Pediatric Annals

A Pediatrician's View

Milton I Levine, MD

Abstract

I hate to admit it, because it dates me, but I was there. 1 was there during the whole period of the development of interest in the emotional care of children. When I was in medical college, the text we used was the 1925 edition of Holt's Diseases of Infancy and Childhood, * in which the approach to children was rigid and restrictive. As an example, in the treatment of masturbation, the tying of the hands and legs to the corners of the crib was advised, and among other treatments suggested were circumcision, separation of the head of the prepuce from the clitoris, and dorsal slitting of the prepuce of the penis. In obstinate cases cauterization of the clitoris "and even blistering the inside of the thighs, the vulva or the prepuce is sometimes useful." In serious cases, suggests the same book, "send the child away from home and keep him from other children."

It is also interesting to note that through my early years of practice one book was read by all the mothers - The Care and Feeding of Children2 - by the same noted pediatrician, L. Emmett Holt, of Johns Hopkins University. This book, first published in 1895, was the most popular book for parents during the next 40-odd years. It, too, was rigid. If a baby refused his vegetables, the mother was advised to stop all other foods until the child was starved into submission. Thumb sucking was to be prevented by the use of metal mitts that covered the hands or by metal restraints on the elbows that prevented them from bending.

And then, in the late '20s, Sigmund Freud made his imprint as a result of his psychoanalytic investigations. He concluded that during the development of the child, three areas of the body - the mouth, the genitals, and the anus - were at various times absorbing areas of erotic pleasure and satisfaction. Freud taught that during the first year or two of a child's life, for example, the zone of erotic - pleasure was located in the lips and mouth.

Following Freud's presentation of his observations, pediatricians and child psychologists began to study the child's activities in the light of these new concepts. Gradually the attitude of pediatricians toward such things as finger sucking and masturbation changed; the rigid restraints once advocated by Holt were replaced by an attitude of great leniency. The 1933 edition of Holt's textbook, for example, stated that "masturbation should not be painted as a shameful thing, but a physiological process to be brought under control like excreta are brought under control." The 1940 edition of the book argues against physical restraints or any punitive treatment.

It should be remembered that until the mid '40s, pediatricians did not consider themselves concerned with the emotional problems of children.. Those were the days before antibiotics and the days before inoculations or vaccines against measles and poliomyelitis. Pediatricians were almost entirely involved with the physical problems of infants and children and, with few exceptions, had neither the time nor the interest nor the background to discuss emotional problems with parents.

And then, in the mid-'30s, an interesting flurry was caused among those engaged in the care of children by John B. Watson, a psychologist at Columbia University. He expounded the theory that we should prepare our children from infancy for the hard knocks they would receive later in life. If the baby cries, said Watson, don't pick him up or rock him or pat him - let him cry it out and learn to realize that he cannot gain his way by…

I hate to admit it, because it dates me, but I was there. 1 was there during the whole period of the development of interest in the emotional care of children. When I was in medical college, the text we used was the 1925 edition of Holt's Diseases of Infancy and Childhood, * in which the approach to children was rigid and restrictive. As an example, in the treatment of masturbation, the tying of the hands and legs to the corners of the crib was advised, and among other treatments suggested were circumcision, separation of the head of the prepuce from the clitoris, and dorsal slitting of the prepuce of the penis. In obstinate cases cauterization of the clitoris "and even blistering the inside of the thighs, the vulva or the prepuce is sometimes useful." In serious cases, suggests the same book, "send the child away from home and keep him from other children."

It is also interesting to note that through my early years of practice one book was read by all the mothers - The Care and Feeding of Children2 - by the same noted pediatrician, L. Emmett Holt, of Johns Hopkins University. This book, first published in 1895, was the most popular book for parents during the next 40-odd years. It, too, was rigid. If a baby refused his vegetables, the mother was advised to stop all other foods until the child was starved into submission. Thumb sucking was to be prevented by the use of metal mitts that covered the hands or by metal restraints on the elbows that prevented them from bending.

And then, in the late '20s, Sigmund Freud made his imprint as a result of his psychoanalytic investigations. He concluded that during the development of the child, three areas of the body - the mouth, the genitals, and the anus - were at various times absorbing areas of erotic pleasure and satisfaction. Freud taught that during the first year or two of a child's life, for example, the zone of erotic - pleasure was located in the lips and mouth.

Following Freud's presentation of his observations, pediatricians and child psychologists began to study the child's activities in the light of these new concepts. Gradually the attitude of pediatricians toward such things as finger sucking and masturbation changed; the rigid restraints once advocated by Holt were replaced by an attitude of great leniency. The 1933 edition of Holt's textbook, for example, stated that "masturbation should not be painted as a shameful thing, but a physiological process to be brought under control like excreta are brought under control." The 1940 edition of the book argues against physical restraints or any punitive treatment.

It should be remembered that until the mid '40s, pediatricians did not consider themselves concerned with the emotional problems of children.. Those were the days before antibiotics and the days before inoculations or vaccines against measles and poliomyelitis. Pediatricians were almost entirely involved with the physical problems of infants and children and, with few exceptions, had neither the time nor the interest nor the background to discuss emotional problems with parents.

And then, in the mid-'30s, an interesting flurry was caused among those engaged in the care of children by John B. Watson, a psychologist at Columbia University. He expounded the theory that we should prepare our children from infancy for the hard knocks they would receive later in life. If the baby cries, said Watson, don't pick him up or rock him or pat him - let him cry it out and learn to realize that he cannot gain his way by crying. And don't kiss or hug the child. If you must show affection or approval, pat him on the head. Also, dig a hole in your back yard and let your creeping youngster fall into it. Don't help him out even if he cries and cries. Stay out of sight and let him creep out of the hole eventually by himself. He must learn in those early months and years how to meet and conquer adversity.

A good many parents and even some pediatricians were influenced by Watson, but this coldblooded method of child care went out of use after about five years.

It should be mentioned also that through the '40s and into the *50s there were organizations, such as the Child Study Association of America in New York and the Association for Family Living in Chicago, staffed by child psychologists, whose purpose was to advise parents on treatment of the behavior difficulties of their offspring. Pediatricians were asked and even urged to send mothers and their problem children to them.

Early in the 1940s, a fairly large number of important books on child development were published and were read by an increasing number of pediatricians. Among these was The Rights of Infants, 3 by Dr. Margaret Ribble, brought out in 1 940. She emphasized that mothers should devote themselves to their infants' emotional lives and psychologic needs more than many earlier authors had advocated. In 1943, the important book by Drs. Arnold Gesell and Frances Hg, of Yale University, was published, Infant and Child in the Culture of Today.* This was an excellent guide to the physical and emotional development of children at specific age levels.

In 1932, a tall young doctor joined our pediatric staff at New York Hospital. He had an excellent pediatric background, but one thing I especially remember about him was that he had been a member of the Yale rowing crew that had become world champions. His name was Benjamin Spock, and he remained on our staff until 1947. He developed an interest in the emotional care of children and would spend long sessions in the clinic advising parents. I further remember that in the early '40s he would spend his summers in the Adirondacks writing a book with the assistance of his wife. He never divulged the subject of this book - at least, not to me. But in 1944 I was among those to whom he brought the manuscript for criticism and suggestion.

This manuscript, Common Sense Book of Baby and Child Care,5 presented a new approach to pediatrics. When it was published, in 1945, it quickly changed the way a whole generation of parents brought up their children and influenced their future pediatric care as well. The rigidity of former days was replaced by flexibility and relaxation. Mothers were reassured of their own ability rather than criticized or threatened. Parental warmth and the happiness of the child were given primary consideration. Dr. Spock's book, then, provided an impetus to pediatric interest in the emotional care of children in addition to their physical care.

I must add that in 1953 Drs. Harry and Ruth Bakwin published a book on this subject specifically for the pediatrician, The Clinical Management of Behavior Disorders in Children.6 Since then the interest in the psychologic aspects of child care has grown rapidly. Most medical colleges and pediatric centers now have child psychologists and psychiatrists on their staffs; pediatric conferences and roundtables are devoted to the subject, many under the auspices of the American Academy of Pediatrics.

Today the well-rounded pediatrician is prepared to accept the responsibility of diagnosing and advising parents on most of the emotional problems of their children, referring the more complex cases to child psychologists and psychiatrists.

As a magazine of continuing pediatric education, Pediatric Annals has from time to time devoted issues to the subject of child behavior. Almost three years ago two excellent issues devoted to parenting and child behavior were presented by Dr. David Bêlais Friedman and Dr. Hershel K. Swinger.

This issue of PEDIATRIC ANNALS is the first of two to present additional aspects of the psychosocial problems in pediatrics. Both of these issues will be under the guest editorship of Drs. Stanford B. Friedman and Richard M. Sarles, of the University of Maryland School of Medicine. They are Director and Associate Director, respectively, of the Division of Child and Adolescent Psychiatry; Dr. Friedman is Professor of Psychiatry and of Pediatrics, Dr. Sarles Associate Professor.

The three articles in this issue deal with the office management of behavior and emotional problems in children and adolescents. The next issue oí the magazine will contain articles on depression, problems created by the divorce of the parents, and psychologic factors in parenting.

The first article in this issue deals with behavioral problems encountered in the office practice of pediatrics. The authors are Drs. Greg Prazar, pediatrician at the Exeter, N.H., Clinic, and Evan Charney, pediatrician-inchief of the Sinai Hospital of Baltimore. This is an overall view of the pediatrician's part in the care of emotional problems and his plan of action. It is noted that today most parents look to the pediatrician for counseling and guidance. Dr. Prazar notes that he depends on pediatric nursepractitioners for the care of well babies in his clinic, while the pediatrician devotes himself to the sick child and to counseling.

Drs. Prazar and Charney present a plan of action that can be used by the pediatrician in the office management of children with behavioral problems, noting that the child's complaints must be kept confidential but that there must also be provision for some feedback to the parents. Indications for referral when the child needs more intensive care are noted.

The second contribution is by Dr. Friedman and Judy Haran, M.S. W., an Assistant Professor of Psychiatry at the University of Maryland School of Medicine. This article, which continues the discussion of office management begun by Drs. Prazar and Charney, notes the advantage the pediatrician has in understanding and treating emotional problems of a child, since often he has watched the child grow from infancy and has built a relationship with the family. Dr. Friedman and Ms. Haran note that in treating the behavioral difficulties of children, other members of the family - the parents and siblings - must always be taken into consideration. Positive reinforcement of favorable behavior is advised and illustrated and specific directions presented for handling various problems of children and adolescents.

The third article deals with the interviewing of adolescent patients and was contributed by Dr. Jean Smith, of the Divison of Behavioral Pediatrics at the University of Maryland School of Medicine, and Dr. Marianne Felice, of the Division of Adolescent Medicine at the University of California School of Medicine in San Diego. This contribution is a guide to pediatricians on relating to adolescents, the most resistant of all age levels. It is stated that the pediatrician must not take sides in family disagreements and that whatever the teenager says will be held in confidence. This excellent paper aims primarily at improving the interviewing skills of the pediatrician in dealing with teenagers. What is the problem? Who is most bothered by the problem - the teenager, parents, or teacher? Clarification of the problems and successful treatment become the major tasks of the pediatrician who will spend the necessary time. The results will usually be rewarding.

REFERENCES

1. Holt, L. E. The Diseases of Infancy and Childhood. New York: D. Appleton & Co., 1925.

2. Holt, L. E. The Care and Feeding of Children, 12th edition. New York: D. Appleton & Co., 1924.

3. Ribble, M. The Rights of Infants. New York: Columbia University Press, 1940.

4. Gesell. H., and Ilg, F. Infant and Child in the Culture of Today. New York: Harper & Row, Publishers. 1943.

5. Spock, B. Common Sense Book of Baby and Child Care. New York: Hawthorn Books, 1945.

6. Bakwin, H., and Bakwin, R. The Clinical Management of Behavior Disorders in Children. Philadelphia: W. B. Saunders Company, 1953.

10.3928/0090-4481-19800601-03

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