Pediatric Annals

A Pediatrician's View

Milton I Levine, MD

Abstract

The role of the pediatrician as the parents' adviser in the emotional care of the child is of comparatively recent origin. Until approximately 30 years ago, the training of the pediatrician in medical schools and pediatric hospital units was devoted almost entirely to the prevention, diagnosis, and treatment of the physical ailments of infancy and childhood. There were very few child psychiatrists and, to my recollection, no departments of child psychiatry in any of the pediatric centers.

The pediatric textbooks were just beginning to discuss the emotional problems, and a primary textbook used by pediatricians who entered practice in 1945 had a section on "PsychoPathological Problems of Childhood." It devoted only a page or two to such subjects as antisocial behavior, emotional reactions, and school difficulties. There were several organizations interested in the emotional care of the child, among them the Child Study Association of America in New York City, the American Institute of Family Relations in Los Angeles, and the Association for Family Living in Chicago. These were staffed by child psychologists, and to them many pediatricians referred their "problem children" and their mothers for psychologic advice.

From the staffs of these organizations, and from individual psychologists, a great many books on the emotional development of children began to emerge. Some of us pediatricians read and absorbed the material written.

Some of these were Infant and Child in the Culture of Today, by Gesell and Hg (1943); the Parents' Manual, by Anna W. M. Wolf (1941); The Nursery Years, by Susan Isaacs (1937); In Defense of Children, by Bert I. Beverly (1941); and a very important book by a psychiatrist, The Rights of Infants, by Margaret Ribble (1943).

The field was ripe for the publication of Benjamin Spock's Common Sense Book of Infant and Child Care (1945). Dr. Spock was a pediatrician who also had a psychiatric background, and he combined these two areas in this book for parents. This book quickly superseded all others for parents in acceptance and popularity.

The quick and wholehearted acceptance of this book coincided with the new era of child care that many of us had sought - an era in which pediatricians were interested not only in the physical condition of the infant and child but in the emotional development as well. But the focus essentially was on mothering. Fathering was still years off, and child care was still thought to be a female occupation. As a matter of fact, many fathers paid little attention to the infant until he was at least three months of age. To many of them the child was little more than an animated vegetable. (And there was presumably scientific literature to back them up, such as a report in 1942 that the newborn's eyes were farsighted and incapable of form or even pattern discrimination and the assertion in 1952 that behavior noted in the first weeks of life was based purely on reflexes.)

The recognition of the father as an integral part of the new family unit came only gradually.

At first, some hospitals left the shades up in the nurseries whenever fathers were visiting so they could stand outside the window and watch their newborn infants as much as they desired. And then, in the mid- 1940s, the idea of rooming-in took root. The mother had her newborn in her room most if not all of the time, and the father could come and hold the baby, diaper him, and grow to know his child and relate to him from the very beginning of his life. Thus there was the concept of a complete family…

The role of the pediatrician as the parents' adviser in the emotional care of the child is of comparatively recent origin. Until approximately 30 years ago, the training of the pediatrician in medical schools and pediatric hospital units was devoted almost entirely to the prevention, diagnosis, and treatment of the physical ailments of infancy and childhood. There were very few child psychiatrists and, to my recollection, no departments of child psychiatry in any of the pediatric centers.

The pediatric textbooks were just beginning to discuss the emotional problems, and a primary textbook used by pediatricians who entered practice in 1945 had a section on "PsychoPathological Problems of Childhood." It devoted only a page or two to such subjects as antisocial behavior, emotional reactions, and school difficulties. There were several organizations interested in the emotional care of the child, among them the Child Study Association of America in New York City, the American Institute of Family Relations in Los Angeles, and the Association for Family Living in Chicago. These were staffed by child psychologists, and to them many pediatricians referred their "problem children" and their mothers for psychologic advice.

From the staffs of these organizations, and from individual psychologists, a great many books on the emotional development of children began to emerge. Some of us pediatricians read and absorbed the material written.

Some of these were Infant and Child in the Culture of Today, by Gesell and Hg (1943); the Parents' Manual, by Anna W. M. Wolf (1941); The Nursery Years, by Susan Isaacs (1937); In Defense of Children, by Bert I. Beverly (1941); and a very important book by a psychiatrist, The Rights of Infants, by Margaret Ribble (1943).

The field was ripe for the publication of Benjamin Spock's Common Sense Book of Infant and Child Care (1945). Dr. Spock was a pediatrician who also had a psychiatric background, and he combined these two areas in this book for parents. This book quickly superseded all others for parents in acceptance and popularity.

The quick and wholehearted acceptance of this book coincided with the new era of child care that many of us had sought - an era in which pediatricians were interested not only in the physical condition of the infant and child but in the emotional development as well. But the focus essentially was on mothering. Fathering was still years off, and child care was still thought to be a female occupation. As a matter of fact, many fathers paid little attention to the infant until he was at least three months of age. To many of them the child was little more than an animated vegetable. (And there was presumably scientific literature to back them up, such as a report in 1942 that the newborn's eyes were farsighted and incapable of form or even pattern discrimination and the assertion in 1952 that behavior noted in the first weeks of life was based purely on reflexes.)

The recognition of the father as an integral part of the new family unit came only gradually.

At first, some hospitals left the shades up in the nurseries whenever fathers were visiting so they could stand outside the window and watch their newborn infants as much as they desired. And then, in the mid- 1940s, the idea of rooming-in took root. The mother had her newborn in her room most if not all of the time, and the father could come and hold the baby, diaper him, and grow to know his child and relate to him from the very beginning of his life. Thus there was the concept of a complete family unit from the very outset.

Later still, the Lamaze method of natural childbirth became known and popularized. In this approach, the husband goes to classes with his wife during the wife's pregnancy, and both prepare for cooperative duties during the period of labor. The father also goes into the delivery room and is with the mother during the birth of the baby.

Fathering, as well as mothering, was beginning to be seen as an essential ingrethent in child rearing, child development, and child behavior.

This change was reflected in the fields of psychology and psychiatry as well. Instead of treating the child alone for a behavior disorder or working only with the parents, practitioners began to employ family therapy, whereby the family was treated as a unit with occasional individual treatment.

Today, although we still speak of mothering and fathering, the term parenting is being used more and more. For it is the influence of both parents - individually and together - mat determines in the largest part the emotional development of the child and, with it, his behavior.

This issue of PEDIATRIC ANNALS is the first of two issues devoted to parenting and its effect on child behavior. It is under the guest editorship of Dr. David Belais Friedman, Professor of Pediatrics and director of the Division of Family and Child Development at the University of Southern California School of Medicine, and of Dr. Hershel K. Swinger, Assistant Professor in the Graduate Program in Rehabilitation Counseling at California State University in Los Angeles. Drs. Friedman and Swinger are project codirectors for the U.S. Department of Public Health, Education, and Welfare's Resource Demonstration Project on Child Abuse and Child Neglect in the HEW Region IX (California, Nevada, Hawaii, Guam, and Trust Territories in the South Pacific).

In arranging the symposium that follows, Drs. Friedman and Swinger have written "bridges" between each subject, showing the connection between one contributor's article and the article that follows.

The first article, "Parenting: A Developmental Process," is by Dr. Friedman and Alma S. Friedman, a pupil services counselor of the Los Angeles School System. The authors emphasize that parents as well as children go through developmental processes and that these differ for each child born. The stages of parent development are specified, as are the parental tasks during each of these periods.

The following article, on "Temperament and the ParentChild Interaction" should be of special interest to the practicing pediatrician, for those of us who have followed many infants since they were born have long realized that children show differing degrees of temperament and activity from birth. We used to tell parents that they had a "hypertonic baby" or a "placid baby."

The authors of this article, Dr. Stella Chess, Professor of Child Psychiatry, and Dr. Alexander Thomas, Professor of Psychiatry, are both at the New York University School of Medicine. Together they began reporting on the temperamental individuality of children almost 20 years ago. They have continued to write on the subject since.

In the present article they discuss the effect of the child's temperament on the parents' attitude and behavior. Naturally a parent is much more relaxed and secure in bringing up a placid, easy child than a difficult hyperactive child. Drs. Chess and Thomas point out that no single set of child-care directions is adequate or even desirable for all infants. They further emphasize that in parentchild problems the parents can frequently be helped by understanding that a child's temperament exists independently and that they do not bear the full responsibility for his behavior.

The next contribution, on "Parenting Styles, Child Behavior, and the Pediatrician," is by Dr. Robert W. Chamberlin, Associate Professor of Pediatrics, University of Rochester School of Medicine, Rochester, N.Y. The author discusses the authoritarian versus the permissive method in the upbringing of children and the problems in attempting to study their effects on child behavior. He concludes that there is no simple cause-and-effect relationship between these styles of upbringing and the behavior of children, as long as extremes are avoided - although there is ample evidence of lasting emotional trauma from neglect and abuse. Dr. Chamberlin warns pediatricians against making snap judgments. He cautions them against focusing on certain specific activities - such as toilet training, sucking, or weaning - or on one diagnosis, such as cerebral dysfunction, as being the only cause of behavioral difficulties.

This is followed by a fascinating article, "Counseling Parents About Day Care," by Peggy Daly Pizzo, day-care consultant of the Coalition for Children and Youth, Washington, D.C. Statistics show that over 14 million children under the age of 14 are in some form of day-care arrangement more than 10 hours a week. The author carefully studies the stresses that lead parents to select day-care facilities for their children and demonstrates how such care relieves much of this stress. She presents evidence that formalized day care does not impair the child's attachment to his mother, and she specifies definite beneficial effects. Finally, Ms. Pizzo discusses how physicians can help when parents seek their advice on the possibility of making day-care arrangements for their child.

The final two articles in the present symposium deal with parenting in families of minority groups, especially in lowereconomic circumstances. The first article, on "Parenting the Black Child," is by Dr. Phyllis Harrison-Ross, Professor of Clinical Psychiatry at the New York Medical College; the second, on "Parenting: Special Needs of LowIncome Spanish-Surnamed Families," is by Teresa Ramirez Boulette, R.N., Ph.D., outreach coordinator for the Santa Barbara County (Calif.) Mental Health Services.

In the first contribution, on parenting the black child, Dr. Harrison-Ross has written an article that, in my opinion, should be read by all people - not just by physicians and not just by black parents and those concerned with the welfare of black persons. This article is of such importance that I hope it will be republished for wide distribution, especially to those engaged in lawmaking, schools, health-care facilities, and the achievement of effective integration. As pediatricians, probably the most emotionally sensitive of all physicians, we must do everything to help parents counteract the effects of a racist society on their children. Dr. Harrison-Ross is the author of the book The Black Child - A Parent's Guide, in which she lists numerous ways in which black parents can continually work and play with their children in a building-up process.

The last article, by Dr. Boulette, covers the special needs of low-income Spanish-surnamed families. This is also an important article, especially for those of us who care for children of these families in our practice or in clinics. Although the author states that little empiric research specific to these families has been reported, she presents a careful study of the problems facing the parents and, more particularly, the children. She lists the prejudice-poverty concomitants that influence their child-rearing practices, such as maternal deprivation, absent fathers or stressful fathering, and the early burdening of the older children with rearing of younger siblings. Dr. Boulette encourages the reader to understand and accept the specific cultural values and practices of the Spanish-surnamed population. This is the primary consideration if we wish to influence their parenting in a positive manner.

The symposium will conclude in October with an issue devoted to "Parenting and the Behavior Disorders of Childhood."

10.3928/0090-4481-19770901-04

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