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Association of Maladaptive Parental Behavior With Psychiatric Disorder Among Parents and Their Offspring
Jeffrey G. Johnson, PhD;
Patricia Cohen, PhD;
Stephanie Kasen, PhD;
Elizabeth Smailes, MPhil;
Judith S. Brook, PhD
Arch Gen Psychiatry. 2001;58:453-460.
ABSTRACT
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Background A longitudinal study was conducted to investigate the role of maladaptive
parental behavior in the association between parent and offspring psychiatric
disorder.
Methods Psychosocial and psychiatric interviews were administered to a representative
community sample of 593 biological parents and their offspring from 2 counties
in the state of New York in 1975, 1983, 1985 to 1986, and 1991 to 1993. In
1975, the offspring were a mean age of 6 years. Maladaptive parental behavior
was assessed in 1975, 1983, and 1985 to 1986. Parent and offspring psychiatric
symptoms were assessed in 1983, 1985 to 1986, and 1991 to 1993.
Results Maladaptive parental behavior substantially mediated a significant association
between parental and offspring psychiatric symptoms. Parents with psychiatric
disorders had higher levels of maladaptive behavior in the household than
did parents without psychiatric disorders. Maladaptive parental behavior,
in turn, was associated with increased offspring risk for psychiatric disorders
during adolescence and early adulthood. Most of the youths that experienced
high levels of maladaptive parental behavior during childhood had psychiatric
disorders during adolescence or early adulthood, whether or not their parents
had psychiatric disorders. In contrast, the offspring of parents with psychiatric
disorders were not at increased risk for psychiatric disorders unless there
was a history of maladaptive parental behavior.
Conclusions Maladaptive parental behavior is associated with increased risk for
the development of psychiatric disorders among the offspring of parents with
and without psychiatric disorders. Maladaptive parental behavior appears to
be an important mediator of the association between parental and offspring
psychiatric symptoms.
INTRODUCTION
INTRAFAMILIAL TRANSMISSION of psychopathology is an important factor
in the etiology of psychiatric disorders.1, 2
Research has indicated that individuals with a familial history of psychiatric
disorder are at elevated risk for onset of psychiatric disorder,3, 4, 5
and that genetic and environmental factors may both play important roles in
intrafamilial transmission.6, 7, 8, 9, 10
Nevertheless, the mechanisms that cause psychiatric disorders to be transmitted
from parents to their offspring remain poorly understood.
Maladaptive parenting has long been viewed as an important determinant
of offspring psychopathology.11 Parental behavior
may be influenced by offspring temperament and parental psychopathology, both
of which are likely to be determined in part by genetic factors.11
However, while numerous studies have examined associations between parental
psychopathology, parental behavior, and offspring psychopathology, few studies
have included a comprehensive assessment of all 3 sets of factors using a
multiwave prospective longitudinal method. Furthermore, no previous study
has assessed parental psychopathology, parental behavior, and offspring psychopathology
repeatedly from childhood through the early adulthood of the offspring, controlling
for the effects of offspring temperament, offspring psychopathology, and parental
psychopathology on parental behavior. Therefore, important questions remain
unanswered about the role that parental behavior plays in the intrafamilial
transmission of mental disorders. The nature of this association is of considerable
interest to clinicians and scientists alike, in part because it may be possible
to reduce the likelihood that children will develop psychiatric disorders
by helping parents to modify their child-rearing behavior.12
Maladaptive parental behavior is likely to be one of the important aspects
of the childhood environment that accounts for the increase in risk for psychiatric
disorders among the offspring of parents with psychiatric disorders. Two bodies
of research support this inference. First, research has indicated that parental
psychopathology is associated with maladaptive parental behavior.11, 13 Second, research has demonstrated
that maladaptive parental behavior is associated with increased offspring
risk for psychiatric disorders.14, 15, 16, 17
It has thus been hypothesized that maladaptive parental behavior plays a significant
role in the association between parental and offspring psychiatric disorder.18, 19, 20
To conduct a systematic examination of this mediational hypothesis,
it is necessary to conduct prospective longitudinal research with a sizable
general population sample, assessing a wide range of psychiatric disorders
and maladaptive behaviors among both biological parents while they are raising
their children, and assessing psychiatric disorders among the offspring during
their childhood, adolescence, and early adulthood. It is also necessary to
control for the effects of parental psychopathology, offspring temperament,
and offspring psychopathology on maladaptive parental behavior.11
We report findings from such a community-based prospective longitudinal study
to investigate whether maladaptive parental behavior mediates the association
between parental and offspring psychiatric disorders.
SUBJECTS, MATERIALS, AND METHODS
SAMPLE AND PROCEDURE
The participants in the Children in the Community Study were 976 randomly
sampled families from 2 upstate New York counties, interviewed in 1975, 1983,
1985 to 1986, and 1991 to 1993.21, 22
The families in this study were representative of families in the northeastern
United States with regard to most demographic variables, but reflected the
region regarding high percentages of Catholic (54%) and white (91%) participants.22 The current analyses were conducted with data from
593 families for whom information regarding psychiatric disorders and maladaptive
parental behavior were available through 1985 to 1986 with regard to both
biological parents, and for whom data were available through 1991 to 1993
regarding offspring psychopathology. These 593 families did not differ from
the remainder of the original sample with regard to the prevalence of maladaptive
parental behavior, difficult offspring temperament, or maternal psychopathology,
although paternal substance abuse in 1975 was less prevalent than in the remainder
of the original sample. During the follow-up interviews, administered by extensively
trained and supervised lay interviewers, the youths and their mothers were
interviewed to assess parental and offspring psychiatric symptoms, parental
behavior, and other psychosocial variables. The mean (SD) age of the youths
was 6 (3) years in 1975, 14 (3) years in 1983, 16 (3) years in 1985 to 1986,
and 22 (3) years in 1991 to 1993. Study procedures were approved according
to appropriate institutional guidelines. Written informed consent was obtained
after the interview procedures were fully explained. Youths and their mothers
were interviewed separately, and both interviewers were blind to the responses
of the other informant. Additional information regarding the study methods
is available from previous reports.21, 22
ASSESSMENT OF OFFSPRING TEMPERAMENT, OFFSPRING PSYCHOPATHOLOGY, AND
PARENTAL PSYCHOPATHOLOGY
Ten dimensions of difficult childhood temperament were assessed during
the 1975 maternal interviews: (1) clumsiness/distractibility; (2) nonpersistence/noncompliance;
(3) anger; (4) aggression to peers; (5) problem behavior; (6) temper tantrums;
(7) hyperactivity; (8) crying/demanding; (9) fearful withdrawal; and (10)
moodiness. Children with severe problems in these domains were identified
as having a difficult temperament.22
The parent and youth versions of the Diagnostic Interview Schedule for
Children23 were administered to assess offspring
anxiety, depressive, disruptive, and substance use disorders in 1983 and 1985
to 1986. In 1991 to 1993, the Diagnostic Interview Schedule for Children was
administered only to the offspring. Mothers and youths were interviewed because
the use of multiple informants increases the reliability and validity of psychiatric
diagnoses among children and adolescents.24, 25
Symptoms were considered present if reported by either informant. The reliability
and validity of the Diagnostic Interview Schedule for Children as employed
in the present study are comparable with those of other structured interviews.26 Items used to assess personality disorders (PDs)
were adapted from instruments including the Personality Diagnostic Questionnaire27 and the Structured Clinical Interview for DSM-III-R Personality Disorders,28 combined
using computer algorithms,29 and modified to
maximize correspondence with DSM-IV diagnostic criteria.
Because PD symptoms must be persistent for an adolescent to be diagnosed as
having a PD,30 a PD was not diagnosed unless
PD diagnostic criteria were met in 1985 to 1986 or 1991 to 1993 and substantially
elevated PD symptom levels were present on both occasions. Research has supported
the reliability and validity of the items and algorithms used to assess PDs.31, 32, 33
Two types of interview data were used to assess parental psychopathology.
Current psychopathology was assessed during the 1975, 1983, and 1985 to 1986
maternal interviews. Lifetime psychopathology was assessed during the 1991
to 1993 maternal interview. Interview items used to assess current maternal
anxiety; depressive, disruptive, personality, and substance use symptoms were
obtained from the Disorganizing Poverty Interview,21
the California Psychological Inventory,34 the
Hopkins Symptom Checklist,35 and instruments
that assessed maternal alienation,36 rebelliousness,37 and other dysfunctional traits.38, 39
Paternal alcohol abuse, drug abuse, and antisocial behavior were assessed
using the Disorganizing Poverty Interview. Lifetime maternal and paternal
anxiety, and depressive, disruptive, personality, and substance use disorders
were assessed using items adapted from the New York High-Risk Study Family
Interview.40 Data regarding the onset of parental
disorders permitted identification of disorders that were evident by the time
that the mean age of the offspring was 16 years.
Diagnostic algorithms were developed using items that assessed DSM-IV diagnostic criteria for maternal anxiety, depressive,
disruptive, personality, and substance use disorders. Diagnoses were not assigned
unless there was clear and convincing evidence indicating that DSM-IV diagnostic criteria were met. Sufficient information was available
to permit the assessment of maternal alcohol abuse, attention-deficit/hyperactivity
disorder, conduct disorder, drug abuse, generalized anxiety disorder, major
depressive disorder, oppositional defiant disorder, personality disorders,
and posttraumatic stress disorder. There was also sufficient information to
permit the assessment of paternal alcohol abuse, antisocial personality disorder,
conduct disorder, drug abuse, generalized anxiety disorder, and major depressive
disorder.
ASSESSMENT OF MALADAPTIVE PARENTAL BEHAVIOR
A wide range of maternal and paternal behaviors were assessed during
the 1975, 1983, and 1985 to 1986 interviews. Inconsistent maternal enforcement
of rules, loud arguments between the parents, low maternal educational aspirations
for the child, maternal difficulty controlling anger toward the child, maternal
possessiveness, maternal use of guilt to control the child, maternal verbal
abuse, parental cigarette smoking, parental supervision, paternal assistance
to the child's mother, and paternal fulfillment of the role of father in the
family were assessed using items from the Disorganizing Poverty Interview
and measures of maternal child-rearing attitudes and behaviors that were administered
during the maternal interviews.21, 22, 41, 42
Harsh maternal punishment, parental affection, parental time spent with the
child, and poor parental communication with the child were assessed in the
maternal and offspring interviews using scales assessing parental warmth,
parent-child communication, and parental support and availability.21, 41, 42 Parental home maintenance
and maternal behavior during the interview were assessed by interviewer observations.
Scales and items assessing each type of parental behavior were dichotomized
at the maladaptive end of the scale, facilitating identification of specific
types of parental behavior that were associated with parental and offspring
psychopathology. Dichotomies were established empirically to identify statistically
deviant parental behaviors. Parental behavior was not defined as maladaptive
unless the percentage of parents engaging in such behavior was at least 1
SD from the sample mean. Four scales, assessing parents' involvement in their
child's life, were not associated with parental or offspring psychopathology.
The types of parental behavior that were associated with parental and offspring
psychopathology, listed in Table 1
and Table 2, were included in
the analyses reported below. A body of research supports the validity of the
measures that were used to assess maternal and paternal behavior.21, 22, 41, 42, 43, 44, 45
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Table 1. Maternal Psychiatric Disorders and Maladaptive Maternal Behaviors
During the Childhood and Adolescence of the Offspring*
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Table 2. Paternal Psychiatric Disorders and Maladaptive Paternal Behaviors
During the Childhood and Adolescence of the Offspring*
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DATA ANALYSES
Analyses of contingency tables were conducted to investigate associations
between parental psychiatric disorders and maladaptive parental behaviors.
All analyses were conducted using 2-tailed significance tests and an 
level of .05. Analyses of covariance were conducted to investigate whether
parents with disorders behaved in a more maladaptive manner than did parents
without disorders. Logistic regression analyses were conducted to investigate
whether maladaptive parental behavior was associated with increased offspring
risk for psychiatric disorders during late adolescence (1985-1986) or early
adulthood (1991-1993) after controlling for parental education, offspring
age, sex, difficult childhood temperament, psychiatric disorders during early
adolescence (1983), and parental psychiatric disorders. Logistic regression
analyses were also conducted to investigate whether parental psychiatric disorders
were associated with increased offspring risk for psychiatric disorders during
late adolescence or early adulthood after controlling for parental education,
offspring age, sex, difficult childhood temperament, psychiatric disorders
during early adolescence, and maladaptive parental behavior. Power analyses
indicated that parental and offspring anxiety, depressive, disruptive, personality,
and substance use disorders were too rare to permit analyses regarding associations
between specific types of parental and offspring psychiatric disorders. Therefore,
multiple regression analyses were conducted to investigate associations between
specific types of parental and offspring psychiatric symptoms after controlling
for parental education, offspring age, sex, difficult childhood temperament,
offspring psychiatric disorders during early adolescence, and maladaptive
parental behavior. Unlike the logistic regression analyses, the multiple regression
analyses took into consideration the severity of maternal and paternal psychopathology.
An established 3-step procedure46 was
used to test whether parental behavior mediated the associations between parental
and offspring psychiatric disorders. For parental behavior to mediate these
associations, 3 conditions are required: (1) parental psychiatric disorders
must predict offspring psychiatric disorders; (2) parental psychiatric disorders
must predict maladaptive parental behavior; and (3) maladaptive parental behavior
must predict offspring psychiatric disorders after parental psychiatric disorders
were controlled statistically. Difficult childhood temperament and offspring
psychiatric disorders during early adolescence were controlled in all of the
mediation analyses.
Logistic regression analyses were also conducted to investigate whether
maladaptive maternal and paternal behaviors independently predicted offspring
psychiatric disorder, the statistical interaction of maladaptive maternal
and paternal behaviors predicted offspring psychiatric disorder, maternal
and paternal psychiatric disorders independently predicted offspring psychiatric
disorder, and the interaction of maternal and paternal psychiatric disorders
predicted offspring psychiatric disorder.
RESULTS
PREVALENCES OF MATERNAL, PATERNAL, AND OFFSPRING PSYCHIATRIC DISORDERS
Data regarding the cumulative prevalence of maternal and paternal psychiatric
disorders before and during the childhood and adolescence of the offspring,
and of offspring psychiatric disorders during late adolescence and early adulthood,
are presented in Table 3.
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Table 3. Prevalence of Maternal, Paternal, and Offspring Psychiatric
Disorders*
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ASSOCIATION BETWEEN PREEXISTING OFFSPRING PSYCHOPATHOLOGY AND SUBSEQUENT
PARENTAL BEHAVIOR
Difficult childhood temperament at a mean age of 6 years was associated
with higher levels of maladaptive parental behavior at a mean age of 14 (t591 = 3.28, P =.001)
and 16 (t591 = 2.37, P =.02) years. Psychiatric disorder at a mean age of 14 years was associated
with higher levels of maladaptive parental behavior at a mean age of 16 years
(t591 = 5.67, P<.001).
ASSOCIATION BETWEEN PARENTAL PSYCHIATRIC DISORDERS AND MALADAPTIVE
PARENTAL BEHAVIOR
Fourteen types of maladaptive maternal behavior and 9 types of maladaptive
paternal behaviors were more prevalent among parents with psychiatric disorders
than among parents without psychiatric disorders. These associations remained
significant after parental education, offspring age, sex, difficult childhood
temperament, and psychiatric disorders during early adolescence were controlled
statistically (Table 1 and Table 2). Overall, parents without psychiatric
disorders had an adjusted mean (SD) of 1.89 (1.84) maladaptive behaviors.
Parents with psychiatric disorders had an adjusted mean (SD) of 3.93 (3.00)
maladaptive behaviors. This difference remained significant after controlling
for the same covariates (F592 = 116.09, P<.001).
ASSOCIATION BETWEEN MALADAPTIVE PARENTAL BEHAVIOR AND OFFSPRING PSYCHIATRIC
DISORDERS
Maladaptive parental behavior was associated with increased offspring
risk for anxiety, depressive, disruptive, personality, and substance use disorders
during late adolescence and early adulthood after the covariates were controlled
statistically. All of these associations remained significant after parental
psychiatric disorders were controlled statistically (Table 4). Offspring psychiatric disorders increased markedly in
prevalence as the number of maladaptive parental behaviors increased. The
same pattern of findings was obtained when the analyses were repeated using
an index of maladaptive parental behavior based solely on the maternal interviews
and an index of offspring psychopathology based solely on the offspring interview
during early adulthood. Supplemental analyses indicated that persistent maladaptive
parental behavior was associated with higher offspring risk for psychiatric
disorders than was episodic maladaptive parental behavior.
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Table 4. Maladaptive Parenting and Offspring Psychiatric Disorders
During Late Adolescence and Early Adulthood*
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Maladaptive maternal (adjusted odds ratio [AOR], 1.38; 95% confidence
interval [CI], 1.22-1.55; P<.001) and paternal
behavior (AOR, 1.19; 95% CI, 1.06-1.34; P =.003)
were independently associated with increased offspring risk for psychiatric
disorder. The statistical interaction of maladaptive maternal and paternal
behavior did not predict offspring risk for psychiatric disorder, although
the addition of 1 maladaptive maternal and paternal behavior was associated
with a 64% increase in offspring risk for psychiatric disorder.
ASSOCIATION BETWEEN PARENTAL AND OFFSPRING PSYCHIATRIC DISORDERS
Parental psychiatric disorders were associated with increased offspring
risk for anxiety, disruptive, personality, substance use, and any psychiatric
disorders during late adolescence and early adulthood after the covariates
were controlled statistically (Table 5).
However, none of these associations remained significant after controlling
for maladaptive parental behavior. The same pattern of findings was obtained
when the analyses were repeated using an index of the total number of maternal
and paternal disorders in each family. Supplemental analyses indicated that
persistent parental psychiatric disorders were associated with higher offspring
risk for psychiatric disorders than were episodic parental psychiatric disorders.
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Table 5. Association Between Parental Psychiatric Disorders and Offspring
Psychiatric Disorders During Late Adolescence and Early Adulthood*
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Maternal (AOR, 2.38; 95% CI, 1.58-3.58; P<.001)
and paternal (AOR, 1.62; 95% CI, 1.08-2.43; P =.02)
psychiatric disorders were independently associated with offspring risk for
psychiatric disorder. Neither the interaction of maternal and paternal psychiatric
disorders nor the interaction of parental psychiatric disorders with maladaptive
parental behavior was associated with offspring risk for psychiatric disorder.
As Figure 1 indicates, the overall
increases in offspring risk for psychiatric disorders as a function of maladaptive
parental behavior were nearly identical among the offspring of parents with
and without psychiatric disorders.
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Association between maladaptive parental behavior and offspring psychiatric
disorders among offspring of parents with and without psychiatric disorders.
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ASSOCIATIONS BETWEEN SPECIFIC TYPES OF PARENTAL AND OFFSPRING PSYCHIATRIC
SYMPTOMS
As Table 6 indicates, symptoms
of parental and offspring anxiety, depressive, disruptive, personality, and
substance use disorders were significantly associated after parental education,
offspring age, sex, difficult childhood temperament, and early adolescent
psychiatric disorders were controlled statistically. Maladaptive parental
behavior was associated with symptoms of offspring anxiety, depressive, disruptive,
personality, and substance use disorders after the covariates listed above,
and parental psychiatric symptoms were controlled statistically. Substantial
reductions in the magnitudes of the associations between parental and offspring
psychiatric symptoms were observed when maladaptive parental behavior was
controlled statistically.
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Table 6. Association Between Parental Psychiatric Symptoms and Offspring
Psychiatric Symptoms During Late Adolescence and Early Adulthood
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PARENTAL DISORDERS, PARENTAL BEHAVIOR, AND OFFSPRING PSYCHIATRIC DISORDERS
DURING EARLY ADULTHOOD
Although statistical controls were used in the above analyses to minimize
the influence of preexisting offspring psychopathology, it would have been
possible to further reduce the influence of preexisting offspring psychopathology
by restricting the analyses to associations involving only those offspring
disorders that were present during early adulthood. However, small numbers
of cases precluded such analyses regarding the 5 specific types of offspring
psychiatric disorders. There was sufficient statistical power to permit analyses
regarding the overall association between parental disorders, maladaptive
parental behavior, and offspring psychiatric disorders during early adulthood.
Results were consistent with the findings reported above: parental psychiatric
disorders were associated with increased offspring risk for psychiatric disorders
during early adulthood before (OR, 1.67; 95% CI, 1.27-2.19), but not after,
controlling for maladaptive parental behavior (AOR, 1.19; 95% CI, 0.87-1.64).
COMMENT
The present findings suggest that maladaptive parental behavior may
play an important role in the association between parental and offspring psychopathology.
In the present study, maladaptive parental behavior met all of the statistical
criteria46 required to indicate that it mediated
this association: parental psychopathology was associated with maladaptive
parental behavior and with increased offspring risk for psychiatric disorders
during late adolescence and early adulthood, and maladaptive parental behavior
was associated with elevated offspring risk for psychiatric disorders after
parental psychiatric disorders were controlled statistically.
Such findings are of particular interest because it may be possible
to prevent the onset of psychiatric disorders among many children and adolescents
by helping parents to modify their child-rearing behavior.12
Importantly, our findings suggest that maladaptive parental behavior may play
a significant role in the development of offspring psychiatric disorders whether
or not the parents have psychiatric disorders. The present findings also indicate
that some parents with psychiatric disorders do not behave in a particularly
maladaptive manner while raising their children, and that their offspring
may not be at substantially elevated risk for psychiatric disorders. Because
some types of maladaptive parental behavior are relatively common in our society,
our findings suggest that it may be important to educate the public about
the kinds of parental behavior that are most strongly associated with risk
for mental disorders among offspring.
These data are consistent with previous research indicating that parental
psychopathology is associated with maladaptive parental behavior,11, 13 that maladaptive parental behavior
is associated with offspring risk for psychopathology,14, 15, 16, 17, 18, 19, 20, 47
that a substantial proportion of the intrafamilial association involving several
types of psychiatric disorders is accounted for by environmental factors,8, 9, 47 and that the effects
of parental behavior on offspring behavior have sometimes been underestimated
because the unique or "nonshared" aspects of the relationship between each
child and his or her parents have not been adequately recognized.48 At the same time, it is also important to note that
there is evidence indicating that genetic factors may play a predominant role
in the intrafamilial transmission of some types of mental disorders, including
schizophrenia and bipolar disorder,6 which
were too rare to investigate in this study.
As noted above, previous research has indicated that parenting can be
adversely affected by parental psychopathology and offspring temperament,
both of which seem to be determined in part by genetic factors.6, 11
In this regard, our findings indicating that the association between maladaptive
parental behavior and subsequent offspring psychiatric disorders was not attributable
to the effects of parental psychopathology, offspring temperament, or offspring
psychiatric disorders during early adolescence are of particular interest.
It will, nevertheless, be of interest for future research to investigate whether
genetic factors that are not expressed in the phenotypic form of either parental
psychopathology or difficult offspring temperament may play a role in the
association between maladaptive parental behavior and offspring psychopathology.
It will also be of interest for future research, designed to optimize the
detection of genetic influences on behavior, to investigate whether a shared
genetic liability for parental psychopathology and maladaptive parental behavior
may affect parental behavior even in the absence of parental psychiatric disorder,
and whether indirect genetic effects may adversely influence parental behavior
through their association with environmental adversities.
The limitations of the present study require consideration. Because
the fathers were not interviewed, data from the maternal and offspring interviews
were used to assess paternal behavior and psychopathology. We considered restricting
the focus of this article to the association between maternal psychiatric
disorder, maladaptive maternal behavior, and offspring psychiatric disorder.
However, our concerns about the paternal data were outweighed by the enhanced
contribution to the field that results from the inclusion of data regarding
both biological parents. Confidence in the validity of the paternal data was
increased because the present findings are consistent with regard to the mediational
roles of maladaptive maternal and paternal behavior, and because the present
findings regarding the estimated prevalence of paternal disorders are similar
to the findings of major epidemiological studies.49, 50
Another limitation is the absence of systematic observational data on parent-child
interactions. Several studies have indicated that observer ratings of parental
and offspring behavior tend to yield higher estimates of the role of the environment
in the association between parental and offspring behavior than are obtained
when parental ratings are used.51 Nevertheless,
the unique methodological strengths of the present study permit the findings
of this investigation to contribute to an increased understanding of the role
of parental behavior in the association between parental and offspring psychiatric
disorders.
AUTHOR INFORMATION
Accepted for publication November 27, 2000.
Supported by grant MH-36971 from the National Institute of Mental Health,
Bethesda, Md (Dr Cohen), and National Institutes of Health grant DA-03188
from the National Institute on Drug Abuse, Bethesda, Md (Dr Brook).
From the Columbia University and the New York State Psychiatric Institute
(Drs Johnson, Cohen, and Kasen and Ms Smailes); and the Mount Sinai Medical
Center (Dr Brook), New York.
Corresponding author: Jeffrey G. Johnson, PhD, Unit 60, New York
State Psychiatric Institute, 1051 Riverside Dr, New York, NY 10032 (e-mail: jjohnso{at}pi.cpmc.columbia.edu).
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