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A Report from the Kauai Longitudinal Study
An Epidemiologic Perspective on Some Antecedents and Consequences of Childhood Mental Health Problems and Learning Disabilities A Report from the Kauai Longitudinal Study
Emmy E. Werner, Ph.D. and Ruth S. Smith, M.A.
Abstract. Interaction effects of perinatal stress and quality of family environment are reported 1(,,- a multiracial cohort of 660 children born on the island of Kauai and followed from the prenatal period to age 18. Antecedents and consequences of childhood mental health problems and learning disabilities illustrate the relationship between social class and vulnerability. the likelihood of persistence of childhood disorders with strong biological and temperamental underpinnings, the pervasive effects of quality of early caretaker-child transactions, the importance of an internal locus of control and communication skills in coping with emotional and academic problems. and the resiliency of most children.
In their report to the Joint Commission on the Mental Health of Children, Kohlberg et al. (1972) noted that "Longitudinal research must be the first order of business of the child clinical community if it is to be established on the basis of research knowledge" (p. 1272). So far, only a few prospective studies have examined the joint contributions of reproductive risk and characteristics of the caretaking environment to the etiology of childhood behavior and learnDr. W~rn~r is Professor of Human Development, Department of Appli~d Behavioral Sciences, University of California, Davis, and Ms. Smith is Clinical Psychologist, Wilcox Memorial Hospital and Health Center, Kauai, Hawaii. Modified from a pap~r presented at the Abramson Research Symposium on Epidemiologic Studies and Child Psychiatry, Annual Muting of the Am~rican Academy of Child Psychiatry, Houston, Texas, October 21,1977. Reprints may be requested from Emmy E. W~rn~r, Ph.D., Room 132 AOB IV, University of California, Davis, CA 95616. 0002-7138179/1802~292$01.30
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ing disorders. Notable examples are the Collaborative Perinatal Project (CPP) of the National Institute of Neurological and Communicative Disorders and Stroke (Broman et al., 1975) and the Isle of Wight Study (Rutter et al., 1970). A prospective epidemiological study of the interaction effects of perinatal stress and quality of family environment that spans nearly two decades is the Kauai Longitudinal Study (Werner et al., 1971; Werner and Smith, 1977; Werner, 1978). In this paper we report highlights of the methodology and findings of our study, focusing on (a) short- and long-term effects of perinatal stress; (b) environmental interaction effects implicated in the etiology of minimal brain dysfunction (MBD); and (c) some significant aspects of the life histories of the children with mental health problems and learning disabilities. We also discuss the implications of the findings for the child clinical professions. METHODOLOGY
During the past two decades a team of public health workers, pediatricians, and psychologists have followed a cohort of some 660 youngsters, born in 1955 on the island of Kauai, Hawaii, from the prenatal period to age 18. The study population consisted of Japanese, Filipino, Hawaiians, and part-Hawaiians, Portuguese, Puerto-Ricans, Chinese, Koreans, and a small group of AngloSaxon Caucasians. They were children and grandchildren of immigrants from Southeast Asia and Europe, who had come to Hawaii to work on the sugar plantations. About half came from families in which the fathers were semiskilled or unskilled laborers and the mothers had less than eight years of education. The study began with an assessment of the reproductive histories and physical and emotional status of the mothers, from the fourth week of gestation to delivery. It continued with an evaluation of the cumulative effects of perinatal stress and quality of family environment on the physical, intellectual, and social development of the children at 2 and 10 years. The follow-u p at age 18 assessed the long-term consequences of behavior and learning problems identified in childhood and evaluated the predictive validity of the multiple screening tools (Werner and Smith, 1977). Throughout the study, attrition rates remained low: 96% of the cohort participated in the 2-year, 90% in the 10-year, and 88% in the 18-year follow-
up.
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Assessment of Preperinatal Complications
A clinical rating based on the presence of conditions thought to have had a deleterious effect on the fetus or newborn was made for each child at the beginning of the study. A pediatrician scored the severity of some 60 complications occurring during the prenatal, labor, delivery, and neonatal periods, and then assigned an overall rating of: 0 = not present; 1 = mild; 2 = moderate; and 3 = severe. Cases with overall scores of 2 and 3 were reviewed independently by a second pediatrician. In this cohort 31 % had mild perinatal complications, 10% suffered from moderate perinatal complications, and 3% experienced serious perinatal stress. In the postpartum period and when the babies were 1 year old, public health and social workers interviewed the mothers at home. The mothers rated their infants on a number of temperamental characteristics, such as activity level, social responsiveness, and ease of handling, and reported any distressing habits of the babies, such as frequent head banging or temper tantrums. At 20 months, pediatric screening examinations, based on a systematic appraisal of all organ systems, were conducted to assess physical status and to search for defects requiring care. Independently, psychologists assessed the children's cognitive development with the Cattell Infant Intelligence Scale and self-help skills with the Vineland Social Maturity Scale. The field staff collected the following information on each child at age 10: I. Records of physicians, hospitals, schools, public health, mental health and social service agencies; 2. Teacher's checklists of physical, learning, and behavior problems observed in the classroom; . 3. Family interviews covering illnesses, accidents, and behavior problems observed in the home; 4. Results of two group tests (the Bender Gestalt and the Primary Mental Abilities test), sampling reasoning, verbal, numerical, spatial, and perceptual-motor skills. A panel consisting of a pediatrician, a psychologist, and a public health nurse reviewed each child's record to determine evidence of significant physical, learning, and behavior problems, the need for further diagnostic examinations (30%) and for medical, educational, or mental health services. The follow-up at age 18 consisted of a survey of the entire cohort
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via a search of educational, health, mental health, and social service agency records, and tests of ability and achievement routinely administered in the schools, as well as an in-depth study via clinical interviews and personality tests (CPI; Locus of Control Scale) of youths with mental health problems and learning disabilities and controls without problems, matched for age, sex, ethnicity, and socioeconomic status (SES). Assessment of the Family Environment
At age 2, family stability was evaluated with the use of information from home interviews conducted postpartum, and at ages 1 and 2, which gave evidence of family cohesiveness or upheaval, and of the type and duration of any instability. Information on the legitimacy or illegitimacy of the child, presence or absence of the father, marital discord, alcoholism, emotional disturbance of parent(s), and long-term separation of the child from mother without adequate substitute caretaker was utilized. At age 10, ratings of emotional support and educational stimulation provided by the home were made by a clinical psychologist. These were based on standardized interviews with the mother conducted by public health nurses and social workers. To rate emotional support an evaluation was made of the information in the interview on interpersonal relations between parents and child, on kind and amount of reinforcement used, on methods of discipline and ways of expressing approval, on opportunities provided for satisfactory identification, and on the presence and absence of traumatic experiences. Educational stimulation was rated by considering the opportunities for enlarging the child's vocabulary, the intellectual interests and activities in the home, the values placed by the family on education, the work habits emphasized in the home, the availability of learning supplies, books and periodicals, and the opportunities for exploration of the larger environment. RESULTS
Effects of Perinatal Stress
By age 10, differences between children exposed to various degrees of perinatal complications and those born without perinatal stress were less pronounced than at age 2 and centered on a small
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group of survivors of moderate and severe perinatal stress. The greatest effect of perinatal complications was found in the proportion of children with physical handicaps related to eNS impairment, requiring placement in special classes (MR; LD) and longterm mental health care ( > 6 months). Table I summarizes significant physical behavior and learning problems observed by age 18 among the youth who had been exposed to moderate or severe perinatal stress. Among the 2% in this cohort who had suffered severe perinatal stress and survived to age 18, 4 out of 5 had significant behavior, learning, and/or physical problems. The incidence of mental retardation in this group was ten times, that of significant mental health problems five times, and that of significant physical handicaps more than twice that found in the total cohort. Table I Significant Problems at ARes 17fiR Years among Youths with Modcra t« and Severe Perinatal Stress (I'S) (1!I'i'i cohort, Kauai, Hawaii)
Problems All sig nificant problems Mental retardation Significant physical handicaps Significant mental health problems (schilOid. paranoid. oIJSessi\"('compulsive) Delinquency Teenage pregnancies
Total 19'i~) cohort (~= 698)
Youths with moderate PS (N =(9)
Youths with severe PS (N = 14)
Of /0
%
Of /0
ss.o
33.0 6.0 6.0
79.0 29.0 14.5
9.0 17.0 14.0 (of F)
14.5 21.5
3.0 6.0
3.0 15.0 6.0 (of F)
o
Incidence rates of significant physical handicaps among the 10% who had survived moderate perinatal stress did not differ from the total cohort by age 18, but the incidence rate of significant mental health problems was three times as high, of mental regardation and illegitimate teenage pregnancies twice as high as that of their peers in the 1955 cohort. In support of reports by Mednick and Schulsinger (1970) from Denmark these findings provide both longitudinal and crosscultural evidence that some significant mental health problems in late adolescence (e.g., schizoid, obsessive-compulsive, paranoid behavior) may be related to perinatal stress. In contrast to the mentally retarded and physically handicapped,
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the mental health needs of youths who suffered from the longterm effects of birth complications were not adequately met: 15% of the youths with severe perinatal complications had significant mental health problems in late adolescence, but none had any contact with community mental health agencies for diagnostic or treatment purposes. Less than half of the youths with moderate perinatal stress who had developed serious mental health problems in adolescence were seen by the Division of Mental Health. Only one person received inpatient psychiatric treatment, the others were seen for diagnostic purposes only. There is no indication that pregnant teenagers in this group (including one whose father had committed incest, and one who was pregnant at age 14) received any kind of positive counseling by community agencies, nor did the girls who underwent therapeutic abortions. We need to keep in perspective that youths with perinatal stress who develop significant mental health problems or sociopathic behavior are a minority (about 6%) of all adolescents in this community who needed help. Yet, by comparison with the much smaller proportion of mentally retarded (3%), they had not received the attention they deserved. Many were doubly vulnerable because of an impaired biological disposition and a nonsupportive home environment.
Effects of the Family Environment Throughout the follow-up studies at 2, 10, and 18 years, we found significant interaction effects between characteristics of the family environment and perinatal stress which produced the largest deficits for the most disadvantaged children. The short- and longterm impact of the caretaking environment appeared more powerful than the residual effects of perinatal complications, except for a small group of the most severely stressed children. Among children who at birth had been diagnosed by pediatricians as having "chronic conditions probably leading to MBD," the highest proportion with long-term mental health problems at age 10 (18%) came from homes rated low in family stability in the first two years of life. Rates of serious mental health problems by age 10 among children considered "at risk" for MBD at birth, whose early family life had been stable, were significantly lower (p < .02) and comparable to those in the cohort who had experienced no perinatal stress (2-3%).
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Among children who at birth had been diagnosed as having chronic conditions probably leading to MBD, low ratings of educational stimulation led to a ninefold increase in the proportion of serious mental health problems at age 10 (18%); low ratings of emotional support led to a sevenfold increase (14%) over children "at risk" for MBD at birth who had grown up in homes with adequate emotional support and educational stimulation between 2 and 10 years. The proportion of long-term mental health problems among the latter (2%) did not differ from that among children without MBD symptoms. There were no sex differences in the proportion of surviving boys and girls who had been exposed to moderate and severe perinatal complications and conditions at birth judged by physicians as "possibly leading to MBD," though more of the severely stressed boys had died in the neonatal period and in infancy. There were, however, significant sex differences in the effects of environmental factors operating in infancy (SES, family stability) and in childhood (educational stimulation and emotional support in the home) that led to a higher rate of poor outcomes (i.e., need for long-term mental health care; need for placement in a learning disability class) for the "high risk" boys than for the "high risk" girls between 10 and 18.
Children with Learning Disabilities (LD) A panel consisting of a pediatrician, psychologist, and public health nurse made the diagnosis of "probable MBD" and referral to an LD class at age lOon the basis of the combined results of group and individual examinations (psychological, medical), grades, and behavior checklists filled out by parents and teachers independently. In this group of 22, lout of 5 had physical evidence of "organicity" on pediatric-neurological examinations at 10. Twice as many boys as girls were among the 3% of the cohort considered in need of placement in an LD class because of serious reading problems (in spite of normal intelligence), perceptual-motor problems, hyperactivity, and difficulties in attention and concentration. Table 2 summarizes differences between LD cases and controls during the perinatal period and at ages I, 2, 10, and 18 years. None of the LD cases in the cohort had suffered from severe perinatal stress, but children who were diagnosed as LD by age 10 had a higher proportion of moderate perinatal complications, chronic conditions judged by pediatricians as "possibly leading to
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MBD" at birth, low birth weight, and congenital defects than controls. At year I, a significantly higher proportion of mothers of infants who later had LD rated their offspring as "not cuddly, not affectionate," and "not good-natured, fretful" than controls (p < .05). More mothers of infants who later were diagnosed as LD were rated as "erratic" or "worrisome" by observers in the home. At 2 years, psychologists conducting the infant examinations characterized infants who later had LD significantly (p < .02) more often as "awkward," "distractible," "fearful," "insecure," "restless," "slow," and "withdrawn" than control children. Mothers of toddlers who later developed LD were described more often as "careless," "indifferent," or "overprotective" than control mothers. Table 2 Di£ferences between Learning Disability Cases Diagnosed at Age 10 and Controls during the Perinatal Period and at Ages I. 2. 10-18 Years Variables
LD Cases (N == 22)
Controls (N == 22)
%
%
11.0 13.0 10.0 9.0
4.'i ".0 0 4.5
53.0 42.0 45.0
20.0 15.0 32.0
30.0
0
37.0 26.0
5.0 5.0 100 116
Perinatal Period Low birth "Tight « 2:·,00 g m) Chronic conditions "probably leading' to MilD" Moderate PS Congenital defects
At Age 1 Mothers rated their infants as "not good-natured, fretful" "not cuddly, not affectionate" "distressing habits" Mothers rated by home observers as "erratic" or "worrisome"
At Age 2 judged by psychologists lnlow a' crug c ill iurcl l. dcv . questionable iutell. dcv, :\Iean Cattell IQ Mean Vineland SQ
88
100
Contact with COII/nllll/it)' Agencies at 10-18 Ycan
Total all agency contacts Special Services, Department of Education School counselors Police Pnblic Health Department :\Jenlal I1eallh
18.0 36.4 36.4 27.3 22.7 13.0
9.0 4.5 0 4.5 0
0
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There were also significant differences between future LO cases and controls on the Cattell Infant Intelligence Scale at age 2. Independent of the psychological examination, pediatricians rated a significantly larger proportion of future LO cases as "below normal" in physical development (p < .05). Only lout of 4 was rated improved by age 18, the lowest proportion among all the groups of youths "at risk." The improvement rate was 1:3 among the 40% who had some help by community agencies. In the overwhelming majority of LO children serious problems persisted throughout the period between 10 and 18 years. Agency records for 4 out of 5 indicated continued academic underachievement, confounded by absenteeism, truancy, a high incidence of repetitive, impulsive, acting-out behavior that led to problems with the police for the boys, and sexual misconduct for the girls, and serious mental health problems less often recognized and attended to. Rates of contact with community agencies were nine times as high as that of controls. Professional assistance in adolescence was considered of "little" help by them. Children in Need of Long-Term Mental Health Services (LMH)
About 4% of the 1955 cohort (N = 25) was considered in need of six months or more of mental health services at age 10, because of emotional problems identified by behavior checklists filled out independently by parents and teachers and confirmed by diagnostic evaluations. In this group 4 out of 5 were acting-out problems; the others were diagnosed as childhood neuroses, schizoid, and sociopathic personalities. Table 3 summarizes differences between children in need of long-term mental health services and controls during the perinatal period and at ages I, 2, 10, and 18 years. Among the LMH children, 44% had been judged to have "chronic conditions, possibly leading to MBO" at birth in contrast to 16% of the control cases; 20% of the LMH cases suffered from moderate to severe perinatal stress as compared with 8% of the controls; and 12% weighed below 2,500 gm in contrast to only 4% of the controls. At age I, mothers of LMH infants rated a higher proportion of their offspring as "not cuddly, not affectionate" than control mothers. Interviewers who observed the mothers at home characterized a higher proportion of mothers of futur~ LM H children
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T able 3 Differences bet ween Ch ild ren l>ia"nosell as Be i/lK in :\eed o f Lon g-Term Ment al Health Services hv ARc 10 a nd Co n tro ls du ti /ll!: thc I'criu nt al Pe ri od a nrl a t ARl'S I. 2. 10-1 8 Years Va ri ables Per il/a tal Period Chronic co n d irions p robabl y le ad ing
to
MBD
M od e rate - severe PS
Low bir th wd ght «:!500 g ill) At A ge J Mothers rated th e ir infants as " n o t cudd ly, not a ffec t io n a te" Mothers rated hy hom e observers as "takes in stride" " ind itfercn t" " d iscon tent ed " "irresponsible"
A t Age 2 T odd ler s rated by p sych olog ists as "i n h ibi ted " "fru st rat ed " "se rio u s"
:-'Io thers ra ted hy psych olog ists as " rna u cr of Iact " " a m b iva le n t
" hos tilc" Co n tact wi th Com nn tn it y Age ncies at J()-J8 Years To ta l a ll agency cont act s Public Welfare (no n fina ncia l) Pol ice Mental H ealth Spec ia l Servi ces, Department o f Education T een ag e pregnan ci es
L:-'IH Ch ild re n (N = 25)
Controls (~ = 25)
0/
/ 0
%
4,1.0 20.0 12.0
16,0 8.0 4.0
33.0
16.0
60.0 l6 .0 12,0 12.0
42,0 4.0 4.0 0
22.U 13.0 13.0
4.0 0 0
40.0 16.0 12.0
3:1.0 0 0
i6.0 32.0 32.0 28.0 20.0 20.0 (of F)
12.0 0 8.0 0 0 0
than co n trol mothers as "ta kes in stride," "indifferent," "unintelligent," "irresponsible," a nd "d isco nte nted." By age 2, toddlers wh o were later in need of LMH were more often characterized as "inhibited," "frustrated," and "se r io us" than co n tro l children, Mothers of future LMH children were more often rated as "matter of fact," "ambivalent," and " ho stile " in their relationship to their toddlers, Only lout of 3 was judged to have improved by age 18; the improvement rate rose to lout of 2 among th e 30% for who m there was so me community in te rve n tion .
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During adolescence more than 3 out of 4 in this group had contacts with community agencies. the majority as a consequence of persistent serious behavior problems. Rates of contact (many with multiple agencies) were six times as high as that for controls. Psychosomatic and psychotic symptoms, sexual misconduct or problems with sexual identity, drinking and drug abuse, assault and battery, theft and burglary, and continued poor academic performance, coupled with absenteeism and truancy, left these youths few co nst r uctive options as they reached young adulthood. Children in Need of Short-Term Mental Health Services (SMH)
The prognosis was much more favorable for about 10% of the 1955 cohort (N = 60) who, at age 10, had been considered in need of mental health services of less than six months' duration. Most of the children in this group were shy or anxious, lacked self-confidence, and had developed some chronic nervous habits to deal with their insecurities. In co n trast to the LD and LMH cases, there were no significant differences between infants later considered in need of SMH services and controls in incidence of perinatal complications, low birth weight, and congenital defects . In the absence of earl y biological stress and early family instability the majority of childhood behavior problems represented by these child re n appeared to be temporary, though at the time painful, reactions to environmental stress. In this group 3 out of 4 came from homes rated low in emotional support by age 10, in contrast to less than lout of 3 of the co n tro l children. The overall rate of agency contacts for these youths during adolescence did not differ from that of the total co ho r t. Only 4 out of 10 had an y contacts, and their problems were less serious and less repetitive than those considered in need of LM H services or those of the LD. Only lout of 10 had been the beneficiary of intervention by community agencies, but 6 out of 10 were rated improved by age 18. With few exceptions the improved cases had been troubled by a lack of self-confidence, anxiety, and/or chronic nervous habits in childhood. Among the 4 out of 10 who remained unimproved by age 18 were most of the children characterized by high anxiety and acting-out behavior at age 10. However, the cha nces for spontaneous improvement in later childhood and adolescence appeared greater for middle-class child r en in this group than for the children of the poor.
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IMPLICATIONS
The Likelihood of Persistence of Childhood Learning Disabilities and Behavior Disorders
Looking across the spectrum of two decades of development, from the prenatal period to the threshold of adulthood, it appears that those childhood behavior and learning disorders that persisted into young adulthood had strong biological and temperamental underpinnings. Many of the children recognized in need of LMH services or placement in a LD class by age 10 had chronic conditions thought by the physicians attending their birth to be leading to MBD, and/or records of moderate to severe degrees of perinatal stress, low birth weight, and/or congenital defects. Controls of the same age, sex, socioeconomic, and ethnic background did not display these factors to a significant extent. In contrast to the LD and LMH cases, there were no significant differences between infants later diagnosed in need of SMH care and controls in incidence of perinatal complications, low birth weight, or congenital low birth weight, or congenital defects. Infant temperamental traits that appeared distressing and nonrewarding to the caretaker, such as very low levels of activity and low social responsiveness, were also noted more frequently, and as early as age I, among children later recognized as LD or in need of LMH services whose problems persisted into young adulthood. These temperamental traits may well have been a consequence of biological stress, and may have set in motion an early disturbed caretaker-child relationship that seemed entrenched by age 2, especially in the presence of family instability. Social Class and Vulnerability
A low standard of living, especially at birth, increased the likelihood of exposure of the infant to both early biological stress and early family instability. But it was the interaction of early biological stress and early family instability that led to a high risk of developing serious and persistent behavior and learning problems, in both lower- and middle-class children. It is important to keep in perspective that poverty alone was not a sufficient condition for the likelihood of significant coping problems. The overwhelming majority of the control children who were drawn in childhood and adolescence from the same poor and "culturally different" backgrounds as the LMH and LD groups coped
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very effectively in the second decade of their lives; few of the control children from very low socioeconomic homes committed any delinquent acts, or presented achievement or discipline problems in school, or were in need of mental health services by the time they reached the threshold of adulthood. The Pervasive Effect of the Quality of Child-Caretaker Interaction
The pervasive effect of non rewarding patterns of child-caretaker interaction that could be documented as early as year 1 by observers in the home and that were verified independently by observations during developmental screening examinations at age 2 was very impressive. They were most pronounced in the records of children who were later recognized as LD, or who developed serious mental health problems, or were involved in repeated, serious delinquencies by the time they reached young adulthood. Often a mother with a relatively low level of education attempted to cope with the needs of an infant perceived by her as difficult, distressing, and non rewarding in an atmosphere of family instability (father absent, home broken, illegitimate birth). By age 2 mother and child were "set" in a vicious cycle of increasing frustration for both caretaker and offspring. By age 10, public health personnel, social workers, and teachers who were unaware of the information obtained on mother-child interaction at ages 1 and 2 noted a pronounced lack of emotional support in the home for most children with serious behavior problems that persisted throughout adolescence. The role of the father appeared more crucial for the LD (most of whom were boys) and for the teenage pregnancies. Parental attitudes (i.e., perceived understanding and support) differentiated significantly between youths with serious childhood learning and behavior problems that improved in adolescence and those whose problems did not, while exposure to different types of intervention by community agencies had a lesser impact. Correlates of Improvement
There is a striking consistency between the findings of a differential improvement rate for different groups of youths "at risk" (the LD, LMH, SMH) in the multiracial sample on Kauai in the 1970s and three other major reports in the literature that deal with different historical time-spans, different ethnic groups, and different cultures (Levitt, 1971; Robins, 1966; Shepherd et al., 1971).
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While the impact of treatment during middle childhood and adolescence was relatively slight, parental attitudes appeared to have a major impact on improvement among all youths with childhood learning and behavior problems, a finding supported by a British survey of childhood behavior and mental health by Shepherd et al. (1971). The pervasive effect of perceived locus of control and competence in communication skills (i.e., reading and writing standard English) among the youth in this cohort who were at risk for LD and serious mental health problems was apparent. The degree to which the youths had faith in the effectiveness of their own actions was related not only to the effectiveness with which they utilized their intellectual resources in scholastic achievement, but also to positive change in coping behavior. An internal locus of control was a significant correlate of improvement. An external locus of control, i.e., a lack of faith in the effectiveness of one's own actions, was especially notable among the LD and the pregnant teenagers, many of whom had significant mental health problems. As a corollary, "hard work and persistence" were the assets most frequently mentioned in the clinical interviews by the youths with serious childhood behavior problems who later improved. The results of the Kauai Longitudinal Study, based on a cohort of children in a community over two decades of their lives, provide a perspective for the child clinical professions that is more difficult to obtain from short-term studies of problem children. While the focus of this report has been on young people who were vulnerable, one could not help but be deeply impressed by the resiliency of the overwhelming majority of children and their potential for positive change and personal growth. Most young people in this cohort were competent in coping with their problems, chose their parents as their models, found their family and friends to be supportive and understanding, and expressed a strong sense of continuity with their families in values attached to education, occupational preferences, and social expectations. Sameroff and Chandler in their 1975 review of risk research have proposed a transactional model that seems to account best for the findings of this longitudinal study. Breakdown from this point of view is seen not simply as the function of an inborn inability to respond appropriately, but as the consequence of some continuous malfunction in the organism-environment transaction across time which prevents the child from organizing his world adaptively.
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Thus. "Any understanding of deviancies in outcome must be seen in the perspective of powerful self-righting tendencies which appear to move children toward normal developmental outcomes under all but the most adverse of circumstances" (p. 235).
REFERENCES BROMAN. S. H., NICHOLAS, P. L. , & KENNEDY, W. W . (1975), PrtSclwollQ . New York: Wiley . KOHLBERG, L. , LACROSSE, J., & RICKS, D. (1972), The predictability of adult mental health from childhood behavior. In : Manual of Child Psychopathology, ed . B.B. Wolman . New York : McGraw-Hili, pp. 1217-1286. LEVITT, E. (197 I). Research on psychotherapy with children. In: Handbook of Psychotherapy and Behavior Change. cd . A . E. Bergen & S. L. Garfield. New York : Wiley, pp. 474-494. MEUNICK, S. A. & SCHULSINGER, F. (1970), Factors related to breakdown in children at high risk for schizophrenia, In: Life History Research in Psychopathology, ed, M . Ross & D. F. Ricks. Minneapolis: University of Minnesota Press, 1:51-93. ROBINS, L. (1966). Deviant Children GroW11 Up. Baltimore: Williams & Wilkins . Rurn:R, M., TIZARll, J., & WHITMORE, K. (1970), Education, Health and Behavior. London: Longmans. SAMt:ROFF, A . & CHANOl.t:R, M. J. (1975) , Reproductive risk and the cont inuum of caretaking ..asualt y. I,,: RPI.i,w ,,[Child Development Research, cd , F. D. Horowitz.. <:hi('ag( >: University of Chicago Press, 4 : 187-244. SIlt:PHt:Rll, M ., OPPENHEIM, B., & MITCHt:L1.• S. (1971), The Childhood Behavior and Mental Health . New York: Grune & Stranon . WERNER, E. E. (1978) , Environmental interaction in minimal brain dysfunctions. In: Handbook of Minimal Brain Dysfunctions, ed. H . Rie & E. Rie, New York : Wiley (in press). - - BIERMAN , J. M., & FRENCH , F. E. (1971), The Children of Kauai: A Longitudinal Study from thr Prenatal Period to Age Ten. Honolulu : University of Hawaii Press. - - - & SMITH, R. S. (1977). Kauai's Children Come of Age. Honolulu : University Press of Hawaii .
Emmy E. Werner, Ph.D. and Ruth S. Smith, M.A.
Abstract. Interaction effects of perinatal stress and quality of family environment are reported 1(,,- a multiracial cohort of 660 children born on the island of Kauai and followed from the prenatal period to age 18. Antecedents and consequences of childhood mental health problems and learning disabilities illustrate the relationship between social class and vulnerability. the likelihood of persistence of childhood disorders with strong biological and temperamental underpinnings, the pervasive effects of quality of early caretaker-child transactions, the importance of an internal locus of control and communication skills in coping with emotional and academic problems. and the resiliency of most children.
In their report to the Joint Commission on the Mental Health of Children, Kohlberg et al. (1972) noted that "Longitudinal research must be the first order of business of the child clinical community if it is to be established on the basis of research knowledge" (p. 1272). So far, only a few prospective studies have examined the joint contributions of reproductive risk and characteristics of the caretaking environment to the etiology of childhood behavior and learnDr. W~rn~r is Professor of Human Development, Department of Appli~d Behavioral Sciences, University of California, Davis, and Ms. Smith is Clinical Psychologist, Wilcox Memorial Hospital and Health Center, Kauai, Hawaii. Modified from a pap~r presented at the Abramson Research Symposium on Epidemiologic Studies and Child Psychiatry, Annual Muting of the Am~rican Academy of Child Psychiatry, Houston, Texas, October 21,1977. Reprints may be requested from Emmy E. W~rn~r, Ph.D., Room 132 AOB IV, University of California, Davis, CA 95616. 0002-7138179/1802~292$01.30
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ing disorders. Notable examples are the Collaborative Perinatal Project (CPP) of the National Institute of Neurological and Communicative Disorders and Stroke (Broman et al., 1975) and the Isle of Wight Study (Rutter et al., 1970). A prospective epidemiological study of the interaction effects of perinatal stress and quality of family environment that spans nearly two decades is the Kauai Longitudinal Study (Werner et al., 1971; Werner and Smith, 1977; Werner, 1978). In this paper we report highlights of the methodology and findings of our study, focusing on (a) short- and long-term effects of perinatal stress; (b) environmental interaction effects implicated in the etiology of minimal brain dysfunction (MBD); and (c) some significant aspects of the life histories of the children with mental health problems and learning disabilities. We also discuss the implications of the findings for the child clinical professions. METHODOLOGY
During the past two decades a team of public health workers, pediatricians, and psychologists have followed a cohort of some 660 youngsters, born in 1955 on the island of Kauai, Hawaii, from the prenatal period to age 18. The study population consisted of Japanese, Filipino, Hawaiians, and part-Hawaiians, Portuguese, Puerto-Ricans, Chinese, Koreans, and a small group of AngloSaxon Caucasians. They were children and grandchildren of immigrants from Southeast Asia and Europe, who had come to Hawaii to work on the sugar plantations. About half came from families in which the fathers were semiskilled or unskilled laborers and the mothers had less than eight years of education. The study began with an assessment of the reproductive histories and physical and emotional status of the mothers, from the fourth week of gestation to delivery. It continued with an evaluation of the cumulative effects of perinatal stress and quality of family environment on the physical, intellectual, and social development of the children at 2 and 10 years. The follow-u p at age 18 assessed the long-term consequences of behavior and learning problems identified in childhood and evaluated the predictive validity of the multiple screening tools (Werner and Smith, 1977). Throughout the study, attrition rates remained low: 96% of the cohort participated in the 2-year, 90% in the 10-year, and 88% in the 18-year follow-
up.
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Assessment of Preperinatal Complications
A clinical rating based on the presence of conditions thought to have had a deleterious effect on the fetus or newborn was made for each child at the beginning of the study. A pediatrician scored the severity of some 60 complications occurring during the prenatal, labor, delivery, and neonatal periods, and then assigned an overall rating of: 0 = not present; 1 = mild; 2 = moderate; and 3 = severe. Cases with overall scores of 2 and 3 were reviewed independently by a second pediatrician. In this cohort 31 % had mild perinatal complications, 10% suffered from moderate perinatal complications, and 3% experienced serious perinatal stress. In the postpartum period and when the babies were 1 year old, public health and social workers interviewed the mothers at home. The mothers rated their infants on a number of temperamental characteristics, such as activity level, social responsiveness, and ease of handling, and reported any distressing habits of the babies, such as frequent head banging or temper tantrums. At 20 months, pediatric screening examinations, based on a systematic appraisal of all organ systems, were conducted to assess physical status and to search for defects requiring care. Independently, psychologists assessed the children's cognitive development with the Cattell Infant Intelligence Scale and self-help skills with the Vineland Social Maturity Scale. The field staff collected the following information on each child at age 10: I. Records of physicians, hospitals, schools, public health, mental health and social service agencies; 2. Teacher's checklists of physical, learning, and behavior problems observed in the classroom; . 3. Family interviews covering illnesses, accidents, and behavior problems observed in the home; 4. Results of two group tests (the Bender Gestalt and the Primary Mental Abilities test), sampling reasoning, verbal, numerical, spatial, and perceptual-motor skills. A panel consisting of a pediatrician, a psychologist, and a public health nurse reviewed each child's record to determine evidence of significant physical, learning, and behavior problems, the need for further diagnostic examinations (30%) and for medical, educational, or mental health services. The follow-up at age 18 consisted of a survey of the entire cohort
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via a search of educational, health, mental health, and social service agency records, and tests of ability and achievement routinely administered in the schools, as well as an in-depth study via clinical interviews and personality tests (CPI; Locus of Control Scale) of youths with mental health problems and learning disabilities and controls without problems, matched for age, sex, ethnicity, and socioeconomic status (SES). Assessment of the Family Environment
At age 2, family stability was evaluated with the use of information from home interviews conducted postpartum, and at ages 1 and 2, which gave evidence of family cohesiveness or upheaval, and of the type and duration of any instability. Information on the legitimacy or illegitimacy of the child, presence or absence of the father, marital discord, alcoholism, emotional disturbance of parent(s), and long-term separation of the child from mother without adequate substitute caretaker was utilized. At age 10, ratings of emotional support and educational stimulation provided by the home were made by a clinical psychologist. These were based on standardized interviews with the mother conducted by public health nurses and social workers. To rate emotional support an evaluation was made of the information in the interview on interpersonal relations between parents and child, on kind and amount of reinforcement used, on methods of discipline and ways of expressing approval, on opportunities provided for satisfactory identification, and on the presence and absence of traumatic experiences. Educational stimulation was rated by considering the opportunities for enlarging the child's vocabulary, the intellectual interests and activities in the home, the values placed by the family on education, the work habits emphasized in the home, the availability of learning supplies, books and periodicals, and the opportunities for exploration of the larger environment. RESULTS
Effects of Perinatal Stress
By age 10, differences between children exposed to various degrees of perinatal complications and those born without perinatal stress were less pronounced than at age 2 and centered on a small
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group of survivors of moderate and severe perinatal stress. The greatest effect of perinatal complications was found in the proportion of children with physical handicaps related to eNS impairment, requiring placement in special classes (MR; LD) and longterm mental health care ( > 6 months). Table I summarizes significant physical behavior and learning problems observed by age 18 among the youth who had been exposed to moderate or severe perinatal stress. Among the 2% in this cohort who had suffered severe perinatal stress and survived to age 18, 4 out of 5 had significant behavior, learning, and/or physical problems. The incidence of mental retardation in this group was ten times, that of significant mental health problems five times, and that of significant physical handicaps more than twice that found in the total cohort. Table I Significant Problems at ARes 17fiR Years among Youths with Modcra t« and Severe Perinatal Stress (I'S) (1!I'i'i cohort, Kauai, Hawaii)
Problems All sig nificant problems Mental retardation Significant physical handicaps Significant mental health problems (schilOid. paranoid. oIJSessi\"('compulsive) Delinquency Teenage pregnancies
Total 19'i~) cohort (~= 698)
Youths with moderate PS (N =(9)
Youths with severe PS (N = 14)
Of /0
%
Of /0
ss.o
33.0 6.0 6.0
79.0 29.0 14.5
9.0 17.0 14.0 (of F)
14.5 21.5
3.0 6.0
3.0 15.0 6.0 (of F)
o
Incidence rates of significant physical handicaps among the 10% who had survived moderate perinatal stress did not differ from the total cohort by age 18, but the incidence rate of significant mental health problems was three times as high, of mental regardation and illegitimate teenage pregnancies twice as high as that of their peers in the 1955 cohort. In support of reports by Mednick and Schulsinger (1970) from Denmark these findings provide both longitudinal and crosscultural evidence that some significant mental health problems in late adolescence (e.g., schizoid, obsessive-compulsive, paranoid behavior) may be related to perinatal stress. In contrast to the mentally retarded and physically handicapped,
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the mental health needs of youths who suffered from the longterm effects of birth complications were not adequately met: 15% of the youths with severe perinatal complications had significant mental health problems in late adolescence, but none had any contact with community mental health agencies for diagnostic or treatment purposes. Less than half of the youths with moderate perinatal stress who had developed serious mental health problems in adolescence were seen by the Division of Mental Health. Only one person received inpatient psychiatric treatment, the others were seen for diagnostic purposes only. There is no indication that pregnant teenagers in this group (including one whose father had committed incest, and one who was pregnant at age 14) received any kind of positive counseling by community agencies, nor did the girls who underwent therapeutic abortions. We need to keep in perspective that youths with perinatal stress who develop significant mental health problems or sociopathic behavior are a minority (about 6%) of all adolescents in this community who needed help. Yet, by comparison with the much smaller proportion of mentally retarded (3%), they had not received the attention they deserved. Many were doubly vulnerable because of an impaired biological disposition and a nonsupportive home environment.
Effects of the Family Environment Throughout the follow-up studies at 2, 10, and 18 years, we found significant interaction effects between characteristics of the family environment and perinatal stress which produced the largest deficits for the most disadvantaged children. The short- and longterm impact of the caretaking environment appeared more powerful than the residual effects of perinatal complications, except for a small group of the most severely stressed children. Among children who at birth had been diagnosed by pediatricians as having "chronic conditions probably leading to MBD," the highest proportion with long-term mental health problems at age 10 (18%) came from homes rated low in family stability in the first two years of life. Rates of serious mental health problems by age 10 among children considered "at risk" for MBD at birth, whose early family life had been stable, were significantly lower (p < .02) and comparable to those in the cohort who had experienced no perinatal stress (2-3%).
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Among children who at birth had been diagnosed as having chronic conditions probably leading to MBD, low ratings of educational stimulation led to a ninefold increase in the proportion of serious mental health problems at age 10 (18%); low ratings of emotional support led to a sevenfold increase (14%) over children "at risk" for MBD at birth who had grown up in homes with adequate emotional support and educational stimulation between 2 and 10 years. The proportion of long-term mental health problems among the latter (2%) did not differ from that among children without MBD symptoms. There were no sex differences in the proportion of surviving boys and girls who had been exposed to moderate and severe perinatal complications and conditions at birth judged by physicians as "possibly leading to MBD," though more of the severely stressed boys had died in the neonatal period and in infancy. There were, however, significant sex differences in the effects of environmental factors operating in infancy (SES, family stability) and in childhood (educational stimulation and emotional support in the home) that led to a higher rate of poor outcomes (i.e., need for long-term mental health care; need for placement in a learning disability class) for the "high risk" boys than for the "high risk" girls between 10 and 18.
Children with Learning Disabilities (LD) A panel consisting of a pediatrician, psychologist, and public health nurse made the diagnosis of "probable MBD" and referral to an LD class at age lOon the basis of the combined results of group and individual examinations (psychological, medical), grades, and behavior checklists filled out by parents and teachers independently. In this group of 22, lout of 5 had physical evidence of "organicity" on pediatric-neurological examinations at 10. Twice as many boys as girls were among the 3% of the cohort considered in need of placement in an LD class because of serious reading problems (in spite of normal intelligence), perceptual-motor problems, hyperactivity, and difficulties in attention and concentration. Table 2 summarizes differences between LD cases and controls during the perinatal period and at ages I, 2, 10, and 18 years. None of the LD cases in the cohort had suffered from severe perinatal stress, but children who were diagnosed as LD by age 10 had a higher proportion of moderate perinatal complications, chronic conditions judged by pediatricians as "possibly leading to
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MBD" at birth, low birth weight, and congenital defects than controls. At year I, a significantly higher proportion of mothers of infants who later had LD rated their offspring as "not cuddly, not affectionate," and "not good-natured, fretful" than controls (p < .05). More mothers of infants who later were diagnosed as LD were rated as "erratic" or "worrisome" by observers in the home. At 2 years, psychologists conducting the infant examinations characterized infants who later had LD significantly (p < .02) more often as "awkward," "distractible," "fearful," "insecure," "restless," "slow," and "withdrawn" than control children. Mothers of toddlers who later developed LD were described more often as "careless," "indifferent," or "overprotective" than control mothers. Table 2 Di£ferences between Learning Disability Cases Diagnosed at Age 10 and Controls during the Perinatal Period and at Ages I. 2. 10-18 Years Variables
LD Cases (N == 22)
Controls (N == 22)
%
%
11.0 13.0 10.0 9.0
4.'i ".0 0 4.5
53.0 42.0 45.0
20.0 15.0 32.0
30.0
0
37.0 26.0
5.0 5.0 100 116
Perinatal Period Low birth "Tight « 2:·,00 g m) Chronic conditions "probably leading' to MilD" Moderate PS Congenital defects
At Age 1 Mothers rated their infants as "not good-natured, fretful" "not cuddly, not affectionate" "distressing habits" Mothers rated by home observers as "erratic" or "worrisome"
At Age 2 judged by psychologists lnlow a' crug c ill iurcl l. dcv . questionable iutell. dcv, :\Iean Cattell IQ Mean Vineland SQ
88
100
Contact with COII/nllll/it)' Agencies at 10-18 Ycan
Total all agency contacts Special Services, Department of Education School counselors Police Pnblic Health Department :\Jenlal I1eallh
18.0 36.4 36.4 27.3 22.7 13.0
9.0 4.5 0 4.5 0
0
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There were also significant differences between future LO cases and controls on the Cattell Infant Intelligence Scale at age 2. Independent of the psychological examination, pediatricians rated a significantly larger proportion of future LO cases as "below normal" in physical development (p < .05). Only lout of 4 was rated improved by age 18, the lowest proportion among all the groups of youths "at risk." The improvement rate was 1:3 among the 40% who had some help by community agencies. In the overwhelming majority of LO children serious problems persisted throughout the period between 10 and 18 years. Agency records for 4 out of 5 indicated continued academic underachievement, confounded by absenteeism, truancy, a high incidence of repetitive, impulsive, acting-out behavior that led to problems with the police for the boys, and sexual misconduct for the girls, and serious mental health problems less often recognized and attended to. Rates of contact with community agencies were nine times as high as that of controls. Professional assistance in adolescence was considered of "little" help by them. Children in Need of Long-Term Mental Health Services (LMH)
About 4% of the 1955 cohort (N = 25) was considered in need of six months or more of mental health services at age 10, because of emotional problems identified by behavior checklists filled out independently by parents and teachers and confirmed by diagnostic evaluations. In this group 4 out of 5 were acting-out problems; the others were diagnosed as childhood neuroses, schizoid, and sociopathic personalities. Table 3 summarizes differences between children in need of long-term mental health services and controls during the perinatal period and at ages I, 2, 10, and 18 years. Among the LMH children, 44% had been judged to have "chronic conditions, possibly leading to MBO" at birth in contrast to 16% of the control cases; 20% of the LMH cases suffered from moderate to severe perinatal stress as compared with 8% of the controls; and 12% weighed below 2,500 gm in contrast to only 4% of the controls. At age I, mothers of LMH infants rated a higher proportion of their offspring as "not cuddly, not affectionate" than control mothers. Interviewers who observed the mothers at home characterized a higher proportion of mothers of futur~ LM H children
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T able 3 Differences bet ween Ch ild ren l>ia"nosell as Be i/lK in :\eed o f Lon g-Term Ment al Health Services hv ARc 10 a nd Co n tro ls du ti /ll!: thc I'criu nt al Pe ri od a nrl a t ARl'S I. 2. 10-1 8 Years Va ri ables Per il/a tal Period Chronic co n d irions p robabl y le ad ing
to
MBD
M od e rate - severe PS
Low bir th wd ght «:!500 g ill) At A ge J Mothers rated th e ir infants as " n o t cudd ly, not a ffec t io n a te" Mothers rated hy hom e observers as "takes in stride" " ind itfercn t" " d iscon tent ed " "irresponsible"
A t Age 2 T odd ler s rated by p sych olog ists as "i n h ibi ted " "fru st rat ed " "se rio u s"
:-'Io thers ra ted hy psych olog ists as " rna u cr of Iact " " a m b iva le n t
" hos tilc" Co n tact wi th Com nn tn it y Age ncies at J()-J8 Years To ta l a ll agency cont act s Public Welfare (no n fina ncia l) Pol ice Mental H ealth Spec ia l Servi ces, Department o f Education T een ag e pregnan ci es
L:-'IH Ch ild re n (N = 25)
Controls (~ = 25)
0/
/ 0
%
4,1.0 20.0 12.0
16,0 8.0 4.0
33.0
16.0
60.0 l6 .0 12,0 12.0
42,0 4.0 4.0 0
22.U 13.0 13.0
4.0 0 0
40.0 16.0 12.0
3:1.0 0 0
i6.0 32.0 32.0 28.0 20.0 20.0 (of F)
12.0 0 8.0 0 0 0
than co n trol mothers as "ta kes in stride," "indifferent," "unintelligent," "irresponsible," a nd "d isco nte nted." By age 2, toddlers wh o were later in need of LMH were more often characterized as "inhibited," "frustrated," and "se r io us" than co n tro l children, Mothers of future LMH children were more often rated as "matter of fact," "ambivalent," and " ho stile " in their relationship to their toddlers, Only lout of 3 was judged to have improved by age 18; the improvement rate rose to lout of 2 among th e 30% for who m there was so me community in te rve n tion .
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During adolescence more than 3 out of 4 in this group had contacts with community agencies. the majority as a consequence of persistent serious behavior problems. Rates of contact (many with multiple agencies) were six times as high as that for controls. Psychosomatic and psychotic symptoms, sexual misconduct or problems with sexual identity, drinking and drug abuse, assault and battery, theft and burglary, and continued poor academic performance, coupled with absenteeism and truancy, left these youths few co nst r uctive options as they reached young adulthood. Children in Need of Short-Term Mental Health Services (SMH)
The prognosis was much more favorable for about 10% of the 1955 cohort (N = 60) who, at age 10, had been considered in need of mental health services of less than six months' duration. Most of the children in this group were shy or anxious, lacked self-confidence, and had developed some chronic nervous habits to deal with their insecurities. In co n trast to the LD and LMH cases, there were no significant differences between infants later considered in need of SMH services and controls in incidence of perinatal complications, low birth weight, and congenital defects . In the absence of earl y biological stress and early family instability the majority of childhood behavior problems represented by these child re n appeared to be temporary, though at the time painful, reactions to environmental stress. In this group 3 out of 4 came from homes rated low in emotional support by age 10, in contrast to less than lout of 3 of the co n tro l children. The overall rate of agency contacts for these youths during adolescence did not differ from that of the total co ho r t. Only 4 out of 10 had an y contacts, and their problems were less serious and less repetitive than those considered in need of LM H services or those of the LD. Only lout of 10 had been the beneficiary of intervention by community agencies, but 6 out of 10 were rated improved by age 18. With few exceptions the improved cases had been troubled by a lack of self-confidence, anxiety, and/or chronic nervous habits in childhood. Among the 4 out of 10 who remained unimproved by age 18 were most of the children characterized by high anxiety and acting-out behavior at age 10. However, the cha nces for spontaneous improvement in later childhood and adolescence appeared greater for middle-class child r en in this group than for the children of the poor.
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IMPLICATIONS
The Likelihood of Persistence of Childhood Learning Disabilities and Behavior Disorders
Looking across the spectrum of two decades of development, from the prenatal period to the threshold of adulthood, it appears that those childhood behavior and learning disorders that persisted into young adulthood had strong biological and temperamental underpinnings. Many of the children recognized in need of LMH services or placement in a LD class by age 10 had chronic conditions thought by the physicians attending their birth to be leading to MBD, and/or records of moderate to severe degrees of perinatal stress, low birth weight, and/or congenital defects. Controls of the same age, sex, socioeconomic, and ethnic background did not display these factors to a significant extent. In contrast to the LD and LMH cases, there were no significant differences between infants later diagnosed in need of SMH care and controls in incidence of perinatal complications, low birth weight, or congenital low birth weight, or congenital defects. Infant temperamental traits that appeared distressing and nonrewarding to the caretaker, such as very low levels of activity and low social responsiveness, were also noted more frequently, and as early as age I, among children later recognized as LD or in need of LMH services whose problems persisted into young adulthood. These temperamental traits may well have been a consequence of biological stress, and may have set in motion an early disturbed caretaker-child relationship that seemed entrenched by age 2, especially in the presence of family instability. Social Class and Vulnerability
A low standard of living, especially at birth, increased the likelihood of exposure of the infant to both early biological stress and early family instability. But it was the interaction of early biological stress and early family instability that led to a high risk of developing serious and persistent behavior and learning problems, in both lower- and middle-class children. It is important to keep in perspective that poverty alone was not a sufficient condition for the likelihood of significant coping problems. The overwhelming majority of the control children who were drawn in childhood and adolescence from the same poor and "culturally different" backgrounds as the LMH and LD groups coped
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very effectively in the second decade of their lives; few of the control children from very low socioeconomic homes committed any delinquent acts, or presented achievement or discipline problems in school, or were in need of mental health services by the time they reached the threshold of adulthood. The Pervasive Effect of the Quality of Child-Caretaker Interaction
The pervasive effect of non rewarding patterns of child-caretaker interaction that could be documented as early as year 1 by observers in the home and that were verified independently by observations during developmental screening examinations at age 2 was very impressive. They were most pronounced in the records of children who were later recognized as LD, or who developed serious mental health problems, or were involved in repeated, serious delinquencies by the time they reached young adulthood. Often a mother with a relatively low level of education attempted to cope with the needs of an infant perceived by her as difficult, distressing, and non rewarding in an atmosphere of family instability (father absent, home broken, illegitimate birth). By age 2 mother and child were "set" in a vicious cycle of increasing frustration for both caretaker and offspring. By age 10, public health personnel, social workers, and teachers who were unaware of the information obtained on mother-child interaction at ages 1 and 2 noted a pronounced lack of emotional support in the home for most children with serious behavior problems that persisted throughout adolescence. The role of the father appeared more crucial for the LD (most of whom were boys) and for the teenage pregnancies. Parental attitudes (i.e., perceived understanding and support) differentiated significantly between youths with serious childhood learning and behavior problems that improved in adolescence and those whose problems did not, while exposure to different types of intervention by community agencies had a lesser impact. Correlates of Improvement
There is a striking consistency between the findings of a differential improvement rate for different groups of youths "at risk" (the LD, LMH, SMH) in the multiracial sample on Kauai in the 1970s and three other major reports in the literature that deal with different historical time-spans, different ethnic groups, and different cultures (Levitt, 1971; Robins, 1966; Shepherd et al., 1971).
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While the impact of treatment during middle childhood and adolescence was relatively slight, parental attitudes appeared to have a major impact on improvement among all youths with childhood learning and behavior problems, a finding supported by a British survey of childhood behavior and mental health by Shepherd et al. (1971). The pervasive effect of perceived locus of control and competence in communication skills (i.e., reading and writing standard English) among the youth in this cohort who were at risk for LD and serious mental health problems was apparent. The degree to which the youths had faith in the effectiveness of their own actions was related not only to the effectiveness with which they utilized their intellectual resources in scholastic achievement, but also to positive change in coping behavior. An internal locus of control was a significant correlate of improvement. An external locus of control, i.e., a lack of faith in the effectiveness of one's own actions, was especially notable among the LD and the pregnant teenagers, many of whom had significant mental health problems. As a corollary, "hard work and persistence" were the assets most frequently mentioned in the clinical interviews by the youths with serious childhood behavior problems who later improved. The results of the Kauai Longitudinal Study, based on a cohort of children in a community over two decades of their lives, provide a perspective for the child clinical professions that is more difficult to obtain from short-term studies of problem children. While the focus of this report has been on young people who were vulnerable, one could not help but be deeply impressed by the resiliency of the overwhelming majority of children and their potential for positive change and personal growth. Most young people in this cohort were competent in coping with their problems, chose their parents as their models, found their family and friends to be supportive and understanding, and expressed a strong sense of continuity with their families in values attached to education, occupational preferences, and social expectations. Sameroff and Chandler in their 1975 review of risk research have proposed a transactional model that seems to account best for the findings of this longitudinal study. Breakdown from this point of view is seen not simply as the function of an inborn inability to respond appropriately, but as the consequence of some continuous malfunction in the organism-environment transaction across time which prevents the child from organizing his world adaptively.
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Thus. "Any understanding of deviancies in outcome must be seen in the perspective of powerful self-righting tendencies which appear to move children toward normal developmental outcomes under all but the most adverse of circumstances" (p. 235).
REFERENCES BROMAN. S. H., NICHOLAS, P. L. , & KENNEDY, W. W . (1975), PrtSclwollQ . New York: Wiley . KOHLBERG, L. , LACROSSE, J., & RICKS, D. (1972), The predictability of adult mental health from childhood behavior. In : Manual of Child Psychopathology, ed . B.B. Wolman . New York : McGraw-Hili, pp. 1217-1286. LEVITT, E. (197 I). Research on psychotherapy with children. In: Handbook of Psychotherapy and Behavior Change. cd . A . E. Bergen & S. L. Garfield. New York : Wiley, pp. 474-494. MEUNICK, S. A. & SCHULSINGER, F. (1970), Factors related to breakdown in children at high risk for schizophrenia, In: Life History Research in Psychopathology, ed, M . Ross & D. F. Ricks. Minneapolis: University of Minnesota Press, 1:51-93. ROBINS, L. (1966). Deviant Children GroW11 Up. Baltimore: Williams & Wilkins . Rurn:R, M., TIZARll, J., & WHITMORE, K. (1970), Education, Health and Behavior. London: Longmans. SAMt:ROFF, A . & CHANOl.t:R, M. J. (1975) , Reproductive risk and the cont inuum of caretaking ..asualt y. I,,: RPI.i,w ,,[Child Development Research, cd , F. D. Horowitz.. <:hi('ag( >: University of Chicago Press, 4 : 187-244. SIlt:PHt:Rll, M ., OPPENHEIM, B., & MITCHt:L1.• S. (1971), The Childhood Behavior and Mental Health . New York: Grune & Stranon . WERNER, E. E. (1978) , Environmental interaction in minimal brain dysfunctions. In: Handbook of Minimal Brain Dysfunctions, ed. H . Rie & E. Rie, New York : Wiley (in press). - - BIERMAN , J. M., & FRENCH , F. E. (1971), The Children of Kauai: A Longitudinal Study from thr Prenatal Period to Age Ten. Honolulu : University of Hawaii Press. - - - & SMITH, R. S. (1977). Kauai's Children Come of Age. Honolulu : University Press of Hawaii .