Child Psychiatry and Human Development Volume 1, Number 1, Fall, 1970

The Emergence of Child Psychiatry as an Academic Discipline E. James Anthony, M.D.

Washington University School of Medicine, St. Louis, Missouri

ABSTRACT: Child psychiatry has come a long way since its tenuous beginnings fifty years ago. A few of the pioneers are still around to remind us of our short history. Its development has not by any means been linear and, from time to time over the years, it has wandered off into nonmedical fields and practices that have impeded its incorporation into the body of medicine. Within the past two decades, it has relinquished its purely guidance role and has been trying, although in a small way, to generate its own specific theory and research. However, it has still some way to go before it can get itself less ambivalently accepted in the medical schools. In making its approach to orthodox medicine, it should continue to remember its own history and not relinquish the many skills it acquired and is still acquiring from the behavioral sciences. George Bernard Shaw was much impressed by the many painful years that it took to make a mature man or woman and felt that with a little human ingenuity it should be possible to abolish the intervening years. This led him to predict in his play Back to Methuselah that, by the year 2700 A . D , human beings would be born from eggs at the end of adolescence, ~o that the long, painful, and purposeless years of childhood could be spent quietly encapsulated, thereby allowing adult society to live in relative ease and tranquility free from student protest and campus riots! Future doctors could get down to their training soon after birth, and the psychiatrists could be incubated and hatched according to demand. At this point in the Shavian fantasy, I began to develop some qualms. I became aware of how significant childhood had become to psychiatrists and how indispensable to the child psychiatrist. (We would have no patients!) When men first began to use themselves as a measure of other men at the dawn of modern psychiatry, they soon realized that in order to do so effectively, they needed to know themselves, and to know themselves, they needed to understand how they had become what they were, and that such understanding demanded a careful scrutiny of their earliest years. The child was not only father to the man, but, in psychiatry, had come to be the explanation of the man. Certain psychiatrists, who have accepted this dictum completely, have undertaken to examine their

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childhood lives systematically so as to afford their patients, both adult and child, a greater measure of understanding. The child psychiatrist, lacking a well-remembered childhood, would have some difficulty in establishing a workable clinical relationship with the child patient. To obtain the degree of contact and closeness necessary to maintain a diagnostic or therapeutic alliance, he should be sufficiently in touch with his own childhood to recall as a firsthand experience what it felt like to be a child at different phases of growing up. For him to be alienated from his youthful memories would be tantamount to being denied access to a basic laboratory in his institution that could provide him with important, confirmatory data. All physicians make use of their past experience in treating their patients, but the psychiatrists of today have extended this use of the self as a clinical instrument to include the pre-professional years. It must seem to you that I am presenting here a stereotype of the psychiatrist as he is viewed by the populace in general; someone whose predominant mode of approach to the patient is intuitive and impressionistic, based on "hunches" extrapolated from an extensive and intensive anamnesis. That we have become fairly skilled professional biographers, as a consequence of the assumption that people are what they become, is certainly true, but I would like to present to you now an expanded conception of the child psychiatrist at work at the present time. This is not in the nature of a job analysis but a portrait in action to indicate some fundamental changes in orientation and practice. I can best introduce this by describing a clinical interview.

A Clinical Interview Tommy was a seven year old who looked healthy enough but had complained throughout the previous year of recurrent attacks of chest pain accompanied by feelings of faintness, "funny" sensations in his arms and legs, and, at times, excessive weakness and tiredness. His pediatrician had speculated on the presence of a rheumatic involvement of the heart, but had been so struck by the child's obvious nervousness that he thought a consultation might be useful before he set up a program of investigation. The mother had called me by telephone on the day prior to the appointment to ask what sort of information I might require. She mentioned that Tommy had been much alarmed at the prospect of seeing still another doctor, but she had reassured him that I was quite a different kind of doctor-a talking doctor who did not give "shots." When he made his appearance in my room, he looked with surprise at the mixed assortment of standard medical equipment and play material as if he sensed some incompatability in this curious coexistence. As the first few minutes of the interview passed without any activity or speech on my part, his anxiety became

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manifest in the tension of his clenched fists and general restlessness. After a while, I asked him why had he come to see me, and he answered, with relief, that his mother had brought him. I then inquired whether there was any problem that he might like to share with me. He said that there was something the matter with his heart since he had overheard the doctor telling his mother that it had been damaged by rheumatism. I asked him what he thought about this, and his reply was that he had always guessed that there was something wrong with his heart ever since he had experienced his first pains in the chest. He added that he did not think he was going to live very long. I wondered how he had reached this pessimistic conclusion, and he said that his mother had curtailed his daily activities fairly rigorously to afford him a better chance of survival. As he spoke of death and dying, I observed that his rate of respiration had increased to about 50 every minute and that he was also hyperventilating with forceful expirations. I asked him whether he was taking any medicine for this condition, and he replied that his mother was giving him aspirins five times a day for his rheumatism. He did not like to take these since they made him feel nauseated, but he made no fuss about it because his mother had pointed out that indigestion was preferable to death. At the mention of the word "death," he began to overbreathe again, but this subsided when he returned to a neutral topic. I then said that I would like to examine him and would he please take off his clothes. He looked startled but began to do so with an increase in the level of his anxiety. I carried out as thorough a physical examination as I could muster, at the same time calling attention to his apprehension as I went about it. Having completed my examination, I informed the boy that I had been unable to find anything unusual but that I would like to carry out a further small test on him. Once again, he looked surprised, but not as much as before; his image of me was apparently undergoing some modification. I encircled his chest with a rubber tube from a pneumograph I had used in a previous investigation, and set him facing the revolving drum on which his respirations were being recorded. I gave him some direction as to amplitude and frequency so that he could recognize the characteristics of his own tracing. I then continued the interview. He informed me that he did not remember his father who had died when he was three from a heart attack. His mother often spoke of this and of her great grief at the time, and she questioned how anyone so young could die. I said that I recognized his own fear of dying, but perhaps there was still a greater fear that his mother might die. The respiratory waves that had been increasing in size and frequency now showed a maximal amplitude and a frequency of about 65 per minute. He was clearly in one of his hyperventilation attacks, and very soon the secondary symptoms of faintness, chest pain, and paraesthesiae of the extremities began to occur. I pointed out the connection between the subject matter of our discussion and the attack as it was visually in evidence on the recording drum, and he sat for a while staring at it. After the respirations had again subsided, I encour-

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aged him to over-brcathe voluntarily, and, very soon, the symptoms were replicated. When he complained of numbness on his face and fingers and I took up a needle off a syringe to demarcate the area, his breathing once again accelerated, and I drew the connection between his fear of being hurt by a "shot," the changes in his breathing, and his set of symptoms. We went on to discuss his anxious preoccupation with being injured, becoming ill, with dying, and with the thought of his mother dying and leaving him all alone. He resented the fact that she over-mothered him, but he would be desolate without her. We were now able to discuss the fearful topic of death, first with moderate changes in the respiration, and subsequently with no change at all. After a while, he was able to recall spontaneously some memories of the death of his father. To be on the safe side, however, I also investigated his urine and blood and had an E.K.G. carried out. Since salicylates can occasionally produce over-breathing when given in large enough doses, I asked the mother to refrain from giving him any further aspirin so that we could observe the effects of abstention. He had no further attacks although I continued to see him regularly once a week to reach further into the sources of his anxiety. It was after the initial diagnostic maneuvers that his mother bad asked him how he liked the new doctor. "You said that he was just a talking doctor," he accused his mother, "and that he wouldn't give me any shots. He's a talking doctor all right, but he's begun to shoot." lie said this, however, without his habitual air of concern, nor was he aware that his simple comment crystallized a new era in the development of child psychiatry.

A Short Perspective of Past History Let me try and review this piece of history briefly for you. Fifty years ago, the first organized training in child psychiatry was brought into being at the Illinois Juvenile Psychopathic Institute in Chicago under the direction of Dr. Herman Adler. During the subsequent decades, child psychiatry took a protracted sabbatical from medicine, passing the time mainly with the behavioral sciences. The child guidance and orthops~chiatrie movements, under the aegis of Dr. William Mealy, developed the concept of teamwork between various diciplines. This was largely a non-medical movement, and the operational ideas were provided by psychology, psychoanalysis, and social work. The concepts of "total personality" and "multiple causation" were very much to the forefront of these movements, and a strong emphasis was placed on the influence of the early years and the interpersonal feelings and relationships at the time on the subsequent emotional development of the child. The American Psychiatric Association opposed the founding of the American Orthopsychiatric Association on the basis of the "unholy alliance" between medical and non-medical personnel. Within the last two decades, the child psychiatrist began his long-delayed trek

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back to the schools of medicine, and, not surprisingly, did not find himself at home in his new setting, nor was he received with open arms. He found that medicine was now busy with the basic sciences and with the applications of basic research, and the laboratories had come to dominate the medical landscape. Everywhere, there was a growing impatience with the old clinical approach, the "human application," andhe found himself unable to speak the language of his colleagues. His consultation reports were criticized as wordy, woolly and esoteric, peculiarly concerned with such intangibles as dreams, fantasies, and feelings. What was even more reprehensible to the men of medicine was that he failed to examine his patients. In fact, he no longer appeared to function in the traditional medical way, and was looked upon as a strange amalgam of psychologist and social worker (his close companions during the exodus) with a touch of the witch doctor. The reasons he gave for not examining his patients' bodies were that he saw as his primary clinical task the establishment of an intimate, personal relationship with them and believed that when this was accomplished, all physical interventions were liable to be misconstrued in terms of assault and seduction. The medical schools, with their traditional emphasis on authority and status, looked coldly on the equalitarian principles which allowed him to set up a system of interchangeable roles with those whom the schools preferred to regard as "ancillary personnel." What had been a virtue in the child guidance movement was now a problem, and he was urged to reconsider his medical ethos in terms of responsibility and control. In his efforts to teach medical students, inured to gross physical pathology, he encountered the same resistance; the students reacting to the exposure of underlying, often primitively-expressed mental conflict with the revulsion of lay people. In addition, what he had to teach was not easily learned without personal involvement, so that his evaluations seemed to lack conviction. The whole training of the medical students inclined them toward concrete and specific action; toward doctor-patient relationships that were active and directive, combining a mixture of toughness and tenderness. They were embarrassed by the intimate nature of the subject matter of psychiatry, and ~nce it could not he demonstrated in a laboratory, they reacted with impatience to the abstract data and the absence of tangible evidence. The gulf was further deepened by the child psychiatrist's negligence of the physical aspects of disease and by the sometimes unwarranted emphasis he always placed on psychic factors to the exclusion of the physical. There was also what Karl Menninger has termed a "secret arrogance" on his part based on an inner belief that he was dealing with the more significant and transcendental portion of the human organism. His colleagues, for their part, persisted in regarding mental illness as "not real" (although it effectively incapacitated a large

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section of the population), and they were as loathe to examine the mind as the psychiatrist was to examine the body. It would be quite untrue to say that the child psychiatrists returned from their sabbatical emptyheaded. They brought with them fascinating interviewing techniques and subtle ways of talking to and understanding children. They were able to establish enduring therapeutic relationships with even small children and to manipulate the relationship in the service of the child's disturbance. They brought a knowledge of personality growth and development, methods of assessing the attitudes and feelings of children and parents toward physicians, and a sensitivity to the psychological reactions of children and their parents to physical illness, hospitalization and convalescence. Where their pediatric colleagues were able to accept them and work with them, a humanizing of medical and surgical procedures occurred, leading to the addition of recreational, educational, and occupational sessions to the daily program of the hospital. Because of them, there was also a growing recognition of psychosomatic problems in pediatrics and the complications of disease introduced by familial disturbances and difficulties. I will now shift to another cardinal problem that has served to keep psychological medicine apart from the main body of medicine-the nature of the clinical data accumulating during the process of evaluation. Whereas medicine has tried to confine itself to objective measurements of observable events, child psychiatry has been more inclined to use introspective techniques. The psychiatrist measures the introspection of the patient against his own or against those of other patients. Where he has subjected himself to systematic introspection, he appears to be in a better position to assess the introspections of others. Compared with the precise language and quantitative measurements of the physical sciences, the method has limitations, but at the present time there is no better substitute for it as a means of studying subjective phenomena-the important things that take place within the mind. I do not think we have to be too apologetic about this. As Bertrand Russell has put it, there is nothing to be ashamed of about introspective data since it is, neurophysiologically speaking, as close to the brain as the extrospective kind. In the last analysis, says Russell, it is all inside our heads and there is therefore no mind-body problem. This is, of course, a philosophical argument. In more pragmatic terms, the manifest incompatibilities cannot be set aside so easily. The data obtained from the two sources are dearly different, and the major problem confronting us at the present time is not only how to add E.E.G.'s and fantasies but how to sell our fantasy products and gossamer dreams on the medical market. When science finds itself in a bind of this nature, it tends to resort to model-making as a means of representing the system under study.

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Child Psychiatry and Human Development A Note on Diagnostic Models

Let me first try to illustrate the developments in child psychiatry as reflected in the diagnostic models that clinicians have used in the evaluation of their child patients at different times over the past 50 years. The earliest model in child psychiatry was, in the main, a biological one; abnormalities in behavior being correlated with structural changes in the brain. On the European continent, the child psychiatrists are still faithful to this model, especially the French version which has nothing on it except some scanty sociological and psychological trimmings. Eneephalopathy and encephalitis are the powerful twin determinants of undesirable or deviant behavior. The concept of "reproductive casualty" has reactivated this model in the United States. There has been a general proclivity over the past decade to construct a model more representative of the complex notions that have come into being in the field of psychological medicine. The interaction between medical and psychiatric thought led first to the elaboration of a psychobiological model and, when this proved not wholly adequate, to the subsequent building of a socio-psychobiological one. Since child psychiatry was dealing with a developing organism, the feature of time was added as a necessary dimension to the general picture. The increasing complexity of the diagnostic model over the past 50 years in child psychiatry has reached a stage when we are accumulating various sections and sub-seetions and sub-sub-sections of data-somatic, psychophysical, psychological, psychiatric, social, and anthropological-so that the modern psychiatric case record is a compendium. Fifty years ago when the model was simpler and the case records correspondingly thinner, I found a record consisting of a single sheet on which was inscribed in somewhat illegible handwriting, the following statements: Alcoholic father, probably GPI. Mother dead. Child lives with grandmother who is mean to her. Interviewed grandmother and thought her a bitch. Child should be better off with fostering if we can find a good family. Diagnosis: slum kid with bad habits. Recommendation: call Mrs. Smith (social worker) and ask her to contact the headmaster with a view to shifting Mary to a teacher who believes in discipline. Also ask her to call the local clergyman and see if he can do anything about Sunday classes. That was the case of Mary in a nutshell. The average case record then ran to about 30 or 40 sentences, making up 300-400 words. The average number of sentences today, 50 years later, in a case record from clinics where child psychiatrists are being trained, varies between 250 to 800 sentences (3,000-10,000 words, and can reach the dimensions of a short novel; from non-training clinics the number of sentences varies between 100-300 (1,200-3,600 words). Of the 8,000 to 10,000 statements in the first type of diagnostic evaluation, between 30% to 50% have proved on investigation

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to be redundant, although, it is extremely difficult to decide beforehand in child psychiatry what statements are necessary and what are redundant. Redundancy is a function of the science in question, its stage of evolution, and the rigor it has managed to develop. Confronted with this heterogeneous mass of data, at times factual and informative, at other times vague and nebulous, at times observable to inspection, and at others "of the stuff dreams are made on," what can one hope to do with it from a scientific point of view? How much of it can be communicated to medical colleagues in a meaningful and understandable way? How can one relate, for the puspose of finding significant connections, hopelessly unreliable data from the mother with reliable data from the medical investigation? What weight can one place on the impressions of the various informants? Most of all, is it possible for a diagnostician to reach a clear-cut formulation of the case that would be replicated by another clinician with roughly the same experience and background? The problem appears formidable and insurmountable. Its vagueness calls forth vagueness in oneself. There are too many mechanisms of distortion involved. According to an unformulated Parkinsonian type of law, the larger the number of specialists from different fields and the greater the amount of time they spend with the patient, the longer will be the case record, the greater the number of investigators, the wider the divergence of opinion. In spite of this pessimistic canon, I would like to discuss possibilities of domesticating such wild and lavish accumulations of disparate data. There are two possible ways that one can handle this information; at the beginning and at the end of the accumulation. One can, for example, supply certain formats to the psychiatrist and his ancillary personnel at the start of the evaluation containing checklists, ratings, and codings that will enable them to put their data into computer-acceptable form. This, of course, affects the characteristic workload of the doctor and forces the data into a priori categories imposed by the needs of the machine. Nearly everyone today feels that our massive psychiatric record-keeping systems are in need of radical overhaul to make them terser, more organized, and more efficient in providing relevant data promptly. However, to force psychiatrists to categorize information in the hope of reducing verbiage and narrative style way interfere with his skills. In addition, there is no empirically based information to determine what variables are important to include nor on the relevance of the coded variables for subsequent diagnostic decisions. Moreover, although case records in child psychiatry are often poorly systematized, unevenly collected and illegible with the content of information largely "soft" (that is, subjective, impressionistic, and judgmental, having poor validity and reliability) and with few areas of information free from distortion in

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recall (and this applies even to seemingly "hard" factual data), one has to bear in mind that it is the major source of information in our work, despite all of its shortcomings, and that it is not only the best thing we have, but the only thing we have to date. The best one can say is that it is collected under naturalistic conditions and therefore relatively free from biases created by artificial laboratory conditions. A second approach to the problem of data-collecting and data-retrieval attempts to transcribe the total information contained in a case record into a system of events. The psychiatrist, therefore, is left to his psychiatric task and carries out his diagnostic procedures in the way that suits him. The transcriber then sets to work on the case record and reduces it to a continuous series of events. Everything that occurs to a patient or to a significant person in his life is defined as an event. Events include actual happenings as illnesses, appointments at the clinic, the birth of a brother, failure in school, that is, occurrences that have a physical or outside validity and may be considered as objective-factnal data, as well as psychological phenomena that cannot be observed but must be inferred and have poor outside validity, such as fears, fantasies, reactions to school failure, etc. Also within this group are attitudes, opinions, impressions, evaluations, and other subjective or judgmental phenomena which psychiatrists find as relevant in describing the behavior of the patient as is the more objective information. The event is, therefore, a common unit in terms of which all information in the record spanning three generations is transcribed, and each event is specified in terms of time, place, and person. The concept of events permits the entire body of the record in all its diverse forms to be encompassed into the same conceptual framework, the same status being granted to data that are factual and objective and data that are subjective and impressionistic. All data are, therefore, equal before the computer and no value judgments are at work in the processing. It might be possible within the next few years to decide how many events are necessary for the waking of any particular diagnosis and which ones are crucial. This would facilitate the training in the essential amnestie process and make child psychiatry records more accessible to our medical colleagues. This, however, is still in the realm of research since it takes about 20 to 30 hours to prepare an average child psychiatric case record for the computer. It is some relief, nevertheless, to know that one fine day we will be able to decide to what extent an ingrowing toenail in the maternal grandmother has played a decisive part in the bed wetting of her third grandson, or more seriously, to what extent a child's socio-economic status determines the nature of his fantasies. Living on Borrowed Theory Child psychiatry has so far borrowed heavily from the behavioral sciences, especially from psychodynamic theory, but it will eventually need to create, if it

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is to retain its status as a sub-discipline, its own body of scientific theory allowing for the conceptual ordering of empirical data as they accrue. Embryonic research in the field of child development and child psychiatry is now beginning to emphasize observations under controlled conditions, and from these will emerge constructs which are operational, that is, which have clearly specified and identifiable empirical referents and hypotheses which are testable and refutable. The fact that child psychiatry has achieved a Board examination should not blind us to the fact that it has little or no systematic theory of its own to offer, and lives mainly on borrowed constructs. In his earlier child guidance form, the child psychiatrist clearly belonged to that half of the universe designated by William James as tender-minded, bound to a "magic torrent of words," uncritical of explanations and "isms," maintaining a happy trust in intuition and awed by the power of the mind. In his ardent clinical activities, he was forever searching and discovering through the use of hypothetico-deductive methods absolute principles of truth, answering to the criteria of coherence and consistency, hut blind to the presence of negating evidence from external sources. He was therefore much more at home in the guidance clinics, where the clinical fate of the individual child was a matter of intense concern to all the staff who shared in the same system of "hunches" and feelings "in the bones," and regarded science with suspicion if not repulsion. When he moved house, the child psychiatrist took some of the old furniture along with him-one of these being a heavy box of words! Conclusion-A Window on the Future

It has taken 50 years for the child psychiatrist to develop his unique sociopsychobiological approach to the child, 50 years to find his way back into the medical world and take his place among other physicians, 50 years to devise training methods approved of by the medical associations, and 50 years to produce 5 comprehensive textbooks of child psychiatry, to institute specialist Board examinations, and to organize an Academy that is already producing its own journal. The natural history of this discipline is reminiscent of that undergone by pediatrics, but whereas pediatrics is now free from its connections to medicine, child psychiatry is still tied dependently to adult psychiatry and to a lesser degree to pediatrics. Currently, they both seem ominously reluctant to sever the connections and allow the new discipline to grow up. I would dare to predict that child psychiatry will have attained independent departmental status in schools of medicine in 50 years. It would be my sincere hope that when it has become a fully-developed medical discipline, it will not forget its antecedents, its history of the past 50 years, and its enriching relationships with the behavioral sciences. The talking doctor still has important things to say to patients, he still has time to listen to them, and he still has the crucial educational task of instructing "shooting" doctors how to talk! May his humanistic characteristics

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never atrophy under rigorous scientific conditions, and may he continue to represent the great naturalistic tradition that goes back in almost unbroken line to Hippocrates. In this presentation, I have described the history and progress of the child psychiatrist, who, having duly trained himself as a physician, wandered away into the distant realms occupied by the behavioral scientist-the psychologist, the anthropologist, the sociologist, edueationalist, the psychoanalyst, the philosopher, the social worker, and even the economist. Over the past 50 years, he has ranged far and wide, retaining his umbilical tie to the medical world but taking whatever he could from every human experience, even from those whom his medical colleagues might be tempted to describe as charlatans. As Paracelsus said, "The universities do not teach all things, so a doctor must seek out old wives, gypsies, sorcerers, wandering tribes, old robbers and such outlaws and take lessons from them." It is to our great advantage today that William Withering followed this advice with respect to the foxglove. The child psychiatrist has now returned to the schools of medicine and is setting up divisions of this discipline within their walls. He appears ready to settle down and for the next 50 years devote himself to the construction and elaboration of a complex sociopsychobiologieal system whose concepts can be communicated to colleagues and taught to medical students and whose researches can be replicated around the globe. I am confident that he will not lose his contacts in the outside world and will continue to fraternize with the many friends he has made outside. From time to time, he must refuel by taking stock of the developments in the social sciences and carry them back to the medical and basic sciences. But he must wander, because he is a go-between for the two worlds and he can serve the useful function of interpreting the one to the other. To quote Paracelsus again, (who I am sure would be a psychiatrist if he were alive today), in his defense of his wayfaring: "The wanderings that I have thus far accomplished have proved of advantage to me, for the reason that no one's master grows in his own house, nor his teacher behind the stove. Also, all kinds of knowledge are not confined to the fatherland but scattered throughout the whole world. They are not in one man nor in one place. They must be brought together, sought and found where they do exist. Is it not true that knowledge pursues no one but that it must be sought? It is written in the laws that a physician must be a traveler. Not merely to describe countries as to how they wear their trousers, but courageously to attack the problems as to what kind of diseases they possess. The English humors are not the Hungarian, nor the Neapolitan the Prussian; therefore you must go where they are. He who wanders hither and thither gains knowledge of many peoples-experience of all kinds of habits and customs, to see which one would be willing to wear out his shoes and hat. Does not a lover go a long way tO see a pretty woman? How much better to pursue a beautiful art!"

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In my own professional life, I have tried to practice what Paracelsus preached. I have wandered from one continent to another and have been instructed by the changes-the English humors are certainly not the American ones nor the English language the American language and English habits, apart from tea drinking, are peculiarly difficult to export. I have lived in medical schools most of my life but I have also wandered far and wide among the behavioral sciences. I have wandered between the world of research and of clinical practice. Having surveyed the field, I am deeply aware how much integration in these several fields of knowledge there remains to be accomplished in the next 50 years. Most of all, I have become aware in wanderings, what an undeserved privilege it is "to pursue a beautiful art." Dr. Anthony is lttleson Professor of Child Psychiatry, Washington University School of Medicine, St. Louis, Missouri.

The emergence of child psychiatry as an academic discipline.

Child psychiatry has come a long way since its tenuous beginnings fifty years ago. A few of the pioneers are still around to remind us of our short hi...
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