Scand. J . Psychol., 1975,16, 217-224
A follow-up study of young cerebral palsied patients Some psychological, educational and vocational aspects HELLE H. NIELSEN
Abstract.-In a follow-up study of 39 non-oligophrenic spastic adolescents and young adults it was found that 85 % attended normal schools, the rest went to schools for physically or mentally handicapped. If retarded children with learning difficulties were left out of account, there were no more than 10% regular problem cases, an incidence which is very close to what is found among ordinary, non-handicapped Danish school children.-With regard to vocational career, nearly 80 % were estimated to be able to obtain and remain in open employment. About one third had experienced rather pronounced vocational problems either because of physical weakness and slowness, or because of personality disturbances or intellectual retardation. Females appeared generally more content with and successful in their jobs than the males. There was an overrepresentation of clients with a mild physical handicap in the problem group, indicating that it may be difficult to occupy such a “marginal” position with its easy access to comparison and competition with the socalled normal standards.-A close relationship was found between the data from the original psychological evaluation and the course of schooling. In contrast, there was a low agreement between the childhood reports and the follow-up employment data.
This report is based on a re-evaluation of a group of young cerebral palsied patients all of whom had been psychologically appraised 8-10 years previously. The investigation was intended to illuminate some psychological aspects in the clients’ development from childhood to young adulthood as well as their present situation, especially with regard to general mental health, educational attainment and employability. IR this way a check could also be made on the predictive value of the first psychological appraisal. A follow-up study of cerebral palsied patients with these objectives in mind has not been found in the literature. Previous studies have been focused either on the special-mostly medical-problems of the cerebral palsied child or on the adult patient. The developmental approach adopted here makes it possible to bridge this artifical distinction between ages.
University of Aarhus, Denmark
METHOD
Subjects In the early ’sixties the author made an intensive psychological study of 40 non-oligophrenic spastic children aged 4-15 years and a control group of non-handicapped children matched for age, IQ, sex and socio-economic background (Nielsen, 1966). In this study an analysis was made of some cognitive and visuo-motor functions together with an investigation of personality characteristics. ~ ~ observations were made Of background and school record. The main conclusion was that a significantly greater number of patients displayed signs of visuo~motordisturbance, learning deficiency and personality disorder than was group. found in the matched The patients were selected among approximately 400 cerebral palsied children who were under treatment in the out-patients’ clinic for handicapped children in the University Hospital of Copenhagen (Rigshospitalet). The criteria for selection were: a chronological age range from 6 to 15 years; a Binet IQ of at least 75; a positive medical diagnosis of spastic hemiplegia or spastic paraplegia-half in each category. (Motivation for these criteria of selection can be found in Nielsen, 1966.) With respect to sex, residence (country or town) and degree of motor handicap the patients were distributed at random. The motor handicap vaned considerably, from a slight motor affection causing no real discomfort to a moderately severe handicap which resulted in great movement difficulties. None of the children were completely helpless, however. One child had a slight hearing impairment, another a slight impairment of vision. Ten of the 20 hemiplegics had an additional diagnosis of epilepsy; none of the paraplegics suffered from convulsive attacks. With regard to socio-economic background the Scand. J . Psychol. 16
~
218
H . H . Nielsen
Table 1. Total sample by diagnosis, severity of handicap, age, IQ and emotional climate in the home (N=39)
Original assessment Diagnosis Hemiplegia Paraplegia Seventy of handicap Mild Moderate Moderately severe
IQ75-89 %110 >110 At fdlow-up Age 14-16 17-19 20-23 Emotional climate in the ome Disharmonious Normal Uncertain
N
%
1Y 20
49 51
21 9 9
54 23 23
5 18
46
16
41
15 10 14
38 26 36
10 17 12
26 44 30
13
Right hemiplegia: N=13. Left hemiplegia: N = 6 .
large majority came from a middle-class milieu, a few from the lower-middle class. The group was not a representative selection of the cerebral palsied population in general. Mentally defective patients were excluded, and there were no representatives of the most severely motorhandicapped patients, who in most cases would be spastic tetraplegics, where all four extremities are affected. The group could be considered to represent only non-oligophrenic, spastic patients with hemiplegia or paraplegia. When the follow-up study was planned 8 years after the original appraisal, a young female patient had died from brain tumour; the remaining 39 of the 40 patients constitute the subjects of the present investigation (cf. Table 1). Unfortunately, there was no possibility of re-evaluating the normal control subjects. Procedures The follow-up data were collected from several sources: through interviews with 95% of the patients, through interviews with parents and teachers, from school and hospital records and from rehabilitation centres. At the first contact with the subjects the purpose with the interview was briefly explained and an offer was made Scond. J . Psychol. 16
to repay transport expenses as well as possible lost earnings in connection with the m e e t i n g . M w cases it had to be emphasised that no tests would be given, either in response to a direct question or because the subjects’ whole attitude showed that such a promise was indicated. About one-third of the patient-group was so young that they were still in treatment at the University Clinic’s outpatients’ clinic for handicapped children (upper age limit about 18 years). These youngsters were contacted in connection with one of their regular visits to the clinic and their cooperation was easily acquired. The remainder were contacted either by phone or by mail; in a few cases it was necessary to make two or three inquiries before cooperation was finally established. In only two cases did the client interview have to be abandoned because no answer was received after several applications. For these 2 patients ample information was available from school and hospital records and from rehabilitation centres. The interview took place at the hospital and usually lasted about 2 hours. It was of an open-ended, semistructured nature, focusing on the following areas: course of schooling, vocational training and education, employment, hobbies, physical handicap, relationship to parents and siblings, to friends and to the opposite sex. Weight was laid on an illumination of any dimculties and problems experienced throughout the years within the different areas, as well as upon information about the present life situation. In the case of patients younger than 18 years the data were supplemented with an interview with one of or both parents. Finally, additional data were gathered from the hospital records. In a few, more complicated cases where the cooperation of the patient and his parents was not entirely satisfactory, teachers and rehabilitation officers assisted in furnishing additional information. Besides obtaining pure factual information such as length of schooling, kind of job, etc., stress was laid on acquiring an impression of the general mental health status of the subjects. This had to be done without the help of projective techniques, as it had been decided already in the planning phases not to depend on tests. It was-rightly-anticipated that some hesitant and reluctant subjects could be persuaded to cooperate when they were assured that no test would be administered. Thus the evaluation of mental health was based on the clinical impression acquired during the interview supplemented with data from appropriate outside sources such as school and hospital records.
Analysis A vast amount of material was accumulated in this way; long and detailed life histories which did not easily lend themselves to quantitative analyses. Thus, a qualitative approach was used extensively. The data to be reported on here were treated within two main categories, the first covering schooling, and the second, employment. On the basis of all available material (interviews, records, etc.) the subjects were classified into one of the following groups: marked problems, no (marked) problems, and uncertain (in case of incomplete information). In order to reduce as much as possible the
Follow-up of cerebral palsied patients effects of experimenter bias, great stress was laid on the subject’s openly expressed feelings about and evaluation of his situation, minimizing clinical interpretation. A classification in opposition to a subject’s own statement was only made in a few cases of unmistakable neurotic denial and repression of problems. In these, as in all other cases, factual, controllable information about the c l i e n t s f m m schools, employment agencies, and hospitals-were used to check the classification. Only ‘marked’ and prolonged emotional, cognitive andlor vocational difficulties resulted in a classification in one of the problem groups. Clients with minor and possibly temporary difficulties, which did not indicate any need for professional intervention, were registered in the nonproblem group together with well-adjusted and mentally healthy subjects. The follow-up results were seen in relation to 1) kind and degree of cerebral palsy, 2) emotional climate in the youngster’s home, and 3) the conclusions from the first psychological appraisal. Kind and degree of cerebral palsy had been diagnosed by a neuro-pediatrician, and this classification was used in the analysis of the correlation between certain physical factors and the follow-up results. Emotional climate in the home was evaluated in the original study and reconsidered at the follow-up. Three broad categories were used: disharmonious home, normal (to harmonious) home, and uncertain. In accordance with the procedure employed throughout the study only pronounced and conspicuous interpersonal problems in the patient’s family led to registration in the ‘disharmonious home’ category. The so-called ‘normal’ category comprised a rather wide range of different family backgrounds: from mentally healthy and harmonious families to homes with minor and possibly transient psychological difficulties. The ‘uncertain’ group included families about which the information was felt to be too sparse or too inconsistent to justify classification. To this category were also referred a few cases where the emotional climate in the home had changed quite considerably, for better or for worse, since the original evaluation. Finally, follow-up results were compared with the original psychological description. This description was based on the total impression gained of the child by the help of cognitive and projective tests, observation, interviews with the parents as well as information from the professional staff in kindergarten, school and hospital (cf. Nielsen, 1%). It included an account of the general level of intellectual functioning, of cognitive and visuo-motor assets and liabilities, a personality description and some predictive considerations. In the analysis the agreement between these early reports and the follow-up data were studied.
RESULTS School In evaluating t h e data concerning the subjects’ schooling, as well as their later vocational training and employment, it should be remembered that the
219
Table 2. Type of school last attended N Secondary or grammar school Primary school School for physically handicapped School for mentally handicapped Total
%
IQ range
14 190
36 49
105-139 7b122
4
10
97-106
2
5
77-83
39
100
One or two of the children from this group may later continue in grammar school.
large majority had normal mental abilities. According to the results from the Binet intelligence test at the first appraisal, only 5 of the 39 patients were retarded, functioning in the 75-90 IQ range (cf. Table I). Table 2 shows the distribution of patients by the type of school last attended. It will be seen that a large proportion (85 %) attended normal schools, and that as much as 36% went to secondary or grammar school. Only one patient left school immediately after the then compulsory seven years; all the others continued schooling on a voluntary basis for one or more years. These rather encouraging results are, of course, partly dependent on the fact that no patient was handicapped to a severe degree, but they probably also reflect the growing interest for the integration of handicapped pupils in the ordinary school system, and for a prolongation of the basic education offered all youngsters. Difficulties in school Nine of the 39 patients (23%) displayed marked problems in school primarily of a cognitive or behavioural nature. This problem-group was, not surprisingly, characterized by including relatively more children of backward intelligence (46%) and more with a disharmonious family background (45 %) than in the material as a whole (13 % and 26 % respectively). The most predominant school problems are summarized in Table 3. General learning difficulties due to slight intellectual retardation were the main problem in more than half of the children. They were all sooner or later transferred to a special class or school, where due regard could be taken to their combined physical/intellectual handicap. Behavioural and Scand. J . Psychol. 16
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H . H . Nielsen
Table 3 . Patients with difficulties in school ( N = 9 ) ~~
Case no.
Diagnosis
Seventy of physical handicap
~
~
~~
IQ
Emotional climate in home
Mild
78
Normal
Mild
82
Normal
Learning difficulties
Yes
Moderate severe Mild
17
Uncertain
Learning difficulties
Yes
78
Disharmonious
Learning difficulties. Introverted and reserved. Reduced hearing Learning difficulties Self-assertiveand dominant. Psychosomatic complaints. Character disorder on ‘‘organic” background
Yes
Right Moderate hemiplegia severe
106
Disharmonious
6M
Modemte severe Mild
111
Disharmonious
101
Disharmonious
25 F
Right hemiplegia Left hemiplegia Left hemiplegia Left hemiplegia Right hemiplegia Paraplegia
27 M 30 M
Paraplegia Paraplegia
8M 12 M 13 F
Problems fcreseen
Behaviour disorder. Passive and negativistic. Defeatist Sensitive, anxious, easily depressed Behaviour disorder. Mental detonation (epilepsy) Learning difficulties
1P
7F
Predominant problems
Mild Mild
83 117
Uncertain Uncertain
Yes No
Yes Yes
Yes No
F=female; M=male. characterological deviations were present in the rest of the cases. Often a disharmonious family background and/or a condition of cerebral dysfunction (epilepsy) was found to be associated with the manifestation of these disturbances (cf. Table 3). As expected, kind and severity of physical handicap did not seem to have any great influence on the course of schooling. A slight overrepresentation of children with a mild handicap in the problem group is in agreement with what was found to be the case with respect to employment, and will be commented on further in that connection. When the follow-up results were compared with the conclusions and predictions from the first psychological appraisal 8-10 years earlier pronounced disagreement with regard to course of schooli n g - a s measured in the present investigation-was found only in 4 cases (10%). Two youngsters had succeeded considerably better than originally expected, rather severe cognitive and behavioural difficulties having been predicted. In one case the encouraging outcome may be ascribed to an unusually sympathetic and constructive family support throughout the years; in the other case the data present no obvious explanation. Two subjects displayed unforeseen and severe emotional and behavioural disturbances (cf. Table 3). One was an asthenic and sensitive boy who Scand. J . Psvchol. 16
came from a rather strenuous family background with growing marital disagreement developing over the years. Information about the other patient’s home environment was rather sparse with no indication, however, of more pronounced psychological and/or socio-economic problems. In his early school years this boy was successfully treated in the department for enuresis and minor behaviour disorders (quick-tempered and aggressive, ambitious with inferiority feelings because of physical handicap). At a control visit one year later, the condition was still so satisfactory that his difficulties were considered to have been temporary and reversible. In late adolescence he had a serious relapse, however, necessitating interruption of grammar school and admittance to a mental hospital where the condition was considered strongly ‘organically’ determined. All in all, school problems of a more serious nature were revealed in only a minority of the cases. If retarded children with learning difficulties are left out of account, no more than 10% were found with marked emotional or adjustment disturbances. Available information about the distribution of personality and behaviour disturbances of a comparable degree among non-handicapped Danish schoolchildren indicate an incidence about 7-10 % (Vedel-Petersen et al.). Thus, the integration of
Follow-up of cerebral palsied patients
22 1
Table 4. Occupation at the time of follow-up
N
Skilled employment or employment requiring some training Unskilled employment Sheltered training or employment Unemployed Under traininga Still at school
5 3 4 4 6 17
Diagnosis
Physical handicap
Hemi- Paraplegia plegia
Mild
2 0 4 1
2 10
3 3 0 3 4 7
2 2 3 3 3 8
Moderate 2 1 0 0
0 6
Moderately severe
IQ
1
102-114 99-122 77- 98 5121 94-1 16 78-139
0 1 1
3 3
range
Teaching college or university. mildly to moderately handicapped children of normal intelligence into the ordinary school system does not seem to present any greater psychological risk for the handicapped pupils. In this connection it should be added that the present data d o not allow of any conclusions as to the probable beneficial effects of integration on the handicapped as well as on the non-handicapped pupils. Training and employment At the time of follow-up, 22 subjects (56% of the total sample) had left school and started further training or sought employment (cf. Table 4). It can be seen from Table 4 that as many as 14 of the 22 subjects were being trained or worked under what can be called competitive conditions: 6 (all females) studied at a teachers’ college or university, 5 had skilled, and 3 unskilled employment. Four patients were in sheltered training or employment: 2 because of a combined physical and mental handicap (mental retardation); one because his impaired sight aggravated the handicapped condition so much that a sheltered workshop was the only employment possibility. Only 4 subjects-all males-were unemployed and 3 of these probably only temporarily: with some vocational training and assistance from the local rehabilitation center they should be able to obtain stable employment and become self-supporting. In the fourth case, employment even under sheltered conditions was estimated as doubtful due to the patient’s severe mental disturbances (mental deterioration, character disorder on ‘organic’ background, epilepsy). The figures in Table 4 give a more optimistic impression of the training and employment possibilities of young cerebral palsied patients than is
usually reported in representative studies (Hansen, 1960; Ingram et al., 1964; OReilly, 1974). Undoubtedly, the reason for this is to be found in the selection of the sample: mentally defective patients were excluded and there were no representatives of the most severely handicapped, e.g. the tetraplegics. A correspondingly positive picture has been found when only patients with relatively mild physical handicaps and average intelligence have been considered (Ingram et al., 1964; Kohmann & Skogrand, 1964). Thus, Ingram et al. report that approximately 92 % of their mildly physically handicapped patients with IQ>90 were in open or niche employment (in ‘niche’ employment, certain allowances are made for the worker’s handicap). In the present study 77% of the patients who had left school were estimated to have potentialities to obtain and remain in open employment. Training and employment difJiculties Most of the subjects appeared reasonably satisfied with their training and employment situation. About one-third did, however, experience rather severe problems either because of physical weakness and slowness or mainly for psychological reasons (character disturbances, mental retardation etc.) (cf. Table 5). The most conspicuous features of this ‘problem group’ are that it includes only 1) males who all except one were just 2) mildly handicapped. The females appeared generally more content with and successful in their jobs. This may, among other things, be related to a generally lower level of aspiration with regard to employment and salary among females than among males who to a higher degree are expected to be able to support a family. Contrary to predictions the relatively most handScand. J. Psychol. 16
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H . H . Nielsen
Table 5. Patients with employment difJiculties ( N = 7 ) Case no. 12M
15M 18M
Seventy
of physical
Diagnosis
handicap
Left Mild hemiplegia Mild Right hemiplegia Left Mild hemiplegia
26M 29 M 31 M
Paraplegia Paraplegia Paraplegia
Mild Mild Moderate
34M
Paraplegia
Mild
IQ
Emotional climate in home
82
Normal
98
Normal
96
Normal
121 110
122
99
Normal Uncertain Disharmonious Dish?monious
icapped were not represented in the problem group. Many of these were females who were undergoing or who had completed further training. In spite of their greater physical handicap they did not experience nearly so serious difficulties as did some of the less handicapped males who were engaged in the labour market. It seems reasonable to assume, as indicated by the clients’ description, that the former milieu comprising teaching colleges, business schools or universities offer a less stressful and competitive environment than manufacturing industries and the like. Some of the young, mildly handicapped men ran into trouble when, after having left school and confident of their own nearly normal physical strength and mobility, they applied for jobs on the open labour market without any prior assistance from rehabilitation officers or other professional agencies. To get fired from a job because of physical weakness or slowness could be a hard blow towards a vulnerable, sensitive adolescent’s self-esteem and precarious ego-identity feeling. The frustrating experience of having “aimed beyond my powers”, as expressed by one youngster, was often followed by depressive and selfdenigrating reactions. The impression that a mild physical handicap may be associated with personal and professional difficulties at least as frequently as a more severe handicap is based on a very limited number of subjects. The same tendency did, however, appear in the school analysis, where a slight overweight of mild cases were found in the problem group (cf. p. 220). In an earlier study (Nielsen, 1966) it was pointed Scand. J . Psychol. 16
Present employment Sheltered employment Sheltered employment Unemployed, invatidity pension Unemployed Unemployed Unskilled labour Unskilled labour
Predominant problems
Problems foreseen
Mental retardation
Yes
Physical handicap and reduced sight Mental detonation, character disorder on “organic” background Physical handicap Physical handicap Unstable and impulsive, -a “drifter” Unstable, defeatist
No No No No
No No
out that a mild handicap may sometimes be felt as a greater mental strain than a severe handicap, because in the latter case the constant comparison and competition with the physically healthy is not so obvious. Degree of physical involvement as such should, however, only be considered as one among several, and perhaps more important, factors influencing the individual course of development. A certain relationship was expected to exist between family background and vocational career in that a relatively higher number of problem cases would come from disharmonious homes. This was not found to be the case. Table 5 indicates that nearly 60%, or a little more than in the group as a whole, had been raised in homes with an emotional climate judged as ‘normal’ or better. The percentage with a disharmonious family background was the same as in the total sample. Thus, no connection could be demonstrated between the emotional climate in a youngster’s home and later employment. In a few cases, to be commented on below, the course of events seemed very much influenced, positively or negatively, by the emotional atmosphere. However, what is important to emphasize here, is that the group tendencies did not indicate an emotional climate in the family, as defined and registered in the present study, to be of any detectable relevance for the course of later training and employment. These findings should be considered in connection with the low agreement found between the results from the original psychological evaluation and the employment data. In Table 5 the column named “Problems foreseen” refers to whether or
Follow-up of cerebral palsied patients
not employment difficulties could be expected on the basis of the original data re-evaluated with this purpose in mind. This estimate was based on a wide range of data, the most important being the child’s cognitive and emotional development and his family background, whereas degree of physical handicap was not assigned any special significance. As in other instances throughout this study, only rather severe indications of malfunctioning-intellectually, emotionally or in the family-led to expectations of later problems. Table 5 shows that only one of the 7 actual ‘problem’ cases could be foreseen: a 20-year-old male client who before he acquired sheltered employment was dismissed from several unskilled jobs which he could not master primarily because of mental retardation. The 6 remaining cases with employment difficulties were not to be foreseen. Three mildly handicapped youngsters with normal mental abilities shared frustrating experiences from the labour market where they had all been fired from manual jobs because of physical inferiority. In 3 other cases the problems seemed mainly associated with characterological disorders which had developed since the time of the original examination, or to be more cautious, were not observable at that time. One youngster began to deteriorate intellectually and characterologically quite seriously at puberty. He was admitted several times to psychiatric hospitals where his deviating and asocial behaviour was ascribed to a strong ‘organic’, epileptic involvement. The last 2 clients listed in Table 5 were two unstable and frequently unemployed workers who went from job to job of a kind which was often below their capabilities. When they were seen as children they both appeared relatively unproblematic and mentally so well integrated that their acknowledged disharmonious family backgrounds were not evaluated as any serious threat to a later professional career. However, in following very closely the social behaviour patterns and employment careers of their parents, they turned out to become two of the ‘exceptional cases’ where family background appeared to have a decisive influence on adult vocational life. To complete the picture of the relationship between ‘predictions’ based on childhood information and the vocational follow-up data, there were 3 cases where employment difficulties were expected
223
incorrectly. It may be more than a coincidence that these 3 clients were all females. As children they
displayed rather pronounced behaviour and personality disorders of a self-assertive and aggressive kind which produced frequent complaints from parents and school authorities. At follow-up, however, they surprised pleasantly by being welladjusted and contented young females with steady, semi-skilled occupations. All in all, the agreement between the expectations based on the original psychological reports and the follow-up data on vocational career turned out to be low. Of the 22 cases in training or employment only 13 were correctly ‘predicted’ whereas 9 (41 %) were expected incorrectly either to have no marked vocational problems (6 cases) or to experience difficulties (3 cases). In the school analysis, marked disagreement between the early ‘predictions’ and the follow-up results were found in only 10% of the cases-compared with 41% in analysis of employment. It is tempting to speculate as to possible reasons for this discrepancy. The most obvious explanation seems to be that the data from the first childhood evaluation, with its cognitive tests and personality descriptions, relate psychologically much more meaningfully to the scholastic behaviour of the adolescent than to the young adult’s vocational competence. The school system forms a relatively more homogeneous milieu than the employment market, and consequently, it may be somewhat easier to define the psychological qualities required to manage there without too serious difficulties. Another factor which should be taken into account is that the individual level of psychological functioning is probably more liable to changes around the time the adolescent or young adult leaves school and starts further training or applies for a job than while he is still attending school. DISCUSSION The findings of the present study should be considered in the light of the following methodological weaknesses: 1) the number of subjects was small and representative of only non-oligophrenic spastic patients. Consequently, nothing can be inferred about severely mentally and physically handicapped cerebral palsied patients. 2) The control group of non-handicapped and non-braindamaged children from the original study was not re-evaluated at Scand. J . Psychol. 16
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follow-up, implying a weaker basis for inferences about the psychological effects of the handicapping condition as such. 3) The data were collected and evaluated by the author solely, leaving room for subjective interpretations and experimenter biased classifications. The small number of subjects making it possible for one person to carry out both the original and the follow-up investigation do, however, also imply certain advantages as in similar intensive studies. Already from the first contact a personal relationship was established between the child and his family and the author, a significant factor, probably, for the high percentage of follow-up attendance (95 %). It is likely that this personal acquaintance made it somewhat easier for the patients and for their parents to volunteer information, and it certainly supplied the author with a broader and a more vaned psychological insight into the individual developmental process.
REFERENCES Hansen, E. (1960). Cerebral palsy in Denmark. Copenhagen: Munksgaard. Ingram, T. T. S.,Jameson, S.,Errington, J. & Mitchell, R. G. (1964). Living with cerebral palsy. Clinics in Develop. Med. 14, 1-106. Kohmann, R. & Skogrand, A. (1964). Den norske cerebral pareseungdoms problemer med hensyn ti1 yrke. In B. Andersen (Ed .) Vitenskapelige arbeiderfra Sentralinstitutfet for Cerebral Parese. Oslo: Sentralinstituttet for Cerebral Parese. Nielsen, H. H . (1%). A psychological study ofcerebral palsied children. Copenhagen: Munksgaard. O’Reilly, D. E . (1974). The adult with cerebral palsy. Develop. Med. Child Neurol. (Cerebr. Palsy Bull.) 16, 707. Vedel-Petersen, J., From, A., L m e , T. & Pedersen, J. M. (1968). B0rns opvzkstvilkcir. The Danish National Institute of Social Research. Publikation 34. Copenhagen: Teknisk Forlag. Postal address: H. H. Nielsen Institute of Psychology University of Aarhus 4 Asylvej DK-8240 Risskov Denmark
Scand. J . Psychol. I6
A follow-up study of young cerebral palsied patients Some psychological, educational and vocational aspects HELLE H. NIELSEN
Abstract.-In a follow-up study of 39 non-oligophrenic spastic adolescents and young adults it was found that 85 % attended normal schools, the rest went to schools for physically or mentally handicapped. If retarded children with learning difficulties were left out of account, there were no more than 10% regular problem cases, an incidence which is very close to what is found among ordinary, non-handicapped Danish school children.-With regard to vocational career, nearly 80 % were estimated to be able to obtain and remain in open employment. About one third had experienced rather pronounced vocational problems either because of physical weakness and slowness, or because of personality disturbances or intellectual retardation. Females appeared generally more content with and successful in their jobs than the males. There was an overrepresentation of clients with a mild physical handicap in the problem group, indicating that it may be difficult to occupy such a “marginal” position with its easy access to comparison and competition with the socalled normal standards.-A close relationship was found between the data from the original psychological evaluation and the course of schooling. In contrast, there was a low agreement between the childhood reports and the follow-up employment data.
This report is based on a re-evaluation of a group of young cerebral palsied patients all of whom had been psychologically appraised 8-10 years previously. The investigation was intended to illuminate some psychological aspects in the clients’ development from childhood to young adulthood as well as their present situation, especially with regard to general mental health, educational attainment and employability. IR this way a check could also be made on the predictive value of the first psychological appraisal. A follow-up study of cerebral palsied patients with these objectives in mind has not been found in the literature. Previous studies have been focused either on the special-mostly medical-problems of the cerebral palsied child or on the adult patient. The developmental approach adopted here makes it possible to bridge this artifical distinction between ages.
University of Aarhus, Denmark
METHOD
Subjects In the early ’sixties the author made an intensive psychological study of 40 non-oligophrenic spastic children aged 4-15 years and a control group of non-handicapped children matched for age, IQ, sex and socio-economic background (Nielsen, 1966). In this study an analysis was made of some cognitive and visuo-motor functions together with an investigation of personality characteristics. ~ ~ observations were made Of background and school record. The main conclusion was that a significantly greater number of patients displayed signs of visuo~motordisturbance, learning deficiency and personality disorder than was group. found in the matched The patients were selected among approximately 400 cerebral palsied children who were under treatment in the out-patients’ clinic for handicapped children in the University Hospital of Copenhagen (Rigshospitalet). The criteria for selection were: a chronological age range from 6 to 15 years; a Binet IQ of at least 75; a positive medical diagnosis of spastic hemiplegia or spastic paraplegia-half in each category. (Motivation for these criteria of selection can be found in Nielsen, 1966.) With respect to sex, residence (country or town) and degree of motor handicap the patients were distributed at random. The motor handicap vaned considerably, from a slight motor affection causing no real discomfort to a moderately severe handicap which resulted in great movement difficulties. None of the children were completely helpless, however. One child had a slight hearing impairment, another a slight impairment of vision. Ten of the 20 hemiplegics had an additional diagnosis of epilepsy; none of the paraplegics suffered from convulsive attacks. With regard to socio-economic background the Scand. J . Psychol. 16
~
218
H . H . Nielsen
Table 1. Total sample by diagnosis, severity of handicap, age, IQ and emotional climate in the home (N=39)
Original assessment Diagnosis Hemiplegia Paraplegia Seventy of handicap Mild Moderate Moderately severe
IQ75-89 %110 >110 At fdlow-up Age 14-16 17-19 20-23 Emotional climate in the ome Disharmonious Normal Uncertain
N
%
1Y 20
49 51
21 9 9
54 23 23
5 18
46
16
41
15 10 14
38 26 36
10 17 12
26 44 30
13
Right hemiplegia: N=13. Left hemiplegia: N = 6 .
large majority came from a middle-class milieu, a few from the lower-middle class. The group was not a representative selection of the cerebral palsied population in general. Mentally defective patients were excluded, and there were no representatives of the most severely motorhandicapped patients, who in most cases would be spastic tetraplegics, where all four extremities are affected. The group could be considered to represent only non-oligophrenic, spastic patients with hemiplegia or paraplegia. When the follow-up study was planned 8 years after the original appraisal, a young female patient had died from brain tumour; the remaining 39 of the 40 patients constitute the subjects of the present investigation (cf. Table 1). Unfortunately, there was no possibility of re-evaluating the normal control subjects. Procedures The follow-up data were collected from several sources: through interviews with 95% of the patients, through interviews with parents and teachers, from school and hospital records and from rehabilitation centres. At the first contact with the subjects the purpose with the interview was briefly explained and an offer was made Scond. J . Psychol. 16
to repay transport expenses as well as possible lost earnings in connection with the m e e t i n g . M w cases it had to be emphasised that no tests would be given, either in response to a direct question or because the subjects’ whole attitude showed that such a promise was indicated. About one-third of the patient-group was so young that they were still in treatment at the University Clinic’s outpatients’ clinic for handicapped children (upper age limit about 18 years). These youngsters were contacted in connection with one of their regular visits to the clinic and their cooperation was easily acquired. The remainder were contacted either by phone or by mail; in a few cases it was necessary to make two or three inquiries before cooperation was finally established. In only two cases did the client interview have to be abandoned because no answer was received after several applications. For these 2 patients ample information was available from school and hospital records and from rehabilitation centres. The interview took place at the hospital and usually lasted about 2 hours. It was of an open-ended, semistructured nature, focusing on the following areas: course of schooling, vocational training and education, employment, hobbies, physical handicap, relationship to parents and siblings, to friends and to the opposite sex. Weight was laid on an illumination of any dimculties and problems experienced throughout the years within the different areas, as well as upon information about the present life situation. In the case of patients younger than 18 years the data were supplemented with an interview with one of or both parents. Finally, additional data were gathered from the hospital records. In a few, more complicated cases where the cooperation of the patient and his parents was not entirely satisfactory, teachers and rehabilitation officers assisted in furnishing additional information. Besides obtaining pure factual information such as length of schooling, kind of job, etc., stress was laid on acquiring an impression of the general mental health status of the subjects. This had to be done without the help of projective techniques, as it had been decided already in the planning phases not to depend on tests. It was-rightly-anticipated that some hesitant and reluctant subjects could be persuaded to cooperate when they were assured that no test would be administered. Thus the evaluation of mental health was based on the clinical impression acquired during the interview supplemented with data from appropriate outside sources such as school and hospital records.
Analysis A vast amount of material was accumulated in this way; long and detailed life histories which did not easily lend themselves to quantitative analyses. Thus, a qualitative approach was used extensively. The data to be reported on here were treated within two main categories, the first covering schooling, and the second, employment. On the basis of all available material (interviews, records, etc.) the subjects were classified into one of the following groups: marked problems, no (marked) problems, and uncertain (in case of incomplete information). In order to reduce as much as possible the
Follow-up of cerebral palsied patients effects of experimenter bias, great stress was laid on the subject’s openly expressed feelings about and evaluation of his situation, minimizing clinical interpretation. A classification in opposition to a subject’s own statement was only made in a few cases of unmistakable neurotic denial and repression of problems. In these, as in all other cases, factual, controllable information about the c l i e n t s f m m schools, employment agencies, and hospitals-were used to check the classification. Only ‘marked’ and prolonged emotional, cognitive andlor vocational difficulties resulted in a classification in one of the problem groups. Clients with minor and possibly temporary difficulties, which did not indicate any need for professional intervention, were registered in the nonproblem group together with well-adjusted and mentally healthy subjects. The follow-up results were seen in relation to 1) kind and degree of cerebral palsy, 2) emotional climate in the youngster’s home, and 3) the conclusions from the first psychological appraisal. Kind and degree of cerebral palsy had been diagnosed by a neuro-pediatrician, and this classification was used in the analysis of the correlation between certain physical factors and the follow-up results. Emotional climate in the home was evaluated in the original study and reconsidered at the follow-up. Three broad categories were used: disharmonious home, normal (to harmonious) home, and uncertain. In accordance with the procedure employed throughout the study only pronounced and conspicuous interpersonal problems in the patient’s family led to registration in the ‘disharmonious home’ category. The so-called ‘normal’ category comprised a rather wide range of different family backgrounds: from mentally healthy and harmonious families to homes with minor and possibly transient psychological difficulties. The ‘uncertain’ group included families about which the information was felt to be too sparse or too inconsistent to justify classification. To this category were also referred a few cases where the emotional climate in the home had changed quite considerably, for better or for worse, since the original evaluation. Finally, follow-up results were compared with the original psychological description. This description was based on the total impression gained of the child by the help of cognitive and projective tests, observation, interviews with the parents as well as information from the professional staff in kindergarten, school and hospital (cf. Nielsen, 1%). It included an account of the general level of intellectual functioning, of cognitive and visuo-motor assets and liabilities, a personality description and some predictive considerations. In the analysis the agreement between these early reports and the follow-up data were studied.
RESULTS School In evaluating t h e data concerning the subjects’ schooling, as well as their later vocational training and employment, it should be remembered that the
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Table 2. Type of school last attended N Secondary or grammar school Primary school School for physically handicapped School for mentally handicapped Total
%
IQ range
14 190
36 49
105-139 7b122
4
10
97-106
2
5
77-83
39
100
One or two of the children from this group may later continue in grammar school.
large majority had normal mental abilities. According to the results from the Binet intelligence test at the first appraisal, only 5 of the 39 patients were retarded, functioning in the 75-90 IQ range (cf. Table I). Table 2 shows the distribution of patients by the type of school last attended. It will be seen that a large proportion (85 %) attended normal schools, and that as much as 36% went to secondary or grammar school. Only one patient left school immediately after the then compulsory seven years; all the others continued schooling on a voluntary basis for one or more years. These rather encouraging results are, of course, partly dependent on the fact that no patient was handicapped to a severe degree, but they probably also reflect the growing interest for the integration of handicapped pupils in the ordinary school system, and for a prolongation of the basic education offered all youngsters. Difficulties in school Nine of the 39 patients (23%) displayed marked problems in school primarily of a cognitive or behavioural nature. This problem-group was, not surprisingly, characterized by including relatively more children of backward intelligence (46%) and more with a disharmonious family background (45 %) than in the material as a whole (13 % and 26 % respectively). The most predominant school problems are summarized in Table 3. General learning difficulties due to slight intellectual retardation were the main problem in more than half of the children. They were all sooner or later transferred to a special class or school, where due regard could be taken to their combined physical/intellectual handicap. Behavioural and Scand. J . Psychol. 16
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H . H . Nielsen
Table 3 . Patients with difficulties in school ( N = 9 ) ~~
Case no.
Diagnosis
Seventy of physical handicap
~
~
~~
IQ
Emotional climate in home
Mild
78
Normal
Mild
82
Normal
Learning difficulties
Yes
Moderate severe Mild
17
Uncertain
Learning difficulties
Yes
78
Disharmonious
Learning difficulties. Introverted and reserved. Reduced hearing Learning difficulties Self-assertiveand dominant. Psychosomatic complaints. Character disorder on ‘‘organic” background
Yes
Right Moderate hemiplegia severe
106
Disharmonious
6M
Modemte severe Mild
111
Disharmonious
101
Disharmonious
25 F
Right hemiplegia Left hemiplegia Left hemiplegia Left hemiplegia Right hemiplegia Paraplegia
27 M 30 M
Paraplegia Paraplegia
8M 12 M 13 F
Problems fcreseen
Behaviour disorder. Passive and negativistic. Defeatist Sensitive, anxious, easily depressed Behaviour disorder. Mental detonation (epilepsy) Learning difficulties
1P
7F
Predominant problems
Mild Mild
83 117
Uncertain Uncertain
Yes No
Yes Yes
Yes No
F=female; M=male. characterological deviations were present in the rest of the cases. Often a disharmonious family background and/or a condition of cerebral dysfunction (epilepsy) was found to be associated with the manifestation of these disturbances (cf. Table 3). As expected, kind and severity of physical handicap did not seem to have any great influence on the course of schooling. A slight overrepresentation of children with a mild handicap in the problem group is in agreement with what was found to be the case with respect to employment, and will be commented on further in that connection. When the follow-up results were compared with the conclusions and predictions from the first psychological appraisal 8-10 years earlier pronounced disagreement with regard to course of schooli n g - a s measured in the present investigation-was found only in 4 cases (10%). Two youngsters had succeeded considerably better than originally expected, rather severe cognitive and behavioural difficulties having been predicted. In one case the encouraging outcome may be ascribed to an unusually sympathetic and constructive family support throughout the years; in the other case the data present no obvious explanation. Two subjects displayed unforeseen and severe emotional and behavioural disturbances (cf. Table 3). One was an asthenic and sensitive boy who Scand. J . Psvchol. 16
came from a rather strenuous family background with growing marital disagreement developing over the years. Information about the other patient’s home environment was rather sparse with no indication, however, of more pronounced psychological and/or socio-economic problems. In his early school years this boy was successfully treated in the department for enuresis and minor behaviour disorders (quick-tempered and aggressive, ambitious with inferiority feelings because of physical handicap). At a control visit one year later, the condition was still so satisfactory that his difficulties were considered to have been temporary and reversible. In late adolescence he had a serious relapse, however, necessitating interruption of grammar school and admittance to a mental hospital where the condition was considered strongly ‘organically’ determined. All in all, school problems of a more serious nature were revealed in only a minority of the cases. If retarded children with learning difficulties are left out of account, no more than 10% were found with marked emotional or adjustment disturbances. Available information about the distribution of personality and behaviour disturbances of a comparable degree among non-handicapped Danish schoolchildren indicate an incidence about 7-10 % (Vedel-Petersen et al.). Thus, the integration of
Follow-up of cerebral palsied patients
22 1
Table 4. Occupation at the time of follow-up
N
Skilled employment or employment requiring some training Unskilled employment Sheltered training or employment Unemployed Under traininga Still at school
5 3 4 4 6 17
Diagnosis
Physical handicap
Hemi- Paraplegia plegia
Mild
2 0 4 1
2 10
3 3 0 3 4 7
2 2 3 3 3 8
Moderate 2 1 0 0
0 6
Moderately severe
IQ
1
102-114 99-122 77- 98 5121 94-1 16 78-139
0 1 1
3 3
range
Teaching college or university. mildly to moderately handicapped children of normal intelligence into the ordinary school system does not seem to present any greater psychological risk for the handicapped pupils. In this connection it should be added that the present data d o not allow of any conclusions as to the probable beneficial effects of integration on the handicapped as well as on the non-handicapped pupils. Training and employment At the time of follow-up, 22 subjects (56% of the total sample) had left school and started further training or sought employment (cf. Table 4). It can be seen from Table 4 that as many as 14 of the 22 subjects were being trained or worked under what can be called competitive conditions: 6 (all females) studied at a teachers’ college or university, 5 had skilled, and 3 unskilled employment. Four patients were in sheltered training or employment: 2 because of a combined physical and mental handicap (mental retardation); one because his impaired sight aggravated the handicapped condition so much that a sheltered workshop was the only employment possibility. Only 4 subjects-all males-were unemployed and 3 of these probably only temporarily: with some vocational training and assistance from the local rehabilitation center they should be able to obtain stable employment and become self-supporting. In the fourth case, employment even under sheltered conditions was estimated as doubtful due to the patient’s severe mental disturbances (mental deterioration, character disorder on ‘organic’ background, epilepsy). The figures in Table 4 give a more optimistic impression of the training and employment possibilities of young cerebral palsied patients than is
usually reported in representative studies (Hansen, 1960; Ingram et al., 1964; OReilly, 1974). Undoubtedly, the reason for this is to be found in the selection of the sample: mentally defective patients were excluded and there were no representatives of the most severely handicapped, e.g. the tetraplegics. A correspondingly positive picture has been found when only patients with relatively mild physical handicaps and average intelligence have been considered (Ingram et al., 1964; Kohmann & Skogrand, 1964). Thus, Ingram et al. report that approximately 92 % of their mildly physically handicapped patients with IQ>90 were in open or niche employment (in ‘niche’ employment, certain allowances are made for the worker’s handicap). In the present study 77% of the patients who had left school were estimated to have potentialities to obtain and remain in open employment. Training and employment difJiculties Most of the subjects appeared reasonably satisfied with their training and employment situation. About one-third did, however, experience rather severe problems either because of physical weakness and slowness or mainly for psychological reasons (character disturbances, mental retardation etc.) (cf. Table 5). The most conspicuous features of this ‘problem group’ are that it includes only 1) males who all except one were just 2) mildly handicapped. The females appeared generally more content with and successful in their jobs. This may, among other things, be related to a generally lower level of aspiration with regard to employment and salary among females than among males who to a higher degree are expected to be able to support a family. Contrary to predictions the relatively most handScand. J. Psychol. 16
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H . H . Nielsen
Table 5. Patients with employment difJiculties ( N = 7 ) Case no. 12M
15M 18M
Seventy
of physical
Diagnosis
handicap
Left Mild hemiplegia Mild Right hemiplegia Left Mild hemiplegia
26M 29 M 31 M
Paraplegia Paraplegia Paraplegia
Mild Mild Moderate
34M
Paraplegia
Mild
IQ
Emotional climate in home
82
Normal
98
Normal
96
Normal
121 110
122
99
Normal Uncertain Disharmonious Dish?monious
icapped were not represented in the problem group. Many of these were females who were undergoing or who had completed further training. In spite of their greater physical handicap they did not experience nearly so serious difficulties as did some of the less handicapped males who were engaged in the labour market. It seems reasonable to assume, as indicated by the clients’ description, that the former milieu comprising teaching colleges, business schools or universities offer a less stressful and competitive environment than manufacturing industries and the like. Some of the young, mildly handicapped men ran into trouble when, after having left school and confident of their own nearly normal physical strength and mobility, they applied for jobs on the open labour market without any prior assistance from rehabilitation officers or other professional agencies. To get fired from a job because of physical weakness or slowness could be a hard blow towards a vulnerable, sensitive adolescent’s self-esteem and precarious ego-identity feeling. The frustrating experience of having “aimed beyond my powers”, as expressed by one youngster, was often followed by depressive and selfdenigrating reactions. The impression that a mild physical handicap may be associated with personal and professional difficulties at least as frequently as a more severe handicap is based on a very limited number of subjects. The same tendency did, however, appear in the school analysis, where a slight overweight of mild cases were found in the problem group (cf. p. 220). In an earlier study (Nielsen, 1966) it was pointed Scand. J . Psychol. 16
Present employment Sheltered employment Sheltered employment Unemployed, invatidity pension Unemployed Unemployed Unskilled labour Unskilled labour
Predominant problems
Problems foreseen
Mental retardation
Yes
Physical handicap and reduced sight Mental detonation, character disorder on “organic” background Physical handicap Physical handicap Unstable and impulsive, -a “drifter” Unstable, defeatist
No No No No
No No
out that a mild handicap may sometimes be felt as a greater mental strain than a severe handicap, because in the latter case the constant comparison and competition with the physically healthy is not so obvious. Degree of physical involvement as such should, however, only be considered as one among several, and perhaps more important, factors influencing the individual course of development. A certain relationship was expected to exist between family background and vocational career in that a relatively higher number of problem cases would come from disharmonious homes. This was not found to be the case. Table 5 indicates that nearly 60%, or a little more than in the group as a whole, had been raised in homes with an emotional climate judged as ‘normal’ or better. The percentage with a disharmonious family background was the same as in the total sample. Thus, no connection could be demonstrated between the emotional climate in a youngster’s home and later employment. In a few cases, to be commented on below, the course of events seemed very much influenced, positively or negatively, by the emotional atmosphere. However, what is important to emphasize here, is that the group tendencies did not indicate an emotional climate in the family, as defined and registered in the present study, to be of any detectable relevance for the course of later training and employment. These findings should be considered in connection with the low agreement found between the results from the original psychological evaluation and the employment data. In Table 5 the column named “Problems foreseen” refers to whether or
Follow-up of cerebral palsied patients
not employment difficulties could be expected on the basis of the original data re-evaluated with this purpose in mind. This estimate was based on a wide range of data, the most important being the child’s cognitive and emotional development and his family background, whereas degree of physical handicap was not assigned any special significance. As in other instances throughout this study, only rather severe indications of malfunctioning-intellectually, emotionally or in the family-led to expectations of later problems. Table 5 shows that only one of the 7 actual ‘problem’ cases could be foreseen: a 20-year-old male client who before he acquired sheltered employment was dismissed from several unskilled jobs which he could not master primarily because of mental retardation. The 6 remaining cases with employment difficulties were not to be foreseen. Three mildly handicapped youngsters with normal mental abilities shared frustrating experiences from the labour market where they had all been fired from manual jobs because of physical inferiority. In 3 other cases the problems seemed mainly associated with characterological disorders which had developed since the time of the original examination, or to be more cautious, were not observable at that time. One youngster began to deteriorate intellectually and characterologically quite seriously at puberty. He was admitted several times to psychiatric hospitals where his deviating and asocial behaviour was ascribed to a strong ‘organic’, epileptic involvement. The last 2 clients listed in Table 5 were two unstable and frequently unemployed workers who went from job to job of a kind which was often below their capabilities. When they were seen as children they both appeared relatively unproblematic and mentally so well integrated that their acknowledged disharmonious family backgrounds were not evaluated as any serious threat to a later professional career. However, in following very closely the social behaviour patterns and employment careers of their parents, they turned out to become two of the ‘exceptional cases’ where family background appeared to have a decisive influence on adult vocational life. To complete the picture of the relationship between ‘predictions’ based on childhood information and the vocational follow-up data, there were 3 cases where employment difficulties were expected
223
incorrectly. It may be more than a coincidence that these 3 clients were all females. As children they
displayed rather pronounced behaviour and personality disorders of a self-assertive and aggressive kind which produced frequent complaints from parents and school authorities. At follow-up, however, they surprised pleasantly by being welladjusted and contented young females with steady, semi-skilled occupations. All in all, the agreement between the expectations based on the original psychological reports and the follow-up data on vocational career turned out to be low. Of the 22 cases in training or employment only 13 were correctly ‘predicted’ whereas 9 (41 %) were expected incorrectly either to have no marked vocational problems (6 cases) or to experience difficulties (3 cases). In the school analysis, marked disagreement between the early ‘predictions’ and the follow-up results were found in only 10% of the cases-compared with 41% in analysis of employment. It is tempting to speculate as to possible reasons for this discrepancy. The most obvious explanation seems to be that the data from the first childhood evaluation, with its cognitive tests and personality descriptions, relate psychologically much more meaningfully to the scholastic behaviour of the adolescent than to the young adult’s vocational competence. The school system forms a relatively more homogeneous milieu than the employment market, and consequently, it may be somewhat easier to define the psychological qualities required to manage there without too serious difficulties. Another factor which should be taken into account is that the individual level of psychological functioning is probably more liable to changes around the time the adolescent or young adult leaves school and starts further training or applies for a job than while he is still attending school. DISCUSSION The findings of the present study should be considered in the light of the following methodological weaknesses: 1) the number of subjects was small and representative of only non-oligophrenic spastic patients. Consequently, nothing can be inferred about severely mentally and physically handicapped cerebral palsied patients. 2) The control group of non-handicapped and non-braindamaged children from the original study was not re-evaluated at Scand. J . Psychol. 16
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follow-up, implying a weaker basis for inferences about the psychological effects of the handicapping condition as such. 3) The data were collected and evaluated by the author solely, leaving room for subjective interpretations and experimenter biased classifications. The small number of subjects making it possible for one person to carry out both the original and the follow-up investigation do, however, also imply certain advantages as in similar intensive studies. Already from the first contact a personal relationship was established between the child and his family and the author, a significant factor, probably, for the high percentage of follow-up attendance (95 %). It is likely that this personal acquaintance made it somewhat easier for the patients and for their parents to volunteer information, and it certainly supplied the author with a broader and a more vaned psychological insight into the individual developmental process.
REFERENCES Hansen, E. (1960). Cerebral palsy in Denmark. Copenhagen: Munksgaard. Ingram, T. T. S.,Jameson, S.,Errington, J. & Mitchell, R. G. (1964). Living with cerebral palsy. Clinics in Develop. Med. 14, 1-106. Kohmann, R. & Skogrand, A. (1964). Den norske cerebral pareseungdoms problemer med hensyn ti1 yrke. In B. Andersen (Ed .) Vitenskapelige arbeiderfra Sentralinstitutfet for Cerebral Parese. Oslo: Sentralinstituttet for Cerebral Parese. Nielsen, H. H . (1%). A psychological study ofcerebral palsied children. Copenhagen: Munksgaard. O’Reilly, D. E . (1974). The adult with cerebral palsy. Develop. Med. Child Neurol. (Cerebr. Palsy Bull.) 16, 707. Vedel-Petersen, J., From, A., L m e , T. & Pedersen, J. M. (1968). B0rns opvzkstvilkcir. The Danish National Institute of Social Research. Publikation 34. Copenhagen: Teknisk Forlag. Postal address: H. H. Nielsen Institute of Psychology University of Aarhus 4 Asylvej DK-8240 Risskov Denmark
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