that we must make better use of the next forty years than we have of the past sixty if the twentieth century is 'really to be the century of the child. In November, 1959, the United Nations adopted a "Declaration of the Rights of the Child," setting forth the rights and freedoms which every child should enjoy. The minimal conditions outlined in the Declaration are a far-distant ideal for much of the world's child population. Even in a country as rich and advanced as the United States, two million children live in destitution in homes in which a parent is absent or ill..' It is estimated that more than half the children in foster care are emotionally disturbed, and for many of them the only' professional help available is a social case worker. Their disturbances are not temporary, like scarlet fever; they are conditions which will permanently affect the welfare of the child and the nation.

Four fifths of all counties in 'the United States still have no psychiatric services whatsoever. Fifty per cent of all clinics are concentrated in the Northeastern states, and only three percent of all psychiatric clinical services are located in areas with a population of under 2500. Studies of school children in various, cities indicate thai seven to twelve per cent of them—that is to say, between two and four million—are in need of psychiatric treatment.

The knowledge we have accumulated points up the importance of organizing resources for the protection and care of the very young child, and here our performance has been especially inadequate. The very young child does not ask for help; it is the responsibility of adults to recognize his need for it. But most parents, when they detect signs of emotional disturbance in a small child, assume—or, at any rate, hope—that he will somehow outgrow it. Thus, nearly all of the children who come to our professional attention are over the age of six, by which time their distress is so acute that parents or teachers can no longer avoid doing something about it. The situation is aggravated by the fact that, even among child psychiatrists, there are few who have been specially trained to handle the child of preschool age.

Perhaps the greatest lag in the field of mental health is the relative lack of action to implement our conviction that emotional health and pathology are determined in early childhood. More than half of all hospital beds in the United States are Occupied by mentally ill patients, yet there exist almost no institutional facilities for the emotionally disturbed preschool child. As long as we neglect the needs of the very young, we will continue to have a large population of adolescents and adults suffering from neurosis or the acuter forms of mental illness.

It seems to me not utopian to suggest that every community of a certain size should have a child health center, which would be equipped to diagnose and treat early disturbances, would assemble data of value to researchers, and would collaborate in various ways with nursery schools, social workers, child guidance services, and psychiatric clinics. We need, also, to set up research centers exclusively concerned with child development, where anthropologists, educators, pediatricians, psychologists, and psychiatrists would have opportunities to join in long-range, systematic research.

In psychiatry, as in other fields, the great advances in the application of knowledge have usually come through social change rather than through the immediate pressure of professional people. The French Revolution freed the mentally ill from chains and prisons. The progress recently made in the mental health movement was spurred by the wartime need for total mobilization; of the millions screened, so many were found to be uneducated or emotionally disturbed that the government was forced to concern itself more seriously with the quality of its manpower. Now President Kennedy has ordered the establishment of a child health center, which will engage in interdisciplinary research, mainly on the problem of mental retardation. This is an encouraging step. One can only hope that it is the beginning of public policies which will carry the thinking of the New Frontier over into the field of child psychiatry.