A Doctor of Their Own: The History of Adolescent Medicine.

A Doctor of Their Own: The History of Adolescent Medicine. By Heather Munro Prescott (Cambridge: Harvard University Press, 1993. xi plus 238pp. $35.00).

In A Doctor of Their Own: The History of Adolescent Medicine, Heather Munro Prescott examines the development of the specialty of Adolescent Medicine in twentieth century America. Prescott argues that society's views of adolescence, issues regarding medical professionalization and specialization, as well as concerns of adolescents themselves all combined to shape the growing specialty of Adolescent Medicine. The book is divided into four chapters, which are not necessarily the best format for making her argument. The first examines American attitudes toward adolescents from the 1920s up to, and including, the World War II period. In addition, this same section examines the development of Pediatrics as a medical specialty, covering roughly the same time period. The second chapter is an in-depth discussion of the career of Dr. J. Roswell Gallagher, the first physician to establish a successful hospital unit devoted exclusively to the care of adolescents. The third chapter, covering primarily the 1950s and early 1960s, focuses on the perspective of patients and their parents, paying close attention to the effect of race, class and gender on adolescent medical care. Chapter Four deals with the development of the specialty in the 1960s and 1970s, placing this development within the context of a rapidly changing youth culture. Prescott discusses contemporary adolescent health issues in the Conclusion, in an attempt to advocate for the continuation of a specialty in Adolescent Medicine.

During the first few decades of the twentieth century, physicians began to specialize, albeit on a small scale, since skepticism regarding specialization was pervasive because it was associated with quackery. In addition, many "generalists," who feared their livelihoods were threatened, were critical of physicians who began to declare expertise in a given area. The new developing specialties, in order to justify their existence, had to claim expertise in a particular area, and for pediatricians it was artificial infant feeding. This scientific technology, aided by the Progressive era welfare reforms, lent credibility to Pediatrics, an important step in a society that gave great authority to science in the early twentieth century. Other new scientific discoveries also aided pediatricians, such as advances in diagnosis, treatment and prevention of childhood diseases, as they sought to establish their authority over generalists and other specialties. Interestingly, as these new discoveries helped to lend credib ility to Pediatrics, they also served to undermine the market for pediatricians' services, and so pediatricians sought other areas in which they could claim expertise. Two strategies were implemented to do this. One included the development of subspecialties within Pediatrics. The other strategy, in contrast, was an increasing use of rhetoric focusing on holistic care, sometimes referred to as the "new pediatrics." This strategy incorporated psychosocial issues into the body of pediatric knowledge.

During roughly the same time period, theories regarding adolescence as a distinct period of childhood were becoming more refined. The nineteenth century transition to an industrial-capitalist economy and the resultant cult of domesticity, caused childhood to be viewed as a distinctive period, apart from adulthood. In addition, distinctions based on race, class and gender were becoming more apparent in American society. By the 1920s, anxiety regarding the behavior of teens had become widespread, and many parents sought help for their teens' behavior in the new "modern" culture of the twenties. A growing parent education movement and the development of new theories regarding child development, often focusing on the relationship between the social and political turmoil of the day and emotional maladjustments, further identified teens as a separate age group in need of expert care. In order to be assured of having emotionally stable leaders, capable of combating communism and fascism, it was essential that teens ' emotional disorders and behavior problems be addressed accordingly.

J. Roswell Gallagher, who established the first service for adolescents in the United States at Boston Children's Hospital, is generally credited with being the founder of Adolescent Medicine. As the director of health services at Phillips Academy in Andover, Massachusetts, he set up a research unit to study adolescent growth and development. His extensive research enhanced his reputation, providing him with the necessary network that led him to establish the unit at Boston Children's. In an attempt to build the adolescent unit at Boston Children's, Gallagher developed assorted marketing strategies aimed directly at teens. Seeing pediatricians not only as health care providers, but also as "guides on the arduous path toward adulthood" (p.76), Gallagher focused a great deal on teens' psychological and emotional needs. The most common reason that patients sought help at the clinic involved school-related problems, such as learning disabilities. Unacceptable teenage behavior, the definition of which was shaped by attitudes regarding gender, was the second most common reason that parents brought their children to the adolescent clinic. Gallagher contended that he and his staff were better able to treat such behavioral and emotional disorders than psychiatrists were because, as pediatricians, they could rule out medical causes, and too, they weren't associated with the stigma of mental illness.

According to Prescott, 1968 was a critical year for adolescent medicine. Physicians from adolescent clinics throughout the country established the Society for Adolescent Medicine (SAM), and within the next decade, nearly half of all pediatric services in the United States had adolescent inpatient wards and/or outpatient clinics. This occurred at a time when hospitals, struggling to survive in the inner cities, attempted to attract paying patients by marketing special services. Because of its holistic approach and the practice of offering psychological care, other medical practitioners viewed Adolescent Medicine as being a less than prestigious specialty. The movement toward this specialization was not without critics and tension. Even Gallagher opposed such a move, perceiving that specialization violated the original goals of providing holistic care. Adolescent Medicine flourished in the 1960s because of the medical and psychological needs of a changing youth culture. Teenagers were increasingly in need of m edical services for sexually transmitted diseases, substance abuse, contraception and non-marital pregnancy. The market for services expanded rapidly, to include a more diverse, and not merely middle class, population. At the same time, Great Society programs provided necessary funding for many new programs that served adolescents. Unfortunately, those funds were markedly cut back with Nixon s New Federalism. In 1991, the American Board of Medical Specialties (ABMS) granted approval to the American Board of Pediatrics to offer subcertification in Adolescent Medicine. The American Board of Internal Medicine has also initiated an application to the ABMS for subcertification, further validation that the subspecialty of Adolescent Medicine continues to thrive.

Prescott establishes a good argument. She has clearly shown how physicians' professionalization and specialization concerns, society's attitudes toward adolescence, and teenagers' needs and desires all combined to mold the specialty of Adolescent Medicine. This is a welcome addition to the limited work on medical specialties, and as Prescott has suggested, such studies function as windows through which one sees the wider society, of which medicine in only a small part. Family relationships and attitudes towards class and gender are understood in greater detail. Unfortunately, the structure of the book makes it difficult to understand the interconnectedness of these factors. Prescott has chosen to lay the foundation of her argument, providing excellent background material, in the first chapter. Although the subsequent two chapters serve to emphasize the tensions inherent within the profession whenever a new specialty is conceived, much of the detail is unnecessary. The highlight of chapter three is a discussi on of the way medical care and theory reflected attitudes toward child development and issues of gender. Although Prescott tries to weave the different elements of her argument into these chapters, the result is that sections are somewhat fragmented and disjointed. The fourth chapter, however, serves to tie all of the arguments together, white focusing on the decade of the sixties. This is a well-researched study and Prescott is to be commended. She has utilized a wide variety of sources including professional journals, annual reports, Children's Bureau records, prescriptive literature and oral histories. In addition, in order to provide an in-depth study of Gallagher's career, she has also used his letters and publications. School and hospital records also serve to support Prescott's arguments. Prescott achieves her goal of identifying the roots of a small specialty.