| The Funny Bone |
The Etiology and Treatment of Childhood Despite this history of clinical neglect, it has been estimated that well over half of all Americans alive today have experienced childhood directly (Seuss, 1990). In fact, the actual numbers are probably much higher, since these data are based on self-reports that may be subject to social desirability biases and retrospective distortion. The growing acceptance of childhood as a distinct syndrome is reflected in its proposed inclusion in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, or DSM-V, slated for publication in 2010 by the American Psychiatric Association. Researchers are still in disagreement about the significant clinical features of childhood, but the DSM-V will almost certainly include the following core markers: congenital onset, dwarfism, emotional lability and immaturity, knowledge deficits, and legume anorexia. Clinical Features of Childhood Although this paper focuses on the efficacy of conventional treatment of childhood, the five clinical markers mentioned above merit further discussion for those unfamiliar with this patient population. Congenital onset. 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. As one psychologist has put it, “we may soon be in a position to distinguish organic childhood from functional childhood” (Rogers, 1979). Dwarfism. 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 stigma of being labeled as children by professionals and friends alike. Knowledge deficits. While many children have IQs at 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 understanding 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, children. Legume anorexia. This last identifying feature is perhaps the most unexpected. Folk wisdom is supported by empirical observation—children will rarely eat their vegetables (Popeye, 1957). 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 several perspectives: Sociological model. Émile Durkheim was perhaps the first to speculate about the sociological causes of childhood. He points out two key observations about children: the vast majority are unemployed, and they represent one of the least educated segments of our society. In fact, it has been estimated that less than 20 percent of children have had more than a fourth-grade education. Clearly, children are an “out-group.” Because of their intellectual handicap, they 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, 1997) has trained victims of severe childhood to sell lemonade. Biological model. Again, 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 (1960) indicated that childhood runs in families. Their survey of more than 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. Impressive evidence of a genetic component of childhood comes from a large-scale twin study by Brady and Partridge (1972). These authors studied more than 106 pairs of twins, looking at concordance rates for childhood. Among identical or monozygotic twins, concordance was unusually high (0.92): When one twin was diagnosed with childhood, the other twin was almost always a child as well. Psychological models. Among the more familiar psychologically based theories of childhood is Seligman’s “learned childishness” model, which holds that 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 has called childhood an expedient label. In seeking conformity, we handicap those whom we find unruly or too short to deal with by labeling 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 attributed to the sheer number of individuals suffering from childhood. Government statistics reveal that more children are 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—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. Therapy essentially becomes one of patient management and of helping the child master basic skills, such as 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 devoted 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 1950s, however, the clinicians’ optimism had waned. Even after years of costly analysis, many victims remained children. The following case (taken from Gumbie and Pokey, 1957) is typical. Billy J., age eight, was brought in for treatment by his parents. Billy’s affliction was painfully obvious. He stood only four-foot-three and weighed a scant 70 pounds, despite his voracious eating habits. Billy presented a variety of troubling symptoms. His voice was noticeably high-pitched for a male. He displayed legume anorexia, and, according to his parents, often refused to bathe. Billy’s 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 behavior.” His parents reported that his condition had been present from birth. The diagnosis was “primary childhood.” After years of painstaking treatment, Billy improved gradually. By age eleven, his height and weight had increased, his social skills had broadened, and he had become functional enough to hold down a paper route. After years of this kind of frustration, startling evidence has come to light suggesting that the prognosis in cases of childhood may not be all gloom. A critical review by Fudd (1991) noted that studies of the childhood syndrome tend to lack careful follow-up. Acting on this observation, Moe, Larrie, and Kirly (1993) began a large-scale longitudinal study. These investigators studied two groups: one with 34 children currently engaged in a long-term conventional treatment program, the other with 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 ten-year follow-up were startling. The investigators (Moe, Larrie, Kirly, and Shemp, 2003) 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. The researchers also reported a spontaneous remission rate of 95 percent, a finding that is certain to revolutionize the clinical approach to childhood. These results suggest that the prognosis for victims of childhood may not be as bad as we have feared. We must not, however, become complacent. Despite its apparently high spontaneous remission rate, childhood remains one of the most serious and rapidly growing disorders facing mental health professionals today. Beyond the psychological pain it brings, childhood has recently been linked to a number of physical disorders. Twenty years ago, Howdi, Doodi, and Beauzeau (1984) demonstrated a six-fold increased risk of chickenpox, measles, and mumps among children as compared with normal controls. Later, Barby and Kenn (1989) 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. Jordan W. Smoller ’91, a psychiatrist at Massachusetts General Hospital and self-proclaimed recovering child, penned this essay while a research assistant fresh out of college; although it has since been reprinted in several publications, we couldn’t resist trotting out this excerpt. This article appeared in the Autumn 2004 issue of the Harvard Medical Alumni Bulletin. Photo: Lambert/Hulton Archive/Getty Images References Barby, B., and Kenn, K. (1989). The plasticity of behavior. In B. Barby and K. Kenn (Eds.), Psychotherapies ’R’ Us. Detroit: Ronco Press. Brady, C., and Partridge, S. (1972). My dad’s bigger than your dad. Acta Eur. Age, 9, 123–126. Flintstone, F., and Jetson, G. (1960). Cognitive mediation of labor disputes. Industrial Psychology Today, 2, 23–35. Fudd, E. J. (1991). Locus of control and shoe size. Journal of Footwear Psychology, 78, 345–356. Gumbie, G., and Pokey, P. (1957). A cognitive theory of iron smelting. Journal of Abnormal Metallurgy, 45, 235–239. Howdi, C., Doodi, C., and Beauzeau, C. (1984). Western civilization: A review of the literature. Reader’s Digest, 60, 23–25. Moe, R., Larrie, T., and Kirly, Q. (1993). State childhood vs. trait childhood. TV Guide, May 12-19, 1–3. Moe, R., Larrie, T., Kirly, Q., and Shemp, C. (2003). Spontaneous remission of childhood. In W. C. Fields (Ed.), New Hope for Children and Animals. Hollywood: Acme Press. Popeye, T. S. M. (1957). The use of spinach in extreme circumstances. Journal of Vegetable Science, 58, 530–538. Popeye, T. S. M. (1968). Spinach: A phenomenological perspective. Existential Botany, 35, 908–913. Rogers, F. (1979). Becoming My Neighbor. New York: Soft Press. Ruler, Y. (1923). Assessing measurement protocols by the multi-method multiple regression index for the psychometric analysis of factorial interaction. Annals of Boredom, 67, 1190–1260. Seuss, D. R. (1990). A psychometric analysis of green eggs with and without ham. Journal of Clinical Cuisine, 245, 567–578. Spanky, D., and Alfalfa, Q. (1997). Coping with puberty. Sears Catalog, 45–46. Temple-Black, S. (1982). Childhood: An ever-so sad disorder. Journal of Precocity, 3, 129–134. Tom, C., and Jerry, M. (1967). Human behavior as a model for understanding the rat. In M. de Sade (Ed.), The Rewards of Punishment. Paris: Bench Press. Further Reading Christ, J. H. (1980). Grandiosity in children. Journal of Applied Joe, G. I. (1965). Aggressive fantasy as wish fulfillment. Archives of General MacArthur, 5, 23–45. Leary, T. (1969). Pharmacotherapy for childhood. Annals of Astrological Science, 67, 456–459. Kissoff, K. G. B. (1975). Extinction of learnt behaviour. Paper presented to the Siberian Psychological Association, 38th annual meeting, Kamchatka. Smythe, C., and Barnes, T. (1979). Behaviour therapy prevents tooth decay. Journal of Behavioral Orthodontics, 5, 79–89. Potash, S., and Hoser, B. (1980). A failure to replicate the results of Smythe and Barnes. Journal of Dental Psychiatry, 34, 678–680. Smythe, C., and Barnes, T. (1980). Your study was poorly done: A reply to Potash and Hoser. Annual Review of Aquatic Psychiatry, 10, 123–156. Potash, S., and Hoser, B. (1981). Your mother wears army boots: A further reply to Smythe and Barnes. Archives of Invective Research, 56, 5–9. Smythe, C., and Barnes, T. (1982). Embarrassing moments in the sex lives of Potash and Hoser: A further reply. National Enquirer, May 16. |
recent. As early as the eighth century, the Persian historian Kidnom made references to “short, noisy creatures” that may well have been what we now call “children.” The treatment of childhood, however, was unknown until the twentieth century, when so-called child psychologists and child psychiatrists became common.
|