Letters to the Editor
pertension--a complication of umbilical vein catheterization, Pediatrics 31: 297, 1963. 12. Hilgartner, M. W., Lanzkowsky, P., and Lipstiz, P.: Perforation of small and large intestine following exchange transfusion, Am. J. Dis. Child. 120: 79, 1970. 13. Tovlovklan, R. J., Kadar, A., and Spencer, R. P.: The gastrointestinal complications of neonatal umbilical venous exchange transfusion: A clinical experimental study, Pediatrics 51: 36, 1973.
Subjectivity? or Objectivity? To the Editor: The "Behavioral Pediatrics" section in the August, 1973, JOURNAL which discusses drug abuse appears to me to make several unwarranted conclusions which are not justifiable on the basis of the facts presented. The questionnaire was distributed to 551 students in a private high school population. There were 473 Jewish students among this group. Of the total questioned, 79 admitted to useage of illicit drugs and 282 had used alcohol. On the basis of the above number it was concluded that a typical profile of a drug user would be a middle-class late adolescent with variable or poor grades, who would not want to go to college, would be sexually active, nervous, have a history of psychiatric difficulties, police arrest, use tobacco, and, in addition, would be Protestant. It would appear self-evident that their sweeping conclusions were made on too small a sample (79 of 551) and in too unusual a setting (private high school--83 per cent Jewish). If the conclusions are further broken down into separate components, they then lose further justification. QUESTIONNAIRE It is stated that 100 per cent compliance was obtained in answering the questionnaires because the students were assured of anonymity and immunity. The study was done in 1969 when the drug hysteria in this country was at its peak and the level of paranoia among youth, either justifiably or not, at a remarkable level. I attempted to do a similar study among middle-class youth and was assured by over one-third of them that they would not answer questions about "dope" truthfully as the principal or the "p!gs" would trace the questionnaire if done in school. The same questionnaire used in a free clinic I helped run produced wild exaggerations such as "I shoot up peanut butter," "I can't write, I have opium under my fingernails,', "I'm a heroin addict and recommend it." When asked about the levity displayed, the kids who trusted me said they obviously would not fill in questions that could be traced or forced out of me and that probably the rooms were bugged anyway! (Were they prophets?) It would also appear to me that students in the ninth and twelfth grades would normally be afflicted with flights into fantasy or at least prone to distortions, exaggerations, and bravado when answering questions, and certainly take a delight in "screwing up" a study done by a couple of well-meaning medical
The Journal o f Pediatrics March 1974
students. On the other hand the 86 per cent of the students who were Jewish may have been culturally predetermined in their answers. They may have played down their guilt (e.g., Portnoy), played up their guilt (e.g., Malamud), joked about their guilt (e.g., Greenburg), imagined their guilt (e.g., Freud), or just tried to protect mother (e.g., Grandmother). A C A D E M I C A C H I E V E M E N T AND I N T E R E S T It is stated that 96 per cent of the students planned to go to college, and yet we have a conclusion based on 14 per cent of the sample using drugs that drug users tend to be uninterested in college. This is based upon a probability of less than 0.01 per cent. I feel that N is too small to be biologically, much less, sociopsychologically valid. If I were at a gambling table and there were 551 winning rolls and 79 losing rolls and then assessed my chances of losing as probably less than 0.01 per cent, the "house" would dearly love me. S O C I A L AND S E X U A L B E H A V I O R It is stated that the use of illicit drugs was far below average for 14 year olds, and, above average for 18 year olds. We then are shown that heterosexual behaviors has a "striking" correlation with drug practices. Is sexual activity not at least as likely, however, to be correlating with age rather than drug use? I certainly did much at 18 that I did not do at 14--and in the fifties when I was 18, marijuana was something that I supposed only Negro drummers smoked. PSYCHOLOGICAL ADJUSTMENT It is reported that those with an excellent relationship with their parents had lower use rates of alcohol and drugs and that psychiatric difficulty correlated positively with drug use. The first conclusion may be more in the nature of Judaism than having to do with the lack of drugs. The second conclusion is based only upon a history of psychiatric consultation or treatment and this I feel is not entirely valid. Psychiatric consultation may merely reflect the higher social class of those private students or the intellectual curiosity of a group that is 96 per cent college oriented. Furthermore, it is stated for purposes of a profile to guide the physician that one who has been arrested may be more likely to use drugs. It is not stated, however, how many of the arrests were due to drugs in the first place, which leads me to conclude only that kids get arrested for taking drugs--not that being arrested has a causal relationship to drug use. ALCOHOL VERSUS DRUGS Two hundred and eight-two students used alcohol, 79 have used drugs, and 83 per cent of the drug users used alcohol. We are given a myriad of statistically probable conclusions on "drug use versus alcohol use" and the different severity of consequence-all this based apparently on the basis of about 13 students who did not use alcohol but did use drugs. Suffice it to say that the "use" as opposed to the "abuse" of drugs is nowhere mentioned in their article. (Does one puff of pot two years previously then cause the private, Protestant student in an exclusive Jewish school to become sexually active, get arrested,
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become nervous, and not go to college?) Finally, I question the use of a study of drug patterns in 1969 in a 1973 journal, when this study purports to give us the profile and characteristics of a drug user. The differences in style of drug abuse, youthful rebellion, and society as a whole is as different today as the "Funky Chicken" is from the "Lindy Hop." It is stated that the profile presented will help the physician identify and offer guidance to students so afflicted. If this is the case I am glad that I am at least Jewish because, alas, I have been nervous, heterosexually active, arrested once (no fishing license), had some poor grades, and use tobacco and alcohol. Edward A. Taub, M.D., F.A.A.P. Tustin Pediatric Medical Group, Inc. 18102 Irvine Blvd., Suite 107 Tustin, Calif. 92680
Reply To the Editor: The purpose of an objective statistical study of drug usage (nowhere do we deal with "abuse" although we do define degrees of usage) is to avoid the subjectivity which Dr. Taub seems to be guilty of in his reference to "drug hysteria" and "paranoia among youths." Admittedly drug usage is an emtionally charged subject; hence the design of our study was to be objective, to have no preconceived ideas, and to distance ourselves as far as is possible from the facts we were trying to gather. We think we avoided the kind of generalization that cannot be subjected to quantification. In response to Dr. Taub's specific objections I cite the following: I personally reviewed each questionnaire and discarded those (fewer than 1 per cent) that showed internal inconsistencies or deliberate distortions. Compliance was voluntary; no student was required to accept the questionnaire. These adolescents were interested and cooperative. They were not, as a group, rebellious, negative, distorting, or fantasy-afflicted, as Dr. Taub has postulated. They enjoyed the questionnaire, according to the spontaneous remarks they appended, and had excellent rapport with the medical-student administrators. Perhaps they were reassured of confidentiality by the fact that they personally witnessed the questionnaires being packed into cartons and removed from the premises of the schools. No "sweeping conclusions" were drawn. The text clearly
Letters to the Editor
states that the sample was representative of the middle-class, private school population of the locality (Brooklyn, New York). The sample size was adequate for the statistical method employed, and I quote: "Associations were analyzed statistically by the chi square method and were considered significant when the p value was 0.01 or less." A statistical study does not deal with causality. Thus, we do not say that drug usage "causes" anything, merely that it is found in association with certain demographic, psychologic, and social features. Nowhere do we state, nor was it a fact, that Protestant students were enrolled in "an exclusive Jewish school." True, the sample was predominantly Jewish; yet the findings coincided closely with those found in a Catholic youth population in the same locality. One wonders whether Dr. Taub is reflecting on the subject of this study, or is he reflecting on his own psyche and on that of the putative collective Jewish psyche chronicled by his literary citations (Portnoy, Malamud, Freud, et al.). With respect to the time of the study and whether the findings are still apposite in 1973, I can cite several studies of the past 12 months that report similar findings. 14 To respond to another of Dr. Taub's criticisms, namely our credibility with young people, I have discussed my publications on drugs with many adolescents and have found them interested and responsive, offering comments that are thoughtful and serious, not stereotyped and self-serving. Doris 1t. Milman, M.D. Department of Pediatrics State University-Kings County Hospital Center 450 Clarkson A re. Brooklyn, N. Y. 11203
REFERENCES 1. Berman, G., and Benierakis, C.: Characteristics of student marijuana users, Can. Psychiatr. Assoc. J. 17: 37, 1972. 2. Blumenfeld, M., Riester, A. E., Serrano, A. C., and Adams, R. L.: Marijuana use in high school students, Dis. Nerv. Syst. 33: 603, 1972. 3. Porter, M. R., Vieira, M. S., Kaplan, G. J., Heesch, J. R., and Colyar, A. B.: Drug use in Anchorage, Alaska, J.A.M.A. 223: 657, 1973. 4. Kandel, D: Adolescent marijuana use: Role of parents and peers, Science 181: 1067, 1973.