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Conduct disorder is among the most commonly diagnosed DSM child and adolescent disorders, in both clinic and community studies, with a lifetime community prevalence of 9.5% in the National Comorbity Survey Replication (1) and a point prevalence of 5% for Ontario youth in a recent Canadian study (2). However, because psychiatrically normal youth can engage in antisocial behaviour for various reasons, CD diagnosis, if based on antisocial behaviour alone, is open to false positives (that is, nondisordered individuals mistakenly diagnosed as disordered). Eliminating such false positives is partly a conceptual challenge of better understanding the distinction between disordered and nondisordered antisocial behaviour. There have been studies of how professionals draw the distinction, but no studies of lay concepts that could illuminate how lay people decide whether an antisocially behaving youth is disordered. Of particular interest is whether professional and lay concepts of disorder are sufficiently similar to allow fruitful communication. The present study examines lay judgments of CD in response to clinical vignettes and compares them with previously reported professional responses to address the question, Is the lay concept of mental disorder, like the professional concept, closer to a dysfunction-based than to a syndromal concept? CD False Positives: Why Impairment Criteria Are Not the Full SolutionGoing back at least to Anna Freud (3), child mental health professionals have expressed concern that CD may be subject to overdiagnosis, both because children have transient developmental phases that may seem disorder-like but spontaneously resolve and because problematic family and community contexts may trigger a normal response that may appear disordered (for example, running away from home when sexually abused). Moreover, normal children may be socialized into a subculture’s behaviour that, in the broader social context, is considered antisocial, as in a mafia family. John Richters and Dante Cicchetti (4) analyzed potential CD false positives and argued that even Tom Sawyer and Huckleberry Finn would likely (and fallaciously) qualify for DSM CD diagnoses. Terry Moffitt (5) maintained that adolescence-limited antisocial behaviour is often a normal response to the gap in modern society between youths’ early physical maturity and lack of responsible adult roles. Moffitt’s argument reflects a common concern that adolescent-onset CD, which has modest predictive validity for later antisocial personality disorder or criminality, may often represent nondisordered delinquency. The epidemiologic literature has grappled with the “caseness” problem of distinguishing CD from similar nondisordered behaviours in community samples, generally using impairment criteria to help make the distinction (6–10). This approach is consistent with the DSM-IV’s strategy of using clinical significance (defined as distress or impairment) to indicate caseness and eliminate false positives. The belief that clinical significance indicators can resolve false-positive problems has recently been criticized on conceptual grounds (11), and empirical studies suggest that impairment criteria may yield false negatives (12). Some social impairment follows almost tautologically from antisocial behaviour, whether disordered or nondisordered; consequently, impairment criteria do not greatly lower prevalence of CD (13). Impairment indicates need for help, but need for help is not equivalent to disorder (14). Interestingly, the DSM-IV itself implies that clinical significance is not a cure for CD false positives. The CD criteria contain a clinical significance criterion, yet (as discussed shortly) the text cautions that a diagnosis should still not be made if underlying dysfunction is not inferred. The implication is that normal delinquency can reach clinical significance. The Dysfunction RequirementIf clinical significance and impairment criteria are not the solution to the false-positive problem, what is? The DSM-IV’s definition of mental disorder requires that, for disorder to be present, syndromal symptoms must be caused by an internal dysfunction (that is, something must have gone wrong with the expected functioning of some internal mechanism or process):
The DSM-IV’s textual commentary on CD reflects the dysfunction requirement, stating that, even if CD syndromal diagnostic criteria are satisfied, disorder should not be diagnosed if symptoms are not caused by dysfunction:
If the dysfunction requirement does override syndromal criteria, then the meaning of much research on CD is thrown into doubt. Almost all CD research and epidemiologic studies rely on the DSM syndromal criteria alone for case identification. The dysfunction requirement is rejected by several prominent accounts of disorder (16–19). A common objection is that laypeople have no concept of mental disorder at all or have only a primitive concept not resembling the professional concept (19). Conversely, the harmful dysfunction analysis of the concept of mental disorder (20–22) holds that lay and professional concepts of disorder are essentially the same and dysfunction-based, although, of course, laypeople lack the specific knowledge and expertise of professionals. The dysfunction requirement has generally been addressed via conceptual arguments. Recently, however, researchers have examined the dysfunction requirement empirically, focusing on professionals’ judgments about CD. The results have supported the claim that clinicians tend to intuitively identify disorder in terms of internal dysfunction. Wakefield, Pottick, and Kirk found that DSM-trained, clinically experienced (average about 4 years) graduate students in psychology and social work, responding to constructed case vignettes that were manipulated to suggest internal dysfunction or nondysfunction in youths meeting DSM-IV CD criteria, tended to judge disorder in accordance with the dysfunction requirement and to judge conditions satisfying DSM criteria as nondisorders if they seemed not to be caused by dysfunctions (23). Hsieh and Kirk, using similar methods, found that disorder judgments of a national sample of psychiatrists also indicated the influence of the dysfunction requirement (24). Whether laypeople in our culture apply the dysfunction requirement when judging youth-disordered conduct compared with nondisordered delinquency remains virtually unstudied, except for one study that provided some indirect support for the dysfunction requirement (see 25). The present study addresses this question directly. We hypothesized that the dysfunction requirement is part of our society’s generally shared concept of disorder, and we tested the following prediction: Even when behavioural symptoms satisfy DSM-IV syndromal CD diagnostic criteria, laypeople, like professionals, tend to distinguish disorder from nondisorder on the basis of whether available contextual information suggests that manifest symptoms are caused by an internal dysfunction, not by symptomatic behaviour alone. Two advantages to using the CD category in exploring the lay concept of disorder are as follows: First, that DSM-IV CD symptoms (requiring 3 symptomatic behaviours and social or academic impairment) have plausible dysfunction and nondysfunction interpretations, allowing for an effective test of the prediction that only when dysfunction is inferred would conditions be classified as disorders. Internal dysfunctions that might cause behaviours satisfying CD criteria include, for example, failures of the capacity for empathy, guilt, moral conscience, or impulse control. Consistent with theory neutrality, no assumption need be made as to the physical or psychological etiology of such failures of normal function. However, CD criteria might also be satisfied by youths having no dysfunction and responding problematically to a negative environment, such as a youth who joins a gang for selfprotection in a threatening neighborhood. Second, the notion of “dysfunction” can be difficult to measure, but the DSM’s textual passage regarding nondysfunction cases satisfying CD criteria provides guidance in formulating clinical vignettes that adequately reflect the intended distinction. Another reason for clarifying the disorder status of CD is that youth antisocial behaviours are managed through 2 social institutions— the juvenile justice social service system and the mental health system. Implicit judgments of the disordered or nondisordered status of behaviour may partially determine which system a youth enters. Moreover, broader social views of disorder status may shape policies regarding which institutions should handle such behaviours. Although the data reported here do not address these issues, they suggest directions for future research about the relation between perceived disorder status and institutional disposition of cases. MethodsSamples Subjects were students at Rutgers University and UCLA who filled out the study questionnaire anonymously in class. Participation was voluntary and informed consent was obtained verbally; Rutgers and UCLA institutional review boards approved the study. There were 3 samples: nurses, nonclinical social workers, and social science undergraduates (all “lay” because they were not mental health professionals). Each subject responded to 2 vignettes; for n subjects, there were n = 2 responses. Nonclinical Social Work Sample Social work graduate students were sampled at Rutgers and UCLA. Many social workers address poverty, administration, social policy, and other nonmental health concerns and are not clinically trained. To eliminate subjects with significant mental health experience, we restricted the analytic sample to those who had not taken a DSM course and who reported 3 months or less of mental health experience. The sample (subject n = 60, response n = 119 [1 missing]) had an average of less than 1 month of mental health experience (mean 0.88 months, SD 1.28); 65% (n = 39) reported no clinical experience at all. Nurse Sample Nursing graduate students were sampled at UCLA. Subjects were experienced general medical or pediatric nurses who had practised for some years after the bachelors of nursing degree before returning to study for an advanced degree. To eliminate subjects with significant mental health experience, we restricted the analytic sample to those who reported 3 months or less of clinical mental health experience. The sample (subject n = 68, response n = 133 [3 missing]), averaged 2 weeks of mental health experience (mean 0.49 months, SD 1.03); 79.4% (n = 54) reported no mental health experience. Undergraduate Sample Nurses and nonclinical social workers may be exposed to the DSM in their courses. Thus we also sampled undergraduates in introductory sociology and social welfare courses at Rutgers and UCLA. To ensure lay status, we limited the analytic sample (subject n = 124, response n = 248) to subjects who reported no professional mental health experience whatever (mean 0 months, SD 0). To facilitate comparisons of nonclinicians with clinicians, the study’s methods were kept consistent with earlier studies of mental health professionals. Vignette Construction Data comprised subjects’ judgments about case vignettes describing youth displaying antisocial behaviours that satisfy DSM-IV CD diagnostic criteria, which require at least 3 behavioural symptoms in the past year (1 within 6 months) and impairment. The case vignettes were manipulated either to offer no explanation of the behaviour, to explain the behaviour as a response to a negative environment, or to suggest internal dysfunction as the cause. For each of 2 hypothetical youths meeting DSM CD criteria—Carlos, a Mexican immigrant aged 12 years, and Judy, a white girl aged 13 years—we prepared 3 versions (context conditions) of the youth’s case vignettes. (Vignettes are described further in Wakefield, Pottick, and Kirk [22]) Symptom-only vignettes present demographic and symptom information satisfying DSM-IV CD criteria but without any information suggesting the cause of the symptoms. Carlos displays 4 DSM CD symptoms (often bullies or threatens classmates, often initiates physical fights, uses a baseball bat as a weapon in a schoolyard fight, and often is truant). Judy displays 6 (broke into a car, often lies to escape her responsibilities around the house, shoplifts, often stays out until late at night despite parental prohibitions, has run away overnight more than once, and frequently is truant). To ensure satisfaction of the DSM-IV’s requirement that “the disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning” (15 p 91), we included statements that Carlos’s bullying and fighting “has seriously limited his social relationships” and Judy’s frequent truancy “has markedly impaired her academic performance.” Symptom-only vignettes form the first paragraph of other vignettes. Environmental-reaction vignettes add a paragraph explaining the problematic behaviour as a response to the environment. Carlos is depicted as reacting to a threatening neighborhood by adopting a tough attitude, joining a gang for protection, and engaging in gang-sanctioned antisocial behaviour. Judy is depicted as responding to threatened sexual abuse by a family member whom she attempts to evade, leading to truancy, staying out late, running away, and other problematic behaviours. Internal-dysfunction vignettes add a paragraph to symptom-only vignettes that offers context to suggest that the antisocial behaviour is caused by an internal dysfunction. For example, behaviours are depicted as disproportional to environmental triggering circumstances, as directed indiscriminately at those in the environment, as continuing when the youth is placed in a more benign environment, as impulsive or rigidly continuing despite punishment, and as lacking empathy, guilt, or concern for consequences. Consistent with the DSM’s theory-neutral approach to diagnosis, the dysfunction vignettes state nothing about the specific nature of the dysfunction but, rather, offer theory-neutral descriptions of behaviour that suggest a dysfunction of some affective, cognitive, or other psychological mechanism. Instrument Each subject responded to 2 vignettes, a version each of “Carlos” and “Judy,” with the order of presentation randomized. Following each vignette, subjects were asked whether they agreed or disagreed with several items, including the following “disorder” item: “According to my own view, this youth has a mental/psychiatric disorder.” Although described youths met DSM CD criteria, we did not use the term conduct disorder in the vignettes or instrument. Each item was rated on a Likert-type ordinal scale ranging from 1 (strongly agree) to 6 (strongly disagree). For analyses reported here, we combined responses into “agree” (strongly, moderately, and mildly) and “disagree” (mildly, moderately, and strongly) and reported the percentage of subjects agreeing. Clinicians typically must decide whether to classify a patient as disordered or not, so dichotomous responses have more clinical relevance. The vignettes did not state that the youth’s condition was caused by a dysfunction or nondysfunction, nor did the internal-dysfunction vignettes present a specific etiology from a particular theoretical perspective to indicate dysfunction. Rather, we presented theory-neutral symptomatic and contextual information of the kind that might emerge in a clinical interview. Hypotheses Our basic hypothesis was that subjects in each of the samples would tend to judge internal-dysfunction vignettes as disordered and environmental-reaction vignettes as nondisordered. We report results for symptom-only vignettes for comparative purposes because they satisfy DSM-IV criteria, although we made no predictions about them. Our hypothesis does not predict that lay and clinician judgments will be the same, only that each group will be strongly influenced by the dysfunction–nondysfunction distinction; there are various reasons (for example, different beliefs, theories, or information) as to why different groups might produce somewhat different judgments, even when applying the same concept. ResultsLay Samples In all 3 lay samples, for both “Judy” and “Carlos” vignettes, significantly larger percentages of subjects agreed to disorder in the internal-dysfunction than in the environmental-reaction context (Table 1; 1-tailed Fisher’s exact test, P < 0.001 in all 6 cases). The differences were substantial in all 6 cases (range of the difference, 49% to 64%).
Comparison of Lay and Clinician Samples Wakefield, Pottick, and Kirk reported on a clinician sample (n = 117; response n = 233) consisting of advanced DSM-trained graduate students in psychology (n = 62) and social work (n = 55) with mean clinical experience of 4 years (22). The literature suggests that this sample’s diagnostic judgments should closely approximate those of experienced clinicians (25). The 2 professions were combined into a single sample because there were no significant differences in rates of disorder judgments on any vignettes. We compared lay responses to these previously reported clinician responses. As Table 1 indicates, clinicians’ judgments were consistent with the dysfunction requirement, with high percentages agreeing with “disorder” in the internaldysfunction context but disagreeing in the environmental-reaction context, for both Judy and Carlos vignettes. Although lay and clinician results were similar in being consistent with the dysfunction requirement, there were some differences. Generally, higher percentages of clinician than lay subjects agreed with “disorder” in the internal-dysfunction context and nondisorder in the environmental-reaction context, but such differences on specific vignettes were rarely significant. Differences between lay and clinician subjects emerged more clearly when we looked at the overall impact of context on disorder judgments rather than at individual vignettes. We measured such impact by subtracting the percentage agreeing with “disorder” in the environmentalreaction context from the percentage agreeing in the internal-dysfunction context. Using this measure, clinicians responded significantly more strongly to context than did any of the lay groups in the Carlos case (2-tailed large sample test, z = 3.16, P = 0.002; z = 3.39, P = 0.001; and z = 2.97, P = 0.003, for comparisons of clinicians with nurses, nonclinical social workers, and undergraduates, respectively); in the Judy case, they responded significantly more strongly than the nonclinical social workers and more strongly, but only with a nonsignificant trend, than nurses and undergraduates (2-tailed large sample test, z = 1.95, P = 0.05; z = 1.72, P = 0.085; z = 1.78, P = 0.075, respectively). DiscussionOur results suggest that, at least regarding adolescent antisocial behaviour, the lay concept of disorder tends to require the presence of internal dysfunction and is more consistent with the DSM-IV’s general definition of mental disorder and its textual CD commentary, both of which emphasize the dysfunction requirement, than it is with the DSM’s CD diagnostic criteria. Laypeople thus tend to judge as “nondisorders” some conditions that satisfy DSM-IV diagnostic criteria for disorder. Like the judgments of previously reported professionals, lay judgments in all samples were highly sensitive to contextual information that went beyond presence of syndromal symptoms and reflected the dysfunction requirement. Undergraduates with no clinical experience judged disorder and nondisorder similarly to professionals. There was a trend, however, for clinician samples to respond somewhat more robustly than lay samples to contextual information. A possible interpretation is that, although laypeople and clinicians tend to share a dysfunction-based concept of disorder, clinical training and experience increases the ability to apply the shared concept and to distinguish disorder from nondisorder. Moreover, although the concept may be shared, laypeople and professionals are in vastly different positions regarding knowledge about mental disorders and their treatment. Despite the robust findings, the study is limited in numerous ways. Lay subjects were graduate and undergraduate students, not a broader spectrum of the public. Case vignettes were simplified descriptions designed to represent relatively clear cases of dysfunction and nondysfunction to test a conceptual point rather than to reflect complexities of clinical reality. A limitation of vignette methodology is that, despite efforts to eliminate confounding factors, case vignettes may not be adequately controlled to eliminate potential alternative explanations of the results. Further studies are needed to identify the source of subjects’ judgments of disorder and nondisorder. Moreover, we studied only CD, and the generalizability of the results regarding the dysfunction requirement to other diagnostic categories remains to be established. A major challenge is to clarify the concept of dysfunction. It has been argued that a dysfunction is a failure of the mind’s biological design and thus is scientifically best understood in evolutionary terms (20–22), that dysfunction covers a broad range of socially undesirable inner states (17,19), and that it is a narrower concept limited to physiological dysfunction (18). The concept of dysfunction thus requires further exploration. Moreover, this study addressed the concept of disorder that people in our culture actually possess. It remains to be considered whether the dysfunction requirement should be embraced as a guide in formulating diagnostic criteria, as do implications of such an approach for revision of diagnostic criteria for the DSM-V, as well as the generalizability of the dysfunction requirement to other cultures. Understanding that lay and professional judgments of disorder tend to agree on the dysfunction requirement could be useful in public discussion of psychiatric diagnosis and in building public consensus about the appropriateness of mental health treatment and reimbursement policies. Such understanding could provide a common framework enabling mental health professionals to respond more effectively to public criticisms of DSM diagnostic criteria, especially the common charge that the DSM does not identify true disorders but merely medicalizes undesirable behaviour. This understanding could guide professionals in more directly addressing the distinction between dysfunction and nondysfunction that may often underlie such concerns. The findings suggest a gap between the syndromal, symptom-based, decontextualized diagnostic approach embodied in DSM CD diagnostic criteria and the dysfunction-based, contextsensitive approach common among both professionals and laypeople. This tension deserves to be addressed in discussion of potential revisions to DSM criteria in the DSM-V. The fact that the DSM’s text appears to correct its own syndromal diagnostic criteria in favour of a dysfunction-based evaluation makes particularly important the consideration of possible overdiagnosis of CD among those living in difficult or threatening environments, as well as in research and epidemiologic studies that use DSM syndromal criteria. Finally, a possible concern is that the results of this study imply that many youths who fall under the DSM CD criteria may not be disordered; consequently, if the dysfunction conceptualization were systematically applied, youth in serious jeopardy due to antisocial behaviour might be turned away from treatment if judged to be delinquent but nondisordered. This raises policy issues that cannot be adequately dealt with here. However, our data (unreported for laypeople; reported for professionals in [22]) indicate that both professionals and lay people generally believe that such nondisordered delinquency should be treated by mental health professionals. This divergence between current policy and general belief needs to be addressed. Simply diagnosing delinquent youths as disordered to obtain reimbursement raises ethical issues and compromises treatment conceptualization. Many nondisorders (for example, pregnancy and birth control) are addressed by the medical system when society judges it appropriate, and prevention efforts also justify intervention. Creative thinking about the social implications of medical reimbursement policy and of “medical necessity” thresholds is needed in light of the mismatch revealed in these data between the concept of disorder and the need for mental health treatment. Funding and SupportThis research was supported in part by the National Institute of Mental Health, grant RO1 MH-43450. References1. Kessler RC, Berglund P, Demler O, Jin R, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2005;62:594–602. 2. Byrne C, Browne G, Roberts J, Gafni A, Bell B, Chalkin L, and others. [Adolescent emotional/behavioural problems and risk behaviour in Ontario primary care: comorbidities and costs. Working paper S02-01, July 2002]. Located at System-Linked Research Unit on Health and Social Service Utilization, McMaster University, Hamilton, Ontario. 3. Freud A. The writings of Anna Freud. Vol 4. Normality and pathology in childhood: assessments of development. New York (NY): International Universities Press; 1965. 4. Richters JE, Cicchetti D. Mark Twain meets DSM-III-R: conduct disorder, development, and the concept of harmful dysfunction. Dev Psychopathol 1993;5:5–29. 5. Moffitt TE. Adolescence-limited and life-course-persistent antisocial behavior: a developmental taxonomy. Psychol Rev 1993;100:674–701. 6. Angold A, Erkanli A, Farmer EMZ, Fairbank JA, Burns BJ, Keeler G, and others. Psychiatric disorder, impairment, and service use in rural African American and White youth. Arch Gen Psychiatry 2002;59:893–901. 7. Bird HR, Canino G, Rubio-Stipec M, Gould MS, Ribera J, Sesman M, and others. Estimates of the prevalence of childhood maladjustment in a community survey in Puerto Rico: the use of combined measures. Arch Gen Psychiatry 1988;45:1120–6. 8. Canino G, Shrout PE, Rubio-Stipec M, Bird HR, Bravo M, Ramirez R, and others. The DSM-IV rates of child and adolescent disorders in Puerto Rico: prevalence, correlates, service use, and the effects of impairment. Arch Gen Psychiatry 2004;61:85–9. 9. Costello EJ, Angold A, Burns BJ, Erkanli A, Stangl D, Tweed DL. The Great Smoky Mountains Study of Youth: functional impairment and serious emotional disturbance. Arch Gen Psychiatry 1996;53:1137–43. 10. Shaffer D, Fisher P, Dulcan MK, Davies M, Piacentini J, Schwab-Stone ME, and others. The NIMH Diagnostic Interview Schedule for Children version 2.3 (DISC–2.3): description acceptability, prevalence rates, and performance in the MECA study. J Am Acad Child Adolesc Psychiatry 1996;35:865–77. 11. Spitzer RL, Wakefield JC. DSM-IV diagnostic criterion for clinical significance: does it help solve the false positives problem? Am J Psychiatry 1999;156:1856–64. 12. Beals J, Novins DK, Spicer P, Orton HD, Mitchell CM, Barón AE,and others. Challenges in operationalizing the DSM-IV clinical significance criterion. Arch Gen Psychiatry 2004;61:1197–207. 13. Angold A, Costello EJ, Farmer EMZ, Burns BJ, Erkanli A. Impaired but undiagnosed. Jn Amer Acad Child Adolesc Psychiatry 1999;38:129–37. 14. Spitzer RL. Diagnosis and need for treatment are not the same. Arch Gen Psychiatry 1998;55:120. 15. Diagnostic and statistical manual of mental disorders. 4th ed. Washington (DC): American Psychiatric Association; 1994. 16. Sedgwick P. Psycho politics: Laing, Foucault, Goffman, Szasz, and the future of mass psychiatry. New York (NY): Harper; 1982. 17. Lilienfeld SO, Marino L. Mental disorder as a Roschian concept: a critique of Wakefield’s “harmful dysfunction” analysis. J Abnorm Psychol 1995;104:411–20. 18. Houts AC. Harmful dysfunction and the search for value neutrality in the definition of mental disorder: response to Wakefield. Part 2. Behav Res Ther 2001;39:1099–132. 19. Kirmayer JL, Young A. Culture and context in the evolutionary concept of mental disorder. J Abnorm Psychol 1999;108:446–52. 20. Wakefield JC. The concept of mental disorder: on the boundary between biological facts and social values. Am Psychol 1992;47:373–88. 21. Wakefield JC. Disorder as harmful dysfunction: a conceptual critique of DSM-III-R’s definition of mental disorder. Psychol Rev 1992;99:232–47. 22. Wakefield JC. Evolutionary versus prototype analyses of the concept of disorder. J Abnorm Psychol 1999;108:374–99. 23. Wakefield JC, Pottick KJ, Kirk SA. Should the DSM-IV diagnostic criteria for conduct disorder consider social context? Am J Psychiatry 2002;159:380–6. 24. Hsieh DK, Kirk SA. The effect of social context on psychiatrists’ judgments of adolescent antisocial behavior. J Child Psychol Psychiatry 2003;44:877–87. 25. Haslam N, Giosan C. The lay concept of “mental disorder” among American undergraduates. J Clin Psychol 2002;58:479–85. 26. Garb HN. Studying the clinician: judgment research and psychological assessment. Washington (DC): American Psychological Association; 1999. Author(s)1. University Professor and Professor in the School of Social Work, New York University, 1 Washington Square North, New York, NY 10003. 2. Professor and Chair, Department of Social Welfare, School of Public Affairs, University of California, Los Angeles, California. | 3. Professor, Institute for Health, Health Care Policy, and Aging Research and the School of Social Work, Rutgers University, New Brunswick, New Jersey. 4. Psychiatric Social Worker, Psychiatric Mobile Response Team, Emergency Outreach Bureau, Los Angeles County Department of Mental Health, Los Angeles, California. 5. Mathematical Statistician, Office of Biostatistics Research at the National Heart, Lung, and Blood Institute, Bethesda, Maryland. Address for correspondence: Dr JC Wakefield, 309 W. 104 St. #9C, New York NY 10025. e-mail: jw111@nyu.edu
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