The “Menace of Psychiatry.”1  The title of pediatrician Joseph Brennemann’s 1931 article was inflammatory, and it was meant to be. Brennemann voiced concerns about psychiatry that many contemporary pediatricians shared at the time.2,3  Under “psychiatry” he included the work of an array of professionals in psychology, child development, and child guidance who, in his opinion, were negatively influencing parents’ attitudes toward their children’s health. These professionals, who were trained in psychoanalysis, mental testing, or the behaviorist psychology of John B. Watson, popularized standards, techniques, and theories that parents could not fully understand. In addition, they led parents to see any variation from a scientifically defined ideal of health as a problem.

Brennemann argued that only pediatricians had sufficient knowledge of the specific and normal conditions of children’s lives to understand each child as an individual and to diagnose pathologic deviations. Yet, lacking the elaborate jargon of the psychoanalysts or the prestige of the behaviorists’ laboratory methods, pediatricians appeared to be losing the ongoing debate over a fundamental question: who is the expert on the mental health of children?4 

Recognizing the validity of Brennemann’s concerns, psychiatrist Leo Kanner,5,6  head of the Division of Child and Adolescent Psychiatry at the Johns Hopkins University (JHU) School of Medicine, called for an alliance between child psychiatry and pediatrics. Here, we examine how Kanner came to that conviction through the influence of psychiatrist Adolf Meyer and pediatrician Edwards A. Park and argue that pediatrics deeply shaped Kanner’s work in child psychiatry.

Meyer, the director of JHU’s Henry Phipps Psychiatric Clinic, saw the roots of mental disorders in the behavioral habits that people develop as defenses against environmental stress.7  Psychobiology, as he called his approach, required a careful examination of the individual’s development to identify the causes of his or her mental condition. Biographical data and information about the family history and environment were as important as physical, mental, and laboratory examinations; all contributed to the patient’s case history, which was the standardized unit of study for the psychiatrist. A person’s childhood became an important part of the patient’s clinical history. In the case of children, the early years of development were crucial.

The head of JHU’s pediatric clinic, Edwards A. Park, helped give Kanner an institutional home. The clinic, founded in 1912 as the Harriet Lane Home for Invalid Children, was the nation’s first pediatric clinic affiliated with a university.8  After becoming its pediatrician-in-chief in 1927, Park opened several specialist clinics and subdepartments.9,10  Joining forces to better understand and treat children’s conditions, Meyer and Park inaugurated a child psychiatry unit within the Harriet Lane Home in 1930.

Park and Meyer shared a deep dissatisfaction with the approach to children’s health in child guidance clinics. An early champion of the mental hygiene movement, Meyer became frustrated because child guidance clinics were not tied to hospitals or universities and thus lacked a solid scientific foundation.11  Other academic psychiatrists also disapproved of the clinics’ lack of connection to teaching hospitals and their increasing adherence to psychoanalytic views instead of taking a “medical approach.”12,13 

As a pediatrician, Park shared Brennemann’s concern that many self-described experts in children’s mental health knew little about real children. Park also worried that child guidance clinics were undermining the influence of pediatricians. These clinics had built their expertise on the psychiatrist–psychologist–psychiatric social worker triad, leaving pediatricians as outsiders, as another leading pediatrician, Bronson Crothers, complained.14,15  Park and Meyer agreed on the need for collaboration and asked Kanner to head their pioneering project for child psychiatry within a pediatric unit.

Excited about this landmark institutional initiative, Kanner devoted most of his publications in the 1930s to fleshing out the connection between psychiatry and pediatrics. Kanner1618  argued that psychiatric diagnosis and treatment of childhood behavioral problems should become “the joint concern of the psychiatrist and the pediatrician.” He called for a pediatric-psychiatric alliance and described the proper relationship between psychiatrists and pediatric specialists as one of “mutual give-and-take collaboration.”

At the Harriet Lane Home for Invalid Children, Kanner facilitated collaboration in casework. He expanded the role of pediatricians in the psychiatric unit, asking them to include in their referral slips their own descriptions of problems and possible causes. The avoidance of diagnostic terminology in referral slips and medical record notes empowered pediatricians to deal with personality problems on their own terms.

How did the close work with pediatricians affect Kanner’s outlook on child psychiatry? His view of mental problems broadened in several respects.

First, Kanner’s interactions with pediatricians made him aware that psychiatrists needed to better understand both the children’s normal development and their unique problems. Kanner thought that examining children’s behavioral issues through the looking glass of adult mental problems hindered child psychiatry. “Behavior disorders of children,” he noted, had “interested the psychiatrists only as they seemed to fit into diagnoses in accordance with classifications devised for adults.” But child psychiatry required that “the common behaviour problems of boys and girls” take center stage, displacing attention from the “extremes and end-products of mental aberrations.”17 

Second, working with pediatricians, Kanner became more aware of the interactions between physical and mental health problems in childhood. He encountered problems connected to hospitalization and developed a better knowledge of acute and chronic illnesses. He was also able to follow the personality development of children who had visited the pediatric clinic as premature or malnourished infants. This work with real children and exposure to a wide variety of personalities led Kanner19  to study “types of psychopathologic problems that are not taken directly to psychiatrists and not commonly seen in child guidance clinics.”

Third, pediatrics also deepened Kanner’s appreciation for the significance of infancy. Classifications of childhood mental disorders compiled in the context of mental hygiene clinics, Kanner noted, tended to neglect “disorders occurring in early infancy.” Those disorders were rarely seen in mental hygiene clinics, but “one working directly with a Pediatric Hospital certainly sees a sufficient[ly] great number of these disorders to wish to have them included in an adequate classification.”20  Queries from the pediatricians at Harriet Lane shaped Kanner’s21  own grouping of the disorders of infancy and early childhood, which had been “the no man’s land of child psychiatry.”

Furthermore, the insights Kanner gleaned from pediatrics left their imprint on his 2 major professional contributions: his 1935 manual of child psychiatry and his proposal of infantile autism as a psychiatric condition.

In Child Psychiatry, the first English textbook on this subject, Kanner22  integrated pediatric knowledge into child psychiatry. As Park’s23  preface noted, this book offered a pediatric-centered perspective. It was “not based on imaginary children” but on the study of actual children from the Harriet Lane clinic. The book shifted the focus of child psychiatry toward the “common behavior disturbances of children” and assumed that the “pediatrically trained mind” could “recognize” them early on and “prevent their development.” Reviewers fully agreed.24 

Kanner’s views on autism are also better understood by seeing them within this pediatric context. One can spot the germ of Kanner’s view of autism as an “early infantile” condition in his emphasis on following personality development since infancy and in his refusal to view children’s mental health issues as mere precursors of adult conditions, such as schizophrenia.25 

Kanner and his mentors Meyer and Park saw the alliance between psychiatry and pediatrics that they had forged as a successful experiment and model. Other hospitals soon emulated their cooperative arrangement. In 1935, Columbia University established a pediatric-psychiatric clinic. Just 2 years later, the Department of Psychological Medicine at Toronto’s Hospital for Sick Children opened.

Throughout the years, the connection between psychiatry and pediatrics has been variously characterized. Some regarded these disciplines as “sister and brother.”26  Others have seen their association as “a long and desultory flirtation”27  or as a “marriage.”2833  As in every relationship, communication problems often resurface, requiring that differences be recognized and worked on.34 

With mental health problems in children and adolescents increasing at alarming rates, it is important that pediatricians continue to see child psychiatry as an ally rather than a menace. One of Kanner’s17,19  stated goals in shaping his “liaison” service was to empower pediatricians to take ownership of common mental health problems in children. Today, integrating children’s mental health into primary care and improving training and competence in mental health have become priorities for pediatric organizations.35,36  The “pediatric advantage” is just as crucial for addressing children’s mental health challenges today as it was in Kanner’s time.

Drs Vicedo and Ilerbaig conceptualized and designed the study, conducted the research on the primary and secondary sources, drafted the initial manuscript, and reviewed and revised the manuscript; and both authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: No external funding.

JHU

Johns Hopkins University

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.