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Child and adolescent psychiatry: past scientific
achievements and challenges for the future
Rutter, Michael
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Zeitschriftenartikel / journal article
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Empfohlene Zitierung / Suggested Citation:
Rutter, Michael: Child and adolescent psychiatry: past scientific achievements and challenges for the future. In:
European Child &
Adolescent Psychiatry
19 (2010), 9, pp. 689-703. DOI:
http://dx.doi.org/10.1007/s00787-010-0111-y
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Final draft 15/03/10
MS973
CHILD AND ADOLESCENT PSYCHIATRY: PAST SCIENTIFIC
ACHIEVEMENTS AND CHALLENGES FOR THE FUTURE
*
By Michael Rutter
1
1. MRC SGDP Centre, Institute of Psychiatry, Kings College London.
Corresponding author:
Professor Sir Michael Rutter, PO 80, MRC, Social, Genetic,
and Developmental Psychiatry Centre, Institute of Psychiatry, Kings College London,
Denmark Hill, London SE5 8AF. 020-7848-0882.
camilla.azis@kcl.ac.uk
Keywords: History, child psychiatry, science, challenges
Short Title: Child and Adolescent Psychiatry
*
This article is based on an invited keynote lecture at an ESCAP-sponsored conference in 2009. The
author was asked to provide a world-wide scientific history of research relevant for an understanding of
psychopathology in childhood and adolescence and to conclude with suggestions for the future of the
discipline in Europe. By design, the review excluded consideration of clinical services. The choice of
scientific achievements to note was based on three criteria: 1) clear evidence of innovation; 2)
widespread recognition of importance as judged by citations in leading reviews and textbooks; and 3)
potential of relevance for clinical advances. Because the issues with respect to the future apply as
much in other parts of the world as in Europe, the discussion of Europe-specific concerns in the
keynote lecture has been omitted. During the preparation of the paper, three of the most important
figures during the last half-century – Eisenberg, Garmezy and Robins died and this article is dedicated
to them for the model of creative policy-relevant science and scientific integrity each of them provided.
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ABSTRACT
The world-wide history of scientific achievements in child and adolescent
psychopathology is reviewed from the mid 20
th
century onwards. Attention is drawn,
for example, to diagnostic distinctions, measures of psychopathology, the several
roles of epidemiological longitudinal studies, temperament and personality,
developmental psychopathology, the use of ‗natural experiments‘ to test causal
inferences, environmental risks, the importance of gene-environment interplay, the
relative coming together of initially diverse psychological therapies, the use of
randomized controlled trials to assess treatment efficacy, and the value and limitations
of pharmacotherapy. The article ends with a look ahead to the most important
opportunities and challenges for child and adolescent psychiatry, plus the hazards that
need to be avoided.
Although there were important roots in the 19
th
century and earlier, child and
adolescent psychiatry only came of age as a recognized specialty in the 20
th
century
[1]. It had its origins in the mental hygiene movement in the United States of
America, a movement characterized by a multi-disciplinary emphasis, a child-welfare
approach, and a focus on environmental causes. The term ―child psychiatry‖ was
probably first used at the Paris congress of 1934, but it had been preceded by the
clinic in Heidelberg in 1926. Kanner‘s text-book in 1935 provided the first English
language systematic account of child psychiatry [2], although there had been several
earlier German text-books which Kanner credited as having constituted an important
influence [3]. There was the role of psychometrics as exemplified in the work of
Binet [4] and there was the growth of psychoanalysis as an influence – accompanied
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MS973
by vitriolic infighting between Melanie Klein and Anna Freud and their respective
groups [5].
<H1>
MID TWENTIETH CENTURY LANDMARKS
There were numerous important scientific contributions in the mid part of the
20
th
century. Their diversity may be illustrated by simply noting several examples. In
many ways the most important of these was Bowlby‘s review [6] for the WHO on the
effects of maternal deprivation. Whilst not all of his claims have stood the test of
time, it was a revolutionary document that forever changed people‘s realization of the
importance of children‘s experiences, and it led to radical changes in the patterns of
care provided for children in hospital (including the introduction of the possibility of
parents staying overnight, and the encouragement of frequent parental visits). This
led on to Bowlby‘s trilogy on attachment [7, 8, 9] which was important in several
different respects. To begin with, it was remarkable in its bringing together of quite
diverse sources of evidence, both human and animal, and quite diverse theoretical
perspectives. It alerted the world to the importance of the development of children‘s
selective attachments in early life and the ways in which they provided the basis for
later social relationships of all kinds. Also it led to key methodological advances by
pioneers such as Ainsworth and Main [10].
Although Bowlby was the leading conceptualizer, the films made by James
and Joyce Robertson [11] on children‘s behavior following admission to hospital
made a huge impact and played a major role in altering hospital practices.
Levy‘s [12] study of maternal overprotection was outstanding in its analysis of
what was involved in this form of parental behavior and particularly in his
identification of the key features both in the child and in the parent that led to the
development of overprotection and its psychological consequences for the child.
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Many of the clinical studies undertaken at this time were of indifferent quality,
but there were also some good examples of high quality research. For example, there
was Hersov‘s [13] study of school refusal and Anthony‘s studies of encopresis [14]
and of infantile psychoses [15]. Kanner‘s delineation of the syndrome of infantile
autism in 1943 forever changed people‘s thinking, and it constitutes a splendid
example of the insights provided by the very careful observations of an unusually
astute clinician [16]. The follow-up studies taken up jointly by Eisenberg and Kanner
[17] did much to increase understanding of the nature and qualities of this particular
behavioral pattern.
The first randomized controlled trial was undertaken in the UK in 1948,
investigating the use of streptomycin to treat Tuberculosis [18]. However, Eisenberg
and Conners in the USA were pioneers in the 1960s in the use of randomized
controlled trials to study the effects of treatments in the field of child and adolescent
psychiatry [19].
In the first half of the 20
th
century, most clinicians and researchers paid little
attention to the importance of diagnostic distinctions, but this was changed by Hewitt
and Jenkins‘ [20] important factor analytic study of patterns of emotional and
behavioral disturbance (which they termed ―maladjustment‖). This led to an
acceptance of the need to differentiate between emotional disturbances on the one
hand and disorders of disruptive behavior on the other hand.
<H1>
VALUE OF LONGITUDINAL STUDIES
The first of the several UK-birth cohort studies was established in 1946 by
Douglas [21], later led by Wadsworth. Amongst other things, it charted the
continuities and discontinuities over time in patterns of psychopathology. Taken in
conjunction with the later birth-cohorts established in 1958 and 1970, it also
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