THE ETIOLOGY & TREATMENT OF CHILDHOOD
Jordan W. Smoller, University of Pennsylvania
Childhood is a syndrome which has only recently begun to receive serious
attention from clinicians. The syndrome itself, however, is not at all
recent. As early as the 8th century, the Persian historian Kidnom made
references to "short, noisy creatures," who may well have been what we now
call "children." The treatment of children, however, was unknown until this
century, when so-called "child psychologists" and "child psychiatrists"
became common. Despite this history of clinical neglect, it has been
estimated that well over half of all Americans alive today have experienced
childhood directly (Suess, 1983). In fact, the actual numbers are probably
much higher, since these data are based on self-reports which may be
subject to social desirability biases and retrospective distortion.
The growing acceptance of childhood as a distinct phenomenon is reflected
in the proposed inclusion of the syndrome in the upcoming Diagnostic and
Statistical Manual of Mental Disorders, 4th edition, or DSM-IV, of the
American Psychiatric Association (1990). Clinicians are still in
disagreement about the significant clinical features of childhood, but the
proposed DSM-IV will almost certainly include the following core features:
* Congenital onset
* Emotional lability and immaturity
* Knowledge deficits
* Legume anorexia
Clinical Features of Childhood:
Although the focus of this paper is on the efficacy of conventional
treatment of childhood, the five clinical markers mentioned above merit
further discussion for those unfamiliar with this patient population.
In one of the few existing literature reviews on childhood, Temple- Black
(1982) has noted that childhood is almost always present at birth, although
it may go undetected for years or even remain subclinical indefinitely.
This observation has led some investigators to speculate on a biological
contribution to childhood. As one psychologist has put it, "we may soon be
in a position to distinguish organic childhood from functional childhood"
This is certainly the most familiar marker of childhood. It is widely known
that children are physically short relative to the population at large.
Indeed, common clinical wisdom suggests that the treatment of the so-called
"small child" (or "tot") is particularly difficult. These children are
known to exhibit infantile behavior and display a startling lack of insight
(Tom and Jerry, 1967).
EMOTIONAL LABILITY AND IMMATURITY
This aspect of childhood is often the only basis for a clinician's
diagnosis. As a result, many otherwise normal adults are misdiagnosed as
children and must suffer the unnecessary social stigma of being labelled a
"child" by professionals and friends alike.
While many children have IQ's with or even above the norm, almost all will
manifest knowledge deficits. Anyone who has known a real child has
experienced the frustration of trying to discuss any topic that requires
some general knowledge. Children seem to have little knowledge about the
world they live in. Politics, art, and science -- children are largely
ignorant of these. Perhaps it is because of this ignorance, but the sad
fact is that most children have few friends who are not, themselves,
This last identifying feature is perhaps the most unexpected. Folk wisdom
is supported by empirical observation -- children will rarely eat their
vegetables (see Popeye, 1957, for review).
Causes of Childhood:
Now that we know what it is, what can we say about the causes of childhood?
Recent years have seen a flurry of theory and speculation from a number of
perspectives. Some of the most prominent are reviewed below.
Emile Durkind was perhaps the first to speculate about sociological causes
of childhood. He points out two key observations about children:
1) the vast majority of children are unemployed, and
2) children represent one of the least educated segments of our society.
In fact, it has been estimated that less than 20% of children have had more
than fourth grade education.
Clearly, children are an "out-group." Because of their intellectual
handicap, children are even denied the right to vote. From the
sociologist's perspective, treatment should be aimed at helping assimilate
children into mainstream society. Unfortunately, some victims are so
incapacitated by their childhood that they are simply not competent to
work. One promising rehabilitation program (Spanky and Alfalfa, 1978) has
trained victims of severe childhood to sell lemonade.
The observation that childhood is usually present from birth has led some
to speculate on a biological contribution. An early investigation by
Flintstone and Jetson (1939) indicated that childhood runs in families.
Their survey of over 8,000 American families revealed that over half
contained more than one child. Further investigation revealed that even
most non-child family members had experienced childhood at some point.
Cross-cultural studies (e.g., Mowgli & Din, 1950) indicate that family
childhood is even more prevalent in the Far East. For example, in Indian
and Chinese families, as many as three out of four family members may have
Impressive evidence of a genetic component of childhood comes from a
large-scale twin study by Brady and Partridge (1972). These authors studied
over 106 pairs of twins, looking at concordance rates for childhood. Among
identical or monozygotic twins, concordance was unusually high (0.92),
i.e., when one twin was diagnosed with childhood, the other twin was almost
always a child as well.
A considerable number of psychologically-based theories of the development
of childhood exist. They are too numerous to review here. Among the more
familiar models are Seligman's "learned childishness" model. According to
this model, individuals who are treated like children eventually give up
and become children. As a counterpoint to such theories, some experts have
claimed that childhood does not really exist. Szasz (1980) has called
"childhood" an expedient label. In seeking conformity, we handicap those
whom we find unruly or too short to deal with by labelling them "children."
Treatment of Childhood:
Efforts to treat childhood are as old as the syndrome itself. Only in
modern times, however, have humane and systematic treatment protocols been
applied. In part, this increased attention to the problem may be due to the
sheer number of individuals suffering from childhood. Government statistics
(DHHS) reveal that there are more children alive today than at any time in
our history. To paraphrase P.T. Barnum: "There's a child born every
The overwhelming number of children has made government intervention
inevitable. The nineteenth century saw the institution of what remains the
largest single program for the treatment of childhood -- so-called "public
schools." Under this colossal program, individuals are placed into
treatment groups based on the severity of their condition. For example,
those most severely afflicted may be placed in a "kindergarten" program.
Patients at this level are typically short, unruly, emotionally
immature,and intellectually deficient. Given this type of individual,
therapy is essentially one of patient management and of helping the child
master basic skills (e.g. finger-painting).
Unfortunately, the "school" system has been largely ineffective. Not only
is the program a massive tax burden, but it has failed even to slow down
the rising incidence of childhood.
Faced with this failure and the growing epidemic of childhood, mental
health professionals are devoting increasing attention to the treatment of
childhood. Given a theoretical framework by Freud's landmark treatises on
childhood, child psychiatrists and psychologists claimed great successes in
their clinical interventions.
By the 1950's, however, the clinicians' optimism had waned. Even after
years of costly analysis, many victims remained children. The following
case (taken from Gumbie & Poke, 1957) is typical.
Billy J., age 8, was brought to treatment by his parents. Billy's
affliction was painfully obvious. He stood only 4'3" high and
weighed a scant 70 lbs., despite the fact that he ate
voraciously. Billy presented a variety of troubling symptoms. His
voice was noticeably high for a man. He displayed legume
anorexia, and, according to his parents, often refused to bathe.
His intellectual functioning was also below normal -- he had
little general knowledge and could barely write a structured
sentence. Social skills were also deficient. He often spoke
inappropriately and exhibited "whining behaviour." His sexual
experience was non-existent. Indeed, Billy considered women
"icky." His parents reported that his condition had been present
from birth, improving gradually after he was placed in a school
at age 5. The diagnosis was "primary childhood." After years of
painstaking treatment, Billy improved gradually. At age 11, his
height and weight have increased, his social skills are broader,
and he is now functional enough to hold down a "paper route."
After years of this kind of frustration, startling new evidence has come to
light which suggests that the prognosis in cases of childhood may not be
all gloom. A critical review by Fudd (1972) noted that studies of the
childhood syndrome tend to lack careful follow-up. Acting on this
observation, Moe, Larrie, and Kirly (1974) began a large-scale longitudinal
study. These investigators studied two groups. The first group consisted of
34 children currently engaged in a long-term conventional treatment
program. The second was a group of 42 children receiving no treatment. All
subjects had been diagnosed as children at least 4 years previously, with a
mean duration of childhood of 6.4 years.
At the end of one year, the results confirmed the clinical wisdom that
childhood is a refractory disorder -- virtually all symptoms persisted and
the treatment group was only slightly better off than the controls.
The results, however, of a careful 10-year follow-up were startling. The
investigators (Moe, Larrie, Kirly , & Shemp, 1984) assessed the original
cohort on a variety of measures. General knowledge and emotional maturity
were assessed with standard measures. Height was assessed by the "metric
system" (see Ruler, 1923), and legume appetite by the Vegetable Appetite
Test (VAT) designed by Popeye (1968). Moe et al. found that subjects
improved uniformly on all measures. Indeed, in most cases, the subjects
appeared to be symptom-free. Moe et al. report a spontaneous remission rate
of 95%, a finding which is certain to revolutionize the clinical approach
These recent results suggests that the prognosis for victims of childhood
may not be so bad as we have feared. We must not, however, become too
complacent. Despite its apparently high spontaneous remission rate,
childhood remains one of the most serious and rapidly growing disorders
facing mental health professional today. And, beyond the psychological pain
it brings, childhood has recently been linked to a number of physical
disorders. Twenty years ago, Howdi, Doodi, and Beauzeau (1965) demonstrated
a six-fold increased risk of chicken pox, measles, and mumps among children
as compared with normal controls. Later, Barby and Kenn (1971) linked
childhood to an elevated risk of accidents -- compared with normal adults,
victims of childhood were much more likely to scrape their knees, lose
their teeth, and fall off their bikes. Clearly, much more research is
needed before we can give any real hope to the millions of victims wracked
by this insidious disorder.
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