Journal o f Autism and Childhood Schizophrenia, Vol. 5, No. 2, 1975
Chiidhood Psychosis The Problem of Differential Diagnosis ~ Anthony Davids ~ Emma Pendleton Bradley Hospital and Brown University
In a study o f 66 former child psychiatric patients, Form E-1 o f Rimland's Diagnostic Check List (DCL) was f o u n d to be an effective instrument f o r differentiating autistic, other psychotic, and nonpsychotic disturbed children. Follow-up study revealed more favorable outcomes in nonpsychotic cases, with significant association between DCL scores and improvement following discharge. Scores indicative o f autism on the DCL were also significantly associated with being o f the Jewish faith. Rimland's (1964) treatise on infantile autism served to stimulate much thought about unsolved problems in the diagnosis of childhood emotional disorders. For years, there has been considerable confusion and ambiguity in the use of diagnostic labels such as autistic, schizophrenic, atypical, and psychotic. In addition to lack of agreement in terms employed in reference to such severely disturbed children, there are conflicting views about etiology, the role of organic and/or psychogenic factors, characteristics of parents of these children, methods of treatment, and prognosis. Rimland has attempted to clarify these matters and stresses the need for empirical research in order to confirm or reject predictions derived from various theoretical formulations. In the appendix of his book, Rimland (1964) presented Form E-1 of a Diagnostic Check List f o r Behavior-Disturbed Children, aimed at facilitating differential diagnosis between the schizophrenic and the autistic child. The main purpose of the present study is to evaluate the effectiveness
'The author gratefully acknowledges the assistance of Susan Lane Markowitz who participated in this research project while an undergraduate honors student in psychology at Brown University. 'Requests for reprints should be sent to Dr. Anthony Davids, Director of Psychology, Emma Pendleton Bradley Hospital, Riverside, Rhode Island 02915. 129 9 P l e n u m P u b l i s h i n g C o r p o r a t i o n , 2 2 7 West 1 7 t h 5treet, N e w Y o r k l N.M. 1 0 0 1 1 . N o part o f t h i s p u b l i c a t i o n m a y be r e p r o d u c e d , stored in a r e t r i e v a l system, o r t r a n s m i t t e d , in a n y f o r m or bY a n y means, e l e c t r o n i c , mechanical, p h o t o c o p y i n g , m i c r o f i l m i n g , r e c o r d i n g , or o t h e r w i s e , w i t h o u t w r i t t e n p e r m i s s i o n o f t h e publisher_
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of this diagnostic check list in differentiating among autistic, nonautistic psychotic, and nonpsychotic cases. This study also attempts to determine relationships between the diagnosis of a case during residential treatment and the follow-up evaluation on that case after discharge. Finally, this study attempts to test Rimland's statement that the percentage of Jewish cases is unusually high among autistic children. METHOD
Instruments Two instruments were used for assessing the behavior of child patients at the time of their admission to Bradley Hospital (a private residential treatment center for emotionally disturbed children) and at the time of the present study. These instruments are Form E-1 of Rimland's (1964) Diagnostic Check List for Behavior-Disturbed Children (DCL) and a followup questionnaire devised at the Bradley Hospital and used originally in a follow-up study by Davids, Ryan, and Salvatore (1968). The DCL consists of a face sheet, on which is recorded certain basic information about the parents ofthe disturbed child, and 76 items to be answered by the parents or informants. The parent is asked to check the appropriate answer among the multiple choices following each question on the inventory. These items cover a wide range of events and experiences undergone by the parents and/or the child from pregnancy through early childhood, including items about the birth experience, appearance and behavior during the neonatal period, feeding, toilet training, physical ailments, accidents and injuries, relations with siblings, responses to parents, motor development and coordination, fears and anxieties, preoccupations, development of language, father's and mother's interests, education, work, and personality characteristics. After the informant has checked the items on the list, two scoring keys are applied to the responses - - one for autism and the other for schizophrenia. The final result is a ratio score designed to reveal whether the child should be viewed as autistic or schizophrenic. As Rimland stated, it will take much work, in treatment centers throughout the country, before the value ofthis diagnostic instrument can be fully assessed. It is hoped that refinements of it will help to unravel many perplexing diagnostic problems that currently exist, and may also lead to greater theoretical understanding that will contribute to improved programs of prevention and treatment of these childhood disorders. 2 2Rimland later made some changes in this instrument and called the revised version Form E-2. More recently, he devised Form E-3, which is designed to obtain supplementary information pertaining to causes of the various forms of childhood psychoses (Rimland, 1974). Form E-1 was used in the present study because it was available at the time this project was initiated, several years ago, and because it is the only form that is accompanied by scoring keys enabling the investigator to score the questionnaire responses without sending them out for computer scoring.
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The follow-up questionnaire consists of 10 questions concerned with the patient's current behavior and the parents' judgment of any comparative improvement or deterioration. The questions are concerned with further psychiatric treatment or institutionalization, education, and general behavior. The aim is to determine how well the children have coped with society after leaving Bradley Hospital and, therefore, the long-term effectiveness of the treatment they received during their hospitalization.
Subjects The following groups of subjects - - ail of whom had been institutionalized for childhood emotional disturbances - - were studied in this research: (I) 21 children who during the 10-year period 1955-1964 were labeled with some form of psychotic diagnosis, such as schizophrenic, autistic, atypical, and so forth; (II) 20 children who were diagnosed as having some form of psychosis, like those in the above-mentioned group, but during the earlier 10-year period from 1945-1954; (III) 20 children who during the 10-year period 1955-1964 were diagnosed as having behavior disorders, such as passive/aggressive personality, without evidence of psychotic symptoms; and (IV) 5 children who during the 10-year period 1955-1964 were diagnosed as neurotic, without evidence of psychotic symptoms. This fourth group was necessarily very small due to the rarity of institutionalization for this type of childhood disorder. Thus there were four groups of children, three of them having been in residence during the period 1955-1964 and the other during 1945-1954. Due to the small number of female patients at Bradley Hospital (particularly in the psychotic groups), only case histories from maie patients were used in these studies. The mean ages of these children, recorded as of the time of admission, were 8 years in Groups I and 1I, 9 years in Group III, and 10 years in Group IV.
Procedure The program of research was divided into four interrelated studies. Our initial approach to research with the Rimland DCL involved working with case records in the Bradley Hospital files. This was a retrospective study employing information in the detailed case records to provide answers for the items on the D C L . In other words, instead of having parents complete the DCL at the time of the child's admission for psychiatric treatment, we attempted to utilize the vast store of data that had accumulated in the Bradley files over the past years in order to discover the ability of the check list to differentiate among types of childhood disorder. For each child
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in the study, the entire case record was read in an attempt to find the answers for items contained in the DCL. After completing these questionnaires for each child, and prior to scoring them, each of the 40 psychotic cases was rated according to the extent o f implication of autism. A four-point diagnostic rating scale was developed, with a score o f four assigned for a definite autistic diagnosis according to Kanner's (1943) criteria. In this category it was necessary for the record to state that the case was an example of infantile autism. A score of three was used for those cases where the word autistic described the general behavior. In these cases autism was not used as an actual final diagnosis. A score of two was used for those cases which were not autistic but were described as displaying autistic thinking or only one or two of the other autistic symptoms. A score of one was used for those cases which were definitely not autistic. In other words, for these cases there was no m e n t i o n of autistic diagnosis behavior or sympt0ms. A score of zero was used for those cases with no mention of any form or sign of psychosis. Ail cases in Groups III and IV received this rating. From this retrospective study, it was possible to (1) obtain normative data o n the DCL, (2) see if these different diagnostic groups actually differed on results obtained from the DCL, and (3) discover positive and negative features of attempting to employ this instrument with data recorded in psychiatric files rather than data obtained from informants at the time of admission. The second study involved mailing the DCL to parents o f the former patients employed in the first study and asking them to complete the items from memory of the facts as they existed at the time of the child's admission to Bradley, which in some cases was many years ago. The data were analyzed to discover similarities and differences between the responses to items obtained from parents and the responses that were obtained from the files in Study I. The third study involved mailing the follow-up instruments to parents of the former patients used in Study I or to the agencies with custody in cases where there was no parent available. The data were analyzed to discover relationships between the child's present behavior, his diagnostic group, and scores on the DCL. In addition, a fourth study was conducted to determine the significance of religious factors in these childhood disorders. In view of previous statements by Kanner (1954) and Rimland (1964), pertaining to the relatively large percentage of Jewish children with autistic case histories, the religions of tbe children in the four groups were tabulated and the percentages compared with normal population expectancies.
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RESULTS
Study I R e s u l t s on the D C L , presented in the f o r m o f the ratio o f autistic scores to schizophrenic scores, are shown in Table I. Scores for G r o u p I range f r o m .94 to 7.50 (.94 shows a slightly greater n u m b e r o f schizophrenic scores, whereas 7.50 is a highly autistic score) with a mean of 2.18 and a variance of 2.09. Scores for G r o u p II range f r o m .65 to 6.60 with a mean o f 2.44 and a variance o f 2.15. A t test between G r o u p I and G r o u p II yields a nonsignificant t of .56. A X2 test also shows no significant difference between Gro.up I and G r o u p II (X~ = .40). Scores for G r o u p III range f r o m .44 to 1.64, with a mean of .95 and a variance o f . 13. The scores o f G r o u p IV range f r o m .86 to 1.45, with a mean of 1.22 and a variance of .06. A t test and a X2 test between G r o u p III and G r o u p IV show no significant difference (t = 1.66; X~ = 1.96). Since the statistical tests revealed no significant differences between Groups I and II and between Groups I I I and IV, the majority o f group comparisons were done on Groups I and II combined versus G r o u p III and IV combined. The t test for Groups I and II versus Groups I I I and IV is significant beyond the .001 level (t = 5.11). The ~~ for Groups I and II versus Groups 111 and IV (X,~ = 10.90) is also significant bevond the .001 level. Comparisons were also m a d e between ratings on the diagnostic rating scale and ratio scores (autism/schizophrenia) on the DCL. Cases with an autistic rating (i.e., rating = 3 or 4) have a mean o f 3.18 on the D C L , and cases with a nonautistic psychotic rating (i.e., rating = 1 or 2) have a mean of 1.58 on the DCL, while cases with a nonpsychotic rating (i.e., rating = 0)
Table I. Ratio Scores (Autism/Schizophrenia) on the Diagnostic Check List for Four Groups of lnstitutionalized Disturbed Children Scores Groups
Mean
Variance
Range
I II III IV I and II III and IV
2.18 2.44 .93 1.22 2.66 .98
2.09 2.15 .13 .06 2.12 .30
.94-7.50 .65-6.60 .44-1.64 .86-1.45 .6~-7.50 .44-1.64
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have a mean of .98 on the DCL. A X2 test of the difference between the autistic group and the nonautistic psychotic group with respect to scores on the DCL. was significant beyond the .001 level (~~ = 12.38). A X2 test of the difference between the nonautistic psychotic group and the nonpsychotic group with respect to scores on the D C L was also significant beyond the .001 level (X8 = 14.11). The p r o d u c t / m o m e n t correlation for ail cases in Groups I and II combined, between the diagnostic rating and the ratio score from the DCL, was significant beyond the .01 level (r = .56). Individual correlations for G r o u p I (r = .52) and for Group II (r = .72) were significant beyond the .02 level and the .01 level, respectively.
Study II For this study, 57 D C L s were mailed to parents (9 cases were referred by state agencies with no access to parents) and 30 were returned completed. O f these, 15 were f r o m G r o u p I, 6 were f r o m G r o u p II, 7 were f r o m G r o u p III, and 2 were f r o m Group IV. The p r o d u c t / m o m e n t correlation between D C L scores as answered f r o m the case history and as answered by the parent was significant beyond the .01 level, (r = .58). Though the groups were small, separate correlations were computed for Groups I and II combined and Groups I I I and IV combined. The correlation for Groups I and II was significant at the .01 level (r = .54), but for Groups I I I and IV the correlation was nonsignificant (r = .20). Differences between scores on the D C L as completed by the parent and completed f r o m the case history are nonsignificant (t = 1.10) for Groups I and II combined and nonsignificant (t = . 18) for Groups III and IV combined.
Study III For this study, 60 follow-up questionnaires were mailed to parents or state agencies (6 cases had not yet been discharged f r o m Bradley Hospital) and 34 were returned. O f these, 18 were f r o m Groups I and II and 16 were f r o m Groups III and IV. Each of the 8 items on the questionnaire was scored in terms of i m p r o v e m e n t shown by the answer (e.g., attending school, not having further treatment, or other conditions). Employing X2 analysis, each item was then tested for association with D C L scores and with type of diagnostic group. A measure of overaU adjustment was also derived for each case on the basis of total points obtained f r o m adding one point for each favorable response on the follow-up questionnaire. With a m a x i m u m possible score of 8, the obtained scores ranged f r o m 0 to 7 with a
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Childhood Psychosis: The Problem of Differential Diagnosis Table II. Relationship between Scores on the Diagnostic Check List and Findings from the Follow-up Evaluation
Diagnostic check list
Follow-up findings No further treatment (36%) Living at home (54%) Attending school (62%) Employed (2%) Good School performance (40%) Good school behavior (32%) Good overall adjustment (30%) Improvement since discharge (64%) Total favorable findings (above median score of 2.5)
Bel0w median (%)
Above median (%)
41 69 82 0 58 50 40 86
29 59 41 6 25 17 20 40
.52 2.53 6.10 a 1.03 2.74 3,00 1.43 6.43 a
65
35
2.94
•
ap < .05. median score of 2.5. These overall improved adjustment scores were also tested for association with sc'ores on the DCL and with the type of diagnostic g r o u p . As shown in Tables II and III, o f 18 X~ tests of association, 6 were found to be significant beyond the .05 level. Relatively low scores on the DCL were significantly associated with attending school and with the parental estimate of improved adjustment since discharge. Significantly more cases from the nonpsychotic diagnostic groups were found at the time of follow-up evaluation to have required no further treatment, to be living Table III. Comparison of Follow-up Findings within Diagnostic Groups Type of diagnosis
Follow-up findings No 9 treatment (36%) Living at home (54%) Attending school (62%) Employed (2%) Good school performance (40%) Good school behavior (32%) Good overall adjustment (30%) Improvement since discharge (64%) Total favorable findings (above median score of 2.5)
ap < .05.
Psychotic (Groups I and II) (%)
Nonpsychotic (Groups III and IV) (%)
•
17 39 44 5 27 18 19 61
56 73 81 0 50 43 43 69
5.81 a 3.92 a 4.86 a .92 1.32 1.72 2.07 .21
35
53
4.25 a
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at home, attending school, and showing a greater degree of overall improvement based on responses to the entire questionnaire. These findings suggest that nonpsychotic, and possibly schizophrenic, children have a greater possibility for improvement after discharge than do the autistic children, The proportion of the total sample of 34 cases showing favorable responses to each item on the follow-up questionnaire ranged from 2~ being employed to 6407o showing improved adjustment since discharge according to parental evaluation.
Study 1V The distribution of religious affiliations, according to the percentages of Jewish, Protestant, and Catholic in each group, is shown in Table IV. For ail groups combined, one-third of these child patients are Jewish, with the largest proportion represented in Group II and the smallest proportion represented in Group III. X2 tests comparing these Bradley Hospital figures with expected frequencies based on national census figures yielded differences significant well beyond the .001 level for the entire sample (X8 = 311.24), for Groups I and II (X,2 = 498.89) and for Groups III and IV IX~ = 99.45). Comparing the percentage of Jews and non-Jews, a X2 test between Groups I and II combined and Groups III and IV combined was nonsignificant (X,~.= 3.22). However, a x 2 test between Groups I and II combined and Group III was significant beyond the .05 level (X~ = 4.27). A X2 test between religious affiliation and scores on the DCL revealed significant association (X,2 = 4.36, p = .05) between high scores on autism and being of the Jewish faith.
Table IV. Distribution of Religious Affiliationsin Groups of Institutionalized Disturbed Children Religion Groups I Il III IV I and II llI and IV Ail four groups Expected on basis o f national census
Jewish (%)
Protestant (%)
Catholic (%)
33 50 15 40 41 20 33
38 25 55 40 32 52 40
29 25 30 20 27 28 27
3
66
26
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DISCUSSION The results of Study I confirm the utility of the DCL as a tool for aiding in the differential diagnosis of children. The significant differences between Groups I and II combined and Groups III and IV combined shows that the DCL is able to distinguish between the diagnostic categories of psychotic and nonpsychotic children, The significant difference in scores on the DCL between the autistic children and the nonautistic psychotic children, as rated on the diagnostic rating scale, supports Rimland's view that finer discriminations can, and should, be made within the present diagnosis of childhood psychosis. Considering Rimland's descriptions of similarities and differences between autistic and schizophrenic children, it seems Iogical that an autistic child should receive a DCL score indicating a great many more autistic responses than schizophrenic responses, whiie a schizophrenic child should have a few more autistic responses than schizophrenic responses. In other words, in view of Rimland's description of schizophrenic children as showing a variety of symptom patterns which usually include a segment of the autistic syndrome, it seems likely that the nonautistic psychotic child should show a number of autistic responses which at the same rime falls far short of the score of the autistic child who exhibits the entire syndrome. It is noteworthy that there is no significant difference between Group I and Group II on the DCL, which implies a certain amount of consistency in the use of the general diagnosis of childhood schizophrenia over the past 25 years. This is an important consideration since there has been considerable controversy during this period as to the correct definition of this diagnosis. The present finding of no significant difference between Groups I and II in either their DCL scores or their ratings on the diagnostic scale suggests that, despite the controversies, the general meaning of the diagnosis childhood schizophrenia has remained relatively unchanged for many years. The results of Study II show a significant correlation between DCLs completed by parents and those completed by the investigators employing the case histories. This provides support for the validity o f the method used in the present retrospective study and indicates that the extensive case histories included the necessary information for complefing the DCLs. In this regard, it is interesting to note that when the cases are categorized into diagnostic groups, the psychotic groups show a significant correlation, whereas the nonpsychotic groups yield a nonsignificant correlation. Two possible explanations could account for this lack of significant correlation in the nonpsychotic groups. The first is a possible difference in the type of parents in the nonpsychotic versus the psychotic groups, with parents of psychotic children tending to keep more careful records of their child's de-
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velopment. A second possible explanation is that the DCL was originally devised specifically for differentiation between infantile autism and childhood schizophrenia; thus it may hOt be as precise an instrument for diagnosing nonpsychotic children. In viewing the results o f Study III, it is noteworthy that although 54~ of the 34 former child patients were living at home instead of institutions and 62% were attending school, only 36% were capable of functioning without further treatment. Moreover, although 640/o were judged by their parents as having shown improved adjustment since discharge, only 40%, 32070, and 30% had shown good academic, behavioral, and overall adjustment, respectively. In other words, while the statistics favor the nonpsychotic and nonautistic child as having a greater chance of improvement, the results for the entire group o f children show only a limited degree of improvement with many of these former child inpatients continuing to function at a far from satisfactory level of social adjustment. Results o f Study IV indicate that a relatively large percentage o f these former patients belong to the Jewish faith. Though it is probable that the national census estimate of 3% Jewish population is an underestimation for the eastern area or New England area of the United States, which would be predominately represented at Bradley Hospital, it is still obvious that the finding of 33% Jewish children in this sample is much greater than chance expectation. At any rate, significant association between this religious category and high scores on the DCL provides some empirical support for Rimland's speculations and hypothesis regarding the nature of infantile autism.
REFERENCES
Davids, A., Ryan, R., & Salvatore, P. Effectivenessof residential treatment for psychoticand other disturbed children. American Journal of Orthopsychiatry, 1968, 38, 469-475. Kanner, L. Autistic disturbances of affective contact. Nervous Child, 1943, 2, 217-250. Kanner, L. To what extent is early infantile autism determinedby constitutional inadequacies? Proceedings of the Association for Research in Nervous and Mental Disease, 1954, 33, 378-385. Rimland, B. Infantile autism. New York: Appleton-Century-Crofts, 1964. Rimland, B. Infantile autism: Status and research. In A. Davids (Ed.), Child personality and psychopathology: Current topics. New York: Wiley-Interscience,1974. Pp. 137-167.
Chiidhood Psychosis The Problem of Differential Diagnosis ~ Anthony Davids ~ Emma Pendleton Bradley Hospital and Brown University
In a study o f 66 former child psychiatric patients, Form E-1 o f Rimland's Diagnostic Check List (DCL) was f o u n d to be an effective instrument f o r differentiating autistic, other psychotic, and nonpsychotic disturbed children. Follow-up study revealed more favorable outcomes in nonpsychotic cases, with significant association between DCL scores and improvement following discharge. Scores indicative o f autism on the DCL were also significantly associated with being o f the Jewish faith. Rimland's (1964) treatise on infantile autism served to stimulate much thought about unsolved problems in the diagnosis of childhood emotional disorders. For years, there has been considerable confusion and ambiguity in the use of diagnostic labels such as autistic, schizophrenic, atypical, and psychotic. In addition to lack of agreement in terms employed in reference to such severely disturbed children, there are conflicting views about etiology, the role of organic and/or psychogenic factors, characteristics of parents of these children, methods of treatment, and prognosis. Rimland has attempted to clarify these matters and stresses the need for empirical research in order to confirm or reject predictions derived from various theoretical formulations. In the appendix of his book, Rimland (1964) presented Form E-1 of a Diagnostic Check List f o r Behavior-Disturbed Children, aimed at facilitating differential diagnosis between the schizophrenic and the autistic child. The main purpose of the present study is to evaluate the effectiveness
'The author gratefully acknowledges the assistance of Susan Lane Markowitz who participated in this research project while an undergraduate honors student in psychology at Brown University. 'Requests for reprints should be sent to Dr. Anthony Davids, Director of Psychology, Emma Pendleton Bradley Hospital, Riverside, Rhode Island 02915. 129 9 P l e n u m P u b l i s h i n g C o r p o r a t i o n , 2 2 7 West 1 7 t h 5treet, N e w Y o r k l N.M. 1 0 0 1 1 . N o part o f t h i s p u b l i c a t i o n m a y be r e p r o d u c e d , stored in a r e t r i e v a l system, o r t r a n s m i t t e d , in a n y f o r m or bY a n y means, e l e c t r o n i c , mechanical, p h o t o c o p y i n g , m i c r o f i l m i n g , r e c o r d i n g , or o t h e r w i s e , w i t h o u t w r i t t e n p e r m i s s i o n o f t h e publisher_
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of this diagnostic check list in differentiating among autistic, nonautistic psychotic, and nonpsychotic cases. This study also attempts to determine relationships between the diagnosis of a case during residential treatment and the follow-up evaluation on that case after discharge. Finally, this study attempts to test Rimland's statement that the percentage of Jewish cases is unusually high among autistic children. METHOD
Instruments Two instruments were used for assessing the behavior of child patients at the time of their admission to Bradley Hospital (a private residential treatment center for emotionally disturbed children) and at the time of the present study. These instruments are Form E-1 of Rimland's (1964) Diagnostic Check List for Behavior-Disturbed Children (DCL) and a followup questionnaire devised at the Bradley Hospital and used originally in a follow-up study by Davids, Ryan, and Salvatore (1968). The DCL consists of a face sheet, on which is recorded certain basic information about the parents ofthe disturbed child, and 76 items to be answered by the parents or informants. The parent is asked to check the appropriate answer among the multiple choices following each question on the inventory. These items cover a wide range of events and experiences undergone by the parents and/or the child from pregnancy through early childhood, including items about the birth experience, appearance and behavior during the neonatal period, feeding, toilet training, physical ailments, accidents and injuries, relations with siblings, responses to parents, motor development and coordination, fears and anxieties, preoccupations, development of language, father's and mother's interests, education, work, and personality characteristics. After the informant has checked the items on the list, two scoring keys are applied to the responses - - one for autism and the other for schizophrenia. The final result is a ratio score designed to reveal whether the child should be viewed as autistic or schizophrenic. As Rimland stated, it will take much work, in treatment centers throughout the country, before the value ofthis diagnostic instrument can be fully assessed. It is hoped that refinements of it will help to unravel many perplexing diagnostic problems that currently exist, and may also lead to greater theoretical understanding that will contribute to improved programs of prevention and treatment of these childhood disorders. 2 2Rimland later made some changes in this instrument and called the revised version Form E-2. More recently, he devised Form E-3, which is designed to obtain supplementary information pertaining to causes of the various forms of childhood psychoses (Rimland, 1974). Form E-1 was used in the present study because it was available at the time this project was initiated, several years ago, and because it is the only form that is accompanied by scoring keys enabling the investigator to score the questionnaire responses without sending them out for computer scoring.
Childhood Psychosis: The Problem of Differential Diagnosis
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The follow-up questionnaire consists of 10 questions concerned with the patient's current behavior and the parents' judgment of any comparative improvement or deterioration. The questions are concerned with further psychiatric treatment or institutionalization, education, and general behavior. The aim is to determine how well the children have coped with society after leaving Bradley Hospital and, therefore, the long-term effectiveness of the treatment they received during their hospitalization.
Subjects The following groups of subjects - - ail of whom had been institutionalized for childhood emotional disturbances - - were studied in this research: (I) 21 children who during the 10-year period 1955-1964 were labeled with some form of psychotic diagnosis, such as schizophrenic, autistic, atypical, and so forth; (II) 20 children who were diagnosed as having some form of psychosis, like those in the above-mentioned group, but during the earlier 10-year period from 1945-1954; (III) 20 children who during the 10-year period 1955-1964 were diagnosed as having behavior disorders, such as passive/aggressive personality, without evidence of psychotic symptoms; and (IV) 5 children who during the 10-year period 1955-1964 were diagnosed as neurotic, without evidence of psychotic symptoms. This fourth group was necessarily very small due to the rarity of institutionalization for this type of childhood disorder. Thus there were four groups of children, three of them having been in residence during the period 1955-1964 and the other during 1945-1954. Due to the small number of female patients at Bradley Hospital (particularly in the psychotic groups), only case histories from maie patients were used in these studies. The mean ages of these children, recorded as of the time of admission, were 8 years in Groups I and 1I, 9 years in Group III, and 10 years in Group IV.
Procedure The program of research was divided into four interrelated studies. Our initial approach to research with the Rimland DCL involved working with case records in the Bradley Hospital files. This was a retrospective study employing information in the detailed case records to provide answers for the items on the D C L . In other words, instead of having parents complete the DCL at the time of the child's admission for psychiatric treatment, we attempted to utilize the vast store of data that had accumulated in the Bradley files over the past years in order to discover the ability of the check list to differentiate among types of childhood disorder. For each child
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in the study, the entire case record was read in an attempt to find the answers for items contained in the DCL. After completing these questionnaires for each child, and prior to scoring them, each of the 40 psychotic cases was rated according to the extent o f implication of autism. A four-point diagnostic rating scale was developed, with a score o f four assigned for a definite autistic diagnosis according to Kanner's (1943) criteria. In this category it was necessary for the record to state that the case was an example of infantile autism. A score of three was used for those cases where the word autistic described the general behavior. In these cases autism was not used as an actual final diagnosis. A score of two was used for those cases which were not autistic but were described as displaying autistic thinking or only one or two of the other autistic symptoms. A score of one was used for those cases which were definitely not autistic. In other words, for these cases there was no m e n t i o n of autistic diagnosis behavior or sympt0ms. A score of zero was used for those cases with no mention of any form or sign of psychosis. Ail cases in Groups III and IV received this rating. From this retrospective study, it was possible to (1) obtain normative data o n the DCL, (2) see if these different diagnostic groups actually differed on results obtained from the DCL, and (3) discover positive and negative features of attempting to employ this instrument with data recorded in psychiatric files rather than data obtained from informants at the time of admission. The second study involved mailing the DCL to parents o f the former patients employed in the first study and asking them to complete the items from memory of the facts as they existed at the time of the child's admission to Bradley, which in some cases was many years ago. The data were analyzed to discover similarities and differences between the responses to items obtained from parents and the responses that were obtained from the files in Study I. The third study involved mailing the follow-up instruments to parents of the former patients used in Study I or to the agencies with custody in cases where there was no parent available. The data were analyzed to discover relationships between the child's present behavior, his diagnostic group, and scores on the DCL. In addition, a fourth study was conducted to determine the significance of religious factors in these childhood disorders. In view of previous statements by Kanner (1954) and Rimland (1964), pertaining to the relatively large percentage of Jewish children with autistic case histories, the religions of tbe children in the four groups were tabulated and the percentages compared with normal population expectancies.
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Childhood Psychosis: The Problem of Differential Diagnosis
RESULTS
Study I R e s u l t s on the D C L , presented in the f o r m o f the ratio o f autistic scores to schizophrenic scores, are shown in Table I. Scores for G r o u p I range f r o m .94 to 7.50 (.94 shows a slightly greater n u m b e r o f schizophrenic scores, whereas 7.50 is a highly autistic score) with a mean of 2.18 and a variance of 2.09. Scores for G r o u p II range f r o m .65 to 6.60 with a mean o f 2.44 and a variance o f 2.15. A t test between G r o u p I and G r o u p II yields a nonsignificant t of .56. A X2 test also shows no significant difference between Gro.up I and G r o u p II (X~ = .40). Scores for G r o u p III range f r o m .44 to 1.64, with a mean of .95 and a variance o f . 13. The scores o f G r o u p IV range f r o m .86 to 1.45, with a mean of 1.22 and a variance of .06. A t test and a X2 test between G r o u p III and G r o u p IV show no significant difference (t = 1.66; X~ = 1.96). Since the statistical tests revealed no significant differences between Groups I and II and between Groups I I I and IV, the majority o f group comparisons were done on Groups I and II combined versus G r o u p III and IV combined. The t test for Groups I and II versus Groups I I I and IV is significant beyond the .001 level (t = 5.11). The ~~ for Groups I and II versus Groups 111 and IV (X,~ = 10.90) is also significant bevond the .001 level. Comparisons were also m a d e between ratings on the diagnostic rating scale and ratio scores (autism/schizophrenia) on the DCL. Cases with an autistic rating (i.e., rating = 3 or 4) have a mean o f 3.18 on the D C L , and cases with a nonautistic psychotic rating (i.e., rating = 1 or 2) have a mean of 1.58 on the DCL, while cases with a nonpsychotic rating (i.e., rating = 0)
Table I. Ratio Scores (Autism/Schizophrenia) on the Diagnostic Check List for Four Groups of lnstitutionalized Disturbed Children Scores Groups
Mean
Variance
Range
I II III IV I and II III and IV
2.18 2.44 .93 1.22 2.66 .98
2.09 2.15 .13 .06 2.12 .30
.94-7.50 .65-6.60 .44-1.64 .86-1.45 .6~-7.50 .44-1.64
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have a mean of .98 on the DCL. A X2 test of the difference between the autistic group and the nonautistic psychotic group with respect to scores on the DCL. was significant beyond the .001 level (~~ = 12.38). A X2 test of the difference between the nonautistic psychotic group and the nonpsychotic group with respect to scores on the D C L was also significant beyond the .001 level (X8 = 14.11). The p r o d u c t / m o m e n t correlation for ail cases in Groups I and II combined, between the diagnostic rating and the ratio score from the DCL, was significant beyond the .01 level (r = .56). Individual correlations for G r o u p I (r = .52) and for Group II (r = .72) were significant beyond the .02 level and the .01 level, respectively.
Study II For this study, 57 D C L s were mailed to parents (9 cases were referred by state agencies with no access to parents) and 30 were returned completed. O f these, 15 were f r o m G r o u p I, 6 were f r o m G r o u p II, 7 were f r o m G r o u p III, and 2 were f r o m Group IV. The p r o d u c t / m o m e n t correlation between D C L scores as answered f r o m the case history and as answered by the parent was significant beyond the .01 level, (r = .58). Though the groups were small, separate correlations were computed for Groups I and II combined and Groups I I I and IV combined. The correlation for Groups I and II was significant at the .01 level (r = .54), but for Groups I I I and IV the correlation was nonsignificant (r = .20). Differences between scores on the D C L as completed by the parent and completed f r o m the case history are nonsignificant (t = 1.10) for Groups I and II combined and nonsignificant (t = . 18) for Groups III and IV combined.
Study III For this study, 60 follow-up questionnaires were mailed to parents or state agencies (6 cases had not yet been discharged f r o m Bradley Hospital) and 34 were returned. O f these, 18 were f r o m Groups I and II and 16 were f r o m Groups III and IV. Each of the 8 items on the questionnaire was scored in terms of i m p r o v e m e n t shown by the answer (e.g., attending school, not having further treatment, or other conditions). Employing X2 analysis, each item was then tested for association with D C L scores and with type of diagnostic group. A measure of overaU adjustment was also derived for each case on the basis of total points obtained f r o m adding one point for each favorable response on the follow-up questionnaire. With a m a x i m u m possible score of 8, the obtained scores ranged f r o m 0 to 7 with a
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Childhood Psychosis: The Problem of Differential Diagnosis Table II. Relationship between Scores on the Diagnostic Check List and Findings from the Follow-up Evaluation
Diagnostic check list
Follow-up findings No further treatment (36%) Living at home (54%) Attending school (62%) Employed (2%) Good School performance (40%) Good school behavior (32%) Good overall adjustment (30%) Improvement since discharge (64%) Total favorable findings (above median score of 2.5)
Bel0w median (%)
Above median (%)
41 69 82 0 58 50 40 86
29 59 41 6 25 17 20 40
.52 2.53 6.10 a 1.03 2.74 3,00 1.43 6.43 a
65
35
2.94
•
ap < .05. median score of 2.5. These overall improved adjustment scores were also tested for association with sc'ores on the DCL and with the type of diagnostic g r o u p . As shown in Tables II and III, o f 18 X~ tests of association, 6 were found to be significant beyond the .05 level. Relatively low scores on the DCL were significantly associated with attending school and with the parental estimate of improved adjustment since discharge. Significantly more cases from the nonpsychotic diagnostic groups were found at the time of follow-up evaluation to have required no further treatment, to be living Table III. Comparison of Follow-up Findings within Diagnostic Groups Type of diagnosis
Follow-up findings No 9 treatment (36%) Living at home (54%) Attending school (62%) Employed (2%) Good school performance (40%) Good school behavior (32%) Good overall adjustment (30%) Improvement since discharge (64%) Total favorable findings (above median score of 2.5)
ap < .05.
Psychotic (Groups I and II) (%)
Nonpsychotic (Groups III and IV) (%)
•
17 39 44 5 27 18 19 61
56 73 81 0 50 43 43 69
5.81 a 3.92 a 4.86 a .92 1.32 1.72 2.07 .21
35
53
4.25 a
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at home, attending school, and showing a greater degree of overall improvement based on responses to the entire questionnaire. These findings suggest that nonpsychotic, and possibly schizophrenic, children have a greater possibility for improvement after discharge than do the autistic children, The proportion of the total sample of 34 cases showing favorable responses to each item on the follow-up questionnaire ranged from 2~ being employed to 6407o showing improved adjustment since discharge according to parental evaluation.
Study 1V The distribution of religious affiliations, according to the percentages of Jewish, Protestant, and Catholic in each group, is shown in Table IV. For ail groups combined, one-third of these child patients are Jewish, with the largest proportion represented in Group II and the smallest proportion represented in Group III. X2 tests comparing these Bradley Hospital figures with expected frequencies based on national census figures yielded differences significant well beyond the .001 level for the entire sample (X8 = 311.24), for Groups I and II (X,2 = 498.89) and for Groups III and IV IX~ = 99.45). Comparing the percentage of Jews and non-Jews, a X2 test between Groups I and II combined and Groups III and IV combined was nonsignificant (X,~.= 3.22). However, a x 2 test between Groups I and II combined and Group III was significant beyond the .05 level (X~ = 4.27). A X2 test between religious affiliation and scores on the DCL revealed significant association (X,2 = 4.36, p = .05) between high scores on autism and being of the Jewish faith.
Table IV. Distribution of Religious Affiliationsin Groups of Institutionalized Disturbed Children Religion Groups I Il III IV I and II llI and IV Ail four groups Expected on basis o f national census
Jewish (%)
Protestant (%)
Catholic (%)
33 50 15 40 41 20 33
38 25 55 40 32 52 40
29 25 30 20 27 28 27
3
66
26
Chiidhood Psychosis: The Problem of Differentiai Diagnosis
137
DISCUSSION The results of Study I confirm the utility of the DCL as a tool for aiding in the differential diagnosis of children. The significant differences between Groups I and II combined and Groups III and IV combined shows that the DCL is able to distinguish between the diagnostic categories of psychotic and nonpsychotic children, The significant difference in scores on the DCL between the autistic children and the nonautistic psychotic children, as rated on the diagnostic rating scale, supports Rimland's view that finer discriminations can, and should, be made within the present diagnosis of childhood psychosis. Considering Rimland's descriptions of similarities and differences between autistic and schizophrenic children, it seems Iogical that an autistic child should receive a DCL score indicating a great many more autistic responses than schizophrenic responses, whiie a schizophrenic child should have a few more autistic responses than schizophrenic responses. In other words, in view of Rimland's description of schizophrenic children as showing a variety of symptom patterns which usually include a segment of the autistic syndrome, it seems likely that the nonautistic psychotic child should show a number of autistic responses which at the same rime falls far short of the score of the autistic child who exhibits the entire syndrome. It is noteworthy that there is no significant difference between Group I and Group II on the DCL, which implies a certain amount of consistency in the use of the general diagnosis of childhood schizophrenia over the past 25 years. This is an important consideration since there has been considerable controversy during this period as to the correct definition of this diagnosis. The present finding of no significant difference between Groups I and II in either their DCL scores or their ratings on the diagnostic scale suggests that, despite the controversies, the general meaning of the diagnosis childhood schizophrenia has remained relatively unchanged for many years. The results of Study II show a significant correlation between DCLs completed by parents and those completed by the investigators employing the case histories. This provides support for the validity o f the method used in the present retrospective study and indicates that the extensive case histories included the necessary information for complefing the DCLs. In this regard, it is interesting to note that when the cases are categorized into diagnostic groups, the psychotic groups show a significant correlation, whereas the nonpsychotic groups yield a nonsignificant correlation. Two possible explanations could account for this lack of significant correlation in the nonpsychotic groups. The first is a possible difference in the type of parents in the nonpsychotic versus the psychotic groups, with parents of psychotic children tending to keep more careful records of their child's de-
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velopment. A second possible explanation is that the DCL was originally devised specifically for differentiation between infantile autism and childhood schizophrenia; thus it may hOt be as precise an instrument for diagnosing nonpsychotic children. In viewing the results o f Study III, it is noteworthy that although 54~ of the 34 former child patients were living at home instead of institutions and 62% were attending school, only 36% were capable of functioning without further treatment. Moreover, although 640/o were judged by their parents as having shown improved adjustment since discharge, only 40%, 32070, and 30% had shown good academic, behavioral, and overall adjustment, respectively. In other words, while the statistics favor the nonpsychotic and nonautistic child as having a greater chance of improvement, the results for the entire group o f children show only a limited degree of improvement with many of these former child inpatients continuing to function at a far from satisfactory level of social adjustment. Results o f Study IV indicate that a relatively large percentage o f these former patients belong to the Jewish faith. Though it is probable that the national census estimate of 3% Jewish population is an underestimation for the eastern area or New England area of the United States, which would be predominately represented at Bradley Hospital, it is still obvious that the finding of 33% Jewish children in this sample is much greater than chance expectation. At any rate, significant association between this religious category and high scores on the DCL provides some empirical support for Rimland's speculations and hypothesis regarding the nature of infantile autism.
REFERENCES
Davids, A., Ryan, R., & Salvatore, P. Effectivenessof residential treatment for psychoticand other disturbed children. American Journal of Orthopsychiatry, 1968, 38, 469-475. Kanner, L. Autistic disturbances of affective contact. Nervous Child, 1943, 2, 217-250. Kanner, L. To what extent is early infantile autism determinedby constitutional inadequacies? Proceedings of the Association for Research in Nervous and Mental Disease, 1954, 33, 378-385. Rimland, B. Infantile autism. New York: Appleton-Century-Crofts, 1964. Rimland, B. Infantile autism: Status and research. In A. Davids (Ed.), Child personality and psychopathology: Current topics. New York: Wiley-Interscience,1974. Pp. 137-167.
