- Email: [email protected]
SOCIAL CLASS, PSYCHIATRIC DISORDER OF MOTHER, AND ACCIDENTS TO CHILDREN
378
groundless assumptions were rapidly seized upon by others. as in the first epidemic, the assumed cause became the direct focus of a generalised psychic contagion, spreading from the central couple, each of whom did have an unrelated, though organic, condition. In both epidemics the central figures played a dominant role, because of the strength of their convictions, accentuated by a complete unawareness (or non-acceptance by the first woman) of the true nature of their own illnesses. The subtle intimation that an unidentified outer cause was responsible resulted in a host of alleged skin troubles amongst their colleagues. It was interesting that the skin maladies mimicked almost but not exactly those of the central figures. This discrepancy allowed the true cause of each epidemic to be detected. The patch-test technique for investigation of industrial skin disease led to the diagnosis of a non-industrial contact eczema in the female employee in the second epidemic. Thus,
DISCUSSION
of skin disorders, completely independent of each other and of psychological origin, affecting a number of industrial employees, are of interest not only for doctors but also for society as a whole. In both epidemics, factories with an important export market were involved. A great deal of investigation was necessary before their cause was discovered. Several months of production were lost because of work stopped while investigations were carried out. During all this time, of the thirty-seven employees involved, only one (the central figure in the first epidemic) had sought medical aid, and even she did not avail herself of the factory’s own ambulance rooms. This reluctance to seek medical help is revealing and fundamental. It suggests a mass phenomenon of dangerous portent. The persons involved seemed to lack the desire to seek outside medical advice about their own health. It was clearly evident from the consensus among the employees that the factory management was directly responsible for their illnesses, so it must cure them without anyone else’s help. Why was there so profound a loss of the instinct for self-protection and indeed self-preservation? The answer may be that there was no longer a sense of individuality, only units in a system of groups of varying sizes. The employee had become the single industrial working unit. This single unit might be regarded as the ideal of the socialist State or system, the industrial worker, the man of the masses. The mass is always swayed by participation mystique, a term coined by Lévy-BruhP for the "pre-logical" mentality of the primitive and later abandoned by him. Jung,2 however, often used the term to denote that state which is none other than an unconscious identity or mutual unconscious relationship. The phenomena observed in these two outbreaks were common during the Middle Ages all over Europe. The phrase to describe the condition was psychic possession. Some 500 years later, this term cannot be bettered. These
two
epidemics
Requests for reprints to A. M., 17 Blackburn BB1 8AF, Lancashire.
Wellington
Street
(St. John’s),
REFERENCES
1. 2.
Lévy-Bruhl,
L. La
mythologie primitive.
Paris. 1935.
Jung, C. G. The Archetypes of the Collective Unconscious. Collected Works; vol. IX, part I, p. 126. London, 1969.
Community Medicine SOCIAL
CLASS, PSYCHIATRIC DISORDER OF
MOTHER, AND ACCIDENTS TO CHILDREN SUSAN DAVIDSON
GEORGE W. BROWN
Bedford College Annexe, 51 Harley Street, London W1N 1DD
Social Research Unit,
The accident risk to the children of a random sample of 458 women living in a former Inner London borough was associated with both a working-class status and the presence of psychiatric disturbance (usually depression) in the mother. The time of onset of the psychiatric disorder in these women and in another sample of women treated for depression by psychiatrists and general practitioners indicates that the mother’s psychiatric disorder greatly increases the risk of accidents to children.
Summary
INTRODUCTION
ACCIDENTS account for 27% of deaths of children aged over 1 year in the U.K.’ Estimates of the rate of non-fatal accidents vary,2but they are undoubtedly a serious public-health problem. A repeated finding has been that working-class children are more vulnerable than middle-class children.3 This has been attributed to various factors, including overcrowding, large families, and unemployment of the father. Psychiatric disorder in the parents has also been linked with a child’s vulnerability to accidents.4-6 We have examined the latter association and its relation to class differences. SUBJECTS
AND METHODS
Our subjects come froma large-scale investigation of the link between life-events and long-term difficulties in the onset and course of depressive disorders.7,8 As part of the study two random samples of women (totalling 458) aged between 18 and 65 living in Camberwell in South London were asked about psychiatric symptoms in the previous year. The date of onset of any psychiatric disorder was established. A schedule of questions developed at the Institute of Psychiatry9.1O was used to identify symptoms and severity of any psychiatric disorder. 17% of the 458 women were considered to have had a definite psychiatric disorder in the year before interview, and these have been called "cases". This judgement was based on clinical criteria-such as, lack of energy, sleep disturbance, and weight-loss-but with the underlying principle that a psychiatrist would not be surprised to see a woman defined as a "case" in a psychiatric outpatient clinic and would regard her as likely to benefit from some form of psychiatric treatment. Community "cases" were typical of psychiatric outpatients, although as a group they were somewhat less disturbed. All had an affective disorder, mostly depressive. Although very few had received any psychiatric care, 60% had contacted their general practitioner about some aspect of their condition. A further 19% of the sample who had reported definite but less severe psychiatric symptoms were termed "borderline cases"; again, depression was the most common component. These women are typical of many patients treated for psychiatric symptoms by general practitioners.8.11 The interviewers asked about life-events and longstanding difficulties. One of the events asked about was any accident to a child living at home, including fractures, severe cuts, burns,
379
chokings, and electrocution. Only accidents needing urgent medical attention were included in the survey. RESULTS
Psychiatric
Disorder in Mothers and A ccidents
to
Children There were 211 "mothers"-i.e., women with at least child under 16 living at home-in the sample of 458 women. The prevalence of definite psychiatric disorder was strongly associated with the social class of the women, particularly for "mothers". 28% of workingclass and 7% of middle-class mothers were cases (r<001), and 18% and 16% respectively were borderline cases. (Social class was determined on the basis of the occupation of the head of household, the "middle class" group including certain skilled manual occupations.7.S) There were 40 accidents in the year before interview among the 420 children under 16 living with these women-a rate of 9.5per 100 children. (There were fewer reports of accidents occurring more than 33 weeks before the interview; an adjusted figure allowing for this is 12-3per 100 per year.) Both social class and the mother’s psychiatric state were highly associated with accident risk to children,and the accident-rate for the children of mothers who were cases (17-2 per 100 children per year) was only slightly more than that for the children of the less disturbed borderline cases (14.3per 100 children per year). Like other workers,12 we found that there had been more accidents to boys than to girls (26 and 14 respectively). The highest accident-rate was in the 8-15 agegroup. Children whose mothers were working-class and were cases or borderline cases were most at risk-19.2 accidents per 100, compared with 9.6 for the rest of the working-class children (see figure). In the middle-class one
figures were 5.3per 100 and 1.5per 100 re14% (36/250) of the working-class (P<0.001). spectively children and 2% (4/170) of the middle-class children group the
had had an accident in the 12 months before the interview (p<0-001). Of the 163children living with mothers who were cases or borderline cases, 16% had had an accident, compared with 5% of the remaining 257
(P<0.001). About half the mothers who were cases or borderline had had an onset of symptoms (or, in a few instances, recovery) not more than a year before interview. The other half had been psychiatrically disturbed for the whole of the year. Since both accident and onset (or recovery) of any disorder were carefully dated, it was cases
16 MOTHER*
TABLE I-ACCIDENTS TO CHILDREN UNDER CONDITION OF
AND PSYCHIATRIC
*Based on 211 women in Camberwell, including 78 psychiatric paand 17 general-practitioner patients with depression.
tients
to compare the accident-rate during weeks in which a mother was a case or borderline case and when she was not. It was only during periods of psychiatric disturbance in the mother that children had an accidentrate above normal. This suggested that the raised rate of, accidents was a direct consequence of the mother’s psychiatric disorder. Because the number of accidents was relatively small, the finding was checked by including a further sample of depressed female psychiatric patients and a series of women attending general practitioners because of depression, altogether giving an extra 95 women with children. All lived in Camberwell and had a recent onset of symptoms. The results for the two sets of women were almost identical and have been combined in table i. The results hold for both social classes. They are also unaffected by the adjustment for the fall-off in reporting of accidents occurring more than 33 weeks before interview.
possible
Life-events and ChildhoodAccidents There is a possibility that adverse life-events lead
as
such
greater risk of accidents to children-for example, a father going to prison or the family being forced to move. There was indeed a tendency in the Camberwell sample for life-events involving any longterm threat to occur more often than expected in the 6 weeks before the accident: 31% (16/52) of mothers whose child had an accident had had a threatening event can
to a
psychiatric state and social class of mother.
previous 6 weeks, compared with an expected proportion of 15% (24/156), r<001. (The 6-week periods used to obtain the expected proportion were drawn from
Based on findings in 420 children under 16.
the non-accident group and matched for mother’s psy-
in the
Number of serious accidents per 100 children
at risk per year
by
380 chiatric state, social class, and maternal age, and also time from the date of interview.) However, these same events can also precipitate depression in mothers,g and it is possible, therefore, that at times it was the mother’s depression and not the event itself that had led to the child’s accident. However, when mothers with an onset of psychiatric disturbance in the year before interview were excluded, 35% of accidents were still preceded by a threatening event, compared with an expected proportion of 18% (r<005). This suggests a direct causal link. Nonetheless, the effect of events on accident risk is modest, involving only a small number of accidents to children in the Camberwell sample. It does not explain the link between psychiatric disorder in women and risk of an accident to a child, but it probably explains some of the class difference in risk, since such events are more common among working-class than middle-class women with children.8
Difficulties in the
Home and ChildhoodAccidents
Another factor of
possible importance
is class differ-
living conditions; certainly in our sample working-class women more often experienced major housing problems. But there is evidence that problems directly ences
in
concerned with the physical environment are not the only ones involved. While collecting information about life-events, we asked about bad housing, poor health of the subject or other person, financial problems, and marital difficulties. Difficulties lasting for 2 years or more and high on an objective severity scale could produce depression in women’’·8 and were more common among the working-class families. This was so in the 211 mothers even after we had excluded bad housing, overcrowding, and a generally poor physical environment: 35% (42/119) of the working-class families with children at home had a serious difficulty lasting 2 years or more -poor health, shortage of money, marital tensions, and so on (i.e., excluding housing)---compared with 18% (17/92) in the middle class (P<001). Such difficulties appeared to play a part in accidents independently of the mother’s psychiatric condition. Two-thirds (8/12) of accidents to children of working-class mothers who were not a case or borderline case occurred in families with at least one such difficulty, compared with 32-17c (34/107) in families with no such difficulty (P<0-01). Psychiatric disorder in the mother and other longstanding difficulties therefore appear to account for much of the class difference in risk of accidents to children. For working-class mothers in Camberwell with either a psychiatric disorder or a serious difficulty (such as bad housing), the rate of accidents was 18.4 per 100 children (32/174), compared with only 5.3per 100
(4/76) for other working-class women (r<001). Mother’s Employment, Size of Accidents
Family, and Childhood
There have been suggestions4 that childhood accidents are associated with "maternal preoccupation", including employment outside the home. We therefore examined both the mother’s employment status and whether or not she was actually present when the accident happened. Although there is a tendency for working-class children whose mothers work full time to have more accidents, there is no overall association between
TABLE II-NO. OF ACCIDENTS TO CHILDREN IN CLASS AND
MOTHER’S
employment of the mother and (table II). Moreover, the mother next
room
when
more
1
YR BY SOCIAL
EMPLOYMENT
accidents to children present or in the than half of the accidents was
occurred.
Family size does not affect the accident risk. CONCLUSIONS
The mother’s psychiatric state and the presence of a serious long-term difficulty or a threatening life-event were related to increased accident risk to children under 16. These factors were more common among workingclass children, and insofar as they are causal, they go a long way to explain the much greater risk of accidents to working-class children. Many mothers report increased irritability, loss of interest in their children, and so on, when depressed or anxious, and this can give rise to manifestations of distress in the child.13.14 It is therefore unlikely that the link between psychiatric disorder in the mother and accidents to children is explained simply by poor supervision. A change in the behaviour of the child is more likely to be involved. Marcus and his colleagues5 suggest that a child’s insecurity and anxiety are increased by family disturbance, and that accidents occur more often to children who rely on action as a mechanism to cope with their anxiety. Manheimer and Mellinger" found a relation between accidents and extraversion, aggression, impulsiveness, and daring, which they think tend to expose children to hazards. If a mother’s psychiatric condition influences a child’s activity level, increased risk could be a consequence of this rather than the result of more complex processes, such as a deliberate attempt "to provoke or punish the parent".16 We have no evidence to support this interpretation; but the fact that accident risk seems so clearly related to obvious changes in the child’s environment suggests that a careful study of the behaviour of children experiencing such changes would be profitable. This research was supported by the Medicaf Research Council, the Social Science Research Council, and the Foundations Fund for Research in Psychiatry. We are greatly indebted to Tirril Harris, Freda Sklair, Sue Pollock, Janet Cabot, Jenny Frankland, Marie Moyer, and Sue Ulrich, who did much of the interviewing. Prof. John Cooper and Dr Michael Kelleher cooperated with us in the measurement of psychiatric disorder in the first community series and Prof. John Wing, Dr Julian Leff, and Dr Sheila Mann in the second series.
Requests for reprints should be addressed to G. W. B. REFERENCES 1. Office of Health Economics. Accidental Deaths. London, 1975. 2. Calnan, M., Wadsworth, M. in Accidents in the Home (edited by S. Burman
and H. Genn); p. 27. London, 1977. 3. Adelstein, A. M., White, G. C. in Child Health: A Collection of Studies. H.M. Stationery Office, 1976. 4. Backett, E. M., Johnston, A. M. Br. med. J. 1959, i, 409. 5. Marcus, I. M., Wilson, W., Kraft, I., Swander, D., Southerland, F., Schulhofer, E. in Accident Research: Methods and Approaches (edited by W. Haddon, Jr, E. A. Suchman, and D. Klein); p. 313. London, 1964.
381
Medical Education
IF I WERE A DEAN
CHARLES CLAOUÉ* SUPPOSE we look at the current-edition medical student. In the eyes of his fellow (non-medical) students he is usually "somehow different" or even "a bit strange". Could it be that medical students are selected on different criteria from those applied to other would-be students ? The non-medicals will usually grudgingly admit that medical students, despite their reputation for high alcohol intake and peculiar jokes, do work hard. Perhaps this is because selection committees choose the students who most resemble themselves. And what opinion do medical students have of themselves? Usually too high, but I think this helps them to survive. Often there is a feeling of great doubt about embarking on a medical career. A tutor told me that about 20% of his medical students saw him during their first term with a view to changing course. In fact, very few do change, and by the start of the second term there is a feeling that "this is the right thing for me to be doing." The actual selection of medical students is a complex interaction between applicant, medical school, and U.C.C.A. The applicant has to play a dangerous game. His U.C.C.A. application form must make him appear interesting but industrious. He must have a reasonable but not excessive number of pastimes, and they should not include such enthusiasms as punk-rock or large motor-cycles. The order of medical schools is all-important, for some schools can easily make their choice from the applicants who list them as first preference. The next step may be the interview. In my own case, I feel that I eventually got into a medical school because it chose not to interview me. (A certain monarchal London medical school was so horrified by my interview performance that I arrived home to discover that they had already rejected me by telephone.) The interviewers have the applicant absolutely at their mercy. What are they, or the unseen selectors, looking for? Presumably an ability to complete a five or six year medical course without too many problems during or after the course,
*Preclinical medical student, Churchill
6. Sibert, R. Br. med. J. 1975, iii, 87. 7. Brown, G. W., Ni Bhrolcháin, M., 8. Brown, G. W., Harris, T. O. Social
College, Cambridge CB3
ODS
Sociology, 1975, 9, 225. of Depression: A Study of Psychiatric Disorder in Women. 1978. London (in the press). 9. Cooper, J., Copeland, J., Brown, G. W., Harris, T. O. Psychol. Med. 1977, Harris,
T. O.
Origins
7, 517.
10. Wing, J. K., Nixon, J. M., Mann, S. A., Leff, J. P. ibid. p. 505. 11. Brown, G. W., Davidson, S., Harris, T. O., Maclean, U., Pollock, S., Prudo, R. Soc. Sci. Med. 1977, 11, 367. 12. Douglas, J. W. B., Blomfield, J. M. Children Under Five. London, 1958. 13. Rutter, M. Children of Sick Patients—An Environmental and Psychiatric
Study. London, 1966. M., Paykel, E. S. The Depressed Woman: A Study Relationships. Chicago, 1976. 15. Manheimer, D. I., Mellinger, G. D. Child Dev. 1967, 38, 491. 14. Weissman, M.
16. Mitchell, R. G. Devl Med. Child Neurol.
1967, 9, 767.
of Social
for either the student or the medical school. One problem at once arises: not all medical graduates will enter clinical practice in the U.K. Some will go into administration, or laboratory research, or emigrate. The heterogeneity of medical students allows them to go off in many directions at the end of their course, and I feel that this heterogeneity is such a good thing that I would be tempted to reserve one place on the course for the least-likely candidate applying each year. Possibly a few should be chosen because they might become good deans. There is no way of judging how good a doctor will eventually be when he is only seventeen. Perhaps the best way to choose is intuitively. How can one judge whether or not that specific individual, whose entire future is in the balance, will be able to maintain the interest and put in the long hard hours required? How many applicants are asked if they are prepared to work a seven-day week? Surely a good applicant should have some idea of suffering and dying as well as the more successful aspects of medicine? There is something romantic and glorious about rushing around curing patients which appeals to young men denied swashbuckling days chasing adventure with a sword at their side; but there is less appeal in holding the hand of an old lady whilst she breathes her last. The candidate who shows no interest, at interview, in the care of the dying will be the same person when qualified. He can be trained, but does this really change his fundamental outlook? When I asked a friend what was the most important attribute to look for in a candidate for medical school, she narrowed her eyes and purred "Supreme self-confidence". Besides this, an ability to pass exams seems to be a good criterion. Much like i.Q. tests, they sort people out according to how good they are under unnatural, precisely defined conditions. The curricula are ludicrous. (What are the metabolic products of pipecolate? Can you name the seventeen or more branches of the internal-maxillary artery? Give a brief account of the hormone tuftsin.) Schools do their share of the damage. Students who arrive at medical school with A-levels in maths, physics, and chemistry are at a grave disadvantage, yet those arriving with biology, chemistry, and physics are very nearly a minority. It is perhaps desirable that medical students should be slightly more numerate, and I would like to see medical schools offering more places to people with biology, chemistry, and the new A-level subject physics-with-mathematics. At present only a perverted 1% of students are prepared to do a third-year course in medical statistics; and, at the other extreme, I have known some to faint at the sight of log tables. Quite often, bright school-students studying biology as one of their A-level subjects are encouraged to apply to read medicine almost as a logical next step. This I suspect has very little effect; people don’t apply for five-year courses unless motivated from within. But what motivation should medical schools be looking for? A wish to cure people? Better become a faith healer. Want to be rich? Try organised crime. Daddy-is-a-doctor? Professional phenotypes are the result of environmental effects on the products of multiple genetic loci, not directly inherited. So why did I want to be a doctor? I think the answer that I would look for as dean is: "Please sir, I really don’t know."
groundless assumptions were rapidly seized upon by others. as in the first epidemic, the assumed cause became the direct focus of a generalised psychic contagion, spreading from the central couple, each of whom did have an unrelated, though organic, condition. In both epidemics the central figures played a dominant role, because of the strength of their convictions, accentuated by a complete unawareness (or non-acceptance by the first woman) of the true nature of their own illnesses. The subtle intimation that an unidentified outer cause was responsible resulted in a host of alleged skin troubles amongst their colleagues. It was interesting that the skin maladies mimicked almost but not exactly those of the central figures. This discrepancy allowed the true cause of each epidemic to be detected. The patch-test technique for investigation of industrial skin disease led to the diagnosis of a non-industrial contact eczema in the female employee in the second epidemic. Thus,
DISCUSSION
of skin disorders, completely independent of each other and of psychological origin, affecting a number of industrial employees, are of interest not only for doctors but also for society as a whole. In both epidemics, factories with an important export market were involved. A great deal of investigation was necessary before their cause was discovered. Several months of production were lost because of work stopped while investigations were carried out. During all this time, of the thirty-seven employees involved, only one (the central figure in the first epidemic) had sought medical aid, and even she did not avail herself of the factory’s own ambulance rooms. This reluctance to seek medical help is revealing and fundamental. It suggests a mass phenomenon of dangerous portent. The persons involved seemed to lack the desire to seek outside medical advice about their own health. It was clearly evident from the consensus among the employees that the factory management was directly responsible for their illnesses, so it must cure them without anyone else’s help. Why was there so profound a loss of the instinct for self-protection and indeed self-preservation? The answer may be that there was no longer a sense of individuality, only units in a system of groups of varying sizes. The employee had become the single industrial working unit. This single unit might be regarded as the ideal of the socialist State or system, the industrial worker, the man of the masses. The mass is always swayed by participation mystique, a term coined by Lévy-BruhP for the "pre-logical" mentality of the primitive and later abandoned by him. Jung,2 however, often used the term to denote that state which is none other than an unconscious identity or mutual unconscious relationship. The phenomena observed in these two outbreaks were common during the Middle Ages all over Europe. The phrase to describe the condition was psychic possession. Some 500 years later, this term cannot be bettered. These
two
epidemics
Requests for reprints to A. M., 17 Blackburn BB1 8AF, Lancashire.
Wellington
Street
(St. John’s),
REFERENCES
1. 2.
Lévy-Bruhl,
L. La
mythologie primitive.
Paris. 1935.
Jung, C. G. The Archetypes of the Collective Unconscious. Collected Works; vol. IX, part I, p. 126. London, 1969.
Community Medicine SOCIAL
CLASS, PSYCHIATRIC DISORDER OF
MOTHER, AND ACCIDENTS TO CHILDREN SUSAN DAVIDSON
GEORGE W. BROWN
Bedford College Annexe, 51 Harley Street, London W1N 1DD
Social Research Unit,
The accident risk to the children of a random sample of 458 women living in a former Inner London borough was associated with both a working-class status and the presence of psychiatric disturbance (usually depression) in the mother. The time of onset of the psychiatric disorder in these women and in another sample of women treated for depression by psychiatrists and general practitioners indicates that the mother’s psychiatric disorder greatly increases the risk of accidents to children.
Summary
INTRODUCTION
ACCIDENTS account for 27% of deaths of children aged over 1 year in the U.K.’ Estimates of the rate of non-fatal accidents vary,2but they are undoubtedly a serious public-health problem. A repeated finding has been that working-class children are more vulnerable than middle-class children.3 This has been attributed to various factors, including overcrowding, large families, and unemployment of the father. Psychiatric disorder in the parents has also been linked with a child’s vulnerability to accidents.4-6 We have examined the latter association and its relation to class differences. SUBJECTS
AND METHODS
Our subjects come froma large-scale investigation of the link between life-events and long-term difficulties in the onset and course of depressive disorders.7,8 As part of the study two random samples of women (totalling 458) aged between 18 and 65 living in Camberwell in South London were asked about psychiatric symptoms in the previous year. The date of onset of any psychiatric disorder was established. A schedule of questions developed at the Institute of Psychiatry9.1O was used to identify symptoms and severity of any psychiatric disorder. 17% of the 458 women were considered to have had a definite psychiatric disorder in the year before interview, and these have been called "cases". This judgement was based on clinical criteria-such as, lack of energy, sleep disturbance, and weight-loss-but with the underlying principle that a psychiatrist would not be surprised to see a woman defined as a "case" in a psychiatric outpatient clinic and would regard her as likely to benefit from some form of psychiatric treatment. Community "cases" were typical of psychiatric outpatients, although as a group they were somewhat less disturbed. All had an affective disorder, mostly depressive. Although very few had received any psychiatric care, 60% had contacted their general practitioner about some aspect of their condition. A further 19% of the sample who had reported definite but less severe psychiatric symptoms were termed "borderline cases"; again, depression was the most common component. These women are typical of many patients treated for psychiatric symptoms by general practitioners.8.11 The interviewers asked about life-events and longstanding difficulties. One of the events asked about was any accident to a child living at home, including fractures, severe cuts, burns,
379
chokings, and electrocution. Only accidents needing urgent medical attention were included in the survey. RESULTS
Psychiatric
Disorder in Mothers and A ccidents
to
Children There were 211 "mothers"-i.e., women with at least child under 16 living at home-in the sample of 458 women. The prevalence of definite psychiatric disorder was strongly associated with the social class of the women, particularly for "mothers". 28% of workingclass and 7% of middle-class mothers were cases (r<001), and 18% and 16% respectively were borderline cases. (Social class was determined on the basis of the occupation of the head of household, the "middle class" group including certain skilled manual occupations.7.S) There were 40 accidents in the year before interview among the 420 children under 16 living with these women-a rate of 9.5per 100 children. (There were fewer reports of accidents occurring more than 33 weeks before the interview; an adjusted figure allowing for this is 12-3per 100 per year.) Both social class and the mother’s psychiatric state were highly associated with accident risk to children,and the accident-rate for the children of mothers who were cases (17-2 per 100 children per year) was only slightly more than that for the children of the less disturbed borderline cases (14.3per 100 children per year). Like other workers,12 we found that there had been more accidents to boys than to girls (26 and 14 respectively). The highest accident-rate was in the 8-15 agegroup. Children whose mothers were working-class and were cases or borderline cases were most at risk-19.2 accidents per 100, compared with 9.6 for the rest of the working-class children (see figure). In the middle-class one
figures were 5.3per 100 and 1.5per 100 re14% (36/250) of the working-class (P<0.001). spectively children and 2% (4/170) of the middle-class children group the
had had an accident in the 12 months before the interview (p<0-001). Of the 163children living with mothers who were cases or borderline cases, 16% had had an accident, compared with 5% of the remaining 257
(P<0.001). About half the mothers who were cases or borderline had had an onset of symptoms (or, in a few instances, recovery) not more than a year before interview. The other half had been psychiatrically disturbed for the whole of the year. Since both accident and onset (or recovery) of any disorder were carefully dated, it was cases
16 MOTHER*
TABLE I-ACCIDENTS TO CHILDREN UNDER CONDITION OF
AND PSYCHIATRIC
*Based on 211 women in Camberwell, including 78 psychiatric paand 17 general-practitioner patients with depression.
tients
to compare the accident-rate during weeks in which a mother was a case or borderline case and when she was not. It was only during periods of psychiatric disturbance in the mother that children had an accidentrate above normal. This suggested that the raised rate of, accidents was a direct consequence of the mother’s psychiatric disorder. Because the number of accidents was relatively small, the finding was checked by including a further sample of depressed female psychiatric patients and a series of women attending general practitioners because of depression, altogether giving an extra 95 women with children. All lived in Camberwell and had a recent onset of symptoms. The results for the two sets of women were almost identical and have been combined in table i. The results hold for both social classes. They are also unaffected by the adjustment for the fall-off in reporting of accidents occurring more than 33 weeks before interview.
possible
Life-events and ChildhoodAccidents There is a possibility that adverse life-events lead
as
such
greater risk of accidents to children-for example, a father going to prison or the family being forced to move. There was indeed a tendency in the Camberwell sample for life-events involving any longterm threat to occur more often than expected in the 6 weeks before the accident: 31% (16/52) of mothers whose child had an accident had had a threatening event can
to a
psychiatric state and social class of mother.
previous 6 weeks, compared with an expected proportion of 15% (24/156), r<001. (The 6-week periods used to obtain the expected proportion were drawn from
Based on findings in 420 children under 16.
the non-accident group and matched for mother’s psy-
in the
Number of serious accidents per 100 children
at risk per year
by
380 chiatric state, social class, and maternal age, and also time from the date of interview.) However, these same events can also precipitate depression in mothers,g and it is possible, therefore, that at times it was the mother’s depression and not the event itself that had led to the child’s accident. However, when mothers with an onset of psychiatric disturbance in the year before interview were excluded, 35% of accidents were still preceded by a threatening event, compared with an expected proportion of 18% (r<005). This suggests a direct causal link. Nonetheless, the effect of events on accident risk is modest, involving only a small number of accidents to children in the Camberwell sample. It does not explain the link between psychiatric disorder in women and risk of an accident to a child, but it probably explains some of the class difference in risk, since such events are more common among working-class than middle-class women with children.8
Difficulties in the
Home and ChildhoodAccidents
Another factor of
possible importance
is class differ-
living conditions; certainly in our sample working-class women more often experienced major housing problems. But there is evidence that problems directly ences
in
concerned with the physical environment are not the only ones involved. While collecting information about life-events, we asked about bad housing, poor health of the subject or other person, financial problems, and marital difficulties. Difficulties lasting for 2 years or more and high on an objective severity scale could produce depression in women’’·8 and were more common among the working-class families. This was so in the 211 mothers even after we had excluded bad housing, overcrowding, and a generally poor physical environment: 35% (42/119) of the working-class families with children at home had a serious difficulty lasting 2 years or more -poor health, shortage of money, marital tensions, and so on (i.e., excluding housing)---compared with 18% (17/92) in the middle class (P<001). Such difficulties appeared to play a part in accidents independently of the mother’s psychiatric condition. Two-thirds (8/12) of accidents to children of working-class mothers who were not a case or borderline case occurred in families with at least one such difficulty, compared with 32-17c (34/107) in families with no such difficulty (P<0-01). Psychiatric disorder in the mother and other longstanding difficulties therefore appear to account for much of the class difference in risk of accidents to children. For working-class mothers in Camberwell with either a psychiatric disorder or a serious difficulty (such as bad housing), the rate of accidents was 18.4 per 100 children (32/174), compared with only 5.3per 100
(4/76) for other working-class women (r<001). Mother’s Employment, Size of Accidents
Family, and Childhood
There have been suggestions4 that childhood accidents are associated with "maternal preoccupation", including employment outside the home. We therefore examined both the mother’s employment status and whether or not she was actually present when the accident happened. Although there is a tendency for working-class children whose mothers work full time to have more accidents, there is no overall association between
TABLE II-NO. OF ACCIDENTS TO CHILDREN IN CLASS AND
MOTHER’S
employment of the mother and (table II). Moreover, the mother next
room
when
more
1
YR BY SOCIAL
EMPLOYMENT
accidents to children present or in the than half of the accidents was
occurred.
Family size does not affect the accident risk. CONCLUSIONS
The mother’s psychiatric state and the presence of a serious long-term difficulty or a threatening life-event were related to increased accident risk to children under 16. These factors were more common among workingclass children, and insofar as they are causal, they go a long way to explain the much greater risk of accidents to working-class children. Many mothers report increased irritability, loss of interest in their children, and so on, when depressed or anxious, and this can give rise to manifestations of distress in the child.13.14 It is therefore unlikely that the link between psychiatric disorder in the mother and accidents to children is explained simply by poor supervision. A change in the behaviour of the child is more likely to be involved. Marcus and his colleagues5 suggest that a child’s insecurity and anxiety are increased by family disturbance, and that accidents occur more often to children who rely on action as a mechanism to cope with their anxiety. Manheimer and Mellinger" found a relation between accidents and extraversion, aggression, impulsiveness, and daring, which they think tend to expose children to hazards. If a mother’s psychiatric condition influences a child’s activity level, increased risk could be a consequence of this rather than the result of more complex processes, such as a deliberate attempt "to provoke or punish the parent".16 We have no evidence to support this interpretation; but the fact that accident risk seems so clearly related to obvious changes in the child’s environment suggests that a careful study of the behaviour of children experiencing such changes would be profitable. This research was supported by the Medicaf Research Council, the Social Science Research Council, and the Foundations Fund for Research in Psychiatry. We are greatly indebted to Tirril Harris, Freda Sklair, Sue Pollock, Janet Cabot, Jenny Frankland, Marie Moyer, and Sue Ulrich, who did much of the interviewing. Prof. John Cooper and Dr Michael Kelleher cooperated with us in the measurement of psychiatric disorder in the first community series and Prof. John Wing, Dr Julian Leff, and Dr Sheila Mann in the second series.
Requests for reprints should be addressed to G. W. B. REFERENCES 1. Office of Health Economics. Accidental Deaths. London, 1975. 2. Calnan, M., Wadsworth, M. in Accidents in the Home (edited by S. Burman
and H. Genn); p. 27. London, 1977. 3. Adelstein, A. M., White, G. C. in Child Health: A Collection of Studies. H.M. Stationery Office, 1976. 4. Backett, E. M., Johnston, A. M. Br. med. J. 1959, i, 409. 5. Marcus, I. M., Wilson, W., Kraft, I., Swander, D., Southerland, F., Schulhofer, E. in Accident Research: Methods and Approaches (edited by W. Haddon, Jr, E. A. Suchman, and D. Klein); p. 313. London, 1964.
381
Medical Education
IF I WERE A DEAN
CHARLES CLAOUÉ* SUPPOSE we look at the current-edition medical student. In the eyes of his fellow (non-medical) students he is usually "somehow different" or even "a bit strange". Could it be that medical students are selected on different criteria from those applied to other would-be students ? The non-medicals will usually grudgingly admit that medical students, despite their reputation for high alcohol intake and peculiar jokes, do work hard. Perhaps this is because selection committees choose the students who most resemble themselves. And what opinion do medical students have of themselves? Usually too high, but I think this helps them to survive. Often there is a feeling of great doubt about embarking on a medical career. A tutor told me that about 20% of his medical students saw him during their first term with a view to changing course. In fact, very few do change, and by the start of the second term there is a feeling that "this is the right thing for me to be doing." The actual selection of medical students is a complex interaction between applicant, medical school, and U.C.C.A. The applicant has to play a dangerous game. His U.C.C.A. application form must make him appear interesting but industrious. He must have a reasonable but not excessive number of pastimes, and they should not include such enthusiasms as punk-rock or large motor-cycles. The order of medical schools is all-important, for some schools can easily make their choice from the applicants who list them as first preference. The next step may be the interview. In my own case, I feel that I eventually got into a medical school because it chose not to interview me. (A certain monarchal London medical school was so horrified by my interview performance that I arrived home to discover that they had already rejected me by telephone.) The interviewers have the applicant absolutely at their mercy. What are they, or the unseen selectors, looking for? Presumably an ability to complete a five or six year medical course without too many problems during or after the course,
*Preclinical medical student, Churchill
6. Sibert, R. Br. med. J. 1975, iii, 87. 7. Brown, G. W., Ni Bhrolcháin, M., 8. Brown, G. W., Harris, T. O. Social
College, Cambridge CB3
ODS
Sociology, 1975, 9, 225. of Depression: A Study of Psychiatric Disorder in Women. 1978. London (in the press). 9. Cooper, J., Copeland, J., Brown, G. W., Harris, T. O. Psychol. Med. 1977, Harris,
T. O.
Origins
7, 517.
10. Wing, J. K., Nixon, J. M., Mann, S. A., Leff, J. P. ibid. p. 505. 11. Brown, G. W., Davidson, S., Harris, T. O., Maclean, U., Pollock, S., Prudo, R. Soc. Sci. Med. 1977, 11, 367. 12. Douglas, J. W. B., Blomfield, J. M. Children Under Five. London, 1958. 13. Rutter, M. Children of Sick Patients—An Environmental and Psychiatric
Study. London, 1966. M., Paykel, E. S. The Depressed Woman: A Study Relationships. Chicago, 1976. 15. Manheimer, D. I., Mellinger, G. D. Child Dev. 1967, 38, 491. 14. Weissman, M.
16. Mitchell, R. G. Devl Med. Child Neurol.
1967, 9, 767.
of Social
for either the student or the medical school. One problem at once arises: not all medical graduates will enter clinical practice in the U.K. Some will go into administration, or laboratory research, or emigrate. The heterogeneity of medical students allows them to go off in many directions at the end of their course, and I feel that this heterogeneity is such a good thing that I would be tempted to reserve one place on the course for the least-likely candidate applying each year. Possibly a few should be chosen because they might become good deans. There is no way of judging how good a doctor will eventually be when he is only seventeen. Perhaps the best way to choose is intuitively. How can one judge whether or not that specific individual, whose entire future is in the balance, will be able to maintain the interest and put in the long hard hours required? How many applicants are asked if they are prepared to work a seven-day week? Surely a good applicant should have some idea of suffering and dying as well as the more successful aspects of medicine? There is something romantic and glorious about rushing around curing patients which appeals to young men denied swashbuckling days chasing adventure with a sword at their side; but there is less appeal in holding the hand of an old lady whilst she breathes her last. The candidate who shows no interest, at interview, in the care of the dying will be the same person when qualified. He can be trained, but does this really change his fundamental outlook? When I asked a friend what was the most important attribute to look for in a candidate for medical school, she narrowed her eyes and purred "Supreme self-confidence". Besides this, an ability to pass exams seems to be a good criterion. Much like i.Q. tests, they sort people out according to how good they are under unnatural, precisely defined conditions. The curricula are ludicrous. (What are the metabolic products of pipecolate? Can you name the seventeen or more branches of the internal-maxillary artery? Give a brief account of the hormone tuftsin.) Schools do their share of the damage. Students who arrive at medical school with A-levels in maths, physics, and chemistry are at a grave disadvantage, yet those arriving with biology, chemistry, and physics are very nearly a minority. It is perhaps desirable that medical students should be slightly more numerate, and I would like to see medical schools offering more places to people with biology, chemistry, and the new A-level subject physics-with-mathematics. At present only a perverted 1% of students are prepared to do a third-year course in medical statistics; and, at the other extreme, I have known some to faint at the sight of log tables. Quite often, bright school-students studying biology as one of their A-level subjects are encouraged to apply to read medicine almost as a logical next step. This I suspect has very little effect; people don’t apply for five-year courses unless motivated from within. But what motivation should medical schools be looking for? A wish to cure people? Better become a faith healer. Want to be rich? Try organised crime. Daddy-is-a-doctor? Professional phenotypes are the result of environmental effects on the products of multiple genetic loci, not directly inherited. So why did I want to be a doctor? I think the answer that I would look for as dean is: "Please sir, I really don’t know."