DEVELOPMENT AS STATE INTEREST

The modern concern for child development has its roots in the public reaction to the rapid industrialization that characterized the United States in the 19th century. Waves of immigration and the mass relocation of families from rural areas into large urban centers overwhelmed existing housing, sanitation, and virtually all municipal services, which resulted in tragically high rates of illness and death among children. Public apprehension for the well-being of children was broadly framed by these general living conditions, but of special concern was the widespread employment of children in a variety of industrial and street occupations, many of them extremely hazardous in nature. Although the peril urban life posed to children took many forms, the exploitation of children working in factories, mills, and on the street was seen as a particularly egregious threat and ultimately served as a distilled image for the development of requisite political will to ultimately address what in fact was a variety of societal threats to children’s well-being at the turn of the 20th century.

Critics of child labor could draw on only a fledgling knowledge base to support their positions. Heavily influenced by Darwin’s theories of evolution, G. Stanley Hall advocated childhood as a series of progressive stages, each requiring freedom from deleterious societal pressures and an emphasis on play and guided exploration.⁷ John Dewey, although conceptualizing on a different basis, also emphasized the need to create environments that would optimize children’s psychological and social development.⁸ However, far more important in shaping public perceptions of vulnerable children was less science than, quite literally, fiction. Following a romantic thread woven earlier by Jean Jacques Rousseau and William Wordsworth, 19th century authors such as Charles Dickens in England, Victor Hugo in France, and Mark Twain in the United States cast, in deeply emotional terms, the transcendent innocence of children mistreated by a harsh and unfeeling adult world.⁹ This body of literature, coupled with the work of reformist photographers, particularly Jacob Riis, Lewis W. Hine, and Wallace Kirkland at Hull House, created powerful public images of children as “innocent victims” and moved the affective center of the prevailing political will to a new position, one far more sympathetic to children and, of significance, to public action on their behalf.

There remained, however, a need to provide social strategies that could transform this political will into effective programs and policies. Ultimately, this was supplied by the emergence at the end of the 19th century of a strong women’s movement in shaping local programs to assist poor children and their families through education, social assistance, and health interventions. Under the leadership of remarkable women such as Jane Addams and her associates at Hull House in Chicago,¹⁰ community-based social work, which Skocpol¹¹ termed maternalistic social reform strategies, provided an alternative to “paternalistic” reform efforts, such as improved wages, worker’s compensation, and safety legislation, which at the time met heavy resistance at both the state and federal levels.

The influence of Addams and her Hull House associates quickly extended beyond local social work. Their studies and advocacy led to a successful campaign to pass the Illinois Juvenile Court Act in 1899. Realizing that judges knew little about the developmental capacities and backgrounds of the children appearing in their court, these advocates helped to establish the Illinois Juvenile Psychopathic Institute in 1909, which pioneered clinical studies of children and their families. They recruited Dr. William Healy to direct the research, and in the process, the discipline of child psychiatry was established, perhaps the only instance in which a medical specialty grew out of community action.

The convergence of these political, scientific, and programmatic forces led to the first White House conference on children, convened by President Theodore Roosevelt in 1909, and ultimately the establishment of the Children’s Bureau in 1912. The Bureau was directed to “investigate and report… upon all matters pertaining to the welfare of children and child life among all classes of our people and shall especially investigate the questions of infant mortality, the birth rate, orphanages, juvenile courts, desertion, dangerous occupations, accidents and diseases of children, employment, legislation affecting children.”¹² Under its first director, Julia Lathrop (an alumna of Hull House), the Bureau embarked on a series of research and support activities to help state and local groups address the general health and well-being of children and mothers.^13,14 However, from the beginning, the Bureau emphasized assisting children “who were abnormal or subnormal or suffering from physical or mental ills” both because of the urgent needs these children demonstrated and in the contention that such assistance “…also serves to aid in laying the foundations for the best service to all children of the Commonwealth” (Bradbury,¹⁵ pp 17, 15, 39). The pediatrician Ethel Dunham was recruited to develop studies for the better prevention and management of prematurity, which paved the way for the development of neonatology as a medical specialty.

Although the Children’s Bureau’s influence was manifold, perhaps its most enduring function was to represent and ultimately to embody a recognition of the federal government’s responsibility to promote the health and welfare of the nation’s children. Until establishment of the Bureau, federal efforts on behalf of children were relatively isolated and idiosyncratic, based mostly on a long-standing reliance on familial provision and local charity. With each new report and local initiative, the Children’s Bureau emphasized and eventually solidified the proposition that there was indeed a state interest in the well-being of children, and that that interest was best served by action at the federal level.

The nature of this initial federal action was to establish a grants-in-aid program to assist agencies at the state level to expand services for young children and their mothers. Passed in 1920, the Sheppard-Towner Act created the means by which the expertise developed at the Children’s Bureau could be transmitted throughout the country. This extended the Bureau’s actions far beyond what its meager budget could ever have allowed in isolation. Among the many improvements that occurred at this time were the establishment or growth of state child hygiene agencies, which incorporated for the first time the latest views on child health and development into its programs; the proliferation of maternal and child health centers, which provided direct health and development services to local communities; and a remarkable increase in the scale and expertise of visiting nurse services throughout the country. Unfortunately, the success of the Sheppard-Towner Act became its undoing, as opposition from conservative politicians and the organized medical establishment blocked its renewal in 1929. Although this was a major setback, the Act, and through it the Children’s Bureau, had already begun the transformation of the well-being of children into a public good, and therefore even the termination of the Act could not reinstate federal indifference to the needs of children. Indeed, the Sheppard-Towner Act’s goals foretold the coming of a new era of public provision, and its structure ultimately provided the basic architecture for federal initiatives for child development to this day.

DEVELOPMENT AS CASUALTY

The period between 1930 and 1950 was defined by two predominant events: the Great Depression and World War II. Although these events were associated with a variety of complex political changes, among the most far-reaching was the popular embrace of the government’s role in advancing social welfare in general and the well-being of children in particular.

The social strategies developed during the years of the Sheppard-Towner Act continued to provide a blueprint for translating this public support into actual programs and services. The recommendations of the 1930 White House Conference on Child Health and Protection gave considerable support for a comprehensive approach to the public provision of maternal and child health services, particularly, for what was then termed “crippled children.” The Conference specifically recommended that “Grants-in-aid constitute the most effective basis for national and state cooperation in promoting child welfare and in securing the establishment of that national minimum of care and protection which is the hope of every citizen.”⁸ This argument was embraced fully with the passage of the Social Security Act of 1935, as it included as Title V (“Promoting Informed Parental Choice and Innovative Programs”) of the Act federal grants to the states for maternal and child health services, including services specifically for “crippled children.”

This period also witnessed a rapid growth in the knowledge base regarding child development. With financial support from private philanthropy, particularly the Laura Spelman Rockefeller Fund and the Commonwealth Fund, a number of child guidance centers and research institutes were created, including the Child Research Council in Denver; The Fels Research Institute at Yellow Springs, Ohio; the Yale Child Study Center in New Haven; and the Berkeley Institute of Child Welfare Research. These programs produced more scientific observations of normal child development, as well as explorations of the determinants of mental retardation and behavioral problems in children. Work done at developing programs in child psychiatry, such as the Judge Baker Foundation in Boston, added to these insights.

Perhaps the most influential early scientific observer and analyst of child development was Arnold Gesell (1880–1961), a psychologist and pediatrician. Working in the early part of the 20th century, Gesell conducted a variety of studies on children with normal development and those with specific physiological challenges, such as children with Down syndrome and those experiencing harmful perinatal events. Although his techniques of observation and analysis were to shape the methods of a broad range of developmental scientists for years to come, Gesell’s theoretical bearings were set by a clear embrace of biological determination and were largely descriptive. Not only did he view the effect of experience as relatively trivial but he also looked with skepticism on the potential of interventions to alter developmental pathways.^16,17

This emphasis on biological determinants included both inherited etiologies of developmental disabilities and nonhereditary biological mechanisms, particularly adverse fetal and perinatal events. This focus attracted a growing body of empirical observations linking early adverse events to later neurodevelopmental outcomes. Much later, this “continuum of reproductive casualty” was a framework that served not only as a conceptual tool for scientific analysis but also as a means for representing the determinants of adverse developmental disorders to the broader public.^18–20 Other events tended to strengthen the public acceptance of biologically determined disabilities, including the impression of casualty transmitted by the large-scale return of disabled soldiers after World War II and later, the tragedy of birth defects caused by the ingestion of thalidomide during pregnancy in the late 1950s.

A strong alternative perspective was being advanced at approximately the same time by those who endorsed the primacy of environmental influences. Generally framed as behaviorism, this perspective was boldly articulated by one of its prominent, early spokesmen, John B. Watson (1878–1958):

This alternative to biological determinism became even more fashionable as behaviorism became more technically grounded by the experiments of B. F. Skinner (1904–1990). Psychoanalytical thought was attracting much attention at this time as well. Although Freud’s concepts were grounded in biology, social interaction was seen as forming the basis for the emergence of emotions and behavior. Erik Erikson (1902–1994) built on this psychoanalytical base to emphasize periods of transition or crisis, heavily shaped by social contexts and culture.²²

Alongside this core tension between biological and environmental determination, the history of child development policies has also been heavily informed by a second arena of research: the extent to which and the mechanisms by which child development is influenced by early life experiences.²³ The research community’s response to these questions was first based in examining the effect of profound early deprivation on later developmental outcomes, primarily among institutionalized infants. These studies suggested that profound isolation and the lack of a nurturing environment could interfere with normal development and result in a variety of adverse conditions, including growth retardation and social maladjustment.²⁴ Spitz,²⁴ Bowlby,²⁵ and others in the 1950s provided observations of early social deprivation in a variety of settings, which ultimately led to a theoretical framework underscoring the importance of early attachment processes between parent and child in shaping developmental outcomes later in life.^26,27

The tension between the biological and environmental models of developmental influence grew as more scientific evidence was generated in support of each of these two perspectives. The child development laboratories and guidance centers continued to increase the knowledge base regarding brain development and adverse biological insults and, at the same time, confirmed the sensitivity of the child to caregiving practices and social pressures. A new formulation was needed, one that could make sense of the disparate findings, powerful enough to engage the complexity of child development, and yet disciplined enough to offer a basis for popular understanding and ultimately for constructive action.

DEVELOPMENT AS JUSTICE

In the 1960s, the directions of political will and the knowledge base began to converge in ways that dramatically altered the nature and scale of child development programs in the United States. Politically, the civil rights movement was elevating public awareness of the profound racial inequalities that had so long characterized American society.²⁸ The publication of Michael Harrington’s The Other America in 1963 extended this awareness to broader economic stratification affecting all racial and ethnic groups.²⁹ These powerful challenges to the status quo were interpreted in a variety of ways and led to a variety of disparate political arguments and movements. What resonated most profoundly in the mainstream of American politics was the notion that existing policies did not facilitate, much less guarantee, equal opportunity for the requirements of a fulfilled life. Indeed, the rhetoric of opportunity permeated the public justification of major ameliorative legislation such as the Civil Rights Act of 1964 and an array of initiatives that were included in President Johnson’s “war on poverty.” Indeed, the legislation enabling the war on poverty was the Economic Opportunity Act of 1964 (our italics).

This political embrace of opportunity as the central theme of policy reform in the early 1960s also began to find support in the scientific community’s reframing of early child development. The antagonism between biological and environmental explanations for adverse developmental outcomes began to lessen as more integrative models became more widely accepted. Empirical and theoretical support grew for the important role of both biological determinants and early life experiences in shaping later developmental outcomes. In addition, a series of studies suggested that many of these outcomes were difficult to predict with certainty and that many were potentially amenable to later remedial interventions.^30,31

Jean Piaget (1896–1980), whose work became well known in the United States in the 1950s and 1960s, challenged the sharp distinctions between biologically determined and behaviorist visions of child development by stressing the dynamic character of cognitive capacities in children. According to his theories, children were not blank slates waiting to be written on but active participants, builders of understanding, constantly creating and testing their own theories of the world.³² This more integrative perspective revealed a more complex and interactive model of child development, one that could incorporate new insights into biological maturation without reducing the potential for environmental influence. Also at this time, there was growing evidence that the developmental consequences of many early deprivations were modifiable by purposeful intervention.^33,34 These findings converged with research that suggested far more pliability in the determination of intelligence than had been widely presumed.^35,36

Together, these observations gave scientific weight to the political argument that early deprivation resulted in more than hardship; it altered life opportunities. This in turn transformed observations of young children’s development and behavior into questions of justice and thereby elevated the realm of child development into the highest reaches of political discourse.

This coupling of early child experiences with broad political debate marked a major shift in the political context of developmental-behavioral policy in the United States. Although this linkage of development science to direct political advocacy generated new policy activity, it had in fact, deep roots in earlier thinking on the relationship between childhood and human freedom. John Locke (1632–1704), drawing on a long thread of philosophical speculation, had popularized the perspective that children were a tabula rasa (translated from the Latin approximately as a “blank slate”), on which experience writes the narrative of an individual’s personality, skills, and ideas (Locke,³⁷ p 26). Jean Jacques Rousseau (1712–1778) argued that children are born into a natural state of relative peace and selflessness and that the many evils of society were the result of dehumanizing social and political structures (Rousseau,³⁸ pp 61-62). However, unlike the debates of the 1960s, these arguments regarding children were not directly concerned with the unfairness of early life deprivation per se; rather, they were the requisite stepping stones to far broader challenges to the then widely accepted view that human competence and merit were the products of innate forces.

At the middle of the 20th century, child development moved from merely offering evidence that societal inequality interacted with child outcomes to directly targeting this relationship for ameliorative intervention. Justice mandated equal opportunity, a “level playing field,” and this had generated a variety of attempts to guarantee such opportunities for adults in voting, employment, and legal protections. Meanwhile, the new science of child development was suggesting that reaching the age of majority was an artificial starting point for guaranteeing equal opportunity. This had the effect of extending into childhood justice arguments that traditionally had been confined to the adult world. Justice mandated equal opportunity and for the first time, this guarantee was cast as inherently developmental.

The influence of this emerging reframing of child development was apparent in the progression of social strategies that were employed. President John F. Kennedy appointed a Panel on Mental Retardation to consider how best to use the growing knowledge base in shaping new public programs. Its recommendations led to the enactment in 1963 of Public Law 88-156, the Maternal and Child Health and Mental Retardation Planning Act, in which the Title V funding mechanism was used to support at the state level a variety of special projects related to mental retardation. In many ways, the Panel’s work and the resulting legislation were transitional. The law was a gesture to the reproductive casualty perspective by focusing on prenatal and newborn prevention interventions, including Maternity and Infant Care Projects and neonatal screening for phenylketonuria and other metabolic disorders. It was also a recognition that poor developmental outcomes occurred disproportionately in “families who are deprived of the basic necessities of life, opportunity and motivation” and enhanced community-based services for affected children and their families.³⁹ The Panel in its findings was even more explicit as it pronounced that “Society [has a] special responsibility to persons with extraordinary needs… to permit and actually foster the development of their maximum capacity.”⁴⁰ It also articulated explicitly the role of social and material deprivation in shaping poor developmental outcomes and recommended the establishment of educational programs for young children in economically disadvantaged communities throughout the country. In order to implement these developing programs, Public Law 88-156 and, in particular, Public Law 90-538, the Handicapped Children’s Early Education Assistance Act, enacted in 1968, set in motion research and training initiatives designed to produce personnel with expertise in education, developmental science, and the special needs of children with disabling conditions, a field now generally known as early childhood special education. These efforts were augmented by subsequent legislation and served to professionalize the providers of early child developmental services. That these programs were influencing pediatric research, education, and practice was evident in the growing pediatric literature on child development.⁴¹ These, in turn, helped improve the quality of these expanding programs and the efforts of the workers charged with implementing them.

The linkage of child development to opportunity and justice concerns culminated with the development of the Head Start program in 1965. Begun as a summer preschool project as part of the war on poverty, Head Start quickly became a national movement with an explicit commitment to parent and community involvement. A basic requirement was that the program be governed by local community boards. It was conceived as a comprehensive program designed to provide early educational experiences for young children in disadvantaged communities, but it also included nutritional guidance, social services, health, and mental health components.⁴² Its goals, its administrative home in the Office of Economic Opportunity, and even its name were shaped by the public concern for equal opportunity, even as its operation was grounded in the daily substrate of child development.

As early childhood demonstration and outreach programs multiplied through the 1970s, the framing of development as justice continued to evolve. Far greater emphasis began to be placed on the civil rights of disabled persons (including children) and, consequently, on political advocacy for greater inclusion in employment and public life, with legal remedies when such inclusion did not occur.⁴³ In response to a variety of constituencies, but particularly to the exceptional advocacy from parents of children with developmental disorders, the passage in 1975 of Public Law 94-142, the Education of All Handicapped Children Act and now named the Individuals with Disabilities Education Act, established the right of all children, regardless of disability and developmental needs, to a free and appropriate public education. It required individual assessments of special needs and that an Individual Education Plan (IEP) be developed for each eligible child. These were to be constructed to provide each child with a comprehensive educational plan to be implemented in the least restrictive environment possible. Significantly, the law stipulated that the IEP assessments be conducted in a nondiscriminatory manner and that procedural and legal recourse was available if parents were dissatisfied with the IEP process.

What followed was a series of state and federal laws challenging long-standing discrimination against disabled persons, including Public Law 93-112, the Vocational Rehabilitation Act, passed in 1973, and its amendment, Public Law 93-516, enacted a year later, which together outlawed discrimination against disabled persons in employment, institutions of higher learning, and access to public facilities. These and other similar pieces of legislation laid a foundation for enhanced services, as well as a basis for subsequent case law protecting the rights of disabled persons in virtually all aspects of daily life.⁴⁴

During this period, developmental disorders were attracting new attention from the medical profession. Many of the traditional threats to child health, particularly acute infectious disease, had been dramatically reduced, and, as a result, developmental disorders became more prominent in pediatric practice.⁴⁵ Although known as the “new morbidity,” these developmental and behavioral disorders were not in fact new but newly discovered by a profession long focused on acute disease. This shift in focus set in motion an important new dynamic by which pediatrics became more intimately involved with the identification and response to developmental disorders and strengthened its training and organization to deal with these issues.⁴⁶

This new attention from the medical profession coincided with the rapid expansion of the Medicaid program, the primary publicly funded health insurance program for poor children in the United States. Not only did Medicaid mandate a variety of screenings and services as part of the Early and Periodic Screening, Diagnostic and Treatment program, but as an entitlement program, its funding levels quickly dwarfed other public programs concerned with child health and development. This had the effect of shifting the center of gravity for developmental services from local programs supported by Title V funds to medical practices, particularly as more effective medications and behavioral treatment strategies were developed to treat developmental and behavioral disorders. Although the stronger medical presence was long overdue, it also put new strains on the systems that had been developed to coordinate services for children with developmental disorders.

This challenge was addressed in part with the passage of the Education for All Handicapped Children Act Amendments of 1986. This legislation required “a statewide, comprehensive, coordinated, multidisciplinary, interagency program of early intervention services for all handicapped infants and their families” (see a cogent discussion of this Act by Shonkoff and Meisels²³). The focus was on providing developmental services in the broadest context with the expressed goal of enhancing the coordination of the full range of services to better assist young children with special needs and their families. The importance of these early intervention services cannot be overstated, inasmuch as they continue to represent among the most generally available and focused interventions for children with a wide array of developmental conditions.

Although it did not provide formal funding streams, the Americans with Disabilities Act of 1990 provided the most comprehensive federal civil rights law ever enacted to protect individuals with mental or physical disabilities from discrimination. The law prohibits discrimination in employment (Title I); in state and local government services (Title II); in public accommodations, including preschools, daycare facilities, and Head Start programs administered by private agencies (Title III); in public transportation (Title IIIB); and in telecommunications (Title IV).⁴⁷

The social strategies to implement child development policies under a rubric of equal opportunity and justice have continued to rely on federal-state partnerships and legal challenges to discrimination. The rapid growth of these programs has generated repeated calls for greater coordination among them and even the elimination of the categorical funding streams associated with these varied pieces of legislation. Although greater efficiency and improvements in the quality of delivered services remain important goals and may require new approaches to funding and organization, there can be no doubt that the convergence of the more integrative scientific base, the political framing as opportunity and justice, and the programmatic strategies through federal legislation and legal action produced the most dramatic expansion in public commitment to the needs of young children in U.S. history.

DEVELOPMENT AS IDENTITY

Although it is difficult to predict how science will affect the field of child development in the near future, there is little doubt that rapid advances in the technology of investigation will generate rapid advances in specific arenas of understanding. Progress in genetics, neuroimaging, and the observational and statistical assessments of environmental influence are already shedding light on developmental processes that have long evaded productive scrutiny.

Among the most important areas of scientific progress has been in the genetics of development and behavior, including the mapping of the human genome. The field of quantitative genetics has made great strides in quantifying the relative and combined contributions of genetic and nongenetic influences on a variety of developmental and psychological disorders in large or special populations (twins and adopted children, for example). Because of the tortured history of statistically partitioning intelligence or behavioral attributes into genetic and nongenetic determinants, these quantitative genetics studies must be viewed critically, particularly in their interpretation by and representation to the broader public.⁴⁸ Of critical importance are the findings that underscore the profound interactions among genetic and environmental influences in generating observed phenotypes and developmental outcomes. These gene-environment interactions have emerged as potentially crucial mechanisms of mediating, if not determining outright, the ultimate phenotypic expression of genetic predisposition.⁴⁹ In addition, explorations of epigenetic phenomena have demonstrated that environmental influences early in life can alter the lifelong expression of a genetic profile.⁵⁰ These studies underscore the urgent need to expand and update more traditional transactional⁵¹ or ecological models⁵² of child development that have served as a useful theoretical base for integrating new insights from a variety of disciplines.

Developments in neuroscience are also likely to have important implications for child development policy. Advances in neuroimaging have permitted detailed examinations of both the structure and function of children’s brains as they grow and develop. Specific patterns of abnormal brain functioning have begun to be associated with a variety of developmental or psychological disorders.⁵³ Of equal usefulness have been new insights into the ways genetic and environmental phenomena shape the molecular and cellular events through which brains develop.

There has also been a growing awareness of the role that culture plays in shaping child development and the appreciation of differences in children’s capacities. Child-rearing beliefs, patterns of caregiving, feeding practices, and approaches to discipline, among many other elements, can all potentially affect developmental processes.⁵⁴ These observations have not only highlighted the need for greater study of these factors⁵⁵ but also have served as an important reminder that child development remains deeply woven into the fabric of family and community life.

Among the most far-reaching effects of this new science is the collapse of the strict boundaries between normal and abnormal that has long characterized the public impression of developmental outcomes. Improved tools of measurement have recast many arenas of behavioral and developmental outcomes as continuums of strengths, weaknesses, or just differences. Detailing the complexity of causation inherent in any broad developmental capacity (such as school performance) or behavior (such as antisocial behavior) has tended to disaggregate these outcomes into a network of component capacities and behaviors, each of which can be tested and assessed. This, virtually by definition, has expanded the potential to identify components that are below or above some expected distribution in the larger population.

There may also be trends in the science and practice patterns of developmental clinicians and psychiatrists that have helped blur the boundaries of normalcy in child development. The emergence of the Diagnostic and Statistical Manual of Mental Disorders as a basis for categorizing diagnoses and, significantly, for billing for services in many jurisdictions, has tended to reify developmental concerns as specific diagnoses. The trends in the knowledge base provide an important context for documenting a rising prevalence of developmental disorders in children.⁵⁶ It is difficult to identify what portion of this increase resulted from increased public awareness, an improved ability to identify problems and specific disorders, changes in the demands on children, or actual increases in the underlying prevalence of these disorders. Regardless of its causes, the high prevalence itself has altered public perceptions of child development by bringing the issue into more homes, making it a more integral component of family and community life. This rise in the prevalence of developmental disorders has occurred at the same time that many of the traditional threats to the health of children continue to be dramatically reduced. This has created an epidemiological scenario in which most children will never experience any major medical illness necessitating hospitalization, much less result in death. Indeed, these trends have generated a kind of “dichotomization” in patterns of child health and disease in which most children are unlikely to experience a serious health problem and the remaining portion of children accounting for a growing portion of services and expenditures.⁴⁵ Accordingly, pediatricians interact mostly with children increasingly unlikely ever to experience a serious acute illness.⁵⁷ This pattern has focused heightened attention on detailed developmental issues of concern to parents and is likely to have the effect of blurring traditional definitions of normalcy, of redefining “well” children to emphasize that they are not necessarily free from a variety of developmental and social problems and disorders.

The rapid growth in the medical involvement in the management of developmental disorders has made child development services vulnerable to pressures occurring in the larger health care system. The intense focus on cost reduction has created strong incentives for implementing strategies that reduce the use of health services through changes in financing and practice. Among the most important has been the direction of children with a variety of disabilities into managed care, particularly if they are enrolled in Medicaid or other public insurance programs. There remains a striking paucity of empirical insight into whether this trend has benefited or harmed this vulnerable population of children. Theoretically, managed care could enhance the coordination of services for these children. However, when cost containment is emphasized, the restrictions on referral for specialty care, medications, and coverage for medical equipment such as wheelchairs and eyeglasses raise deep concerns that this strategy could erect new barriers to appropriate care for these children and their families.

In association with this growing capacity to describe developmental attributes, there has been a dramatic shift in the kinds of capacities required in the workforce and, therefore, in schools. The growing need for communication and information-based skills has placed new demands on the developmental capacities of children and youth in ways that are likely to unmask even subtle problems in learning or cognitive performance. Therefore, as the capacity to test for developmental problems has grown, so too has the apparent need for this testing.

The rapid expansion in the science of child development, the growing accessibility of developmental testing, and the increased prevalence of developmental disorders have occurred at the same time that health issues have become among the most prominent domains of popular culture. News programs, magazines, and the Internet offer new discoveries regarding health as a central staple for their audiences. The science of health, including the science of development, has been elevated into the public consciousness in unprecedented ways. Medical research that would just a few years ago have remained the province of a highly specialized audience is now widely accessible through virtually all forms of public media.

The rapid dissemination of research findings into the general culture has meant that the identification of new developmental syndromes, genetic predispositions, or environmental risks for behaviors or development problems is now far more likely to generate public concerns than ever before—perhaps even prematurely, before their complexity has been adequately explored.

SUMMARY

Any review of the history of child development policies in the United States must conclude that the 20th century was one of enormous progress. Remarkable strides in understanding the biology of child development have been accompanied by empirical insights into the role of the social environment in shaping developmental outcomes. Although these advances in the knowledge base of child development have fueled long-standing tensions between biological and social explanations for developmental outcomes, they have also been associated with new, integrated conceptual reframings of biological and environmental interactions. These in turn, have helped to ground the new professional discipline of developmental-behavioral pediatrics in scientific evidence and methodological rigor.

The translation of this knowledge base into policy requires both practical social strategies for implementation and the political will to act. The historical development of social strategies designed to optimize child development has been characterized by rapid progress. The emergence of federal-state partnerships for a variety of specialized programs for children with developmental disorders has been linked to strong legal provisions to help ensure the inclusion of such children in the mainstream of educational and other aspects of community life.

The actual implementation of child health policies, however, is always dependent on political will. Advocates for enhanced child development policies have always lamented that children cannot directly influence the political process in the United States. This is often voiced as “Children don’t vote.” Perhaps the real question is “Why should they have to?” Children’s political voices have always been defined by the development of proxy constituencies. Repeatedly, these political proxies have been motivated parents and professionals, particularly those affected by the tragic inadequacy of programs and policies available for children. Broader political proxies are almost always required and depend on larger currents of political perceptions and sensibilities, which in turn emerge from a variety of economic, demographic, and cultural forces.

Together, the evolution of the knowledge base, social strategies, and political will continue to shape both the nature and scope of children’s health policies in the United States. In spite of many obstacles, services for children with developmental disorders generally improved greatly over the course of the 20th century. However, old challenges remain and new ones have developed. Programs for children have generally fared poorly amid intense competition for public funding. In part, this reflects the current pressures on social spending in general. However, perhaps more troubling is the lack of a compelling public argument for an enhanced commitment to children’s development and behavioral health. As highlighted in From Neurons to Neighborhoods,⁵⁵ a remarkably cogent review of advances in child development science, the rapidly emerging biological insights into the determinants of developmental and behavioral outcomes have yet to generate a clear message that is accessible to wide public understanding. It will be the task of the now broad array of professional disciplines concerned with child development to create the policy-based strategies and services that are not only increasingly effective but also ultimately reach all children in need.

DEVELOPMENTAL AND BEHAVIORAL PEDIATRICS TIMELINE