State of Child and Adolescent Psychiatry 50 Years Ago

The development of child and adolescent psychiatry in the first half of the 20th century was well described by Achenbach (1974), Cameron (1956), Kanner (1959), Parry-Jones (1989) and Warren (1974) with respect to both its strengths and limitations. The establishment of community child guidance clinics, much influenced by the Mental Hygiene movement, had the value of viewing psychopathology in the context of young people’s real-life circumstances. The cost, however, was that there was both geographical and professional isolation from general psychiatry, pediatrics and academic research. Most treatment tended to be very open-ended and prolonged, usually without a well-defined focus (Rutter, 1982a). There tended, also, to be a rigid separation in the functioning of the unholy trinity of the psychiatrist, the psychologist and the psychiatric social worker. In addition, there was a tendency to blame parents for the disorders of their children – as indexed by concepts of the schizophrenogenic mother (Jackson, 1960) and “refrigerator” parents (Bettelheim, 1967), in relation to schizophrenia and autism, respectively. The dominant theories were the several varieties of psychoanalysis (Eisenberg, 2001), clinical practice was mostly not evidence-based, and there was a paucity of specific treatments (Chess, 1988). Furthermore, very little attention was paid to diagnosis. The prevailing terminology concerned “maladjustment” and official classifications referred only to “behavior disorders of childhood. ” However, very important changes were afoot (Rutter, 1998). Although systematic diagnosis was not yet in fashion, Kanner (who wrote the first definitive English-language textbook in 1935) had already done much to foster critical thinking about different patterns of psychopathology and to encourage a questioning approach (as exemplified by his 1969 paper on differential diagnosis). Also, his first description of autism (Kanner, 1943) not only provided a model of top-level clinical observation, but established the reality of a disorder that was distinctively different from others. Similarly, approaching diagnosis psychometrically rather than clinically, Hewitt and Jenkins (1946) wrote a pioneering monograph identifying different patterns of psychopathology. The tide was beginning to turn with respect to both diagnosis and classification in both child and adult psychopathology (Meehl, 1954). Although biological causes had only a very limited role in clinical thinking at that time, Pasamanick and Knobloch (1966), in relation to their concept of a continuum of reproductive casualty, postulated the importance of prenatal and perinatal risk factors. Studies of children with epilepsy as, for example, by Pond (1961) and by Ounsted (1955) were also influential in pointing to the interplay between biological and psychosocial risk factors. The concept of so-called “minimal brain dysfunction” was beginning to be established. It did not stand the test of empirical investigation (Rutter, 1982b) but, nevertheless, it did force people to pay attention to biological risk factors. In the realm of treatment, the value of stimulants in the treatment of children with hyperkinetic disorders was beginning to be appreciated and, in adult psychiatry, neuroleptics were starting to be developed for the treatment of schizophrenia. At about the same time, there was the birth of behavioral therapies (Wolpe, 1958). At first, these were largely considered in relation to adults, rather than children, but the application to children soon followed (Rachman, 1962; Yule & Berger, 1972). Academic child and adolescent psychiatry scarcely existed in the 1950s although there were some chairs in the subject in North America and mainland Europe and there were the beginnings of systematic clinical research (Hersov, 1986; Remschmidt & van Engeland, 1999; Schowalter, 2000). However, the report that probably did most to change the field in a radical fashion was Bowlby’s (1951) review of “maternal deprivation” for the World Health Organization. Spitz and Goldfarb had previously drawn attention to the damaging effects of institutional care but Bowlby drew on a much wider range of evidence and did most to pull together the ideas. For quite a while, his views were treated with extreme hostility by both academic psychologists and by psychoanalysts. The former pointed to the weakness of much of the research and the latter to the heresy that the causal factors lay in real-life experiences rather than internal conflict. Despite the controversies, Bowlby’s observations on young children’s responses to separation from their parents led to enduring changes in hospital practice. Professionals, almost for the first time, were forced to become aware of young