Social
Competence
and
Behavioral
Adjustment
of Children
Who
Are
Long-Term
Survivors
of Cancer
Raymond K. Mulhern, PhD, Abby L. Wasserman, MD,
Alice G. Friedman, PhD, and Diane Fairclough, DrPH
From the Departments of Child Health Sciences and Biostatistics, St Jude Children’s
Research Hospital, Memphis
ABSTRACT. Relatively little is known about the special needs of long-term survivors of childhood cancer or the factors that make this growing population vulnerable to
chronic psychologic disorders. We therefore surveyed 183
children who had been treated for cancer at St Jude
Children’s Research Hospital and were free of the disease
for 2 years after completing therapy. Parental responses
to the Child Behavior Checklist, a standardized inventory
of social competence and behavioral problems, were ana-lyzed in relation to demographic and medical variables,
as well as the children’s appearance and functional status.
School-related problems and somatic complaints of
un-determined origin were increased fourfold relative to age-and gender-adjusted rates for peer groups in the general population. The presence of functional but not cosmetic impairments increased the risk of academic and
adjust-ment problems. An older age at evaluation, treatment
with cranial irradiation, and residence in a single-parent
household were also associated with an increased risk of
psychologic problems. General pediatricians must
even-tually assume responsibility for the extended follow-up
care of children who have survived a malignancy. Their awareness of the high-risk groups described in this report should facilitate more timely identification of problems
and referral of the children to appropriate services.
Pe-diatrics 1989;83:18-25; cancer, psychologic disorder, social competence, behavior.
It has been estimated that by 1990, one in every
1,000 adults reaching the age of 20 will be a long-term survivor of childhood cancer.’ Although this constitutes a remarkable medical achievement, the
late morbidity in this growing survivor population
has become an area for concern.”2 Long-term,
dis-Received for publication Dec 7, 1987; accepted Feb 9, 1988. Reprint requests to (R.K.M.) Division of Psychology, St Jude Children’s Research Hospital, 332 N Lauderdale, Memphis, TN 38101.
PEDIATRICS (ISSN 0031 4005). Copyright © 1989 by the
American Academy of Pediatrics.
ease-free survival is obviously the goal of modern cancer therapy, but it does not ensure an adequate quality of life.’
The biologic and psychologic late effects of child-hood cancer and its treatment have been sought in recent studies. Somatic complications have in-cluded inhibition of linear growth, sterility, cardio-pulmonary dysfunction, hepatic and renal toxici-ties, and second malignancies.”4 Psychologic
prob-lems have consisted of learning disabilities and
academic failure, behavioral and other adjustment problems, and depression.2’4’#{176} Only rarely has it been possible to identify specific risk factors for psychologic disturbances or protective factors as-sociated with their absence.”
Within the past several years, certain combina-tions of demographic variables, disease and treat-ment factors, and residual physical disabilities have been suggested as predictors ofultimate psychologic adjustment in survivors of childhood cancer. Gen-der,’2 disease severity and aggressiveness of treat-ment,” age at diagnosis,6’7”3 time since completion of therapy,7”2”3 and cranial irradiation7’8”4 have been among the most consistently cited risk factors. The role of cosmetic and functional impairments secondary to cancer and its treatment in determin-ing psychologic adjustment is less clear. The On-tario Child Health Study, a large epidemiologic
survey, found a higher risk of psychiatric disorders
among children with a chronic disease and physical
disability than among those with a chronic disease
only.’5 No relationship between the severity of physical impairment and psychologic adjustment
was found among 116 survivors ofchildhood cancer,
however.’6
Early detection of psychosocial problems and their causes would permit more timely intervention,
knowledge, there have been no surveys of the social competence and behavioral adjustment of a large
sample of children who had attained the status of
long-term survivors. We describe here the results of standardized psychosocial assessments of 183
children who have been free of cancer for 5 years
or more and who were 15 years of age or younger
at the time of the survey.
MATERIALS AND METHODS
Subjects
From January through September 1986, 465
pa-tients were seen during their semiannual or annual visit to the After Completing Therapy Clinic at St
Jude Children’s Research Hospital.’7 To qualify for the clinic, patients must be free of their disease, 5
years or more from the date of diagnosis, and 2 years or more from the completion of therapy. For the present study, we limited the sample to
consec-utively enrolled patients who had had a primary diagnosis of cancer and were still children (15
years old) at the time of their last clinic visit. Of
191 patients who met these criteria, eight were
excluded because of irregularities in administering or completing the Child Behavior Checklist. Thus,
183 patients were considered fully evaluable.
Child Behavior Checklist
The Child Behavior Checklist is a psychologic inventory designed to identify deficient social com-petence and excessive behavioral problems among
4- to 16-year-old children “within the past 6 months,” as reported by their parents or other
primary caretakers.’8 The checklist was standard-ized with 1,300 children from the general
popula-tion as compared with 2,300 children referred for
mental health services. In the Social Competence
section, there are 40 questions about the child’s
activities (sports, jobs), social involvement (orga-nizations, friends), and school performance (grades, special classes). In the Behavior Problems section,
there are 113 questions that provide wide coverage
of a variety of childhood behavioral syndromes on several subscales and three global scales. Because
it was shown by factor analysis that the clustering
of behavioral problem items into subscales was dependent on age and gender, one subscale, Somatic Complaints, is consistent across all groups. In the
Somatic Complaints scale, physical problems (eg,
nausea, vomiting, headaches, dizziness) “without known medical cause” are measured. The three global scales are Externalizing, Internalizing, and Total Behavior Problems. The Externalizing score is a measure of aggressive, antisocial, and
under-controlled behavior. The Internalizing score is a measure of fearful, inhibited, and overcontrolled behavior.
To complete the Child Behavior Checklist, a fifth grade reading level is needed and approximately 20 minutes. Raw scores are converted to standard scores with a mean of 50 and a SD of 10, with the norms of the test developers. Child Behavior Checklist results were visually inspected to ensure completeness and then scored by a commercially available microcomputer program.’9 The Child Be-havior Checklist was chosen because of its wide use
as a screening inventory in pediatric and
psychiat-nc clinics and because of recent evidence indicating its appropriateness for children with cancer.9’2#{176}
Procedures
In addition to routine laboratory procedures,
physical examinations, and medical histories, the patients were evaluated with the Child Behavior Checklist as completed by their parents. None of the parents refused to mark the checklist. If abnor-malities were noted on any of the patients’ clinical
studies, they were presented to the family with
recommendations for intervention.
The medical records of all patients were thor-oughly reviewed to identify major medical events such as diagnoses and therapies received. The so-cioeconomic levels of the families were ranked from 1 to 7 according to the Hollingshead Index, the same system used in the standardization of the Child Behavior Checklist.’8’2’ Cosmetic and func-tional impairments were rated separately as nor-mal, mild, moderate, or severe, with modifications of criteria in previous studies oflong-term survivors of childhood cancer.’6
Study Design
The Child Behavior Checklist was designed to identify children with deficient social competence and excessive behavioral problems rather than to characterize variations within the range of normal childhood behavior. Additionally, the obtained dis-tribution of scores was truncated and could not
satisfy statistical criteria for multiple regression analysis. Hence, the basis for our analysis was the
frequency of scores that departed from the norma-tive mean in the direction of maladjustment by 1.5 SD, after adjustment for age and gender, rather than the standard scores obtained with the scales.
TABLE 2. Characteristics of Patient Sample*
Complaints, Internalizing, Externalizing and total scores for the Behavior Problems section was
de-termined. Demographic variables included the
pa-tient’s age at diagnosis (3 v >3 yr), gender,
socio-economic level, and parental marital status.
Medi-cal variables included the type of cancer diagnosed;
time since diagnosis (9 v >9 years); duration of therapy (2 v >2 years); time since completion of
therapy (7 v >7 years); age at follow-up evaluation (12 V >12 years); treatment with surgery, radia-tion therapy, or chemotherapy; disease recurrence;
and ratings of cosmetic and functional
impair-ments. Ratings of functional impairments, which
included physical as well as psychologic (learning
problems, mental retardation, psychiatric disorder) problems, were analyzed globally and then for chil-dren who manifested physical problems only. Time
and age variables were dichotomized at the median
values for the sample.
Logistic regression analyses were used to
gener-ate odds ratios as estimates of relative risk. Odds
ratios are measures of the risk of occurrence of an outcome given the presence of another event. Using
this method allowed us to discriminate subgroups
of children who were at relatively greater risk for
adjustment problems. Two-tailed tests of statistical significance (a = 0.05) were computed and 95%
confidence intervals are given when significance resulted.
RESULTS
The distributions of gender, race, and family
socioeconomic status in our sample closely approx-imated those of the general population of active patients at St Jude Children’s Research Hospital (Tables 1 and 2). Boys and girls were represented in similar proportions, and 11% of the population
consisted of minority families. The average family
was from the lower middle-class range according to
TABLE 1. Demographic Characteristics of Patient
Sample*
Variable No. (%) of
Total
Sex
Male 107 (58.5)
Female 76 (41.5)
Race
White 163 (89.1)
Black 19 (10.4)
Other 1 (0.5)
Parental marital status
Intact or blended* 152 (83.1)
Single parent 31 (16.9)
* “Blended” refers to a situation in which one or both
parents have remarried.
Variable Median Range
Socioeconomic levelt 4 1-7
Age at diagnosis 2.7 0.1-9.7
Total duration of treatment 2.0 0.1-4.8
Time
Since diagnosis 8.6 5.0-15.2
Since completion of treatment 6.9 2.1-14.8
Age at evaluation 12.2 7.0-15.9
* All numerical values except socioeconomic level are
given as years.
t
Ratings were determined by Hollingshead’s ranking ofparental occupations.2’
TABLE 3. Most Frequent Severity
Chronic Problems of Any
Variable No. (%) of Total
Scars 82 (45)
Visual impairment 29 (16)
Learning problems 25 (14)
Obesity 23 (13)
Short stature 19 (10)
Scoliosis or kyphosis 19 (10)
Psychiatric disorder 18 (10)
Hypoplasia or atrophy 17 (9)
Hormone deficiency 6 (3)
Dental abnormality 6 (3)
Mental retardation 5 (3)
Hearing loss 5 (3)
the Hollingshead Index of parental occupations,
consistent with the normative sample of the Child
Behavior Checklist. The median age at diagnosis
was 2.7 years (maximum, 9.7 years), making this
group younger than our overall population of cancer
survivors. These children had received an average of 2 years of therapy. At the time of the survey, the median interval from completion of therapy was 7 years.
The majority of long-term survivors had a
cliag-nosis of acute lymphocytic leukemia (45%), Wilms
tumor (12%), retinoblastoma (11%), or neuro-blastoma (10%). Only two children with CNS
tu-mors were included because such patients were not
enrolled in formal St Jude treatment programs until recently. No children with osteosarcoma and only two with Hodgkin disease were surveyed, because the long-term survivors of these diseases were too old for participation in the study. A total of 80% of the sample had been treated according to estab-lished institutional protocols; 60% had received chemotherapy, 67% radiation therapy, and 67% surgery; no child had had an amputation. Only 6% of these long-term survivors had experienced a
re-currence of their disease.
According to chart review, the most frequent
Variable No. (%) of Total Criteria
Mild impairment
64 (35.0)
64 (35.0)
115 (62.8)
28 (15.3)
100
40
30
20
10
C
a, 0 .C
0
0 C
a,
0
a,
0
#{163}1
ActMtlei Sod& School bt
SocaI Competence Deficits
NIernalIzIng EoNrnalzNg Somatic #{149}b*
Behavior Problems Figure. Percentage of long-term survivors of childhood
cancer who exhibit significant deficiencies in social
corn-petence or an increased frequency ofbehavioral problems.
TABLE 4. Composite Cosmetic and Functional Impairment Ratings
Cosmetic impairment None
Moderate impairment
Severe impairment
Functional impairment
None
Mild impairment
Moderate impairment
Severe impairment
Inapparent physical residua except that biopsy scar
may be present Physical residua obvious
only during physical ex-amination or when
sub-ject is wearing a bathing suit, facial disfigurement can be covered by
cosmet-ics
47 (25.7) Physical residua obvious
when subject wears street
clothes, facial
disfigure-ment remains obvious even with use of cosmetics
8 (4.4) Physical residua constitute
obvious deformity
No interference with normal activities for age Problems necessitate daily
attention but cause little disruption of normal ac-tivities
38 (20.8) Subject requires help with
activities of daily living normally performed inde-pendently
2 (1.1) Subject requires frequent
help and assistance with
activities of daily living
3). One or more ofthese complications were present in 83% of the children. Composite ratings of the patients’ chronic cosmetic and functional
impair-ments are shown in Table 4. Excellent interrater
reliability was obtained for both cosmetic (95%)
and functional (87%) ratings with a random sample of 37 patients. In spite of the high incidence of
residual problems, the distribution of severity
rat-ings favored normal appearance and function, with
more than 70% of the sample having normal or
only mild impairments in either category. Only 4%
and 1% were rated as having severe cosmetic and
functional impairments, respectively.
The distribution of scores from principal scales of the Child Behavior Checklist was clearly
abnor-mal (Figure). The incidence of clinically elevated scales, defined as 1.5 SD from the normative mean for age and gender, ranged from 17% to 33%, in contrast with the 7% incidence expected on the
basis of the standardization sample. The most fre-quently noted elevations reflected poor school
per-formance and increased somatic complaints. One or more Social Competence scales were abnormally low in 54% of the sample, which is significantly
greater than the general population (P < .005). The
Lon-rm Sw
ClO*t,00d Cancer
PC- Norms
33
23
Activities, Social, and School Performance scales
were also deficient (P < .005). There were
eleva-tions in one or more of the Behavioral Problems scales (P < .005), including frequent Internalizing and Externalizing Syndromes as well as Somatic Complaints (P < .005), in 42% of the children. Of
significantly more frequent than in the general population (P < .005).
Risk factor analyses were performed to identify the variables that had made the largest contnibu-tions to Social Competence deficiencies and in-creased Behavior Problem scores. The findings are presented in Tables 5 and 6, where the numerical
values represent increases in the likelihood of prob-lems given the presence of a particular factor. None
of the factors analyzed were significantly associated
with deficiencies on the Activities, Social, or Total Social Competence scales. On the other hand, the presence of any functional impairment, physical disability, treatment of leukemia with cranial inra-diation, an age of 12 years or older at the time of follow-up evaluation, and residence in a single-parent household were each significantly associated with a two- to fourfold greater risk of school-related problems. Of the total samples, 26% had repeated
one or more grades in school and 11% had a history
of special educational placement.
The relationships between risk factors and the
Behavioral Problems scales of the Child Behavior
Checklist are summarized in Table 6. The risk of
significant Somatic Complaints, Internalizing and
Externalizing Syndromes, and Total Behavioral Problems was increased two- to threefold in pa-tients with any functional impairment. An age of
12 years or greater at the time of follow-up evalu-ation was associated with an almost twofold higher risk of Somatic Complaints. A twofold higher risk
of having an Internalizing Syndrome was seen among children from a single-parent household.
There was no apparent association between
physi-cal disability or cranial irradiation for leukemia and
behavioral problems. Despite thorough analysis, six factors failed to show any significant relation to deficient social competence or behavioral problems in our sample. There were cosmetic impairment, socioeconomic status of the patient’s family, gender of the patient, duration of therapy, history of
sun-gary or chemotherapy, and disease recurrence.
DISCUSSION
We present the results of the largest psychosocial
survey yet completed of children who have become
long-term survivors of cancer. Age- and
gender-TABLE 5. Estimated Relative Risk for Deficient Social Competence*
Variable Child Behavior Checklist Social Competence Scales
Activities Social School Total
Any functional impairment NS NS 4.3 (2.2-8.2) NS
Physical disabilityt NS NS 2.3 (1.0-5.0) NS
Cranial radiation therapy for NS NS 3.3 (1.8-6.3) NS
leukemia
>12 yr of age at follow-ups NS NS 2.2 (1.2-4.2) NS
Single-parent family NS NS 2.2 (1.0-4.9) NS
* Numerical values indicate the increase in risk for problems given the presence of that
variable. P < .05 for School by two-tailed tests. Numbers in parentheses represent 95% confidence intervals.
t
Includes scars, visual impairment, obesity, short stature, scoliosis or kyphosis, hypoplasia or atrophy, hormone deficiency, dental abnormality, and hearing loss.:1:
Significantly correlated with time since diagnosis and time since completion of therapy.TABLE 6. Estimated Relative Risk for Behavioral Abnormalities*
Variable Child Be havior Checklist Behavior Problem s Scales
Somatic Internalizing Externalizing Total
Complaints Symptoms Symptoms
Any functional impair- 2.4 (1.3-4.5)t 2.4 (1.2-5.0)t 2.8 (1.3-6.2)t 2.9 (1.5-5.9)t ment
Physical disabi1ity NS NS NS NS
Cranial radiation ther- NS NS NS NS
apy for leukemia
>12 yr of age at fol- 1.9 (1.0-3.6)t NS NS NS
low-ups
Single-parent family NS 2.7 (1.7-6.2)t NS NS
* Numerical values indicate the increase in risk for problems given the presence of that variable.
t
P < .05 by two-tailed tests. Numbers in parentheses represent 95% confidence intervals.:1:
Includes scars, visual impairment, obesity, short stature, scoliosis or kyphosis, hypoplasia or atrophy, hormone deficiency, dental abnormality, and hearing loss.adjusted scores on a standardized inventory of child behavior indicated a three- to fourfold higher
mci-dence of deficits in social competence and behav-ioral abnormalities compared with normative
find-ings in the general population. School problems and
somatic complaints of undetermined origin were most common. Factors that placed children at risk
for maladjustment included functional and physical limitations, cranial irradiation for leukemia, an
older age at follow-up, and residence in a
single-parent family.
The incidence of adjustment problems among the 183 long-term survivors was substantially higher
than one would expect from the behavior of children
with similar socioeconomic backgrounds in the gen-eral population.’8 Elevations in one or more of the scales of the Child Behavior Checklist, were seen
for approximately two thirds of the patients, which reflected behavioral, social, or school-related prob-lems. More than half of the children had scores suggestive of excessive behavioral problems, and
nearly as many had deficits in areas of social
com-petence. The incidence of adjustment problems
among our former patients is consistent with pre-vious reports of chronic maladjustment among
vic-tims of childhood cancer.2’5’6
Difficulty in school was the most frequent abnor-mality among the social competence variables.
Many children with academic problems had ne-peated one or more grades in school or had learning difficulties that necessitated their placement in spe-cial education classes. The rate of school problems corresponds closely with the finding of Lansky et al2 that nearly 30% of their sample of adult survi-vors of childhood cancer reported having academic
problems.2 In our sample, school-related problems
were associated with functional disabilities, whether psychologic or physical, as documented in the child’s medical record. Cadman et al’5 also
found a relation between functional disabilities and
school difficulties. In this recent, large-scale epi-demiologic study, children with chronic illnesses and disabilities that interfered with normal
func-tion had an increased risk of school problems com-pared with children with chronic illness and no
disability or with healthy children. In contrast, O’Malley et al’6 could find no relationship between
the degree of physical impairment and psychosocial adjustment among an older group of long-term
sun-vivors of childhood cancer.’6 They relied primarily on global ratings of adjustment rather than stand-ardized measures, however, and the average age in
their sample was 18 years, precluding an examina-tion of the relationship between disability and
school performance.
Cranial irradiation for leukemia was associated with a greater than threefold increase in
school-related problems. The precise relationship between
this component of preventive CNS therapy and
neurobehavioral development has been the subject
of much debate and remains undefined.7’8”4’22 School problems among this population may also
be related to declines in academic ability secondary
to prolonged absence from school. Other investi-gators have reported that during the first year of treatment, leukemic children miss an average of
42% of the school year and that the rate of absences
remains significant during the second and third
years.22 An older age at the time of follow-up
eval-uation, indicating a longer time since diagnosis and treatment, also increased the risk of school
prob-lems. Children who were older at follow-up were
more likely to have been treated when radiation therapy was more intensive. Additionally, the late psychologic effects of treatment may not become apparent for many years after the completion of
therapy.7
Almost one third of the sample had abnormally frequent somatic complaints that lacked a known medical cause. This may reflect hypochondriacal tendencies on the part of the former patients or a lack of awareness by the parents that their chil-dren’s symptoms were medically relevant. The first
explanation is supported by the increased risk of
somatic complaints in children with documented
functional impairments but not physical disabilities and by the generalized pattern of psychologic dis-turbances noted on the other Behavior Problem scales. An older age at follow-up and a necessarily longer time since the completion of treatment
like-wise increased the risk of somatic complaints
with-out concomitant effects on other behavioral syn-dromes. Thus, these somatic complaints may be related to the delayed appearance of medically im-portant symptoms whose significance was not ap-preciated by the parents.
Children from single-parent households had a twofold increase in the risk of school problems and
a greater risk of showing fearful, inhibited, or
ov-encontrolled behavior. Single parents have more
difficulty meeting their children’s medical and
ac-ademic needs than do parents with a spouse on
whom to rely, making the children more vulnerable
to problems in school and other settings. Likewise, social support may be more accessible in an intact
family and may serve as a buffer to protect the
child against such problems.”23
in-creased risk of psychologic problems was surprising
given the enormous financial burden that typically
accompanies medical treatment.24 However, medi-cal treatment and transportation, as well as food
and lodging, are provided by this institution to all
patients and a parent, thereby reducing the
eco-nomic impact of treatment to less than that
en-countered at most other centers.5 Although the
recurrence of disease has been cited as increasing
the risk for psychopathology,5 we could not confirm
this finding in our sample, largely because there
were so few patients who had relapsed.
Impairments in physical appearance, which are
rarely analyzed independently in survivors such as
ours, did not appear to increase the risk of
psy-chologic disturbance. One might speculate that
chil-dren with more severe disfigurement, such as
am-putees, would have greaten psychologic problems
than patients who had not undergone disfiguring
surgery. However, at least one study of long-term survivors of cancer-related amputations during
ad-olescence found that most of the patients were
adequately adjusted.25 Results of the composite
rat-ings of our patients’ appearance and functional
status suggest that severe residual impairments are
not usual sequelae of the childhood malignancies
included in this survey. For the majority of children,
the physical effects ofprevious treatment for cancer
were no longer obvious when the subjects were
dressed in street clothes. Only a small proportion
of the sample had residual problems of sufficient severity to constitute an obvious deformity or to necessitate help with activities of daily living. Most
of the observed impairments were expected and
have been associated with childhood disease and
treatment factors in previous studies.”4”#{176} The
in-clusion of children surviving treatment for brain tumors would have undoubtedly influenced these findings in the direction of greater debilitation and
psychologic adjustment problems.26
Attention to age- and gender-related behavioral
variations among peers in the general population
allowed us to obtain more reliable estimates of the
prevalence of specific problems as well as a more
rigorous analysis of risk factors. Several changes in
clinical practice are suggested by the present
ne-sults. Because a high prevalence of adjustment
problems was noted in long-term survivors, cancer
centers should provide routine objective screening
soon after the child completes therapy. Serial as-sessments should be conducted annually, especially for children with previously recognized functional impairments or physical disabilities, those who
re-ceived cranial irradiation, and those from
single-parent households. Once problems are detected,
efforts toward intervention should be made in
con-cert with the children’s private physicians to ensure
maximum use of community resources. Preventa-tive programs for these high-risk groups, such as supplementation of schooling to compensate for absences, should be developed to minimize or avoid
chronic adjustment problems.
ACKNOWLEDGMENTS
This work was supported, in part, by the American
Lebanese Syrian Associated Charities.
We thank P. Ward, D. Hodge, A. Thompson, E.
Thompson, K. Yatsula, and D. June for their contribu-tions to the completion of this project, and J. Gilbert for his editorial assistance with this paper.
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20. Mulhern RK, Wasserman AL, Fairclough D, et al: Memory function in disease-free survivors of childhood acute lym-phocytic leukemia given central nervous system prophylaxis with or without 1800 cGy cranial irradiation. J Clin Oncol 1988;6:315-320
21. Hollingshead AB: Two Factor Index of Social Position. New Haven, CT, Yale University Press, 1957
22. Lansky SB, Cairns NU, Lansky LL, et al: Central nervous system prophylaxis: Studies showing impairment in verbal skills and academic achievement. Am J Pediatr Hematol
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STIPULATIONS
AMERICAN
ACADEMY
OF PEDIATRICS
FELLOWSHIPS, 1989
RESIDENCY
To enable young physicians to complete their pediatric training, the American
Academy of Pediatrics will grant a small number of fellowships of $500 to $3,000 each to pediatric interns and residents for the year beginning July 1. Candidates must meet the following requirements:
1. Be legal residents of the United States or Canada.
2. Have completed, or will have completed by July 1, a qualifying approved
internship (P1-0) or have completed a P1-i program and have a definite
commitment for a first-year pediatric residency (P1-i or P1-2) acceptable
to the American Board of Pediatrics; or
3. Be pediatric residents (P1-i, P1-2, or P1-3) in a training program and have
made a definite commitment for another year of residency (not fellowship)
in a program acceptable to the American Board of Pediatrics;
4. Have a real need of financial assistance; and
5. Support their applications with a letter from the Chief of Service
substan-tiating the above requirements, especially the financial need; if a change
in residency program is contemplated (ie, moving to another institution), a letter from the Chief of this Service certifying acceptance to this program
will also be necessary.
Although the fellowships awards are intended primarily for the support of
first- and second-year pediatric residents, it is also recognized that some physicians may desire a third or fourth year of pediatric residency. Up to 25% of the fellowships may be awarded to persons in this category.
The fellowships have been provided through grants to the American Academy
of Pediatrics by Mead Johnson Nutritional Division, the Gerber Products
Company, and the McNeil Consumer Products Company.
The Committee on Residency Fellowships of the American Academy of Pediatrics will make the final decision on the granting of the awards. Those interested in applying may write to Edgar 0. Ledbetter, MD, Director,
Depart-ment of Maternal, Child and Adolescent Health, American Academy of Pedi-atrics, P0 Box 927, Elk Grove Village, IL 60009-0927, for application forms.
