890
2. Goodyer I, Taylor DC. Hysteria Arch Dis Child 1985; 60: 680-81. 3. Øster J. Recurrent abdominal pain, headache and limb pains in children and adolescents. Pediatrics 1972; 50: 429-36. 4. Hinman A. Conversion hysteria in childhood. Am J Dis Child 1958; 95: 42-45. 5. Lehmkuhl G, Blanz B, Lehmkuhl U, Braun-Scharm H. Conversion disorder (DSM-III 300.11): symptomatology and course in childhood and adolescence. Eur Arch Psychiat Neurol Sci 1989; 238: 155-60. 6. Leslie SA. Diagnosis and treatment of hysterical conversion reactions. Arch Dis Child 1988; 63: 506-11. 7. Maloney MD. Diagnosing hysterical conversion reacitons in children. J Pediatr 1980; 97: 1016-20. 8. Hersov L. Emotional disorders. In: Rutter M, Hersov L, eds. Child and adolescent psychiatry: modern approaches, Oxford: Blackwell, 1985: 368-81. 9. Schneider S, Rice DR. Neurologic manifestations of childhood hysteria. J Pediatr 1979; 94: 153-56. 10. Bangash H, Worley G, Kandt RS. Hysterical conversion reactions mimicking neurological disease. Am J Dis Child 1988; 142: 1203-06. 11. Spierings C, Poels PJE, Sijben N, Gabreëls FJM, Renier WO. Conversion disorders in childhood: a retrospective follow-up study of 84 patients. Dev Med Child Neurol 1990; 32: 865-71. 12. Steinhausen H-C, v. Aster M, Pfeiffer E, Gobel D. Comparative studies of conversion disorders in childhood and adolescence. J Child Psychol Psychiatry 1989; 30: 615-21. 13. Grattan-Smith P, Fairley M, Procopis P. Clinical features of conversion disorder. Arch Dis Child 1988; 63: 408-14. 14. Wyllie E, Friedman D, Rothner D, et al. Psychogenic seizures in children and adolescents: outcome after diagnosis by ictal video and electroencephalographic recording. Pediatrics 1990; 85: 480-84. 15. Thomson APJ, Sills JA. Diagnosis of functional illness presenting with gait disorder. Arch Dis Child 1988; 63: 148-53. 16. Dubowitz V, Hersov L. Management of children with non-organic (hysterical) disorders of motor function. Dev Med Child Neurol 1976; 18: 358-68. 17. Lesser RP. Psychogenic seizures. In: Pedley TA, Meldrum BS, eds. Recent advances in epilepsy 2. Edinburgh: Churchill Livingstone, 1985: 273-96. 18. Rivinus TM, Jamison DL, Graham PJ. Childhood organic neurological disease presenting as psychiatric disorder. Arch Dis Child 1975; 50: 115-19.
Child sexual abuse and the limits of
responsibility Child sexual abuse is not a subject that readily lends itself to clearcut guidelines. Considerable sympathy for those who zealously attempt to root out practices that offend our deepest moral sensibilities is matched by equally strong feelings about the disruption of normal happy families on the strength of unsubstantiated evidence. Small wonder that social workers involved in such cases seek refuge in apparent certainties-eg, the dogma that what children report can be regarded as the literal truth or the belief that there are irrefutable physical signs of abuse that can be demonstrated by adequately trained paediatricians. The latter assumption is critically examined in a report launched this week by the Royal College of Physicians.1 The report, compiled for the guidance of the College’s paediatrician members, will serve as a useful vade-mecum for inexperienced doctors who become enmeshed in the investigation of abuse. The working party have produced a succinct, practical document, although the clear line diagrams might have been usefully supplemented by colour photographs. They make clear that medical evidence in most cases can by itself neither exclude nor establish the diagnosis with certainty. Nevertheless, such evidence will often help if taken together with other
information on the child and his or her family. This view was likewise propounded in the Butler-Sloss report that followed the Cleveland sexual abuse
episode.2 If there is no way of arriving at legal certainty in suspected abuse cases, what are social workers to do to fulfil their responsibilities-which are as much or more to society at large as to their clients and clients’ families? More training, more inquiries and reports, and more scolding by the press are unlikely to help. Surely the time has come to take another look not at what individual social workers (or doctors) do or fail to do but at the setting and the way in which they operate. Although we have a right-even a duty-to intervene in very private matters if moral conventions are being overturned, we should think carefully about the appropriate balance between protecting children and allowing families the moral space in which to live their own lives in their own way without snooping, surveillance, or arbitrary interference. In striking such a balance society must necessarily come down on the side of supporting what is healthy rather than rooting out what is diseased. The recommendations of the Butler-Sloss inquiry cannot but command assent, but errors of commission and omission are still made and often fly in the face of common sense rules of thumb—eg, that the abused are likely to become abusers, that step-fathers may not feel bound by the semi-indestructible prohibition of incest that applies in "ordinary" families, and that concerns of neighbours and teachers should not be abandoned in favour of abstract theories. Moreover, what merit can there be in taking drastic acute action-to the extent of plucking screaming children from their homes-in response to a chronic series of events? There are serious fears about the manner in which administrative procedures to deal with child sexual abuse have evolved. In the UK, much hinges on the case conference, at which the participants examine the evidence that abuse is taking place and decide what action is necessary. At such conferences the accused and the accuser are seldom heard in person; the "judge" may be the probation officer; and crucial evidence of neighbours and school teachers tends to be obtained second hand. It may now be timely to introduce a system, as practised in some European countries, in which the key figure is the examining magistrate. Hearings could be held in camera, and the magistrate would have the power to subpoena and examine witnesses (including accuser and accused), to enforce decisions, and to take the case to court if necessary. One thing is clear, we have struggled long enough with the existing system to acknowledge that it cannot be made to work effectively in a large proportion of cases. Royal College of Physicians. Physical signs of sexual abuse in children. London: RCP, 1991. 2. Report of the Inquiry into Child Abuse in Cleveland 1987. London. HM Stationery Office, 1988. 1.
2. Goodyer I, Taylor DC. Hysteria Arch Dis Child 1985; 60: 680-81. 3. Øster J. Recurrent abdominal pain, headache and limb pains in children and adolescents. Pediatrics 1972; 50: 429-36. 4. Hinman A. Conversion hysteria in childhood. Am J Dis Child 1958; 95: 42-45. 5. Lehmkuhl G, Blanz B, Lehmkuhl U, Braun-Scharm H. Conversion disorder (DSM-III 300.11): symptomatology and course in childhood and adolescence. Eur Arch Psychiat Neurol Sci 1989; 238: 155-60. 6. Leslie SA. Diagnosis and treatment of hysterical conversion reactions. Arch Dis Child 1988; 63: 506-11. 7. Maloney MD. Diagnosing hysterical conversion reacitons in children. J Pediatr 1980; 97: 1016-20. 8. Hersov L. Emotional disorders. In: Rutter M, Hersov L, eds. Child and adolescent psychiatry: modern approaches, Oxford: Blackwell, 1985: 368-81. 9. Schneider S, Rice DR. Neurologic manifestations of childhood hysteria. J Pediatr 1979; 94: 153-56. 10. Bangash H, Worley G, Kandt RS. Hysterical conversion reactions mimicking neurological disease. Am J Dis Child 1988; 142: 1203-06. 11. Spierings C, Poels PJE, Sijben N, Gabreëls FJM, Renier WO. Conversion disorders in childhood: a retrospective follow-up study of 84 patients. Dev Med Child Neurol 1990; 32: 865-71. 12. Steinhausen H-C, v. Aster M, Pfeiffer E, Gobel D. Comparative studies of conversion disorders in childhood and adolescence. J Child Psychol Psychiatry 1989; 30: 615-21. 13. Grattan-Smith P, Fairley M, Procopis P. Clinical features of conversion disorder. Arch Dis Child 1988; 63: 408-14. 14. Wyllie E, Friedman D, Rothner D, et al. Psychogenic seizures in children and adolescents: outcome after diagnosis by ictal video and electroencephalographic recording. Pediatrics 1990; 85: 480-84. 15. Thomson APJ, Sills JA. Diagnosis of functional illness presenting with gait disorder. Arch Dis Child 1988; 63: 148-53. 16. Dubowitz V, Hersov L. Management of children with non-organic (hysterical) disorders of motor function. Dev Med Child Neurol 1976; 18: 358-68. 17. Lesser RP. Psychogenic seizures. In: Pedley TA, Meldrum BS, eds. Recent advances in epilepsy 2. Edinburgh: Churchill Livingstone, 1985: 273-96. 18. Rivinus TM, Jamison DL, Graham PJ. Childhood organic neurological disease presenting as psychiatric disorder. Arch Dis Child 1975; 50: 115-19.
Child sexual abuse and the limits of
responsibility Child sexual abuse is not a subject that readily lends itself to clearcut guidelines. Considerable sympathy for those who zealously attempt to root out practices that offend our deepest moral sensibilities is matched by equally strong feelings about the disruption of normal happy families on the strength of unsubstantiated evidence. Small wonder that social workers involved in such cases seek refuge in apparent certainties-eg, the dogma that what children report can be regarded as the literal truth or the belief that there are irrefutable physical signs of abuse that can be demonstrated by adequately trained paediatricians. The latter assumption is critically examined in a report launched this week by the Royal College of Physicians.1 The report, compiled for the guidance of the College’s paediatrician members, will serve as a useful vade-mecum for inexperienced doctors who become enmeshed in the investigation of abuse. The working party have produced a succinct, practical document, although the clear line diagrams might have been usefully supplemented by colour photographs. They make clear that medical evidence in most cases can by itself neither exclude nor establish the diagnosis with certainty. Nevertheless, such evidence will often help if taken together with other
information on the child and his or her family. This view was likewise propounded in the Butler-Sloss report that followed the Cleveland sexual abuse
episode.2 If there is no way of arriving at legal certainty in suspected abuse cases, what are social workers to do to fulfil their responsibilities-which are as much or more to society at large as to their clients and clients’ families? More training, more inquiries and reports, and more scolding by the press are unlikely to help. Surely the time has come to take another look not at what individual social workers (or doctors) do or fail to do but at the setting and the way in which they operate. Although we have a right-even a duty-to intervene in very private matters if moral conventions are being overturned, we should think carefully about the appropriate balance between protecting children and allowing families the moral space in which to live their own lives in their own way without snooping, surveillance, or arbitrary interference. In striking such a balance society must necessarily come down on the side of supporting what is healthy rather than rooting out what is diseased. The recommendations of the Butler-Sloss inquiry cannot but command assent, but errors of commission and omission are still made and often fly in the face of common sense rules of thumb—eg, that the abused are likely to become abusers, that step-fathers may not feel bound by the semi-indestructible prohibition of incest that applies in "ordinary" families, and that concerns of neighbours and teachers should not be abandoned in favour of abstract theories. Moreover, what merit can there be in taking drastic acute action-to the extent of plucking screaming children from their homes-in response to a chronic series of events? There are serious fears about the manner in which administrative procedures to deal with child sexual abuse have evolved. In the UK, much hinges on the case conference, at which the participants examine the evidence that abuse is taking place and decide what action is necessary. At such conferences the accused and the accuser are seldom heard in person; the "judge" may be the probation officer; and crucial evidence of neighbours and school teachers tends to be obtained second hand. It may now be timely to introduce a system, as practised in some European countries, in which the key figure is the examining magistrate. Hearings could be held in camera, and the magistrate would have the power to subpoena and examine witnesses (including accuser and accused), to enforce decisions, and to take the case to court if necessary. One thing is clear, we have struggled long enough with the existing system to acknowledge that it cannot be made to work effectively in a large proportion of cases. Royal College of Physicians. Physical signs of sexual abuse in children. London: RCP, 1991. 2. Report of the Inquiry into Child Abuse in Cleveland 1987. London. HM Stationery Office, 1988. 1.
