Like many medical students before me, I had been deeply moved and troubled by my first encounters with the life-shattering onset of schizophrenia in young adulthood: such pain and disorientation in the mind, at such a promising era of life. There simply had to be better ways to reduce the morbidity of these illnesses for these young people and their families, or at least to catch them before they crested Holden Caulfield’s cliff.

Such thinking drew me away from pediatrics and adult psychiatry, and into working with ever younger children, looking earlier and earlier for when to help and how to comprehend their distress. I eventually found myself standing at NICU bassinettes with anyone I could find who could help me fathom how things could go so wrong, so fast, and so often for children. Luckily, I found smart, humane mentors in people like Al Solnit and Sally Provence who discouraged simplistic formulations and helped me embrace the complexity of early experience with all the intellectual rigor I could muster.

It struck me from the beginning that child and adolescent psychiatry had it right. It was onto something vitally important; the earlier the better—for diagnosis, treatment, parent guidance, and whatever we could do to help families grow with their vulnerable children. It also struck me as extremely shortsighted to dissect out the child—even intellectually—from the family for diagnostic studies, economies of time, convenience of intervention, or cost containment. Such myopia was like a celestial navigator trying to identify a constellation by fixing on but one star with his sextant; then as now, a really good way to get good and lost.

So how could one stay on course in this odyssey to effective intervention and prevention? Is it better to consult the gene map (nature) or the family tree (nurture) as primary navigational aids? From the beginning of developmental mental health explorations in the 1920s and 30s, child psychiatry seemed destined to distrust the facile nature vs. nurture dichotomy offered up as dogma by so many behavioral scientists. Careful clinical investigations and longitudinal inquiry fell short again and again of affirming it as the best way to formulate helpful interventions.

Contemporary science has further relieved us of this distraction, helping us to conceptualize the dichotomy less as competition, and more as dialogue or transaction. It has proven more illuminating to investigate how we nurture nature than to officiate at a face-off between the two. Tierney et al. highlight clearly the interaction between environment and genome as accounting for more of the variance in clinical outcomes of illness than either genetics or environment alone (1). The compelling studies by Caspi of G(ene) × E(xperience) (2), and Kaufman (3) of gene interactions and environmental modifiers of depression in children provide elegant empirical grounding to that effect. Taken together, their work addressing G × E
interactions between severity of child abuse, 5HT transporter polymorphisms, and outcomes of depression and conduct disorder have profound implications for future societal and mental health intervention.

The outcomes of well designed longitudinal studies of young children and families at risk also encourage us to focus on this discourse between gene and environment so that we can design more effective and relevant service, policy, and research agendas. Sroufe concludes from his Minnesota Study of Risk and Adaptation from Birth to Adulthood that “early history is not destiny, important as it is … [D]ata suggest a renewed focus on the lived experience of the child and [less] preoccupation with inherent biological variations (4).”

This perspective protects us from too narrow a focus on the behavior of the child as we struggle to understand how to decrease the morbidity of psychopathology and increase resilience around vulnerabilities. Hechtman’s discussion of the research into long-term outcomes of childhood disorders encourages us to cast a broad net as we hunt for salient factors affecting outcome that extend well beyond behavior (5). She reminds us to look beyond age, gender, IQ, comorbid conditions, physical, and emotional health to include socioeconomic status, family function, and composition, and child rearing practices.

It is the need to capture this complexity—not to avoid or oversimplify it—that defines child psychiatric clinical competence. We have tried to conceptualize this visually in textbook after textbook by drawing concentric circles outward from the child to include all the factors that shape development, per se; particularly when we adhere to classical definitions of development as the melding of genetic predisposition, or maturation, with experience. But such visuals typically fall short, because as Spitz so efficiently summarized, “Maturation is a useful concept, but in reality there is only development (6).” In the end, it is the environment that processes any given child’s genetic blueprint, through maturation, into lived experience.

Herein lies the core purpose in diagnostic and intervention strategies: encompass and embrace the complexity of the child’s experience to understand and treat, while fully incorporating age and circumstance. This is precisely what obligates the researching and treating physician to employ the child-, family-, and systems-centered approach embraced in this textbook.

Families render humans human. Era-specific developmental forces within the family and the child define the salient relationships and intimacies that draw the infant into the human race, one human transaction at a time. The family in all its permutations ultimately embraces that child’s maturational promise and, through powerful reciprocal forces, converts tissue, synapse and instinct into human development. Although family processes seem linear (from birth and growth to decline and death, repeated through each generation), family process itself appears more helical. Each generation must accommodate to its own unique life cycle agenda simultaneously. Consequently, it may be more helpful to visualize family processes as intertwined developmental courses, not unlike Watson and Crick’s double helix. Running parallel, the generations develop together, intimately connected to, but nevertheless distinct from, other generations in the family.

Another way to imagine the development of the family maintains this helical image, but consists of different conceptual strands. One axis is the trail of generational myths, expectations, attributes, memories, and secrets—the family’s “givens.” This is the family’s narrative about itself, so eloquently described by Pincus and Dare (7) and Vangelisti (8). The narrative evolves much like folk songs in the oral tradition, passed on at home, as children are taught who and what their family is now, has been, and is hoped to be.

The other axis is the family’s forward progression through time in its own life cycle. This encompasses the usual stresses and opportunities of the family’s children’s developmental requirements and the intrusion of “fateful events.” How the family copes with the course of development, accidents, and intrusions from outside and within is determined in part by whether these two axes intersect at strong or weak points. Real trouble seems most likely when a vulnerable stretch on the transgenerational axis intersects with an equally vulnerable stretch on the developmental axis. For example: A family narrative axis carries the myth/expectation that “Jones boys always marry wild women” at a time when, on the developmental axis, the Jones’ first born son is starting his adolescence by easing up on his academic discipline and testing behavioral boundaries. He tells his parents progressively less about his life and whereabouts (appropriately), especially where girls are concerned and voilà—his and his family’s fantasies about “wild women” fuse and sparks fly.

Family development as a dynamic phenomenon is particularly hard to embrace because clinicians tend to encounter families at just one nodal point in time, depriving them of critical longitudinal perspective. Research suggests strong links between early loss, trauma, and disturbance in the family and later interpersonal dysfunction (9,10,11). At any given time in our interaction with a family, we may be uncertain about which direction the causal links may be moving (such as whether a vulnerable child destabilizes the family, or vice versa) (12). Nevertheless, we are wise to keep in mind that most mental illnesses are not the result of a sole inborn factor, or some single extraneous perturbation, but rather the multiply determined end result of human development gone awry, which has become apparent at some seemingly discrete moment.

Sociologists have suggested that current cycles of family life are undergoing accelerating change. Lower birth rates, substantial (though declining) divorce rates, increasing remarriage rates, and longer life expectancies have reduced childbearing from being the major occupation of parents to what is now less than 50% of parents’ lifelong commitment.

Typically, historians urge caution whenever referring to “unprecedented change.” Demos (13), and Laslette and Wall (14), have dispelled the myth of the ideal three-generational family holding sway in pre-industrial family life. Nevertheless, a social process has occurred over the past several hundred years, and in particular over the past few decades, that has effected major changes in family functioning. Hareven summarizes: “Through a process of differentiation, the family gradually surrendered functions previously concentrated within it to other social institutions. During the pre-Industrial period, the family not only reared children, but also served as a workshop, a school, a church, and an asylum”(15) (p. 460). The difficulties faced by contemporary families are rooted in this diminished capacity to adapt and cope (partly because of smaller size) and the further narrowing in the range of the family’s socioeconomic functions and independence.

The declining maternal and child death rates of the 1950s, combined with a higher marriage rate and longer life span created a higher percentage of children growing up in stable, two-parent families than had ever occurred in America’s history. Beginning with the next decade, however, multiple determined trends began to reshape the ideal and real traditional nuclear family. The sexual revolution uncoupled the societal association of sexual and reproductive behavior, particularly for women. From 1971 to 2002, the percentage of unmarried American girls 15 to 19 years of age who engaged in sexual intercourse rose from 28% to 60%. Second, married women
with children moved into the paid workforce: There was an increase from the 1960 level of 19% of married women with children younger than 6 years of age in the labor force to a real figure of 66% in 2001. Historian Robert Griswold noted that these forces, combined with attitudinal changes toward coparenting, have brought increasing numbers of fathers into the nurturing domain (16).

Fertility and fecundity also declined in the United States beginning in the 1960s. We are now at levels lower than those necessary for the replacement of the population, having moved from an average of 3.7 children per woman in 1960 to 1.79. Increased child survival over the last century, combined with women having their first children later, may also be contributing to families having fewer children.

The divorce rate in America, though currently slowing, brought us past a landmark in 1974, when for the first time in our history, more marriages concluded in divorce than in the death of a spouse. The percentages of unmarried couples, same-sex couples, serial and stepfamilies, and single-parent families (single by choice or not) have all increased, whereas nuclear unit percentages continue to decrease.

Finally, it is the opinion of many clinicians and researchers that the quality of life for children in the past 30 years has not improved at the same rate as it has for adults. Also, rates of distress seem to be on the rise. Achenbach and Howell studied the changes over 13 years in the prevalence of children in the general population with behavioral/emotional problems (17). They found more untreated children who needed psychological intervention in the 1989 sample than in the 1976 sample. The 2005 Kids Count Report by the Annie E. Casey Foundation documented a downturn in child well-being trends with increasing child poverty, infant low birthweight and mortality, and a teen death rate increase over the previous five-year report. This suggests that the trend noted by Achenbach has yet to reverse itself.

Though family structure continues to evolve to include different constellations, the majority of children continue to long for meaningful relationships with both biological parents in, his or her life (18). The family structure that is most influential in the child’s development, however, is the one perceived by the child as his or her family, not the one perceived by the Census Bureau.

Many contemporary statistics illustrate an important, irreducible fact about change in the American family: Mothers are in the labor force to stay. The 2003 Bureau of Labor Statistics report documented that 16% of all married couple families have a wage-earning father and a stay-at-home mother; the number was 67% in 1940 (19). Child rearing families also tend to receive more societal and economic support when both parents are committed to the job in all its complexity. Families have changed, yet the institutions the families rely on most heavily, schools and the workplace, have been slow in responding to these changes in the family system.

Each child who enters the family changes it permanently and irreversibly, rendering the child’s perception of the family unique to his or her own experience. Sameroff and Fiese have helped us move away from the restrictions of the linear, interactional model of child development, and toward one that better encompasses the progressive, dynamic, reciprocal forces that have helped children change families and vice versa (20). Their “transactional model” emphasizes the need for incorporating social and economic as well as biological forces. Proposing a “continuum of caretaking causality,” such increased emphasis on the qualitative aspects of the nurturing domain, has encouraged clinicians and researchers to think anew about who in the family is doing what with the children, and not simply how long they are doing it.

The Berkeley Adult Attachment Interview (21) in its application to family development (22) serves as an example of growing skill in our capacity to assess the adult’s state of mind (and not simply his or her behavior) with regard to attachment to his or her children, and vice versa. The interview for the Adult Attachment Classification System is done separately with mother and father. This is an example of how we are returning to the exploration of the overriding significance of the quality, sensitivity, and intent of the nurturing interaction, and not merely the biological predispositions of the interactors. Mothers, fathers, grandparents, aunts, uncles, and siblings—all form unique attachments to children that, in formative settings, are welcomed and easily integrated by the child into a mosaic of consistent, predictable, comforting internalizations of the nurturing experience. Therefore, internalization of the nurturing experience, be it positive or negative, is not merely the result of a single adult attachment.

Optimal child development is fostered by optimal family development, whatever shape that family takes. This occurs by translating the recognizable maturational stages of child development into the transactional modalities and developmental dynamics of the family. Optimal family development, as perceived by the child, begins with a secure individual relationship, which the infant typically makes with its primary caregiver, typically the mother. Fathers as primary caregivers, however, certainly have the capacity to rear their children without placing them at developmental risk (24,25,26). Radin and Harold-Goldsmith cite the advantages to young children of paternal involvement, independent of the reasons for the father’s presence (27). The other optimal phenomenon for promoting development in the family network consists of the capacity of mothers and fathers to form reciprocal, empathic relationships with the child, aided by a broad and complete range of affective expression. Both parents must be ready to accept developmental progression and change, because it comes rapidly, particularly in the first year, aided by appreciation for the child’s idiosyncratic traits, temperament, skills, and vulnerabilities.

Much clinical literature, however, falls short in its attempts to clarify distinct maternal and paternal antecedents to psychological syndromes. For example, although Bezirganian et al. found that maternal overinvolvement, paired with maternal inappropriateness, combined to form pathogenic predispositions toward borderline personality disorder in children (23), paternal measures, which were included, were not commented on in their discussion.

Despite the dramatic increase in the number of publications on fathering since the mid-1980s (28), fathers continue to be vastly underrepresented in the literature, though fathers are now more engaged with their young children than in any era since the Industrial Revolution; the father’s share of childcare more than doubled between 1965 and 1998 (29). A typical example of how this remains neglected in the literature: A major prospective, longitudinal study on parental psychopathology, and parenting styles as related to the risk of social phobia in children failed to include any data on fathers (30).

Phares and Compas reviewed research papers in the major journals dealing with clinical child development published from 1984 to 1991 and found that nearly half of all studies involved mothers only (31). Nearly one-fourth of the remaining studies did include father-related material, but did not differentiate its effects. The final one-fourth did measure father–child effects and found them consistently present. So
when researchers do bother to look for father effects, they typically find them. The authors suggested that the over-reliance on mothers as research participants has fostered not only an incomplete data set with regard to child development, but also one that is heavily gender biased because “relations cannot be found among variables that are not investigated (31).” (p. 406)

As the child psychiatrist works to understand the child’s experience, despite such lacunae in the literature, he or she is best served by viewing the family as a system, in which change in one segment of the family resonates throughout the system; negative or positive change in one segment promotes or discourages development in others. Families must “raise the children” while socializing their young, balancing risk and protective factors (32), and simultaneously meeting the demands of rapidly evolving maturational forces in the child. It is crucial, then, to appropriately evaluate the family system’s potential for preparing its children for adulthood.

Skinner et al. created the Family Assessment Measure, consisting of a general and dyadic scale to distinguish reliably between normal and problem families (33). Mrazek et al. developed the Parenting Risk Scale, which uses a semistructured interview to rate difficulties and concerns regarding parental commitment, knowledge base, control, psychiatric disturbance, and emotional availability (34). Fleck described an efficient, five-factor method for assessing the system’s capacity to support the development of its children, consisting of a) leadership, b) boundaries, c) emotional climate, d) communication, and e) the establishment and accomplishment of goals and tasks throughout the life cycle (35). As we begin to examine the family’s development across the life cycle, it is critical to remain conscious of these five factors.

Leadership is the decisionmaking, facilitating source of power and discipline used by the parents who lead the family unit. It is shaped by the presence or absence of mutual support and esteem, and by the effectiveness of the communication between the leaders of the family unit. Leadership itself is quite complex, as seen in the work of Minuchin, who has tracked its migration between family members and generations depending on the particular mix of strengths, vulnerabilities, or developmental demands that are preoccupying the family at any given moment.

Family boundaries refer to boundaries a) within the individual that define the self, b) between generations, and c) between the family and the community. It is important that these boundaries be semipermeable, permitting contact and discourse with others outside the family boundary. Self- and generational boundaries remain relatively stable throughout the life cycle, whereas family/community boundaries must become increasingly permeable as children cross them with increasing frequency to participate in the community around them.

The emotional climate or affectivity of the family unit is the connective tissue that binds the family together as a functioning entity. It sustains—or erodes—the family’s capacity to care for and support one another, especially since the family has ceased to be such a self-contained economic unit. Chronic scapegoating of a family member, child abuse, and neglect are classic signs of failure in the family’s emotional climate.

Communication within families is verbal and nonverbal. Communicative language and its uses for deepening relationships are learned best within the family, assuming a healthy emotional climate. Experiences and affect are shared through the medium of language, whereas values and culture are differentiated and reinforced by the consistency, tone, and content of communication within the family.