THE ETIOLOGY AND 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
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 significan clinical features of childhood,
but the proposed DSM-IV will almost certainly include the following core
- Congenital onset
- Emotional lability and immaturity
- Knowledgy 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
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 biological contribution to childhood. As one psychologist has put it,
"we may soon be in a position to distinguish organic childhood from
functional childhood" (Rogers, 1979).
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 IQs 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 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
Emile Durkind was perhaps the first to speculate about
sociological causes of childhood. He points out two key observations about
- the vast majority of children are unemployed, and
- 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 grad 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 rehabilitaion 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 and Din, 1950)
indicated 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 childhood.
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 human 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 minute."
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 problem 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 intervention.
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 and 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 noticably 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 at 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
assess 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 to childhood.
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 professionals 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 need before we can give any
real hope to the millions of victims wracked by this insidious disorder.
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