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Epidemiology and child psychiatry: Historical and conceptual development
Epidemiology and Child Psychiatry: Historical and Conceptual Development Felton Earls
I
T COULD BE ARGUED that child psychiatry and epidemiology have little to contribute to one another. Child psychiatry has managed to survive as a “stepchild” of general psychiatry, and a “cousin” of pediatrics, while epidemiology has steadily matured as an exact and basic science of social medicine and public health. Epidemiology makes demands that measurable disorders and diseases be discrete in time and space. Child psychiatry struggles to extract meaningful information from the ‘noise” of behavior. Epidemiologists can all too easily dismiss child psychiatrists more as patrons than practitioners of medicine. Child psychiatrists, recognizing the complexity of behavior, are not too readily moved to assign its complexity to categories or reduce its variations to rating scales. This paper, the first in a series exploring interaction between these two disciplines, examines some important historical landmarks. The argument is made that past relations between epidemiology and other medical specialties began in a manner not dissimilar to the present relationship between it and child psychiatry. The current level of development in child psychiatry as a medical science might be reasonably compared to the pre-Pasteur era in internal medicine. Epidemiology assumed a major role during this latter period in producing evidence on the distribution and spread of infectious diseases as exemplified in the seminal work of John Snow on cholera. This work was joined with laboratory sciences to thrust internal medicine into a rapid phase of development. It is unlikely that this movement would have been successful if either had occurred alone. A similar argument may be applied to child psychiatry. It is doubtful that clinical or laboratory methods alone will result in sufficient scientific catalysis to make fundamental changes in the practice of the profession. The origins of child psychiatry took place in response to the progressive industrialization and urbanization of our social environment. ’ The changes brought about in forms of work, family relationships, and group tensions have been ably documented. The “mental hygiene movement” formulated by William Healy,2 the obstetrician, and Adolph Meyer, the psychiatN3 represent the wellsprings from which child psychiatry emerged as a separate professional activity. Its focus, however, on the treatment of delinquents and the prevention of crime did not find ready acceptance with adult psychiatrists or pediatricians. Considered a subdiscipline of general psychiatry, it was as much
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influenced by social work as it was ignored by pediatricians. During this same phase in the growth of child psychiatry, the first few decades of the century, epidemiology was expanding its area of inquiry to include chronic noninfectious diseases. Mental illnesses were gradually included in the epidemiologic perspective. At a slower rate of development, psychiatric and developmental disorders of childhood have become the subject of epidemiologic methods. DEFINITION
AND
BRIEF HISTORY
OF EPIDEMIOLOGY
Epidemiology took its origins from informal exercises to understand and control the spread of infectious disease. During the 19th century, this informal exercise gradually assumed the status of a basic medical science. Both the prescientific and scientific phases of epidemiology have in common a fundamental grounding in social observation. Daniel Defoe’s A Journnl ofthc Pltrglrc, YCLII.S”represents an example of the informal prescientific epidemiology. concerned with the careful documentation of episodes of illness and patterns of spread within the community. The methods used by Defoe were to be repeated 100 years later by John Snow. during the birth of epidemiology as a science. Snow carried out sequential investigations on a series of cholera epidemics that hit London between 1849 and 1854.” He noted that fatalities were concentrated in the Broad Street and Golden Square areas of central London. By suspecting contaminated water supply as the source of the disease, and by locating the position of dwellings in which fatalities occurred. he was able to isolate the Broad Street pump as the nidus of the epidemic. He. thus, recommended removal of the handle of the pump. Though the epidemic was on the decline by this point, this investigation prompted him to conduct a more definitive experiment during a subsequent outbreak of cholera in 1853. This time around he was able to isolate the particular water company responsible for the contaminated water. The suspense created in Snow’s original monograph is fascinating. He appears as the first epidemiologic detective, synthesizing facts gathered from his knowledge of the pathophysiology. symptoms, and course of the disease, and patterns of its spread in time and space. What lifted epidemiology from the status of medical journalism to science was the addition of systematic inductive reasoning, empiricism, and the addition of an experimental attitude to meticulous care in natural observation. Classic studies of the 19th century, such as those of Semmelweiss demonstrating the link between what was a common medical practice at the time (i.e.. surgeons not observing sterile precautions in moving from the dissecting laboratory to the operating room) follow in the tradition of John Snow by consolidating these features in the use of sequential strategies to describe the distribution and etiology of infectious disease.” Since epidemiology’s first pursuit is to count cases of a disease in a given population. much attention has traditionally been given to definitions of what constitutes a case. Once an agreed-upon definition of “caseness“ is determined, counts of the disease may be made within a defined population. Prevalence, the number of cases existing within a given time frame, and incidence. the number of new cases appearing within a given time period. are the common
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strategies used to describe the distribution of disease in the population. Having established the prevalence and incidence of a disease, epidemiologists have a number of options at their disposal: (1) to compare prevalence and incidence rates in different populations; (2) to carry out longitudinal studies to investigate the natural history of the disease; (3) to translate epidemiologic findings to experimental laboratory investigation for confirmation; (4) to construct a theory of etiology with the objective of applying a preventive measure, and (5) to construct models of transmission of the disease. These various strategies were scientifically integrated in the early years of this century as epidemiologic ideas began to influence the study of infectious and noninfectious chronic diseases. Goldberger’s7 sequential investigations into the case of pellagra highlight the transition of epidemiology from the exclusive study of infectious disease epidemics and mortality, to the study of chronic disease and morbidity. Just as John Snow was able, through observational skill, logic, and an experimental attitude, to postulate the etiology of cholera to a “materies morbi,” 30 years before Koch isolated the Vibrio chlorea, Goldberger was able to clearly demonstrate that pellagra was not an infectious or a hereditary disease, as the prevailing opinions thought, but a nutritional one. Goldberger began his studies in 1914 by noting that in institutions where pellagra was common, no cases were reported in the medical or attending staffs. He proceeded over the next several years through a series of case-control studies and controlled field trials (in one experiment Goldberger actually innoculated himself with the secretions of pellagrinous patients) to radically change medical opinion by showing, conclusively, the nutritional basis of the disease. All this occurred two decades before ElvehjemX announced that nicotinic acid would cure blacktongue in dogs, the recognized counterpart of human pellagra. The tradition in epidemiology that was crystallized in the work of Goldberger was carried forth in such important studies as those of Doll and Hill,s demonstrating the association between smoking and bronchiogenic carcinoma, and the Framingham study, which examined risk factors of coronary artery disease. lo The scope and methods of epidemiologic research have now become well established, and are well represented in such textbooks as McMahon’s Epidemiology Principles and Methods, 11 Morris’s The Use of Epidemioll2 and more recently Lilienfeld’s Foundations of Epidemiology.” ogy 9 Psychiatric epidemiology could of course share in the triumph of Goldberger’s studies of pellagra, since individuals with this disease were in many instances institutionalized in mental hospitals or prisons. There were other important occasions in the 19th century when psychiatrists made notable contributions to what might be considered the prescientific era in the evolution of psychiatric epidemiology. Jarvis’s13 attempts to account for differential psychiatric morbidity between Irish immigrants and the indigenous population of Massachusetts in the 186Os, and Tuke’sL4 reformation in the recording and maintenance of hospital admissions statistics in England are two such examples. The most important era that might be considered a precursor for premonitory to psychiatric epidemiology occurred during the tenure of Adolph Meyer of the
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Johns Hopkins Hospital in the early years of this century. Meyer, through his influential teachings about social factors in mental illness and his penchant for thoroughness, created an environment in which psychiatric epidemiology flourished. Many of the prominent American psychiatric epidemiologists were students of Meyer: Lemkau, Gruenberg, Leighton, Srole. The emphasis in this Meyerian influence was to study variations in the rate of all mental illnesses as a function of the social environment. More recently, epidemiologists have put emphasis on standardizing diagnostic techniques,‘“,‘” and applying these techniques to a narrower spectrum of psychopathology.L7*‘X While this represents progress in development of psychiatric epidemiology as a science, it has necessarily tended to balance the former emphasis on social factors, with interest in the biologic components of various mental disorders. The assumption that social and biologic factors act together to produce the major forms of mental illness should be of particular interest to child psychiatrists. Perhaps even more than the adult psychiatrist, the child psychiatrist must always integrate his assessments against a biologic and developmental gradient. l9 The child psychiatrist constantly weighs the competing alternatives of biologic and social factors to explain the phenomena under his observation. Three broad areas of interest are rapidly developing in psychiatry that have a profound effect on concepts, treatments, and research in child psychiatry. First. there is interest in genetic factors in mental illness etiology. This has led to a fair amount of enthusiastic research in examining the “risk” of developing a major psychotic disorder in individuals considered genetically vulnerable.“’ Secondly, there is interest in nongenetic biologic factors, such as perinatal morbidity and environmentally induced injury to the developing brain. Thirdly. there are studies of social and psychodynamic factors that have occupied, by far, a dominant position in the history of psychiatry, but which are now undergoing active revision as they become conceived of as only partial contributors to mental illness morbidity. Exactly how these factors will influence future interactions between epidemiology and psychiatry will be the topic of a later paper in this series. CLASSIC
STUDIES
IN PSYCHIATRIC EPIDEMIOLOGY DISORDERS
OF CHILDHOOD
Morris’s’” definition of the seven uses of epidemiology provides a frame of reference to appreciate the scope of the scientific applications: ( I) the study of historical trends: (2) community diagnosis; (3) completion of the clinical picture; (4) the assessment of individual risk; (5) syndrome identification, (6) the search for causes, and (7) the working of health services. To highlight previous contributions of epidemiology to the diagnosis and treatment of psychiatric disorders of childhood, and to the growth of concepts and the development of a scientific attitude in the field, I have selected several studies for review. Each of these studies approximates one of the seven applications included in Morris’s definition. Selection of the studies was based on the originality. time of appearance, and strength of its experimental design. In several cases there were other studies comparable in experimental design and originality. but the earliest published
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study was chosen. In another instance, a later published workzl represented a more sophisticated research design, but the earlier work= had to be credited with originality. By such criteria, I have evaluated several scores of studies in child psychiatry and psychology, all of which I have considered epidemiologic in design. The rationale for my decision of what constitutes an epidemiologic study was not in every case the same as the author’s. In one case the author did not refer to the research as epidemiologic in design, but by virtue of its originality in methods and its stimulus value to subsequent epidemiologic work, it must certainly be considered an epidemiologic study. HISTORICAL TREND: THE PREVALENCE AND INCIDENCE OF MENTAL RETARDATION Goodman and TizardZ3 reported the prevalence of severe forms of mental retardation in two English counties 30 years after the pioneering survey of Lewis.‘j They postulated that the prevalence of mental retardation in their later survey would reveal a higher rate than shown in Lewis’s survey. This assumption was based on evidence of a decreasing infant mortality and a concomitant increase in the survival of handicapped children generally. The increasing incidence of handicapped children generally was expected to contribute to a higher prevalence at the later time period. The authors found a “true” prevalence of severe mental retardation (defined as IQ less than 50) of 3.81 per 1000 children aged IO-14 years. As in most surveys, this age-specific prevalence rate is the highest of all age groups. This figure compares to the 3.76 per 1000 that Lewis found for English urban areas in the 1920s. and represents no change over the 30-year interval. However, the authors knew from a survey that had been completedZ5 prior to their work, that the incidence of mongolism was on the increase. They decided to subtract the rate of mongolism from their overall survey results, as well as from the figures derived by Lewis. Surprisingly, this examination revealed a general decline in the prevalence of nonmongol-related mental retardation. One of the several merits of this work that justifies its classic status is the penetrating interpretation of results that failed to support their original hypotheses. For instance, they considered the changes in the definition of mental retardation, changes in the construction and administration of intelligence tests, the effects of advances in public health practices that led to early identification and treatment, the decline in certain specific syndromes such as mental retardation secondary to congenital syphillis, and the effects of changes in demography and fertility patterns. This carefully reasoned discussion concludes a relatively brief compact paper that is a gem in the anything but lucid field of mental retardation research. From an epidemiologic perspective, the strength of this paper rests in the decision to restrict the inquiry to severe forms of mental retardation. Had the investigators not made this decision, and included mild and borderline forms of the disorder, the discreteness of the entity, mental retardation, would have been lost, and the resulting trend in prevalence obscured.
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AND CHILD PSYCHIATRY
SYNDROME IDENTIFICATION: THE BERKELEY “GUIDANCE”
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STUDY
There is little doubt that Kanner’s”” description of the syndrome of infantile autism represents the best established behavior syndrome known to child psychiatry on clinical grounds. Approximating this is the description of the tic associated with the Gilles de la Tourette syndrome.‘5 and perhaps some of the disorders considered in the special symptom category of childhood psychiatric disorder. for example, encopresis. 2x Beyond this there are few other instances of diagnosis based strictly on behavioral criteria. Clinical work in child psychiatry has tended to obscure the distinction between objective behavior descriptions and interpretations of behavior. While this practice was becoming deeply rooted in child guidance clinics across the country, Jean McFarlane and her collaborators at the University of California were quietly conducting one of the most important studies in child development research of this century. The Guidance Study,“” as it has come to be known, began in 1928 with a sample of 250 20-month-old babies representing every fourth birth born to parents living in Berkeley California. The sample was randomly divided into a “guidance” group, and a control group. As the study progressed, following their sample prospectively over the next 16 years. children and families in the guidance group were closely monitored and given regular health and behavior assessments. Those in the control group were seen only once a year for a routine assessment. and were given intervention only when it was specifically requested. Reports of the work are only partially representative of the findings from the many years of research that have gone into this project. An early monograph gives a complete presentation of the sampling technique and the health. behavioral, and social assessments of the children.:‘” A later monograph presents findings from the control group’s annual assessments over a 12-year period when the children were between 5- and 16-years old.31 It thus represents one of the most carefully followed prospective, longitudinal groups in the literature on behavior development, and is probably one of the best existing sources of normative developmental trends in behavior. Unfortunately. much of the other data on the guidance and control groups is not easily accessible. For instance, it would be good to know what the relationship was between behavioral and physical development, since they were both measured throughout the longitudinal period. How effective were the interventions given the guidance group’? The predictive significance of behavior problems occurring early in life to later physical, psychophysical, or emotional disorder has not been reported (although there are reports on the stability of personality dimensions over time).:3’ The importance of McFarlane’s work, aside from its thoroughness. is the introduction to empirically derived. objective techniques for the assessment of behavior adjustment. The method allowed her to report the prevalence of a wide range of behaviors of different ages, and to observe how some behaviors tended to cluster to form patterns. The published accounts of McFarlane’s work suggest that she did not make much diagnostic import out of the behavior clusters as descriptive entities alone, but was more interested in how the
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symptoms emerged within a given family constellation, and what the symptoms meant to the developing child. 33 A reading of her descriptions with modern diagnostic schema in child psychiatry in mind, however, indicates that she observed syndromes that would clearly be called neurotic and conduct disorders by today’s diagnostic standards. The demand for empirical data and operational definition set a trend for future epidemiologic studies in the field. McFarlane never used the word “epidemiology” in her writing, yet this was an epidemiologic study in every respect. The work remains all the more valuable because archives of data have been maintained on this sample at the University of California, over a SO-year period. Following the period of middle adolescence, the sample was less frequently assessed, but contact with a respectively large percentage of the sample has been maintained even to today. The archives represent a veritable goldmine for hypothesis generation for researchers in human development. COMMUNITY DIAGNOSIS OF BEHAVIOR DISORDERS: THE PREVALENCE OF EMOTIONAL DISORDERS IN CHILDREN While McFarlane’s work is cast in a developmental longitudinal design, the work of Rema LaPouse and her colleague, Mary Monk, was designed to test the power of a single diagnostic interview in distinguishing normal from abnormal behavior. The general thrust of this study was to examine the prevalence of behavior disorder in the general population. This is the classic first step of a true epidemiologic enterprise. The results of the LaPouse and Monk work, conducted in Buffalo, New York, is presented in a series of six papers,23,34-38 each paper representing a logical, sequential step in the analysis and interpretation of data. Perhaps the most important characteristic of these papers is the emphasis placed on methodology. These are perhaps the first papers examining emotionally derived behavior disorder in childhood that actually use the word, “epidemiology” to describe the study design. Its use is well qualified in this study, because of the technical considerations given both the denominator (sampling the population base) and the numerator (number of cases) in the determination of prevalence. The first papers detail the sampling technique and interview methodsz2 A reliability and validity study is also incorporated in this methodological paper. Unfortunately, this latter study was not independently published. An early paper concentrates on the prevalence of single behavioral symptoms and clusters of symptoms.34 The findings of these studies indicate that symptoms, such as fears and worries of children, are quite common and could not be used to discriminate between normal and abnormal behavior. To the authors, this was a challenge to expand the definition of psychiatric disorder beyond the limits of symptom formation. To broaden the definition of psychiatric disorder, LaPouse defines two other categories. They are social adjustment, which includes a number of parameters of interpersonal behavior, and educational adaptation. The last of the papers37,38 examines the relationship between psychiatric symptoms and social adjustment. Traditional epidemiologic concepts and terminology are admirably handled in these papers. For example, the relative risk of poor social adjust-
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ment in the presence of various types and severities of behavior symptoms is determined. An excellent discussion of the sensitivity and specificity of the symptom loading approach to psychiatric diagnosis is discussed.37 It is apparent that the authors were carefully working towards a synthesis of all the data collected in their 1955 survey. The final paper in the series promised that another would follow, describing the relationship between deviant behaviors and educational adaptation as a final step in the synthesis of their collected data. LaPouse’s untimely death in 1967 prevented the ultimate synthesis of the Buffalo survey, but the methodological sophistication and logical attack of this work represent a milestone in the fragile marriage of epidemiology to child psychiatry. COMPLETING THE CLINICAL PICTURE: THE ADULT FOLLOW-UP CHILDREN Al-l-ENDING THE CHILD GUIDANCE CLINIC
OF
One of the essential services provided by the work of child psychiatrists is the expectation that risk of adult mental illness will be substantially reduced, a (straight-mindedness). concept captured by the neologism “orthopsychiatry” Because psychiatric disorder in childhood must be viewed against development gradient, completion of the clinical picture requires a period of follow-up to assimilate knowledge on the ultimate outcome of diagnostic and treatment methods. The 30-year retrospective, longitudinal study (or follow-back study) of Robins represents one of the major works on the natural history of a psychiatric disorder.:l” The study reports on the adult psychiatric status of over 500 children who were seen at a St. Louis child guidance clinic in the 1920s. The project is best known for its finding on the stability of antisocial behavior disorder over a 30-year interval. the period between first appearance in the child guidance clinic and the adult follow-up. As important as this finding has been to the practice of child psychiatry, suggesting the need for improved methods of prevention, diagnosis, and treatment for this group of disorders. of equal importance is the contribution it has made to the methodology of longitudinal studies. Some of these important technical points include: (1) the careful consideration given to selection of a control group: (2) success in reaching over 90% of the child guidance sample at follow-up; (3) the convergence of data from official records and personal interviews in reaching a broad informational base from which diagnoses were made, and (4) the careful attention given to the numerous sources of biases attendant in such studies. An additional advantage of the Robins study is the full and rigorous presentation of all aspects of the project in the monograph, Dct’ictnt Childrrrz Glon,tz Up. The fact that the monograph makes details of the design and results of the study accessible quite naturally increases its pedagogic value. Not only has this study set a precedent on the scientific quality of longitudinal studies in child psychiatry. it has also made a notable contribution to diagnosis and classification of sociopathic disorders. The study was one of the first to suggest that hysterical features in women might be equivalent to sociopathic behavior in males. This observation has become one of the important contributions of the -‘St. Louis School” of psychopathology to the de-
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velopment of models of disease transmission in psychiatry.40 The operational criteria for the diagnosis of sociopathy established in the Robins work have been a powerful influence on both the St. Louis classification and the American Psychiatric Association’s Diagnostic and Statistical manuals II and III. One of the more heuristically provocative conclusions reached in Robins’ work is the finding that antisocial children tend to have antisocial fathers. This result first raises the question of whether or not the association is spurious or real. If real, it invites inquiry to explain what the etiologic basis of sociopathic disorders might be. Robins has now extended her studies to examine second generational influences in the transmission of the disorder.41,4’ THE SEARCH FOR CAUSES: CONTINUUM OF REPRODUCTIVE CASUALTY The most rational critique on the quality of child psychiatry as a science is to examine its explanations of cause and effect. What distinguishes a science from other systems of knowledge is the adaption of testable hypotheses. Through application of objective test methods, the hypothesis is either confirmed or disconfirmed, and knowledge is advanced. Examination of the range of hypotheses in child psychiatry applicable to epidemiologic methods reveals that it spans the scope of child psychiatry generally, including (1) biologic factors; (2) social factors, and (3) factors that are presumed to result from an interaction of biologic and social phenomena. Few of these hypotheses have been the basis of an epidemiologic study for some obvious reasons: vague conceptualizations, lack of standardization in measurement capacity, and restricted application of the phenomena under study. An exception is the hypothesis developed by Lilienfeld and Pasamanick termed the “continuum of reproductive casualty.“43 This hypothesis posits that the degree of injury to the central nervous system (CNS) at birth can explain a spectrum of disorders ranging from stillbirths to behavioral problems. Stillbirths and neonatal deaths are placed at the lethal end of the spectrum and represent maximal damage to the CNS; moderate degrees of CNS insult, reflected in such disorders as cerebral palsy and epilepsy, are placed in an intermediate position: lesser degrees of insult are assumed to result in behavioral problems and mental retardation. Pasamanick and his coworkers recognized the eminent applicability of this hypothesis to epidemiologic investigation, and applied it to a series of studies. 43-47Using public records to select target populations, and hospital records and birth certificates to assign degrees of perinatal insult, they produced evidence in large samples of children to support the hypothesis. In addition to data on the degree of insult was qualitative evidence that the type of insult was related to the spectrum of outcomes at all levels of insult. In each case, the authors found that insult resulting in anoxic damage (toxemia and bleeding) rather than mechanical damage (operative procedures and dystocia) was associated with unfavorable behavioral and cognitive outcomes. While the limitations of these studies are several (reliance on public records and sample selection, study of association of variables that do not imply that a causative relationship exists, confounding of perinatal injury with prematurity, and retrospective research design), they project a powerful explanatory
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framework linking psychiatric and neuroiogic disorders. Particular reference to the investigations of behavioral problems points out two major limitations. One has to do with the sample selection procedure adopted by the authors. Children with behavioral problems were obtained from a list of children known to a special education department of the local school system. Despite an attempt to select only those children with psychiatric disorder, it was realized that the list tended to confound social problems of children (such as neglect and school absenteeism) with behavioral problems. The second limitation concerned the adequacy of the environmental ratings employed. It was found that as more data were provided on the home circumstances of the children (parental education, family size, parental age, broken home). differences in outcome between the experimental and control groups disappeared. Since the authors postulate an interaction between perinatal insult and environmental circumstances, it may be that both factors received differential rating depending on the relative position of the disorder on the “continuum.” If this is true, then the findings on behavioral problems suggest a relatively high environmental contribution to etiology. The authors realized the preliminary nature of their findings, and suggested a prospective longitudinal study to separate biologic and social variables in the causative framework. To date, several studies of this nature are being conducted, and there continues to be general support for the hypothesis though it is far from conclusive.“.‘!’ THE INTEGRATION OF A THEORY OF CAUSE WITH DESlGN SERVICE; THE CHlCAGO AREA PROJECT
OF A
One of the significant potentials of epidemiology is the study of the contribution of the social environment to behavior disorders. The work of Shaw and McKay. published in Jm~c~nilc Delinqucnqv in Urhtrn AWLIS, M’represents a fine example of a study examining the influence of social, ecologic factors on a behavioral problem. The extent to which juvenile delinquency is a psychiatric disorder is unclear, yet child psychiatrists have traditionally been summoned as agents of intervention. The Shaw and McKay study challenges the very idea that social agencies, the psychiatric profession included, have very much to offer in reaching ultimate solutions to the problem of juvenile delinquency. If the distribution of juvenile delinquency in time and space follows a pattern tied to the physical structure and social organization of cities, as these authors report. the solution to the problem is in local neighborhood reorganization, and local self-determination. Shaw and McKay reach this conclusion by an unusually thorough investigation of official records of delinquency in Chicago and eight other American cities. By the ingenious use of cartographic methods, they were able to demonstrate that rates of delinquency were highest in the centers of cities. areas of physical deterioration and social disorganization. A progression from the inner cities to outlying metropolitan areas demonstrated a regular decrease in rates from a high of 18.9 per 100 male population ages IO-16 years, to a low rate of 0.5 per 100 male population ages 10-16. The superimposition of concentric rings separated by l-2 mile gradients on city maps graphically illustrates this highly ordered phenomenon. When exceptions to the pattern were encountered
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(for example, in Boston), they were readily explained on the basis of the proximity of residential sections to industrial centers, which were stimulating physical deterioration of the neighborhoods. The fact that delinquency was highly intercorrelated with such factors as poor housing, poverty, immigrant and minority group status, rates of adult crime, infant mortality, tuberculosis, and mental illness, further suggested that all these conditions have their roots in some common phenomenon like social disintegration. In fact, the work of Shaw and McKay has much in common with a demonstration by Faris and Dunham51 (also based in Chicago) that shows that rates of first hospital admissions for schizophrenia also followed an ordered ecologic pattern. Both these studies have been criticized for their exclusive reliance on official records. It can be argued that if these investigators had included data from private as well as public services, or better yet, had defined their target behaviors apart from official recognition, such large area differences might not have been found. Substantive as this criticism is, it does not distract from the originality of this work. The efforts of this rigorously conducted epidemiologic study resulted in a clear proposal for intervention. If delinquency was to be conceived of as a product of community forces, then its solution rests in community reorganization. To accomplish this task, the Chicago Area Projects,52 much encouraged by the work of Shaw, was begun. The projects were essentially an effort to establish and promote local neighborhood control over human resources. Six neighborhoods in Chicago participated. With support from the Institute of Juvenile Research and the Behavior Research Fund, boards of directors composed of community residents were established. Planning and management of problems, and community activities designed to decrease the rate of delinquency, were carried out exclusively by local residents. Central to the argument of Shaw was the need for local residents to achieve a sense of selfreliance. Improvements in the physical environment of neighborhoods were combined with enhanced self-esteem, and articulation of agreed-upon values among the participating local residents. Such recommendations could easily be considered mundane, except for the fact that in this case they were based on scientific study of urban environments. I cannot find references to a report of outcome data from the Projects. My impression is that the study of outcome was ill-conceived at the outset, with too much emphasis being placed on fostering the “corrective” social processes within the neighborhoods. Furthermore, their success was disrupted by the postwar migration of southern Blacks moving to these centrally located areas, and by the continued growth of industry and commerce surrounding them. CONCLUSIONS
In this paper, I have highlighted some important contributions of epidemiologic thinking and methods to child psychiatry. Several examples of studies were presented to persuade the reader that the past 50 years have not been devoid of interaction between these two disciplines. Yet, epidemiology has not been absorbed into child psychiatry to the same degree that it has in adult psychiatry, or, for that matter, most other medical specialities. While
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genetics, the neurosciences. and pharmacology are being summoned for their basic scientific contributions to understanding the etiology and treatment of child psychiatric disorders, there is no comparable group of methods and strategies to represent the environmental contribution. Over the years, the interest that child psychiatrists have shown to this environmental component of disorders has been studied by a variety of techniques, few of which have been sufficiently well organized to invite replication or satisfy skeptics. One point of providing examples of past contributions of epidemiology to child psychiatry is to make the argument that epidemiology should become an integral part of the methods and concepts in child psychiatry, occupying the position of a basic social or environmental science to the discipline. At the beginning of this paper, a brief history of epidemiology in relation to the study of infectious disease was given. If it is reasonable to assume that the science of child psychiatry will proceed as did other sciences, then the contributions of epidemiology to child psychiatry now may be similar to the epidemiolic contributions of 120 years ago in developing control over infectious diseases. A fundamental weakness in the science of child psychiatry is its lack of testable hypotheses. This may, in part, be due to the fact that ideas have tended to come obliquely into the profession (from the retrospective accounts of adult psychopathology or by generalizing from learning curves or conditioning experiments with low order mammals to the human condition). There is insufficient data accumulated from careful observation and knowledge on environmental conditions that produce and sustain deviant behavior in children. Twenty-five years ago, Levy optimistically forecasted that the future vitality of child psychiatry would rest on such studies.;‘” Epidemiology should be a particularly powerful method in this regard. “Counting heads,” based on careful observation, in the tradition of Daniel Defoe and John Snow. and building associations while controlling for bias may be necessary steps in the sceintific evolution of child psychiatry. In addition. robust hypotheses capable of disconfirmation are being developed and applied. In subsequent work. I intend to critically appraise currently available epidemiologic techniques used in child psychiatry and child development research. and to interpret future trends regarding potential developments between these two disciplines. It is with a variety of laboratory, clinical, and epidemiologic tools ready for application that child psychiatry will progress towards full recognition as an essential medical discipline. REFERENCES I. Lrvy D: Beginnings of the child guidance movement, Am J Orthopsychiatry 38:799-804, 1968 2. Healy W. Bronner F: A New Light on Delinquency, New Haven, Yale University Press, 1936 3. Winters E (ed): The Collected Papers of Adolf Meyer: Medical Hygiene vol 4. Baltimore. Johns Hopkins Press. 1952, pp XIXXXVI
4. Defoe D: A Journal of the Plague Years. New York. New American Library, 1960 5. Frost W (ed): Snow on Cholera. New York. Hafner Publishing, 1965 6. Lilienfeld AM: Foundations of Epidemiology. New York, Oxford University Press. 1976 7. Terris M ted): Goldberger on Pellagra. Baton Rouge, Louisiana State University Press. 1964
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8. Elvehjem CA: Relation of nicotinic acid to pellagra. Physiol Rev 20:249-271, 1940 9. Doll R, Hill AB: Mortality in relation to smoking: Ten years’ observation of British doctors. Br Med J 1:1399-1404, 1964 10. Truett J, Cornfield J, Kannel W: A multivariate analysis of risk of coronary heart disease in Framingham. J Chronic Dis 2051 l-524, 1967 Il. McMahon B, Pugh TF: Epidemiology. Principles and Methods, Boston, Little, Brown, 1970 12. Morris JN: Uses of Epidemiology (ed 3). Edinburgh, Livingstone Press, 1976 13. Jarvis E: Influence of distance from and nearness to an insane hospital on its use by the people. Am J Insanity 22:361-407, 1866 14. Tuke DH: Insanity in Ancient and Modern Life, with Chapter on its Prevention, London, MacMillan, 1878 IS. Wing JK, Cooper JE, Sartorius N: The Measurement and Classification of Psychiatric Symptoms, Cambridge University Press, 1974 16. Spitzer RL. Endicott J, Fleiss JL, et al: The psychiatric status schedule; A technique for evaluating psychopathology and impairment in role functioning. Arch Gen Psychiatry 23:41-55, 1970 17. Cooper JE, Kendell RE, Gurland BJ, et al: Psychiatric Diagnosis in New York and London. London, Oxford University Press, 1972 18. World Health Organization, Schizophrenia: A multinational study, public health papers, no. 63, WHO, Geneva. 1975 19. Eisenberg L: Development as a unifying concept in psychiatry. Br J Psychiatry 1311225-237. 1977 20. Garmezy N: Children at risk: The search for the antecedents of schizophrenia. Schizophr Bull 8: 14-90, 1974 21. Rutter M, Tizard J, Whitmore K: Education. Health and Behavior, London, Longmans, 1970 22. LaPouse R. Monk M: An epidemiological study of behavior characteristics in children. Am J Public Health 48: I l34- 1144, 1958 23. Goodman N, Tizard J: Prevalence of imbecility and idiocy in children. Br Med J 1:216219, 1962 24. Lewis EO: Report on an investigation into the incidence of mental deficiency in six areas, 1925-27. Report of the Mental Defic Committee, part IV, London, H.M.S.O., 1929 25. Carter CO: A life table for mongols with the causes of death. J Ment Detic Res 2:64-74, 1958
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26. Kanner L: Autistic disturbances of affective contact. Nervous Child 2:217-250. 1943 27. Corbett JA, Matthews AM, Connell PH. et al: Tics and Gilles de la Tourette’s syndrome: A follow-up study and critical review. Br J Psychiatry 115: 1229-1241. 1969 28. Anthony EJ: An experimental approach to the psychopathology of childhood: Encopresis. Br J Med Psycho1 30:146-175, 1957 29. MacFarlane JW: The relation of environmental pressures to the development of the child’s personality and habit patterning. J Pediatr 15:142-152, 1939 30. MacFarlane JW: Studies in Child Guid-’ ante. I. Methodology of Data Collection and Organization, Monographs of the Sot Res Child Development, 3. No 6. Serial No 19, 1938 31. MacFarlane JW, Allen L, and Honzik MP: A Developmental Study of the Behavior Problems of Normal Children Between 21 Months and 14 Years. Berkeley, University of California Press. 1954 32. Jones M, Bayley N. MacFarlane J, et al: The Course of Human Development. Waltham, Mass. Xerox Pub, 1971 33. MacFarlane JW: Some findings from a ten year guidance research program. Progressive Education 15:529-535, 1938 34. LaPouse R. Monk M: Fears and worries in a representative sample of children. Am J Orthopsychiatry 29(4):803-818. 1959 35. LaPouse R, Monk M, Street E: A method for use in epidemiological studies of behavior disorders in children. Am J Public Health 54(2):207-222. 1964 36. LaPouse R, Monk M: Behavior deviations in a representative sample of children: Variation by sex. age, race, social class and family size. Am J Orthopsychiatry 34(3):436446, 1964 37. LaPouse R: The relationship of behavior to adjustment in a representative sample of children. Am J Public Health 55(8): 1130-1141. 1965 38. LaPouse R: The epidemiology of behavior disorders in children. Am J Dis Child 1 I1:594-599. 1966 39. Robins LN: Deviant Children GrownUp: A Sociological and Psychiatric Study of Sociopathic Personality. Baltimore, Williams & Wilkins, I%6 40. Reich T, Cloninger CR. Guze S: The multifactional model of disease transmission. 1. Description of the model and its use in psychiatry. Br J Psychiatry 127:1-IO, 1975 41. Robins LN. Lewis RE, The role of the
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AND CHILD PSYCHIATRY
antisocial family in school completion and delinquency: A three-generation study. Sot Q 7:500-514. 1966 41. Robins LN: Arrests and delinquency in two generations: A study of black urban families and their children. J Child Psycho1 Psychiatry 16: 125-140. 1975 43. Lilienfeld A, Pasamanick B: The association of prenatal and paranatal factors with the development of cerebral palsy and epilepsy. Am J Obstet Gynecol 70:93-101. 1955 44. Rogers ME, Lilienfeld A. Pasamanick B: Prenatal and paranatal factors in the development of childhood behavior disorders. Acta Psychiatr Neurol Stand Supp: 101. 1955 45. Pdsamanick B. Lilienfeld A: Association of maternal and fetal factors with mental deficiency. I. Abnormalities of the prenatal and paranatal periods. JAMA 159: 155-160. I954 46. Pasamanick 8. Constantine FK. Lilienfeld AM: Pregnancy experience and the development of childhood speech disorder: An epidemiological study of the association with maternal and fetal factors. Am J Dis Child YI:ll3-I 18. 1956 47. Pasamanick B, Kawi A: A study of the
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association of prenatal and paranatal factors with the development of tics in children: A preliminary investigation. J. Pediatr 48:596-601. 1956 48. Rutter M, Graham P. Yule W: A Neuropsychiatric Study in Childhood. Clinics in Developmental Medicine Nos. 35136. London. Spastics lnternational Med Publications. 1970 49. Werner E. Burman J, French F: The Children of Kauai: A Longitudinal Study From the Prenatal Period to Age Ten. Honolulu. Univ of Hawaii Press, 1971 50. Shaw C, McKay H: Juvenile Delinquency and Urban Areas, Chicago. tlniv of Chicago Press. 1943 51. Faris RE. Dunham. HW: Mental Disorders in Urban Areas: An Ecological Study of Schizophrenia and Other Psychoses. Chicago. Univ of Chicago Press. 1939 57. Shaw C: The Chicago Area Project, chap 7. in Bogue DJ: ted): The Basic Writings of Ernest W. Burgess. Chicago. Univ of Chicago Press, 1974, pp 81-89 53. Levy D: The critical evaluation of the present state of child psychiatry. Am J Psychiatry 108:481-490. 1952
I
T COULD BE ARGUED that child psychiatry and epidemiology have little to contribute to one another. Child psychiatry has managed to survive as a “stepchild” of general psychiatry, and a “cousin” of pediatrics, while epidemiology has steadily matured as an exact and basic science of social medicine and public health. Epidemiology makes demands that measurable disorders and diseases be discrete in time and space. Child psychiatry struggles to extract meaningful information from the ‘noise” of behavior. Epidemiologists can all too easily dismiss child psychiatrists more as patrons than practitioners of medicine. Child psychiatrists, recognizing the complexity of behavior, are not too readily moved to assign its complexity to categories or reduce its variations to rating scales. This paper, the first in a series exploring interaction between these two disciplines, examines some important historical landmarks. The argument is made that past relations between epidemiology and other medical specialties began in a manner not dissimilar to the present relationship between it and child psychiatry. The current level of development in child psychiatry as a medical science might be reasonably compared to the pre-Pasteur era in internal medicine. Epidemiology assumed a major role during this latter period in producing evidence on the distribution and spread of infectious diseases as exemplified in the seminal work of John Snow on cholera. This work was joined with laboratory sciences to thrust internal medicine into a rapid phase of development. It is unlikely that this movement would have been successful if either had occurred alone. A similar argument may be applied to child psychiatry. It is doubtful that clinical or laboratory methods alone will result in sufficient scientific catalysis to make fundamental changes in the practice of the profession. The origins of child psychiatry took place in response to the progressive industrialization and urbanization of our social environment. ’ The changes brought about in forms of work, family relationships, and group tensions have been ably documented. The “mental hygiene movement” formulated by William Healy,2 the obstetrician, and Adolph Meyer, the psychiatN3 represent the wellsprings from which child psychiatry emerged as a separate professional activity. Its focus, however, on the treatment of delinquents and the prevention of crime did not find ready acceptance with adult psychiatrists or pediatricians. Considered a subdiscipline of general psychiatry, it was as much
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EPIDEMIOLOGY
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AND CHILD PSYCHIATRY
influenced by social work as it was ignored by pediatricians. During this same phase in the growth of child psychiatry, the first few decades of the century, epidemiology was expanding its area of inquiry to include chronic noninfectious diseases. Mental illnesses were gradually included in the epidemiologic perspective. At a slower rate of development, psychiatric and developmental disorders of childhood have become the subject of epidemiologic methods. DEFINITION
AND
BRIEF HISTORY
OF EPIDEMIOLOGY
Epidemiology took its origins from informal exercises to understand and control the spread of infectious disease. During the 19th century, this informal exercise gradually assumed the status of a basic medical science. Both the prescientific and scientific phases of epidemiology have in common a fundamental grounding in social observation. Daniel Defoe’s A Journnl ofthc Pltrglrc, YCLII.S”represents an example of the informal prescientific epidemiology. concerned with the careful documentation of episodes of illness and patterns of spread within the community. The methods used by Defoe were to be repeated 100 years later by John Snow. during the birth of epidemiology as a science. Snow carried out sequential investigations on a series of cholera epidemics that hit London between 1849 and 1854.” He noted that fatalities were concentrated in the Broad Street and Golden Square areas of central London. By suspecting contaminated water supply as the source of the disease, and by locating the position of dwellings in which fatalities occurred. he was able to isolate the Broad Street pump as the nidus of the epidemic. He. thus, recommended removal of the handle of the pump. Though the epidemic was on the decline by this point, this investigation prompted him to conduct a more definitive experiment during a subsequent outbreak of cholera in 1853. This time around he was able to isolate the particular water company responsible for the contaminated water. The suspense created in Snow’s original monograph is fascinating. He appears as the first epidemiologic detective, synthesizing facts gathered from his knowledge of the pathophysiology. symptoms, and course of the disease, and patterns of its spread in time and space. What lifted epidemiology from the status of medical journalism to science was the addition of systematic inductive reasoning, empiricism, and the addition of an experimental attitude to meticulous care in natural observation. Classic studies of the 19th century, such as those of Semmelweiss demonstrating the link between what was a common medical practice at the time (i.e.. surgeons not observing sterile precautions in moving from the dissecting laboratory to the operating room) follow in the tradition of John Snow by consolidating these features in the use of sequential strategies to describe the distribution and etiology of infectious disease.” Since epidemiology’s first pursuit is to count cases of a disease in a given population. much attention has traditionally been given to definitions of what constitutes a case. Once an agreed-upon definition of “caseness“ is determined, counts of the disease may be made within a defined population. Prevalence, the number of cases existing within a given time frame, and incidence. the number of new cases appearing within a given time period. are the common
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strategies used to describe the distribution of disease in the population. Having established the prevalence and incidence of a disease, epidemiologists have a number of options at their disposal: (1) to compare prevalence and incidence rates in different populations; (2) to carry out longitudinal studies to investigate the natural history of the disease; (3) to translate epidemiologic findings to experimental laboratory investigation for confirmation; (4) to construct a theory of etiology with the objective of applying a preventive measure, and (5) to construct models of transmission of the disease. These various strategies were scientifically integrated in the early years of this century as epidemiologic ideas began to influence the study of infectious and noninfectious chronic diseases. Goldberger’s7 sequential investigations into the case of pellagra highlight the transition of epidemiology from the exclusive study of infectious disease epidemics and mortality, to the study of chronic disease and morbidity. Just as John Snow was able, through observational skill, logic, and an experimental attitude, to postulate the etiology of cholera to a “materies morbi,” 30 years before Koch isolated the Vibrio chlorea, Goldberger was able to clearly demonstrate that pellagra was not an infectious or a hereditary disease, as the prevailing opinions thought, but a nutritional one. Goldberger began his studies in 1914 by noting that in institutions where pellagra was common, no cases were reported in the medical or attending staffs. He proceeded over the next several years through a series of case-control studies and controlled field trials (in one experiment Goldberger actually innoculated himself with the secretions of pellagrinous patients) to radically change medical opinion by showing, conclusively, the nutritional basis of the disease. All this occurred two decades before ElvehjemX announced that nicotinic acid would cure blacktongue in dogs, the recognized counterpart of human pellagra. The tradition in epidemiology that was crystallized in the work of Goldberger was carried forth in such important studies as those of Doll and Hill,s demonstrating the association between smoking and bronchiogenic carcinoma, and the Framingham study, which examined risk factors of coronary artery disease. lo The scope and methods of epidemiologic research have now become well established, and are well represented in such textbooks as McMahon’s Epidemiology Principles and Methods, 11 Morris’s The Use of Epidemioll2 and more recently Lilienfeld’s Foundations of Epidemiology.” ogy 9 Psychiatric epidemiology could of course share in the triumph of Goldberger’s studies of pellagra, since individuals with this disease were in many instances institutionalized in mental hospitals or prisons. There were other important occasions in the 19th century when psychiatrists made notable contributions to what might be considered the prescientific era in the evolution of psychiatric epidemiology. Jarvis’s13 attempts to account for differential psychiatric morbidity between Irish immigrants and the indigenous population of Massachusetts in the 186Os, and Tuke’sL4 reformation in the recording and maintenance of hospital admissions statistics in England are two such examples. The most important era that might be considered a precursor for premonitory to psychiatric epidemiology occurred during the tenure of Adolph Meyer of the
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AND CHILD PSYCHIATRY
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Johns Hopkins Hospital in the early years of this century. Meyer, through his influential teachings about social factors in mental illness and his penchant for thoroughness, created an environment in which psychiatric epidemiology flourished. Many of the prominent American psychiatric epidemiologists were students of Meyer: Lemkau, Gruenberg, Leighton, Srole. The emphasis in this Meyerian influence was to study variations in the rate of all mental illnesses as a function of the social environment. More recently, epidemiologists have put emphasis on standardizing diagnostic techniques,‘“,‘” and applying these techniques to a narrower spectrum of psychopathology.L7*‘X While this represents progress in development of psychiatric epidemiology as a science, it has necessarily tended to balance the former emphasis on social factors, with interest in the biologic components of various mental disorders. The assumption that social and biologic factors act together to produce the major forms of mental illness should be of particular interest to child psychiatrists. Perhaps even more than the adult psychiatrist, the child psychiatrist must always integrate his assessments against a biologic and developmental gradient. l9 The child psychiatrist constantly weighs the competing alternatives of biologic and social factors to explain the phenomena under his observation. Three broad areas of interest are rapidly developing in psychiatry that have a profound effect on concepts, treatments, and research in child psychiatry. First. there is interest in genetic factors in mental illness etiology. This has led to a fair amount of enthusiastic research in examining the “risk” of developing a major psychotic disorder in individuals considered genetically vulnerable.“’ Secondly, there is interest in nongenetic biologic factors, such as perinatal morbidity and environmentally induced injury to the developing brain. Thirdly. there are studies of social and psychodynamic factors that have occupied, by far, a dominant position in the history of psychiatry, but which are now undergoing active revision as they become conceived of as only partial contributors to mental illness morbidity. Exactly how these factors will influence future interactions between epidemiology and psychiatry will be the topic of a later paper in this series. CLASSIC
STUDIES
IN PSYCHIATRIC EPIDEMIOLOGY DISORDERS
OF CHILDHOOD
Morris’s’” definition of the seven uses of epidemiology provides a frame of reference to appreciate the scope of the scientific applications: ( I) the study of historical trends: (2) community diagnosis; (3) completion of the clinical picture; (4) the assessment of individual risk; (5) syndrome identification, (6) the search for causes, and (7) the working of health services. To highlight previous contributions of epidemiology to the diagnosis and treatment of psychiatric disorders of childhood, and to the growth of concepts and the development of a scientific attitude in the field, I have selected several studies for review. Each of these studies approximates one of the seven applications included in Morris’s definition. Selection of the studies was based on the originality. time of appearance, and strength of its experimental design. In several cases there were other studies comparable in experimental design and originality. but the earliest published
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study was chosen. In another instance, a later published workzl represented a more sophisticated research design, but the earlier work= had to be credited with originality. By such criteria, I have evaluated several scores of studies in child psychiatry and psychology, all of which I have considered epidemiologic in design. The rationale for my decision of what constitutes an epidemiologic study was not in every case the same as the author’s. In one case the author did not refer to the research as epidemiologic in design, but by virtue of its originality in methods and its stimulus value to subsequent epidemiologic work, it must certainly be considered an epidemiologic study. HISTORICAL TREND: THE PREVALENCE AND INCIDENCE OF MENTAL RETARDATION Goodman and TizardZ3 reported the prevalence of severe forms of mental retardation in two English counties 30 years after the pioneering survey of Lewis.‘j They postulated that the prevalence of mental retardation in their later survey would reveal a higher rate than shown in Lewis’s survey. This assumption was based on evidence of a decreasing infant mortality and a concomitant increase in the survival of handicapped children generally. The increasing incidence of handicapped children generally was expected to contribute to a higher prevalence at the later time period. The authors found a “true” prevalence of severe mental retardation (defined as IQ less than 50) of 3.81 per 1000 children aged IO-14 years. As in most surveys, this age-specific prevalence rate is the highest of all age groups. This figure compares to the 3.76 per 1000 that Lewis found for English urban areas in the 1920s. and represents no change over the 30-year interval. However, the authors knew from a survey that had been completedZ5 prior to their work, that the incidence of mongolism was on the increase. They decided to subtract the rate of mongolism from their overall survey results, as well as from the figures derived by Lewis. Surprisingly, this examination revealed a general decline in the prevalence of nonmongol-related mental retardation. One of the several merits of this work that justifies its classic status is the penetrating interpretation of results that failed to support their original hypotheses. For instance, they considered the changes in the definition of mental retardation, changes in the construction and administration of intelligence tests, the effects of advances in public health practices that led to early identification and treatment, the decline in certain specific syndromes such as mental retardation secondary to congenital syphillis, and the effects of changes in demography and fertility patterns. This carefully reasoned discussion concludes a relatively brief compact paper that is a gem in the anything but lucid field of mental retardation research. From an epidemiologic perspective, the strength of this paper rests in the decision to restrict the inquiry to severe forms of mental retardation. Had the investigators not made this decision, and included mild and borderline forms of the disorder, the discreteness of the entity, mental retardation, would have been lost, and the resulting trend in prevalence obscured.
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AND CHILD PSYCHIATRY
SYNDROME IDENTIFICATION: THE BERKELEY “GUIDANCE”
261
STUDY
There is little doubt that Kanner’s”” description of the syndrome of infantile autism represents the best established behavior syndrome known to child psychiatry on clinical grounds. Approximating this is the description of the tic associated with the Gilles de la Tourette syndrome.‘5 and perhaps some of the disorders considered in the special symptom category of childhood psychiatric disorder. for example, encopresis. 2x Beyond this there are few other instances of diagnosis based strictly on behavioral criteria. Clinical work in child psychiatry has tended to obscure the distinction between objective behavior descriptions and interpretations of behavior. While this practice was becoming deeply rooted in child guidance clinics across the country, Jean McFarlane and her collaborators at the University of California were quietly conducting one of the most important studies in child development research of this century. The Guidance Study,“” as it has come to be known, began in 1928 with a sample of 250 20-month-old babies representing every fourth birth born to parents living in Berkeley California. The sample was randomly divided into a “guidance” group, and a control group. As the study progressed, following their sample prospectively over the next 16 years. children and families in the guidance group were closely monitored and given regular health and behavior assessments. Those in the control group were seen only once a year for a routine assessment. and were given intervention only when it was specifically requested. Reports of the work are only partially representative of the findings from the many years of research that have gone into this project. An early monograph gives a complete presentation of the sampling technique and the health. behavioral, and social assessments of the children.:‘” A later monograph presents findings from the control group’s annual assessments over a 12-year period when the children were between 5- and 16-years old.31 It thus represents one of the most carefully followed prospective, longitudinal groups in the literature on behavior development, and is probably one of the best existing sources of normative developmental trends in behavior. Unfortunately. much of the other data on the guidance and control groups is not easily accessible. For instance, it would be good to know what the relationship was between behavioral and physical development, since they were both measured throughout the longitudinal period. How effective were the interventions given the guidance group’? The predictive significance of behavior problems occurring early in life to later physical, psychophysical, or emotional disorder has not been reported (although there are reports on the stability of personality dimensions over time).:3’ The importance of McFarlane’s work, aside from its thoroughness. is the introduction to empirically derived. objective techniques for the assessment of behavior adjustment. The method allowed her to report the prevalence of a wide range of behaviors of different ages, and to observe how some behaviors tended to cluster to form patterns. The published accounts of McFarlane’s work suggest that she did not make much diagnostic import out of the behavior clusters as descriptive entities alone, but was more interested in how the
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symptoms emerged within a given family constellation, and what the symptoms meant to the developing child. 33 A reading of her descriptions with modern diagnostic schema in child psychiatry in mind, however, indicates that she observed syndromes that would clearly be called neurotic and conduct disorders by today’s diagnostic standards. The demand for empirical data and operational definition set a trend for future epidemiologic studies in the field. McFarlane never used the word “epidemiology” in her writing, yet this was an epidemiologic study in every respect. The work remains all the more valuable because archives of data have been maintained on this sample at the University of California, over a SO-year period. Following the period of middle adolescence, the sample was less frequently assessed, but contact with a respectively large percentage of the sample has been maintained even to today. The archives represent a veritable goldmine for hypothesis generation for researchers in human development. COMMUNITY DIAGNOSIS OF BEHAVIOR DISORDERS: THE PREVALENCE OF EMOTIONAL DISORDERS IN CHILDREN While McFarlane’s work is cast in a developmental longitudinal design, the work of Rema LaPouse and her colleague, Mary Monk, was designed to test the power of a single diagnostic interview in distinguishing normal from abnormal behavior. The general thrust of this study was to examine the prevalence of behavior disorder in the general population. This is the classic first step of a true epidemiologic enterprise. The results of the LaPouse and Monk work, conducted in Buffalo, New York, is presented in a series of six papers,23,34-38 each paper representing a logical, sequential step in the analysis and interpretation of data. Perhaps the most important characteristic of these papers is the emphasis placed on methodology. These are perhaps the first papers examining emotionally derived behavior disorder in childhood that actually use the word, “epidemiology” to describe the study design. Its use is well qualified in this study, because of the technical considerations given both the denominator (sampling the population base) and the numerator (number of cases) in the determination of prevalence. The first papers detail the sampling technique and interview methodsz2 A reliability and validity study is also incorporated in this methodological paper. Unfortunately, this latter study was not independently published. An early paper concentrates on the prevalence of single behavioral symptoms and clusters of symptoms.34 The findings of these studies indicate that symptoms, such as fears and worries of children, are quite common and could not be used to discriminate between normal and abnormal behavior. To the authors, this was a challenge to expand the definition of psychiatric disorder beyond the limits of symptom formation. To broaden the definition of psychiatric disorder, LaPouse defines two other categories. They are social adjustment, which includes a number of parameters of interpersonal behavior, and educational adaptation. The last of the papers37,38 examines the relationship between psychiatric symptoms and social adjustment. Traditional epidemiologic concepts and terminology are admirably handled in these papers. For example, the relative risk of poor social adjust-
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AND CHILD PSYCHIATRY
263
ment in the presence of various types and severities of behavior symptoms is determined. An excellent discussion of the sensitivity and specificity of the symptom loading approach to psychiatric diagnosis is discussed.37 It is apparent that the authors were carefully working towards a synthesis of all the data collected in their 1955 survey. The final paper in the series promised that another would follow, describing the relationship between deviant behaviors and educational adaptation as a final step in the synthesis of their collected data. LaPouse’s untimely death in 1967 prevented the ultimate synthesis of the Buffalo survey, but the methodological sophistication and logical attack of this work represent a milestone in the fragile marriage of epidemiology to child psychiatry. COMPLETING THE CLINICAL PICTURE: THE ADULT FOLLOW-UP CHILDREN Al-l-ENDING THE CHILD GUIDANCE CLINIC
OF
One of the essential services provided by the work of child psychiatrists is the expectation that risk of adult mental illness will be substantially reduced, a (straight-mindedness). concept captured by the neologism “orthopsychiatry” Because psychiatric disorder in childhood must be viewed against development gradient, completion of the clinical picture requires a period of follow-up to assimilate knowledge on the ultimate outcome of diagnostic and treatment methods. The 30-year retrospective, longitudinal study (or follow-back study) of Robins represents one of the major works on the natural history of a psychiatric disorder.:l” The study reports on the adult psychiatric status of over 500 children who were seen at a St. Louis child guidance clinic in the 1920s. The project is best known for its finding on the stability of antisocial behavior disorder over a 30-year interval. the period between first appearance in the child guidance clinic and the adult follow-up. As important as this finding has been to the practice of child psychiatry, suggesting the need for improved methods of prevention, diagnosis, and treatment for this group of disorders. of equal importance is the contribution it has made to the methodology of longitudinal studies. Some of these important technical points include: (1) the careful consideration given to selection of a control group: (2) success in reaching over 90% of the child guidance sample at follow-up; (3) the convergence of data from official records and personal interviews in reaching a broad informational base from which diagnoses were made, and (4) the careful attention given to the numerous sources of biases attendant in such studies. An additional advantage of the Robins study is the full and rigorous presentation of all aspects of the project in the monograph, Dct’ictnt Childrrrz Glon,tz Up. The fact that the monograph makes details of the design and results of the study accessible quite naturally increases its pedagogic value. Not only has this study set a precedent on the scientific quality of longitudinal studies in child psychiatry. it has also made a notable contribution to diagnosis and classification of sociopathic disorders. The study was one of the first to suggest that hysterical features in women might be equivalent to sociopathic behavior in males. This observation has become one of the important contributions of the -‘St. Louis School” of psychopathology to the de-
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velopment of models of disease transmission in psychiatry.40 The operational criteria for the diagnosis of sociopathy established in the Robins work have been a powerful influence on both the St. Louis classification and the American Psychiatric Association’s Diagnostic and Statistical manuals II and III. One of the more heuristically provocative conclusions reached in Robins’ work is the finding that antisocial children tend to have antisocial fathers. This result first raises the question of whether or not the association is spurious or real. If real, it invites inquiry to explain what the etiologic basis of sociopathic disorders might be. Robins has now extended her studies to examine second generational influences in the transmission of the disorder.41,4’ THE SEARCH FOR CAUSES: CONTINUUM OF REPRODUCTIVE CASUALTY The most rational critique on the quality of child psychiatry as a science is to examine its explanations of cause and effect. What distinguishes a science from other systems of knowledge is the adaption of testable hypotheses. Through application of objective test methods, the hypothesis is either confirmed or disconfirmed, and knowledge is advanced. Examination of the range of hypotheses in child psychiatry applicable to epidemiologic methods reveals that it spans the scope of child psychiatry generally, including (1) biologic factors; (2) social factors, and (3) factors that are presumed to result from an interaction of biologic and social phenomena. Few of these hypotheses have been the basis of an epidemiologic study for some obvious reasons: vague conceptualizations, lack of standardization in measurement capacity, and restricted application of the phenomena under study. An exception is the hypothesis developed by Lilienfeld and Pasamanick termed the “continuum of reproductive casualty.“43 This hypothesis posits that the degree of injury to the central nervous system (CNS) at birth can explain a spectrum of disorders ranging from stillbirths to behavioral problems. Stillbirths and neonatal deaths are placed at the lethal end of the spectrum and represent maximal damage to the CNS; moderate degrees of CNS insult, reflected in such disorders as cerebral palsy and epilepsy, are placed in an intermediate position: lesser degrees of insult are assumed to result in behavioral problems and mental retardation. Pasamanick and his coworkers recognized the eminent applicability of this hypothesis to epidemiologic investigation, and applied it to a series of studies. 43-47Using public records to select target populations, and hospital records and birth certificates to assign degrees of perinatal insult, they produced evidence in large samples of children to support the hypothesis. In addition to data on the degree of insult was qualitative evidence that the type of insult was related to the spectrum of outcomes at all levels of insult. In each case, the authors found that insult resulting in anoxic damage (toxemia and bleeding) rather than mechanical damage (operative procedures and dystocia) was associated with unfavorable behavioral and cognitive outcomes. While the limitations of these studies are several (reliance on public records and sample selection, study of association of variables that do not imply that a causative relationship exists, confounding of perinatal injury with prematurity, and retrospective research design), they project a powerful explanatory
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framework linking psychiatric and neuroiogic disorders. Particular reference to the investigations of behavioral problems points out two major limitations. One has to do with the sample selection procedure adopted by the authors. Children with behavioral problems were obtained from a list of children known to a special education department of the local school system. Despite an attempt to select only those children with psychiatric disorder, it was realized that the list tended to confound social problems of children (such as neglect and school absenteeism) with behavioral problems. The second limitation concerned the adequacy of the environmental ratings employed. It was found that as more data were provided on the home circumstances of the children (parental education, family size, parental age, broken home). differences in outcome between the experimental and control groups disappeared. Since the authors postulate an interaction between perinatal insult and environmental circumstances, it may be that both factors received differential rating depending on the relative position of the disorder on the “continuum.” If this is true, then the findings on behavioral problems suggest a relatively high environmental contribution to etiology. The authors realized the preliminary nature of their findings, and suggested a prospective longitudinal study to separate biologic and social variables in the causative framework. To date, several studies of this nature are being conducted, and there continues to be general support for the hypothesis though it is far from conclusive.“.‘!’ THE INTEGRATION OF A THEORY OF CAUSE WITH DESlGN SERVICE; THE CHlCAGO AREA PROJECT
OF A
One of the significant potentials of epidemiology is the study of the contribution of the social environment to behavior disorders. The work of Shaw and McKay. published in Jm~c~nilc Delinqucnqv in Urhtrn AWLIS, M’represents a fine example of a study examining the influence of social, ecologic factors on a behavioral problem. The extent to which juvenile delinquency is a psychiatric disorder is unclear, yet child psychiatrists have traditionally been summoned as agents of intervention. The Shaw and McKay study challenges the very idea that social agencies, the psychiatric profession included, have very much to offer in reaching ultimate solutions to the problem of juvenile delinquency. If the distribution of juvenile delinquency in time and space follows a pattern tied to the physical structure and social organization of cities, as these authors report. the solution to the problem is in local neighborhood reorganization, and local self-determination. Shaw and McKay reach this conclusion by an unusually thorough investigation of official records of delinquency in Chicago and eight other American cities. By the ingenious use of cartographic methods, they were able to demonstrate that rates of delinquency were highest in the centers of cities. areas of physical deterioration and social disorganization. A progression from the inner cities to outlying metropolitan areas demonstrated a regular decrease in rates from a high of 18.9 per 100 male population ages IO-16 years, to a low rate of 0.5 per 100 male population ages 10-16. The superimposition of concentric rings separated by l-2 mile gradients on city maps graphically illustrates this highly ordered phenomenon. When exceptions to the pattern were encountered
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(for example, in Boston), they were readily explained on the basis of the proximity of residential sections to industrial centers, which were stimulating physical deterioration of the neighborhoods. The fact that delinquency was highly intercorrelated with such factors as poor housing, poverty, immigrant and minority group status, rates of adult crime, infant mortality, tuberculosis, and mental illness, further suggested that all these conditions have their roots in some common phenomenon like social disintegration. In fact, the work of Shaw and McKay has much in common with a demonstration by Faris and Dunham51 (also based in Chicago) that shows that rates of first hospital admissions for schizophrenia also followed an ordered ecologic pattern. Both these studies have been criticized for their exclusive reliance on official records. It can be argued that if these investigators had included data from private as well as public services, or better yet, had defined their target behaviors apart from official recognition, such large area differences might not have been found. Substantive as this criticism is, it does not distract from the originality of this work. The efforts of this rigorously conducted epidemiologic study resulted in a clear proposal for intervention. If delinquency was to be conceived of as a product of community forces, then its solution rests in community reorganization. To accomplish this task, the Chicago Area Projects,52 much encouraged by the work of Shaw, was begun. The projects were essentially an effort to establish and promote local neighborhood control over human resources. Six neighborhoods in Chicago participated. With support from the Institute of Juvenile Research and the Behavior Research Fund, boards of directors composed of community residents were established. Planning and management of problems, and community activities designed to decrease the rate of delinquency, were carried out exclusively by local residents. Central to the argument of Shaw was the need for local residents to achieve a sense of selfreliance. Improvements in the physical environment of neighborhoods were combined with enhanced self-esteem, and articulation of agreed-upon values among the participating local residents. Such recommendations could easily be considered mundane, except for the fact that in this case they were based on scientific study of urban environments. I cannot find references to a report of outcome data from the Projects. My impression is that the study of outcome was ill-conceived at the outset, with too much emphasis being placed on fostering the “corrective” social processes within the neighborhoods. Furthermore, their success was disrupted by the postwar migration of southern Blacks moving to these centrally located areas, and by the continued growth of industry and commerce surrounding them. CONCLUSIONS
In this paper, I have highlighted some important contributions of epidemiologic thinking and methods to child psychiatry. Several examples of studies were presented to persuade the reader that the past 50 years have not been devoid of interaction between these two disciplines. Yet, epidemiology has not been absorbed into child psychiatry to the same degree that it has in adult psychiatry, or, for that matter, most other medical specialities. While
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genetics, the neurosciences. and pharmacology are being summoned for their basic scientific contributions to understanding the etiology and treatment of child psychiatric disorders, there is no comparable group of methods and strategies to represent the environmental contribution. Over the years, the interest that child psychiatrists have shown to this environmental component of disorders has been studied by a variety of techniques, few of which have been sufficiently well organized to invite replication or satisfy skeptics. One point of providing examples of past contributions of epidemiology to child psychiatry is to make the argument that epidemiology should become an integral part of the methods and concepts in child psychiatry, occupying the position of a basic social or environmental science to the discipline. At the beginning of this paper, a brief history of epidemiology in relation to the study of infectious disease was given. If it is reasonable to assume that the science of child psychiatry will proceed as did other sciences, then the contributions of epidemiology to child psychiatry now may be similar to the epidemiolic contributions of 120 years ago in developing control over infectious diseases. A fundamental weakness in the science of child psychiatry is its lack of testable hypotheses. This may, in part, be due to the fact that ideas have tended to come obliquely into the profession (from the retrospective accounts of adult psychopathology or by generalizing from learning curves or conditioning experiments with low order mammals to the human condition). There is insufficient data accumulated from careful observation and knowledge on environmental conditions that produce and sustain deviant behavior in children. Twenty-five years ago, Levy optimistically forecasted that the future vitality of child psychiatry would rest on such studies.;‘” Epidemiology should be a particularly powerful method in this regard. “Counting heads,” based on careful observation, in the tradition of Daniel Defoe and John Snow. and building associations while controlling for bias may be necessary steps in the sceintific evolution of child psychiatry. In addition. robust hypotheses capable of disconfirmation are being developed and applied. In subsequent work. I intend to critically appraise currently available epidemiologic techniques used in child psychiatry and child development research. and to interpret future trends regarding potential developments between these two disciplines. It is with a variety of laboratory, clinical, and epidemiologic tools ready for application that child psychiatry will progress towards full recognition as an essential medical discipline. REFERENCES I. Lrvy D: Beginnings of the child guidance movement, Am J Orthopsychiatry 38:799-804, 1968 2. Healy W. Bronner F: A New Light on Delinquency, New Haven, Yale University Press, 1936 3. Winters E (ed): The Collected Papers of Adolf Meyer: Medical Hygiene vol 4. Baltimore. Johns Hopkins Press. 1952, pp XIXXXVI
4. Defoe D: A Journal of the Plague Years. New York. New American Library, 1960 5. Frost W (ed): Snow on Cholera. New York. Hafner Publishing, 1965 6. Lilienfeld AM: Foundations of Epidemiology. New York, Oxford University Press. 1976 7. Terris M ted): Goldberger on Pellagra. Baton Rouge, Louisiana State University Press. 1964
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8. Elvehjem CA: Relation of nicotinic acid to pellagra. Physiol Rev 20:249-271, 1940 9. Doll R, Hill AB: Mortality in relation to smoking: Ten years’ observation of British doctors. Br Med J 1:1399-1404, 1964 10. Truett J, Cornfield J, Kannel W: A multivariate analysis of risk of coronary heart disease in Framingham. J Chronic Dis 2051 l-524, 1967 Il. McMahon B, Pugh TF: Epidemiology. Principles and Methods, Boston, Little, Brown, 1970 12. Morris JN: Uses of Epidemiology (ed 3). Edinburgh, Livingstone Press, 1976 13. Jarvis E: Influence of distance from and nearness to an insane hospital on its use by the people. Am J Insanity 22:361-407, 1866 14. Tuke DH: Insanity in Ancient and Modern Life, with Chapter on its Prevention, London, MacMillan, 1878 IS. Wing JK, Cooper JE, Sartorius N: The Measurement and Classification of Psychiatric Symptoms, Cambridge University Press, 1974 16. Spitzer RL. Endicott J, Fleiss JL, et al: The psychiatric status schedule; A technique for evaluating psychopathology and impairment in role functioning. Arch Gen Psychiatry 23:41-55, 1970 17. Cooper JE, Kendell RE, Gurland BJ, et al: Psychiatric Diagnosis in New York and London. London, Oxford University Press, 1972 18. World Health Organization, Schizophrenia: A multinational study, public health papers, no. 63, WHO, Geneva. 1975 19. Eisenberg L: Development as a unifying concept in psychiatry. Br J Psychiatry 1311225-237. 1977 20. Garmezy N: Children at risk: The search for the antecedents of schizophrenia. Schizophr Bull 8: 14-90, 1974 21. Rutter M, Tizard J, Whitmore K: Education. Health and Behavior, London, Longmans, 1970 22. LaPouse R. Monk M: An epidemiological study of behavior characteristics in children. Am J Public Health 48: I l34- 1144, 1958 23. Goodman N, Tizard J: Prevalence of imbecility and idiocy in children. Br Med J 1:216219, 1962 24. Lewis EO: Report on an investigation into the incidence of mental deficiency in six areas, 1925-27. Report of the Mental Defic Committee, part IV, London, H.M.S.O., 1929 25. Carter CO: A life table for mongols with the causes of death. J Ment Detic Res 2:64-74, 1958
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EARLS
26. Kanner L: Autistic disturbances of affective contact. Nervous Child 2:217-250. 1943 27. Corbett JA, Matthews AM, Connell PH. et al: Tics and Gilles de la Tourette’s syndrome: A follow-up study and critical review. Br J Psychiatry 115: 1229-1241. 1969 28. Anthony EJ: An experimental approach to the psychopathology of childhood: Encopresis. Br J Med Psycho1 30:146-175, 1957 29. MacFarlane JW: The relation of environmental pressures to the development of the child’s personality and habit patterning. J Pediatr 15:142-152, 1939 30. MacFarlane JW: Studies in Child Guid-’ ante. I. Methodology of Data Collection and Organization, Monographs of the Sot Res Child Development, 3. No 6. Serial No 19, 1938 31. MacFarlane JW, Allen L, and Honzik MP: A Developmental Study of the Behavior Problems of Normal Children Between 21 Months and 14 Years. Berkeley, University of California Press. 1954 32. Jones M, Bayley N. MacFarlane J, et al: The Course of Human Development. Waltham, Mass. Xerox Pub, 1971 33. MacFarlane JW: Some findings from a ten year guidance research program. Progressive Education 15:529-535, 1938 34. LaPouse R. Monk M: Fears and worries in a representative sample of children. Am J Orthopsychiatry 29(4):803-818. 1959 35. LaPouse R, Monk M, Street E: A method for use in epidemiological studies of behavior disorders in children. Am J Public Health 54(2):207-222. 1964 36. LaPouse R, Monk M: Behavior deviations in a representative sample of children: Variation by sex. age, race, social class and family size. Am J Orthopsychiatry 34(3):436446, 1964 37. LaPouse R: The relationship of behavior to adjustment in a representative sample of children. Am J Public Health 55(8): 1130-1141. 1965 38. LaPouse R: The epidemiology of behavior disorders in children. Am J Dis Child 1 I1:594-599. 1966 39. Robins LN: Deviant Children GrownUp: A Sociological and Psychiatric Study of Sociopathic Personality. Baltimore, Williams & Wilkins, I%6 40. Reich T, Cloninger CR. Guze S: The multifactional model of disease transmission. 1. Description of the model and its use in psychiatry. Br J Psychiatry 127:1-IO, 1975 41. Robins LN. Lewis RE, The role of the
EPIDEMIOLOGY
AND CHILD PSYCHIATRY
antisocial family in school completion and delinquency: A three-generation study. Sot Q 7:500-514. 1966 41. Robins LN: Arrests and delinquency in two generations: A study of black urban families and their children. J Child Psycho1 Psychiatry 16: 125-140. 1975 43. Lilienfeld A, Pasamanick B: The association of prenatal and paranatal factors with the development of cerebral palsy and epilepsy. Am J Obstet Gynecol 70:93-101. 1955 44. Rogers ME, Lilienfeld A. Pasamanick B: Prenatal and paranatal factors in the development of childhood behavior disorders. Acta Psychiatr Neurol Stand Supp: 101. 1955 45. Pdsamanick B. Lilienfeld A: Association of maternal and fetal factors with mental deficiency. I. Abnormalities of the prenatal and paranatal periods. JAMA 159: 155-160. I954 46. Pasamanick 8. Constantine FK. Lilienfeld AM: Pregnancy experience and the development of childhood speech disorder: An epidemiological study of the association with maternal and fetal factors. Am J Dis Child YI:ll3-I 18. 1956 47. Pasamanick B, Kawi A: A study of the
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association of prenatal and paranatal factors with the development of tics in children: A preliminary investigation. J. Pediatr 48:596-601. 1956 48. Rutter M, Graham P. Yule W: A Neuropsychiatric Study in Childhood. Clinics in Developmental Medicine Nos. 35136. London. Spastics lnternational Med Publications. 1970 49. Werner E. Burman J, French F: The Children of Kauai: A Longitudinal Study From the Prenatal Period to Age Ten. Honolulu. Univ of Hawaii Press, 1971 50. Shaw C, McKay H: Juvenile Delinquency and Urban Areas, Chicago. tlniv of Chicago Press. 1943 51. Faris RE. Dunham. HW: Mental Disorders in Urban Areas: An Ecological Study of Schizophrenia and Other Psychoses. Chicago. Univ of Chicago Press. 1939 57. Shaw C: The Chicago Area Project, chap 7. in Bogue DJ: ted): The Basic Writings of Ernest W. Burgess. Chicago. Univ of Chicago Press, 1974, pp 81-89 53. Levy D: The critical evaluation of the present state of child psychiatry. Am J Psychiatry 108:481-490. 1952