“Men are haunted by the vastness of eternity. And so we ask ourselves: will our actions echo across the centuries? Will strangers hear our names long after we are gone, and wonder who we were, how bravely we fought, how fiercely we loved?”
David Benioff, Original Screenplay, Troy
“In the history of medicine, it is not always the great scientist or the learned doctor who goes forward to discover new fields, new avenues, and new ideas.”
Elizabeth Kenny
INTRODUCTION
The major religions of the world have all advocated a progressive and inclusive outlook toward people with disability. In reality, for much of recorded history, disability was regarded as the result of evil spirits, the devil, witchcraft, or God's displeasure. History is rife with illustrations of the inhumane and shameful treatment of people with disabilities.
Gradually, “the doctor and the scientist replaced the priest as custodian of societal values and curing processes.” Institutions for the disabled were established to allow other family members to meet work obligations and also to train the former for some vocational productive activity. The goal of interventions was to provide the person with the appropriate skills to rehabilitate or deal with it.
According to Jayne Clapton and Jennifer Fitzgerald, “Institutions became the instruments for the facilitation of exclusion and social death.” In recent times, the notion of “disability” is seen from a rights-based sociopolitical assertion. The focus has moved away from exclusion and dependence (state-run institutions) to inclusion and independence (community-based facilities and care); countries have enacted legislation, which seeks to address issues of social justice and discrimination.2
The history of developmental behavioral pediatrics is the story of pediatricians taking disability away from these rigid frameworks into a promotive as well as a healing positive space. This is the story of their emerging interest and expertise in developmental psychology and behavioral psychology: and the combination of both disciplines to shape this interdisciplinary field, and ultimately making its own space within general pediatrics to become a subspecialty.
William Healy, a Chicago physician, in 1909, setup the first child guidance clinic to deal with children exhibiting antisocial behavior, thus attempting to separate delinquency from the criminal justice system and establishing the role of personality that lay behind much of their behavioral problems. His pioneering work to separate behavioral psychology from the justice system has its roots in early theories of child development that have thereafter shaped modern theories of developmental behavioral pediatrics.
Since the late 1800s, the field of human development is a field devoted to identifying and explaining changes in behavior, abilities, and attributes that individuals experience throughout their lives. Charles Darwin's A Biological Sketch of an Infant, and more significantly, his famed theory of evolution was the driving force behind the discipline of developmental psychology and inspired many. Among them, G Stanley Hall considered to be the founder of American developmental psychology, believed that human development follows a course similar to that of the evolution of the species. His mentee at Clark University, Sigmund Freud proposed that development occurs through the resolution of conflict between what a person wants to do versus what the person should do. This notion formed the basis of Freud's theory of psychosexual development. Freud's interactionist perspective believed that both, biological and environmental factors, influenced human development (although he believed that environmental factors, such as parenting, were far more impactful). In contrast, the maturational theory of Arnold Gesell represents the biological theory that child development is a naturally unfolding progression that occurs according to some internal biological timetable and learning and teaching cannot override this timetable. Gesell held that children are “self-regulating” and develop only as they are ready to do so. He established the statistical norms to describe this sequence, as well as the age range within which each early behavior normally appears updated versions of which are still in use as general guidelines for normal development. He was the first to capture children's observations on film and also pioneered the use of one-way viewing screens.
Gesell's work on similarities across children's development and his focus on patterns of behavior set the stage for Jean Piaget. Unlike Gesell's method, in which the researcher stood apart from his objects of study, Piaget developed a research technique known as the clinical method. He worked on the study of the nature of knowledge in young children, as well as how it changes as 3they grow older. He termed this area of study genetic epistemology. According to his cognitive-developmental theory, children universally progress through a series of stages: the sensorimotor stage (birth to age 2 years), the preoperational stage (ages 2–7 years), the concrete operational stage (ages 7–11 years), and the formal operational stage (ages 11 years and beyond). He emphasized that children play an active role in their own development. This contribution laid the foundation for behavioral genetics.
Piaget's theory was at variance with Lev Vygotsky's sociocultural perspective, which emphasized the role of social interactions in cognitive development. According to Vygotsky, cognitive development occurs when children incorporate and internalize feedback from adults, parents, and teachers.
Pediatrics with its charter for preventive as well as curative care of children during their entire childhood (from birth to adulthood) was the natural specialty of medicine to see the developmental and behavioral problems first and try to manage them. Bronson Crothers, an eminent pediatric neurologist at Boston Children's Hospital, posited that ideally the pediatrician was in the best position to deal with children's behavior in the context of the family with emphasis on prevention and early diagnosis.
Thus, the basis for this subspecialty lay in the work of many pioneers in the early part of the last century that emphasized the common interests of psychology, psychiatry, and pediatrics. In 1970, Stanford Friedman was perhaps the first to use the term “behavioral pediatrics”; he defined behavioral pediatrics as “an area within pediatrics which focuses on the psychological, social, and learning problems of children and adolescents.” He later added that in addition to “problem oriented” aspects of pediatrics, behavioral pediatrics also included prevention, advocacy, ward and clinic management, and the interdisciplinary delivery of health care.
In the 1975 special issue of Pediatric Clinics of North America, Julius Richmond titled his article “An Idea Whose Time Has Come”. The other articles in this issue defined the different areas of behavioral pediatrics by major early investigators in the field and the list of chapter headings in the issue is an interesting way to gauge the field at that point of time.
In May 1982, Esther Wender and colleagues in the United States proposed the development of a permanent academic organization for sharing research findings in behavioral pediatrics and child development, to promote its teaching in pediatric residency programs, and act as a resource and advocacy group to promote mental health needs of children. As happens in a vibrant academic environment, after considerable ado over challenges to name and domain (and turf), this organization is what we are today know as Society for Developmental and Behavioral Pediatrics—thus formally bringing together the two streams of developmental medicine and behavioral psychology.4
One of the leading lights of this movement, Melvine Levine extolled how we are “inextricably bound to general pediatric primary care” as one of the attributes that define us, along with “functioning at the tight junctions between psyche and soma, between the indigenous forces of nature and the shaping powers of nurture.”
The initiative of pioneers like Marvin Gottlieb led to the publication of the Journal of Developmental and Behavioral Pediatrics (JDBP), in March of 1980.
Thus, though developmental behavioral pediatrics has strong roots going back to the 1920s; the reality in clinical practice was summarized, amusingly, in 1985 by Stanford Friedman as “those aspects of pediatrics generally ignored by most pediatric training programs.” This was the beginning of incorporating developmental behavioral pediatrics as a subspecialty in pediatrics residency programs and also establishing subspecialty certification in developmental behavioral pediatrics.
THE INDIA STORY
According to Janeway, the course taken by most subspecialty areas of pediatrics traverses thus—“A small group of innovative pioneers develops new skills (both clinical and research), they come together at meetings and found their own society, train successors, publish a scientific journal, and finally obtain subspecialty certification. This whole process usually takes 20–30 years.” The Indian Academy of Pediatrics (IAP) played a stellar role by offering a platform for developmental behavioral pediatrics in India. Publication of the first National Consensus Guidelines for Autism, attention deficit hyperactivity disorder (ADHD), learning disability and newborn hearing screening in 2017, establishment of the IAP fellowship for developmental and behavioral pediatrics and now the first official handbook representing a nationwide and beyond repertoire of authors has firmly established this subspecialty in India. The author acknowledges the support of innumerable stalwarts from IAP in this pioneering effort.
THE FUTURE
The number and quality of conferences and training programs has significantly increased and spread across the country, especially with the digital format post the coronavirus disease-2019 (COVID-19) lockdown and the emergence of dIAP (digital IAP). However, the real success of this movement will be judged more by how well this research and training involves general pediatricians and their practices. This needs to result in improving the developmental and behavioral health of children in the country. Considering the huge numbers needing help, there will never be enough specialists and 5it is left to a collaboration between general pediatricians and developmental behavioral pediatricians to care for every child needing these services.
Sharing the views of Ruth Stein, “The early workers recognized that the longitudinal process of child development distinguishes pediatric medicine from all other medical specialties, and child development and behavior have an impact on every pediatric healthcare encounter. This fascination drew many general pediatricians who saw development and behavior as the foundation of pediatrics and involved themselves with clinical care, teaching, and research activities of development and behavior as a general pediatrician. They saw development and behavior as so fundamental to all clinical pediatrics that it was hard to segregate it as a subspecialty. Hence, in the words of Haggerty and Richmond, we must hold forth that “Child development is a basic science of pediatrics and must be a central part of the skills of all pediatricians. The task now for developmental behavioral pediatrics is to complete the circle by finding ways to train pediatricians in the treatment and prevention of the large numbers of children with developmental, behavioral, and educational problems and not to become an isolated silo of expertise.”
It now devolves upon the present generation of pediatricians and developmental behavioral pediatricians to make these dreams a reality.
FURTHER READING
- Crothers B. A Pediatrician in Search of Mental Hygiene. The Commonwealth Fund. New York: London Oxford Press; 1937.
- Friedman SB. Introduction: Behavioral Pediatrics. Pediatr Clin N Am. 1975;22:55.
- Haggerty RJ, Friedman SB. History of developmental-behavioral pediatrics. J Dev Behav Pediatr. 2003;24(1):S1–18.
- Hansen RL. Magical history tour of the Society for Developmental and Behavioral Pediatrics: Reflections on deletions, slashes, hyphens, and developmental context. Dev Behav Pediatr. 2010;31(5):441–8.
- Holmbeck G, Jandasek B, Sparks C, Zukerman JM, Zurenda L. Theoretical Foundations of Developmental-Behavioral Pediatrics, Developmental-Behavioral Pediatrics. Elsevier Inc.; 2008.
- Janeway CA. Growth and development of academic pediatrics in North America. Pediatr Res. 1971;5:560.
- Richmond JB: Child development: A basic science of pediatrics. Pediatrics. 1967;39(5):649–58.
- Stein REK. Are we on the right track? Examining the role of developmental behavioral pediatrics. Pediatrics. 2015;135(4):589–91.
- The History of Disability: A History of ‘Otherness’. [online] Available from: http://www.ru.org/index.php/human-rights/315-the-history-of-disability-a-history-of-otherness (Last accessed December, 2021).
- Wender EH, Friedman SB. Proceedings of the National Conference on Behavioral Pediatrics, March 3–5, 1985, Easton, Maryland. J Dev Behav Pediatr. 1985;6:179.