Spring 2024 Issue

The Mental Health of Children
By Emily Rubin, LICSW, MSW, MA
Social Work Today
Vol. 24 No. 2 P. 12 The Mental Health of Children

An Evolution of the Understanding From the Mid-19th to Early 20th Century

Today, we take for granted that mental illness is a subject unto itself and children’s mental health is a discipline worthy of study. However, this wasn’t always the case. Just 200 years ago, in the early 19th century, the discipline of general psychiatry did not exist, and very little was written about the emotional lives of children. Distinct phases in the mid to late 19th and early 20th centuries reflect the evolution of our current understanding of childhood mental health, in which children are recognized as psychological beings who may suffer from particular behavioral disorders and who require specific forms of treatment.

Early Efforts to Understand Children’s Mental Health
In the early to mid-19th century, it wasn’t thought possible that children could suffer from mental illness. Insanity was understood to be a loss of reason; since children were not born with reason, and reason developed within individuals by early adulthood, it was therefore believed that only adults could become insane.1 During this period in history, behavioral problems in children were viewed not as medical issues but as evidence of a lack of morality to be remedied by punishment.2 In the later part of the 19th century, British psychiatrist Henry Maudsley reinforced this idea, referring to children as “brute” creatures, subjected to whims of passion rather than reason.1

To underscore the absence of children in psychiatric discourse in the 19th century, it should be noted that Benjamin Rush, MD, widely perceived to be the first American psychiatrist, did not refer to children at all in his 1812 authoritative textbook entitled Medical Inquiries and Observations Upon the Diseases of the Mind.2

By the late 19th and early 20th centuries, children began to make an appearance in textbooks on psychiatry. In 1895, Maudsley acknowledged “mental defectiveness” among children in “The Insanity of Early Life,” a chapter in his textbook on general psychiatry.2 Referring to children with emotional and intellectual disabilities as having moral defects was commonplace during this time. For example, in “The History of Attention Deficit Hyperactivity Disorder,” Lange et al present a 1902 case study of a young boy who pathologically repeated the phrase “good night” and another young boy who was unable to focus on the tasks at hand; both boys were described as having “moral defect(s).”3

The discovery in the late 19th century that germs were linked to physical illness led to the concept that mental illness was caused by physiological reasons.4 This was an enormous departure from the belief in moral deficiency as the prevailing cause of mental illness. Also, by the end of the 19th century, the role of heredity began to be understood as a precursor for developing symptoms of mental illness.2 As generational manifestations of mental illness within families appeared, connections were starting to be made; sometimes, individuals with maladaptive behaviors produced children with similar behaviors.

Somatic theories about mental illness became popular among medical practitioners by the late 19th century; these practitioners believed that mental illness was caused by irregularities in the nervous system.5 By the turn of the 20th century, interest grew in Sigmund Freud’s theories of personality development, and his emphasis on psychoanalysis, and many practitioners adopted an appreciation for the psychological underpinnings of mental illness. The emergence of psychotherapy was promoted in America by Boris Sidis, MD, PhD, who, like Freud, believed strongly in the subconscious and practiced psychotherapy among his wealthy patients in an opulent setting known as the Sidis Psychotherapeutic Institute in New Hampshire.5

In 1895, neurologist Bernard Sachs authored A Treatise on the Nervous Diseases of Children, the first American textbook on child psychiatry. Sachs opposed the psychoanalytical approach promulgated by Freud and believed it could be dangerous to children. He even included a chapter on the “evils of psychoanalysis” in his third book on children’s mental health, The Normal Child, published in 1926.4

By the first decade of the 20th century, another scientific advance was made, although it was not systematically proven with evidence-based rigors in place today: Lange et al describe the introduction of “minimal brain damage” as a physiological explanation for emotional problems among children. Sir George Frederic Still, in 1902, and Alfred Frank Tredgold, in 1908, each reported cases of brain lesions identified in emotionally disturbed children. Tredgold postulated that mild brain damage in infancy could develop into behavioral problems that would surface in school.3 It’s compelling to realize that the seeds of medical or physical causes of children’s mental illness that were planted during this time formed the foundation of our current understanding that many types of mental illness can be classified as brain disorders.

Children Endured Trauma Without Appropriate Treatment
It’s important to remember the living conditions of the poor majority, including children, during the mid to late 19th century, the stress of which could trigger mental health problems. Social reformer and New York City police reporter Jacob Riis described devastating conditions in 1890 of starvation and disease among children, many of whom were living on the streets. He reported lifeless infants strewn in the streets and drowned children floating in rivers.6 The environmental conditions endured by children during Riis’ time would likely be viewed today as traumatic events.6

In the mid-19th century, American social reformer Dorothea Dix was appalled by conditions among individuals with mental illness, who were housed in prisons and poorhouses, and she was instrumental in the creation of humane asylums. She was a remarkably ambitious and successful advocate for people with mental illness. Despite her noble intentions, however, after several decades, conditions deteriorated dramatically in the asylums, which were overcrowded and inadequately staffed.7 In “Mental Health Policy in America: Myths and Realities,” Gerald Grob points out that long-term cases of institutional patient populations grew exponentially between 1830 to 1870 and 1890 to 1950, which suggests severe overcrowding by the end of the 19th century.8

Asylums played a key role in the segregation of children with mental health needs. A retrospective study by child psychiatrist Kate Gingell reveals horrific conditions endured by child patients, who were treated in the same manner as adult patients and were likely subjected to abuse, including sexual abuse. In “The Forgotten Children: Children Admitted to a County Asylum Between 1854 and 1900,” Gingell reviews 195 cases of children aged 4 to 16 admitted to the Powick Asylum in England.1 It’s daunting to realize that most of these children likely transferred from one dysfunctional setting to another since Gingell reports that places of referral included prisons and workhouses.

Diagnostic categories in the Powick Asylum included idiocy, moral imbecility, mania, epilepsy, and dementia, with highest diagnostic percentages in mania and epilepsy, though almost half of the children were given comorbid diagnoses. Gingell points out, interestingly, that idiocy was the most cost-effective diagnosis since children labeled as idiots were not deemed dangerous and were therefore able to do manual labor and contribute to the maintenance of the hospital. Treatments were scantily documented and included “bromide, chloroform, blisters, brandy, ammonia, and digitalis.”1 Other treatments may have been used as well; the Ethics Committees of the American Academy of Child and Adolescent Psychiatry and the American Psychiatric Association note that hydrotherapy and hypothermia were also commonly used treatments.9 Gingell notes there was an unusually high death rate among children in the asylum; the death rate rose from one in three in the community to one in five in the asylum.1

There seems to have been a disturbingly ambiguous set of criteria for referring children to asylums. A 1917 referral letter of a young girl from St Cadoc’s Home in Wales, a home for orphaned girls, indicates that the child was referred for being dishonest. The medical superintendent, William F. Nelis, MD, wrote: “It appears that the child has a very deficient moral sense in the matter of truthfulness and honesty, and I think her example may have an evil influence on the other children in the Home. … I think she would be much better placed in an institution for mentally deficient children where the training and discipline would be more suited to her case.”10

It’s difficult to imagine a world in which a child’s dishonesty would justify referral to an asylum, but it’s certainly reflective of a lack of understanding of child development.

Around 1900, the rise of the eugenics movement took hold in the United States, described by Jeffrey Brosco, MD, PhD, in his peer-reviewed article “Navigating the Future Through the Past: The Enduring Legacy of Federal Children’s Health Programs in the United States.” State laws were enacted to sterilize “feeble-minded” adults with intellectual disability, and immigration policies developed to prevent the influx of people with disabilities from entering the country.11 Tredgold was a proponent of eugenics, which is especially disconcerting given his status as a physician and expert in mental illness; in his 1908 book Mental Deficiency, Tredgold espoused eugenics as “the antidote to degeneracy.”12

Looking at the 19th century through the lens of trauma awareness, it’s clear that enormous numbers of adults and children were traumatized—by poverty, by abusive and abhorrent living conditions, and, at the end of the century, by the politics of eugenics. One such traumatized figure, Clifford Beers, used his personal experience to educate others and increase understanding of mental illness, with far-reaching implications. Though not considered an advocate of children’s mental health, Beers was an influential figure in the first decade of the 20th century. As a young man, he suffered a nervous breakdown following the death of his brother and was admitted to public and private mental institutions, where he was exposed to abuse and inhumane conditions. When released, he wrote an expose on the cruel treatment he received. His 1908 memoir, A Mind That Found Itself, led to the development of the National Committee on Mental Hygiene in 1909. That committee went on to become Mental Health America, one of the early proponents of child guidance clinics, which became the foundation for clinical care in the 20th century. Today, Mental Health America is an active nonprofit organization that continues to promote mental health.13

Planting the Seeds for Contemporary Views on Children’s Mental Health
Although it’s commonly known today that children pass through developmental phases that differentiate them from adults, in prior centuries, children were not seen as distinctly different from adults. It wasn’t until after the Civil War that pediatrics, which had been considered an aspect of obstetrics, became its own discipline under the leadership of Abraham Jacobi.6 Incidentally, this “Father of American Pediatrics” promoted the idea that masturbation in children—which is now considered a normal part of child development—led to major neuroses.14 By the late 1800s, pediatrics was established as a medical subspecialty.9

While there was growing recognition that children needed to be treated differently than adults, it was difficult to implement proper care because there was a crisis of orphans in the 19th century. The lack of stable family units due to economic uncertainties and early parental death placed many children in untenable situations that led to impoverishment and homelessness, placement in poorhouses, or referrals to asylums.

Distressed by the plight of thousands of orphaned children living on the streets of New York City, minister Charles Loring Brace founded the Children’s Aid Society in 1853. His idea was to remove these children from their unhealthy urban environments where prospects were dismal and relocate them to rural farm settings with a chance to start new lives. Beginning in 1854, 100,000 impoverished children were transported by orphan trains to join new families on the Western frontier. The Orphan Train movement is widely perceived to be the starting point of modern foster care in America.15

During the Orphan Train Movement, rural life was arguably a healthier physical environment than city life, where poor sanitation was rampant, and contagious illnesses like cholera bloomed as a result of close proximity. While not every child on the Orphan Train was placed in a functional family, there were enough positive results that the experiment was considered successful.15 The Orphan Train movement promoted a critically important concept: the environment played an integral role in children’s development, and this was a significant step in understanding children’s mental health.

The origins of child psychiatry as a field of study in America can be traced back to the creation of the first juvenile court in Chicago in 1899.16 John Schowalter, MD, in the Psychiatric Times article “A History of Child and Adolescent Psychiatry in the United States,” explains the impact of the first juvenile court. The creation of the court set into motion a series of events with a lasting impact on the present day. Distressed by juvenile delinquency, the Jane Addam’s Hull House Board of Directors, made up primarily of wealthy women, created the first “Juvenile Psychopathic Institute” and employed neurologist William Healy, MD, to direct the institute in 1909. The new center viewed violence among youth as a serious mental health and public health problem. Healy developed a team-based approach to address prevention and treatment among juvenile delinquents: he joined together a neuropsychiatrist, a social worker, and a psychologist. This team treatment approach became the basis of child guidance clinics established in the first decade of the 20th century and continues as a blueprint for clinical mental health care today.16

By 1825, the New York House of Refuge appeared, followed by other Houses of Refuge. These punitive reformatories, which were repositories for juvenile delinquents, appear to have housed children and adolescents with mental health needs that today might be classified as mood disorder not otherwise specified, oppositional defiant disorder, conduct disorder, and ADHD. A New York Times staff writer described the New York House of Refuge in “Our City Charities: The New York House of Refuge for Juvenile Delinquents,” published on January 23, 1860. At that time, 560 inmates were imprisoned, aged 8 to 17, 80 of whom were female. With a heavy emphasis on moral and religious “instruction,” the house ranked inmates based on behavior. The highest grade comprised children who were “vicious, stubborn, and refractory.” Punishment for children who were “evil in their natures” included solitary confinement for up to six consecutive hours, full-time labor, and deprivation of meals. A large number of the children, upon discharge, were either readmitted to the house or sent to prison.17

Clearly, efforts to reform these children were not entirely successful, very likely because many of the children had undiagnosed mental health needs that were not adequately treated. Today, we see a similar dynamic in prisons and juvenile detention facilities that stem back to the Houses of Refuge, which focused on trying to rehabilitate criminals without addressing their mental health issues.

There were many significant factors that shaped ideas about children’s mental health in the late 19th and early 20th centuries, and one of them was a shift in attitude about a sense of agency regarding children. As Cynthia Connolly, PhD, points out in “Late 19th and Early 20th Century Pediatrics: The Development of a Specialty,” vagrant children were viewed as “innocent victims” of their undeserving parents, whose lack of morality was evidenced by poverty, homelessness, or inability to provide for their families.6 By the end of the 19th century, as the punitive nature of reformatories suggested, children began to be viewed as their own agents, responsible for their own actions and the consequences of those actions.

Where Are We Now?
The 20th century was marked by huge leaps in the understanding of children’s mental health: advances in psychiatry and neurology to better understand brain development and the central nervous system, growth of prescription medicines to help mitigate symptoms of mental illness, legislation to protect children with disabilities, deinstitutionalization, and public awareness campaigns about the stigma of mental illness.

In order to understand children’s mental health today, we need to appreciate the discoveries, events, and attitudes in the late 19th and early 20th centuries that shaped beliefs among practitioners and within society. The field of child psychiatry grew out of a specific set of social and economic conditions, and interestingly, the maladaptive behaviors of children in the 19th century are remarkably similar to those of children of today.

The study of children’s mental health is a relatively young discipline, and we are still in the learning phase of what causes mental disturbances among children and how to effectively remedy their problems. Today, in the 21st century, we are grappling with a different set of concerns pertaining to children: an epidemic of psychiatric diagnoses, an often unwarranted pathologization of children’s behavior, the rise of a pharmaceutical industry that potentially has capitalized on children’s behavioral problems, and public school systems that are ill-equipped to respond to the demand of educating children with mental health needs. We are headed in the right direction, but as history has shown, children’s mental health is a complex subject with many moving parts.

— Emily Rubin, LICSW, MSW, MA, is an assistant professor in psychiatry at UMass Chan Medical School, director of Sibling Support at the Eunice Kennedy Shriver Center, and a part-time teaching associate at Harvard Medical School. Rubin’s research interests relate to resiliency among family members of people with disabilities. Her current research examines the impact of a child’s mental illness on typically developing siblings and caregivers and strategies to build resiliency and decrease trauma within these families. She has published and presented her work widely.

References
1. Gingell K. The forgotten children: children admitted to a county asylum between 1854 and 1900. Psychiatr Bull. 2001;25(11):432-434.

2. Rey JM, Assumpcao FB, Bernad CA, et al. History of child and adolescent psychiatry. In: Rey JM, ed. IACAPAP eTextbook of Child and Adolescent Mental Health. Geneva: International Association for Child and Adolescent Psychiatry and Allied Professions; 2015.

3. Lange KW, Reichl S, Lange KM, Tucha L, Tucha O. The history of attention deficit hyperactivity disorder. Atten Defic Hyperact Disord. 2010;2(4):241-255.

4. Early American psychiatry: diseases of the mind. National Library of Medicine website. https://www.nlm.nih.gov/hmd/diseases/. Published 2006. Accessed January 22, 2024.

5. Holtzman E. A home away from home. Monitor on Psychology. 2012;43(3):24.

6 Barbara Bates Center for the Study of the History of Nursing. University of Pennsylvania website. http://www.nursing.upenn.edu/nhhc/Pages/Late-NineteenthandEarly-CenturyPediatrics.aspx. Accessed January 22, 2024.

7. American Experience. PBS website. https://pbs.org/wgbh/amex/nash/timeline/index.html. Accessed January 22, 2024.

8. Grob GN. Mental health policy in America: myths and realities. Health Aff (Millwood). 1992;11(3):7-22.

9. Sondheimer AN, Klykylo WM; Ethics Committee, American Academy of Child and Adolescent Psychiatry; Ethics Committee, American Psychiatric Association. The Ethics Committees of the American Academy of Child and Adolescent Psychiatry and the American Psychiatric Association: history, process, education, and advocacy. Child Adolesc Psychiatr Clin N Am. 2008;17(1):225-236, xi-xii.

10. Misunderstanding mental health in the early 20th century. Hidden Lives Revealed website. https://www.hiddenlives.org.uk/blog/2014/04/misunderstanding-mental-health-early-20th-century/. Published April 4, 2014. Accessed January 22, 2024.

11. Brosco JP. NAVIGATING the future through the past: the enduring historical legacy of federal children’s health programs in the United States. Am J Public Health. 2012;102(10):1848-1857.

12. Tredgold AF. Mental Deficiency (Amentia). New York, NY: William Wood & Co; 1912.

13. Our history. Mental Health America website. http://www.mentalhealthamerica.net/our-history. Accessed January 22, 2024.

14. Combs S. Abraham Jacobi on masturbation in children. Pediatrics. 1995;96(1):68.

15. The orphan trains. PBS website. https://www.pbs.org/wgbh/amex/orphan/. Accessed January 22, 2024.

16. Schowalter JE. A history of child and adolescent psychiatry in the United States. Psychiatric Times. September 1, 2003. https://www.psychiatrictimes.com/view/history-child-and-adolescent-psychiatry-united-states. Accessed January 22, 2024.

17. Our city charities: the New-York House of Refuge for Juvenile Delinquents. The New York Times. January 23, 1860. https://www.nytimes.com/1860/01/23/archives/our-city-charities-the-newyork-house-of-refuge-for-juvenile.html