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Academic year: 2020



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Barbara Korsch, M.D., Katharine Cobb, Ph.D., and Barbara Ashe, M.D.

Department of Pediatrics, Cornell University Medical College, and New York Hospital

The study received support from the Department of Pediatrics, a grant (M-3453[A]), from the National

Institute of Mental Health, Public Health Service and from the Ross Laboratories.

ADDRESS: (B.K.) 525 East 68th Street, New York 21, New York.




consistently need to

esti-mate the developmental level and intel-ligence of patients. Generally, these

esti-mates are not made in a systematic

man-ner. As part of a continued interest in investigating the pediatrician-patient

rela-tionship on a more objective basis, a study

was undertaken to determine the degree of

accuracy with which pediatricians are able to estimate the patients’ intelligence, in comparison with the results of standard psychologic tests, and the factors that

in-fluence accuracy.

The accuracy of pediatric appraisals ob-tained in this study was not determined by the factors expected to be relevant, such as whether or not the pediatrician making the

appraisal was an experienced pediatrician,

how long he had known the patient or what he stated to be the basis of his appraisal.

Instead certain categories of patients were

more difficult to assess than others. The findings have implications for clinical

prac-tice as well as for pediatric education.


General Procedure

Eighty-eight pediatricians with varying de-grees of experience rated 1 or more of 242 children, aged 1 through 9 years. The children

were also given psychologic tests. All the chil-dren were patients of the New York Hospital

Department of Pediatrics. Almost every child

was seen by two pediatricians, and all ap-praisals were made independent of other

rat-ings and test scores. The 477 appraisals which

were obtained were compared with the results of psychologic tests administered by a psy-chologist who had no prior knowledge of the pediatricians’ estimates. The same two psy-chologists gave all the tests for this study. The study covered a period of 18 months.

Of the 242 children tested, 216 were given

Form L of the Stanford-Binet intelligence scales,’ which covers an age range of 18 months to adulthood; 26 of the younger

chil-dren were given the Cattell Infant intelligence

scale.2 Every child for whom a basal age could be determined was given the Stanford-Binet scale; the remaining children were given the

Cattell scale.#{176}

For each child, the pediatrician was asked to complete the appraisal form shown in Fig-ure 1. At first, children were rated within scale intervals of 10 intelligence quotient points, but

soon it was discovered that more accurate ap-praisals resulted from the use of intervals of 5

points, as shown in Figure 1. The pediatricians were also asked to state how many times they had seen the particular child, how confident they were concerning the appraisal, whether they were basing their estimate primarily on the patient’s history or on their own observa-tion of the child and the criteria on which they were basing their judgment. Some of the appraisals were made on routine pediatric visits; others were made on visits specifically scheduled for purposes of appraisal. However, even on appraisal visits, the usual practices of

taking the history and making a physical

ex-amination were carried out.

When all patients had been appraised, 55 pediatricians with varying degrees of experi-ence, 36 of whom had made appraisals for the

study, were interviewed concerning their usual practices in evaluating patients’ intelligence and

developmental level. They were asked to list

their criteria for making appraisals and

subse-quently were requested to state whether their estimates or their confidence in their ability

to judge were influenced by the following

fac-tons: the intelligence and personality of the

parents, the parent’s occupation and education,

0 Results of the Goodenough Draw-a-Man test, also administered to the children over 5 years of



Name of Child


Hit,ox7 No._____________

clinic oi. Ij #{149}

Pl.aa chsck ( ) in ths &ppropriat. row of ths coluan below, your o#{243}tiaat. of this ohild’ tnteuig.nc..

Stanford Bin.t (L) IQs Clasaification

Lboy 135 V’y aa’to’

- -- T

-fl-- --- &iht




2r - Av.rage


- Low avsrg


-- ) Dull


5!.69 )

Below 65 Dufctiva

If you prefer, ataio this

and ntha:


child’s approziwate d.vsloustsl age in year.

Pleas. state briefLy I What (if ay) .p.cific finding. y are basing your judentI

Is ‘our jud.nt based on the iiother’a report?

c%the child’s behavior?__________ On both?__________

How confident are yo in your rating of this child? Please check:

Quite confident_______ Fairly oonfid.nt_ Doubtful_______

How much contact have you had with this child? Please check: Or:. visit


Several visits_________ Msry visit._________

At there specific reasons for your ccnfidnce or lack of confid.nc#{149} in you1. rating of this particular child?_______ If so, plea.. stat. thea tri.fi.y,

Dute Pediatrician ‘a Signatur.

FIG. 1. Appraisal form used in estimating developmental level of child.

the family’s race and economic status, the

sib-lings’ intelligence, the child’s own appearance

and personality and known physical illness or handicap in the child. Also, they were asked whether or not their confidence varied in esti-mating intelligence of patients in different age groups (infant, preschool and school), in

differ-ent intelligence ranges (superior, normal and defective), of different sex, and with physical

illness or handicap. Finally, inquiry was made

to determine their over-all level of confidence in

appraising children’s intelligence.

Among the pediatricians interviewed, there

were no striking differences in responses

be-tween more and less experienced pediatricians

or between those who had and those who had

not made appraisals for the study. Since the interviews revealed a widespread lack of aware-ness of factors shown in this study to influence pediatric appraisals of patients, these factors will be quoted as background material for the results of the appraisals.

The Appraising Pediatricians

The 88 pediatricians who made appraisals


de--‘--Urban Stanford Binet’

Sample N:t964

Appraisal Study

imple N=242


Fic. 2. Intelligence

25- 35- 45- 55- 65- 45-

55-34 44 54 64 74 84 94 04 114 24 34 44 54 64 74

quotients of children in study group standardization group.

and in Stanford-Binet

termine the effect of this factor upon appraisal. The 36 pediatricians in the experienced group were those at least 5 years past their residency training in Pediatrics; approximately half of them had been in practice from 5 to 8 years and the others from 10 to 25 years. The group of 52 inexperienced physicians included more junior members of the full-time and attending

staff, research fellows, house staff members, and

a few senior medical students working under supervision in the Pediatric Clinics.

The Subjects

The children appeared to be a representative

sample of patients of the New York Hospital Pediatric Department. Some were appraised and tested for the usual indications as part of the regular clinical services. Others were

selected for the purposes of the study even though there were no specific indications for psychologic evaluation. Although children were

selected from different clinics and from the wards at different periods, there were no major

shifts in the composition of the group after the

selection of the first 50 cases, strengthening the impression of its representativeness.

Table I shows the number of children of

each age, sex and race who were tested and ap-praised. The children are evenly distributed

over the entire age range, with slightly larger numbers at ages 4 through 6 years, which is expected among pediatric patients; 23% were

Negroes and 52% were boys. Throughout the

sample there was even distribution as to age and sex.

The sample is representative of the Amen-can urban child population in the distribution of intelligence. Figure 2 compares the

intelli-gence quotients of the children studied with

those of the urban standardization group of

the 1937 Revision of the Stanford-Binet scales.’ The curves are very similar except for a slightly

larger percentage of mentally retarded children in the study group. This is to be expected in a clinic population that includes some children brought in for study because of suspected

mental netardation. Such children are

promi-nent among those referred by staff pediatni-cians.

Table II shows the means and standard devi-ations of the intelligence quotients of all the

children in the study by sex and by race. Al-though the mean for the total group compares closely with that of the standardization group, the mean for the Negro children studied is

lower than that for the white children by a

0 Of the 282 children referred and accepted, 242


S Five-point scale only; midpoint of interval used.






Age in Years

All Ages

1 2 8 4 .5 6 7 8 9



1 11 11 19 19 16 13 13 14

14 14 11 15 17 14 8 14 7

l8 114

White Negro

O 18 19 7 7 S 16 1 16

6 7 3 7 9 7 5 6 5



Total 6 5 34 36 30 1 7 1 Q4

statistically significant amount (p < 0.03). Sev-eral factors probably contribute to this differ-ence. First, no Negroes were included in the standardization group for the Stanford-Binet scales; therefore, the scales are more appropriate

for white children. Second, while valid

generali-zations concerning real racial differences cannot be made at the present time, the performance of Negro children is often reported to be

slightly lower than that of white children and is usually accounted for by their relative cultural deprivation. For example, it is known that

in-telligence and socioeconomic status are come-lated.4 None of the parents of the Negro

chil-dren in this study were in the higher

socio-economic brackets (as measured by father’s occupation), but some of the parents of white children were. The race of the examiner is another factor which the present authors be-lieve deserves more attention than is usually given in interpreting test performance of Negro children. Pasamanick and Knobloch5 suggest that when the examiner is white, the verbal

expression of Negro children begins to be ad-versely affected in the early preschool years. The psychologists of this study, both white, are

of the opinion that the Negro children were more constrained than the white children, even under otherwise ideal testing conditions.

Criterion of Accuracy

Psychologic test results were used as the

criterion for determination of the accuracy of the appraisals in this study. Many of the par.

ticipating pediatricians and others interested in

the study have challenged the validity of using

tests as the criterion, suggesting that the pedia-tricians’ estimates might be more valid than the tests. Therefore, there follows a brief statement

of the reasons for choosing the tests as the criterion measure.

Individually administered intelligence tests

have now been in use for over 50 years. Their

validity within certain specific limits is well established. (Individual tests should not be




Int4ligence Quotients Appraisals5

Number Mean S.D. Number Mean S.D.



18 101.7 19.8

114 101.1 .S

148 106. 15.0

116 105.5 13.9



187 103.3 1.7

55 95. 17.

05 107. 14.1

59 101.6 14.6


fused with group tests, used for screening

pur-poses only and not applicable to young

chil-dren.) In general, the results of individual tests

are considered to be more accurate for school children than for younger children, and special training is required of the psychologist who

ex-amines preschool children.#{176}

Although the tests have been found ex-tremely helpful in planning for children, as

shown by their widespread use, they are by no

means infallible. Their choice as the criterion

measure in this study is well explained by the following quotation from an authority in the field. In discussing this matter, and with special

reference to an early study by Binet6 himself

concerning teachers’ appraisals of the

intelli-gence of school children, Goodenough states:

In spite of its date [1911], this study remains

one of the best demonstrations of the many sources of error in the use of informal methods of apprais#{149} ing intelligence. Not that such judgments are

a!-ways in error; they may be, and sometimes are,

more accurate than standardized tests. But whereas the validity of a test can be appraised once and

for all on the basis of its correlation with a suitable criterion or series of criteria, the validity of

in-formal estimates will vary from person to person and even, to some extent, with the same person on

different occasions. Thus one can never know how much confidence may be placed in them. Moreover, because of the lack of quantitatively expressed

standards of reference, such judgments can never

be truly quantitative. This lack of precision renders

them less useful in the practical guidance of chil-dren and of utile value for scientific research.

An objective criterion was required, which

could be duplicated and uniformly applied to all children whose performance was to be corn-pared with the pediatricians’ assessments.

The 1937 Revision of the Stanford-Binet scales is the most widely used and valid mdi-vidual mental test for young children today. There exists voluminous literature8 on its use.

It is frequently the major criterion used in

establishing the validity of new intelligence

tests. The reliabilities (correlation between


forms, L and M, given to the same children)

for different age groups have a median value

of 0.91, ranging from 0.85 to 0.95. The

reliabilities for children of school age are slightly

0 One of the authors (K.C.), especially trained

and experienced in testing young children, gave all the tests to children under 5 years of age. Her

as-sistant, Miss Elizabeth Saelens, MA., examined all

the thfldren over 5 years old.

higher than for younger children; the median value for children between 2 and 6 years is

0.88, and that for children above 6 years is 0.93. There are slightly different reliabilities for

different ranges of ability, with the highest re-liability at the lower ability levels. For example, a score below 70 has a reliability of 0.98.1 The

very high degree of dependability of the tests

at the lower levels of intelligence will be

me-lated to the results of the pediatricians’

ap-praisals in this range.


Comparison of Appraisals and Test Results

The pediatricians’ appraisals have been

compared with the results of the

psycho-logical tests in two ways. The Pearsonian r correlation between the pediatricians’ ap-praisals and the test scores was determined;

then the percentages of the appraisals fall-ing within defined limits of the test scores

were calculated. All the comparisons pre-sented here by correlation, and the

per-centages are based on the data from the use

of the five-point scale only, a total of 264 appraisals.

The correlation between the appraisals and the test scores for the entire age range is 0.65, which means that the appraisals made in this study may be expected to pre-dict the test score 25% better than a random guess. This degree of relationship between the appraisals and the criterion compares

favorably with the values reported in most studies of the relationship between

teach-ers’ estimates and the tested intelligence of their pupils. The most comparable study9 to

the present investigation employed an

earlier form of the Stanford-Binet scales and

reported a correlation of 0.65, identical with

that found in this study.

Representative of most of the teachers’

studies is a recent report’#{176} of only a slightly

better than chance relationship between teachers’ estimates and test scores with use



M1m DSVIOH.nS #{149}-Q -5 fl. DsvIotIo,s









#{149}-‘ T”’


with the results of several tests on the same

children. There have been no previous

stud-ies comparing test scores with appraisals

made by pediatricians.

Another way of describing the

relation-ship between the appraisals and the test results is shown in Figure 3. Here,

succes-sive degrees of agreement between the

cri-tenon and the appraisals are shown; 26%

of the appraisals are within 5 points of the

test score, 51% within 10 points, and 68% within 15 points. The median of the

in-terval of five points within which each

appraisal fell was used as the score to be compared with the actual intelligence quo-tient. Figure 3 also shows a tendency for

the pediatricians to overestimate the intelli-gence of the children they rated. Of 264

ratings, 114 deviated below and 150 above the actual intelligence quotients. How far

an appraisal may deviate from the best

estimate of a child’s ability, and still con-tribute in a positive manner to his

manage-ment, varies with a number of clinical

con-siderations that will be discussed.

The distribution of the appraisals is



114 20

93 15

!_ 10

67 5

36 SjlO


:: 113



S 43 35 33 14 12

j2 35 43 57

FIG. 3. Degrees of accuracy of pediatricians’

ap-praisals compared to results of psychologic tests.

similar in form to that of the test scores, as

shown by a comparison of the two curves in Figure 4. A tendency to avoid the

ex-tremes of the intelligence range in the

pediatric appraisals is at once apparent. The

regression toward the mean of a second set

of measures when they are compared with

a first set of measures on the same

mdi-viduals is an expected statistical

phenome-non. However, this tendency toward

grouping in the middle range is real as

well as statistical and applies to ratings of individual children on which practical decisions are based.






-- - -Appraisals













25- 35- 45- 55- 65- 75- 85 95- 05- 115- 25- 35- 145-,

155-34 44 54 64 74 84 94 04 114 24 34 44 54 64 Ii4


ii :ii H



U -4



Fic. 4. Distribution of pediatricians’ appraisals and results of psychologic


The dotted lines at the extremes of the distribution of the curve for the appraisals represent 20 appraisals (4% of total) that could not be properly located on the graph because the ratings were below 65 or above 135. Thirteen are below 65;

of these, 10 are in essential agreement with the test scores and 8 are not. Seven

are above 135; of these, 3 are in essential agreement with the test scores and 4 are not.


d V




-- I


ii i: i:












Age in Years

1, & S 4, 5 & 6 7, 8 & 9 All Ages

N5 r5 N r N r N r



4 0.51

40 0.7

50 0.70

58 0.6

35 0.74

39 0.57

17 0.65

137 0.64

Total 8 0.64 108 0.66 74 0.70 E264 0.65

S N =number of appraisals ; r correlation coefficient.


The correlation between two appraisals

of the same child is 0.69. This represents the extent of agreement between two

pedi-atric appraisers of the same child, without reference to the criterion. In this context it

is of interest that the correlation between the results of two examiners using Form L

of the Stanford-Binet scales has been

re-ported12 to be as high as 0.94 for

experi-enced examiners.

Factors Unrelated to Accuracy

of Appraisals

LENGTH OF PEDIATRIC EXPERIENCE: At-tributes of the participating pediatricians and the conditions of rating were examined

for factors which might affect accuracy.

Almost all the pediatricians interviewed

ex-pressed the conviction that the more ex-perienced pediatricians would be the most accurate. Surprisingly, however, the length

of time spent in conventional pediatric ex-perience was not a factor in determining accuracy, as is shown in Table III. The

appraisals made by the experienced pedia-tricians were no more accurate than those

of their less experienced colleagues. Table III also shows that there were no consistent

trends for the pediatricians of either group

to rate children of one age more accurately than another.

CONFIDENCE: The pediatricians making the appraisals were asked to express their degree of confidence in rating each child. When interviewed, most of them expressed

considerable over-all confidence in their

ability to rate children’s intelligence. They were much more conservative in expressing their confidence in ratings on particular

children; in most instances they described

themselves as only fairly confident. Fig-ure 5, which compares the percentages of ratings, within 10 points of the actual

in-telligence quotients, for several factors,

among them degree of confidence shows that a high degree of confidence in rating a particular child is not significantly associ-ated with accuracy.

NUMBER AND TYPE OF Visrrs: According

to the pediatricians’ statements when inter-viewed, and as recorded by them on the

appraisal forms, it is clear that they be-lieved that their most successful appraisals

were made on children whom they knew well and with whom they had many visits. However, an analysis of the most accurate

appraisals (those within 10 points of the actual scores) shows that children seen only

once and those seen several or many times

were appraised with a similar degree of

accuracy. These findings (Fig. 5), were a

surprise to all concerned.

Some of the appraisals were made during routine pediatric visits while others were

made during visits specially scheduled for

appraisal; the latter visits were immediately


Number of Visit.

and Accuracy of Appraisal

52’4 55%


321 77 53

Ratings Ratings Ratings




SI Degree of Confidence

and Accuracy of Appraisal

80 70



SI ,


SI 49%

40 40

30 30

85 290 68 20

20 #{149} Roings Ratnqs Rotnqs







--- - U’




Medical Diagnosis


-and Accuracy of Appraisal







-53% 50

50 - 46% 44, 44




-30 30

-291 74 71 66 20

20 Ratings Ratings Ratings Ratngs







- -



0-*EL CO SLOUS OR *NOC ,(,,*, 8LO* 5 Q 85-i4 0 ABOVE 4 0

Foc. 5. Accuracy of appraisals as related to various factors. (Ratings employed in construction of the graphs are those where the pediatricians’ appraisal was within ± 10 of the intelligence quotient as

determined in the psychologic test.)

I Q Range and

Accuracy of Appraisal







265 77

Ratings Ratings

The Stated Bases for Appraisal

The criteria which the pediatricians gave ARTICLES

made under these two conditions shows that the regular examination did not give the pediatricians an advantage.


When the study was undertaken it was ex-pected that certain pediatricians would

prove consistently more accurate than others. This was not found to be the case.

Any pediatrician who made more than

three or four appraisals made some

esti-mates within 5 points of the test result and

deviated on others more than 15 points. It

has already been pointed out that the length of experience in pediatrics did not affect the rater’s accuracy. In this study no other ascertainable attribute of the

pedia-tricians appeared to have a consistent effect

on accuracy either.

on the forms


the bases for their

ap-praisals were readily grouped into nine

categories of functioning. These are listed in Table IV, in order of the frequency with which they were mentioned. For the entire sample, the factors by far the most

corn-monly mentioned were those relating to the

child’s 1) general response to the clinical

situation and the doctor, 2) speech, his language development and comprehension,

3) grasp of general information and 4) early neuromotor development, as

ascer-tamed by history and by observation.

It is also demonstrated in Table IV that certain areas of functioning were given greater emphasis in one age period than

in others; for example, as might be

ex-pected, there is greater reliance on



Freqnency of Listing for Various Age Gronps



-1, tt S 4, 5 t(. 7, x (. 9 All Ages

Response to the clinical situation 76 114 68 58

Speech development and content 82 108 .58 248

General information 27 69 34 130

Early neuromotor developsnent 63 35 26 124

School performance 0 26 60 86

Social adjustment and maturity IS 31 19 63

Activities of daily living and play 26 27 5 .58

Mother’s impression 15 14 8 .37

Child’s drawings 5 22 4 31



velopment was emphasized above all other

aspects of functioning and was often the single criterion upon which assessment of

younger children was reported to be based. When accuracy of appraisal was com-pared for the three age groups studied

(1 to 3, 4 to 6 and 7 to 9 years), no trend with age was found between appraisals and test scores. The pediatricians

ap-proached with equal confidence the

pre-school child whose intellectual functioning is still nebulous and the school child whose

achievements are better defined. Confidence in appraising the younger children probably

reflects the greater emphasis on this age group in pediatric practice and training.

Attributes of Patients and Accuracy

of Appraisals

Although it was impossible to

demon-strate attributes in the examiners that were related to accuracy in appraising

develop-mental level, or to document pediatric methods of appraisal which made for greater accuracy, it was found that in cer-tam groups of patients intelligence was consistently underestimated or



STATUS: Among the factors concerning the children scrutinized for possible influence

upon accuracy of rating were age, sex, race

and socioeconomic status as measured by

parents’ occupations. None of these factors

was related to accuracy. There was only

one directional trend, a slightly greater tend-ency to overrate Negroes than white

chil-dren, if the same weight can be given to their intelligence quotients as to those of the white children; but for reasons already

discussed, the Negro children’s intelligence

quotient may be slightly low rather than their appraisals too high.

MEDICAL DIAGNOSES 0 For the purpose of

investigating the possible influence of the

children’s medical diagnoses on the accu-racy of pediatric appraisal, the children were grouped as follows:

1) Well children with no known relevant

physical or psychological illness, who attended clinic for health supervision.

2) Those who had major physical illness or poor health histories, including pro-longed, repeated hospitalizations or

chronic conditions requiring frequent clinic visits.

3) Those who had physical or emotional handicaps, or both, which might be

ex-pected to have an influence upon their general behavior and development. 4) Those attending the clinic primarily

because of slow development and

sus-pected mental retardation.

Figure 5 shows the percentage of children

in each of these groups who were appraised within 10 points of their actual intelligence

quotients. Pediatricians tended to estimate

intelligence of children with significant



handicaps, and mentally defective children, slightly less accurately than intelligence of

well children.

The graph (Fig. 5) also indicates the

di-rection of error, as shown by the arrows

above the bars, in the two groups for whom

a distinctive trend was noticeable. These are of special interest in light of the over-all

tendency of the doctors to overestimate the children studied. Intelligence of children with physical illness was almost always

un-derestimated, contrary to the expressed views of some of the pediatricians inter-viewed, who thought they allowed for or

even over-compensated for such handicaps ill their appraisals of this group of patients.

Intelligence of mentally retarded children

was grossly overestimated. The graph in

Fig-ure 5 showing results for different ranges

throws into even sharper relief this

statisti-cally significant trend. Here the children have been placed in three groups according

to intelligence quotient: 85-114, the normal range on the Stanford-Binet scale; below 85;

and above 114. It is at once apparent that

fewer accurate estimates have been made for

children at the extremes than in the normal

range; this tendency is especially marked

for those with scores below 85, where

al-most no estimates were too low (between

58% and 28%, p < 0.001; between 58 and

44% p < 0.02).

In analyzing the cases where gross errors

were made (where the ratings of the doctors

differed by more than 20 points from the test scores), it was found that all gross

errors in judging children with scores of less than 100 were overestimates, and those

in children with scores above 114 were un-derestimates. In the children with scores

below 85 the pediatricians’ ratings in eight appraisals were 35 to 48 points higher than

the test scores.

In one other rather complicated case of

a 2-year-old child whose parents initially presented conflicting historical data

(sub-sequenfly felt attributable to difficulty in

accepting their child’s extreme degree of

retardation), the first physician’s rating was

“low average” (85-94), and the test score was 31. The second pediatrician who saw

this child interpreted the parents’ histories

more discerningly and appraised the child

more accurately, as “under 65.”

In the children with scores above 114, there were six appraisals in which the pedi-atricians rated the children from 35 to 41 points below their test scores.


Approximately half of the children were

appraised within 10 points and two-thirds within 15 points of the psychologic test

scores. To estimate a child’s intelligence anywhere within the average range may be

quite sufficient in the case of the young

child who lives in his own home and pre-sents no serious medical, psychological or

school problems. On the other hand,

inac-curacies in judgment of a few points may lead to opposing and confusing

recom-mendations concerning a child for whom remedial instruction, special class, adoption, foster home or institutional placement is

being considered. ‘Special consideration should be given to the patient groups which were most often inaccurately appraised.

One group in which intelligence was less well estimated by the pediatricians was the

group of patients with major physical

ill-ness. As previously mentioned, almost all pediatricians interviewed stated that they thought they were able to compensate for the effects of physical illness on the child’s

mental development. Most of them believed that they would not only compensate but

would be prone to “bend over backwards”

in order to give the child the benefit of the

doubt. This was not found to be the case, and underestimates were the rule in this group, although overestimates also occurred

in some cases.

It is easy to understand that pediatricians

concerned with the urgent medical needs of

seriously ill children may place less

em-phasis on these children’s mental abilities

than on other aspects of their functioning.


more can be done for these children in medical treatment, the prevention of psy-chological handicaps assumes greater

sig-nificance than ever before. Children with

serious physical illness are already denied

So many sources of self-respect,

self-confi-dence and satisfaction that it is essential

that their strengths and assets be

recog-nized so that opportunity can be given for

the full realization of their intellectual abilities. Often academic achievement is of special importance, since there may be physical limitations preventing occupations

requiring bodily strength and stamina. On the other hand, overestimating the abilities of a child who is already under

stress may cause him to be placed under

too much pressure for academic

achieve-ment. More refined assessment of the

abili-ties of these children, who constitute one

of the pediatrician’s main concerns, is

there-fore essential, and psychologic evaluation

may be indicated more frequently for this

patient group than for some of the others.

The second group that was less accurate-ly appraised by the pediatricians were

chil-dren with mental retardation. With respect

to this patient group, collaboration with

psychologists is already more prevalent but should be encouraged and strengthened. On

interview, pediatricians believed themselves

at least as competent in appraising the

in-telligence of mentally retarded children as

of those within the normal range. This belief has already been stated by Perlstein,’ an

authority on the evaluation and treatment of mentally retarded children, as follows:

A pediatrician who has seen a lot of normal children is supposed to have a sort of built-in Gesell scale, so that he can readily look at a child and get a pretty good idea of where this child belongs in relationship to mental ade-quacy.

In effect, it was shown in the study that they were able to estimate the lowest

in-telligence range least accurately. Errors ranged from a few points to over 45 points from the test score. As pointed out in the description of the criterion, the test


in the mentally defective range are most


Most of the pediatricians’ gross errors in

this group were overestimates. These may

at first glance seem relatively unimportant;

however, on closer inspection this type of

error can have serious implications. Failure

to recognize the extent of the child’s

limi-tations may deny him the opportunity for

an educational program which would en-able him to optimally benefit from

appro-priate social and educational experiences.

Adults who find it difficult to accept a slow-learning or defective child are often further encouraged, by the pediatrician’s

overesti-mate, to be unrealistic. Great harm and confusion can result in situations where too much pressure is created at home and

at school because the child’s limitations are not adequately understood and accepted. Emotional and behavioral disturbances may

develop in the child himself, and situations may be created which impair the

relation-ship between the child, his parents and his teachers. These considerations may be

rele-vant, also, in the children of low average intelligence.

It should be remembered that psycho-logic tests are not infallible for mentally retarded children or for any other group; but where questions as to their validity

arise the tests can be repeated after an

in-terval, or additional or alternative ones can be given for comparison or confirma-tion. The pediatrician performs a valuable

service at times by questioning the validity

of test results in order to prevent false

diag-nosis of a child as slow or mentally


Inaccuracies of estimates on bright

chil-dren may also render children a real dis-service, since almost always the tendency

in this study was to underestimate them. If an unusually gifted child is insufficiently challenged at home or in school, his aca-demic interests and performance may

dete-riorate and personality problems may arise.

Superior intellectual endowment in a child

should be recognized to encourage optimal


his parents’ and teachers’ understanding of his special needs. Misjudgments of even a

few points at the borderline ranges

be-tween the average intelligence and higher abilities may influence parental

expecta-tions and so cause serious errors in realistic

educational planning.

The fact that the experienced

pediatri-cians who participated in this study did not make more accurate appraisals than

the inexperienced pediatricians is contrary

to general expectation and contrary to the

expressed conviction of all the pediatricians

interviewed, except for a few whose confi-dence had been somewhat shaken by

par-ticipating in the study and having the

op-portunity to check their clinical impressions

against psychologic test results and the findings of other pediatric examiners. The failure to achieve greater skill in this

as-pect of pediatric practice during prolonged

experience in conventional pediatrics may

reflect a lack of emphasis on child develop-ment and mental achievement and a dearth

of opportunity for the pediatrician to

vali-date clinical impressions by collaboration

with psychologists. There is a general tend-ency to assume that this portion of

pedi-atrics can be included in what is generally considered the art of medicine and is,

therefore, relegated to an intuitive common sense level of functioning instead of being subject to the vigorous, critical, scientific standards prevalent in other spheres of medical knowledge and practice.14

The lack of significant correlation

be-tween the pediatricians’ confidence in mak-ing appraisals and the accuracy of their

estimates also suggests that the critical

self-awareness and need to subject hypoth-eses and impressions to objective scrutiny and quantification which is ideally preva-lent in medical practice has not been ex-tended into the areas concerned with

psy-chological functions.

Having known a child well, and having

had many pediatric visits with a particular

patient, did not result in more accurate

ap-praisals by the pediatricians. It may be

as-sumed that during a long and close

rela-tionship with a sick child, the pediatrician

becomes less objective in his appraisal of

the child patient. This assumption is further

supported by the fact that a dispropor-tionately high number of children who were

grossly misjudged by the pediatricians were found to be described in the records as appealing and attractive, suggesting that pediatricians are less objective in

apprais-ing children whom they like. The warm re-lationship between pediatrician and sick child is of basic importance for pediatric practice and is, of course, to be cherished. However, when the moment comes to make

a clinical judgment that is to serve as the basis for the treatment and plans for the

child, it seems desirable for the pediatrician

to have at his disposal methods for making the necessary judgments reliably and


It will be recalled that appraisals were

slightly more accurate when made on visits

specially scheduled for an appraisal.

Al-though the actual procedure followed by

the physician during these visits was

gen-erally the same as that on routine pediatric

visits, and although no more time, often

less, was spent with the child, this is inter-preted to indicate that when attention is focused on this aspect of the child’s

func-tioning, the pediatrician is capable of a higher level of accuracy than when he is preoccupied with his other duties to the

child. The individual pediatricians who par-ticipated in the study did not do so over

a sufficient time period, nor did they

per-form a large enough number of appraisals

to make it possible to document learning

on the part of the individual pediatrician in the course of the study. However, the

same pediatricians made appraisals on spe.

cial appraisal visits and on routine pediatric

visits and performed more accurately in the former context.

While the study was in progress in the

Pediatric Department, there was a

notice-able toning up of interest and performance

of all the pediatricians in relation to

ex-ploring and assessing the developmental


very fact of investigative activity, the pos-sibility of having one’s impressions

corn-pared to more objective standards, and the expressed and manifest interest in the sub-ject appeared to become the incentive for pediatricians to learn more and function

bet-ter in this area.

These observations suggest that more re-search activity and more objective knowl-edge on the subject of mental development

should be available to pediatricians in

train-ing and practice, so as to make possible learning and so as to focus their attention

on this important aspect of their work. It should be kept in mind, however, that even under optimal conditions there are

inherent limits to the accuracy of ratings

of human attributes by anyone, the

delinea-tion of which has been the subject of con-siderable psychologic research.15 Ratings

made by trained and experienced raters are rarely sufficiently reliable for use in

classi-fying individuals; they are used mainly for making group distinctions or for rating

in-dividuals when no better method is

avail-able. In view of these limitations of the rating method, quantitative and objective methods of evaluation should be more ex-tensively used.

This topic has not been discussed at

length in the pediatric literature, but in several recent it has been

sug-gested that pediatricians use tests or

por-tions of tests as part of their procedures in evaluating children’s mental development. There is insufficient emphasis given to the fact that taking the tests out of context

and using them without the special

train-ing required destroys their validity. Closer

collaboration with properly trained and

ex-perienced psychologists can increase the pediatrician’s skill in making assessments within his own professional framework and

assist in avoiding misuse of standard

psy-chologic instruments thrOugh lack of

un-derstanding the tests and their


When the study was initiated, it was hoped that meaningful relationships

be-tween the methods used by the

pediatri-cians making the appraisal and the accu-racy of the resultant estimates would be demonstrated. Exhaustive analysis of the stated bases for appraisal, both the number

and nature of criteria the pediatricians put down on their appraisal forms, failed to

yield any consistent or meaningful findings. The pediatricians were apparently insuffi-ciently aware of the actual bases of their

judgments to state them clearly; thus, the recorded criteria seemed not truly

repre-sentative of the method by which the

as-sessment was made. It is hoped that in the future it may be possible to determine which aspects of the child’s functioning are readily accessible for study by the

pedia-trician during his usual clinical contacts with his patients and would be most useful

to him in assessing mental development ac-curately.


Four hundred seventy-seven estimates by

pediatricians of developmental level and intelligence of 242 patients from 1 through

9 years of age were compared with results of standard psychologic tests. Approxi-mately a half of the pediatricians’ appraisals were accurate within 10 points of the psy-chologic test results, and about a third

deviated more than 15 points.

None of the attributes of the

pedia-tricians or the conditions under which they

made their appraisals were related to accu-racy. However, not all estimates were made equally well. The greatest accuracy was shown in the estimates for children within

the normal range of intelligence. The two groups most consistently misjudged by the

pediatricians were the physically ill and the mentally retarded. Levels of development were most frequently underestimated in physically ill children and grossly

over-estimated in mentally retarded children. Implications of the findings for pediatric practice and education are presented.


1. Terman, L. M., and Merrill, M. A. :

Meas-uring Intelligence. Boston,


2. Cattell, P. : The Intelligence of Infants.

New York, Psychological Corp., 1940. 3. Burt, C. : The distribution of intelligence.



Psychol., 48: 161, 1957.

4. Jones, H. : The environment and mental

development, in Manual of Child

Psy-chology, Ed. 2. New York, Wiley,


5. Pasamanick, B., and Knobloch, H. : Early

language behavior in Negro children and the testing of intelligence.



Psy-chol., 50:401, 1955.

6. Binet, A. : Nouvelles recherches sur la

mesure du niveau intellectuel chez les

enfants d’#{233}cole. L’Ann#{233}e Psychol., 17: 145, 1911.

7. Goodenough, F. L. : Mental Testing. New

York, Rinehart, 1949, p. 36.

8. The Fifth Mental Measurements Yearbook. Edited by Buros, 0. K. Highland Park, N.J. Gryphon Press, 1959.

9. Wallin,


E. W. : The consistency shown by intelligence ratings based on

stand-ardized tests and the teachers’ estimates.


Educ. Psychol., 14:231, 1923.

10. Alexander, A. M. : Teacher judgment of

pupil intelligence and achievement is not enough. Elem. Sch.


53:396, 1953.

1 1. Olander, H. T., and Walker, B. S. : Can

teachers estimate IQ’s? Sch. Soc., 44:

744, 1936.

12. Curr, W., and Gourlay, N. : Differences be-tween testers in Terman-Merrill testing.



Stat. Psychol., 9:75, 1956.

13. Perlstein, M., in The Evaluation and Treat-ment of the Mentally Retarded Chil-dren in Clinics. New York, Nat’l.

As-soc. Ret. Child., 1956, p. 35.

14. Tyler, E. : Psychiatry: Inherited or ac-quired knowledge.


Med. Educ., 35: 689, 1960.

15. Wagner, R. : The employment interview: a

critical summary. Pers. Psychol., 2:17, 1949.

16. Bakwin, R. M. : Office evaluation of

in-telligence of children. PEDIATRICS, 23:

989, 1959.

17. Coleman,


M., Iscoe, I., and Brodsky, M. : The “Draw-a-Man” test as a

pre-dictor of school readiness and as an

in-dex of emotional and physical maturity.




Barbara Korsch, Katharine Cobb and Barbara Ashe



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