James A. Norton

Prognosis in autism: A follow-up study

A follow-up study involving 85 autistic boys and 35 girls, c. 5 1/2 years of age at initial evaluation and 12 years at follow-up, is presented and discussed in considerable detail. Measures, also applied to 26 non-psychotic subnormal controls, included speech, social, educational, and family adequacy ratings, IQs, and neurological data. Most autistic children remained educationally retarded and 42% were institutionalized. Good agreement with 2 studies by other authors indicated the following prognosis in autism: 1–2% recovery to normal, 5–15% borderline, 16–25% fair, and 60–75% poor. The best predictor of functional capacity in a work/school setting was the childs rating at intake. Performance IQ and severity of illness were next to best predictors. Case histories of 20 children with the best outcome, including 2 functioning normally, are compared and analyzed. Also, etiological implications of results are outlined in support of theories linking the cause of autism to biological factors.

The Diabetes Education Study: A Controlled Trial of the Effects of Diabetes Patient Education

The Diabetes Education Study (DIABEDS) was a randomized, controlled trial of the effects of patient and physician education. This article describes a systematic education program for diabetes patients and its effects on patient knowledge, skills, self-care behaviors, and relevant physiologic outcomes. The original sample consisted of 532 diabetes patients from the general medicine clinic at an urban medical center. Patients were predominantly elderly, black women with non-insulin-dependent diabetes mellitus of long duration. Patients randomly assigned to experimental groups (N = 263) were offered up to seven modules of patient education. Each content area module contained didactic instruction (lecture, discussion, audio-visual presentation), skill exercises (demonstration, practice, feedback), and behavioral modification techniques (goal setting, contracting, regular follow-up). Two hundred seventy-five patients remained in the study throughout baseline, intervention, and postintervention periods (August 1978 to July 1982). Despite the requirement that patients demonstrate mastery of educational objectives for each module, postintervention assessment 11–14 mo after instruction showed only rare differences between experimental and control patients in diabetes knowledge. However, statistically significant group differences in self-care skills and compliance behaviors were relatively more numerous. Experimental group patients experienced significantly greater reductions in fasting blood glucose (−27.5 mg/dl versus −2.8 mg/dl, P < 0.05) and glycosylated hemoglobin (−0.43% versus + 0.35%, P < 0.05) as compared with control subjects. Patient education also had similar effects on body weight, blood pressure, and serum creatinine. Continued follow-up is planned for DIABEDS patients to determine the longevity of effects and subsequent impact on emergency room visits and hospitalization.

Risk Factors for Disseminated or Fatal Histoplasmosis: Analysis of a Large Urban Outbreak

An outbreak of histoplasmosis in Indianapolis involving 488 clinically recognized cases including 60 patients with disseminated or fatal infection permitted statistical analysis of risk factors. Being male, white, under 5 years of age, having chronic obstructive lung disease, and living near the presumed source of the outbreak were not risk factors for fatal or disseminated histoplasmosis. Age greater than 54 years and immunosuppression were the only risk factors for disseminated or fatal infection. Dissemination should be excluded in patients with histoplasmosis who are immunosuppressed or older than 54 years. Specific antifungal treatment is more likely to be required in those two groups rather than in patients without risk factors.

The family's adaptation to childhood leukemia.

This baseline study obtained data measuring the specific effects of the stress of childhood leukemia on family life and on the lives of individual family members. Mothers, fathers, siblings, and patients were included in the data collection. Specific variables measured were marital adjustment, anxiety level, dynamics of family interaction, and the school behavior of patients and siblings. The data were collected at designated intervals over a one year period beginning at the time of diagnosis. In addition, the data were utilized to speculate on those families that appeared to be at risk for the development of long-term psychosocial problems secondary to, or aggravated by the illness. Results indicated that patterns of coping for families, as well as for individual family members, were relatively constant over time. Families with predominantly stable relationships and adequate support within the family unit were able to maintain their usual quality of life over an extended period of time despite the onset of acute stress. However, families with pre-existing problems prior to diagnosis for the most part experienced increased deterioration in family life and had difficulty coping. Results of the Spielberger State-Trait Anxiety Scale, the Locke-Wallace Marital Adjustment Test, the Moos Family Environment Scale, the MMPI, and school data supporting these conclusions are given.

The diagnostic laboratory tests for histoplasmosis: analysis of experience in a large urban outbreak.

Of 495 patients reported in a large urban histoplasmosis outbreak, we studied 276 whose serologic tests were done in a single laboratory. Serologic test results were positive in 96% of these patients (compared with less than 5% of controls from an endemic area), cultures were positive in 22%, and special stains in 19%. The immunodiffusion test results were negative in 13% of patients who had positive findings by complement fixation, and 1% had positive results only by immunodiffusion. The complement fixation test was almost twice as sensitive as the immunodiffusion test in patients with subclinical infection. The serologic response differed significantly among the clinical syndromes with higher titers in cavitary and lower titers in disseminated disease. Factors associated with titers of 1:64 or greater to both antigens were black race and immunocompetence. High mycelial titers were also associated with more intense exposure, and high yeast titers were associated with age less than 36 years. No prognostic significance could be proved for fourfold titer rises or falls or persistence of precipitins.

A prospective study of change in bone mass with age in postmenopausal women.

For the first time a model for age-related bone loss has been developed from prospective data utilizing a new weighted least squares method. Two hundred and sixty-eight Caucasian women ranging in age from 50 to 95 were studied. A quadratic function best fit the data, and correcting for body weight and bone width reduced variance. The derived equation is: bone mass = (0.6032) (bone width) (cm) + (0.003059) (body weight) (kg) - (0.0163) (age - 50) + (0.0002249) (age - 50)2. Analysis of cross-sectional data on 583 Caucasian women of similar age showed a quadratic function with very similar coefficients. This quadratic function predicts an increase in bone mass after age 86, therefore 42 women over age 70 who had been followed for at least 2.5 yr were identified to test for this effect. of these, 13 had significantly positive regression coefficients of bone mass on age, and rate of change in bone width was positive in 40 of 42 individuals, of which 5 were significant. Since photon absorptiometry measures net changes on all bone envelopes, the most likely explanation for the observed changes is an early exponential loss of endosteal bone which ultimately slows or perhaps stops. There is a positive balance on the periosteal envelope which only becomes apparent in later years when the endosteal loss stops. These new statistical methods allow the development of models utilizing data collected at irregular intervals. The methods used are applicable to other biological data collected prospectively.

Diagnostic accuracy and confusability analyses: an application to the Diagnostic Interview for Genetic Studies

The dominant, contemporary paradigm for developing and refining diagnoses relies heavily on assessing reliability with kappa coefficients and virtually ignores a core component of psychometric practice: the theory of latent structures. This article describes a psychometric approach to psychiatric nosology that emphasizes the diagnostic accuracy and confusability of diagnostic categories. We apply these methods to the Diagnostic Interview for Genetic Studies (DIGS), a structured psychiatric interview designed by the NIMH Genetics Initiative for genetic studies of schizophrenia and bipolar disorder. Our results show that sensitivity and specificity were excellent for both DSM-III-R and RDC diagnoses of major depression, bipolar disorder, and schizophrenia. In contrast, diagnostic accuracy was substantially lower for subtypes of schizoaffective disorder-especially for the DSM-III-R definitions. Both the bipolar and depressed subtypes of DSM-III-R schizoaffective disorder had excellent specificity but poor sensitivity. The RDC definitions also had excellent specificity but were more sensitive than the DSM-III-R schizoaffective diagnoses. The source of low sensitivity for schizoaffective subtypes differed for the two diagnostic systems. For RDC criteria, the schizoaffective subtypes were frequently confused with one another; they were less frequently confused with other diagnoses. In contrast, the DSM-III-R subtypes were often confused with schizophrenia, but not with each other.

Alzheimer's disease is rare in Cree

A community survey and subsequent clinical assessment of 192 Cree aged 65 years and over registered in two Reserves in Northern Manitoba identified only one case of probable Alzheimers disease among eight cases of dementia, giving a prevalence of 0.5% for Alzheimers disease and 4.2% for all dementias. This contrasted with an age-adjusted prevalence of 3.5% for Alzheimers disease and 4.2% for all dementias in an age-stratified sample of 241 English-speaking residents of Winnipeg. Although it was not so for all dementias, the difference between the groups for prevalence of Alzheimers disease was highly significant (p < .001). The age-specific patterns of all dementias in the two groups were significantly different, however (p = .0254).

Supersensitivity to melatonin suppression by light in young people at high risk for affective disorder. A preliminary report

Affective illness aggregates in families and appears to be heritable. Bipolar affective patients have been found to be supersensitive to the suppressive effect of light on the nocturnal secretion of melatonin, both in ill and well states. We tested young people aged 15 to 25 years with one manic-depressive parent (n = 18), major affective disorder on both sides of the family (n = 7), and age-matched controls (n = 20). The subjects in the high-risk groups were more likely to show supersensitivity in melatonin response to light at night than controls. Follow-up studies are necessary to assess the predictive value of this response.

TWINAN90: A FORTRAN program for conducting ANOVA-based and likelihood-based analyses of twin data

We discuss the program, TWINAN90, which can perform several different types of analysis of twin data. TWINAN90 incorporates the ANOVA-based twin analyses from the TWINAN twin analysis program, and also includes maximum likelihood estimation of parameters from three path models. Another feature of TWINAN90 is the optional output of a pedigree file which can be read by the quantitative genetics package FISHER. The diagnostic features of the program make TWINAN90 useful also for preliminary analyses prior to the use of more sophisticated modeling procedures which are available in packages such as LISREL and FISHER. An annotated printout from TWINAN90 is presented to illustrate the statistical analyses performed in the program.