CHILD PSYCHIATRY

The study, treatment, and prevention of psychiatric disorders of childhood—including transient reactions, habit disturbances, conduct disturbances, neurotic traits, neuroses, and psychoses.The psychiatric disorders of children received little attention before the present century. In his long-accepted classification Kraepelin made no mention at all of children’s disturbances, simply assuming that they belonged in the adult categories. Little if any treatment was given at his time or before, since, as Rosen and Gregory (1965) put it, these disorders were “regarded fatalistically as the irreversible results of hereditary degeneracy, excessive masturbation, overwork or religious preoccupation.”In the early 1900s several developments took place which focused attention on the child and his problems. Freud and Meyer began to emphasize the effect of childhood experiences on later adjustment, and as a result, the biographical history became an important part of every psychiatric examination. Groups of educators in Germany, Austria, and Switzerland, inspired by the early educators Pestalozzi and Von Fellenberg, established remedial programs dealing with learning and behavior problems. In France Binet advanced the study of the individual child by developing the first effective intelligence test. In the United States the first juvenile courts were established, and in 1909 the first systematic investigations of disturbed and delinquent children were made by William Healy.At about the same time the mental- hygiene movement began to emphasize the prevention of mental illness during childhood, and by the early 1920s child guidance clinics had been established in a number of cities. However, it was not until the 1930s that the first modern book on child psychiatry was published by Leo Kanner. In the years that followed, increasing attention was given to child disorders, leading to the discovery of special reaction types, such as infantile autism; the development of special treatment techniques, such as activity group therapy and play therapy; the establishment of specialized treatment facilities, including residential centers and children’s departments in mental hospitals; and attempts to create a milieu in the home, school and neighborhood that would foster mental health.The classification of children’s disorders remains a key problem. Many of these disturbances, such as symbiotic psychosis, enuresis and school phobia do not fall within the standard adult categories. Some psychiatrists have even abandoned formal diagnosis in favor of terms which describe outstanding symptoms, such as “hyperactive and impulsive.” As Noyes and Kolb (1963) point out, “Since there is less fixity of patterns of disturbed behavior because of the plastic personality of the child, there is less unanimity in regard to the diagnostic schemata for the disorders of childhood than for those of adulthood.” The American Psychiatric Association classifies the disorders that cannot be directly related to major adult syndromes as adjustment reactions of infancy, childhood, or adolescence and puts them under the general heading of “transient situational personality disorders.” The infancy reactions include undue apathy, excitability, feeding difficulties, and sleeping difficulties resulting from emotional deprivation or other injurious conditions in the family. The childhood reactions include habit disturbances (thumbsucking, nail-biting, masturbation, temper tantrums, enuresis), conduct disturbances (truancy, lying, fire-setting, stealing, destructiveness, cruelty, sexual offenses, use of alcohol), and neurotic traits (tics, somnabulism, overactivity, stuttering, specific fears, school phobia). The adolescent reactions comprise rebellion, vacillation, mood- swings and other emotional behavior.The Group for the Advancement of Psychiatry (GAP) has recently (1966) proposed to replace the three broad groupings of the APA with the following descriptive categories: (1) healthy responses (normal variations in all areas; transient developmental and situational crises, such as separation anxiety and grief reaction); (2) reactive disorders (arising out of illness, accident, hospitalization, parental attitudes); (3) developmental deviations (lags, unevenness, or precocities; deviations in motor, sensory, speech, cognitive, psychosexual, affective, and social functions); (4) psychoneurotic disorders (anxiety, phobic, conversion, obsessive-compulsive, dissociative, depressive reaction types); (5)personality disorders (compulsive, hysterical, anxious, overly dependent, oppositional, overly inhibited, overly independent, isolated, mistrustful, impulse-ridden, neurotic, antisocial); (6) psychotic disorders (early childhood: infantile autism, symbiotic psychosis; later childhood: schizophreniform reactions; adolescence: acute confusional states,schizophrenic reactions); (7) psychophysiologic disorders (covering all body systems, and including, among others: neurodermatitis, rheumatoid arthritis, bronchial asthma, migraine, ulcerative colitis, reactive obesity, dysmenorrhea, idiopathic epilepsy, vertigo); (8) brain syndromes (acute, due to infection, poison, trauma, and chronic, due to cerebral palsy, syphilis, convulsive disorder); (9) mental retardation (caused by biological defect or environmental and psychological conditions, or both). This classification and that of the APA indicate the wide variety among children’s disorders. The major types are discussed in this volume under separate topics.The lack of uniformity in identifying and classifying children’s psychiatric disorders makes it extremely hard to estimate their incidence. Moreover, the statistics we have are largely confined to cases which the parents recognize and bring to the clinics. Nevertheless a few broad though tentative findings can be reported. In general, most clinics see two to three times as many boys as girls, possibly because boys exhibit more aggressive symptoms that disturb the parents or the school. Several studies have shown that more patients in child clinics come from middle and upper economic levels than from lower levels, although this may be a function of the ability to recognize psychiatric disorder. The over-all estimates of the number of children who need attention or care for emotional maladjustment, mild or severe, hover around 20 per cent. According to The National Committee against Mental Illness (1966), about four million children under fourteen need some kind of psychiatric help, and from one half to one million are so severely disturbed that they need immediate treatment.The incidence of different disturbances, as well as the age at which they occur, varies widely. Persistent bed-wetting becomes a problem (enuresis) only after the age of four or five, but this difficulty may recur during a stressful adolescence. Restless sleep, disturbing dreams, physical timidity, and demanding of attention all tend to have two periods of high frequency, one in the pre-school years and the other in late pubescence. Speech difficulties, temper tantrums, and specific fears are most commonly reported at age three to three and a half; while overactivity and destructiveness reach their peak at about five. The normal “developmental stuttering” that occurs between two and four years of age must be sharply distinguished from the persistent, pathological form that reflects emotional tensions and conflicts in later childhood. Nail-biting is a problem among about 40 per cent of girls and 33 per cent of boys; it increases in frequency till about eleven in girls and somewhat later in boys.There are two distinct forms of school phobia: the one occurring on entering school is considered a form of “separation anxiety”; the other, occurring in later childhood, is usually found in families with deeply disturbed parents who cannot handle their children. It is important to distinguish tics of psychogenic origin from those resulting from encephalitic disease; similarly, functional hyperactivity must be differentiated, if possible, from overactivity associated with brain damage, epilepsy, or mental retardation. Masturbation is practiced by over 90 per cent of children, but is a symptom of emotional disturbance in only a small number.As indicated in the GAP classification cited above, all the major neurotic syndromes are found among children, though they occur far less frequently than among adults. The same theory applies to child neurosis as to adult neurosis—that is, the symptoms are interpreted as defenses against anxiety. Many children have neurotic personalities but no full-blown neurosis. As a rule, these children tend to be shy, self-conscious, inhibited, conformist, and afflicted with feelings of insecurity and inadequacy, often as a result of excessively high standards imposed by the parents. Most forms of affective psychosis are rare before age fifteen, though psychotic depressions are sometimes observed in childhood and early adolescence. Psychoses resembling simple schizophrenia are more prevalent; the major symptoms are withdrawal, autistic thinking, and loss of affect. See SCHIZOPHRENIA (CHILDHOOD TYPE),EARLY INFANTILE AUTISM, SYMBIOTIC PSYCHOSIS.The behavior disorders or conduct disturbances of childhood consist of various forms of persistent delinquency, sexual deviation, and addictions to glue- sniffing, kerosene or gasoline sniffing, codeine cough syrup, and benzedrine inhalers. The addictions of childhood do not usually have the permanence of addictions in adolescence and adulthood. Stealing, vandalism, fire-setting, and other conduct disorders are often interpreted as a way of acting out problems and bidding for attention and help. In some cases antisocial behavior may be associated with school failure caused by learning disturbances. See BEHAVIOR DISORDERS, JUVENILE DELINQUENCY.Infancy and early childhood are a peak period for organic brain syndromes, which may produce either temporary or permanent damage to the central nervous system. Minimal brain injury, often of unknown origin, is believed to be one of the major causes of learning and behavior disorders; severe brain lesions of the congenital type may result in more obvious defects such as blindness, paralyses, cerebral palsy, or mental deficiency—all of which may have lasting effects on personality and behavior. Brain lesions occurring after birth may result in partial or complete arrest of intellectual development, loss of sensory or motor functions, and behavior disorders. Most of the acute brain syndromes are due to high fevers and convulsions associated with infectious diseases, but some cases may follow head injury, cerebral- vascular accidents, intracranial tumors, or toxic disorders such as lead poisoning, which may be associated with pica. Chronic brain syndromes, which may lead to mental deterioration, speech defects, and behavior problems, are largely the result of epidemic encephalitis, juvenile paresis, and epilepsy. The incidence of epilepsy among school-age children is estimated at seven per one thousand. The brief, mild attacks known as pyknolepsy may disappear spontaneously; other seizures may continue unless controlled by sedation. In a study of 1640 cases, Lennox (1949) found that 67 per cent were of normal intelligence, 23 per cent slightly subnormal, and only 10 per cent severely deteriorated. See MINIMAL BRAIN DYSFUNCTION, BRAIN DISORDERS, EPILEPSY, JUVENILE PARESIS, EPIDEMIC ENCEPHALITIS, PICA.Since etiology and treatment are discussed under the separate disorders, we will give only a brief overview of these topics. As to the problem of causation, biological factors are most prominent in hereditary types of mental retardation, in brain disorders due to rubella (German measles) and other congenital conditions, in difficult births, in head injuries, and in brain inflammations that occur during infancy and early childhood. Some investigators (Bender, 1947; Goldfarb, 1961) suggest that brain abnormalities may underlie childhood schizophrenia, while others (for example, Rimland, 1964) also apply this theory to infantile autism, though neurological tests have so far been inconclusive. Twin studies on preadolescent schizophrenia (Kallmann and Roth, 1956) suggest the possibility of hereditary influences, since the concordance rate between monozygotic twins is much higher than between dizygotic twins of the same sex. Others, such as Shields and Slater (1960), claim similar results in twin studies on children with juvenile delinquency, behavior disorders, and neurotic traits. Stott (1959, 1962) believes he has found evidence that “prenatal stress” can be a major factor in reading and learning disabilities which are accompanied by withdrawal, lack of confidence, and poor motivation; and Kawi and Pasamanick (1959) found a significant percentage of obstetrical complications among the mothers of boys afflicted with severe reading problems. As noted in our article on juvenile delinquency, Glueck and Glueck (1956) found a suggestive relationship between delinquency and an athletic, “mesomorphic” body build.As to psychological factors, it seems true that only a minority of functional disorders are due to single traumatic events, such as the sudden death or desertion of a parent, sexual assault, or other intensely frightening experiences. Far more often the emotional disturbances of children appear to be associated with a progressive weakening of the personality by such long-term conditions as neglect, coldness, excessive criticism, maternal overprotection (especially when accompanied by feelings of rejection), and favoritism toward another sibling. This general finding is supported by the fact that a high percentage of children treated in child guidance and juvenile delinquency clinics come from broken homes. There is also evidence that a lack of “mothering” may be a major factor in schizoid and schizophrenic reactions. See MATERNAL DEPRIVATION.Recent personality studies, using the MMPI, have indicated that parents of child patients show considerably more disturbances than parents of normal children, and presumably create an injurious psychological environment (Marks, 1961; Wolking et al., 1964). In cases of juvenile delinquency, the parents were often found to be outwardly conforming yet inwardly rebellious—which suggests that they may unconsciously encourage antisocial behavior in their children as a vicarious gratification of their own impulses (Johnson, 1959). Wolking et al. (1964) also found a possible relation between neurotic tendencies in parents and in their children—boys with conversion reactions tended to have hypochondriacal fathers, and girls and boys with psychosomatic symptoms were often found to have mothers with similar problems. All these studies, however, are still in their early stages. See MINNESOTA MULTIPHASIC PERSONALITY INVENTORY Sociocultural factors are even harder to assess. Far too little data is available on child disorders in different cultures and on different social levels. A few suggestive studies of child-rearing practices have been made, however. Davis and Havighurst (1946) found lower- class parents more permissive, relaxed, and undemanding than middle-class parents—but more recent studies (Klatskin, 1952; Sears et al., 1957) describe middle-class mothers as more gentle and less punitive than working-class mothers, especially on such matters as toilet training, dependency, sex training, and expression of aggressive impulses. The middle-class mothers were also somewhat warmer, more demonstrative and democratic toward their children, and less likely to reject them. A study by Kohn and Carroll (1960) showed that middle-class mothers expected their husbands to be more encouraging and supportive than disciplinarian toward their children; working-class mothers, on the other hand, wanted their husbands to be authoritarian and directive, though the men themselves often avoided this role and left the childrearing responsibilities entirely to their wives. Most important, from the point of view of delinquency, is the fact that lower-class boys usually found it much harder to identify with their fathers than middle-class boys.Since the beginning of this century the field of child therapy has gradually broadened, and today it is possible to select the approach which seems most likely to meet the needs of the individual child. Among the many techniques are: (1) play therapy, in which the young child is encouraged to release his emotions and test out new ways of behaving through the use of play materials in a permissive and accepting environment; (2) activity group therapy, in which older children achieve self-understanding and develop constructive relationships through group activities; (3) environmental manipulation, such as sending the child to a boarding school, or placing the child in a carefully chosen foster home when the family situation is intolerable; (4) remedial work with children who have learning and reading problems, including those with brain dysfunction; (5) individual supportive therapy involving such techniques as persuasion, suggestion, and direct guidance; (6) individual nondirective therapy, in which a therapeutic relationship is established and the child is encouraged to draw on his own capacities and create a more satisfying self-image; (7) learning theory or behavior therapy, which reinforces healthy behavior and extinguishes unhealthy patterns, such as nail-biting or stuttering; (8) milieu therapy, which utilizes a total residential setting in the treatment of retarded, delinquent or emotionally disturbed children (Alt, 1960); (9) relationship therapy, in which maladjusted children are given an opportunity to develop warm and satisfying relationships with a therapist, house- parent, or other child-care worker; (10) team therapy in child guidance clinics,with a psychiatrist treating the child and a social worker counseling the parents; (11) family-centered therapy, in which the same therapist treats the child, his parents and his siblings. See RELEASE THERAPY, PLAY THERAPY, ACTIVITY GROUP THERAPY, FAMILY THERAPY, BEHAVIOR THERAPY, RELATIONSHIP THERAPY, MILIEU THERAPY, MINIMAL BRAIN DYSFUNCTION.