LETTERS TO TH E EDITOR
to a tricyclic, and the presence of side effects from a generic which did not occur with the brand name agent. Herbert A. Schreier , M .D. Children ' s Hospital Oakland, California REFERENCES
Flament , M. , Whitaker , A. , Rapoport, J. et al. (1989), An epidemiological study of obsessive-compulsive disorder in adolescence. In: Obsessive-Compulsive Disorder in Children and Adolescents, ed. J. Rapoport. Washingto n: American Psychiatric Press, Inc. , 253-268. Leonard , H., Goldberger, E., Rapoport , J. et al. (1990), Childhood rituals: normal development or obsessive-compulsive symptoms? J . Am . Acad . Child Adolesc. Psychiat ry , 29;1:17- 23. Weller , E. , Weller , R. & Carr, S. (1989), Imipramine treatment of trichotillomania and coexisting depression in a seven-year-old. J . Am . Acad . Child Adolesc. Psychiatry , 28:952-953.
Catchers in the Rye Dear Dr. Schowalter: Your presidential address was excellent. Excellent! Excellent! I have been doing child psychiatry for 20 years. I am thinking of going into child psychiatry and geriatric psychiatry immediately and permanently. I shall try to apply your teachings. So keep it up and some will filter down to me. Don't we realize yet that all adults are grown-up children? And that all adult psychiatry relates to childhood experiences that should be studied by psychiatrists? Yes, I know they are being studied- but not enough, not nearly enough. Tell your students the world has an enormous need for them, for all of them, and their students, and all their grandchildren's students; that there will still be lots of misunderstood and ill-understood and not-understood children. Look at the children playing in that field of rye, many near the edge, and we oldsters feel so alone. We may be playing near another ledge ourselves. Carry on, Dr. Schowalter. It is a great life if you don't weaken. The trouble is you do weaken. You can only clap hands or shake your head. I am clapping my hands. Carry on. "S ail on," as Columbus said, " Sail on" ! Karl Menninger, M.D. AACAP Honorary Member REFERENCE
Schowalter, J. E. (1990) , Catchers in the rye. J . Am. Acad . Child Adolesc . Psychiatry, 29:10- 16.
Tinker to Evers to Chance: The Triple Board To the Editor: In the course of my career, I was (N)Ever wont to Tinker much with the future and , therefore , most of my opportunities came by Chance. This may not be a good way to proceed, but fortune , nonetheless, managed to smile on me. The Triple Board that John Schowalter describes in his November Editorial represents a bold and intriguing approach to a process through which many of us have gone with less organized planning. It seems to solve the concerns, personal and internal, which spurred us to move from pediatric training (never in the opposite direction) to seek the knowledge, both of the field and, importantly, of ourselve s, that was offered by psychiatry . J.Am .Acad. Child Adolesc. Psychiatry , 29:4 , Jul y 1990
Those of us who persevered in either planned or , often , idiosyncrati c courses , all ended up in child psychiatry and gave various amounts of credit to our pediatric background . Many of us were successful in becoming bridge persons; using our disciplinary memberships in joint curricular and accreditation enterprises. This was true of the excellent programs sponsored by the Commonwealth Fund and offered by Milton Senn at Cornell and Yale. Despite the expectation that pediatricians, after immer sion in psychiatric training, would return to academic posts in pediatri c departments , most attached to their newer psychiatric post. Not well documented, however, is the use we made of our pediatri c knowledge nor of its impact on our psychiatric practice. The name of our discipline suggests a greater affiliation with the psyche aspect than the ped . Because of this situation, it is most encouraging to read of the planned evaluation at the University of North Carolin a. It is hoped that it will answer two questions which seem important from my vantage point. I. Are the amounts of time spent in the three segments of training proportionally correct? 2. What will these trainees be, professionally, when they complete their experience (and what will they be called)? It is good that Dr. Schowalter has shared this progress report with us. It stimulates me and, I hope , others to visit one or more of these programs to see at first hand what is happening . I hope additional reports will be forthcoming. Henry H. Work, M.D . Bethesd a , Maryland REFERENCE
Schowalter , J. E. (1989), The triple board: Tinker to Evers to Chance. J. Am . Acad . Child Adolesc . Psychiatry , 28:829 .
Language Delay and Parental Perceptions To the Editor: Numerous studies show increased risk for behavior disorders in children with language delays (Cantwell and Baker , 1987). These studies indicate that the prevalence of attention deficit disorder , oppositional disorder, conduct disorder , anxiety disorders , and learning disabilities in children with language impairment are significantly greater than would be expected in the general population. Few studies , however, have looked at very young children. Stevenson and Richman (1978) conducted an epidemiological study of langua ge and behavior and found that 59% of 3-year-olds with language delays showed behavior disorders , compared to 14% of the normally speaking population. Many clinician s would consider 2-year-olds with little expressive language as representing the lower end of the normal spectrum of language development and expect that these children would go on to develop normal language. While parents of these toddlers are often counseled to wait until their children .. grow out " of the delay, there is some evidence that failure to talk by age 2 may presage longer term deficits (Paul, 1989). We were interested in examin ing behavior disorders in toddlers with slow expressive language growth in order to determine whether , even at this early age, the behavioral difficultie s so frequently associated with chronic language delay were present. We examined parental perceptions of behavior disorder in two groups of 2-year-olds matched for age, sex ratio, socioeconomic status, and birth order: one identified as late in the acquisition of expressive language (N = 34), and one developing language normally (N = 33). All children scored above 85 on the Bayley Scales of Infant Mental
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Development , all passed hearing screening at 25 dB, and all passed observational screening for autism or frank neurological disorder. The children were categorized as late talkers (LT) or normals on the basis of parental report of expressive vocabulary size on the Language Development Survey (Rescorla, 1989). This instrument is reported to show excellent reliability, validity, sensitivity , and specificity in identifying language delay in this age group. The Childhood Personality Scale (Cohen, 1975) was used as a parent rating instrument. Parents were asked to rate their child's behavior on a numerical scale to indicate the frequency with which they observed the indicated behavior in the child . The items on the CPS were divided into four factors: Activity/Attention, Relationships, Conduct, and Mood. Any items referring specifically to language behavior (e.g. , " talks with delight") were eliminated from the analysis. Results revealed that there were significant differences between the groups on the Activity/Attention (t = 2. 9, P < 0.01), Conduct (t = 2.7, p < 0.01), and Mood (t = 2.5, p < 0.03) factors, while differences in Relationship s were not found to be significant. These data suggest that, like older language impaired children, toddlers with slow expressive language acquisition are perceived by their parents to show difficulties in the regulation of activity and attention as well as in conduct and affect when compared to the perceptions of parents of toddlers with normal speech developmen t. It may be the immature language itself that results in the LT parents' perceptions of behavior disturbance , particularly in the area of conduct, where inability to produce and comprehend language can result in the appearance of noncompl iance (Volkmar et aI. , 1985). However, many items on this scale (e.g ., " impulsive ," "gives long attention to toys , objects, books that interest him ," " smiles to a friendly person," " seems to have little zest for normal activities; acts tired. " ) can be seen to operate independently of language, and eliminating the specific language items should go some distance toward reducing this possibility. Regardless of whether the perceived behavioral disturbance is secondary to the language deficit or evidence of some co-occurring temperamental or neurological difference , the fact rema ins that parents do see toddlers with slow language growth as more active , inattentive, and difficult to manage than their normally speaking peers. This perception could affect the parents' ability to interact optimally with these toddlers and, thus, to provide them with the language stimulation they need. It would follow , then, that part of the assessment of toddlers referred for delayed language growth should include evaluation of parental percepti on of behavior. An important aspect of counseling for these familie s would be the acknowledgment of the
difficulties such youngsters seem to present in the areas of attention, activity, conduct, and affect. Additionally, the familie s could benefit from parent training not only in language stimulation techniqu es, but also in behavior management of the activity , attention , and conduct disorders. Educational or therapeutic interventions for this population might also do well to plan for the amelioration of these problems. Rhea Paul , Ph.D. Denise F. James , M.S . Portland State University REFERENCES
Cantwell, D. & Baker , L. (1987), Developmental Speech and Language Disorders. New York: The GUilford Press. Cohen, D. J. (1975), The Childhood Personality Scale. Washington , DC: NIMH. Paul, R. (1989), Outcomes of early expressive language delay. Paper presented at the Symposium for Research in Child Language Disorders, Madison, WI. Rescorla, L. (1989), The Language Development Survey: a screening tool for delayed language in toddlers. J . Speech Hear . Disord., 54:587-599. Stevenson, J. & Richman, N. ( 1978), Behavior language and development in three-year-old children . Journal ofAutism and Childhood Schizophenia, 8:299-3 13. Volkmar, F. , Hoder, L. & Cohen , D. J. (1985), Compliance , " negativism, " and the effects of treatment and structure in autism : a naturalistic behavior study . J. Child Psychol. Psychiatry, 26:865877.
Letters to the Editor are welcome. The y will be considered for publication but may not necessarily be published, nor will their receipt be acknowledged. Letters should, in general, not exceed 750 words, including a maximum of six references. They must be submitted in duplicate and typed double-spaced. All letters are subject to editing and shortening; the contents are the sole responsib ility of the author. The Editor reserves the right to publish replies and solicit responses. Opinions expressed in this column are those of the authors of the letters and do not reflect opinions of the Journal. Please direct your letters to John F. McDermott, Jr., M.D . , Editor, Journal of the American Academy of Child and Adolescent Psychiatry, University of Hawaii School of Medicine at Kapiolani Medical Center, 1319 Punahou St. , Honolulu, HI 96826-1032 .
Erratum The article, " The Response of Aggressive and Nonaggressive ADHD Children to Two Doses of Methylphenidate," published in the November issue of the Journal (1989 , 28:873881J incorrectly stated on page 873 that a prior study by Klorman et al. (1988, Journal of Abnormal Psychology . 97:4 13-422) did not systematically monitor the side effects of stimulant medication .
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J.Am.Acad. Child Adolesc .Psychiatry, 29:4, July 1990
to a tricyclic, and the presence of side effects from a generic which did not occur with the brand name agent. Herbert A. Schreier , M .D. Children ' s Hospital Oakland, California REFERENCES
Flament , M. , Whitaker , A. , Rapoport, J. et al. (1989), An epidemiological study of obsessive-compulsive disorder in adolescence. In: Obsessive-Compulsive Disorder in Children and Adolescents, ed. J. Rapoport. Washingto n: American Psychiatric Press, Inc. , 253-268. Leonard , H., Goldberger, E., Rapoport , J. et al. (1990), Childhood rituals: normal development or obsessive-compulsive symptoms? J . Am . Acad . Child Adolesc. Psychiat ry , 29;1:17- 23. Weller , E. , Weller , R. & Carr, S. (1989), Imipramine treatment of trichotillomania and coexisting depression in a seven-year-old. J . Am . Acad . Child Adolesc. Psychiatry , 28:952-953.
Catchers in the Rye Dear Dr. Schowalter: Your presidential address was excellent. Excellent! Excellent! I have been doing child psychiatry for 20 years. I am thinking of going into child psychiatry and geriatric psychiatry immediately and permanently. I shall try to apply your teachings. So keep it up and some will filter down to me. Don't we realize yet that all adults are grown-up children? And that all adult psychiatry relates to childhood experiences that should be studied by psychiatrists? Yes, I know they are being studied- but not enough, not nearly enough. Tell your students the world has an enormous need for them, for all of them, and their students, and all their grandchildren's students; that there will still be lots of misunderstood and ill-understood and not-understood children. Look at the children playing in that field of rye, many near the edge, and we oldsters feel so alone. We may be playing near another ledge ourselves. Carry on, Dr. Schowalter. It is a great life if you don't weaken. The trouble is you do weaken. You can only clap hands or shake your head. I am clapping my hands. Carry on. "S ail on," as Columbus said, " Sail on" ! Karl Menninger, M.D. AACAP Honorary Member REFERENCE
Schowalter, J. E. (1990) , Catchers in the rye. J . Am. Acad . Child Adolesc . Psychiatry, 29:10- 16.
Tinker to Evers to Chance: The Triple Board To the Editor: In the course of my career, I was (N)Ever wont to Tinker much with the future and , therefore , most of my opportunities came by Chance. This may not be a good way to proceed, but fortune , nonetheless, managed to smile on me. The Triple Board that John Schowalter describes in his November Editorial represents a bold and intriguing approach to a process through which many of us have gone with less organized planning. It seems to solve the concerns, personal and internal, which spurred us to move from pediatric training (never in the opposite direction) to seek the knowledge, both of the field and, importantly, of ourselve s, that was offered by psychiatry . J.Am .Acad. Child Adolesc. Psychiatry , 29:4 , Jul y 1990
Those of us who persevered in either planned or , often , idiosyncrati c courses , all ended up in child psychiatry and gave various amounts of credit to our pediatric background . Many of us were successful in becoming bridge persons; using our disciplinary memberships in joint curricular and accreditation enterprises. This was true of the excellent programs sponsored by the Commonwealth Fund and offered by Milton Senn at Cornell and Yale. Despite the expectation that pediatricians, after immer sion in psychiatric training, would return to academic posts in pediatri c departments , most attached to their newer psychiatric post. Not well documented, however, is the use we made of our pediatri c knowledge nor of its impact on our psychiatric practice. The name of our discipline suggests a greater affiliation with the psyche aspect than the ped . Because of this situation, it is most encouraging to read of the planned evaluation at the University of North Carolin a. It is hoped that it will answer two questions which seem important from my vantage point. I. Are the amounts of time spent in the three segments of training proportionally correct? 2. What will these trainees be, professionally, when they complete their experience (and what will they be called)? It is good that Dr. Schowalter has shared this progress report with us. It stimulates me and, I hope , others to visit one or more of these programs to see at first hand what is happening . I hope additional reports will be forthcoming. Henry H. Work, M.D . Bethesd a , Maryland REFERENCE
Schowalter , J. E. (1989), The triple board: Tinker to Evers to Chance. J. Am . Acad . Child Adolesc . Psychiatry , 28:829 .
Language Delay and Parental Perceptions To the Editor: Numerous studies show increased risk for behavior disorders in children with language delays (Cantwell and Baker , 1987). These studies indicate that the prevalence of attention deficit disorder , oppositional disorder, conduct disorder , anxiety disorders , and learning disabilities in children with language impairment are significantly greater than would be expected in the general population. Few studies , however, have looked at very young children. Stevenson and Richman (1978) conducted an epidemiological study of langua ge and behavior and found that 59% of 3-year-olds with language delays showed behavior disorders , compared to 14% of the normally speaking population. Many clinician s would consider 2-year-olds with little expressive language as representing the lower end of the normal spectrum of language development and expect that these children would go on to develop normal language. While parents of these toddlers are often counseled to wait until their children .. grow out " of the delay, there is some evidence that failure to talk by age 2 may presage longer term deficits (Paul, 1989). We were interested in examin ing behavior disorders in toddlers with slow expressive language growth in order to determine whether , even at this early age, the behavioral difficultie s so frequently associated with chronic language delay were present. We examined parental perceptions of behavior disorder in two groups of 2-year-olds matched for age, sex ratio, socioeconomic status, and birth order: one identified as late in the acquisition of expressive language (N = 34), and one developing language normally (N = 33). All children scored above 85 on the Bayley Scales of Infant Mental
669
LEITERS TO THE EDITOR
Development , all passed hearing screening at 25 dB, and all passed observational screening for autism or frank neurological disorder. The children were categorized as late talkers (LT) or normals on the basis of parental report of expressive vocabulary size on the Language Development Survey (Rescorla, 1989). This instrument is reported to show excellent reliability, validity, sensitivity , and specificity in identifying language delay in this age group. The Childhood Personality Scale (Cohen, 1975) was used as a parent rating instrument. Parents were asked to rate their child's behavior on a numerical scale to indicate the frequency with which they observed the indicated behavior in the child . The items on the CPS were divided into four factors: Activity/Attention, Relationships, Conduct, and Mood. Any items referring specifically to language behavior (e.g. , " talks with delight") were eliminated from the analysis. Results revealed that there were significant differences between the groups on the Activity/Attention (t = 2. 9, P < 0.01), Conduct (t = 2.7, p < 0.01), and Mood (t = 2.5, p < 0.03) factors, while differences in Relationship s were not found to be significant. These data suggest that, like older language impaired children, toddlers with slow expressive language acquisition are perceived by their parents to show difficulties in the regulation of activity and attention as well as in conduct and affect when compared to the perceptions of parents of toddlers with normal speech developmen t. It may be the immature language itself that results in the LT parents' perceptions of behavior disturbance , particularly in the area of conduct, where inability to produce and comprehend language can result in the appearance of noncompl iance (Volkmar et aI. , 1985). However, many items on this scale (e.g ., " impulsive ," "gives long attention to toys , objects, books that interest him ," " smiles to a friendly person," " seems to have little zest for normal activities; acts tired. " ) can be seen to operate independently of language, and eliminating the specific language items should go some distance toward reducing this possibility. Regardless of whether the perceived behavioral disturbance is secondary to the language deficit or evidence of some co-occurring temperamental or neurological difference , the fact rema ins that parents do see toddlers with slow language growth as more active , inattentive, and difficult to manage than their normally speaking peers. This perception could affect the parents' ability to interact optimally with these toddlers and, thus, to provide them with the language stimulation they need. It would follow , then, that part of the assessment of toddlers referred for delayed language growth should include evaluation of parental percepti on of behavior. An important aspect of counseling for these familie s would be the acknowledgment of the
difficulties such youngsters seem to present in the areas of attention, activity, conduct, and affect. Additionally, the familie s could benefit from parent training not only in language stimulation techniqu es, but also in behavior management of the activity , attention , and conduct disorders. Educational or therapeutic interventions for this population might also do well to plan for the amelioration of these problems. Rhea Paul , Ph.D. Denise F. James , M.S . Portland State University REFERENCES
Cantwell, D. & Baker , L. (1987), Developmental Speech and Language Disorders. New York: The GUilford Press. Cohen, D. J. (1975), The Childhood Personality Scale. Washington , DC: NIMH. Paul, R. (1989), Outcomes of early expressive language delay. Paper presented at the Symposium for Research in Child Language Disorders, Madison, WI. Rescorla, L. (1989), The Language Development Survey: a screening tool for delayed language in toddlers. J . Speech Hear . Disord., 54:587-599. Stevenson, J. & Richman, N. ( 1978), Behavior language and development in three-year-old children . Journal ofAutism and Childhood Schizophenia, 8:299-3 13. Volkmar, F. , Hoder, L. & Cohen , D. J. (1985), Compliance , " negativism, " and the effects of treatment and structure in autism : a naturalistic behavior study . J. Child Psychol. Psychiatry, 26:865877.
Letters to the Editor are welcome. The y will be considered for publication but may not necessarily be published, nor will their receipt be acknowledged. Letters should, in general, not exceed 750 words, including a maximum of six references. They must be submitted in duplicate and typed double-spaced. All letters are subject to editing and shortening; the contents are the sole responsib ility of the author. The Editor reserves the right to publish replies and solicit responses. Opinions expressed in this column are those of the authors of the letters and do not reflect opinions of the Journal. Please direct your letters to John F. McDermott, Jr., M.D . , Editor, Journal of the American Academy of Child and Adolescent Psychiatry, University of Hawaii School of Medicine at Kapiolani Medical Center, 1319 Punahou St. , Honolulu, HI 96826-1032 .
Erratum The article, " The Response of Aggressive and Nonaggressive ADHD Children to Two Doses of Methylphenidate," published in the November issue of the Journal (1989 , 28:873881J incorrectly stated on page 873 that a prior study by Klorman et al. (1988, Journal of Abnormal Psychology . 97:4 13-422) did not systematically monitor the side effects of stimulant medication .
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J.Am.Acad. Child Adolesc .Psychiatry, 29:4, July 1990
