Psychological Medicine, 1992, 22, 805-813 Printed in Great Britain

RESEARCH REPORT

The Medical Research Council Unit in Child Psychiatry ERIC TAYLOR1 AND MICHAEL RUTTER From the MRC Unit in Child Psychiatry, Institute of Psychiatry, London

DEVELOPMENTAL PSYCHOPATHOLOGY To understand anything, it is helpful to know its history. All psychiatrists are confronted by clinical problems that have developed over a large part of their patients' life span. This applies most obviously to the disorders of personality, but it is also true of many disorders arising in adult life. The roots of depression can sometimes be traced back to suffering and loss in childhood. Schizophrenia is often preceded by long periods of cumulative problems in personal relationships; and recent theory has drawn attention to very early signs of abnormality in the perinatal period. Many child psychiatric disorders present as enduring traits. The model of 'psychiatric illness' tends to emphasize the change and discontinuity from previous life, but it is also necessary to understand the extent to which an individual's plight can be seen as the product of character and stress. Developmental psychology and biology have been core sciences for establishing this kind of understanding. Both have tended to concentrate on normal processes and to describe the typical course of development rather than the nature of differences between individuals. In more recent years, however, a new strain has emerged - one that can be described as 'developmental psychopathology'. This science represents the application of developmental thinking to the study of disorders. The questions raised by developmental psychopathology are about the factors leading to variations in lines of development, and the factors determining differences between individ1 Address for correspondence: Dr Eric Taylor, MRC Unit in Child Psychiatry, Institute of Psychiatry, De Crespigny Park, London SE5 8AF.

uals. Discontinuities in development become as interesting as continuities, and both may cast light on the determinants of development. The interplay between nature and nurture becomes the chief thing to investigate, rather than an unwelcome complexity for investigators. The approach does not necessarily imply that all child or adult disorders are determined by the interplay of the same factors that determine normal development: on the contrary, there may be qualitative differences between normal and abnormal development (as in the case of autism); but the extent to which a given disorder represents an exaggeration of normal lines or a discontinuity from normal development becomes a key and interesting question. THE MRC UNIT The MRC Unit in Child Psychiatry opened in 1984. Its aim is to advance the understanding of the developmental processes involved in psychopathology. Its particular focus is on the psychological disorders arising in childhood and the continuities and discontinuities with adult mental disorder. It represents a collaboration between an unusually wide variety of scientists, ranging from behavioural geneticists to social anthropologists. Most of the Unit's studies are based on epidemiological and longitudinal strategies, and several studies involve a focus on developmental continuities over unusually long time spans. They therefore have to grapple with major changes in people as they age, and differentiate changes into those that come from biological maturation and those that are consequent upon life experience. Genetic strategies have become increasingly important - not so much to determine the size of the inherited component in disorder, but as a means of understanding

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psychopathological processes. New ways of analysing and thinking about longitudinal data have to be worked out, so there is a need for complex mathematical models of longitudinal change. Many of the studies have found it necessary to advance the basic tools for description of psychopathology and personal interactions. Neither simple rating scales nor highly structured interview approaches have been adequate to capture the phenomena in the detail required; observational and investigator-based interview techniques have become crucial. LONGITUDINAL STUDIES OF HIGHRISK GROUPS Epidemiological studies have made it clear that psychiatric disorder in childhood and adult life is very often associated with psychosocial risk factors. Accordingly there needs to be a programme of research that follows the course of cohorts who are defined by their exposure to one or other of these factors. The two major examples in our current work are the stresses that are associated with being brought up in an institution and being brought up in a family where a parent is mentally ill. We have been able to make an unusually long-term study of the impact of family illness. During the late 1960s a detailed and systematic study was made of the families of adult psychiatric patients and their children. This was in itself a controlled, longitudinal study, involving five assessments over a 4-year period. Systematic and reliable data were gathered on the parents and up to two of their children, focusing on the presence of psychiatric disorder in parents and children, the psychosocial circumstances and the patterns of family life and relationships between different family members. That study showed a strong association between conduct disorder in the children and the presence of discordant hostile relationships in the families. Indeed, in the absence of such relationship problems, there was little association between child and parental disorder. It seemed that the operation of parental mental disorder, as a risk factor for children, was determined by the way that the disorder itself gave rise to deviant personal relationships. The next question was of the effect which these experiences would have upon the adult

adjustment of the children. Accordingly, a detailed follow-up of the families was undertaken at a time when the children had reached adult life. The clearest, and in some ways the most disconcerting finding was the extent to which disorder persisted - both in the parents and in their offspring. In both boys and girls, there was a strong continuity between childhood and early adulthood for moderate emotional and behavioural problems. Indeed, emotional problems were as likely to persist as were conduct problems. This is a quite different finding from that which has emerged from general population studies, where emotional disorders very often clear up spontaneously. The type of disorder may also change. In particular, the girls showed a striking switch. Conduct problems in childhood very often led on to depression and anxiety in adulthood. The continuity is therefore not like the direct persistence of a syndrome, but is more likely to reflect the way that conduct disorder itself alters the environment one lives in, and creates risk factors for other disorders. The second example of investigating a risk factor is the experience of being brought up in an institution. An institutional home can be stable in its form and organization but it lacks some key aspects of normal family life. Stable parental attachmentfiguresare seldom available. Again, a group was available for long-term follow-up. Subjects could be followed into adult life who had been investigated in their teenage years because they had spent much of their childhoods in one of two group cottage children's homes. Control subjects had been identified at the same time who had never been in care, but who had also been raised in a deprived inner-city area. They were followed up to the point where they were adults themselves, and many had children of their own. The institutionalized group had many more difficulties in adulthood. Rearing in a children's home is not as protective for children ' rescued' from appalling family circumstances as most people had thought. The analysis was able to show some of the reasons for this continuity in disadvantage. Conduct disorder was particularly likely to persist and to entail other kinds of problem. At the same time, changes in environmental circumstances could alter parenting and social function. This was most clearly the case when girls had been able to make a

Research report: MRC Unit in Child Psychiatry

supportive marriage. In the rare cases where this happened, the women who had been institutionalized were just as good parents as were the mothers in the comparison sample, regardless of their earlier emotional and behavioural adjustment. Personality and environment could interact: good experiences at school made it more likely that institutionalized girls would exert planning in their approach to life challenges, and this in turn made it more likely that they would make a harmonious marriage to a non-deviant man, and therefore survive relatively unscathed into a satisfactory adult adjustment. Future studies will need to clarify the extent to which persistence is a general characteristic of conduct disorder or the result of interaction with psychosocial risk factors.

LONGITUDINAL STUDIES OF EPIDEMIOLOGICALLY DEFINED GROUPS Any one type of adversity, such as those considered above, will apply only to a minority of children who show disturbances in their psychological development. The Unit, therefore, includes a variety of studies that follow up groups of children identified from the general population - either to show the influence of particular factors such as school atmosphere, or to chart the progress of those children who showed some particular psychological problem such as a behaviour problem or a difficulty in learning to read. One such study is following four groups of children in London, who were first surveyed at the age of 10 and are now in their late twenties. The work so far has shown a strong overlap between reading difficulties and conduct disturbance. Truancy and drop-out from school play an important role in the poor scholastic attainments of reading retarded boys. A poor outcome is not inevitable. For instance, a comparison of black and white teenagers showed that a greater persistence in education among the black group (especially the girls) resulted in a marked 'catch up' in formal scholastic attainments. This finding, like those in the later adjustments of girls reared in institutions, illustrates an important theme. People create their own environments. The way they plan, and

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respond to life changes and challenges, is determined by their previous environments and helps to determine their later environments: it constitutes a key mediator between different stages of development. Understanding this process will require the input from developmentalists about how the transition into adult life is normally managed; and from clinical scientists about how self-esteem and depression alter the ways in which people decide the next steps in their lives. Another programme of study is trying to clarify the nature of school effects on children's behaviour and attainments. It was necessary first of all to show how far school influences did indeed exist. It is perhaps surprising that until recently this was a contentious issue among researchers. However, a comparative study of twelve inner London secondary schools demonstrated marked differences between them affecting not only the academic progress of the children but also their behaviour, out of school as well as in it. Two sets of factors in the school seemed especially important: first, the mix or balance in the intakes - especially the ability spread of pupils; and, second, the social organization of the school and its atmosphere. The influence of the ethos of the school has been explored in two further studies that tested how far aspects of the social environment of a school were open to change. First, an intervention study was mounted as a kind of action research. It involved working with schools in order to produce changes of the kind that previous research had shown to be associated with a more advantageous progress in the children, and an evaluation of the results of doing so. Some change could be demonstrated, but the results were not dramatic and they stressed the long-term nature of many of the processes involved. A second, naturalistic study was of schools where new head teachers had been appointed some years before. It provided rather clearer evidence of the feasibility of changes in practice, because the changes had had longer to produce their effects. There were several instances of a substantial improvement in children's attendance and attainments at school consequent upon the introduction of new school policies. The logical next step in this process is to make prospective studies of the way that school

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organizations can change after a new head teacher is appointed. However, there have recently been great changes in education. Industrial actions in schools, major uncertainties about the future, and the transfer of responsibility from a London Authority to its component boroughs have all conspired to make research in this area extremely difficult. STUDIES OF CLINICAL CONDITIONS Psychopathological research is being maintained into a variety of disorders presenting during childhood. The major conditions being studied are depression, autism, conduct disorder and hyperkinesis. The range is deliberately wide and the conditions have been selected not only because of their clinical importance but also because of the way that they offer rather contrasting examples about the operation of risk factors during development. In autism, for example, there is a clear continuity in the development of affected people and apparently a considerable discontinuity between affected people and the general population. In hyperactivity there is a rather more complex pattern of continuity, with considerable uncertainty about how the disorder changes and acts as a risk. Childhood depression raises in very clear form the developmental issues about reactions to acute stress and chronic adversity that are also being tackled in our longitudinally based studies mentioned above. Conduct disorder is not only a persisting problem, but a risk for other sorts of disorder as well.

CHILDHOOD DEPRESSION Childhood depression is less common than depression in adults, but more common than was realized until recent years. Depressed children are at high risk for continuing psychopathology and deficiencies in social relationships, school performance and emotional development. Many receive no professional psychiatric treatment at all; the suicide rate has been rising in the adolescent age group. A good deal of groundwork has to be done to allow research to advance. We know that depression is associated with many other diagnoses, particularly anxiety and conduct dis-

orders. We do not know whether the people with a second diagnosis are showing the result of the depression, or have a primary condition to which depression itself is secondary. We lack quite basic information about the links between child and adult depression, and need to clarify the existence of these links as well as seeking clues for the mechanisms that may give rise to continuity between different stages of the life span. We know that there is a substantial rise in the prevalence of affective disorder during adolescence, and the reasons for this ought to be clinically important. Some advances in methodology are needed. Accordingly, a comprehensive, standardized, investigator-based, psychiatric interview has been established, with parallel versions for use with parents and children (Child and Adolescent Psychiatric Assessment, CAPA). It includes a wide coverage of psychiatric symptoms, separate measurement of symptom intensity and social incapacity, explicit assessment of onsets and of the timing of changes in severity of symptoms and incapacity; and compatibility with different classification systems. We shall be able to chart the age and sex trends in depressive phenomena in a clinical sample of patients (aged from 8 to 16) who have been newly referred to community and hospital psychiatric clinics. This basic information is required before a full-scale, epidemiologically based, longitudinal design can be mounted to study developmental influences upon depression. The need for longitudinal study into adult life has also made it necessary to make some advances in the methodology of assessing the development of personality and social functioning in adult life. These are notoriously difficult areas in which to achieve either reliability in recording information or descriptions that give a sufficiently full account of an individual's functioning to be of predictive value. New, investigator-based interview techniques have therefore been developed to allow for the reliable recording of rich clinical information concerning personality function and adult psychosocial functioning. The latter (the Adult Psychosocial Functioning Assessment, APFA) systematically covers functioning in six domains: cohabiting love relationships, friendships, work, interpersonal negotiations, non-specific social contacts and day-to-day household responsibilities.

Research report: MRC Unit in Child Psychiatry

Interrater reliability is good, there is good differentiation between individuals, and the six domains can be combined to provide an overall measure of personality functioning. These measures are already being applied in a twenty-year, controlled follow-up of people who had depressive symptoms when they were assessed as children at the Maudsley Hospital. We have linked to this a family genetic study. It is of course known that major depressive disorders in adult life follow a familial pattern, that there is a substantial genetic component and that environmental factors also contribute to familial aggregation. A family genetic strategy offers an important way of examining the continuities that may exist between childhood and adult depression. Is, for example, childhood onset depression a nosologically distinct kind of problem? Is the presence of co-morbidity, already noted, a familially transmitted phenomenon? Does familial loading vary according to whether the disorders, in probands and their relatives, are associated with environmental risk factors? The use of a genetic strategy is valuable in casting light on environmental factors and gene-environment interactions, just as much as it is in clarifying genetic mechanisms of transmission. AUTISM Our understanding of autism is now based upon extensive research over decades. As a result, many aspects of autism are better understood than is usually the case in child psychiatric conditions. It is clearly a biologically based, pervasive disorder of development and virtually always imposes a handicap. Even so, there is still some controversy about the boundaries of the syndrome and the extent to which there is a continuum with normal mental life. More discriminating measures of language, social and behavioural functioning have had to be devised. A standardized, investigator-based parental interview and a standardized observational schedule have been developed and shown to have satisfactory reliability and discriminative validity; and a set of experimental socioemotional tasks have been designed and tested. The interview is now being applied in a range of different studies. Our present work is designed to examine the psycho-

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logical deficit that may characterize autism, the genetic basis of the disorder, and the neurobiology of the condition. The links between these research strategies are important, so that for example it is highly desirable to be able to use genetic strategies to try to clarify whether any neuropsychological deficit that is found is itself the inherited basis of the disorder or rather the consequence of the inherited psychiatric condition. Genetic studies have already shown unmistakable signs that there is an inherited basis. Twin studies carried out from the Institute of Psychiatry made it clear that concordance is very much higher for monozygotic than for dizygotic twins. Autism itself is not the only characteristic of affected family members: many show a much broader range of cognitive abnormalities. It seems probable that the phenotype of autism includes both cognitive and social impairment. A longitudinal perspective has been important here, for the non-autistic monozygotic twins of autistic children have shown an increasing rate of emerging social deficits during adolescence and adult life. At the same time, comparative studies of children with autism and other developmental impairments of language have shown the variety that exists in the co-morbidity of language deficit and social impairment. Children with developmental disorders of representational language tend later on to develop quite marked evidence of social impairment and in a few cases this has gone on to the unexpected appearance of florid psychoses. This is an outcome that does not characterize the later course of autistic people. Meanwhile other biological and neuropsychological researches have produced interesting results. For example, CAT scanning of adults with autism has shown structural changes in the region of the caudate nucleus. The fragile X chromosome anomaly has a much weaker association with autism than was previously appreciated. Cognitive psychological approaches have suggested that autistic children may be characterized by difficulties in understanding other minds and by difficulties in understanding emotional aspects of the world. These lines of study now need to be brought together, to cast light on what is inherited and what determines the expression of disorder.

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HYPERACTIVITY

Research into hyperactivity is the most recent line of research to be brought into the MRC Unit. Previously, clinical and epidemiological surveys showed that much 'hyperactive' behaviour was situationally specific but diagnostically non-specific and reflected poor socialization rather than brain dysfunction. A US-UK investigation indicated that most of the apparent difference between nations in the prevalence of hyperactivity arose from the way that the clinical diagnosis was made in different places. A followup study showed that diagnosed children had a poor prognosis - many of them had substantial personality problems in adult life. The next phase of research, therefore, involved the development and testing of a set of more precise and quantitative measures of various aspects of hyperactive behaviour and impaired attention. These reliable measures were then applied in clinic surveys of referred children. Statistical classification techniques identified a separable but uncommon group of cases showing a hyperkinetic disorder. Examination of the associations of the newly defined hyperkinetic disorder indicated that it was indeed linked to other evidence of brain dysfunction. Treatment trials were used to validate the disorder by its reponse to therapy. A large epidemiological survey confirmed the concept of hyperkinesis and indicated the prevalence and the associations of the condition. The establishment of research diagnostic criteria has led on to the current phase of research: experimental analysis of the disorder from the perspective of several disciplines. This includes psychological and neurophysiological analysis of the attention deficit, analysis of the reasons for the large excess of affected males, measuring the friendship patterns and family relationships of affected children, and identifying psychosocial factors that determine the course of disorder. We are also collaborating with other centres in Europe to help in the assessment of outcome in clinical trials, and with the University of Hong Kong for a cross-cultural study of prevalence. The main purpose of bringing this research into the Unit is to enable a focus on longitudinal studies designed to clarify the mechanism through which hyperactivity develops and the

nature of the factors that maintain it after it has appeared. DEVELOPMENTAL PSYCHOLOGY STUDIES Developmental psychology is not only a donor to the study of disorder; psychopathology raises new questions about the course of normal development and makes new demands for methods of study. Peer relationships are important predictors of psychological adjustment later, and we need to know more about the qualities of relationships that are important. Accordingly, a programme of study is tracing social conflict and prosocial behaviour in normal children; and the effect of normal transitions such as starting at school. In the first three years of life there seems to be something of a rise and fall in prosocial behaviour - the latter as more pragmatic, rulefollowing considerations take over from spontaneous helpfulness. Peer relationships and school adjustment are also influenced by the quality of close family relationships, but the relationships are complex. The effect of maternal depression is being assessed by a set of studies, and observational methods of measuring the subtleties of exchange between mother and child are being developed and applied. GENETIC STUDIES Genetic strategies have become increasingly important, and are now a core aspect of the work. Examples have been given for the various psychopathological disorders under study. The distinctive aspect is the combination of family genetic with longitudinal studies, and this approach is also being taken in two twin studies. One focuses on conduct disorder referred for psychiatric help during childhood, and studies probands and their co-twins; the aim of this study is to examine genetic and environmental influences on persistence or discontinuity of disorder from childhood into adult life. The other study involves collaboration with an epidemiological study of school-age twins in Virginia who are followed over four years. This study will examine several questions, including the role of genetic influences on the onset and

Research report: MRC Unit in Child Psychiatry

persistence of disorder, the relative importance of age versus puhertal changes in increasing rates of disorder in adolescence, and whether comorbid disorders represent distinct genetic subtypes or occur for other reasons. These prospective genetic strategies need to be applied to other childhood psychiatric disorders. The Unit's work so far has led to a number of publications, and those from the last two years are appended as a bibliography. Readers who would like to explore the work further will find general accounts in the following: Robins & Rutter (1990), for the developmental approach to longitudinal research; Rutter, Bolton, Harrington et al. (1990) and Rutter, Macdonald, LeCouteur et al. (1990) for the genetic approaches; and Rutter, Maughan, Mortimore et al. (1979) for the schools-based studies. This outline of the Unit's work has taken examples of investigations to illustrate the main intellectual themes. The senior staff of the Unit - Drs Hay, Maughan, Pickles and Quinton as well as ourselves - are all engaged in building links between psychosocial and clinical sciences to encourage new ways of thinking about developmental psychopathology. This exchange may prove to be one of the most important functions of the Unit. BIBLIOGRAPHY Recent publications from members of the MRC Child Psychiatry Unit Birns, B. & Hay, D. F. (eds) (1988). Different Faces of Motherhood. Plenum: New York. Bollon, P. & Rutter, M. (1990). Genetic influences in autism. International Review of Psychiatry 2, 67-80. Cantwell, D. P., Baker. L., Rutter, M. & Mawhood, L. (1989). Infantile autism and developmental receptive dysphasia: a comparative follow-up in.o middle childhood. Journal of Autism and Developmental Disoraers 19, 19-31. Caplan, M. Z. & Hay, D. F. (1989). Preschoolers' responses to peers' distress and beliefs about bystander intervention. Journal of Child Psychology and Psychiatry 30, 231-242. Champion, L. (1990). The relationship between social vulnerability and the occurrence of severely threatening life events. Psychological Medicine 20, 157-161. Couchley, R. & Pickles, A. (1989). An empirical comparison of conditional and marginal likelihood methods in a longitudinal study. Sociological Methodology 19, 161-183. Cox, A., Rutter, M. & Holbrook, D. (1988). Psychiatric interviewing techniques: a second experimental study: eliciting feelings. British Journal of Psychiatry 152, 64-72. Everall, I. & Le Couteur, A. (1990). Firesetting in an adolescent boy with Asperger's syndrome. British Journal of Psychiatry 157, 284-287. Folstein, S. & Rutter, M. (1988). Autism: familial aggregation and genetic implications. Journal of Autism and Developmental Disorders 18, 3-30.

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Golding, J., Hull, D. & Rutter, M. (1988). Child health and the environment. In Child Health in a Changing Society (ed. J. O. Forfar), pp. 122-154. Oxford University Press: Oxford. Harrington, R. C. (1989). Child and adolescent depression: recent developments. Current Opinion in Psychiatry 2, 480-483. Harrington, R. C. (1989). Child and adult depression: concepts and continuities. Israel Journal of Psychiatry and Related Science 26, 1-2, 12-29. Harrington, R. C. (1990). Depressive disorder in children and adolescents. British Journal of Hospital Medicine 43, 108-112. Harrington, R., Hill, J., Rutter, M., John, K., Fudge, H., Zoccolillo, M. & Weissman, M. (1988). The assessment of lifetime psychopathology : a comparison of two interviewing cycles. Psychological Medicine 18, 487-493. Harrington, R. C , Fudge, H., Pickles, A., Rutter, M. & Hill, J. (1990). Adult outcomes of childhood and adolescent depression. I. Psychiatric status. Archives of General Psychiatry 47, 465-473. Harrington, R. C , Fudge, H., Rutter, M., Pickles, A. & Hill, J. (1991). Adult outcomes of childhood and adolescent depression. II. Links with antisocial disorders. Journal of the American Academy of Child and Adolescent Psychiatry 30, 434-439. Hay, D. F. (1988). Relationships and development. In Handbook of Personal Relationships (ed. S. Duck), pp. 117-120. Wiley: Chichester. Hay, D. F. (1988). Studying the impact of ordinary life: a developmental model, research plan and words of caution. In Studies of Psychosocial Risk: The Power of Longitudinal Data (ed. M. Rutter), pp. 245-254. Cambridge University Press: New York. Hay, D. F. (1990). Self-interest and humanity: some reactions to Dunn's "The Beginnings of Social Understanding'. Developmental Review 10, 311-316. Hay, D. F. & Lockwood, R. (1989). Girls' and boys' success and strategies on a computer-generated hunting task. British Journal of Developmental Psychology 7, 17-27. Hay, D. F., Stimson, C. A. & Castle, J. (1990). Imitation and desire: a meeting of minds in infancy. In Children's Developing Theories of Minds (ed. D. Frye and C.Moore), pp. 115-137. Erlbaum: Hillsdale, NJ. Herold, S., Frackowiak, R. S. J., Le Couteur, A., Rutter, M. & Howlin, P. (1988). Cerebral blood flow and metabolism of oxygen and glucose in young autistic adults. Psychological Medicine 18, 823-831. Hill, J., Harrington, R., Fudge, H., Rutter, M. & Pickles, A. (1989). Adult personality functioning assessment (APFA): an investigatorbased standardised interview. British Journal of Psychiatry 155, 24-35. Howlin, P. & Rutter, M. (1989). Mothers' speech to autistic children: a preliminary causal analysis. Journal of Child Psychology and Psychiatry 30, 819-843. Jacobson, R., Le Couteur, A., Howlin, P. & Rutter, M. (1988). Selective sub-cortical abnormalities in autism. Psychological Medicine 18, 39-48. James, A. & Taylor, E. (1990). Sex differences in the hyperkinetic syndrome of childhood. Journal of Child Psychology and Psychiatry 31, 437-446. Le Couteur, A. (1988). The role of genetics in the aetiology of autism, including findings of the links with the fragile X syndrome. In Aspects of Autism: Biological Research (ed. L. Wing), pp. 38-52. Gaskell Psychiatry Series: London. Le Couteur, A. (1990). Autism: current understanding and management. British Journal of Hospital Medicine 43, 448-452. Le Couteur, A., Rutter, M., Summers, D. & Butler, L. (1988). Fragile X in female autistic twins. Journal of Autism and Developmental Disorders 18, 458-460. Le Couteur, A., Trygstad, O., Evered, C , Gillberg, C. & Rutter, M. (1988). Infantile and urinary excretion of peptides and proteinassociated peptide complexes. Journal of Autism and Developmental Disorders 18, 181-190. Le Couteur, A., Rutter, M., Lord, C , Rios, P., Robertson, S., Holdgrafer, M. & McLennan, J. D. (1989). Autism Diagnostic

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Interview: a standardised investigator-based instrument. Journal of Autism and Developmental Disorders 19, 363-387. Lord, C , Rutter, M., Goode, S., Heemsbergen, J., Jordan, H., Mawhood, L. & Schopler, E. (1989). Autism Diagnostic Observation Schedule: a standardised observation of communicative and social behaviour. Journal of Autism and Developmental Disorders 19, 185-212. Macdonald, H., Rutter, M., Howlin, P., Le Couteur, A., Evered, C. & Folstein, S. (1989). Recognition and expression of emotional cues by autistic and normal adults. Journal of Child Psychology and Psychiatry 30, 865-877. Maughan, B. (1988). School experiences as risk/protective factors. In Studies of Psychosocial Risk: The Power of Longitudinal Data (ed. M. Rutter), pp. 200-220. Cambridge University Press: New York. Maughan, B. (1989). Growing up in the inner city: findings from the inner London longitudinal study. Paedialric and Perinatal Epidemiology 3, 195-215. Maughan, B. & Champion, L. (1990). Risk and protective factors in the transition to young adulthood. In Successful Ageing: Perspectives from the Behavioural Sciences (ed. P. B. Baltes and M. M. Baltes), pp. 296-331. Cambridge University Press: Cambridge. Maughan, B. & Dunn, G. (1988). Black pupils' progress in secondary school. In Educational Attainments: Issues and Outcomes in Multicultural Education (ed. G. Verma and P. Pumfrey), pp. 112-127. Falmer Press: London. Maughan, B. & Pickles, A. (1990). Adopted and illegitimate children growing up. In Straight and Devious Pathways from Childhood to Adulthood (ed. L. Robins and M. Rutter), pp. 36-61. Cambridge University Press: New York. Maughan, B. & Rutter, M. (1990). Peer commentary on P. Bryant and U. Goswami: comparisons between backward and normal readers - a risky business. BPS Educational Section Review 14, 19-21. Maughan, B., Ouston, J., Pickles, A. & Rutter, M. (1990). Can schools change? I. Outcomes at six London Secondary Schools. School Effectiveness and School Improvement 1, 188-210. Mawhood, L., Goode, S. & Howlin, P. (1990). Evaluation of the Bromley autistic project: Hamilton House. Communication 24, 59-62. O'Farrell, P. & Pickles, A. (1989). Entrepreneurial behaviour within male work histories: a sector specific analysis. Environment and Planning 21, 311-331. Ouston, J., Maughan, B. & Rutter, M. (1991). Can schools change? II. Changes in practice. School Effectiveness and School Improvement 2, 3-13. Pickles, A. (1989). Statistical modelling of longitudinal data. In Studies of Psychosocial Risk: The Power of Longitudinal Data (ed. M. Rutter), pp. 62-76. Cambridge University Press: New York. Pickles, A. & Crouchley, R. (1991). Applications of stochastic process models in clinical psychology and psychiatry. In Applications of Statistics in Medicine (ed. F. Dunstan and J. Pickles), pp. 125-148. Oxford University Press: Oxford. Pickles, A. & Davies, R. B. (1989). Inference from cross-sectional and longitudinal data from dynamic behavioural processes. In Contemporary Developments in Quantitative Geography (ed. J. Hauer, H. Timmermans and N. Wrigley), pp. 81-104. Reidel: Amsterdam. Power, M. J. & Champion, L. (1988). Perspectivas cognitivas da depressao: Critica teorica. Analise Psicologica 2, 183-196. Power, M. J., Champion, L. & Aris, S. J. (1988). The development of a measure of social support: the Significant Others Scale. British Journal of Clinical Psychology 27, 349-359. Prendergast, M., Taylor, E., Rapoport, J. L., Bartko, J., Donnelly, M., Zametkin, A., Ahearn, M. B., Dunn, G. & Wieselberg, H. M. (1988). The diagnosis of childhood hyperactivity. A US-UK crossnational study of DSM-III and ICD-9. Journal of Child Psychology and Psychiatry 29, 289-300. Quinton, D. (1988). Urbanism and child mental health. Journal of Child Psychology and Psychiatry 29, 1-20.

Quinton, D. (1989). Longitudinal approaches to intergenerational studies: definition, design and use. In Studies of Psychosocial Risk: The Power of Longitudinal Data (ed. M. Rutter), pp. 272-284. Cambridge University Press: New York. Quinton, D. (1989). Adult consequences of early parental loss. British Medical Journal 299, 694-695. Quinton, D. & Rutter, M. (1988). Parenting Breakdown: The Making and Breaking of Intergenerational Links. Avebury: Gower. Quinton, D., Rushton, A. & Treseder, J. (1988). New Parents for Older Children. BAAF: London. Quinton, D., Rutter, M. & Gulliver, L. (1990). Continuities in psychiatric disorders from childhood to adulthood in the children of psychiatric patients. In Straight and Devious Pathways from Childhood to Adulthood (ed. L. Robins and M. Rutter), pp. 259-278. Cambridge University Press: Cambridge. Robins, L. & Rutter, M. (eds) (1990). Straight and Devious Pathways from Childhood to Adulthood. Cambridge University Press: New York. Rutter, M. (1988). Epidemiological approaches to developmental psychopathology. Archives of General Psychiatry 45, 486 500. Rutter, M. (1988). Review Symposium: The comprehensive experiment : a comparison of the selective and non-selective school organisation. British Journal of Sociology of Education 9, 107 112. Rutter, M. (1988). Biological basis of autism: implications for intervention. In Preventive and Curative Intervention in Menial Retardation (ed. F. J. Menolascino and J. A. Stark), pp. 265 294. Paul H. Brookes Publishing: Baltimore. Rutter, M. (1988). Autism: biological concepts and treatment prospects. In A Challenge to Child Psychiatry (ed. R. Takagi and L. Wing), pp. 31-54. Iwasaki Gakujutsu Shuppansha: Tokyo. Rutter, M. (1988). Depressive disorders. In Assessment and Diagnosis in Child Psychopathology (ed. M. Rutter, A. H. Tuma and I. S. Lann), pp. 347-376. Guilford Press: New York. Rutter, M. (1988). DSM-III-R: a postscript. In Assessment and Diagnosis in Child Psychopathology (ed. M. Rutter, A. H. Tuma and I. S. Lann), pp. 453-464. Guilford Press: New York. Rutter, M. (ed.) (1988). Studies of Psychosocial Risk: The Power of Longitudinal Data. Cambridge University Press: Cambridge. Rutter, M. (1988). Psychosocial risk trajectories and beneficial turning points. In Early Influences Shaping the Individual (ed. S. Doxiadis), pp. 229-239. Plenum: New York. Rutter, M. (1989). Attention deficit disorder/hyperkinetic syndrome: conceptual and research issues regarding diagnosis and classification. In Attention Deficit Disorder: Clinical and Basic Research (ed. T. Sagvolden and T. Archer), pp. 1-24. Erlbaum: Hillsdale, NJ. Rutter, M. (1989). Intergenerational continuities and discontinuities in serious parenting difficulties. In Child Maltreatment (ed. D. Cicchetti and V. Carlson), pp. 317-348. Cambridge University Press: New York. Rutter, M. (1989). Temperament: conceptual issues and clinical implications. In Temperament in Childhood (ed. G. A. Kohnstamm, J. E. Bates and M. K. Rothbart), pp. 463-479. Wiley: Chichesler. Rutter, M. (1989). Approche psycho-educative pour le traitement des autistes. In Aulisme et Troubles du De'veloppement Global de tEnfant (ed. G. Lelord, J. P. Muh, M. Petit and D. Sauvage), pp. 172-188. Expansion Scientifique Francaise: Paris. Rutter, M. (1989). Psychiatric disorder in parents as a risk factor for children. In Prevention of Mental Disorders, Alcohol and other Drug Use in Children and Adolescents (ed. D. Shaffer, I. Philips and N. B. Enzer), pp. 157-189. OSAP Prevention Monograph 2. Office for Substance Abuse Prevention, US Department of Health and Human Services: Rockville, Maryland. Rutter, M. (1989). Autism: current concepts, research findings and implications for services. In Proceedings of Workshop on ' Working with Young Handicapped Children - The Way Ahead', pp. 52-65. Heep Hong Society: Hong Kong. Rutter, M. (1989). Pathways from childhood to adult life. Journal of Child Psychology and Psychiatry 30, 23-51. Rutter, M. (1989). Age as an ambiguous variable in developmental research: some epidemiological considerations from developmental

Research report: MRC Unit in Child Psychiatry psychopathology. International Journal of Behavioral Development 12, 1-34. Rutter, M. (1989). Annotation: child psychiatric disorders in ICD10. Journal of Child Psychology and Psychiatry 30, 499-513. Rutter, M. (1989). Isle of Wight revisited: twenty-five years of child psychiatric epidemiology. Journal of the American Academy of Child and Adolescent Psychiatry 28, 633-653. Rutter, M. (1990). Role de la cognition dans le developpement et les troubles de 1'enfant. In Nouvelles Approches de la Same Mentale de la Naissance a tAdolescence pour TEnfant et sa Famille (ed. C. Chiland and J. G. Young), pp. 275-307. Presses Universilaires de France: Paris. Rutter, M. (1990). Psychological implications for youth of biopsycho-social and societal-individual mismatches. In Annual Report 1989/90, pp. 15-22. Johann Jacobs Foundation: Zurich. Rutter, M. (1990). Psychosocial resilience and protective mechanisms. In Risk and Protective Factors in the Development of Psychopathology (ed. J. Rolf, A. Masten, D. Cicchetti, K. Neuchterlein and S. Weintraub), pp. 181-214. Cambridge University Press: New York. Rutter, M. (1990). Changing patterns of psychiatric disorders during adolescence. In Adolescence and Puberty (ed. J. Bancroft and J. M. Reinisch), pp. 124-145. Oxford University Press: New York. Rutter, M. (1990). Commentary: some focus and process considerations regarding effects of parental depression on children. Developmental Psychology 26, 60-67. Rulter, M. (1990). Interface between research and clinical practice in child psychiatry - so-ne personal reflections: discussion paper. Journal of the Royal Society of Medicine 83, 444-447. Rutter, M. (1991). Autism: pathways from syndrome definition to pathogenesis. Comprehensive Mental Health Care 1, 5-26. Rutter, M. (1991). Childhood experiences and adult psychosocial functioning. In The Childhood Environment and Adult Disease (ed. G. R. Bock and J. Whelan), pp. 189-200; discussion pp. 200-208. Ciba Foundation Symposium No. 156. Wiley: Chichester. Rutter, M. (1991). A fresh look at 'maternal deprivation'. In The Development and Integration of Behaviour (ed. P. Bateson), pp. 331-374. Cambridge University Press: Cambridge. Rutter, M. (1991). Age changes in depressive disorders: some developmental considerations. In The Development of Emotion and Dysregulation (ed. J. Garber and K. Dodge), pp. 273-300. Cambridge University Press: Cambridge. Rutter, M. (1991). Autism as a genetic disorder. In The New Genetics of Mental Illness (ed P. McGuffin and R. Murray), pp. 225-244. Heinemann Medical Oxford. Rutter, M. & Pickles, A. (1990). Improving the quality of psychiatric data: classification, cause and course. In Data Quality in Longitudinal Research (ed. D. Magnusson and L. R. Bergman), pp. 32-57. Cambridge University Press: Cambridge. Rutter, M. & Schop'er, E. (1988). Autism and pervasive developmental disorders. In Assessment and Diagnosis in Child Psychopathology (ed. M. Rulter, A. H. Tuma and I. S. Lann), pp. 408-434. Guilford Press: New York. Rutter, M. & Schopler, E. (1988). Autism and pervasive developmental disorders: concepts and diagnostic issues. In Diagnosis and Assessment in Autism (ed. E. Schopler and G. Mesibov), pp. 15-36. Plenum: New York. Rutter, M, & Tuma, A. H. (1988). Diagnosis and classification: some outstanding issues. In Assessment and Diagnosis in Child Psychopathology (ed. M. Rutter, A. H. Tuma and I. S. Lann), pp. 437-452. Guilford Press: New York. Rutter, M., Maughan, B., Mortimore, P., Ouston, J. & Smith, A. (1979). Fifteen Thousand Hours. Open Books: London. Rutter, M., Le Couteur, A., Lord, C , Macdonald, H., Rios, P. & Folstein, S. (1988). Diagnosis and sub-classification of autism: concepts and instrument development. In Diagnosis and Assessment in Autism (ed. E. Schopler and G. Mesibov), pp. 239-259. Plenum: New York.

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Rutter, M., Tuma, A. H. & Lann, I. S. (eds) (1988). Assessment and Diagnosis in Child Psychopalhology. Guilford Press: New York. Rutter, M., Bolton, P., Harrington, R., Le Couteur, A., Macdonald, H. & Simonoff, E. (1990). Genetic factors in child psychiatric disorders. I. A review of research strategies. Journal of Child Psychology and Psychiatry (Annual Research Review) 31, 3-37. Rutter, M., Macdonald, H., Le Couteur, A., Harrington, R., Bolton, P. & Bailey, A. (1990). Genetic factors in child psychiatric disorders. II. Empirical findings. Journal of Child Psychology and Psychiatry (Annual Research Review) 31, 39-83. Rutter, M., Quinton, D. & Hill, J. (1990). Adult outcome of institution-reared children: males and females compared. In Straight and Devious Pathways from Childhood to Adulthood (ed. L. Robins and M. Rutter), pp. 135-157. Cambridge University Press: New York. Shaffer, D., Gould, M. S., Rutter, M. & Sturge, C. (1991). Reliability and validity of a psychosocial axis in patients with child psychiatric disorder. Journal of the American Academy of Child and Adolescent Psychiatry 30, 109-115. Simonoff, E. & Heath, A. C. (1989). A model-fitting approach to the estimation of genetic and environmental factors from twin data. International Review of Psychiatry 1, 297-306. Taylor, E. (1988). Commissioned review - psychopharmacology in childhood. Newsletter, Association for Child Psychology and Psychiatry 10, 3-6. Taylor, E. (1988). Attention deficit and conduct disorder syndromes. In Assessment and Diagnosis in Child Psychopathology (ed. M. Rutter, A. H. Tuma and I. S. Lann), pp. 377-407. Guilford Press: New York. Taylor, E. (1988). On the epidemiology of hyperactivity. In Attention Deficit Disorder, Clinical and Basic Research (ed. T. Sagvolden and T. Archer), pp. 31-52. Erlbaum: Hillsdale, NJ. Taylor, E. (1989). Diagnosis of hyperactivity: a British perspective. In Attention Deficit Disorder: Criteria, Cognition and Intervention. Journal of Child Psychology and Psychiatry Supplement No. 5 (ed. L. Bloomingdale and J. Sergeant), pp. 141-160. Pergamon: Oxford. Taylor, E. (1989). Disorders of self-regulation. In Head Injured Children: Who Cares'! (ed. D.Johnson), pp. 111-120. Headway: London. Taylor, E. (1989). Externalising disorders: priorities for future research. In Needs and Prospects of Child and Adolescent Psychiatry (ed. M. H. Schmidt and H. Remschmidt), pp. 67-81. Hogrefe & Huber: Bern. Taylor, E. (1990). Nutritional effects on behaviour - Do they occur? In The Food Challenge: Common and Uncommon Reaction to Food and Drink (ed. R. Cottrell), pp. 13-29. British Nutrition Foundation: London. Taylor, E. (1990). Research issues in attention deficit. In Attention Deficit Disorder: Current Concepts and Emerging Trends in Altentional and Behavioral Disorders of Childhood. Journal of Child Psychology and Psychiatry Supplement No. 6 (ed. L. Bloomingdale and J. Swanson), pp. 313-334. Pergamon: Oxford. Taylor, E. (1990). The interaction of psychological and biological processes in children. In Brain and Behavior in Child Psychiatry (ed. A. Rothenberger), pp. 3-15. Springer-Verlag: Berlin. Taylor, E. (1991). Developmental neuropsychiatry. Journal of Child Psychology and Psychiatry 32, 3-47. Taylor, E. & Hemsley, R. (1990). Dietary treatment in autism and hyperactivity. Communication 24, 50-52. Taylor, E. & Heptinstall, E. (1990). Dietary treatment for hyperactivity - does it work? Maternal and Child Health 15, 98-102. Taylor, E., Sandberg, S., Thorley, G. & Giles, S. (1991). The Epidemiology of Childhood Hyperactivity. Maudsley Monographs No. 33. Oxford University Press: Oxford. van Goor-Lambo, G., Orley, J., Poustka, F. & Rutter, M. (1990). Classification of abnormal psychosocial situations: preliminary report of a revision of a WHO scheme. Journal of Child Psychology and Psychiatry 31, 229-241.