Dr. KROGMAN. Well, sir, if you will permit an alliteration, my thinking always has been "from germination to termination." So, we encompass the entire scope of human life. I would myself, in the work that has been going on in Philadelphia, take it for granted that the parent-child, maternal-child, relationship is inherent in the understanding of problems of child health and human development. This, to me, goes without saying, sir.

The CHAIRMAN. And you think that this Institute will do the job that needs to be done and one that has not been done in the past?

Dr. KROGMAN. I think it would, sir, largely in the sense of bringing together many of us who have, so to speak, each contributed one facet to the entire problem. Again, I refer to this theme of coordination, integration, or this cliche of multidisciplinary approach. I would say all this is encompassed in the possibility of one Institute of Child Health and Human Development; yes, sir.

The CHAIRMAN. Thank you again, Dr. Krogman, for giving us your time.

Our next witness if Dr. Julius B. Richmond, College of Medicine, State University of New York, Syracuse, N.Y.

STATEMENT OF DR. JULIUS B. RICHMOND, COLLEGE OF MEDICINE,

STATE UNIVERSITY OF NEW YORK, SYRACUSE, N.Y.

Dr. RICHMOND. Mr. Chairman, you have just paid tribute to the various witnesses who have appeared before you. I would like, on behalf of many of the witnesses, to take this opportunity to pay tribute to you for your perseverance, your stamina, and your great attentiveness to what we had to say today.

The CHAIRMAN. Thank you. You are very kind.

Dr. RICHMOND. As you have indicated, I am Dr. Julius B. Richmond. I serve as professor of pediatrics and chairman of the department at the college of medicine at the State University of New York, Syracuse. In addition, I am president-elect of the American Psychosomatic Society, and I serve as vice president of the Child Welfare League of America.

I am appearing today, however, as vice president of the Society for Pediatric Research, an organization which Dr. Aldrich indicated he has also represented here today. This is a group of approximately 250 young pediatric research workers and educators in various pediatric centers throughout the United States and Canada. This organization traditionally has had within its membership scientific workers who have played a major role in the improvement of child health and welfare which has come about through research on the diesases of children and on all aspects of their growth and development.

The Society of Pediatric Research has gone on record as favoring the establishment of a new National Institute on Child Health and Human Development.

I might interject here, Mr. Chairman, to say that the matter of the title for the Institute did come up for discussion among the members of our society, and we felt rather strongly that the designation as given is very appropriate. We felt that it does not identify various disciplines, current or future, who may some day elect to work in the child health and human development field. It does not differentiate the sexes, maternal or paternal.

We thought that the overriding emphasis on human development including the whole lifespan, as other witnesses have so well stated, is appropriate. It was for these reasons that our members went on record as favoring the designation of this Institute as it has been proposed.

We support this bill, Mr. Chairman, mindful of the considerable contributions which the existing National Institutes of Health and other governmental agencies, such as the Children's Bureau, have made to the health of children.

The membership of the society has concluded, however, that more optimal stimulation and support for research in child health and human development will be provided by a specific institute concerned with these issues. We take this position with a deep sense of responsibility for continuing to advance our knowledge of child health and human development in the light of the rapidly expanding child population in the United States.

As some of the major child health problems are being controlledthe infectious and diarrheal diseases and nutritional disorders, for example other problems become relatively more significant. The problems resulting from congenital anomalies, mental retardation, tumors, and disordered metabolism merit increasing attention. Although existing institutes pay some attention to these matters, it is our feeling that workers specifically concerned with all aspects of the growth and development of children should have a central stimulating and supporting institute. The categorical institutes do not now provide such a central emphasis, unfortunately, although they have made great efforts to support research concerning children.

Because of the increasing complexity of research relating to children, it is important that collaborative efforts among the various professional workers concerned with children be fostered. Thus the problems of child health and human development are being studied by obstetricians, embryologists, geneticists, pathologists, pediatricians, child psychiatrists and psychologists, social workers, and behavioral scientists generally. These collaborative efforts must have a more specific central source for continuing support.

It is important to keep in mind that the work relating to children will have significant implications for adding to our knowledge concerning adult health. The work of the proposed Institute would, therefore, have significant implications for existing institutes.

I would again interject here, Mr. Chairman, that the establishment of this Institute would have many implications for increasing our understanding of the aging process. We speak of growth not only relating to children, but we also speak of growing old; I believe that all of us who think about this Institute on Child Health and Human Development think of the growth process during adult life as well.

It is quite likely that the existence of a National Institute on Child Health and Human Development at the time of the construction of the Clinical Center of the National Institutes of Health would have resulted in more adequate and specific provisions for the care of. children. As it developed, the Clinical Center has had to improvise in its facilities and staff for the study and care of children. We feel that this is not conducive to the development of the best research efforts concerning the diseases of children or child development.

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As our society grows in complexity, it becomes apparent that we need to concern ourselves increasingly with the intellectual, emotional, and social growth of our children. At a time when we are greatly concerned with helping children attain their greatest intellectual potentialities and with fostering the development of creativity, resourcefulness, and emotional maturity, it would seem appropriate that we establish an institute which would have as its primary objective the development of new knowledge which would help us achieve these goals.

It is estimated that 1 out of 10 children now attending elementary schools will spend some part of his life in treatment for an emotional disorder. We are aware of the very considerable burden of juvenile delinquency, narcotic addiction, alcoholism, and other psychosocial problems to our society.

The problem of out-of-wedlock pregnancy has been mentioned earlier here today, Mr. Chairman, as a very important one. All of us who see teenagers clinically are very much concerned about the lowering age of out-of-wedlock pregnancies generally. We feel that this does have an important implication for the outcome of these pregnancies, for, as maternal age drops below 20, the complications of pregnancy tend to be greater, and the incidence of prematurity tends to be greater.

We are concerned about the behavioral aspects of this problem in terms of why youngsters get into situations which cause out-ofwedlock pregnancies-the psychological and social implications of this trend toward a lowered age rate. We think that the establishment of the new Institute could do much to direct appropriate emphasis and research to problems such as this one.

There is the whole matter of accident prevention. We need know that the major cause of childhood deaths today is not a disease but accidents. We need to know why parents permit situations to develop in which their young children will experience accidents; we need to know more about why repeated accidents occur in some households. The whole matter of the effectiveness or lack of it-in parent education in this connection, as well as in connection with child rearing generally, requires much more intensive research than it has received up to the present time.

A coordinated approach combining the biological, psychological, social, and cultural aspects for the study of child development has the potentiality for increasing our understanding of the origins of these disorders and their prevention and management.

The field of research in child life, as any field of research, depends upon the development of highly qualified research workers. In contrast to the areas receiving categorical research support, training funds for the support of pediatric research workers, as one example, have been relatively small. Should this situation continue, it is possible that promising young investigators will be attracted to other fields in which support is more available. This has been a matter of serious concern to senior investigators in the field of pediatric research for the past several years.

We wish to make it clear that we take a position supporting a new National Institute of Child Health and Human Development not because of vested interest in research relating to children. Rather, we do so because we are aware of the importance of all aspects of the health

of children for the future of our Nation. And we are convinced that the health and growth and development of children will be fostered best by a new institue.

Thank you very much, Mr. Chairman.

The CHAIRMAN. Thank you, Dr. Richmond.

Of course, I appreciate very much the fine things you have had to say about the Chair. I am also grateful to you for having mentioned the field of accident prevention, with which this subcommittee has been concerned for a number of years.

Certainly, if we could find some answers in this field of accidents, which is, as you know, the greatest killer of our potential strength, the teenage group, I think that alone would justify the establishment of this Institute.

In looking at this problem and knowing, too, that we are rapidly becoming a nation of urban centers, leaving the period of our growth when we were primarily an agricultural nation, do you think that the growth of large cities has any impact on this problem?

Dr. RICHMOND. I believe it does, Mr. Chairman. The whole matter of urbanization, the whole matter of industrialization, mechanization, all of this has shifted the base of child rearing very considerably into densely populated urban areas.

I think that we as a nation have not yet caught up with ourselves in terms of trying to develop child-rearing practices, or child-rearing patterns which will deal with this new sociology as effectively as we might. I think this is a very serious problem which faces us as a nation today. I think it has complicated our situation concerning family life very greatly.

The CHAIRMAN. I am sure you know that the Congress has been deeply concerned with this problem of juvenile delinquency. There have been many hearings held, and efforts have been made to try to find some measures, if not to eradicate it, certainly to try to control it to a greater degree than it is being controlled at the present time. Some of the witnesses have expressed the viewpoint here that if we knew more about some of the emotional problems of children and could get to them before the child reaches the point that he knows he is not accepted and that he is not conforming to the other members of his age group, that in many cases we would have a much better chance of making him a good citizen than we do at the present time. What is your opinion on that?

Dr. RICHMOND. Well, I think you have brought up a very significant and complicated problem that faces us. I think in the whole

area of delinquency we cannot expect any quick answers.

I would hope, Mr. Chairman, that out of the research efforts of an institute such as the one proposed we would develop a deeper and more adequate understanding of the causes of delinquency in order that we can deal with them more effectively.

One of the great problems that we have today relates to the many proposals for action which do not take into account adequately the basic roots of the problem. I do not want to oversimplify the whole matter of causation because I think one of the reasons why we cannot act very effectively is that we are dealing with a problem of multiple causation, and we have to begin to fractionate out of this whole wastebasket classification that we refer to as juvenile delinquency, various subgroups. In some instances we know that constitutional

factors may play a role-not the sole factor. Cosmetic defects, for example, may be an important factor in a small number of juvenile delinquents. Social and cultural patterns, particularly rapid changes in the culture are significant in many more instances. Certainly behavioral scientists have much to contribute in this type of research. But unless our investigations are very basic and unless they recognize that we are not dealing with a problem which has a single cause but, rather, which has multiple causes, I think we will not proceed very rapidly. I think this is one of the greatest difficulties that we have today, Mr. Chairman: many proposals for action without understanding the basic causation.

The CHAIRMAN. I believe you stated that your group, your centerit is the sense of your group that the administration title, the title contained in the administration bill, will sufficiently describe the activities which should be carried on under this bill?

Dr. RICHMOND. Yes. We felt that this has a sufficient emphasis on the growth and developmental processes over the entire lifespan to encourage research in all age groups. Any proposals that have thus far been considered for modification seem to limit the scope of the Institute to the point which we felt would be undesirable.

We are very interested in the impact of growth and development as a process on the organism. Although our membership carries on its work largely with the childhood population, our interest is, however, in growth and development over the entire lifespan, and we feel that the objectives of our organization would be well served by the title as it stands at the present time.

The CHAIRMAN. Thank you again, Doctor, for your remarks.
This will conclude the hearings.

The Chair would like to announce that the record will remain open for 5 days to give everyone a chance to supply other material or to correct remarks.

The Chair would like to thank all of the witnesses, the press, and other interested parties who have taken part in the hearing. I personally feel that you have made a very fine record, and it has been a very interesting and beneficial experience for the chairman and the members of the subcommittee.

The subcommittee will now adjourn.

(The following data was submitted for the record:)

STATEMENT OF DR. LYTT I. GARDNER, PRESIDENT-ELECT, THE SOCIETY FOR PEDIATRIC RESEARCH; PROFESSOR OF PEDIATRICS, STATE UNIVERSITY OF NEW YORK, UPSTATE MEDICAL CENTER, SYRACUSE, N.Y.

Gentlemen, I wish to express my support of the legislation embodied in H.R. 8398. There is little doubt that we have now reached a stage in the evolution of our medical research culture when the establishment of such a National Institute of Child Health and Human Development is appropriate. In the beginning our National Institutes of Health were so organized that research rela.ing to children was exclusively organized around organ systems and diseases. A child was looked upon as the host of an interesting kidney, or adrenal gland. Perhaps this organ system orientation was unavoidable in the beginning, but it nevertheless resulted in a degree of incompatibility with the principles of developmental physiology implicit in the field of pediatrics and child health. One of the fundamental differences between the care of infants and children and the care of adults is the axiom that "the child is not a little man." The newborn infant operates on different physiological levels from the 3-month-old; and the 3-monthold has different ground rules than a 9-year-old. The pediatrician or worker in child health research must always reckon on the dimension of time; the pathologic