LETTERS TO THE EDITOR
is of factors which are largely inert on their own but, to use a chemical analogy, serve as catalysts when combined with acute stressors of some type.... When they tend to reduce the effect of stressors, they are usually termed protective factors (as considered by Rutter, 1979)" (p. 340--341). The article then went on to consider the detection of statistical interaction effects in relation to the postulated protective influence of social networks and close personal relationships. The 1979 article stated: "The first point to make is the very great importance of interactive effects" (p.51). A more recent article (Rutter, 1987) dealt at length with the importance of the concept of protective mechanisms as interaction effects and of the implications for data analysis that flow from this recognition. In short, the theoretical position that I have advocated for over a decade is precisely that put forward by Jenkins and Smith and so elegantly dealt with in their own important empirical study. One additional point needs to be made, however, and that is that there are many circumstances in which it is misleading to equate interaction mechanisms with a statistically significant interaction term in the multivariate analysis. Some of the reasons why that is so are discussed in Rutter (1983), and a more extended conceptual and statistical account is provided in Rutter and Pickles (in press). Michael Rutter, M.D., F.R.S. Institute of Psychiatry London REFERENCES
Jenkins, J. M. & Smith, M. A. (1990), Factors protecting children living in disharmonious homes: maternal reports. J. Am. Acad. Child Adolesc. Psychiatry, 29:60--69. Rutter, M. (1979), Protective factors in children's responses to stress and disadvantage. In: Primary Prevention ofPsychopathology: Vol. 3: Social Competence in Children, eds. M. W. Kent & J. E. Rolf. Hanover, NH: University Press of New England. - - (1981), Stress, coping and development: some issues and some questions. J. Child Psychol. Psychiatry, 22:323-356. - - (1983), Statistical and personal interactions: facets and Perspectives. In: Human Development: An interactional perspective, eds. C. Magnusson & V. Allen. New York: Academic Press, pp. 295319. - - (1987), Psychosocial resilience and protective mechanisms. Am. J. Orthopsychiatry, 57:316-331. - - Pickles, A. (in press), Person-environment interactions: concepts, mechanisms and implications for data analysis. In: OrganismEnvironment Interaction, eds. R. Plomin & T. Wachs. Washington, DC: American Psychological Association.
Autism and Asperger's: Same or Different? To the Editor:
We found it interesting to read the paper by Szatmari and colleagues (1990) on the neurocognitive aspects of Asperger's syndrome (AS), which is likely to be a subcategory of the pervasive development disorders (POD) in ICD-lO (Rutter, 1989). However, general opinion among researchers and now Szatmari's group is that AS is merely a variant of high-functioning autism (HFA), raising the question of how discrete is the autistic syndrome. This paper is the first controlled study of the question of diagnostic subcategories among individuals who have POD but are not mentally retarded. Szatmari et al.'s careful, considered, analysis provides some fascinating and unexpected findings on the neuropsychological profile of the normal intelligence (lQ > 85) POD group as a whole but failed to find very important differences between HFA and AS. This appears to provide additional evidence for the unnecessary subclassifiction of POD, but the authors admit that there are reasons for considering limitations in their study. These include the wide age range of the subjects, varying recruitment
152
sources, and mixed retrospective and prospective diagnostic assessments. We are in the process of studying children (5 to 12 years) who have POD (by DSM-III-R) and have a testable intelligence in the nonretarded range. They are being compared with language impaired and behavior disordered (control) children on a number of neuropsychological and neurobiological variables. Within the POD group, we believe there are three clinical subgroups; namely, classical (or Kanner's) autism, language impaired POD, and nonlanguage impaired POD. Only the latter would be considered AS by our criteria. After our review of this paper, we decided to assess the validity of our proposed groupings by analyzing preliminary data from the first 41 subjects (26 POD and 15 controls) we had assessed. To create our three PDD subgroups, we merely took the clinical data obtained from a parent interview, devised by Dr. Szatmari, for diagnosing POD and blindly rated for the presence of classical autism (i.e., aloofness, echolalia, pronoun reversal, need for sameness, etc., before 3 years of age). If the criteria were not fulfilled, the remaining subjects were differentiated by the presence or absence of developmental language disorder. We found that a discriminant analysis using the global scales of the Kaufman-ABC (five scores derived from the individual test scores of this battery) revealed a correct diagnostic classification 76% of the time (Kappa = 0.68). Only two POD subjects were placed in an alternative POD group. Given that there were overall IQ differences between groups, repeated discriminant analyses were performed on the mental processing composite score (MPC, comparable but not equivalent to an IQ score) alone and after deleting it from the analysis, which produced correct classifications of 41% and 37%, respectively. The analysis of MPC alone produced two groups, high and low functioning, in which POD subjects were evenly distributed independent of our subgroupings. It was therefore apparent that differentiation between groups was a consequence of the full range of neuropsychological skills. Furthermore, the groups showed fairly specific profiles on the subtests. The autistic group was typified by strengths in Gestalt closure, number recall, triangles, and reading/decoding and reading/understanding and by significant weakness in achievement measures requiring abstract processing (e.g., riddles). Language impaired PDD subjects were weak in all subtests. Nonlanguage impaired PDD subjects were comparatively weak in Gestalt closure, spatial memory, and photo series, but achievement scores were above intellectual expectation. We do not present this data to refute Szatmari's findings, not the least because we have not completed our studies, nor subjected them to peer scrutiny. However, we did find a more traditional pattern of psychological strengths and weaknesses in our autistic group. Given that diagnostic criteria for AS are unclear and if the remaining POD subjects were therefore grouped all as AS, there would be little likelihood of eliciting a difference between AS and HFA because their very different neuropsychological patterns would be lost in the group data. The differences we found may be because of different measures (Wechsler Intelligence Scale for Children-Revised versus KaufmanABC), different subject selection (more mild or subtle disorders in our cohort), or that we have merely selected three levels of severity of POD. Although these errors may prove to be true, this does not explain the different group profiles and would warrant caution in eliminating POD subgroups of clinical and heuristic value. John C. Pomeroy, MBBS, MRC Psych. Carol Friedman, Ph.D. Laurie Stephens, M.A. State University of New York at Stoney Brook REFERENCES
Rutter, M. (1989), Child psychiatric disorders in ICD-lO. J. Child Psychol. Psychiatry, 30:499-513. J.Am.Acad. Child Adolesc.Psychiatry, 30:1 ,January 1991
LEITERS TO THE EDITOR
Szatmari, P., Tuff, L. , Finlayson, M. A. J. & Bartolucci , G. (1990), , Asperger' s syndrome and autism: neurocognitive aspects. J . Am. Acad. Child Adolesc. Psychiatry, 29:130-136.
Szatmari, P., Bartolucci, G. & Bremner, R., (1989), Asperger' s Syndrome and autism: comparisons on early history and outcome. Dev. Med. Child Neurol. 31:709-720
Maternal versus Fetal Rights
Dr . Szatmari replies : I was very interested to read the letter submitted by Dr. Pomeroy land colleagues. The point that they make in reference to our earlier 'article (Szatmari et aI. , 1990) is that if one divides POD subjects into 'three subgroups, distinct neuropsychological profiles might emerge . :The data they have provided would certainly seem to substantiate this trend. Perhaps with larger numbers, they may be able to make some 'more definite conclusions. There is no doubt that the study in progress, reported by Dr. Porneroy, has certain methodological advantages over our study. For ex'ample, there is a much closer matching of age and IQ. In addition, 'when we began our study of Asperger' s syndrome in 1984, there was 'no clear consensus about diagnostic criteria for this group of children. (rhus, their ability to separate POD subjects into three subgroups is 'an important advance. In a cluster analysis of POD subjects that we 'performed (Szatmari et al., 1989), we too were able to identify similar subgroups, but we could not carry this analysis much further because of the small sample size involved. : There is, however, a conceptual point that I would like to make with respect to the letter submitted by Dr. Pomeroy and colleagues. They suggest that because we were unable to find significant differences in neuropsycholocial profiles between autistic and Aspergcr's syndrome children, this latter group is "merely a variant of highfunctioning autism. " Furthermore , our data "appear to provide further evidence for the unnecessary subclassification of POD." The key Issue it seems to me, is to consider what data would be required to justify the subclassification of POD. It is not at all clear that the criteria previously outlined for the diagnostic validity of a disorder (Rutter, 1978) should also apply to the classification of subtypes of POD. One possible interpretation of the available literature is that Asperger's syndrome and autism differ in their clinical features but not necessarily on their etiology. Similarity in neuropsychological profiles between these two disorders, presumably, might reflect similar pathogenic mechanisms. However, just because two disorders share a similar etiology is not necessarily a reason to collapse them. For example, Tourette's syndrome and obsessive-compulsive disorders appear to share a common genetic etiology. However, no one would seriously consider these as the same disorder. , Perhaps diagnostic validity is best considered a relative rather than an absolute term. Under these circumstances, it may make more sense to consider whether subclassification is " useful" rather than "correct." Under certain circumstances (such as genetic studies or brain imaging studies), it may be useful to collapse autistic and Asperger's syndrome subjects into a general category. On the other hand, there may be other circumstances (such as for follow-up studies or intervention studies) where it may be more useful to separate and subclassify them. i The data that Pomeroy et al. have provided in their pilot study certainly suggest additional reasons for continued investigation into Asperger's syndrome. Perhaps the real disadvantage in considering Asperger' s syndrome as a nonvalid disorder or " merely a variant of high-functioning autism" is that additional research into this fascinating group of children would be discouraged. Peter Szatmari, M.D ., F.R.C.P.(C) McMaster University, Hamilton, Ontario REFERENCES
Rutter, M. (1978), Diagnostic validity in child psychiatry. Advances . in Biological Psychiatry, 126:983-987.
l .A m.Acad. Child Adolesc . Psychiatry, 30:1. January 1991
To the Editor: In 1914, Supreme Court Justice Cardozo was quoted as saying. " Every human being of adult years and sound mind has a right to determine what shall be done with his own body, and a surgeon who performs an operation without his patient's consent commits an assault, for which he is liable for damages" (Schloendorff, 1914). In contrast, there have been recent court-ordered obstetrical procedures such as caesarean sections that have resulted in fetal rights to treatment supplanting maternal rights to refuse treatment (Deusen-Gerber and Lothian, 1985; Kolder et aI., 1987). Lately, there has been much controversy in both the lay press and medical literature regarding the rights of the mother versus the rights of her unborn child . To add to the confusion, the District of Columbia Court of Appeals in the case of In Re A .C. (1990) ruled that a pregnant patient's decision to refuse medical treatment is almost always paramount, and that if she is incompetent or unable to give informed consent , then the decision should be by substituted judgmen t. Thus the court decisions so far have not established a clear legal precedent. This uncertainty about the legal status of maternal rights versus fetal rights can fuel negative countertransference in physicians who must face the challenge of deciding how to manage the obstetrical patient who refuses medical intervention that is in the best interests of the fetus. This can also be a challenging situation for the psychiatric consultant who is asked to render an opinion on the pregnant patient's competency to refuse this treatment. The following case illustrates these issues. Betty, a twenty-six-year-old unmarried , multiparous female , appeared in the emergency room because her " water had broken." As in her four previous pregnancies, she had not sought prenatal care. Betty was admitted to labor and delivery where she refused gynecological examination, blood tests, and a peripheral venous line despite repeated encouragement by the obstetrical housestaff. She would only consent to the application of an external fetal monitor , and this indicated fetal distress. When Betty was informed of the fetal distress, the seriousness ofthis finding, and the need for more intensive monitoring , she responded by saying that she wanted to be in the hospital , but that she would not allow more intrusive medical interventions. She then reminded the obstetrical team that she had successfully delivered her other children without these invasive procedures. The labor and delivery staff became angry and disgusted with Betty' s refusal of treatment. The housestaff decided to discontinue external fetal monitoring because of their fear that they could be held liable for documenting fetal distress. The psychiatry consult team was called to assess Betty' s competence to refuse medical treatment. The obstetrical staff bitterly complained that " we have a woman here who is refusing treatment and yet will not sign out against medical advice." Upon our arrival in labor and delivery, we were informed that the obstetrical intern was now in with the patient, again trying to convince her to cooperate with treatment. Shortly afterwards, this intern stormed out of Betty' s room in response to her continued refusal of treatment. During psychiatric examination, Betty's sensorium was clear, there was no evidence of psychosis, and the mental status exam suggested low average to borderline intellectual functioning. She appeared to be in marked pain and spoke in short but coherent phrases. Betty again explained that her fear of a painful pelvic examination prevented her from cooperating with the obstetrical team' s recommendations. In view of the evidence for fetal distress, lack of fetal monitoring , and strong countertransference feelings that appeared to be adversely influencing medical judgment, the hospital attorney was consulted on
153
is of factors which are largely inert on their own but, to use a chemical analogy, serve as catalysts when combined with acute stressors of some type.... When they tend to reduce the effect of stressors, they are usually termed protective factors (as considered by Rutter, 1979)" (p. 340--341). The article then went on to consider the detection of statistical interaction effects in relation to the postulated protective influence of social networks and close personal relationships. The 1979 article stated: "The first point to make is the very great importance of interactive effects" (p.51). A more recent article (Rutter, 1987) dealt at length with the importance of the concept of protective mechanisms as interaction effects and of the implications for data analysis that flow from this recognition. In short, the theoretical position that I have advocated for over a decade is precisely that put forward by Jenkins and Smith and so elegantly dealt with in their own important empirical study. One additional point needs to be made, however, and that is that there are many circumstances in which it is misleading to equate interaction mechanisms with a statistically significant interaction term in the multivariate analysis. Some of the reasons why that is so are discussed in Rutter (1983), and a more extended conceptual and statistical account is provided in Rutter and Pickles (in press). Michael Rutter, M.D., F.R.S. Institute of Psychiatry London REFERENCES
Jenkins, J. M. & Smith, M. A. (1990), Factors protecting children living in disharmonious homes: maternal reports. J. Am. Acad. Child Adolesc. Psychiatry, 29:60--69. Rutter, M. (1979), Protective factors in children's responses to stress and disadvantage. In: Primary Prevention ofPsychopathology: Vol. 3: Social Competence in Children, eds. M. W. Kent & J. E. Rolf. Hanover, NH: University Press of New England. - - (1981), Stress, coping and development: some issues and some questions. J. Child Psychol. Psychiatry, 22:323-356. - - (1983), Statistical and personal interactions: facets and Perspectives. In: Human Development: An interactional perspective, eds. C. Magnusson & V. Allen. New York: Academic Press, pp. 295319. - - (1987), Psychosocial resilience and protective mechanisms. Am. J. Orthopsychiatry, 57:316-331. - - Pickles, A. (in press), Person-environment interactions: concepts, mechanisms and implications for data analysis. In: OrganismEnvironment Interaction, eds. R. Plomin & T. Wachs. Washington, DC: American Psychological Association.
Autism and Asperger's: Same or Different? To the Editor:
We found it interesting to read the paper by Szatmari and colleagues (1990) on the neurocognitive aspects of Asperger's syndrome (AS), which is likely to be a subcategory of the pervasive development disorders (POD) in ICD-lO (Rutter, 1989). However, general opinion among researchers and now Szatmari's group is that AS is merely a variant of high-functioning autism (HFA), raising the question of how discrete is the autistic syndrome. This paper is the first controlled study of the question of diagnostic subcategories among individuals who have POD but are not mentally retarded. Szatmari et al.'s careful, considered, analysis provides some fascinating and unexpected findings on the neuropsychological profile of the normal intelligence (lQ > 85) POD group as a whole but failed to find very important differences between HFA and AS. This appears to provide additional evidence for the unnecessary subclassifiction of POD, but the authors admit that there are reasons for considering limitations in their study. These include the wide age range of the subjects, varying recruitment
152
sources, and mixed retrospective and prospective diagnostic assessments. We are in the process of studying children (5 to 12 years) who have POD (by DSM-III-R) and have a testable intelligence in the nonretarded range. They are being compared with language impaired and behavior disordered (control) children on a number of neuropsychological and neurobiological variables. Within the POD group, we believe there are three clinical subgroups; namely, classical (or Kanner's) autism, language impaired POD, and nonlanguage impaired POD. Only the latter would be considered AS by our criteria. After our review of this paper, we decided to assess the validity of our proposed groupings by analyzing preliminary data from the first 41 subjects (26 POD and 15 controls) we had assessed. To create our three PDD subgroups, we merely took the clinical data obtained from a parent interview, devised by Dr. Szatmari, for diagnosing POD and blindly rated for the presence of classical autism (i.e., aloofness, echolalia, pronoun reversal, need for sameness, etc., before 3 years of age). If the criteria were not fulfilled, the remaining subjects were differentiated by the presence or absence of developmental language disorder. We found that a discriminant analysis using the global scales of the Kaufman-ABC (five scores derived from the individual test scores of this battery) revealed a correct diagnostic classification 76% of the time (Kappa = 0.68). Only two POD subjects were placed in an alternative POD group. Given that there were overall IQ differences between groups, repeated discriminant analyses were performed on the mental processing composite score (MPC, comparable but not equivalent to an IQ score) alone and after deleting it from the analysis, which produced correct classifications of 41% and 37%, respectively. The analysis of MPC alone produced two groups, high and low functioning, in which POD subjects were evenly distributed independent of our subgroupings. It was therefore apparent that differentiation between groups was a consequence of the full range of neuropsychological skills. Furthermore, the groups showed fairly specific profiles on the subtests. The autistic group was typified by strengths in Gestalt closure, number recall, triangles, and reading/decoding and reading/understanding and by significant weakness in achievement measures requiring abstract processing (e.g., riddles). Language impaired PDD subjects were weak in all subtests. Nonlanguage impaired PDD subjects were comparatively weak in Gestalt closure, spatial memory, and photo series, but achievement scores were above intellectual expectation. We do not present this data to refute Szatmari's findings, not the least because we have not completed our studies, nor subjected them to peer scrutiny. However, we did find a more traditional pattern of psychological strengths and weaknesses in our autistic group. Given that diagnostic criteria for AS are unclear and if the remaining POD subjects were therefore grouped all as AS, there would be little likelihood of eliciting a difference between AS and HFA because their very different neuropsychological patterns would be lost in the group data. The differences we found may be because of different measures (Wechsler Intelligence Scale for Children-Revised versus KaufmanABC), different subject selection (more mild or subtle disorders in our cohort), or that we have merely selected three levels of severity of POD. Although these errors may prove to be true, this does not explain the different group profiles and would warrant caution in eliminating POD subgroups of clinical and heuristic value. John C. Pomeroy, MBBS, MRC Psych. Carol Friedman, Ph.D. Laurie Stephens, M.A. State University of New York at Stoney Brook REFERENCES
Rutter, M. (1989), Child psychiatric disorders in ICD-lO. J. Child Psychol. Psychiatry, 30:499-513. J.Am.Acad. Child Adolesc.Psychiatry, 30:1 ,January 1991
LEITERS TO THE EDITOR
Szatmari, P., Tuff, L. , Finlayson, M. A. J. & Bartolucci , G. (1990), , Asperger' s syndrome and autism: neurocognitive aspects. J . Am. Acad. Child Adolesc. Psychiatry, 29:130-136.
Szatmari, P., Bartolucci, G. & Bremner, R., (1989), Asperger' s Syndrome and autism: comparisons on early history and outcome. Dev. Med. Child Neurol. 31:709-720
Maternal versus Fetal Rights
Dr . Szatmari replies : I was very interested to read the letter submitted by Dr. Pomeroy land colleagues. The point that they make in reference to our earlier 'article (Szatmari et aI. , 1990) is that if one divides POD subjects into 'three subgroups, distinct neuropsychological profiles might emerge . :The data they have provided would certainly seem to substantiate this trend. Perhaps with larger numbers, they may be able to make some 'more definite conclusions. There is no doubt that the study in progress, reported by Dr. Porneroy, has certain methodological advantages over our study. For ex'ample, there is a much closer matching of age and IQ. In addition, 'when we began our study of Asperger' s syndrome in 1984, there was 'no clear consensus about diagnostic criteria for this group of children. (rhus, their ability to separate POD subjects into three subgroups is 'an important advance. In a cluster analysis of POD subjects that we 'performed (Szatmari et al., 1989), we too were able to identify similar subgroups, but we could not carry this analysis much further because of the small sample size involved. : There is, however, a conceptual point that I would like to make with respect to the letter submitted by Dr. Pomeroy and colleagues. They suggest that because we were unable to find significant differences in neuropsycholocial profiles between autistic and Aspergcr's syndrome children, this latter group is "merely a variant of highfunctioning autism. " Furthermore , our data "appear to provide further evidence for the unnecessary subclassification of POD." The key Issue it seems to me, is to consider what data would be required to justify the subclassification of POD. It is not at all clear that the criteria previously outlined for the diagnostic validity of a disorder (Rutter, 1978) should also apply to the classification of subtypes of POD. One possible interpretation of the available literature is that Asperger's syndrome and autism differ in their clinical features but not necessarily on their etiology. Similarity in neuropsychological profiles between these two disorders, presumably, might reflect similar pathogenic mechanisms. However, just because two disorders share a similar etiology is not necessarily a reason to collapse them. For example, Tourette's syndrome and obsessive-compulsive disorders appear to share a common genetic etiology. However, no one would seriously consider these as the same disorder. , Perhaps diagnostic validity is best considered a relative rather than an absolute term. Under these circumstances, it may make more sense to consider whether subclassification is " useful" rather than "correct." Under certain circumstances (such as genetic studies or brain imaging studies), it may be useful to collapse autistic and Asperger's syndrome subjects into a general category. On the other hand, there may be other circumstances (such as for follow-up studies or intervention studies) where it may be more useful to separate and subclassify them. i The data that Pomeroy et al. have provided in their pilot study certainly suggest additional reasons for continued investigation into Asperger's syndrome. Perhaps the real disadvantage in considering Asperger' s syndrome as a nonvalid disorder or " merely a variant of high-functioning autism" is that additional research into this fascinating group of children would be discouraged. Peter Szatmari, M.D ., F.R.C.P.(C) McMaster University, Hamilton, Ontario REFERENCES
Rutter, M. (1978), Diagnostic validity in child psychiatry. Advances . in Biological Psychiatry, 126:983-987.
l .A m.Acad. Child Adolesc . Psychiatry, 30:1. January 1991
To the Editor: In 1914, Supreme Court Justice Cardozo was quoted as saying. " Every human being of adult years and sound mind has a right to determine what shall be done with his own body, and a surgeon who performs an operation without his patient's consent commits an assault, for which he is liable for damages" (Schloendorff, 1914). In contrast, there have been recent court-ordered obstetrical procedures such as caesarean sections that have resulted in fetal rights to treatment supplanting maternal rights to refuse treatment (Deusen-Gerber and Lothian, 1985; Kolder et aI., 1987). Lately, there has been much controversy in both the lay press and medical literature regarding the rights of the mother versus the rights of her unborn child . To add to the confusion, the District of Columbia Court of Appeals in the case of In Re A .C. (1990) ruled that a pregnant patient's decision to refuse medical treatment is almost always paramount, and that if she is incompetent or unable to give informed consent , then the decision should be by substituted judgmen t. Thus the court decisions so far have not established a clear legal precedent. This uncertainty about the legal status of maternal rights versus fetal rights can fuel negative countertransference in physicians who must face the challenge of deciding how to manage the obstetrical patient who refuses medical intervention that is in the best interests of the fetus. This can also be a challenging situation for the psychiatric consultant who is asked to render an opinion on the pregnant patient's competency to refuse this treatment. The following case illustrates these issues. Betty, a twenty-six-year-old unmarried , multiparous female , appeared in the emergency room because her " water had broken." As in her four previous pregnancies, she had not sought prenatal care. Betty was admitted to labor and delivery where she refused gynecological examination, blood tests, and a peripheral venous line despite repeated encouragement by the obstetrical housestaff. She would only consent to the application of an external fetal monitor , and this indicated fetal distress. When Betty was informed of the fetal distress, the seriousness ofthis finding, and the need for more intensive monitoring , she responded by saying that she wanted to be in the hospital , but that she would not allow more intrusive medical interventions. She then reminded the obstetrical team that she had successfully delivered her other children without these invasive procedures. The labor and delivery staff became angry and disgusted with Betty' s refusal of treatment. The housestaff decided to discontinue external fetal monitoring because of their fear that they could be held liable for documenting fetal distress. The psychiatry consult team was called to assess Betty' s competence to refuse medical treatment. The obstetrical staff bitterly complained that " we have a woman here who is refusing treatment and yet will not sign out against medical advice." Upon our arrival in labor and delivery, we were informed that the obstetrical intern was now in with the patient, again trying to convince her to cooperate with treatment. Shortly afterwards, this intern stormed out of Betty' s room in response to her continued refusal of treatment. During psychiatric examination, Betty's sensorium was clear, there was no evidence of psychosis, and the mental status exam suggested low average to borderline intellectual functioning. She appeared to be in marked pain and spoke in short but coherent phrases. Betty again explained that her fear of a painful pelvic examination prevented her from cooperating with the obstetrical team' s recommendations. In view of the evidence for fetal distress, lack of fetal monitoring , and strong countertransference feelings that appeared to be adversely influencing medical judgment, the hospital attorney was consulted on
153
