BRITISH MEDICAL JOURNAL 30 JUNE 1973

MEDICAL PRACTICE

Contemporary Themes

Which of you by taking thought can add one cubit unto hisstature ?Psychosomatic Illness n ildren: A Modern Synthesis*

JOHN APLEY

British MediealJournal, 1973, 2, 756-761

My tlide, taken from the King James Bible, became rathermore apt when I tumed to the New Enlish Bible of 1970.Here the word "thought" is more precisely translated as"anxious thought"; and it is the rela¢i between anxiousthought and stature, between emotional and bodily processes,that I am discussing.This lecture commemorates Charles West, to whom chil-

dren's hospitals and children owe so much. I cannot findthat he used the word psychosomatic, though it was Imownin his time. Like Willis and Sydenham before him he did,however, describe patients with what today would belabelled psychosomatic disorders. When he did so, admitted-ly under the broad heading of Malingerng, he logicallyruled out organic disease. Since his time psychosomaticshas turned from speculations to hard facts in this age of mani-cured medicine. It has a special appeal because it lendsitself to the controls of biological science and to measure-ment. In Ryle's memorable phrase, we are learning to"measure the measurable, and make measurable the immeas-urable."

If you are politely surprised to have listened so far with-out hearing a definition of psychosomatic illness, prepareyourselves for more. I do not propose to define the term.

*Chales westLecture delivered at theRoyl College ofPhysidiansofLondonon 7 Februny, 1973.

Even though I use it I distrust it. It tends to perpetuate theillusory duality of mind and body associated with Descartesand his intellectual supermarket. There are no separateminds and separate bodies-only human beings. As childrenthemselves might do, let me put this in a simple phrase:"The il child is ill all over."So "psychosomatic" will have to explain itself as we go

along. But first I should like to savour with you a few wordsthat describe the psychosomatic approach almost lyrically:"Listening to the child talking with his body." The poet?My friends and I thought it was Anna Freud, distinguisheddaughter of Sigmund Freud, himself (as Leo Rosten writes)"the Columbus of psychology, which still awaits its Euclid."Anna Freud, however, has charmingly denied the attribu-tion, and I do not know the author's name.

Stature

By my definition the paediatrician is "a measuring doctor,"and stature or height is undeniably his concern. Knowledgeof the process of growth is still far from complete. Discuss-ion used to turn on its "genetic inevitability" and its "inbomsequence"-such complacent phrases. But genes must en-joy the appropriate environment if they are to achieve theirpotential. It is now clear that many non-genetic factors canstunt growth. These factors may even be non-physical. Ma-ternal deprivation has now been linked with stunting ofgrowth; what is called "deprivation dwarfism" occurs notonly in institutions but im the home.How could emotional factors check growth? In one or

more of several ways, as by their effects on metabolism oron the hypothalamus, or by increasing cortisol secretion. It

Bristol Royal Hospital for Sick Children. Bristol BS2 8BJJOHN APLEY, Cs.E., M.D., F.R.C.P., Psediatrician

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has been reported that growth hormone production in thechild can be depressed in a disordered family environment,'though at Bristol my colleagues D. Russell Davis, M. Har-tog, and C. Griraldi and I have been unable to confirmsuch abnormal growth hormone levels.To our growth clinic at Bristol children are referred be-

cause their growth is stunted without any obvious cause.Most of the patients we see are short (below the third cen-tile) and thin; they are chming miniatures with normalbodily proportions (fig. 1). Physical investigations (includinggrowth hormone estimations in some) have proved negativein most cases,' though in some a slight retardation of boneage occurs.

97.'-

3. -

FIG. 1-Twelve-year-old girl under 3rd centile in height. Stunting becomesincreasingly obvious with age.

There are abnormal findings, but they are not physical.They fall into two groups. Firstly, our studies confirm that adisturbed family environmente can retard growth. As I havewritten elswhere, "The child is a barometer of the familyemotinal climate."

It is our second finding that was unexpected. In four-fifthsof the cases there was no shortage of food but the child'seating was deficient and his diet often grossly abnormal.Bizarre feeding habits were almost the rule. Many of thechildren seem to exist largely on Coca-Cola and crisps, witha sprinkling of ice-cream or raspberry-flavoured Nesquik.Paediatricians might have known, remembering all thosepink, plump children whose mothers complain sadly that"Hardly a morsel of food passes his lips." Some mothers'estimates of what their children eat obviously cannot beaccepted, and we are going further with our dietary investi-gations. An American source' rightly comments on an aston-ishing omission-that accurate dietary assessments are ut-terly lacking from previous reports on growth retardation. Atlong last, in the study of dwarfism, measurement is beingapplied-not only to the child's height but even to his diet.Most of our stunted children do not get enough calories

or proteins, though, of course, we do not claim that there areno other contributory factors. Not surprisingly, two depriva-tions go together-emotional and nutritional. It seems likelythat a pattern of disturbed family relationships influeces

757

the child so that he eats less and he grows less. In these in-stances stunting of growth is psychosomatic.My colleague Professor Russell Davis remarks that we

have not yet found a way to alter the distorted family pat-tern; but because we know it can alter itself, with good effecton the child's appetite and growth, we have hopes that guid-ance and advice could help. Treatment with growth hor-mone is useless where it is not deficient, but we are tryingthe effects of stimulating the appetite with cyproheptadine'(Periactin) in a controlled trial.

If what I have had to say about growth is confirmed itwill show that by taking thought doctors could influence theirown therapeutic stature; and they may then be able to in-crease their patients' physical stature, so long as theirpatients are children.For orthopaedic surgeons matters are simpler. Fig. 2

shows a girl with scoliosis treated by pelvis-halo traction.Even she did not gain a whole cubit, but she did gain 5 in(12-7 cm) in height-and infinite happiness.

ft.5-

4-

3.

2.

ft.5-

4-

3-

2_]FIG. 2-Pelvis-halo traction for scoliosis. The patient's apparent height wsincreaed by 5 in (12-7 cm).

Obesity

Another parameter of growth is obesity. It provides an in-teresting contrast. Just as chronic under-eatng can retardgrowth in height and bone age, so chronic over-eating canaccelerate growth in height and bone age. There is no onesingle cause for the over-eating which results in obesity, butthe over-eating often reflects the individual's mental attitudeand reaction to living. "Simple" obesity-it is never simple-is a psychosomatic or psychosocial disorder, with mentaland physical changes interdependent. It may have started ata critical or sensitive penod, when the infant was given toomuch carbohydrate. I constantly hear of mothers who addedstarch to the baby's milk as early as the second or even thefirst week of life; bec.ause of the mother's attitudes, whichreflect those of the society in which they and we live, thechild's physique may be blown out for the rest of his 1Overfeeding in the first year of life can permanently incrcasethe body's total number of obese cells and so play a pertin lifelong obesity. How the increased number of obese cells

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is matched with the individual's increased appetite remainsto be worked out.The natural history of severe obesity is typical of many

psychosomatic disorders in several respects: (a) it runs inthe family, (b) the pattern is set early, (c) it is chronic (orrecurrent), (d) it may shorten lIfe.

Age Influences

Turning from growth, in stature or weight, I do not intendto press on you a glossy catalogue of so-called psychosoma-tic diseases. I prefer, as a new approach, to discuss the in-fluence of age and development. Do you recall your child-hood fears? Just as fears have a chronology of their own, sohave psychosomatic disorders.At different stages in development the child's responses to

stress are not necessarily the same. The periodic syndromein childhood includes vomiting, fever, headache, abdominalpain, and probably limb pains.7 As the patient grows upvomiting and fever recede, while the pains may migrate tothe head.8 Hammond found that out of 12 children withcyclical vomiting 8 grew up with migraine. The complaintsmay change with age but a common denominator persists.The symptoms are expressions of a reaction pattern tostress, which is usually part of a family pattern too.From infancy to adolescence not only may the responses

alter but so may the effective stresses alter. Asthma illus-trates both. Often in asthmatic children a reaction which wasseen mainly in the skin moves and the target organ becomesthe bronchi; allergic stimuli may later come to be nforcedor even superseded by emotional ones.

In all ilness we must be mindful of underlying processes;among the chronological changes of psychosomatic disorderswe must persistently seek out "the pain beneath the pain."The gut is the main target organ of children's psychoso-

matic disease. Its disorders tend to range in time from vom-iting to "3-month colic," the "irritable bowel syndrome," re-current abdominal pain, and occasionally peptic ulcer. And,with us at all ages, there is constipation, that obvious sub-ject for "a time and motion study."A few examples of the peak periods at which psychoso-

matic disorders commonly occur are given below. I shallcomment on two.

Peak Periods of some Psychosomatic Disorders

Infancy to pre-schoolSchool agePuber...

BRITISH MEDICAL JOURNAL 30 JUNE 1973

Some Current Contributions

Just as neurology is being rationalized by neurophysiology,so psychosomatic medicine is being rationalized by psy-chophysiology. Psychosomatic medicine has advanced a longway since the early attempts to relate so-called disease en-tities to specific situations, personalities, or emotions; theyare either entities nor specific.The emotion most thoroughly studied is anxiety."3 We

know from experience what widespread changes can occur inhealthy people who are anxious. The mouth becomes dry,the palms damp, the heart beats fast, the pupils may dilate,pain or "butterflies" may be felt, bladder or bowel mayempty. These changes, which are more pronounced andlonger lasting in patients who are ill with anxiety, are large-ly mediated by the autonomic system.Many have been measured. Anxious patients, even when

they are at rest, show abnormally high levels of physiologicalactivity. From this can be seen to s,tem two important conse-quences. Firstly, because they are already responding at ahigh level, anxious patients react to stimuli less than normalpeople do. Secondly, and for the same reason, they showinpaired adaptation to the environment.This is not just speculation. Both statements are borne

out by studies of the reactions of the pupils.1' The pupil isan obvious though neglected end-organ for the measurementof automatic function. At Bristol we have investigated twomain groups of children with psychosomatic disorders, onegroup with asthma and the other with recurrent abdominalpain; as controls we compared them with unaffected chil-dren.s " The pupil reactions were measured in the light andthe dark, at rest and under stres (a hand placed in coldwater). In the patents (a) the pupils tended to be larger, bothin the rest condition and under stress, and (b) the changes inpupil size provoked by stress were less (fig. 3). I draw attentionto an interesting observation. We have found a few motherswho had noticed that the child's pupils became larger at thestart of an attack of abdominal pain, or at other odd times.One was a 7-year-old boy. When he was sitting in my out-patient clinic his pupils were of nornal size. As he wentfrom there to the pupillometry laboratory his pupils wereobserved to become steadily larger. They were very largeindeed by the time he saw the gadgetry (fig. 4). When he wascomforted and reassured they became smaller.

If abnormal pupil reactions reflect autonomic dysfunctionwe ought to know whether the dysfunction is familial. Dr.J. Robinson is currently measuring pupil reactions in theparents of my patients with asthma or recurrent abdominal

.. .. .. .. Vomiting, breath-holding attacks

.. .. .. .. Enuresis, recurrent pams, tics. . Anorexia nervosa

At rest After stress

The infant's soma behaves as if it and the mother's psychetogether form one unit. Children's doctors know that re-peated vomiting in the young infant may result fromhandling by a mother who is tensely anxious; when a placidnurse takes over, or when the mother is taught to relax, thevomiting stops.An explanation for bedwetting (primary noctumal

enuresis) is that a severe disruption in the family occurswhen the child is about 3 or 4 years of age. This, which wasa clincial impression,n n has been confirmed statistically.tThe child is disturbed emotionally at the sensitive period ofdevelopment when he should be learning the physical skill ofbladder control.Among the age factors, or chronological determinants,

maturation of the nervous system must be important. I sug-gest that some part is played also by social and culturalinfluences. No, I shall not start here a discussion on whatare called sociopsychosomatic diseases. They all are.

7-5 -

E

1-7.5

E-0C.CL

CL

6-5

R.A.R children

_ Nrml _h!d ----------

-YmPtON-or Parentofs___________

*Symptomotc parents of R.A.PchilIdren

7.5

7-0

6-5

FIG. 3-Pupil sizes at rest and after stress (a) in a group of normal childrenand (b) in children with recurrent abdominal pain (R.A.P.), (c) in normaladults and (d) in parents of R.A.P. children who themselves have symptoms.(Note: discrepancy in sizes at rest between (c) and (d) is due to the normaldecrease in size of pupils with the age of the subjects, because the age of thenormal adults was considerably lower than of the symptomatic parents.)

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FIG. 4-Widely dilated pupils with anxiety in 7-year-old boy.

pain. About 20 have been studied so far. In many of theparents who themselves have symptoms it looks as ifautonomic dysfunction does indeed run in the family (fig. 3).

If autonomic dysfunction is familial, as psychosomaticdisorders certainly are, and if it is accompanied by symp-

toms, we should not expect too much from medical treat-

ment using present-day methods. Experience of psycho-somatic disorders suggests this caution to be necessary. Letme illustrate from the "little bellyachers," the children withrecurrent abdominal pains. In this disorder the emotionalfactors which MacKeith and O'Neill17 indicated have re-

peatedly been confirmed. At Bristol we have shown that onlyabout one case in 20 has an organic basis; in 19 out of every

20 the pains are psychosomatic.18I once wrote "Little bellyachers grow up to be big belly-

achers." This gloomy conclusion was based on a study inwhich 30 children, virtually untreated, were followed into earlyadult life. Now at last we have been able to complete a

similar long-term follow-up survey, again of 30 little belly-achers.19 But these had been treated by us with reassurance

based on sympathetc listening, explanations, and discus-sions. For want of a better term this is what we call informalpsychotherapy. A cynic might describe any form of psycho-therapy not as the laying on of hands but as the laying backof ears; but informed listening does play a valuable part.Comparing the two groups I have to report that the pro-

portions in whom abdominal pains ceased were the same. Itis true that the treated children who lost their pains did somore quickly than the untreated ones. It is true also thatrather more of the treated children were free from othersymptoms when they grew up. But the main difference wasthat nearly all those who had been treated, unlike those whohad not been treated, were enjoying a normal life, even ladouceur de vivre. I infer that while we cannot at presentabolish the underlying disorder, we can help the patientsto understand, to miimie their own reactions, and toadapt satisfactorily. I hope we shall be able to do better forthe pains as such, and prevent the patients from becomingrecidivists, when we learn to treat the underlying dys-function.Here I must digress to the fascinating part played by

conditioning and the autonomic, involuntary nervous systemin psychosomatic processes.

ConditioningThe word autonomic means "a law unto itself," while in-voluntary means "not under the influence of the cortex."And yet the autonomic systlem is capable of being taught. In

759

the past few years Neale MillerP has brilliantly illmnatedthe subject with his experimental work.The method used is trial and error learning or operant

conditioning. Unlike Pavlovian conditioning it is an activelearning process. In this process the behaviour of the subjectchanges; it does so as a consequence of his own reactions.The changes may be built up step by step, using preferen-tial reinforcement, even to a stage at which highly complex,even abstract behaviour can be introduced.By operant is meant any behaviour that modifies the

environment. Everyone who is a parent, even an uncle,knows that the infant who smiles or who begins to sayDa-da modifies and operates on his environment. What is hisreward? He may get ecstatic praise and a warm hug, whichthemselves act to reinforce his smile or his sounds. Sothere will be more and bigger smiles, more and biggerwords-what we rather ponderously call the developmentof social behaviour or of linguistics.

Miller's early work was with animals, using food andother rewards. He showed that by preferential reinforce-ment various functions might be increased or, alternatively,decreased to order. Salivation, heart rate, blood pressure,blood flow could be altered. Such is the power of rewardsto rats. Miller claims that humans are just as smart as rats.In humans successes have been claimed by other investi-gators in modifying the blood pressure or the heart rate, inimproving cardiac arrhythmias or migraine.

I am intrigued by the rewards which induced such changesin our fellow humans. An obvious one was money; volun-teers might leave the laboratory with both a lowered bloodpressure and a raised bank balance. Some students actedas subjects. They were duly rewarded, perhaps with a sliceof American cheesecake or a photograph of an Americanblonde from Playboy.

Something that may prove of great therapeutic importanceseems to be emerging from experience of operant condition-ing. It is not essential that the reward offered should be atangible one; equally effective as a reward may be a symbolof success, such as a coloured light or a musical tone, oreven the knowledge itself of success. What does all thismean? Psychosomatic disorders, largely dependent on theautonomic system, are learnt or conditioned. A learningprocess is always involved in the development and in themaintenance of the disorders. Since they have been learntnay they not be unlearned?-since conditioned why not un-conditioned, by operant methods?Operant conditioning in humans is still under trial and

there may be unsuspected snarls or snags. Reports of controlseries unfortunately are rare and one cannot yet predict howlasting will prove any induced changes. None of the reportsI have seen refer to children. Yet it seems reasonable tosuggest that a learning process-or equallv an unlearningprocess-should be easier to observe in childhood and easierto modify. What is an adult but an obsolete child?

I wonder if operant conditioning or preferential reinforce-ment may help to explain why rsychosomatic disorders areso common in our present-day WVestern society? A hundredyears ago if the child had a tummy-ache it would be un-usual for him even to be seen by a doctor. Nowadays hewill be seen and fussed. He used to be dosed with old-fashioned, nasty castor oil; now he is lured with new-fashioned medicine tasting like ice-cream. He will be keptaway from school-is not this preferential conditioning tofeel pain? He may be kept away yet again to see a specialist.Perhaps all this is not the best treatment if he is sufferingfrom a passing anxiety state, or even a passing green apple?What we need to find and exploit are effective rewards

for not feeling pain or other psvchosomatic symptoms. Weshould be able to make schooling not too stressful, evenattractive. I am experimenting with deconditioning using in-angible rewards, like telling a girl patient how much pretder

..,.! *.-:--Ammdw

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BRITISH MEDICAL JOURNAL 30 JUNE 1973

she is becoming now that the pains are less frequent-andwhat I say is accurate too.

Expectancy (E) Waves

My last digression is an analogy that is almost an animtedcartoon. It comes from electroencephalography. Over a widearea of the cerebral cortex slow changes of electricalpotential occur. Their importance lies in the fact that theyare more than isolated physical phenomena; they are relatedto the person's mental state and to his involvement with theenvironment.What has become the best studied of these remarkable

phenomena was discovered by Grey Walter and hiscolleagues.2n It can be called the expectancy wave or E wave(contingent negative variation or C.N.V.) (fig. 5). What hap-pens? Two stimuli are applied. First comes a warningstimulus, then comes the second or imperative stimulus.The subject knows that he must respond as quickly as hecan to the second stimulus. He has to take a decision to dosomething (like pushing a button). The E wave appears inanticipation of the second stimulus.

CLICK

.-Jual-

FIG. 5-Expectancy (E) wave. First stimulus by clicking sound,second stimulus by flashes of light. When subject is warned the Ewave (shaded area) appears before second stimulus.

The E wave is associated with psychological constructs,such as attention or motivation. It is modified if the sub-ject is distracted (fig. 6) or highly anxious. It is related tomeasures of autonomic function, such as the heart rate.3Here, then, is a physical variable-and it can be measuredin highly respectable millivolts-which reflects subjectivemental states. I suggest that the E wave offers not merelyan analogy but possibly an approach to further understand-ing of psychosomatic reactions.

Psychopathology of Psychosomatic Disorder

Before ending I shall try to outline a model of the psycho-

Not distractedA.

wDIstracted by talking

'Distracted by music

,'.. i e -, FLASHEttt.S-CLICK. , so, - FLASHES

FIG. 6-Expectancy (E) wave (shaded area) modified bydistracting the subject (see text).

pathology of psychosomatic disorder. I am happy to ack-nowledge my indebtedness to Lader,n who has collated ex-perimental evidence from many studies of anxiety.Perhaps words are spoken and sound waves enter the ear.

A stimulus reaches the person and so to it he reacts.How he reacts depends on inborn and acquired factors.

These include his genetic make-up, his previous experiences,and what I have called the chronological determinants. Wehave to remember that psychosomatic reactions are likeimmunological responses in two fundamental respects: thesubject is sensitive to something (an emotional stress or aforeign protein), and his reactions are influenced by whathas happened to him before. 4

The stimulus, having been transmuted into nervous im-pulses, makes its impact (figs. 7 and 7a). First, there is astage of arousal, which may be consciously perceived as anemotional change but may not. At the same time bodily(physiological) changes occur. Both may subside and returnto a state of rest when the normal individual adjustshealthily.

STIMULU NORMAL|

bdily +pssyholog ica I

recions

VULNERABILITY $ CONDITIONING

response organ

|PSYCHOSOMATIC ILLNESS|

FIG. 7-Psychophysiological basis for psychosomatic disorders. Compositemodel (see text).

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BRITISH MEDICAL JOURNAL 30 JUNE 1973 761

STIMULUS NORMAL

iqh healthyrousal adjustmentstate

bodily +psycholoqicalrea ctions

FIG. 7a-Psychosomatic reactions. Normal sequence.

He may not adjust healthily (fig. 7b and 7c). It might bethat the stimulus was too intense or too often repeated. Itmight be that anxiety has exaggerated the reaction. It mightbe that the patient or the target organ is particularly vulner-able. It has been said that vulnerability is always inborn, butas a clinician it appears to me that it is sometimes condi-tioned or learnt.

VULNERABILITY CONDITIONINGGenetic (LEARNING)

Environmental Past experiences(esp. family) Preferential

Critical periods reinforcement

IFIG. 7b-Psychosomatic disorders. Vulnerability and conditioning.

Ind ividua Chronologicalpattern deter mi nants

Feedback Self-perpetuation

|PSYCHOSOMATIC ILLNESSFIG. 7c-Psychosomatic illness. Recurrent or chronic.

Vulnerability and conditioning-these are the two majorfactors in building up chronic or recurrent psychosomaticillness. There are various mechanisms which can make thedisorder self-reinforcing: one is a loss of adaptation thatgoes with anxiety; another is the awareness of symptoms,like pain, which itself acts as a feedback and so increasesanxiety. Together with autonomic conditioning or prefer-ential reinforcement these make psychosomatic diseasecharacteristically self-perpetuating.

After a variable period anatomical damage may follow, asoccurs in the lungs of asthmatics. Death may result from

psychosomatic disease. Much more often the older patientcomes to terms with what is virtually a life sentence.Gropingly he may attempt to build his own model of eventsand reactions to indicate how and where he believes he canprotect himself. Medical models such as I have drawn,indicate to us how and where we think we can intervene onhis behalf. At the same time models expose the many areasof our ignorance. Yet, admitting these, a rational approachto psychosomatic disorders is now becoming feasible, andin childhood above all it must find its greatest opportunities.

Epilogue

Many details have had to be omitted from this presentation.Some philosophy has crept in, though I know that, likeMontaigne, most doctors are "unpremeditated philoso-phers." Yet what is medicine if it is not a personal philosophytempered by science and experience and put into practice?We have been concerned here with psychosomatic medi-

cine and "Philosophy asks the simple question 'What is it allabout?"' (Whitehead). Mine is one paediatrician's answer.The child's world is small in time and space; it is small,too, in population and in concepts. Surely, then, it lendsitself to exploration and so to comprehension? We have tocomprehend because every child is a child and so in need ofhelp. We have to comprehend also because the child's ex-periences and conditioning act as a template, patterning thewhole of his life and, in turn, his child's life. None of thefactors that influence wellbeing and illness can be ignored,call them physical, psychological, social, or what we will.At last this is being realized, and comprehension comes in-creasingly within our reach. And so, increasingly, we mayhope to bring every child nearer the full measure of histrue stature.

I am indebted to Dr. W. C. McCallum for helpful advice andmterial on E waves.

References1 Patton, R. G., and Gardner, L. I., Growth Failure in Maternal Depriva-

tion. Springfield, Thomas, 1963.2 Powell, G. F., Brasel, J. A., and Blizzard, R. M., New EnglandJournal of

Medicine, 1967, 276, 1271.3 Apley, J., Davies, J., Davis, D. R., and Silk, B., Proceedings of the Royal

Society of Medicine, 1970, 64, 135.4 Whitten, C. F., Pettit, M. G., and Fischhoff, J., Journal of the American

Medical Association, 1969, 209, 1675.6 Kibel, M. A., Central African Journal of Medicine, 1969, 15, 229.Brook, C. G. D., Lloyd, J. K., and Wolf, 0. H., British Medical Journal,

1972, 2, 25.7 Naish, J. M., and Apley, J., Archives of Disease in Childhood, 1951, 26, 134.8 Apley, J., and MacKeith, R., The Child and his Symptoms, 2nd edn.

Oxford, Blackwell Scientific, 1968.9 Hammond, J., Archives of Disease in Childhood, 1973, 48, 81.1*Davis, D. R., in Introduction to Psychopathology. London, Oxford Uni-

versity Press, 1957.11 MacKeith, R. C., Developmental Medicine andChildNeurology 1964,6, 111.12 Douglas, J. W. B., in Recent Advances in the Knowledge of Bladder Control

in Children. Clinics in Developmental Medicine, No. 48. London,Heinemann, 1973.13 Lader, M., and Marks, I., Clinical Anxiety. London, Heinemann, 1972.

14 Rubin, L. S., Barbero, G. J., and Sibinga, M. S., Psychosomatic Medicine,1967, 29, 111.

'sApley, J., Haslam, D. R., and Tulloh, C. G., Archives of Disease in Child-hood, 1970, 46, 337.

"Robinson, J. E., and Apley, J. To be published.17 MacKeith, R., and O'Neill, D., Lancet, 1951, 2, 278.18 Apley, J., The Child with Recurrent Abdominal Pains. Oxford, Blackwell

Scientific, 1959.19Apley, J., and Hale, B., Long-term Follow-up Survey of Children with

Recurrent Abdominal Pain who were Treated. To be published.20 Miller, N. E., Science, 1969, 163, 434.21 Walter, W. G., Cooper, R., Aldridge, V. J., McCallum, W. C., and

Winter, A. L., Nature, 1964, 203, 380.22 McCallum,'W.'C., and Knott, J. R., eds. Ekctroecephalography andClinical

Neurophysiology, Suppl. No. 33. 1973 Elsevier, Amsterdam." Lader, M., in Modern Trendis in Psychosomatic Medicine, ed. 0. W. Hill,

(2). London, Butterworths.

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