Todays pediatrician is the parent's first child psychologist. The parents turn to him or her with confidence for answers to their child's emotional problems.
This role is now generally accepted by all pediatricians, a role which has gradually developed in the past 40 odd years. Prior to that time the training of pediatricians in medical schools and pediatric hospital units was almost entirely devoted to the prevention, diagnosis and treatment of the physical ailments of infants and children. There were very few child psychiatrists and, to my recollection, no departments of child psychiatry in any of the hospitals or pediatric centers.
In 1945 a leading pediatric textbook devoted only one or two pages to its section on "Psychopathological Problems of Childhood." In this short discussion it briefly covered such subjects as antisocial behavior, emotional reactions, and school difficulties.
Slowly books on the emotional development of children began to appear, many read by parents and pediatricians alike: Infant and Child in the Culture of Today by Gerell and Hg (1943); The Parents' Manual by Anna Wolf (1941); The Nursery Years by Susan Isaacs (1937); and a most important book by a psychiatrist, The Rights of Infants by Margaret Ribble (1943).
Interest in the emotional development of children was expanding rapidly and in 1945 came Benjamin Spock's Common Sense Book of Infant and Child Care. Dr. Spock had both a pediatric and psychiatric background and in his book he combined these disciplines.
Soon most pediatricians began to take an interest in the emotional development of children and the problems that occur during childhood and adolescence. Also, the parents started turning to the pediatrician for answers or direction on many of the questions that arose concerning their children. Why were they having disciplinary problems? Why was their 5-year-old child still bed-wetting? Why was their child so hyperactive? Why was their child inattentive in school? Why was he or she so aggressive or negative? Why did the child have such problems learning to read? Why did a child do so poorly in school? Why did the boy or girl have so few friends? These were only a few of the questions brought to us by parents, and we were expected to give them answers.
Then the question arose - how many of these questions was the well-trained pediatrician capable of answering, and how many should be referred to further study and direction by child psychologists or psychiatrists?
It used to be much easier to make such decisions, for almost all pediatricians made house visits. In the home we were able to view a child in his or her environment, the father-mother relationship, their attitudes toward the child, sibling adjustment, and the general atmosphere in which the child was living.
Many, if not most of us have, however, developed a fairly good understanding of the emotional needs of children and a knowledge of what to expect of them developmentally at various ages.
But one fact we must be aware of is that if we sincerely and accurately wish to understand a child's emotional problems the examination cannot be rushed. It cannot be adequately performed in a limited period of 30 or even 40 minutes.
A great deal depends upon the age of the child and the nature of his or her emotional disorder. We must obtain a detailed history from the parents, we must know the child's birth history and the physical development through the years, the developing emotional pattern, sibling and peer relationships and many other important factors. If of school age, the child's teacher should also be questioned. You may wish to observe a young child in the waiting room, and you may wish to question an older child without parents present.
Many pediatricians weighed down by a patient load may find this a difficult assignment. But if they want to give their best to the boys and girls under their care such attention is essential.
Psychological assessment of our patients, however, is only the first step. The second step, if we find treatment indicated, is how to handle the disorder. Is the pediatrician capable of handling the problem by him or herself or should the child be referred for further specialized professional help?
Many of the minor problems can be successfully handled by a well-trained, interested and devoted pediatrician. At times, under special circumstances, pharmacotherapy is indicated. Examples are the use of Imipramine for enuresis, and methylphenidate (Ritalin) or pemoline (Cylert) for attention deficit disorders.
This issue of Pediatric Annais will discuss the latest information on a number of common psychiatric problems and should clarify this area of pediatric practice. The Guest Editor is Dr. Mina K. Dulcan, Assistant Professor of Child Psychiatry, and Associate Director of Residency Training in General and Child Psychiatry at the University of Pittsburgh. She is also Associate Medical Director for Outpatient Services of the Child Psychiatry Treatment Service of the Western Psychiatric Institute and Clinic, Pittsburgh, Pennsylvania.
The first three articles in this symposium deal with the evaluation of children during various periods of development. The last article discusses the pharmacotherapy of the ADD disorder of childhood and adolescence.
The first article - "The Developmental Assessment of the Preschool Child" is written by Dr. Michael G.G. Thompson, Associate Professor of Psychiatry at the University of Toronto, and Executive Director of the West End Creche Child and Family Clinic, Toronto, Ontario.
This article clearly details the various approaches pediatricians can use in evaluating the infant and young child largely through observation and play techniques.
When we realize how many of the emotional problems of the years that follow are founded on early childhood experiences, the importance of the pediatrician in recognizing and correcting the difficulties becomes evident.
Dr. Thompson directs the assessment of the young child first through observation of temperament, activity and mother-child relationship, and developmental adequacy.
The various office tests recommended are simple and easily performed in the pediatrician's office. These include physical skills, alertness, language development, and power of perception.
The second article deals with the assessment of the school age child. It is authored by Dr. David A. Brent, Assistant Professor of Child Psychiatry, Western Psychiatric Institute and Clinic, Pittsburgh, Pennsylvania.
Dr. Brent begins by noting that the child with a psychiatric disorder may differ from the normal child in that there is a strong tendency for the disorder to persist, it is usually accompanied by some other difficulties such as poor school performance or poor peer relationships, or the child exhibits signs of distress.
The evaluation must be based on the combined information gathered from the child, the parents, and the child's school. To this must be added the pediatrician's observations.
The third paper discusses the assessment of a child with problem behavior during adolescence. It is written by Dr. Dorothy Otnow Lewis, Associate Director of Adolescent Psychiatry, and Professor of Psychiatry at the New York University Medical Center, New York, New York.
All experienced pediatricians realize that the teenage years are usually the most difficult and dangerous years from a behavioral point of view. Most of the problems relate to aggressive tendencies but these are often years where depression and suicide are prevalent.
Dr. Lewis notes the care with which the evaluation of adolescent maladjustment must be made. She states that many of these boys and girls who come for an assessment have had a variety of problems in the past. She describes very clearly the manner in which to interview adolescents. A misdiagnosis may be dangerous.
The fourth paper is by Dr. Mina K. Dulcan, the Guest Editor. She deals very comprehensively with the subject of "Attention Deficit Disorder: Evaluation and Treatment."
The diagnosis of attention deficit disorders has recently been subdivided into three types: with hyperactivity, without hyperactivity, and residual. This syndrome is not new to the pediatrician and many of us previously attributed it to what was termed "minimal brain dysfunction." We first tried to alleviate the problem by studying each case for environmental causes but when correction of this was ineffective we found that certain drugs were helpful. The hyperactivity subsided, the children became more attentive, the attention was maintained. The first drug used was dextroamphetamine (Dexedrine); later came methylphenidate (Ritalin) and still later pemoline (Cylert).
Dr. Dulcan discusses the pharmacology of these drugs and the favorable results of studies comparing their effect and that of placebos.
In this excellent and interesting review the shortterm effects are first presented - the motor effects, cognitive effects and interpersonal effects, such as classroom disruption. Following this are the longterm results and side effects.
Also included in this discussion is the question of when to medicate for attention disorders and hyperactivity and how to initiate medication. Furthermore, once a child has adjusted to the proper therapeutic dose, how long should treatment be maintained?
Dr. Dulcan concludes with the statement that with appropriate evaluation and monitoring the treatment is safe and efficacious in relieving some of the symptoms of ADD in children and adolescents. Statements in the article are well-documented.
Throughout this whole symposium the pediatrician should realize that although a number of psychiatric disorders may be corrected by the use of drug therapy, many patients will still require psychotherapy. The pediatrician, as the child's first psychological advisor, must make the decisions which, at times, may greatly influence the future of a human being.