The field of child mental health in general and child psychiatry in particular is a relatively recent one. Work in the area increased dramatically in the 20th century with an explosion of knowledge over the past several decades in particular. This body of work draws on various, sometimes distinctive and sometimes overlapping, historical and professional traditions, including the expanding knowledge about both normative child development and developmental processes as well as about the origins, expression, and treatment of psychopathology. Parts of the field have their origins in the social welfare movement and the concern for better approaches to juvenile justice. Another contribution stems from long-standing concerns for children with significant intellectual deficiency (mental retardation). All of these efforts had their origins in an interest in children and their development that had begun in the 1700s and was fueled by concerns for the education of future citizens and decreasing rates of child mortality.

Interest in understanding children’s development can be traced to ancient times. Several different models of development were proposed. The prefomationists included individuals such as Hippocrates who assumed that body structured in the embryo were formed simultaneously. Others, such as Aristotle, suggested that development was more dynamic with the embryo formed by a series of transformations and differentiations (Hunt, 1961). Preformationist thought continued well into the 1600s when, with the development of the microscope, small humans were initially seen in views of human sperm (Figure 1.1)!

The period referred to as the Enlightenment in the 18th century had a major impact on changes in many areas, including an increased interest in education of citizens in the newly independent United States. The Enlightenment was not a single movement, and indeed, many of the philosophers central in it had divergent and sometimes contradictory views. For example John Locke, the Scottish physician and philosopher, was interested in education and psychological development. He suggested that babies are born with a mind that is a blank slate (“tabula rasa”) upon which experience and growing conscious awareness shape the developing child. For him, education was therefore essential. Although agreeing with Locke on the importance of education, in contrast, the philosopher Jean-Jacques Rousseau believed that children were innately good and that a corrupt society contributed to their difficulties.

In the 19th century, the growing emphasis on education, attempts to reform child labor laws (as well as concerns about slavery), and an expanding interest in women’s rights (including the right to an education) had a major impact. Darwin’s work on evolution revolutionized psychology as well as biology. Darwin was interested in psychological development in men and animals (and published a book on facial expressions in man and animals) to clarify potential biological relationships. His interest in children also reflected an awareness that, to some extent, children’s development has important similarities, particularly at the embryologic level, to evolutionary development. Darwin also kept a detailed diary of one of his children’s development. His work inspired subsequent psychologists, including Freud as well as individuals such as G. Stanley Hall, who tried to understand child development in an evolutionary context.

Reduced rates of infant and child mortality also meant that more children survived to need educational and other services. Beginning in the 19th century, several factors contributed to reducing mortality rates. These included better nutrition; housing; sanitation; various public health efforts (e.g., the mechanisms of disease pathogenesis became clear); the development of immunizations to prevent frequent, serious childhood infections; and, finally, the development of antibiotics. Before the 1800s, child mortality in general and infant mortality in particular were high, with considerable fluctuation reflecting epidemics, famine, conflict, and other factors. Probably at least one-third of infants succumbed to illness on average.

Pediatrics began to develop as a specialty with the growing awareness of differences in medical care in younger patients reflecting differences in physiology and drug metabolism. Hospitals for the care of sick children began to be established in Europe and the United States. These physicians were also increasingly concerned with fostering children’s development and providing practical guidance to parents.

Interest in intellectual deficiency and mental retardation also contributed to the development of the various child mental health specialists. Although recognized since antiquity, scientific interest increased as attempts were made to understand the underlying brain basis of
severe cognitive impairment. For example, the English anatomist Thomas Willis related intellectual deficiency to small brain size, and by 1866 John Down suggested that the syndrome that now carries his name (trisomy 21) reflected an evolutionary throwback in development. Inspired by Darwin, individuals in the Eugenics movement suggested the idea of improving society through selective breeding (see Gould, 1996).

A different, and more optimistic, approach to the care of mentally retarded individuals arose in France where work by Itard on the so-called feral child Victor (Figure 1.2) stimulated his interest in the remediation of significant developmental difficulty. He inspired the French physician Édouard Séguin, leading to a new approach in classifications and attempts to improve functional outcome. Sequin immigrated to the United States and had a profound influence on the development of intervention programs. In the United States, a series of special institutions, originally focused on rehabilitation of developmentally disabled children, developed. Other such institutions were established to care for children with blindness or deafness. A professional organization was established in 1876 that became what is today the American Association on Mental Retardation. The development of the first reliable tests of intelligence by Binet and Simon (see Chapters 3 and 5) also contributed to earlier identification of less
severely impaired children with developmental delays. Clinics for the care of children with developmental difficulties began to be established in the late 19th century. Although the development of institutions and better approaches to assessment were positively intended, both led to abuses. Intelligence tests were used, sometimes highly inappropriately, to bolster the efforts of the Eugenics movement and, over time, the many negative effects of institutionalization also became apparent In the United States, G. Stanley Hall, a pioneer psychologist and educator, began to use new approaches to studying normative development. He used questionnaires to assess what children had learned and to document their interests and activities. He used this information to help teachers understand development. The growing child study movement led to the establishment in the early 20th century of a number of research centers across the country. Around this time, the length of children’s years of education began to increase as increase in technology required a more educated workforce. Hall’s work influenced many of the next generation of researchers, including Arnold Gesell and Gesell’s student, Benjamin Spock.

Children who had difficulties with the law became a focus of increased concern. In the early 1900s, Healy established a clinic that advised the juvenile court regarding children. Healy’s psychologically informed approach proved influential. He collaborated with a number of individuals, including Jane Adams, whose work at Hull House in Chicago served as a base for the development of social work as a discipline. Healy eventually moved to Boston, where he and a colleague founded the clinic supported by the Judge Baker Foundation. Around the same time, Arnold Gesell, one of the first PhDs in developmental psychology, moved to Yale, where he completed medical and pediatric training and founded what would become the Yale Child Study Center. In contrast to Healey’s work, that of Gesell strongly emphasized the recognition of innate factors in development. Gesell conducted innovative work in charting normal development in infants and younger children using techniques such as still frame movie cameras to examine more precisely the aspects of infant motor development. His work had a profound influence on pediatrics, education, and childrearing practices. The contrasting views of various individuals, each emphasizing either biological or environmental factors, paralleled an earlier debate on the relative contributions of nature versus nurture (see Chapter 2). These tensions continued theoretically (e.g., in the tensions among theories of development grounded in behaviorism and psychoanalysis).

The increased interest in children with developmental, mental health, and legal issues led to the establishment of the American Orthopsychiatric Association in the 1920s. This organization strongly supported the importance of interdisciplinary collaboration in child mental health work. The interface of mental health issues with pediatrics led to the formal establishment of child psychiatry as a discipline. Although psychiatrists such as Maudsely in the 1800s had recognized the childhood onset of major psychiatric difficulties, it was only in 1930 that Leo Kanner was recruited to Johns Hopkins to serve as a liaison between pediatrics and psychiatry there. Kanner had strong connections to both departments and wrote the first textbook of child psychiatry. Among his many accomplishments was his pioneering work in pediatric consultation-liaison psychiatry (see Chapter 26) and the recognition of autism as distinctive conditions (see Chapter 4). Before World War II, pediatricians were beginning to spend time training in child psychiatry as fellows in various sites across the country. At that time, psychoanalytic influences also became strong and were further strengthened by an influx of European psychoanalysts before and after the war. Shortly after the war, the federal government established the first training grants. As the Child Guidance clinics increased, so did the need for psychiatrists with specialized pediatric training. The American Academy of Child Psychiatry was established in 1953, and by 1957, the field was recognized as a subspecialty of psychiatry with standards for training and board examinations and its own journal.

Over the past century, a number of attempts have been made to provide broad, overarching theories of development. Typically, these approaches draw on one or more perspectives in their attempt to account for the complex interplay of biological and experiential or psychological
factors that play a role as children grow and develop. These approaches vary in a number of respects. Some focus more on one aspect of development (emotional or cognitive), and others are more concerned with mechanisms (e.g., of learning). Although many early theories, such as Freud’s, were concerned with early development, subsequent work has often extended these theories to other aspects of the life cycle (e.g., Erik Ericson was inspired by psychoanalytic theory and provided an overarching model for development from infancy to old age).

An increased awareness of the complexity of both genetic and experiential mechanisms and their interaction has also clarified important issues in development. For example, genes may change in their function over time. Specific environmental factors may have more effects at some points than at others. For example, early exposure may predispose some children to develop allergic responses. Another complexity arises because some traits, behaviors, and features may reflect a stronger genetic or psychological component. Environmental factors, including both endogenous and exogenous ones, may contribute, in varying degrees, to development. The idea of experience-dependent plasticity has been used when there are strong effects of experience at certain points in development. A child deprived of vision early in life may later have trouble, if sight is restored, in coordinated use of the eyes and perception of depth and three dimensions. Finally, of course, development occurs in family-societal contact. The environment that children experience is itself partly shaped by the parents’ experience and endowment.

All theories of development face several important challenges. How is the interplay between endowment (nature) and experience (nurture) to be understood (see Chapter 2)? How and why does change happen? Is development continuous or discontinuous? For example, for a theorist such as Piaget who proposes rather major changes in cognitive functioning over childhood, what accounts for these changes? Relating theories to age and normative expectations presents another challenge. Early studies of child development were initially concerned with documenting normative processes. It became possible to describe typical behavior of a 1-year-old child simply by evoking age as an explanation. Given major changes and developmental accomplishments, it is typical for presentations on children’s development to be constructed around intervals that are roughly age defined (e.g., infancy, toddler, preschool, school age, adolescent). Although understandable, this type of exposition tends to perpetuate the notion that somehow developmental change is caused by age alone. Over time, the field has moved from an initial focus on simple measures and age-related correlation to more sophisticated approaches. Although many broad theories of development have been postulated, a recent trend has been the focus on very specific aspects of development. In this chapter, we briefly summarize three major theories of development that have had a major impact on the field—psychoanalysis, Piaget’s cognitive theory, and learning theory.