ACADEMY PUBLIC POLICIES

 Child Psychology : How to Discipline a Child That Does Not Listen

Historical Views and Breakthroughs

 These were feverish, melancholy times; I cannot remember to have raised my head or seen the moon or any of the heavenly bodies; my eyes were turned downward to the broad lamplit streets and to where the trees of the garden rustled together all night in undecipherable blackness; . . .

-Robert Louis Stevenson, describing memories of childhood illness and depression (quoted in Calder, 1980)

The ability of a society to help children develop normal lives and competencies requires not only medical, educational, and psychological resources but also a social philosophy that recognizes children as persons with a value independent of any other purpose. Although this view of children should seem self-evident to us today, valuing children as persons in their own right has not been a priority of previous societies. Early writings suggest that children were considered servants of the state in the city-states of early Greece. Ancient Greek and Roman societies believed any person-young or old-with a physical or mental handicap, disability, or deformity was an economic burden and a social embarrassment, and thus was to be scorned, abandoned, or put to death.

Prior to the 18th century, children’s mental health problems, unlike adult disorders, were seldom mentioned in professional or other forms of communication. Some of the earliest historical interest in abnormal child behavior surfaced near the end of the 18th century. The Church used its strong influence to attribute children’s unusual or disturbing behaviors to their inherently uncivilized and provocative nature. In fact, during this period nonreligious explanations for disordered behavior in children were rarely given serious consideration because possession by the devil and similar forces of evil was the only explanation anyone needed. No one was eager to challenge this view, given that they too could be seen as possessed and dealt with accordingly.

Sadly, during the 17th and 18th centuries, as many as two-thirds of children died before their fifth birthday, often because there were no antibiotics or similar medications to treat deadly diseases. Many children were subjected to harsh treatment or indifference by their parents. Cruel acts ranging from extreme parental indifference and neglect to physical and sexual abuse of children went unnoticed or were considered an adult’s right for educating or disciplining a child. For many generations, the implied view of society that children are the exclusive property and responsibility of their parents was unchallenged by any countermovement to seek more humane treatment for children. A parent’s prerogative to enforce child obedience, for example, was formalized by Massachusetts’ Stubborn Child Act of 1654, which permitted parents to put “stubborn” children to death for misbehaving. (Fortunately, no one met this ultimate fate.) Into the mid-1800s, the law allowed children with severe developmental disabilities to be kept in cages and cellars.

 The Emergence of Social Conscience

If the children and youth of a nation are afforded the opportunity to develop their capacities to the fullest, if they are given the knowledge to understand the world and the wisdom to change it, then the prospects for the future are bright. In contrast, a society which neglects its children, however well it may function in other respects, risks eventual disorganization and demise.

-Urie Bronfenbrenner (1977)

Fortunately, the situation gradually improved for children and youths throughout the 19th century and progressed significantly during the latter part of the 20^th century. However, until very recent changes in laws and attitudes, children (along with women, members of minority groups, and persons with special needs) were often the last to benefit from society’s prosperity and were the primary victims of its shortcomings. With the acuity of hindsight, we know that before any real change occurs, it requires a philosophy of humane understanding in how society recognizes and addresses the special needs of some of its members. In addition to humane beliefs, each society must develop ways and means to recognize and protect the rights of individuals, especially children, in the broadest sense (UN Convention on the Rights of the Child, 1989). An overview of some of these major developments provides important background for understanding today’s approaches to children’s mental health issues.

In Western society, an inkling of the prerequisites for a social conscience first occurred during the 17th century, when both a philosophy of humane care and institutions of social protection began to take root. One individual at the forefront of these changes was John Locke (1632–1704), a noted English philosopher and physician who influenced the beginnings of present-day attitudes and practices of childbirth and child rearing. Locke believed in individual rights, and he expressed the novel opinion that children should be raised with thought and care instead of indifference and harsh treatment. Rather than seeing children as uncivilized tyrants, he saw them as emotionally sensitive beings that should be treated with kindness and understanding, and given proper educational opportunities. In his words, “the only fence [archaic use, meaning ‘defense’] against the world is a thorough knowledge of it.”

Then, at the turn of the 19th century, one of the first documented efforts to work with a special child was undertaken by Jean Marc Itard (1774–1838). Explains how Itard treated Victor (discovered living in the woods outside Paris) for his severe developmental delays rather than sending him to an asylum. Symbolically, this undertaking launched a new era of a helping orientation toward special children, which initially focused on the care, treatment, and training of what were then termed “mental defectives.”

As the influence of Locke and others fostered the expansion of universal education throughout Europe and North America during the latter half of the 19th century, children unable to handle the demands of school became a visible and troubling group. Psychologists such as Leta Hollingworth (1886–1939) argued that many mentally defective children were actually suffering from emotional and behavioral problems primarily due to inept treatment by adults and lack of appropriate intellectual challenge. This view led to an important and basic distinction between persons with mental retardation (“imbeciles”) and those with psychiatric or mental disorders (“lunatics”), although this distinction was far from clear at the time. Essentially, local governments needed to know who was responsible for helping children whose cognitive development appeared normal but who showed serious emotional or behavioral problems. The only guidance they had previously had in distinguishing children with intellectual deficits from children with behavioral and emotional problems was derived from religious views of immoral behavior: Children who had normal cognitive abilities but who were disturbed were thought to suffer from moral insanity, which implied a disturbance in personality or character. Benjamin Rush (1745–1813), a pioneer in psychiatry, argued that children were incapable of true adult-like insanity, because the immaturity of their developing brains prevented them from retaining the mental events that caused insanity. Consequently, the term moral insanity grew in acceptance as a means of accounting for nonintellectual forms of abnormal child behavior.

Th e implications of this basic distinction created a brief yet significant burst of optimism among profession professionals. Concern for the plight and welfare of children with mental and behavioral disturbances began to rise in conjunction with two important influences. First, with advances in general medicine, physiology, and neurology, the moral insanity view of psychological disorders was replaced by the organic disease model, which emphasized more humane forms of treatment. This advancement was furthered by advocates such as Dorothea Dix (1802–1887), who in the mid-19th century established 32 humane mental hospitals for the treatment of troubled youths previously relegated to cellars and cages (Achenbach, 1982). Second, the growing influence of the philosophies of Locke and others led to the view that children needed moral guidance and support. With these changing views came an increased concern for moral education, compulsory education, and improved health practices.

These early efforts to assist children provided the foundation for evolving views of abnormal child behavior as the result of combinations of biological, environmental, psychological, and cultural influences.

 Victor of Aveyron

Victor, often referred to as the “wild boy of Aveyron,” was discovered in France by hunters when he was about 11 or 12 years old, having lived alone in the woods presumably all of his life. Jean Marc Itard, a young physician at the time, believed the boy was “mentally arrested” because of social and educational neglect, and set about demonstrating whether such retardation could be reversed. Victor-who initially was mute, walked on all fours, drank water while lying fl at on the ground, and bit and scratched-became the object of popular attention as rumors spread that he had been raised by animals. He was dirty, nonverbal, incapable of attention, and insensitive to basic sensations of hot and cold. Despite the child’s appearance and behavior, Itard believed that environmental stimulation could humanize him. Itard’s account of his efforts poignantly reveals the optimism, frustration, anger, hope, and despair that he experienced in working with this special child. Itard used a variety of methods to bring Victor to an awareness of his sensory experiences: hot baths, massages, tickling, emotional excitement, even electric shocks.

After 5 years of training by Dr. Itard, Victor had learned to identify objects, identify letters of the alphabet, comprehend many words, and apply names to objects and parts of objects. Victor also showed a preference for social life over the isolation of the wild. Despite his achievements, Itard felt his efforts had failed, because his goals of socializing the boy to make him normal were never reached. Nevertheless, the case of Victor was a landmark in the effort to assist children with special needs. For the first time an adult had tried to really understand-feel and know- the mind and emotions of a special child, and had proved that a child with severe impairments could improve through appropriate training. This deep investment on the part of an individual in the needs and feelings of another person’s child remains a key aspect of the helping orientation to this day.

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Safer Drugs for Kids

 Many of the medicines children take have never been proven safe and effective for them. A new law will help change that Parents assume that when a pediatrician prescribes a drug for their child, that drug has been tested and proven safe and effective.

If only it were so. Only half of the medicines doctors prescribe to patients 18 and younger have been through the same rigorous trials as those drugs prescribed to adults. The other half are given off-label-that is, in circumstances for which they were never properly vetted, putting children at risk for overdoses, side effects, and long-term health problems. For newborns, that fraction rises to 90 percent. In July the U.S. Congress gave the Food and Drug Administration new authority to compel companies to test their products for kids. The law should improve the situation, but it has worrying gaps.

As biologists have come to appreciate, drug metabolism is one of the many ways in which kids are not just small adults. When doctors downsize an adult dosage to suit a child’s weight or body surface area, a drug can prove ineffective or harmful. Infants have immature livers and kidneys, so even a seemingly small dose of medicine can build up quickly in their bodies. As children mature, their organs can develop faster than their body size, so they need to take disproportionately more of the drug. For example, some recent pediatric clinical trials have found that the asthma medication albuterol does not work for children younger than four when taken through an inhaler. The seizure drug gabapentin (Neurontin) requires higher-than-expected doses for children under five.

The reason that drug companies neglect their youngest customers is simple. Children make up a small fraction of the world’s drug recipients, so developing and testing new medicines for them is rarely worthwhile from a business perspective. Pediatric trials are especially expensive and complex, in part because of the difficulty of finding enough patients to enroll in them.

Congress began to address the issue in 1997, and its latest legislation, known as the FDA Safety and Innovation Act, strengthens those earlier efforts. The law requires pediatric studies for certain drugs and provides incentives to test others, such as a six-month patent extension. In addition, the law requires better advance planning of pediatric studies, improves the transparency of data, and makes special provisions for newborns. The American Academy of Pediatrics praised the law: “The bill ensures that children will have a permanent seat at the table for drug research and development.” Still, the law leaves many children vulnerable. It does little for youngsters with cancer, who rely disproportionately on undocumented drugs. Earlier this year Genentech won FDA approval for the skin cancer drug vismodegib, which intervenes in the same molecular process thought to be involved in a childhood brain tumor, yet the company was under no obligation to test the drug in younger patients.

Congress needs to close this loophole, and in the meantime the FDA should continue to work closely with pharmaceutical companies and pediatric oncologists to find new ways of identifying and testing promising cancer medicines in children.

Another problem is that doctors are worryingly in the dark about the long-term health effects of pediatric drugs. Young people take medications for asthma, diabetes, arthritis and many other chronic conditions, yet rarely are side effects recorded and followed up on. In its February report “Safe and Effective Medicines for Children,” the Institute of Medicine recommended that the FDA make greater use of its authority to require long-term safety studies when it approves a product for pediatric use. That said, the FDA Safety and Innovation Act is an important achievement. Children’s medications are safer now than at any time in history, and many doctors and children’s health advocates are so elated by the act’s passage that they are reluctant to talk about what still needs to be done. But now is not the time to let up on our drive to make drugs safe for all our citizens. We hope this legislative victory will breed even more success.