Psychological Medicine, 1976, 6, 505-516

RESEARCH REPORT

Institute of Psychiatry Department of Child and Adolescent Psychiatry1 There has been a child psychiatry research group within the Institute of Psychiatry since 1952. At first it constituted a section of the Department of Psychiatry and for a while it formed part of the MRC Social Psychiatry Research Unit. However, in 1973 London University established a Chair of Child Psychiatry and since that time there has been a separate Department of Child and Adolescent Psychiatry. The research in this field undertaken up to 1967 has been described previously (Rutter, 1968 a) and the present report brings the account up to date with a summary of work carried out during the last eight years. The research has been varied in both topic and method but in each case the aim has been to carry out a systematic programme of interlinked studies into clinical problems with each new investigation based on the issues arising from earlier work. The research has been interdisciplinary in character with a particular emphasis on the contributions of psychology, sociology, education and developmental neurology. As a result, the work has often involved collaboration with colleagues in other Departments of the Institute of Psychiatry or in other Institutes of the University of London. Epidemiological methods have been employed throughout and, because of the often atypical nature of hospital samples, there has been frequent recourse to general population surveys. The usual procedure has been to begin with a systematic description of the clinical phenomena to be explained, to develop appropriate methods of measurement, and then to attempt to clarify the concepts and issues involved (see e.g. Rutter, 19686, 1974, 1976a; Rutter & Yule, 1975). When possible, the clinical problem has been redefined in the light of research findings and

epidemiological approaches have been followed by both experimental investigations and also the evaluation of innovations in treatment or service provision. NEUROPSYCH1ATRIC STUDIES

The early studies of Pond and his co-workers (see Pond, 1961) had shown that the link between neurological abnormality and psychiatric disorder in childhood was not a direct one. Nevertheless, there did appear to be some association. The total population epidemiological studies of school-age children on the Isle of Wight (see Rutter et al. (19766) for a fuller account of these studies) were used to investigate the nature and extent of that association (Rutter et al. 1970a). It was found that children with organic brain conditions involving a lesion above the brain stem had a rate of psychiatric disorder several times that in the general population and well above that in children with chronic physical handicaps which did not involve brain pathology. The differences remained even after factors such as IQ level, visibility of handicap and degree of physical impairment had been taken into account. It seemed that it was the fact of brain.damage itself which played the major role in increasing the psychiatric risk. However, statistical adjustments are never an entirely satisfactory substitute for direct matched comparisons. As a consequence, a further epidemiological study was undertaken in North London of children, all of whom had both normal intelligence and a visibly crippling physical handicap (Seidel et al. 1975). Comparisons within this group according to the presence or absence of brain pathology confirmed the increased psychiatric risk associated with lesions above the brain stem. The study also 1 Address for correspondence: Professor M. Rutter, showed that brain damage tends to lead not Institute of Psychiatry, De Crespigny Park, Denmark Hill, only to a lowering of general intelligence but London SE5 8AF. 505 33-2

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also to specific reading difficulties even in individuals of normal IQ. The Isle of Wight studies had indicated that most psychiatric disorders in children with brain damage were of the same type as found in youngsters without neurological conditions. There was no particular behavioural syndrome which resulted directly from cerebral injury. However, the data were based on relatively crude ratings of behaviour and there was a need for a more detailed and quantified approach to the finer points of children's behaviour. This was provided in a study undertaken by Dr D. Shaffer and his colleagues (1974). Various objective techniques were used to measure children's motor activity and attention. Overactivity and impulsiveness were found to be common characteristics of children with psychiatric disorder but they were not specifically related to neurological abnormality. In all these studies most of the children with neurological conditions had suffered generalized brain damage early in life and it remained possible that the psychiatric sequelae varied according to the locus of brain injury and to the age of the child at the time of injury. This possibility was investigated by means of an investigation of children with cortical lesions which had arisen as a result of a unilateral compound depressed fracture of the skull with associated dural tear and gross damage to the brain substance confirmed at operation (Shaffer et al. 1975). As in the previous studies, the brain-damaged children showed a rate of behavioural deviance well above that in controls matched for age, sex and school class. But the presence of psychiatric disorder was not influenced by either the locus of injury or the age of the child at injury. On the other hand, psychiatric disorder was strongly associated with psychosocial disadvantage of various kinds (marital discord, parental mental disorder, etc.). Putting all available findings together, it was concluded that the fact of brain damage put the child at increased psychiatric risk, that the specific characteristics of the brain damage were not crucial, and that both cerebral pathology and psychosocial disturbance were important in aetiology. These findings still left open the question of how brain damage caused an increased vulner-

ability to psychiatric disorder. In an attempt to elucidate some of the relevant factors a two-year prospective study of children with a recent head injury is currently being undertaken by Dr O. F. D. Chadwick and Ms G. Brown with Dr D. Shaffer and Professor M. Rutter. The objectives are to study the process of recovery of cognitive function and to examine the pattern of family responses to the child after injury with the ultimate aim of identifying ways in which the ill-effects can be modified or reduced. At one time it had been assumed by many psychiatrists that hyperactivity and poor attention were usually due to some form of brain pathology. The investigations described above showed that this was not the case. A high proportion of children with conduct disorders are inattentive and overactive. However, some are not. It remains uncertain whether the presence of hyperactivity/inattention is an important differentiating feature and it is not known whether extreme degrees of these behaviours have a different significance from milder varieties. These issues are being investigated by Dr E. Taylor and Dr S. Sandberg by means of a study of hyperactive children using objective measures of behaviour, psychophysiological techniques and neurological assessments. Special attention is being paid to congenital physical anomalies which have been found to be connected with hyperactivity in previous American studies. INFANTILE AUTISM

Although Leo Kanner first described the syndrome of infantile autism in 1943, even as recently as fifteen years ago most child psychiatrists were still using the relatively broad undifferentiated category of child psychosis or childhood schizophrenia (Rutter, 1974). There was little agreement on diagnostic usage and the delineation of diagnostic criteria seemed the first research task at that time. A systematic controlled study showed that psychoses developing in early childhood were characterized by a particular type of language retardation, an abnormality in the development of social relationships and the presence of various ritualistic phenomena (Rutter, 1966 a). They were also associated with a pattern of intellectual abilities which suggested a serious defect in cognitive

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skills involving language (Lockyer & Rutter, 1970). These psychoses beginning in the first 30 months of life appeared quite different from the schizophrenic disorders starting in the preadolescent period and from the disintegrative psychoses of middle childhood (Rutter, 19726). A follow-up study indicated that IQ level, degree of language impairment, and schooling were the most important prognostic indicators for children with infantile autism or infantile psychosis (Rutter et al. 1967; Lockyer & Rutter, 1969) and that many developed epileptic fits during adolescence (Rutter, 1970a). This was especially the case among the psychotic children who also showed mental retardation. The findings suggested the need to explore the nature and meaning of the cognitive deficit and to study the value of educational approaches to treatment. A comparison between autistic children and children with severe developmental disorders of language retardation ('dysphasia') demonstrated that, although the language problem in the two groups was similar in many ways, the language retardation associated with autism differed in terms of severity and breadth (the impairment involved all language modalities), it included a deficit in the social usage of language, and it was associated with a different pattern of cognitive skills (Bartak et al. 1975). Discriminant function analyses showed that there was very little overlap between the autistic and dysphasic groups in terms of behaviour, language features, and cognitive patterns. Furthermore, largely the same children were grouped together regardless of whether behavioural, linguistic or cognitive criteria were employed (Bartak & Rutter, 19766). Within the autistic group the severity of autistic-type language impairment was strongly associated with the degree of autistic-type social and behavioural symptomatology. Mr P. Clark is now starting a series of studies to determine the extent to which the experimental manipulation of cognitive variables influences social behaviour, and vice versa. Autism is sometimes associated with a family history of speech delay, and American studies have produced contradictory findings regarding the presence of so-called 'thought disorder' in the parents. Ms Carolyn Lennox, supervised by Ms Maria Callias and Professor M. Rutter,

has recently carried out an investigation to resolve that issue. It was found that different tests of thought disorder do not measure the same thing, but that the parents of autistic children did not differ from the parents of normal children on any of the tests used. The rate of autism in the sibs of autistic children is quite low (about 2%) but it is well above population norms. Whether this is due to genetic factors, perinatal influences or common patterns of upbringing is not known. Accordingly, Dr Susan Folstein is currently making a systematic study of some two-dozen same-sexed twin pairs, in each of which one or both twins is autistic, to find out whether there are genetic factors regarding autism as such, or regarding language delay, cognitive impairment or social difficulties. While autism is strongly linked with a particular form of cognitive deficit involving language, it does not appear to be associated with any particular psychosocial environment (except that it is commoner in middle-class families). Cox et al. (1975) showed that autistic children did not differ from 'dysphasic' children in terms of environmental stresses, quality of family relationships or parental personality features. Dr D. Cantwell has examined the finer points of parent-child interaction through systematic observations in the home, utilizing time-sampling techniques. The findings so far have been equally negative. However, the social burden on the families of autistic children is quite considerable and Dr Peter Hill has recently begun a study to determine how far these burdens are associated with emotional or behavioural problems among other (non-autistic) children in the same families. A 3^-year longitudinal study of the progress of autistic children in three rather different units confirmed the predictive value of the children's level of intelligence but also demonstrated the value of schooling (Bartak & Rutter, 1973; Rutter & Bartak, 1973). Children made most educational progress in a structured school environment with an emphasis on the teaching of specific skills. But social gains tended to be rather situation-specific unless steps were taken to ensure generalization of gains. The studies of cognitive impairment in autistic children suggested that appropriate intervention in the pre-school period might serve to reduce some ii-3

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of the later social and behavioural abnormalities (Rutter & Sussenwein, 1971) and the findings on situation specificity indicated that the intervention should be in the home and school rather than in the hospital clinic or ward. A developmental^ based home programme of working with the parents of autistic children using behavioural and counselling techniques has been established on an experimental basis (Howlin et al. 19736; Marchant et al. 1974) and its efficacy is being assessed by means of comparisons with children treated in other ways. A special attempt is being made to measure possible gains in parental coping skills and new measures have been devised to assess both language performance (Howlin el al. 1973a) and sequences of parent-child interaction. NOCTURNAL ENURESIS

Epidemiological studies on the Isle of Wight showed that enuresis was a common complaint which occurred in boys more frequently than girls and which was associated with other evidence of behavioural deviance and psychiatric disorder (Rutter et al. 19736). A detailed examination of the pattern of temporal associations in a longitudinal study of the same children indicated a stronger and more basic connection between enuresis and behavioural deviance than had previously been thought. Research to determine the mechanisms involved was needed (Rutter, 1973). Dr D. Shaffer is directing a series of investigations into the nature of enuresis with special reference to its psychiatric correlates. Circadian rhythms of urine production in enuretic and non-enuretic children are being compared and functional bladder capacity is being related to enuresis and psychiatric disorder over time as the same children gain bladder control. The drug imipramine is also being utilized to investigate the mechanisms involved in enuresis. It is known to control enuresis in a high proportion of children but it is a drug with multiple pharmacological actions and it is not known which action is relevant in this connection. This problem is being studied by means of two strategies. First, the effectiveness of imipramine is being compared with other drugs which share only one of its pharmacological properties (for ex-

ample, indoramine was used to study the importance of alpha-blocking activity). Secondly, in a programme of laboratory studies, the pharmacological effects of local and systematically administered imipramine on bladder function are being investigated by Dr V. Thomas and Dr J. Stephenson. Areas of particular interest are the local anaesthetic and the central effects of the drug. SPECIFIC READING RETARDATION

At the time the Isle of Wight studies were being planned little was known about the frequency of reading difficulties and there was considerable controversy over the measurement of underachievement and over its classification. However, traditionally, a distinction had been drawn between general reading backwardness (i.e. low attainment in comparison with other children of the same age) and specific reading retardation (i.e. reading which is retarded in relation to general intellectual abilities as well as to age). It was decided to investigate the validity of this distinction in the course of assessing the prevalence of reading difficulties. First, it was found that the usual achievement ratios or quotients were unsatisfactory measurements and that it was necessary to use a multiple regression formula (Yule, 1967). Secondly, serious reading difficulties of both types were found to be quite common in 9- to 10-year-old Isle of Wight children and most such children were not receiving any kind of special help (Rutter et al. 19706). Thirdly, a follow-up of these children to age 14 years showed that the prognosis was generally poor (Yule, 1973). Overall the children who had had reading difficulties at 10 years were reading only at the 9-year level in their last year of school and their spelling was even worse. Fourthly, the concept of specific reading retardation was shown to have validity in statistical (Yule et al. 1974), neurodevelopmental (Rutter & Yule, 1975), and educational terms (Yule, 1973). However, in contrast to some notions of dyslexia (Rutter, 1969), specific reading retardation did not appear to be a single homogeneous entity. It was found to be associated with multiple factors, including developmental delays (especially in speech, language and sequencing), temperamental attributes, family

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characteristics, and quality of schooling (Rutter et al. 19706; Rutter & Yule, 1973). It was also found to be twice as prevalent in Inner London as on the Isle of Wight (Berger et al. 1975). In both areas there was a substantial overlap between reading difficulties and psychiatric disorder (Rutter et al. 19706; Sturge, 1972). The mechanisms involved in this association require further study. INTELLECTUAL RETARDATION

Intellectual retardation (defined in terms of an IQ two standard deviations below the mean) was present in 2\ % of 9- and 10-year-old children living on the Isle of Wight (Rutter et al. 19706). Half of these children attended ordinary schools. Intellectual retardation (particularly severe retardation) was associated with a high rate of neurological abnormality and of defects in speech and language. The children tended to be short in stature and to have more physical abnormalities and illness than children of normal intelligence. Psychiatric disorder was much more common in children of low IQ than in the general population. Psychosis and the hyperkinetic syndrome were especially frequent in the severely retarded but most of the mildly retarded showed disorders which were similar in type to those found in those of higher intelligence (Rutter, 1971a). A consideration of the pattern of associations suggested that mental subnormality predisposed children to psychiatric disorder but it did not cause it directly. However, as shown by the studies of autistic children (see above) the level of IQ was important not only in causation but also in prognosis. Even within the psychiatric category of autism, the presence of severe retardation was associated with both a different and a worse prognosis (Rutter, 1970a). The pattern of symptoms in autistic children with an IQ below 70 differs somewhat from the pattern in those with an IQ in the normal range but the main difference lies in the high prevalence of epileptic fits and the low proportion in paid employment in the low IQ group (Bartak & Rutter, 1976 a). CLASSIFICATION

Classification, as a means of ordering information and of grouping phenomena, is basic to

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all forms of scientific enquiry. Its importance in child psychiatry was recognized early (Rutter, 1965) and many of the clinical studies undertaken in the Department have been planned to increase knowledge in this field. Several different approaches have been followed. First, as with autism, enuresis, the hyperkinetic syndrome and specific reading retardation, there have been studies to determine the characteristics, correlates and course of particular syndromes. Other studies have been made of hysteria (Caplan, 1970), anorexia nervosa (Warren, 1968), depression (Pearce, 1974), tics (Corbett et al. 1969), suicide (Shaffer, 1974) and school refusal (Hersov, 1960; Smith, 1970). Second, there have been investigations to determine how far various aetiological influences are linked with specific psychiatric conditions. Particular attention has been paid to cerebral dysfunction (see above) and to various forms of family pathology (see below). Third, comparative studies have been undertaken to determine how far different psychiatric categories differ in terms of symptom patterns, aetiology, associated handicaps, response to treatment and outcome. Thus, emotional disturbances and disorders of conduct have been found to differ in terms of sex distribution, association with reading difficulties (Rutter et al. 19706), association with family discord (Rutter, 19716), and longitudinal course (Graham & Rutter, 1973). The validity of the syndrome of autism has been established by the same means (Rutter, 1971c). Fourth, a combination of cross-sectional and longitudinal studies have been utilized to examine differences according to age of onset. It has been found, for example, that, unlike those beginning in earlier childhood, conduct disorders with an onset in adolescence are not associated with educational retardation (Rutter et al. 1976a). Fifth, comparisons have been made between psychiatric disorders occurring in both childhood and adult life and those confined to either the earlier or later age periods (Zeitlyn, 1972; Rutter, 19726). By these means it has been possible to make a modest start on the process of delineating valid categories of psychiatric disorder as they occur in childhood. However, the matter of classification also involves the further issues of how the categories should begrouped, how far diagnostic distinctions

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can be made reliably, and how schemes of classification should be organized. These issues all require co-operation between psychiatrists with a differing theoretical orientation and working in various clinical settings. Professor M. Rutter and Dr D. Shaffer have both worked with the World Health Organization in undertaking this type of research. The possible value of a multi-axial approach to classification in child psychiatry arose in a WHO Seminar (Rutter et al. 1969) and this approach was systematically evaluated in a later investigation (Rutter et al. 1973 a, 1975*). Case histories were used to assess the reliability of diagnostic coding and a clinical study with a one-year follow-up was employed to determine the practicality and usefulness of classification. It was found that a multi-axial system (with axes for clinical psychiatric syndrome, intellectual level, biological factors and psychosocial influences) had important advantages over a multi-category system as normally used. There was reasonable reliability for most of the main categories but the classification of psychosocial influences was unsatisfactory and clearly required further development before it could be usefully employed. INTERVIEW MEASURES

An early study (Rutter, 19666) had shown that mental illness in parents was often associated with psychiatric disorder in the children. This was particularly the case when the parent suffered from a personality disorder, when both parents were ill and when the symptoms of the parental illness directly involved the child in some way (often in the context of overt or covert hostile feelings). A longitudinal study of families with a mentally ill parent was planned to investigate further this association between psychiatric disorder in parents and children. However, in order to make such a study it was necessary first to develop adequate tools to assess family life and relationships and also the various social and clinical aspects of psychiatric disorder. Between 1962 and 1965 new measures of the family were developed and tested by Professors M. Rutter and G. W. Brown and their colleagues (Brown & Rutter, 1966; Rutter & Brown, 1966). It

was found that different techniques were required to obtain information on family events and activities from those needed to measure emotions and feelings. However, with systematic training and the use of standardized procedures, interviewers could make reliable and valid assessments of both aspects of family life. Subsequent work showed that marital discord was the aspect of family relationships most strongly associated with psychiatric disorder in the children (Rutter, 19716). Accordingly, special attention has been paid to the evaluation of marital relationships by means of interview measures. Ratings of the marriage have been shown to be reliable and free of social class bias, to be consistent between husbands' and wives' accounts, and to be highly predictive of subsequent marriage breakdown during a four year longitudinal study (Quinton et al. 1976). Studies on the Isle of Wight were used initially to evaluate different methods of assessing psychiatric disorder in children (Graham & Rutter, 1968; Rutter & Graham, 1968; Rutter et al. 19706). It was found that a detailed and systematic interview with the mother provided the greatest range of information needed to make a psychiatric diagnosis. This method of interview assessment proved to be reliable, to agree well with other measures and to have predictive validity. Moreover, it was shown that, with the use of standardized techniques, trained social scientists could make assessments of psychiatric disorder which agreed very well with those made by psychiatrists (Rutter et al. 1975a). The assessments were shown to be as reliable and valid in London studies as in the earlier Isle of Wight enquiries. Similar attention was paid to the assessment of psychiatric disorder in parents and again interview techniques proved to have satisfactory reliability and validity (Rutter, 19766, 1977). Although the parental interview was the single best measure of child psychiatric disorder, it was found that children's behaviour at school frequently differed from that shown at home (Rutter et al. 19706) and it was necessary to develop means of assessing behavioural deviance at school. A teacher's questionnaire (Rutter, 1967) was developed for this purpose and following testing on the Isle of Wight (Rutter et al. 19706) it was modified and improved (Rutter

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et al. 1975a). Scores on the questionnaire not only correlated highly with contemporaneous interview measures of behaviour but also they were effective predictors of children's behaviour over the next four years (Rutter, 19766). The various studies designed to develop interview assessments were successful in their aim of obtaining reliable and valid measures of both family functioning and psychiatric disorder. However, they also indicated the importance of interviewer skills and highlighted our lack of understanding of just what are these skills. As a result, over the last three years Dr A. D. Cox and Ms K. Hopkinson have been investigating the effects of different interviewer styles and techniques. Video-tape recordings have been made of clinical interviews with the parents of child patients attending the Maudsley Hospital. Reliable measures of interviewer-informant interaction have been obtained and a naturalistic study has been undertaken in which different interviewers have been contrasted in terms of the behaviour they elicit from informants. It is now planned to proceed to an experimental investigation in which interviewer styles will be deliberately modified to determine their effects on the informants' expressions of feelings and provision of information. FAMILY STUDIES

The interview measures which had been developed were employed in a longitudinal study of families in which one or both parents had some form of psychiatric disorder. The Camberwell Register was used to obtain a representative sample of parents living in one London borough who had been newly referred to a psychiatric clinic. The families were first studied shortly after referral and were then seen each year for the next four years (Rutter et al. 1977). Most of the parents suffered from neurotic or depressive disorders which tended to recur or persist during the follow-up period. It was found that the prognosis of these disorders was related more to personality characteristics and to aspects of family life than to the social situation or duration of the acute episode which led to referral. Family discord was strongly associated with mental illness and the two tended to run a parallel course. Many of the spouses of patients

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developed psychiatric problems during the four years of the study. The children in the patients' families were twice as likely as classroom controls to show persisting psychiatric disorder. This finding at the start of the study was confirmed by the longitudinal data which showed that a high proportion of patients' children who were too young initially to receive a psychiatric rating developed psychiatric disorder during the followup period. The diagnosis of the parent's acute mental illness did not affect the psychiatric risk for the children. However, disorder in the children was most likely to develop if there was marital discord, if the parent had a personality disorder and if there, was high exposure to symptoms involving both neurotic disturbance and hostile feelings. Patterns of discipline seemed less important. Boys were more susceptible than girls to the effects of marital discord (Rutter, 19706), temperamental attributes were very important in relation to children's vulnerability (see below) and children who showed psychiatric disorder (especially disturbances of conduct) at the onset of the study were highly likely to be still showing disorder several years later (Rutter, 19766). When the study began, it was thought by many psychiatrists that separation experiences were a serious and common cause of child psychiatric disorder. The results of the family illness study and later general population studies (see below) showed this view to be mistaken. It was not separation as such which caused most of the damage but rather the family discord which led to and followed the separation (Rutter, 19716). Admission into care was strongly associated with child psychiatric disorder, probably as a consequence of the serious family disturbance which was the lot of most children taken into short-term care (Wolkind & Rutter, 1973). These and other findings led to a re-appraisal of the rather heterogeneous experiences previously grouped together under the general concept of 'maternal deprivation' (Rutter 1972a). The links between psychiatric problems in parents and in their children raised the question of how far there were intergenerational continuities in the various types of disadvantage and what were the mechanisms which underlay the

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continuities and discontinuities which occurred. The research findings and concepts involved in these issues were reviewed by Professor M. Rutter and Ms Nicola Madge (1976) for the Social Science Research Council. Mr D. Quinton and Professor M. Rutter are now starting a combined retrospective and prospective study of childhood experiences as possible determinants of parenting behaviour a generation later. Persons admitted into care during their childhood are being used as a sample of people likely to have experienced family discord or adversity. Ms P. Dixon is examining the social behaviour of children currently in care at the time they start primary school. AREA STUDIES

As the family illness study involved a sample of patients it was important to check whether the associations still held in the general population. Accordingly a study was made of a representative sample of 10-year-olds and their families living in the same London borough. A closely similar pattern was found. As in the patient sample, child psychiatric disorder was associated with parental mental disorder, marital discord and admission into care. In the course of these studies it had become apparent that the prevalence of various sorts of disorder and deviance was higher in London than had been found in the Isle of Wight. Because the measures and ages of children were not always identical in the two areas it was necessary to obtain samples of children of the same age (10 years) studied in the same way with the same measures by the same team of investigators. When this was done it was found that both child psychiatric disorder (Rutter et al. 1975a) and specific reading retardation (Berger et al. 1975) were indeed twice as common in Inner London as on the Isle of Wight. It was shown that this difference could not be explained in terms of any kind of methodological bias or error. The next task was to determine why disorders were so much commoner in the metropolis. In order to answer that question the first step was to find out the correlates of disorder in the two areas. In both, child psychiatric disorder was associated with measures of family disturbance,

parental deviance, social disadvantage, and school difficulties (Rutter et al. \915d). The second step was to consider whether these features were more common in London. They were. London families were more likely to experience discord and mental illness, to live in poor social circumstances and the children were more likely to go to schools characterized by a high turnover in staff and pupils. The question, then, was whether the higher rate of these features was sufficient to explain the twofold increase in prevalance of psychiatric disorder in London over the Isle of Wight. The features associated with disorder were therefore combined into two indices of'family adversity' and 'school adversity'. The rates of child psychiatric disorder in London and the Isle of Wight were recompared after standardizing for scores on the two adversity indices (Rutter & Quinton, 1976). There was no longer any difference in rates. In short, the higher rate of child disorder in London was simply due to the fact that family adversity and school adversity were much more frequent in the capital. Children living in like circumstances had an equal risk of psychiatric disorder in the two areas. That finding, of course, raised the further issue of why illness in adults and why family discord was commoner in London. Examination of the data on neurosis or depression in the mothers suggested a possible explanation. On the Isle of Wight neurosis/depression was strongly related to interpersonal difficulties of various kinds and was not associated with social class. In contrast, in London, neurosis/depression was less related to interpersonal difficulties but was strongly associated with low social status. In fact it was only in working-class women that there was an area difference in maternal mental disorder (Rutter & Quinton, 1976). It appeared that in London, unlike the Isle of Wight, neurosis/depression developed in connection with stresses associated with low social status. The nature of the particular stresses associated with city life and the nature of possible protective influences in small towns and villages is still being investigated. Nevertheless, it is clear already that psychiatric disorder is related to community influences and living conditions as well as to personal factors.

Research Report: Institute of Psychiatry CHILDREN IN IMMIGRANT FAMILIES

In order to make valid comparisons with the Isle of Wight, London children in immigrant families were excluded from the analyses noted above. However, immigrant families constitute an integral part of the population and they were studied in the same way. Particular attention was paid to families from the West Indies as they constituted much the largest recent immigrant group in the borough studied. It was found that children from West Indian families showed rather more behavioural difficulties at school than did indigenous children but they did not differ in terms of psychiatric disorder shown at home nor did they differ in terms of emotional disturbance in any setting (Rutter et al. 1974). On the other hand, the West Indian children, especially those born abroad, did show markedly lower educational attainments (Yule et al. 1975). In many respects the West Indian and the non-immigrant families were closely similar. However, the West Indian parents were more likely to hold semi-skilled or unskilled jobs and to live in poor-quality overcrowded housing; although they were also more likely to own their own house. West Indian families had many more children and differed somewhat in their patterns of child-rearing (Rutter et al. 1975 c). West Indian children were more likely to have experienced minding by non-relatives in the pre-school period and they were more likely to have attended schools with adverse features. These differences in family and social circumstances are likely to have played a part in influencing the children's development.

SCHOOL STUDIES

These area studies showed the importance of school variables in connection with children's behaviour and educational progress. The earlier investigations of autistic children (Bartak & Rutter, 1973; Rutter & Bartak, 1973) had also demonstrated the importance of differences in the way teachers interacted with children. It seemed important to learn more about how schools might influence children's behaviour and development. The first point was to check that the school differences were not a result of a methodological

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artefact. The differences between primary schools in children's behaviour were re-examined after controlling for where the children lived and for differences in family discord and family poverty. Substantial school differences still remained. Nevertheless, the possibility that the differences were due to variations in the intake of 'difficult' pupils could not be excluded. This could not be directly assessed in relation to primary school differences but if the children were followed through into secondary school, intake differences could be taken into account in connection with variations in children's behaviour in secondary school. Accordingly the primary-school children studied at age 10 years were all followed into the third year of secondary school. It was found that there were considerable differences between schools in their intake of behaviourally deviant and educationally retarded childien. However, even after these differences had been taken into account statistically using both standardization and multiple regression techniques (Rutter, 1976 ft), very substantial variation between secondary schools remained (Yule & Rutter, in preparation). It was concluded that schools could and did have an impact, for better or worse, on children's behavioural development. The next step was to find out what it was about a school that made a difference. To answer that question Ms Barbara Maughan, Mr P. Mortimore and Dr Janet Ouston are making a detailed study of twelve secondary schools included in the earlier investigation and which are known to vary in several crucial respects. Aspects of the school in terms of its characteristics as a social institution, of its organization of teaching and of pastoral care, of its patterns of privileges and of discipline, of its relationships with families and the community and of its style of teacher-child interaction are being related to differences in children's behaviour and scholastic progress.

ISLE OF WIGHT STUDIES

Apart from the investigations mentioned above, there have been a series of studies over the last ten years into handicapping conditions in schoolage children living on the Isle of Wight. The main emphasis in these studies has been on the

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prevalence and pattern of handicaps with special reference to the planning of services. The studies are more fully described elsewhere (Rutter et al. 19766). INDIVIDUAL DIFFERENCES

In all the studies there have been striking individual differences in how children respond to various types of stress. The prominent sex differences have already been noted (Rutter, 19706), some differences are due to the presence of neurological impairment (Rutter et al. 1970a), or chronic physical handicap (Rutter et al. 19706), and others are a result of variations in intellectual capacity (Rutter, 1971 a). However, in addition to these variables earlier work in the USA (Rutter et al. 1964) had suggested the importance of temperamental factors. These were systematically investigated as part of the family illness study (see above). An interview with mothers was devised to assess the 'how' of the children's behaviour - that is, their characteristic style in terms of features such as intensity of emotional expression, malleability, activity, and approach/withdrawal to new people (Graham et al. 1973). It was found that children who showed low regularity of physiological functioning (such as shown in the sleep/wake cycle), low malleability and low fastidiousness were those most likely to develop psychiatric disorder a year later. Deviant scores on these temperamental attributes were combined to form a 'temperamental adversity index' (Rutter et al. 1977). Children with high scores on this index were much more likely to show psychiatric disorder or behavioural deviance at school during the next four years of the longitudinal study than were children with low scores. However, there was a 'transactionaF effect. That is to say, children showing temperamental adversity were not only more vulnerable to parental hostility and criticism but also they were more likely than other children to experience such stresses. It seemed that children with adverse temperamental features were more likely to be scapegoated at times of family difficulty. Individual differences have played but a small part in child psychiatric research up to now. These and similar findings from other research centres make clear that they will have to receive more attention in the future.

CONCLUSION

The value of most of the studies undertaken over the last decade has depended to a considerable extent on opportunities to develop appropriate measures and on the possibility of links and cross comparisons between the various studies. This would not have been possible without long-term support. In this connection we are particularly indebted to the Foundation for Child Development (New York), the MRC, the SSRC, the Nuffield Foundation, the Department of Education and Science, and the Department of Health and Social Services. MICHAEL RUTTER

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Research Report: Institute of Psychiatry Howlin, P., Cantwell, D., Marchant, R., Berger, M. & Rutter, M. (1973a). Analyzing mothers' speech to young autistic children: a methodological study. Journal of Abnormal Child Psychology 1, 317-339. Howlin, P., Marchant, R., Rutter, M., Berger, M., Hersov, L. & Yule, W. (19736). A home-based approach to the treatment of autistic children. Journal of Autism and Childhood Schizophrenia 3, 308-336. Lockyer, L. & Rutter, M. (1969). A five to fifteen-year follow-up study of infantile psychosis. III. Psychological aspects. British Journal of Psychiatry 115, 865-882. Lockyer, L. & Rutter, M. (1970). A five to fifteen-year follow-up study of infantile psychosis. IV. Patterns of cognitive ability. British Journal of Social and Clinical Psychology 9, 152-163. Marchant, R., Howlin, P., Yule, W. & Rutter, M. (1974). Graded change in the treatment of the behaviour of autistic children. Journal of Child Psychology and Psychiatry 15, 221-227. Pearce, J. B. (1974). Childhood depression. M.Phil. Thesis, University of London. Pond, D. A. (1961). Psychiatric aspects of epileptic and brain damaged children. British Medical Journal 2, 1377-1382, 1454-1459. Quinton, D., Rutter, M. & Rowlands, O. (1976). An evaluation of an interview assessment of marriage. Psychological Medicine 6 (in press). Rutter, M. (1965). Classification and categorization in child psychiatry. Journal of Child Psychology and Psychiatry 6, 71-83. Rutter, M. (1966a). Behavioural and cognitive characteristics of a series of psychotic children. In Early Childhood Autism: Clinical, Educational and Social Aspects (ed. J. K. Wing). Pergamon: London. Rutter, M. (19666). Children of Sick Parents: An Environmental and Psychiatric Study. Institute of Psychiatry Maudsley Monographs No. 16. Oxford University Press: London. Rutter, M. (1967). A children's behaviour questionnaire for completion by teachers: preliminary findings. Journal of Child Psychology and Psychiatry 8, 1-11. Rutter, M. (1968a). Child psychiatry. In Studies in Psychiatry (ed. M. Shepherd & D. Davies). Oxford L. University Press: London. Rutter, M. (1968 6). Concepts of autism: a review of research. Journal of Child Psychology and Psychiatry 9, 1-25. Rutter, M. (1969). The concept of dyslexia. In Planning for Better Learning (ed. P. Wolff & R. MacKeith). Heinemann/ S.I.M.P.: London. Rutter, M. (I970o). Autistic children: infancy to adulthood. Seminars in Psychiatry 2, 435-450. Rutter, M. (19706). Sex differences in children's responses to family stress. In The Child and His Family (ed. E. J. Anthony & C. Koupernik). Wiley: New York. Rutter, M. (1971a). Psychiatry. In Mental Retardation: An Annual Review, vol. in (ed. J. Wortis). Grune & Stratton: New York. Rutter, M. (19716). Parent-child separation: psychological effects on the children. Journal of Child Psychology and Psychiatry 12, 233-260. Rutter, M. (1971 r). The description and classification of infantile autism. In Infantile Autism: Proceedings of the Indiana University colloquium (ed. D. W. Churchill, G. D. Alpern& M. K. DeMyer).Chas.C.Thomas:Springfield, 111. Rutter, M. (1972a). Maternal Deprivation Reassessed. Penguin Books: Harmondsworth. Rutter, M. (19726). Relationships between child and adult psychiatric disorder. Ada Psychiatrica, Scamlinavica 48, 3-21. Rutter, M. (1973). Indications for research. III. In Bladder

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Control and Enuresis (ed. I. Kolvin, R. C. MacKeith & S. R. Meadow). Clinics in Developmental Medicine, Nos. 48/49. Heineman/S.I.M.P.: London. Rutter, M. (1974). The development of infantile autism. Psychological Medicine 4, 147-163. Rutter, M. (1976a). Brain damage syndromes in childhood: concepts and findings. Journal of Child Psychology and Psychiatry 17 (in press). Rutter, M. (19766). Prospective studies to investigate behavioural change. In Methods of Longitudinal Research in Psychopalhology (ed. J. S. Strauss, H. M. Babigian & M. Roff). Plenum: New York. Rutter, M. (ed.) (1977). The Child, His Family and The Community. Wiley: London. (In preparation.) Rutter, M. & Bartak, L. (1973). Special educational treatment of autistic children: a comparative study. 11. Followup findings and implications for services. Journal of Child Psychology and Psychiatry 14, 241-270. Rutter, M. & Brown, G. W. (1966).The reliability and validity of measures of family life and relationships in families containing a psychiatric patient. Social Psychiatry 1, 38-53. Rutter, M. & Graham, P. (1968). The reliability and validity of the psychiatric assessment of the child. 1. Interview with the child. British Journal of Psychiatry 114, 563-579. Rutter, M. & Madge, N. J. H. (1976). Cycles of Disadvantage. Heinemann Educational: London. (In press.) Rutter, M. & Quinton, D. (1976). Psychiatric disorderecological factors and concepts of causation. In Ecological Factors in Human Development (ed. H. McGurk). North Holland: Amsterdam. Rutter, M. & Sussenwein, F. (1971). A developmental and behavioral approach to the treatment of pre-school autistic children. Journal of Autism and Childhood Schizophrenia 1, 376-397. Rutter, M. & Yule, W. (1973). Specific reading retardaticn. In The First Review of Special Education (ed. L. Mann & D. A. Sabatino). Buttonwood Farms Inc.: Philadelphia. Rutter, M. & Yule, W. (1975). The concept cf specific reading retardation. Journal of Child Psychology and Psychiatry. (In the press.) Rutter, M., Birch, H. G., Thomas, A. & Chess, S. (1964). Temperamental characteristics in infancy and the later development of behavioural disorders. British Journal of Psychiatry 110,651-661. Rutter, M., Greenfeld, D. & Lockyer, L. (1967). A five to fifteen-year follow-up study of infantile psychosis. 11. Social and behavioural outcome. British Journal of Psychiatry 113, 1183-1199. Rutter, M., Lebovici, L., Eisenberg, L., Sneznevskij, A. V., Sadoun, R., Brooke, E. & Lin, T.-Y. (1969). A tri-axial classification of mental disorders in childhood. Journal of Child Psychology and Psychiatry 10, 41-61. Rutter, M., Graham, P. & Yule, W. (1970a). A Neuropsychiatric Study in Childhood. Clinics in Developmental Medicine, Nos. 35/36. Heinemann/S.I.M.P.: London. Rutter, M., Tizard, J. & Whitmore, K. (eds.) (19706). Education, Health and Behaviour. Longmans: London. Rutter, M., Shaffer, D. & Shepherd, M. (1973a). Preliminary communication: an evaluation of the proposal for a multiaxial classification of child psychiatric disorders. Psychological Medicine 3, 244-250. Rutter, M., Yule, W. & Graham, P. (19736). Enuresis and behavioural deviance: some epidemiologica! considerations. In Bladder Control and Enuresis (ed. I. Kolvin, R. MacKeith & S. R. Meadows). Clinics in Developmental Medicine, Nos. 48/49. Heinemann/S.I.M.P.: London. Rutter, M., Yule, W., Berger, M., Yule, B., Morton, J. & Bagley, C. (1974). Children of West Indian Immigrants. 1. Rates of behavioural deviance and of psychiatric disorder. Journal of Child Psychology and Psychiatry 15, 241-262.

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Rutter, M., Cox, A., Tupling, C , Berger, M. & Yule, W. (1975«). Attainment and adjustment in two geographical areas. I. The prevalence of psychiatric disorder. British Journal of Psychiatry 126, 493-509. Rutter, M., Shaffer, D. & Shepherd, M. (19756). An Evaluation of the Proposal for a Multiaxial Classification of Child Psychiatric Disorders. WHO Monograph. WHO: Geneva. Rutter, M., Yule, B., Morton, J. & Bagley, C. (1975c). Children of West Indian immigrants. 111. Home circumstances and family patterns. Journal of Child Psychology and Psychiatry 16, 105-123. Rutter, M., Yule, B., Quinton, D., Rowlands, O., Yule, W. & Berger, M. (1975tf). Attainment and adjustment in two geographical areas. 111. Some factors accounting for area differences. British Journal of Psychiatry 126, 520-533. Rutter, M., Graham, P., Chadwick, O. F. D. & Yule, W. (1976a). Adolescent turmoil: fact or fiction? Journal of Child Psychology and Psychiatry 17, 35-56. Rutter, M., Tizard, J., Yule, W., Graham, P. & Whitmore, K. (19766). Research report. Isle of Wight Studies, 1964-1974. Psychological Medicine 6, 313—332. Rutter, M., Quinton, D. & Yule, B. (1977). Family Pathology and Disorder in Children. John Wiley & Sons: London. (In preparation.) Seidel, U. P., Chadwick, O. F. D. & Rutter, M. (1975). Psychological disturbances in physically disabled children. Developmental Medicine and Child Neurology 17, 563-573. Shaffer, D. (1974). Suicide in childhood and early adolescence. Journal of Child Psychology and Psychiatry 15, 275-291. Shaffer, D., McNamara, N. & Pincus, J. H. (1974). Controlled observations on patterns of activity, attention, and impulsivity in brain-damaged and psychiatrically disturbed boys. Psychological Medicine 4, 4-18.

Shaffer, D., Chadwick, O. F. D. & Rutter, M. (1975). Psychiatric outcome of localized head injury in children. In Outcome of Severe CNS Damage (ed. R. Porter & D. Fitzsimons). Proceedings of C1BA Conference, Nov. 1974. Excerpta Medica. (In press.) Smith, S. L. (1970). Schocl refusal with anxiety: a review of 63 cases. Canadian Psychiatric Association Journal 15, 257264. Sturge, C. (1972). Reading retardation and antisocial behaviour. M.Phil. Thesis, University of London. Warren, W. (1968). A study of anorexia nervosa in young girls. Journal of Child Psychology and Psychiatry 9, 27-40. W o l k i n d . S . & Rutter, M. (1973). Children who have been ' I n C a r e ' - an epidemiological study. Journal of Child

Psychology and Psychiatry 14, 97-105. Yule, B. & Rutter, M. (In preparation.) Yule, W. (1967). Predicting reading ages on Neale's analysis of reading ability. British Journal of Educational Psychology 37, 252-255. Yule, W. (1973). Differential prognosis of reading backwardness and specific reading retardation. British Journal of Educational Psychology 43, 244-248. Yule, W., Rutter, M., Berger, M. & Thompson, J. (1974). Over- and under-achievement in reading: distribution in the general population. British Journal of Educational Psychology 44, 1-12. Yule, W., Berger, M., Rutter, M. & Yule, B. A. (1975). Children of West Indian immigrants. II. Intellectual performance and reading attainment. Journal of Child Psychology and Psychiatry 16, 1-17. Zeitlyn, H. (1972). A study of patients who attended the children's department and later the adult's department of the same psychiatric hospital. M.Phil. Thesis: University of London.