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15. Remington, J. S., Miller, M. J., Brownlee, I. (1968) ‘IgM antibodies in acute toxoplasmosis: 1. Diagnostic significance in congenital cases, and a method for their rapid demonstration.’ Pediatrics, 41, 1082. 16. Sinks, L. F., Newton, W. A., Nagi, N. A., Stevenson, T. D. (1966) ‘A syndrome associated with extreme hyperuricemia in leukemia.’ Journal of Pediatrics, 68, 578. 17. Jaffe, N., Kim, B. S., Vawter, G. F. (1972) ‘Hypocalcemia-a complication of childhood leukemia.’ Cancer, 29, 392. 18. Stein, R. C. (1971) ‘Hypercalcemia in leukemia.’ Journal of Pediatrics, 78, 861. 19. Field, M., Block, J. B., Levin, R., Hall, D. P. (1966) ‘Significance of blood lactate elevations among patients with acute leukemia and other neoplastic proliferative disorders.’ American Journal of Medicine, 40, 528. 20. Rosman, N. P., Kokulas, B. A., Richardson, E. P. (1966) ‘Central pontine myelinolysis in a child with leukemia.’ Archives of Neurology, 14, 273. 21. Cadman, T. E., Rorke, L. B. (1969) ‘Central pontine myelinolysis in childhood and adolescence.’ Archives of Disease in Childhood, 44, 342. 22. Valsamis, M . P., Peress, N. S., Wright, L. D. (1971) ‘Central pontine myelinolysis in childhood.’ Archives of Neurology, 25, 307. 23. Martin, J., Mainwaring, D. (1973) ‘Coma and convulsions associated with vincristine therapy.’ British Medical Journal, 4, 782. 24. Whittaker, J. A., Parry, D. H., Bunch, C., Weatherall, D. J. (1973) ‘Coma associated with vincristine therapy.’ British Medical Journal, 4, 335. 25. Kay, H. E. M., Knapton, P. J., OSullivan, J. P., Wells, D. G., Harris, R. F., Innes, E. M., Stuart, J., Schwartz, F. C. M., Thompson, E. N. (1972) ‘Encephalopathy in acute leukaemia associated with methotrexate therapy.’ Archives of Disease in Childhood, 47, 344. 26. Duttera, M. J., Bleyer, M. A., Pomeroy, T. C., Leventhal, C. M., Leventhal, B. G. (1973) ‘Irradiation, methotrexate toxicity and the treatment of meningeal leukaemia.’ Lancet, ii, 703. 27. Price, R. A., Jamieson, P. A. (1975) ‘The central nervous system in childhood leukemia. 11. Subacute leukoencephalopathy.’ Cancer, 35, 306. 28. Rubinstein, L. J., Herman, M. M., Long, T. F., Wilbur, J. R. (1975) ‘Disseminated necrotizing leukoencephalopathy :A complication of treated central nervous system leukemia and lymphoma.’ Cancer, 35, 29 1. 29. Flament-Durand, J., Ketelbant-Balasse, P., Maurus, R., Regnier, R., Spehl, M. (1975) ‘Intracerebral calcifications appearing during the course of acute lymphocytic leukemia treated with methotrexate and x-rays.’ Cancer, 35, 319. 30. Saiki, J. H., Thompson, S., Smith, F., Atkinson, R. (1972) ‘Paraplegia following intrathecal chemotherapy.’ Cancer, 29, 370. 31. Pratt, C. B., Choi, S. I., Holton, C. P. (1971) ‘Low-dosage asparaginase treatment of childhood acute lymphocytic leukemia.’ American Journal of Diseases of Children, 121,406. 32. Walker, A. E., Adamkiewiez, J. J. (1964) ‘Pseudo-tumor cerebri associated with prolonged corticosteroid therapy: Reports of four cases.’ Journal of the American Medical Association, 188, 779. 33. Freeman, J. E., Johnston, P. G. B., Voke, J. M. (1973) ‘Somnolence after prophylactic cranial irradiation in children with acute lymphoblastic leukaemia.’ British Medical Journal, 4, 523. 34. Nieri, R. L., Burgert, E. O., Groover, R. V. (1968) ‘Central nervous system complications of leukemia: A review.’ Mayo Clinic Proceedings, 43, 70. 35. Aur, R. J. A. (1974) rn Cleyton, F. J., Crowther, D., Malpas, J. S. (Eds.) Reviews in Leukaemia and Lymphoma, Vol. 1. Advances in Acute Leukaemia. Amsterdam: North Holland. 36. Burchenal, J. H., Murphy, M. L. (1965) ‘Long term survivors in acute leukemia.’ Cancer Research, 25, 1491.

BEHAVIOUR DISORDER: A PREVENTABLE LATE SEQUEL OF ILLNESS IN CHILDHOOD A recent paper by SIGAL and GAGNON’ discusses the effects of parental and medical worry about a child’s acute and serious illness on that child’s subsequent behaviour. As it stands, the paper is rather hard to absorb using as it does criteria for (and descriptions ot) behavioural disturbance which are based on other papers which readers may not have readily to hand. It does, however, give several important reminders which are worthy of further comment. Firstly: Parents know when they are worriers and their children know it too. Secondly: Paediatricians usually know when a child is seriously ill, and what is the likely prognosis in terms of length of acute illness and subsequent progress. Thirdly: Paediatricians have a good idea which illnesses are likely to worry parents most and in which of these the worry may persist inappropriately.

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Fourthly: -and this is the point of the paper-undue preoccupation by both parents with their child‘s survival after an acute illness (at least in $child of two to five years) may later lead to intractable conduct disturbance in the child. Although not spelt out in this paper, other writers describe behavioural disturbances such as aggression, sleeplessness, headache and school phobia2. Such disturbances could possibly have been prevented if the paediatrician had been more alert to their aetiology. The illnesses discussed by SEAL and GAGNON are gastroenteritis, nephrosis and croup, but in the context of acute, alarming illness most paediatricians would also include asthma and convulsions. Perhaps we should go even further and instead of our usual almost blase approach to the handling of sick children, recognise afresh that to have a child ill in hospital is a major crisis for any family, disrupting the normal mechanics of family life, releasing strong emotions such as separation anxiety in everyone and fear, foreboding and even guilt in those left at home. Within the hospital, in addition to our fatal familiarity with illness, our problems largely are twofold : (a) ignorance of any particular family’s make-up and (b) a tendency to concentrate almost exclusively on the child’s present physical needs (apart from gestures in the dircction of mothers rooming in or play-ladies acting out). Maybe we should make it a practice as part of our history-taking to ask the parents whether they are worriers. Granted that some of them make the fact obvious, yet even then this may not register as a prognostic index for the child’s later emotional health when the crisis is past. To digress a little, that we ourselves can have a profound influence on parental attitudes i s illustrated in any ‘at risk‘ baby-clinic by the number of pre-term babies who have quadrupled their birth weight by five months. Weight has been the criterion for progress offered at every telephone call to the Special Care Baby Unit in the neonatal period, and still is the major yardstick to many. “He was a two pound prem”, was the excuse offered by a mother for helping her perfectly able nine-year-old son to undress. He was to her forever fragile, however huge. Thus, with the acutely ill child,unless we imprint the parents with appropriate attitudes at the time of the illness and when it is over, the long-term effects can be distressing to all of us. Our trouble is remembering to do our imprinting consciously, instead of leaving our frequent examinations, anxious frowns and huddled discussions to do it for us unconsciously. In a personal communication, Dr. R. Mac Keith writes: “I’ve always thought that the fact that mothers of asthmatic and epileptic children have often seen their child ‘dying’ may make them expect it to happen next time, and that these experiences are likely to affect their expectations and their management. I asked 70 mothers and children at the outpatient department whether they were frightened in the attacks of asthma and about 80 per cent of mothers said that they had been frightened and 65 per cent said that they had feared their child was dying. About 60 per cent of children said they had been frightened and 30 per cent said they had been frightened of dying: (there were a few children I thought it better not to ask).” The question raised by this is: did anyone realise at the time how scared they were? There is a secret school of thought which (unforgivably) argues that it is better to magnify than to minimise a child’s danger so that everyone is relieved when he improves and is not so shocked should he chance to die. However, too often we need prompting to mention at all how ill we think the child is, how long the illness will last and what we expect the outcome to be, so that unspoken fears may be met and their expression encouraged in both parents and (where appropriate) the child. If the admitting doctor is too junior to know all 95

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the answers, the senior should regard this as important a part of management as checking the drip rate. It can be, after all, preventive paediatrics. It may be obvious to us that we are dealing with “just another febrile fit”, but to a parent who has never heard of such an entity the child has just been at Heaven’s gate. As well as it being an act of charity to enlighten and forewarn about fevers and fits, such advice may also prevent many a sleepless night “listening for him breathing”, with subsequent disturbance in the parent-child equilibrium. We must also give parents repeated opportunities to express their worry. On admission they may be speechless with anxiety. An invitation to attend the consultant’s round may provide the necessary chance to open up, and will also give the paediatrician a chance to explore and expand parental understanding of the illness. Knowing which illnesses are most emotive will also help at this stage to curb future anxiety. It is worth spelling out the risks of over-protection and lax discipline that will now be undoubted temptations for parents, and the playing-up or clinging behaviour which may be temporarily expected in the child. Even though it may demand superhuman willpower to treat a recently ill child as ‘normal’, this should be our aim for the very near future. In conditions likely to recur, each recovery should be regarded as what we all expected. However, fears of future braindamage, of being a respiratory cripple and so on, should also be recognised and allowed opportunity of expression-and the fears should be met-both during the admission and at subsequent outpatient visits. There are many very sensible parents who regain balance and restore the child to normal family life with promptness and relief. There are others who take the discussion only partly to heart. One of these was the mother of a small survivor from meningococcal septicaemia, who closed the conversation with fine discrimination: “We don’t mind her being a bit spoilt, but we wouldn’t want her ruined.” At least these parents understood that the outcome largely rested with them. JANET GOODALL City General Hospital, Newcastle Road, Stoke-on-Trent ST4 6QG. REFERENCES 1. Sigal, J., Gagnon, P. (1975) ‘Effects of parents’ and pediatricians’ worry concerning severe gastroenteritis

in early childhood on later disturbances in the child’s behavior.’ Journal of Pediatrics, 87, 809. 2. Green, M., Solnit, A. (1964) ‘Reactions to the threatened loss of a child: a vulnerable child syndrome.’ Pediatrics, 34, 58.

“WE WOULD GREATLY APPRECIATE A COPY OF YOUR ARTICLE” WITH photocopying processes as simple as they are nowadays, automatized requests for reprints are obsolete and should stop. A request comes for a reprint of a ‘letter to the Editor’, 10 lines in length. Postage from the United States is 12 cents; postage back is 11 pence. Time taken is several weeks; the writer could have had a photocopy immediately. It is not only doctors who have this behavioural deviance-psychologists have it too. Of course it is flattering to be asked for a reprint, even though there may be only one request. Some authors order 500 or lo00 reprints which they mail around, but epoch-making

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Behaviour disorder: a preventable late sequel of illness in childhood.

DEVELOPMENTAL MEDICINE AND CHILD NEUROLOGY. 1976, 18 15. Remington, J. S., Miller, M. J., Brownlee, I. (1968) ‘IgM antibodies in acute toxoplasmosis...
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