The extensive financial support which has been received from many sources to make these case studies possible over the years since 1930 has been acknowledged in the first paper in this series. The present
continuing support from tile Research Grants Division of the Public Health Service has provided for the analyses of thesc health histories and the prepariition of this report based upon them.
941
PEDIATRICS, November, Part II, 1959
PATTERNS
OF
ILLNESS
EXPERIENCES
Isabelle Valadian, M.D., M.P.H., Harold C. Stuart, M.D.,
and Robert B. Reed, Ph.D.
INTRODUCTION
T HIS PAPER reports the illness
experi-ences of 134 children enrolled in the
Maturity Series as described in the first
paper in this Supplement, that is, of the 67
boys and 67 girls followed from birth to
their 18th year of age. The purpose is to
reveal the variety of patterns resulting from
tilese experiences as they unfold at
succes-sive age periods and the differences in the
total illnesses of the group during
child-ilood. In order to obtain some indication of
the probable impact of each illness upon the
child, a point score has been assigned which
takes into account the character of the
ill-Iless, its areas of involvement or
complica-tiOIls, its severity and its duration. The data
resulting from these studies provide for each
child, as vel1 as for boys and girls grouped
separately, the total number of illnesses, a
numerical score for each illness and total
scores for each year of age and for selected
age periods. Very marked differences have
been found in all of these aspects of
ill-ness experiences between children at any
age and in tile patterns of change in tilem
throughout cilildhOOd.
SOURCES OF DATA
The sources of the ratings assigned to each
child have been the pediatrician’s records
ob-tamed at every routine visit of a child to the
clinic which served this research project. This “health history” was obtained by the
pedia-trician in charge of this research or by an
assist-ant on his staff. During approximately the first
10 years of each child’s life, when visits were
at 6-month intervals and the mother was
usu-ally the only person interviewed, 20 minutes
was assigned to the pediatricians for taking this
history. Very occasionally the child was brought
by the father or some other relative, in which
case the information was obtained in so far as
possible, but a separate history or amplification of it was obtained from the mother by the staff flU5C on a home visit or by the pediatrician at a later appointment.
Between 10 and 18 years of age the health
histories were assigned more time, in part
be-cause of the need to cover the whole preceding
year and also because they were often taken
separately from the adolescent and the mother
so that the two histories had to be reconciled.
During the late ears, the entire history was
most often obtained directly from the
adoles-cent, but supplemental information was usually
available from the mother at the clinic, by
tele-phone call or letter, or at home visit by the
nurse. Most adolescents went through a period
of reluctance to communicate information, but this was characteristically of silort duration, that is, affecting only one or two age periods, at which time special effort was made to secure
a full report from the mother. After this, the
usual experience was that of a real desire to
give a full and accurate account, often to
de-scribe episodes in great detail. The interest
of the adolescent in himself, which usually
en-compasses his health and his physique, proved
to be an asset in obtaining a health history,
although questions and discussions tended to
make this process very time consuming. Older
adolescents tended to be quite precise, often
coming prepared to report about each and
every illness. They were usually able to state,
for example, how mans’ days had been lost from
school because of illness during a given year.
The regular pediatric histories were
supple-mented from time to time by interval notes
derived from various sources, such as reports
chil-ILLNESS EXPERIENCE
dren had been referred. Information was
oh-tamed at times about one child when an
en-rolled sibling was in the clinic with the mother
for examination. Not infrequently, also, when
nutritionist, social worker or psychologist
picked up clues to health occurrences, these
were reported to the nurse or physician and
proved to be worthy of medical attention and
incorporation in the running health history.
The assistant pediatrician to the project
shared with the pediatrician-in-charge taking
the clinical histories and making the
accom-panying examinations. There were several
changes in the person serving as assistant
pedia-trician over the years, but the director worked
closely with the assistant in training,
super-vision and sharing at history taking and at
examinations. Procedures for classifying and
recording reports of illnesses were reviewed
together.
The Monograph I (Reference 3, Bibliography
p. 972) frequently referred to in the preceding
papers, provides more details as to history and
physical examination procedures during the
first 8 years of the project; usually these were
maintained until each child approached
adoles-cence. From this age onward the history
tak-ing tended to be less formal and ordered,
questions being asked and notes made before,
during and subsequent to examinations. The
combination of these two procedures was
as-signed 1 hour for each adolescent and often
required much longer. During these years, the
physician-in-charge being a man, the assistant
pediatrician was by choice a woman; these
often worked together, sometimes checking
physical ratings and often one recording while
the other examined.
The basic continuing health histories include
many notes of health problems or recurrent
complaints, which collectively may deserve a
supplemental study but which are not included
here as illnesses. Localized pathology or
devia-tions from normal expectancies in clinical or
laboratory findings not associated with any
clinical symptoms also have not been included
as illnesses.
The notes on illnesses in the records were kept
as brief as possible and an attempt was made
to record interpretative judgments when such
were required. However, quotes were recorded
at times to give a picture of the ideas or
at-titudes expressed by mother or child. For
example, if a mother reported “frequent heavy
colds” this statement might be recorded with
an attempt to add specifically the number,
severity and duration of each and to determine
the areas primarily involved. When the latter
was possible, colds were recorded as upper,
lower, or upper and lower respiratory infections
of mild, moderate, or severe degree lasting 1 to
4 days, 1 week, or longer periods.
In general it was in the very’ mild and
short-duration illnesses that the memory of the
per-son interviewed was too vague to permit an
approximation of severity, duration and
loca-lion of complaints, and most of the former fell
into the category of mild upper respiratory
in-fections of short duration. When illnesses
per-sisted for several weeks, it was at times
diffi-cult to determine their severity week-by-week,
but in most such cases the time given covered
a terminal period which probably represented
convalescence, and this was assigned a mild
rating. Chronic conditions proved much more
difficult to rate in these terms, but fortunately
very few of these children had illnesses which
should properly be called chronic. A few
chil-dren suffered from allergies which at certain
ages produced symptoms so frequently that
records could not be precise and rather ar-bitrary decisions had to be made in assigning
both number of illnesses and scores for
ill-nesses.
In attempting to differentiate between
fre-quently recurrent illnesses and chronic
ill-nesses with exacerbations, and otherwise to
check on the mother’s reports of the severity
of illness, much help has been obtained by
comparing the histories with the records of
examinations. For example, if a mother reports
that a child has recently had a severe attack
of tonsillitis, and examination at this time
shows inflamed tonsils with exudate or
en-larged and tender lymph nodes, these findings
tend to validate her report. If, on the other
hand, the mother is constantly reporting
re-cent events, with no evident pathology found
at or shortly after the report, the episode
re-ported has been presumed to be deserving of
a lesser score for severity. It is recognized that a mother’s or a child’s report of an illness 5
months after its occurrence is less reliable in
respect to type, severity or duration than is
that of an illness that has recently occurred.
Also, the physical signs are less useful under
these circiinistances.
Birth to 2 years 2 to 6 years 6 to 10 years lOto 14 years 14 to 18 years Birth to 18 years
- Infancy
- Preschool
- School
- Early Adolescence
- Late Adolescence
- Total Childhood
CHILD HEALTH AND DEVELOPMENT 943
differ greatly in their psychological approach to illness and, in general, toward reporting, and
that these facts tend to diminish absolute
re-liability. However, the mothers and their
chil-dren in this study were under repeated
oh-servation over a period of 18 years and were
constantly being encouraged to observe and
report accurately; in addition, they were often
contacted between regular visits by the nurse.
These circumstances should have helped
greatly to minimize inaccuracies. Also, the
staff being aware of these limitations, and
knowing the mothers and children from
fre-quent contact, were on guard against exaggera-tions or careless omissions.
With records of illnesses available as
de-scribed and with accompanying physical
ex-amination forms, laboratory tests and reports of special examinations, one of the authors
(
IV.) prepared case summaries, listing allillness experiences together by year of age in
one column, with physical findings, reports of
roentgenograms and special tests in an
ad-jacent column. These entries were made as
precise as tile records permitted in terms of
type of illness, principal symptoms, areas of
involvement or complications, severity and
duration. These summaries were used to
deter-mine tile number, severity and duration of all illnesses experienced b’ each child in each
year and thus provide the basis for the
anal’-ses which follow.
METHODS OF STUDY OF THE DATA
First, episodes of illnesses for each child
were distributed by the age period of their
occurrence. The age periods used were as
fol-lows:
Following this, illnesses were classified
ac-cording to their type or category, number,
severity and duration. The basis for classifica-tion was as follows:
Categories of Illnesses; Related Attributes
RESPIRATORY ILLNESSES: Total respirators’
ill-1&’SSCS, IIICIU(1iii g l)Otll infections and allergies,
are presented in this paper. Different
corn-ponents of this group of illnesses are being
studied and will be the subject of a subsequent
report.
GASTROINTESTINAL INFECTIONS: Primary in-fections only are considered here. When accom-panying other illnesses, gastrointestinal
mani-festations are listed with them as part of the
symptom complex or as a complication.
Gastro-intestinal disturbances of dietary origin are not included.
COMMUNICABLE DISEASES : Measles,
chicken-pox, mumps, whooping cough, scarlet fever,
and German measles are included in this
cate-gory.
“OTHER” ILLNESSES: All illnesses of any other
type occurred too infrequently to be dealt with
as separate categories, and are listed under this
heading. Therefore, this group includes a large
variety of miscellaneous diagnoses. ACCIDENTS AND SURGERY
COMPLICATIONS : Specific complications oc-curred in connection with illnesses in each
cate-gory and sometimes involved a combination of
categories.
NUMBER: Each illness has been located on a time or age scale for each child and the total
occurring in each age period has been counted
for the age periods already indicated as well
as the grand total for childhood. Similarly,
ill-nesses have been counted by separate
cate-gories. From these data, means and standard
deviations are available by age periods when
justified by the number of occurrences. The
re-sulting data dealing with distributions by type
or category of illness are to be reported in a
subsequent paper; the purpose of the present
paper is to report total illness experiences. How-ever, categories of illness are shown in Figures
10 to 19 in charting each illness of individual
children.
SEVERITY: This had been rated as “mild,”
“moderate” or “severe.”
DURATION: In most instances this could be
assigned to periods of under 4 days, 1 week,
13 weeks, etc. The problem of assigning a value
for duration to occasional instances of
fre-quentlv recurrent or chronic illnesses is
ILLNESS EXPERIENCE
SCORE SYSTEM EMPLOYED
Recognizing that the number of illnesses is a
limited measure of the total stress imposed by
them upon an individual’s health or of the
effects upon his growth and development, a
more meaningful estimate for these purposes
was sought by use of a Score system applied
to every illness. The goal of this scoring has
been to provide a measure which will permit
comparisons of all illnesses of different types
and with different complications. A numerical value is assigned under it to each illness, based first on the type of illness and then modified
according to both its severity and its duration.
Although the values decided upon were adopted
quite arbitrarily, they were assigned in every
case as consistently as the evidence in the
record permitted.
For purposes of maintaining the greatest
pos-sible consistency in assigning Scores, the
princi-pal author (IV.) rated every illness for every
child at every’ age. The second author (H.C.S.)
assigned Scores independently to every third
child. When differences of more than a few
unit-points in total Score were encountered, the
values assigned by each investigator to each
illness were compared and the basis of differ-ences were discussed together. There was close
agreement between these physicians in most
cases; the major disagreements were found to
be in cases with chronic or frequently repeated
respiratory illnesses, for which the evidence as
to the severitr or even constancy of illness was
vague. It is recognized that the method of se
lection of Score values and of equating them in
this study is one that might produce different
results for other investigators attempting to
apply them to groups of children elsewhere.
However, since all Scores used in this study
were assigned by one individual, with repeated
checks by a second and within a short period of
time, it is believed that the method serves its
purposes-to compare one child with another
and each child with himself at succeeding age
periods.
The plan for assigning predetermined point
or unit values to different kinds and degrees of
illness has several important elements, which
can best be made clear by describing their
application to respiratory illnesses. These
dominate the whole picture and the application
of the system to other illnesses can then be
indicated briefly in equivalent terms.
respiratory illness with evidences of
involve-ment of both upper and lower respiratory
areas, of moderate severity and lasting about
1 week. If the signs and symptoms indicate
involvement only of upper areas referred to as
“upper respiratory infections,” the assigned
value is reduced to “3k”. However, if there are
complications of simple upper respiratory
in-fections, such as otitis media, otitis media with
rupture or incision and drainage, acute sinus
involvement, acute tonsillitis and/or cervical
adenitis, the base Score is increased for each
by adding from “3” to “1” unit, depending on
the complication. Independently’ of these
corn-plications any illness may be rated as “mild”
or “severe” rather than “moderate” based upon
the report of symptoms, such as degree of
fever, severity of cough, or amount and nature
of exudate. If the severity is rated “mild”
rather than “moderate,” the value is reduced
bs’ a half. Conversely, a severe rating would
change a moderate rating of “3k” to “1”. When
the diagnosis of pneumonia has been confirmed,
the Score for a lower respiratory infection is
raised from “1” to “3” under usual
circum-stances. The severity rating is increased also
by
other specific reports of major clinical signsdenoting serious illness, such as radiographic
evidences suggesting tuberculous infection and
a positive tuberculin test.
Adjustments of Score, to take into account
the duration of each illness, have been made in
accordance with the following general plan.
The calculated value based on type and
sever-ity is multiplied by the value assigned to dura-tion. The divisions of duration adopted are:
under 4 days, 1 week, 13 weeks, 2 weeks, etc.,
with corresponding unit values of “W’, “1” and
“1W’, etc. As an example, a moderate upper
and lower respiratory infection which has a
basic value of “1” would be multiplied by “3k”
if it lasted less than 4 days, by “1” if it lasted
a week, etc. A mild upper respiratory infection
with a base value of “3”, if it lasted only 3 days,
would be assigned a rating of “g’ X
“c’,
re-ducing the value to “3k”. This is the lowest
Score assigned and has been used frequently’
for mild head colds. In contrast, the highest
Scores assigned to single though prolonged
complicated illnesses were “20” and “233”
respectively. These Scores were given to two
siblings who were sick for approximately 33
CHILD HEALTH AND DEVELOPMENT 945
the need for step by step assignment of Score
values in complicated situations.
The first child, a girl, age 3 years 5 months,
developed an acute upper respiratory infection
which became complicated in sequence by
bilateral otitis media with purulent discharge
lasting 4 weeks, pneumonia, septicemia and
empyema with thoracotomy and purulent
drain-age for six weeks. Hospitalization was
re-quired for over 2 months.
The second child, a boy 2 years of age,
developed at the same time as his sister a
similar respiratory infection complicated
pro-gressively by left purulent otitis media, lobar
pneumonia, erysipelas, submental adenitis,
mas-toiditis and left jugular thrombosis. The
opera-tions required for these were: incision and
drainage of the middle ear, mastoidectomv,
incision and drainage of the left submaxillary
gland and ligation of the left jugular vein. He
was hospitalized 3 months.
The Score value assigned to an illness of
longer duration than 1 week presents sharply
the problem of changing values for the same
illness with time. Occasionally an illness of
moderate severity during the first week
be-comes more severe during the second week
due to spread or complications, but more
corn-monly the severity rating diminishes toward
the end of an illness. Thus an illness described
as of 3-weeks duration might be rated severe
for the first week, moderate the second and
mild for the last. Not infrequently a chronic
illness has been considered very mild,
manifest-ing only slight or intermittent symptoms and
has been assigned a value per week of half
the usual mild value, as in the case of a child
having paroxysmal cough for weeks following
pertussis, but showing no persistent signs of
bronchitis. These small values aim to
recog-nize that persisting symptoms may have some
effects upon general health and yet not unduly
weight a child’s total Score because of them.
Specific Scores for other illnesses, operations
and accidents were assigned in a similar
man-ner to that described for respiratory illnesses,
but with differing basic values depending upon
the type or area of involvement. As examples,
uncomplicated moderate communicable
dis-eases lasting a week were assigned a value of
“1”. Primary pneumonia, however, was given
a value of “3”. Simple appendectomy was
as-signed “13 whereas ruptured appendix with
peritonitis and illness lasting 2 weeks was
as-signed a value of “4”. A child who had
hy-dronephrosis with complicating pyuria and
who required nephrectomy, which resulted in
hospitalization for 2 months, accumulated a
Score of “25” points.
After assigning Scores to each illness, the
total Score for each child has been counted
for each of the age periods both for total
ill-nesses alld by categories. As in dealing with
number of illnesses, means and (when appropri-ate) standard deviations have been calculated for these Scores.
CLASSIFICATION OF CASES BY SCORE
AND NUMBER OF ILLNESSES
Having assigned a Score to each illness for
each child and having calculated the total
Score and the total number of illnesses
sepa-rately for each child in the five age periods
described, Score symbols A, B or C and
num-ber symbols a, b or c have been assigned in
every case for each age period and for total childhood.
“A” or “a” for values of “Score” or “number,”
respectively, range from 1 to 2, inclusive, per
year; “B” or “b” for values over 2 to 4,
in-elusive, per year; and “C” or “c” for values
over 4 per year.
Therefore the following values are assigned by age periods:
“A” indicates a Score of 1 to 4, inclusive,
for the 2 years of infancy and 1 to 8,
in-elusive, for each subsequent 4-year
pe-nod to which it is assigned.
“B” indicates a Score of over 4 to 8,
in-elusive, for infancy and over 8 to 16,
inclusive, at any later 4-year period.
“C” indicates a Score of more than 8 for
infancy and more that 16 at any later
4-year period.
In similar manner, but referring to number
of illnesses:
“a” indicates 1 to 4, inclusive, illnesses in
infancy and 1 to 8, inclusive, at each
subsequent 4-year period.
“b” indicates over 4 to 8, inclusive, illnesses
in infancy and over 8 to 16, inclusive,
at any later 4-year period.
“e” indicates more than 8 illnesses in infancy
and more than 16 at any later 4-year
period.
“A” and “a” when applied to Total
Child-hood indicate values between 1 and 36,
ILLNESS EXPERIENCE
“B” and “b” indicate values between 36 and
72.
“C” and “e” indicate values greater than 72.
“0” and “o” indicate no illness recorded.
Rating
By combining “Score” (A, B or C) witil
“number” (a, b or e) a composite letter code,
hereinafter referred to as Rating, becomes
available. This summarizes the illness
experi-ences of each child, either for an age period,
as for example Infancy, in which case it is
called the Infancy Rating or for Total
Child-hood when it is referred to as Total Rating.
FINDINGS AND COMMENT
Number of Illnesses
During Total Childhood, boys
experi-enced from a minimum of 17 to a maximum
of 99 illnesses and girls from 17 to 104. The
median number for boys is 52.0 whereas for
girls it is 41.7. Figure 1 gives the
distribu-tions of number of illnesses for Total
Child-hood and for age period and subdivisions.
Each distribution is divided into “a”, “b”
and “c” groupings. The distributions for
Total Childhood show that the boys are
pre-dominantly in the “b” group whereas more
girls are found in the lower half of “b” and
the upper half of “a”. The greater
fre-quency of illnesses among the boys than the
girls is characteristic of all the age periods
except 10 to 14 years, but most striking for
the age periods 2 to 6 and 6 to 10 and least
so between birth and 2 years. In infancy
the distributions for boys and girls are
much alike and predominantly in the “b”
grouping. However, in the preschool period
the “c” group predominates for boys and
the “b” group for girls, with more girls than
boys found in “a”. In both adolescent
periods there are more boys than girls in
the “c” group. The median numbers of
ill-nesses in the five age periods (as defined
in Methods) from infancy to late
adoles-cence are: for boys, 6.7, 16.6, 12.2, 6.1 and
5.6; and for girls, 5.8, 12.7, 9.4, 6.2 and 4.0.
Scores for Illness During Total Childhood
The Scores for boys range from a
mini-mum of 6 to a maximum of 61 and
from 9 to 103. Tile median Score for boys
was 29.2, w’hereas for girls it was 27.6.
Figure 2 gives the distributions of Scores
for illnesses for Total Childhood and for
each age-period subdivision in the same
manner as given in Figure 1 for numbers.
The distributions for Total Childhood show
that Scores for both boys and girls are
pre-dominantly in group “A” and only three
girls and no boys were in “C”. Boys and
girls had Scores which varied similarly
be-tween age periods.
In both Infancy and Prescilool periods,
the great majority of boys and girls have
Scores in groups “A” and “B”, about equal
in each. In the School period there are
eon-siderably more girls in “A” than in “B”, but
boys are still more nearly equal in both.
During both periods of adolescence the
great majority of both boys and girls have
Scores in “A”. The median Scores for
ill-nesses for each of tile five age periods are:
for boys, 3.7, 9.4, 7.2, 2.3 and 1.8; for girls,
3.4, 10.0, 6.2, 2.3 and 2.3.
Both number and Score are at the
iligh-est levels in the Prescilool period witil
rela-tively higil levels in Infancy and School
periods and a definite decrease after 10
years. Both number and Score are at their
lowest levels (luring Late Adolescence.
In summary, it is clear from mllspection of
Figures 1 and 2 that there is a movement
of concentration of individuals from low
brackets in Infancy to higiler brackets
dur-ing the Preschool period with a gradual
fall in the School period followed by a
sharp fall during Early Adolescence to the
lowest brackets in Late Adolescence.
By further comparing Figures 1 and 2 it
is seen that in both sexes, but slightly more
in boys than girls, number predominates
over Score; this indicates that, on the
aver-age, illnesses were mild to moderate. This
is made more evident in tile Figures which
follow.
Figures 3 to 8 show the scatter of tile
data for individuals when Score is plotted
against number of illnesses, first for Total
947
BOYS
3 100
90
C 80
70
60
b
40
0
20
$0
0
CHILD HEALTH AND DEVELOPMENT
0-18 Yrs.
1RLS
NUMBER OF ILLNESSES
O-2Ws.
I
2-6 Yrs. 6-10 Ws.
10-l4Ws. I4-I8Ws
40
20’ 30
C C
__________________ i: Ii
BOYS
3
3 3
0-18
3GIRLS
F
I3
SCORES FOR ILLNESSES
O2Yrs.
BOYS GIRLS
C
2-6 Yrs. 6-10 Yrs.
50
10-14 Yrs.
=
50
40
30 C
20
?o
14-18 Yrs.
L
=-‘----V -‘‘ 1t?ttt “ _______________
Fic. 2. Distribution of Scores for illnesses for Total Childhood and by age-group subdivisions-boys and girls.
100-90 C
80
70
60
850
40
30
20 A
10
40
30
50
40
30
ChILl) HEALTH AND I)EVELOPMENT 949
TOTAL CHILDHOOD
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NUMBER OF ILLNESSES
Fic. 4. Scores of individuals plotted against number of illnesses-Infancy.
INFANCY
BOYS
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CHILD HEALTH AND DEVELOPMENT 951
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: -__---___--.__-._-_- - --- - - I L I I I I I Ii1/__1._ I I I I I
0 2 4 6 8 12 14 lB 2022242628303234363840
NUMBER OF ILLNESSES
CHILD HEALTH AND DEVELOPMENT
EARLY ADOLESCENCE
953
30
28
26
24
22
20
lB
6
“ 4 BOYS
C
2 B
IC
8
#{128}
4
2
I 2 4 6 10 14 16 18 20 22 24 26 28 30 32 34 36 38 4
NUMBER OF ILLNESSES
a:
ol U
U)
FIG. 7. Scores of individuals plotted against number of illnesses-Early Adolescence.
7
--//
/ /
/
NLNBER OF LLNESSES
CHILD HEALTH AND DEVELOPMENT 955
Score coincides with number, that is, if the
average of his illnesses is “1” Score unit and
one number, his position will be on the
diagonal line. The divisions “A”, “B” and
“C” for Score and “a”, “b” and “c” for
num-ber are also demarcated on these figures.
Figure 3 shows the scattergram for Total
Childhood. Points for all but two of the
boys and most of the girls are seen to fall
below the diagonal line. The majority of
boys are in the “Ab” group, whereas girls
appear equally in the “Aa” and “Ab” groups.
In fact, only six boys have a total rating of
“Aa” against 25 girls, whereas there are
more points for girls than boys scattered in
the extremes of rating. The extremes of
average Score are represented by a boy who
had 73 illnesses with a Total Score of 23 (an
average Score of about 0.3 per illness)
whereas another boy accumulated a total
Score of 42 in 37 illnesses (an average
Score of 1.1 per illness). Among girls the
extremes for ratios of Scores to illnesses are
0.3 (51 illnesses and a Score of 14), and 1.9
(36 illnesses and a Score of 67).
Figure 4 presents tile scattergram for
in-dividuals during Infancy and shows that
the points for boys and girls scatter in a
very similar way, the majority falling well
below tile diagonal line. The extremes in
ratios for this age are represented for boys
by 0.2 (7 illnesses against the Score of 1.25)
and 1.56 (7 illnesses against the Score of
11). For girls the extremes were 0.1 and
1.8, respectively.
Figure 5 presents the scattergram for tile
Preschool period. In contrast to Infancy,
there is a marked spread of individuals at
this period, particularly toward the higher
zones. More individuals are in the “Cc”
group than at any other age period. For
boys the predominant group is “Bc” with
the next in order “Ab”, and for girls “Aa”
followed by “Bb.” In this period 22 boys,
in contrast to 12 girls, have ratings of “Bc”
and 4 boys, in contrast to 15 girls, have
ratings of “Aa.”
Figure 6 shows that during the School
period there is a shift of ratings of
mdi-viduals toward the lower ratings and this
is particularly true for tile girls.
Twenty-nine girls and 13 boys are in the “Aa” group
at this period.
Figure 7 shows a further movement of
ratings of individuals during Early
Ado-lescence into the lower ratings, a decrease
in their spread and an appearance of
clus-ters of cases at given points indicating that
more children are alike in ratings. All of
these features are more marked for girls
than for boys. There are still eight boys but
only two girls in group “Ac.”
Figure 8 shows that the trend described
for Early Adolescence continues into Late
Adolescence. All of these features again are
more marked in girls than boys. The Late
Adolescent boys appear very similar to
Early Adolescent girls in their movement to
a lower rating with decrease in the spread
and increase in the clustering of ratings of
individuals. (Figs. 1-8.)
Discussion thus far has dealt with the
status of children at given age periods. The
next step is to recognize the changes with
time in the number and Score of individuals
and groups.
Ratings
The objective just mentioned is met by
comparing the Ratings assigned to each
individual for consecutive age periods
(“Rating” is defined in the earlier section on
Classification as combining “Score” and
“number”). The sequence of Age Period
Ratings for each individual identifies the
changes in the illness experiences
through-out childhood. This sequence is expressed
for the individual by putting first his Total
Rating for childhood followed by his
sue-cessive Age Period Ratings. For example,
“Bb Aa Cc Ab Aa Aa” identifies a girl
whose Total Rating was “Bb” but whose
successive Age Period Ratings were as
listed.
Table I lists the individual rating
se-quences for all children in the Maturity
Series. In this Table, the children are first
TABLE I
INDIVIDUAL SEQUENCES OF AGE PERIOD RATINGS FOR ALL CHILDREN IN THE MATURITY SERIES
Age Period in u’hich Illness
Predominates Pattern*
Sequence of Age Period Ratings
Boys Girls Total Rating* Aa 6 boys 3 girls Infancy Preschool School Early Adolesence Infant & Preschool Preschool & School Infancy & School
Spread I 5 girls II I boy 8 girls 111(a) 4 boys 6 girls
Aa Ab An Aa Aa
Aa Ab Aa Ac Oo
Aa Aa Aa An An
Aa Aa Aa Aa An
Aa Aa An Aa Aa
Aa An An An An
Ab 11b Aa An An An An AII Oof :\a fib Bb Aa Aa An An An An AII An
Cc Ab An An An
An An Ab Ab Aa Aa An An An An Ab An Ab Ab Rb fib Bb Rb Aa Ab An An An An An An An Oo Oo Oo
An Bc Aa An An
An Gb An An An
An An Ab An An
Ab Ab An An An
Ab Rb Rb An An
Cb Al) Bc Oo An
An An An An An An An An An An An An An An An Ab Ab Ab Ab An An An Ab Al) Ab All An Al) Oo An ILLNESS EXPERIENCE
Rating; after this, and within such groups,
individuals are listed according to the age
period to which their maximum rating was
assigned. This rating indicates the period
in which each child’s illnesses predominated
and this rating is in italic type in his
se-quence. In the example just given the girl
is classified in Table I under the group
“Bb” and sub-group Preschool period
be-cause “Cc” is her maximum rating, and
“Cc” is in italic type.
Some children did not show any single
age period of predominance, their illnesses
either being spread throughout childhood
or predominance occurring in adjacent age
periods. A few children had other
com-bnations of age predominance. Tile
nurn-her of children in different age periods of
predominance is summarized in Table II.
These features of age pre(1o111i11tnce are
further shown in Figure 9 which gives one
chart for boys and another for girls. The
position of each child is located on the
appropriate chart according to tile age
period or combination of age periods of his
or her maximum rating and the
“Score”-“number” category of that rating. Each dot represents a single child, the letters
follow-ing the dots indicate his or iler Total
Rating. When a dot for a child applies to
two adjacent age periods, the dot and
di-TABLE I (CoriLinued)
T()t(1l Ratl ng
---Age Period in which illness Predominates
- ----
-Pattern
----Sequence of Age Period Ratings
-Boys Girls
Iv
Bc Bc Bc Bc Bc Cc Ab Ab 43 boys i6 girls Infancy Preschool School Early A(lOlesceflce Late Adolescence Illfnncy & PreschoolInfnncy, Preschool & School Preschool & School
School &Early Adolescence
Sprend
Ab Cc Aa An An
Ab An Ac An An
V
20 l)oys
6girls
vi
11boys
5 girls VII 2 l)Oys I girl %111 I boy 2 girls 111(h) 2 girls
Bc Bc Bc An An
An Ac Ac Aa An
CHILD HEALTH AND DEVELOPMENT - 957
7 l)O5
6 girls
Ac Ab An An An
Bc Ab Bb An An
Bc Bb Bb An An
Li Bb Bb An An
Cc Bb Al) Aa Aa
Cc Ab Ab Ab An
Cc Bc Ab An An
Ab Rb An An Ab
An Rb Ab Ab Aa
An Bb Ab Ab Ab
An Bb Ab An An
Ab Bb Ab Ab Aa
An Bc Ali An Ab
Ba Bc Ab An An
Ab Bc Ab An An
Ab Be Bh An An
Ab Bc Ab An An
An Bc Bb Ab Ab
An Bc Ab Ac An
Bb Bc Bli Ab An
Bb Bc Ab An An
Bh Cc Ab An An
Bc Cc Ah Aa Aa
Be Cc Ab An An
Bb C’c Ab An An
Bb (‘c Ah Ab Ab
Bc Cc Bc An An
An Al) Ac Aa An
An Al) Ac An An
Aa Ab Ba An An
Ab Ab Bb An Aa
Ab Ab Rb An An
Ab Ab Rb An An
An Ab Bc An An
Ab Ab Bc An An
An Ab Bc An An
Ab Ac Bc An Aa
An Bb Bc An An
Ac Ab Ab Bc Ac
Rb Rb Ab Ac Ab
Bc Bc An An An
Ab Al) An An
Bn An Aa Aa
Bb An An An
Bb An An Ab
Bb Bb An An
Ab Al) Aa Aa
Rb Ac Ac Aa
An Bc Ab Ab An
Ab Bc An An Aa
Ab Bc Ab An An
Ac Bc An An An
Ab Ab An Al) An Ab Bh Bb Bc Bc Bc Bc An An An An An An An An
Ab Bb Ac Bc An
An Ab Al) An An An Ab An Ac Ac
Bc Bc An An An
Ab Ab Bc Bc Bc lic Aa Aa Aa An
An Ac Rb Rb An
Total Rating
4ge Period in n’hich illness
Predominates Pattern
Sequence of Age Period Ratings
Boys Girls
Bc 3 boys 3 girls
TABLE I (Continued)
Ac
5 boys
Preschool
Infnncy & Preschool School & Late Adolescence Preschool & School Infancy & Late Adolescence
Ab Bc An Ac An
Bc Bc Ab Ab Ac
Ab Ab Ac Ab Ac
An Bc Bc Ac Ac
Bc Ab An Ac Bc
Ba 1boy i girls
School
Preschool & School Infancy & Preschool
Al) Rb Rb Bn An
An Bh (‘c An (lu
Cc Cc Aa An Aa
Bh
9 boys It) girls
Infnncy
Preschool
School
Late Adolescence Infnncy & Preschool
Preschool & School
Ix
‘2 girls
x
Bb Cc Bb Aa An
Aa Cc An Aa All
‘2 l)oys 6 girls
XI
L boys Ab Be (‘c An An
2 girls (1 An (‘c An An
IL Re Ab Ab (c
XII (‘h Be An Ab Ab
(#{149}l) 1k An An Ba
3 l)OVS (‘(- (‘e Rb An Aa
Ba lie Bc Ab An
(a Bh Bc An An
Cc Bc Ab An An
An (‘(- Al) An An
Ab (‘c Ab An Aa
Ab Cr Ab An Ab
Bb (‘c Ac An Ab
BE) (c Ac An Al)
Bc (‘c Cb Bb An
Bb Bb Bc Aa An
Bb Bc (‘c Ab An
Infnncy XIII (c
(#{149}(-Be
BC
Bc
Ab
Ab
Ac
Ab
Cb
Preschool R- (‘i. Rh Ba Bn
Infancy, Preschool & School
Bc (‘c Bc Bb An
Bc (‘c Be Ac Ac
Be BC 1k An An
(‘c An Bli (‘c Bn
(‘c (‘c Rb Bb An
Cc (‘c (‘c Bb Al)
0 The numbers of children assigned a given Total Rating may be more than the total numbers assigned
to Pattern because single case examples of Age Period of maximum illness have not been assigned a Pattern, except in the high illness categories Be, Cb and Cc where single examples predominate.
+Oo = No illness recorded. Cb Infancy & Adolescence I girl
Cc Infnney & Preschool 2 girls Infnncy, Preschool & School
XIV
viding line. These charts are divided hori- vided according to numbers (“a”, “b” and
zontally by age periods and include a “c”). Figure 9 shows clearly predominance
column entitled “spread.” Vertically they of cases in the Preschool period for both
are divided into three broad ranges accord- sexes. There are more girls in the “A”
CHILD HEALTH AND DEVELOPMENT 959
the total Maturity Series showed the age
predominance of illness to be in one of
the Adolescent periods. This is also shown
in Table I. In addition, Figure 9 shows that,
regardless of the ratings of the early age
periods, tile Adolescent period is free of
illness or has relatively fewer ones.
Patterns of Ratings
The individual sequences of Age Period
Ratings (grouped as explained in Table I)
provide the basis for the selection of
pat-terns. Wherever there are several children
with generally similar characteristics a
pat-tern is assigned to them. Arbitrary decisions
had to be made to define the limits of a
pat-tern. In its simplest and most rigid
expres-sion, a pattern is formed each time that at
least two individuals share absolutely
iden-tical sequences of Age Period Ratings. One
hundred thirteen different rating sequences
are found among the 134 children, from
which 15 patterns can be detected with 2
or more children in each (13 patterns have
2, 1 has 3 and 1 has 7 children alike in
their Rating seq uences). However, th is
rigid definition of pattern brings only 36
children into tile patterns thus defined.
A different grouping of children, based
on similarity in Total Rating and similarity
TABLE II
AGE PEnloDs OF MAXIMUM ILLNESS, WITH
Nun-BEllS OF ChILDREN ASSIGNED TO EACH PERIOD
Age Period. in which illness Predom mates
Number of Cases
-____________ Boys ‘ -(rlrls Boys +Girl.s Infnncy Preschool School Early Adolescence Late Adolescence Infancy and Preschool Preschool and School School and Adolescence Infancy, Preschool and School Other Age Period Combinations Spread throughout Childhood
9 13 25 lL H 9 2 0 I 2 6 4 4 3 0 1 2 2 2 ‘3 4 8 67 67 L2 47 21 2 ‘3 10 7 1 4 5 12 134
in the Rating for the age of maximum
ill-ness, provides tile possibility of 57 different
groupings. Out of these emerged 21 patterns
of which 7 included from 6 to 13
individ-uals in each. This has been used as the
basic method for selecting patterns and
assigning cases to them; however, it leaves
too many children in the group as single
examples. The final selection of patterns was
based on Total Rating and Age Period of
maximum illness, disregarding actual rating
at this age. Two or more children with the
same Total Rating and Age Period are
re-quired to constitute a pattern. Within each
such pattern children are listed (Table I)
grouped by Rating in period of Maximum
Illness in order of magnitude of this Rating.
The resulting patterns are as follows.
Pattern Titles
(First two letters in each are Total Ratings.)
I Aa-Illness predominating in Infancy
II Aa-Iliness predominating in the
Pre-school Period
III Aa and Ab-Illness spread
through-out Childhood
I\ Ab-Iliness predominating in Infancy
\T Ab-lilness predominating in the
Pre-scilOol Period
VI Ab-Iiiness predominating in the
School Period
VII Ab-Iliness predominating in Infancy
and tile Preschool Period
VIII Ab-Iliness predominating in the
Pre-school and School Periods
IX Bb-Iliness predominating in Infancy
x
Bb-Illness predominating in thePre-scilool Period
XI Bb-Illness predominating in the
School Period
XII Bb-Illness predominating in Infancy
and the Preschool Period
XIII Bc-Illness predominating at
Differ-ent Age Periods
XIV Cb, Cc-Illness predominating at
Dif-ferent Age Periods
Figures 10 to 19 illustrate Patterns,
giv-ing single case examples of the different
category. (Example: In Figure 10 all cases
in Pattern I are girls; three cases have been
selected to illustrate the different “Infancy
Ratings” encountered in this Pattern).
Fig-ure 11 illustrates Pattern III with one boy
and three girls and demonstrates a scatter
throughout age periods without any period
of predominance. Figures 12 through 19
present in similar manner case examples of
individual variations in the types, seventies
and durations of illnesses among children
falling into the Pattern indicated. The case
examples were all selected on the basis of
difference in “Ratings” in the age period of
predominance. The features of cases
pre-sented in these figures which appear to be
of particular interest from the standpoints
of case similarities, differences or other
characteristics are commented upon in
footnotes to the Figures.
The graphic presentation used in Figures
10-19 takes into account the nature or type
of illness, its severity and duration. All
re-spiratory illnesses are represented by wavy
lines and gastrointestinal illnesses by
inter-rupted ones. All other illnesses are depicted
by uninterrupted lines, and operations or
accidents in columns of circles. The height
of each line corresponds to the Score of the
illness it represents and the breadth of the
line to its duration. In cases of chronicity,
corresponding lines run horizontally at the
level of the severity of the illness over the
period of its duration. SUMMARY
This report is concerned chiefly with
in-dividual differences in the patterns of total
illnesses as revealed by number and Score
of
each child’s illness experiences atsue-cessive age periods and in relation to Total
Childhood. Marked differences are revealed
for each child, by age periods and between
individuals at the same ages. Differences
with age have been found in the average
Score for illness based upon differences in
the type, severity and duration of illnesses.
The Preschool Period has been found to be
the age of maximum Scores and numbers,
for both sexes, with the Periods of Infancy,
School, Early Adolescence and Late
Adoles-cence having diminishing incidents, in tilis
order.
It is planned to report in a subsequent
paper the findings from these children
re-lating to the different categories of illness,
comprising the totals here reported and
their variable relationships by age and sex.
The records of tile total illnesses
experi-eneed by each child in the Maturity Series
have been summarized in terms of number
and Score for Total Childhood and for each
of five age-period subdivisions. Score and
number have been combined by letter
symbols to provide a Rating for each
period. The sequences of these Ratings
reveal the Pattern of illness experiences
en-countered among these children and the
number of children alike or closely similar
in their sequences. A series of Patterns have
emerge(l based on Total Rating and the age
period in which tile child had tile maximum
Rating.
No comparison is made in this paper
be-tween the present findings and earlier
studies of others of the incidence of
ill-nesses in childhood. Many of these studies
have been of populations of children by age
groupings and a few have been short-term
longitudinal ones. In addition, most
pub-lished studies deal with the relative
fre-quencies of categories of illnesses. The
au-thors believe that a more constructive
dis-cussion of findings by others can be
pre-sented in a subsequent paper which will
deal with categories of illness.
Acknowledgment
The names of the pediatricians, nurses and
other staff members who participated in
obtain-ing the information and recording the findings
at different periods of the project were given in the first paper in this series. The authors of
this paper wish to acknowledge particularly
the indispensable care and thoroughness which
these former associates exercised in making the
BOYS
FIG. 9. l)istributioas of individual Total Ratings according to Rating of age period in which illness predominates.
AGE PERIODS BY YEARS OMBINED A PERIOD SPREAD
L #{149}Ab.c #{149} #{149}AbR. R #{149}Ab#{149}b #{149}Ab Ab#{149}9 lAb #{149}Bc .eb C
#{149}Ab SAD .Ab.Bb.BC
F- . AD
a Bb B C #{149}Ab SAl SAb #{149} #{149}Ab#{149}Ab.AI #{149}Ab#{149}Ab#{149}Ac
Ac.Ab #{149}Ab #{149}
D#{149}Ab #{149}Ab r
#{149}Ab #{149}Ab
#{149}Ab #{149}Ab
Ac
Rb_SAD
#{149}AD #{149}Ab SAD
#{149}Ac b #{149} AbSAb #{149} Abb Ab B. S AD SAb a #{149}Ab
C #{149}Ab S
S AD
Ab SAD SAc
IA
S AD
b SAo SAD
SA. SAs
a
SAs 5*0
GJL_ 0-2 2-6 6-10 10-14 4- 18 0-10 OTHER 0-18
C 5Db 5 #{149}Ab #{149} Cc #{149}BbSBbSE #{149}Bb.BbSA Bo #{149}Bb
SAc 5Cc 5Cc
C --b a lAo #{149}Bb.BbSA #{149}Ao #{149}Bb B C lAb #{149}Ab
#{149}AD SAb S
SAb
#{149}Ab #{149}Ao
SAb
AD SAb #{149}
#{149}Ab #{149} #{149}Ab #{149}Ab SAb #{149}Bb Ab SAb Ab #{149}Bc #{149}Ab S *0 b -SAC #{149}Ao #{149}Ao #{149}Aa #{149}Ao #{149}AD S
#{149}Ao Ac S
Ab
a
C SAD SAb
A - #{149}Ab El #{149}Ao oAo #{149}* Ao #{149}Ao *o #{149}Ao SAD #{149}Ao #{149}AD SAc I Ac
.
I SAc SAcw
0
U
U)
2-U) U)
LU
z
-J
::: “2
2
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ , -‘ ‘
GIRL CASE 204
l
IIhI
I. ii
1
III
I
I
iiI
I
‘2
3
LU
LU
z
2
GIRL CASE 151
PATTERN I GIRLS
I. ) 11
It
I
I
lGIRL CASE 242
2-I
I , IIII
I II II,
I
Ii
it
PATTERN :ii GIRLS &BOYS
H1I1i11H11i1ILIiI1l
GIRL CASE 145
II
GIRL CASE 92
I
III, I
BOY CA 49
2
‘ I
Ii DI I
II
GIRL CASE 18
‘‘ ‘ ‘I‘‘f’’’ ‘I ‘‘‘, ‘‘‘-f’ . ‘ , ,- - ‘P!’ ,
GIRL CASE 5
I I I
I1
ki
I
, . II 1110 I 2 3 4 5 6 7 8 9 0 II 12 3 14 5 16 7 8
CHRONOLOGICAL AGE IN YEARS
LU
a:
0
:
I I IIt
‘ ‘
H,.
i
.. - ‘ ‘ , ) Il 1,GIRL CASE 221
Hfl1 ! J , ,
II
,II i,.
; - - tillI
GIRL CASE 277
It1
#{149} 1LiL
t
I
. . - - . - ‘ - i,CHILD HEALTH AND DEVELOPMENT 963
rJi i ii Itt GIRLS e BOYS
BOY CASE 56
2
-GIRL CASE 27
I
I
2
,
II 1L 4
‘ ,1
tIE,I1l!1,
0 I 2 3 4 5 6 7 8 9 10 II 12 3 14 15 16 7 8
CHRONOLOGICAL AGE IN YEARS
FIG. 1 1. This Figure shows cases with illnesses spread throughout childhood. Boy 56 and Girl 221 have Aa ratings at all age periods with a Total Rating An. Girls 277 and 27 had combinations of Aa and Ab
period ratings with a Total Rating of Ab.
NOTES TO FIG. 10. The first two Patterns (selected according to the code described in text for the con-strttction and classification of pattern of illness experiences) are shown in this Figure. All other patterns are shown in the succeeding Figures and their characteristic differences are listed in Table I.
Pattern I includes cases with Total Rating Aa and with) maximum illness experience in Infancy. Three girls in this Pattern are charted to illustrate different degrees of Infancy ratings, i.e. Ab (Case 242), Bb (Case 145) and Cc (Case 92). The sequences of Ratings for these girls are as follows.
242: Aa-Ab Aa An An Oo
145: Aa-Bb An Aa An An
92: An-Cc Ab Aa An An
The graphs for these girls show clearly the relatively slight amount of illness experienced i)y Case 242 with chief concentration in Infancy. The greater amount for Case 145 in early Infancy is due to a single nloderntely severe illness requiring operation. Case 92 shows a combination of more frequent illness
with higher Score during this period, accounting for a C Score and a c number; she also had a few
inure illnesses in the Preschool years. Otherwise these girls had few and mild to moderate illnesses, and they are the children with a minimum illness experience in the entirc Maturity Series.
Pattern II shows cases with Total Ratings An, but illnesses predominating in the Preschool years. One
boy (Case 49) and four girls (Cases 204, 18, 151 and 5) illustrate increasing degrees of Preschool Rating.
Boy 49 and Girl 204 had Preschool Ratings of Ab, Girl 18 of Bh, Girl 151 of Bc and Girl 5 of Gb. The
sequences of their ratings are as follows.
49: An-An Ab An An An
204 : An-An Ab An An An
18: An-An Bb Ab An Oo
151: An-An Bc An An Aa
3
2
WI a:
0 U
U)
LU
z -J
I
III
ii L I hJIII
I I II fl !i IBOY CASE 299
I
I 1111
I II
Ii I
:
, 1II
:BOY CASE 94
-
I
L
. . 11 .. 1 1 ! ‘-:
I
‘2
:
:
i
IL
-I I I
,
,
-GIRL
,__1___,
CASE
Lit
CASE
292
I
LLi.
301
I: p
I
i
1.
GIRL
964
FTTERN GIRLS a BOYS
I
I
0 I 2 3 4 5 6 7 8 9 lO II 2 3
CHRONOLOGICAL AGE IN YEARS
14 15 16 7 8
Fic. 12. This Pattern is for Total Rating Al) with illnesses predominating in Infancy. From the 13 chil-dren in this Pattern (as indicated in Table I to be a relatively high frequency) four cases have been selected to illustrate increasing Infancy ratings, Bc (Boy 299 and Girl 292), Cc (Boy 94 and Girl :301). The sequences of ratings for these are as follows.
299: Ab-Bc Ab Bb An An
292: Ab-Bc Ba An An An
94 : Ab-Gc Bb Ab An An
301: Ab-Cc Ab Ab Aa An
It is of interest to compare this Figure with Figure 10 (Pattern I) since 1)0th) present children with illness predominating in Infancy. This comparison gives a graphic view of the niarkcd differences in both
CHILD HEALTH AND DEVELOPMENT 965
PATTERN GIRLS & BOYS
2-1 BOY CASE I88
1, I [1 1 t i JJll I ,
I
..
,UIJ
, ,2 BOY CASE 152
3
L
Ii
uI
1lI I j , 11111
I
Id
111
.‘ i, 1 1,BOY CASE 238
. l
h
1,
I[
II
i[
.
I, I , ib
II , ,:; GIRL CASE 60
jj
I
1111111
,Ii
IllL
L
, ,‘ - ‘GIRL CASE 166
it.
j
,iiIj.HIEL
IILI.
,;,
2i
I
GIRL CASE 250j
JLI
1II
tiI
I 3 I1L1L
CHRONOLOGICAL AGE IN YEARS
Fic. 13. Pattern V is the largest group and includes 26 children (20 boys and 6 girls). These have Total Rating of Ab and a maximum illness period in Preschool at different degrees of Rating. Three boys and three girls arc selected to give examples of the various Preschool Ratings in increasing order: Bb (Boy
188 and Girl 60), Bc (Boy 152 and Girl 166), Cc (Boy 238 and Girl 250), the rating sequences being as follows.
188: Ab-An Bh Ab Al) Aa
60: Ab-Ab Bh Ac Ac Aa
152: Ab-Aa Bc Bb Ab Al)
166: Ab-Ab Bc An An An
238: Ab-Bc Cc Ab An An
250: Ab-Ab Cc Aa An An
I . ., ._,_; -I.--, I,t, II, , I,
BOY CASE 146
2ii1LiJ
)1JiUII1 ‘ ‘ ‘ HI, , I, ,LU 0
U) U)
U)
z
_I i
BOY CASE 158
0 I 2 3 4
966
PATTERN BOYS & GIRLS
BOY CASE III
I
II
II
IIIIII I1
II
II I
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GIRL CASE II
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21
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5 6 7 8 9 10 II 12 13 14 15 6 7 8 CHRONOLOGICAL AGE IN YEARS
Fic. 14. This shows cases with Total Rating of Ab and School Age predominance. The ratings of the
cases selected are as follows.
Boy 111 and Girl 11 : School period rating of Ac Boy 146: School period rating of Bb
