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A History of Child and Adolescent Psychiatry in the United States

A History of Child and Adolescent Psychiatry in the United States

Next month in Miami, the American Academy of Child and Adolescent Psychiatry will hold its 50th anniversary meeting. In recognition of this event, the following is a brief history of the organization and of this subspecialty (Schowalter, 2000, 1994).

Most historians of child psychiatry date its beginning in this country to 1899, when Illinois established the nation's first juvenile court in Chicago. This occurrence set forth the following sequence of events. A group of influential, socially concerned women on the board of directors of Jane Addam's Hull House was shocked by juvenile delinquency. They wanted to understand its origin, prevention and treatment. These women were approximately 90 years ahead of the Centers for Disease Control and Prevention's decision to accept violence as a public health problem. In 1909, these foresighted women created the Juvenile Psychopathic Institute and hired a neurologist, William Healy, M.D., to be its first director. Although a neurologist interested in studying the delinquents' brain functioning and IQ, the perspective of the settlement house's board of directors made sure that attention also was paid to the delinquents' social factors, attitudes and motivations. To accomplish these broad evaluations and treatment strategies, Healy formed teams composed of a neuropsychiatrist, a psychologist and a social worker. This approach became the template used by most child guidance clinics for most of the 20th century. Child psychiatry's roots became implanted in the community, rather than in medical schools, and colleagues were more likely to be teachers, judges, social workers and social scientists, rather than physicians.

Child guidance clinics blossomed in essentially all U.S. cities during the next two generations. The influence of European child psychoanalysts such as Hermine Hug-Hellmuth, Anna Freud and Melanie Klein became pervasive in this country. In the 1920s, Americans went abroad to study, and during the 1930s and 1940s, many psychoanalytically minded clinicians immigrated to the United States to escape religious persecution. Many, if not most, of these clinicians were women.

At the edges of the dominant psychodynamic and psychosocial viewpoints were organic psychiatry and behaviorism. Organic, or biologic, psychiatry was widely considered a failed pathway espoused by forgotten old men near retirement age. Behaviorism became popular in academic psychology, with John Watson and B.F. Skinner being articulate advocates. However, translations of strict academic behavioral paradigms to clinical use mainly failed. The majority of clinicians believed the behaviorists were so narrow and dogmatic that the "whole child" was lost. Anna Freud's The Ego and the Mechanisms of Defense, first published in German in 1936 and in English in 1946, and the first edition of Child Psychiatry by Leo Kanner, M.D., in 1935 were very influential. Kanner took the name from the German term Kinderpsychiatrie.

While it might seem curious, World War II helped child psychiatry in a number of ways. Because of the huge military draft, background histories were available for hundreds of thousands of late adolescents and young adults with varied backgrounds and socioeconomic levels--rich, poor, white, African-American, educated, uneducated, urbanite and farmer. By the end of the war, it was obvious that soldiers who had behavior problems as children were much more likely to be prematurely discharged, disciplined, wounded or killed. It was a statistic that could not be ignored.

On July 3, 1946, President Harry Truman declared war on mental illness when he signed the National Mental Health Act. Three years later, the National Institute of Mental Health was born. Prevention was an important goal and the quality of mothering was considered key. Women's magazines cropped up like mushrooms. If mothers failed, professionals were needed to be available to intervene. A cadre of experts was building. Increasing numbers of trained psychiatrists spilled over into a greater number of child psychiatrists. At the same time, many pediatricians found that the new antibiotics made their specialty consist largely of well child care. Some found this boring. Federal training funding became available to convert pediatricians into pediatric psychiatrists.

The American Academy of Child Psychiatry was founded in 1953. It was preceded by two organizations interested in children's mental health. One such organization, the American Orthopsychiatric Association (AOA), was formed in 1924. It was multidisciplinary, and its main focus was prevention. Politically, members often leaned to the left and tended to view diagnoses as hurtful labels. In 1948, 54 child guidance clinics created an organization of clinics. The foci of this group, the American Association of Psychiatric Clinics for Children (AAPCC), were to develop standards for clinical care and for training. Before child psychiatry residencies, the gold standard credential for child psychiatry was an AAPCC certificate of training.

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