Syracuse, New York
Birch and Belmont make the further
argu-ment that many factors must be taken into ac-count in the decision to institutionalize or not,
a problem covered quite adequately in the
original Centerwall and Centerwall paper, and a criticism that fails to recognize the fact that a scientist can generally study only one van-able at a time, not all variables at once. The
decision to institutionalize should be, of course,
a clinical judgment based on many factors, but
only when the clinician has available the
ob-jective evidence of the effects of these many variables, studied one at a time, can he make
a judgment supported by facts rather than
personal bias. Studies of some of the
non-developmental variables involved in the
de-cision re institutionalization have recently been published.4 5
The third point by Birch and Belmont is the most critical, since it questions the validity of the Centerwalls’ results, not merely their
con-clusions. Birch and Belmont argue that the
greater number of non-walkers in the foster-reared group is evidence for the initial “signifi-cantly greater neurologic deficit” in that group. They thus use age of onset of walking as a sin-gle reliable diagnostic indicator of initial neu-rologic deficit, a position the validity of which
is doubtful and for which they offer no support.
Ideally, the home-reared and foster-reared groups should have been matched for potential
IQ during the neonatal period, but there is as
yet no reliable method for IQ matching at this
age. The Centerwalls had no choice but to
match for age at testing and to select randomly for IQ potential at birth, which is exactly what
they did. When control by matching is not
possible, control by randomization is expeni-mentally sound and valid.
Carefully controlled research on mental re-tardation, like the Centerwall and Centerwall
study, is still relatively rare. Given the support it deserves, it will contribute to our under-standing of retarded children, serve as a stimu-lus for further research, and help the clinician make judgments on the basis of fact rather than feeling.
LEONARD HERSHER, Ph.D. Department of Pediatrics State University of New York Upstate Medical Center
REFERENCES
1. Birch, H. C., and Belmont, L. : The problem of comparing home rearing versus foster-home
rearing in defective children. PEDIATRICS, 28:
956, 1961.
2. Centerwall, S. A., and Centerwall, W. R. : A
study of children with mongolism reared in
the home compared to those reared away from home. PEDIATRICS, 25:678, 1960. 3. Tizard, J.: Residential care of mentally
handi-capped children. Brit. Med. J., 1 : 1041, 1960.
4. Farber, B.: Effects of a severely mentally
re-tarded child on family integration. Monogr.
Soc. Res. Child Develop., 24:No. 2, 1959.
5.
Farber, B.: Family organization and crisis:maintenance of integration in families with a
severely mentally retarded child. Monogr. Soc.
Res. Child Develop., 25:No. 1, 1960.
EDIToR’s Noit:
The two groups of authors largely quoted here, have been asked to comment on Dr. Hersher’s
let-ter, and have responded as follows:
To rira EDITOR:
One can only agree with Dr. Hersher that
“carefully controlled research on mental
re-tardation is relatively rare and that given the
support it deserves will contribute to our un-derstanding of retarded children, serve as a
stimulus for further research, and help the
clinician make judgments on the basis of fact rather than feeling.” It is unfortunate that de-spite such mutuality of interest we cannot agree
that the research on the foster-placement of
mongoloid infants by Centerwall and
Center-wall’ is carefully controlled and establishes a
basis for the making of judgments on “fact
rather than feeling.” Moreover, we note with regret that Dr. Hersher’s comments introduce additional features of methodologic confusion
which, if accepted, can only contribute
nega-tively to the development of effective
methodol-ogy for retrospective research in the area of mental retardation. For these reasons, we take
this opportunity to reply to Dr. Hersher’s
letter.
Dr. Hersher has chosen to rearrange the
or-den of the arguments presented by Birch and
Belmont2 and thus to confuse substantive and
methodologic questions. This is unfortunate, since it is our first point (called the third by Hersher) which is the one that has greatest
re-LETTERS TO THE EDITOR 1009
search on child development. In our article we pointed out as follows:
“Three questions arise when these
(Center-walls’) conclusions are ranged against data
presented: (1) Is there in fact any evidence
that the initial differences noted are the prod-uct of differential rearing; (2) what is the
func-tional significance of the statistically significant differences noted; (3) what other conclusions
may possibly be drawn when the data as pre-sented are placed in relation to other studies?”
The central issue, stated in point one, there-fore, was whether the differences found at age
7 by Centerwall and Centerwall to exist in
their samples of institutionalized mongols were the product of the differences in early
environ-ment due to placement or whether they derived from initial differences, existing at birth, in the degree of severity of defect present in the two groups of children studied. Obviously, if the
children who were put in foster placement in
early infancy were initially more defective, one could not easily conclude that it was the
char-acter of their early placement experiences which
determined later disturbance in function.
Rather, the more parsimonious explanation
would be that the children who were put in
foster placement in early infancy constituted
initially more defective individuals who
re-mained consistently more defective in the
course of later development. Therefore, from the point of view of methodology, the critical
question to be asked of the Centerwall and Centerwall study is whether or not initial dif-ferences in degree of damage or defect existed
between the placement and home-reared
groups.
The data available in the article by Center-wall and Centerwall provided three kinds of
op-portunity for determining whether or not
in-itially significant differences existed between
the placement and home-reared groups of
mongoloid children. The first of these was
neuromuscular development. When the two
groups of children were compared for these
factors, it was found that 15 of the children in the foster-reared group were still nonwalkers
at the age of the study and that in the
home-reared groups only four individuals had failed
to walk by this time. Further, no single
in-dividual in the home-reared groups was a non-walker after the age of 6 years, whereas the foster placement group had eight nonwalkers
who were in age range of 6 7/12 to 8 5/12
years. We, therefore, did not use “the age of onset of walking as a single reliable diagnostic indicator of initial neurologic deficit” as Her-sher maintains. On the contrary, we used per-sistent indications of inadequate neuromus-cular organization as an indicator of initial differences in neurologic defect between the two groups of children. We used neuromus-cular development to explore the hypothesis of initial difference merely because it was the best
indicator available in the data presented by
Centerwall and Centerwall. If more extensive data are available, clearly they too should be used.
The second analysis that we used for testing
the possibility that placement-reared
mdi-viduals were, in fact, originally inferior in their potentialities to the home-reared group, was the analysis of deterioration slopes after
in-stitutional placement. This analysis too sup-ported the view that the placement group was initially more defective than the home-reared
children. The third form of analysis that was explored was that of institutional course. This
analysis too supported the view that the
place-ment group was initially more defective than
was the home-reared group. We therefore
con-cluded, and still conclude, that the data
pre-sented by Centerwall and Centerwall are
in-appropriate for answering the question of how home-rearing versus foster-rearing affects the development of adaptive capacities in mongo-bid children.
Neither Dr. Hersher’s references to studies
by 4 on nondevelopmental variables
involved in the decision to institutionalize nor
his general and incorrect statement that “a scientist can generally study only one variable at a time-not all variables at once” have direct relevance for the methodologic point at issue. Farber’s studies were concerned with intra-familial factors which affected decisions to
in-stitutionalize. We, in our criticism, were
con-cemed with intraorganismic characteristics
which might facilitate the making of such a
decision in early infancy. The statement about scientists studying only one variable at a time
contains within it the implication that in the
mean-ingful study of the role played by any single variable in the study of a multiply determined
consequence requires that this variable be
studied under conditions in which adequate control of the other relevant variables has taken
place or by methods which permit one to
de-termine the degree to which these
uncon-trolled influences contribute to the end result.
As a matter of fact such techniques as the
analysis of variance and covariance’ were
de-veloped precisely because of the need in
re-search to deal with more than one variable
at a time. The study of a single variable
with-out reference to other influential factors is not a characteristic of the scientific method but is perhaps more characteristic of primitive and prescientific thought.
Of further relevance to the methodologic
point at issue is Dr. Hersher’s statement that “the Centerwalls have no choice but to match
for age at testing and to select randomly for
I.Q. potential at birth.” This is precisely what
the Centerwalls did not do. They “picked at
random from cards by birth date and date of
admission and matched as to present age” (p. 679). Such a procedure by no means
ran-domizes the two groups for initial intellectual capacity nor for any other feature of infantile
functioning. At best, it serves merely to pre-vent additional investigator bias from being
influential. Biases and selective factors
affect-ing initial placement are entirely unaffected by the procedure.
From the point of view of method the Cen-terwalls had three possible lines of approach to their problem. First, they could have per-formed an anterospective determination on all infants who were to have been included in the
study and thereby studied only matched pairs
who were differentially managed in the
neona-tal period-one in foster placement and the
other retained in the home. Second, they could have attempted a true randomness of selection
at the time of birth. Third, if one were to elim-nate the possibility for the conducting of such anterospective studies, then retrospective
anal-ysis carries with it the responsibility for the exploration of the hypothesis of no initial
dif-ference. To engage in such an exploration re-quires that certain independent indicators of initial differences between groups be deter-mined and their characteristics in each of the groups explored. When this procedure was
en-gaged in by Dr. Belmont and myself, the
re-suits of the analysis suggested that the home-reared and placement-reared groups studied by
Centerwall and Centerwall were in fact initially different and that their later differences in
de-gree of defect could best be viewed as
repre-senting a continuation of this initial difference rather than as representing the result of early
foster placement.
One further statement of Dr. Hersher
re-quires correction. He points out “that Center-wail and Centerwall compared home-reared
children not with infants brought up in sterile impersonal institutions but with infants reared
in ostensibly benign foster homes.” It should be noted that Centerwall and Centerwall pro-vide no evidence of the benignity or otherwise of the foster placements and state “that no at-tempt would be made to distinguish between one type of foster placement and another” (p. 679). The problem of what constitutes either a benign or an optimal developmental
en-vironment for the neonate is by no means a
settled question, and much research is required
to identify the elements of physical and
inter-personal stimulation which are most significant
in affecting early development (cf. Casler). The need for fuller information on this problem is
acute, since in the foreseeable future some
in-fants will have to be reared in institutions. It is to be hoped that carefully controlled studs’ of factors influencing early development will re-suit in knowledge useful in promoting the well-being of children both in institutions and at home.
HERBERT C. BIRcH, M.D., Ph.D.
Associate Research Professor
Department of Pediatrics
Albert Einstein College of Medicine
New York 61, New York
REFERENCES
1. Centerwall, S. A., and Centerwall, W. R. : A study of children with mongolism reared in the home compared to those reared away from home. PicmAmlcs, 25:678, 1960.
2. Birch, H. G., and Belmont, L. : The problem of comparing home rearing versus foster-home rearing in defective children. PEDLATRICS, 28:
956, 1961.
3. Farber, B. : Effects of a severely mentally re-tarded child on family integration. Monogr. Soc. Res. Child Develop., 24:No. 2, 1959.
4.
Farber, B. : Family organization and crisis:LETTERS TO THE EDITOR 1011
severely mentally retarded child. Monogr. Soc.
Res. Child Develop., 25:No. 1, 1960.
5. Fisher, R. A. : The Design of Experiments,
Ed. 4. London; Oliver & Boyd; 1946. 6. Casler, L. : Maternal deprevation: a critical
re-view of the literature. Monogr. Soc. Res.
Child Develop., Vol. 26, 1961.
To THE EDITOR:
Thank you for your invitation to comment
on the discussions of our study of children with
mongolism.1 We are glad that so much sincere interest has been shown in this subject. It bodes well for further studies and for better care for retarded children and better guidance for their parents.
Hersher has expressed many of the views we
have about Birch and Belmont’s paper,’ and we
thank him particularly for his insight into the problem of clinical studies of this type.
One point that max’ be worthy of further
discussion is the developmental levels to be expected of mongoloid children. Birch and Bel-mont made a statement, based on one publica-tion,’ that mongoloid children have a mean I.Q. of 50. Presumably, this is for older children; but the article is not available to us here in
India. We do not believe that these data can
be duplicated on a representative sample of
mongoloid children above 5 years of age. These authors devoted a page (including tables and a graph) analyzing the significance of the de-creasing I.Q.’s which both groups showed. They failed to recognize that this is the usual find-ing with all mongoloid children in this age range. A recent report by Koch et al. from the Child Development Clinic at the Children’s Hospital in Los Angeles demonstrates this fact. They followed a group of 40 children with mongolism who were in their own homes.
These authors stated: “Developmental quo-tients often varied from 60 to 80 during early infancy and gradually declined to 30 to 40 by
age three to four.” This compares well with
our data, which showed that the home-cared-for group had an average I.Q. of 43 at an average age of 3. Repeated testings at Pacific
State Hospital, Pomona, California, indicate
that I.Q. ratings continue to decline slowly up
to about 7 years of age. Therefore one would not expect a plateauing of I.Q.’s as Birch and
Belmount suggested. They are further
con-cerned that the home-reared children have the more rapid rate of decline after
institutionaliza-tion. They claim that this is “a finding not at
all in accord with the Centerwall hypothesis.”
We will take the liberty of stating the
hypothe-sis : that being reared outside their own homes
has a depressing effect on the development of infants and young children with mongolism and the younger the child is when placed the
greater the expected effect. We do not say
that institutionalization will not affect the young child who previously has been reared at
home. The mongoloid child of 3 to 5 years of
age who has been reared at home and who enters an institution for the first time suffers psychologically, and until he adjusts, his I.Q. will fall more than the usual decline. But he
does adjust and continues at a level above his foster-reared counterpart.
The other point of discussion to which we
would add some comments is the practical significance of the difference found in these groups of children. We agree that a listing of
what the tests actually measure presents a meager picture of the advantages of the higher
I.Q.’s and S.Q.’s. We believe, however, that
there is significance beyond these
standard-ized measures. Hersher has mentioned the
effect of I.Q. rating on the child’s program and, depending on the institution, this effect will be found to some degree. We stressed the ages of walking because no matter where the child is, this is a milestone that effects all spheres of activity. Half of the foster-reared children were not walking at 5 years of age.
More important, it should be realized that
neither the Stanford-Binet or the Vineland
Social Maturity Scale tells all there is to know
about children. They do not measure a happy
disposition, liveliness of interest, and response
to affection. It is these unmeasurable things that have impressed the physician, nurse, and
social worker with the value of home-rearing
for retarded children. But science demands
objectivity, and so we were content with the dispassionate measures of standardized scales.
It also should be remembered that even the home-reared children in this study were placed in the institution at a relatively early age (i.e., between 23 and 434 years). There is certainly the possibility that a few more years at home
would bring added benefits to the children.
Finally as Birch and Belmont suggest, the
