A total of 2,500 cases were taken from the 1954 files of the principal child guidance center in four of the nation's five largest cities. The problems or complaints given as the reason for referral were tabulated by age-group and sex, using a common set of ten "referral categories" empirically derived for optimum discrimination and comparability. Some highlights of the findings were :The most frequently cited reason for referral is "academic difficulties" (45%). Much of this is attributable to mental deficiency, but a considerable amount appears to be related to emotional adjustment problems. School clinics differ markedly from the community (orthopsychiatric) clinics in the relative frequency of academic-intellectual and emotional-behavioral referrals.Boys are referred for guidance more frequently than girls in all age groups and for all problem categories. The over-all ratio is about 2j.7 to 1. Foi "aggressive and anti-social behavior" the difference runs almost 4 to 1. A biosocial interpretation is offered, involving both innate sex differences and adjustment to social role expectancies.3. Referral for "sexual behavior problems" appears to be inordinately infrequent, (2%"31c of all cases). One obvious explanation appears to be the reluctance of adults in our culture to recognize or discuss sexual maladjustment in children.
Accumulating data from three fields of research and practical endeavor point to strong similarities in the way in which service delivery systems operate. Psychotherapy, medical delivery systems, and client behavior in addiction treatment all show the "same" negatively accelerating, declining, decay curve that is based, respectively, on attrition, noncompliance, and relapse across a wide range of independent variables within each research area. Unification and understanding of outcome data and comparisons across treatment modalities can be enhanced by recognition of the apparent universality of the decay function.
PROBLEM AND METHOD From sociological and learning theory viewpoints, the question can be raised as to whether the referral of behavior problem children for psychological help follows any systematic pattern. An intropsychic hypothesis such as the psychoanalytic one may be construed to mean that the occurrence of behavior problems stems from a non-cultural (Le., psychosexual) base. This would mean that the probability of any child in the family being disturbed is equal to that of any other child, given typical psychosexual development. I n the interest of testing the psychoanalytic hypothesis the files of a public guidance center and those of the author's private practice were studied as to ordinal position and sex of 635 children referred for help. The records covered 7% years from the former source, 4 years from the latter. Other 1 122 19.21 1 28 04.41 Totals 1 445 70.08 1 190 29.92 I RESULTS The findings are tabulated in Table 1. The population studied excluded children under age 2 or over 16, and all others admitted for administrative or nonpsychologi-PSYCOLOGICAL HELP TABLE 1. ORDINAL POSITION AND SEX DISTRIBUTION AMONG 635 CHILDREN REFERRED FOR -Birth I Boys I Girls I Totals 150 23.62 635 100.00 Order ! N % % 76.38 Oldest 239 37.64 108 17.01 347 54.65 Only ! 84 13.23} 1 54 0 8 . 5 d 1 138 21.37 50.87 25.52 cal purposes. Only behavior problem cases referred ostensibly for psychological help were included. Control data came from the 1950 U. S. Census(12), and are adequate for comparison with the clinical group except that the Census cases cover ages zero t o 17, inclusively, and represent all cultural groups. Fertility rates data show 21.6Tqof the families (base: women, ages 15-59 inclusively) with zero children, 24.19; with 1 child, 23.5% with 2, 13% with 3, and 17.8% with 4 or more. The first-born incidence equals 44.12%, non first-born 55.88%. Hence from frequence of first-born in general population, we would expect about 44T0 occurrence of the same group in the clinical population. Table 1 shows the incidence of first-born in the clinical population t o be 76.38% (where, as above, first-born includes only children). A significance of difference in proportion test shows the critical ratio between these two proportions (obtained 76% us. expected 44 %) to be 16.24, with p > .001. Thus the null hypothesis which asserts that no difference in the ordinal position exists among children referred for psychological help is rejected at a high level of confidence. I n the same way the intropsychic hypothesis that behavior problems are not primarily due to learning-cultural factors is likewise rejected. This conclusion is limited to these data and does not apply to other aspects of psychoanalytic theory. Looking further at the data we see that the incidence of boys in the clinical population is 70%, a difference 10.14 times the standard error of the difference be-
Phillips, E. L. (1988a). Patient compliance: New light on health delivery systems in medicine and psyche therapy. Bern, Switzerland: Hans Huber. Phillips, E. L. (1988b, June). Three basic patterns of psychotherapy delivery systems and what they mean. Paper presented at the annual meeting of the Society for Psychotherapy Research, Sante Fe, NM.
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