DEVELOPMENTAL DIAGNOSIS AND SUPERVISION: SOME

POSTWAR POSSIBILITIES*
ARNOLD GESELL, M.D.
Clinic of Child Devtlopment, Yale University, Ntw Haven, Conn.

THE theory and practice of developmental diagnosis rest on the premise that
development as well as disease falls within the scope of clinical medicine. The
interaction of disease and development is, of course, very close. Developmental
factors influence the incidence and nature of many diseases. Conversely, many
diseases have an acute or chronic effect upon the completeness of child develop
ment.
Postwar medicine, however, will place an increasing emphasis on the preven-
tion of disease and defect. It will also use biological science and clinical methods
for the purpose of enhancing well being. For this enlarging outlook we need a
formula which will bring physical and mental health into closer identification,
and which will make the goal of health more dynamic both for parent and child.
The concept of optimal development is such a formula.
Development is a unifying concept. It tends to reduce the dualisms of psyche
and soma, of heredity and environment, of structure and function, of normality
and abnormality. But development is more than an ideological abstraction. De-
velopment is a process, just as real and valid as metabolism, respiration, glandular
secretion, or any other vital function. It is in fact the summating and integrated
resultant of all the life functions of an organism moving through a self-limited
cycle of time.
As a living process, growth or development (the terms may be used inter-
changeably) has become a major preoccupation of the biological sciences. Witness
such recent works as Needham’s Chemical Embryology (3 volumes), Needham’s
Biochemistry and Morphogenesis, D’Arcy Wentworth Thompson’s classic volume
on Growth and Form, Spemann’s Embryonic Development and Induction. A vast
literature in related fields of physiological anatomy, genetic psychology, and
physical anthropology, to say nothing of child development, reflects a wealth of
scientific knowledge, much of it quantitative and experimental. This knowledge
is not yet ripe for full application, but it is ripening and its potentialities are
enormous. It is safe to predict that we shall some day have biometric techniques,
which will use biological methods for precise appraisal of developmental status.
Naturally such techniques fall in the province of clinical medicine.
To some extent the techniques have already found a lodgment there, notably
in the field of clinical pediatrics. Pediatrics concentrates on a limited sector of
the life cycle. Most specialties such as ophthalmology and urology deal with
specific organ systems. Pediatrics, in contrast, is concerned with the total organ-
ism and is, as Osler indicated, “the specialty of general medicine.”
As such it has had a unique historical evolution. Devoted a t first to the dis-
* Prepared for presentation at the 1945 Annual Meeting, cancelled because of ODT ruling.
5x0
 ARNOLD GESELL 511

eases of childhood, it became increasingly interested in the developmental con-

sequences of disease, and in the basic problems of growth and nutrition. The
supervision of nutrition brought healthy as well as sick babies into the purview
of medicine. As early as 1892 Pierre Constant Budin established the first con-
sultation center for nurslings at La Charith, Paris, and thereby made a far-reaching
contribution to preventive medicine. This consultation center became the fore-
runner of well-child conferences which in America represent a large scale applica-
tion of positive medicine, diagnostic and advisory, in close association with par-
ent guidance.
The supervision of infant nutrition, both in health centers and in private
practice, is steadily expanding to include mental as well as physical welfare. This
leads to individualized, periodic contacts with the growing child. His behavior
characteristics, his psychological maturity and hygiene are then taken into ac-
count. With the increase of scientific knowledge the protection of child health
evolves into a form of developmental supervision.
Recognizing this trend, The American Academy of Pediatrics has made the
field of “Growth and Development” one of its major requirements for certifica-
tion. The importance of more facilities for the training of pediatricians and gen-
eral practitioners in the field of mental health was recently stressed in a “Report
of Committee on a Consideration of Child Health in the Postwar Period.”’
Through this report the Academy has taken a position which in the estimate
of its official journal has “the potentiality of becoming the most forward-looking
step in the development of sound child health activities for the future that has
been made in years.” The problems of child health have been formulated “in a
way which can fit into any program which may evolve for medicine in the post-
war United States.”
The administrative organization of that program cannot, of course, be pre-
dicted. But many surveys and projections have been made which indicate the
needs and the trends of a more coordinated health service for the nation. Espe-
cially notable are the findings of the United States Senate Committee on Educa-
tion and Labor. The Interim Report2 of its Subcommittee on Wartime Health
and Education (Claude Pepper, Chairman) urges an integrated system of health
services with health centers in every community to combine preventive, diag-
nostic, and curative care. Four basic types of facilities are proposed: the small
neighborhood or community health center, the rural hospital, the district hos-
pital, and finally, the large base hospital, with constant exchange between these
units of information, training, consultation service, and personnel.
1 Am. J. Pediatrics, December 194,Vol. 25. Proc. 13th Annual Meeting of the American Academy
of Pediatrics! pp. 599-635.
* A. Interim Report from the Subcommittee on Wartime Health and Education to the Committee
on Education and Labor, United States Senate, pursuant to S. Res. 74;A resolution authorizing an
investigation of the educational and physical fitness of the civilian population as related to national
defense, January 1945.United States Government Printing Office, January 1945,pp. 1-22. B. Hear-
ings before a Subcommittee on Education and Labor, United States Senate Seventy-Eighth Congress,
Second Session pursuant to S. Res. 74. Part 6, September 1944,pp. 1873-2176.
512 DEVELOPMENTAL DIAGNOSIS: POSTWAR POSSIBILITIES

We are not here concerned with the financial and governmental aspects of
such a vast program. The proposals, however, have brought into focus the kind
of arrangements necessary for a more fundamental child health protection. This
protection must be consecutive and individualized rather than piecemeal; it
should be based on a periodic, and so far as possible, a personalized supervision.
Otherwise we cannot get a t the preventive roots of mental abnormality-the
maladjustments of child life and family life.
The Rochester Child Health Project looks forward to such objectives. This is
“a complete preventive medical program for children,” under the auspices of the
Mayo Clinic. Dr. C. Anderson Aldrich, in outlining the program; describes five
principal types of care: the antepartum clinic, hospital care, well baby clinic, pre-
school clinic, and school health program. “The project itself has two main ob-
jectives: first, to offer all the children of Rochester supervision of health based on
the needs of the individual child for optimal growth; second, to study the growth
of these children from conception to maturity by means of continuous observa-
tion and records. . . . We are interested in finding out whether, by mass educa-
tion as to prevention, we can obtain a better result, with less expenditure of time
and money than has been obtained under existing methods. This seems to us a
practical objective, since mental disease is one of the major problems of the pres-
ent time.”
The clinical protection of child-development demands routine regard for be-
havior symptoms in private practice, in infant welfare examinations, in child-
health supervision, in children’s hospitals, and in all child-care agencies charged
with administrative responsibilities. A t the lowest minimum, there should be a
behavior inventory which will disclose the most serious developmental defects
and deviations. Such an inventory will not have diagnostic conclusiveness, but it
will have a‘prediagnostic screening value, and may become a useful part of the
child’s record. A screening-type of behavior survey by inventory and develop-
mental examination is destined to become a standard feature of child protection,
both in private practice and in child welfare administration. How else can we do
justice to children who are not developing normally, who are temporarily wards
of hospitals or permanent wards of the community?
Timely diagnosis of mal-development depends upon routine developmental ex-
aminations of infant behavior. Through the application of behavior tests, nearly
all cases of mental deficiency (amentia) can be recognized in the first year of life.
Instabilities and emotional abnormalities also declare themselves early, when di-
agnosis is directed to the appraisal of developmental maturity. The examination
of behavior serves to disclose sensory defects in vision and hearing, and motor
disabilities which might otherwise escape detection. Such an examination is es-
sential to a discriminative diagnosis of selective cerebral injury and amentia.
Cerebral birth injuries frequently simulate amentia, and children with motor de-
fects are often mistakenly classified as mentally deficient. Developmental diag-
a C. Anderson Aldrich, M.D. SigntJ5cancc of a Complete Preventive Medical Program for Children.
Am. J. Dis. of Children, September 1944,pp. 168-171.
 ARNOLD GESELL 5x3

nosis reveals normal and constructive features as well as shortcomings in an in-

fant's behavior equipment. A discriminating insight into behavior potentialities
is essential to any intelligent program of guidance and treatment. All handicaps
require interpretation in terms of their developmental significance.
Every sizable community already needs specialized facilities for the diagnostic
study of the more complex forms of mal-development; the outpatient division
of a hospital is the logical place for such facilities. The developmental appraisal
should not be a by-product but a separate undertaking, using all available evi-
dence, but directed to a careful analysis of behavior status. This means a separa-
rate locus, special equipment, and trained personnel on a par with electro-
encephalography, ophthalmology, radiology, or any other diagnostic department.
The arrangements must be planned to insure optimal responses of the infant and
the young child. Such arrangements are indispensable for the systematic follow-
up supervision and parent guidance so seriously needed in all cases of mal-
developmen t.
A permanent diagnostic department will also become a natural center for
demonstration, teaching, and intern training. It alone can establish the high
standards of diagnosis which are necessary as a safeguard against superficial
forms of applied psychology. The problems of child adoption and of foster home
placement will assume increased importance in the postwar period. Adequate
social control' of these problems likewise requires clinical safeguards in the form
of developmental examinations under medical auspices.

Development does not take care of itself. I n a complicated society it needs to

be subjected to periodic diagnosis and supervision. Such supervision will have
regard for assets as well as liabilities and will seek to conserve what is excellent
in child and family.
A developmental supervision which is personalized in terms of the parents and
individualized for the child will be conducted in a democratic spirit. Only through
a democratically conceived system of developmental supervision can we attain a
more just and universal distribution of developmental opportunity for infants
and preschool children. If, in the period of postwar reconstruction, first things
are in fact made first, we shall approach all problems of child conservation with
a chastened outlook.