889
Overall, therefore, it seems that salpingostomy is heading for obsolescence, although there will still be a need for tubal surgeons with microsurgical skills for indications. This type of surgery should be to tertiary referral centres where sufficient experience will accrue to audit the results and compare them with the outcome of IVF.
specific
confined
1. Lilford RJ, Dalton ME. Effectiveness of treatment for infertility. Br Med
J 1987; 295: 609. 2. Bromwich P, Walker A, Kennedy S, et al. In vitro fertilisation in a small unit in the NHS. Br Med J 1988; 296: 759-61. 3. Dubois M, Stassen M, Hircourt M, et al. Comparison between micro-surgery and IVF in the treatment of tubal infertility. Hum Rep
1987; 2: 82-83. Hassiakos DK, Damewood MD, Rock JA. Neosalpingostomy for distal tubal obstruction: prognostic factors and impact of surgical technique. Fertil Steril 1990; 54: 984-90. 5. Watson AJS, Gupta JK, O’Donovan P, Dalton ME, Lilford RJ. The results of tubal surgery in the treatment of infertility in two non-specialist hospitals. Br J Obstet Gynaecol 1990; 97: 561-68. 6. Laatikainen TJ, Tenhunen AK, Venesmaa PK, Apter DL. Factors influencing the success of microsurgery for distal tubal occlusion. Arch Gynecol Obstet 1988; 243: 101-06. 7. Fifth report of the Interim Licensing Authority for In Vitro Fertilisation and Embryology 1990. Human Fertilisation & Embryology Authority, Clements House, 14-18 Gresham Street, London EC2V 7JE. 8. Daniell JF, Diamond MP, McLaughlin DS, et al. Clinical results of terminal salpingostomy with the use of the CO2 laser: report of the intra-abdominal laser study group. Fertil Steril 1986; 45: 175-78. 9. Dubuisson JB, Bouquet de Joiniere J, Aubriot FX, et al. Terminal tuboplasties by laparoscopy: 65 consecutive cases. Fertil Steril 1990; 54:
4. Schlaff WD,
401-03. 10. Lilford RJ, Watson
AJ. Commentary: has in vitro fertilization made salpingostomy obsolete? Br J Obstet Gynaecol 1990; 97: 557-60.
Neurological conversion disorders in childhood Conversion disorders
can
be
regarded as forms of
or as enactments of sickness2 that in present response to a predicament of which the resolution is beyond the patient’s control. Abdominal or limb pains and headaches occur without apparent organic cause in up to 20% of schoolchildren,3 but account for only 0-3% of admissions to a general paediatric hospital.The reported prevalence of conversion disorders varies from 0-5 to 10% in childhood psychiatric clinics,s°6 and is 16-7% in paediatric inpatients who are referred to psychiatrists.’That symptoms referrable to the central nervous system are the main presenting features in childhood8 accords with the observation that 65% of children seen for conversion disorders by the psychiatric service in a hospital with an active paediatric neurology department had had previous contact with neurologists.6 About 2% of paediatric neurological referrals are for conversion disorders.9,10 The most usual presentations are episodic loss of awareness such as pseudoseizures and syncope; motor dysfunction, including gait disturbances and pareses; and sensory abnormalities, mainly pain and numbness or disorders of the special senses.l,5--7,9-13 Headaches, dizziness,
body language1
sleep difficulties, eating disorders, vomiting, hiccups,
psychogenic cough, and tremors are common accompanying complaints. 11,13,14 Multiple organ systems are often involved, especially in older children.5 The most important component of assessment is observation of the child during day-today activities. This can be supplemented by videoelectroencephalography and serum prolactin measurements if pseudoseizures are suspected; by the mirror test for blindness; by Hoover’s sign when a leg is paralysed; by holding the hand over the face and letting it go, in upper limb paresis; and by sensory mapping which, in conversion disorders, reveals sharply demarcated borders that do not cross the midline or follow dermatomes.9,10 In most cases
some
investigations for organic disorder are appropriate, but such tests should be strictly limited. Non-specific electroencephalographic changes are common 5,10,11,13 and can make differentiation between epileptic seizures and pseudoseizures very difficult, especially when these conditions coexist. Conversion disorders are extremely rare in children younger than 6 years.4,5,7,9,11,13 The sex ratio is equal under the age of 10, but in adolescence females predominate in ratios up to 3:1.4-9,11-14 Pre-existing or co-existing organic disease does not preclude the presence of a conversion disorder ,11,13,15,.16 and in many cases an infection or other incident seems to trigger illness behaviour.2,6,11,16 It may be hard to identify the underlying predicament. Conventional mental state examination may not be helpful, since many of the children do not have a formal mental disorder.22 Family difficulties are often covert.5,9,13,15 A close family or social associate often acts as a model for the symptoms,7,11-13 and grief reaction is a very important precipitant.Family disharmony is common, but not more so than in other children attending psychiatric clinics.5,7 Incestuous relationships and other forms of sexual abuse are said to be precipitants of pseudoseizures in particular.13,14,17 Other stresses that have been identified are academic failure and peer conflicts.56 Once a conversion disorder is suspected, combined and neurological care and investigation allow options for diagnosis and early treatment in either or both areas.1,16,18 Up to 46% of children in a psychiatric serviceand 6% of those initially thought by paediatric neurologists to have conversion disorders 1,11,18 are found later to have organic explanations for their symptoms. Abnormalities of posture and deterioration in schoolwork are strong indicators of neurological abnormalities.18 Spinal cord tumours, epileptic seizures, and neurodegenerative diseases, especially juvenile neuronal ceroid lipofuscinosis, are the conditions most likely to be misdiagnosed as conversion disorders.10,11,18
psychiatric
1. Maisami
M, Freeman JM. Conversion reactions in children as body language: a combined child psychiatry/neurology team approach to the management of functional neurologic disorders in children. Pediatrics 1987; 80: 46-52.
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.
Overall, therefore, it seems that salpingostomy is heading for obsolescence, although there will still be a need for tubal surgeons with microsurgical skills for indications. This type of surgery should be to tertiary referral centres where sufficient experience will accrue to audit the results and compare them with the outcome of IVF.
specific
confined
1. Lilford RJ, Dalton ME. Effectiveness of treatment for infertility. Br Med
J 1987; 295: 609. 2. Bromwich P, Walker A, Kennedy S, et al. In vitro fertilisation in a small unit in the NHS. Br Med J 1988; 296: 759-61. 3. Dubois M, Stassen M, Hircourt M, et al. Comparison between micro-surgery and IVF in the treatment of tubal infertility. Hum Rep
1987; 2: 82-83. Hassiakos DK, Damewood MD, Rock JA. Neosalpingostomy for distal tubal obstruction: prognostic factors and impact of surgical technique. Fertil Steril 1990; 54: 984-90. 5. Watson AJS, Gupta JK, O’Donovan P, Dalton ME, Lilford RJ. The results of tubal surgery in the treatment of infertility in two non-specialist hospitals. Br J Obstet Gynaecol 1990; 97: 561-68. 6. Laatikainen TJ, Tenhunen AK, Venesmaa PK, Apter DL. Factors influencing the success of microsurgery for distal tubal occlusion. Arch Gynecol Obstet 1988; 243: 101-06. 7. Fifth report of the Interim Licensing Authority for In Vitro Fertilisation and Embryology 1990. Human Fertilisation & Embryology Authority, Clements House, 14-18 Gresham Street, London EC2V 7JE. 8. Daniell JF, Diamond MP, McLaughlin DS, et al. Clinical results of terminal salpingostomy with the use of the CO2 laser: report of the intra-abdominal laser study group. Fertil Steril 1986; 45: 175-78. 9. Dubuisson JB, Bouquet de Joiniere J, Aubriot FX, et al. Terminal tuboplasties by laparoscopy: 65 consecutive cases. Fertil Steril 1990; 54:
4. Schlaff WD,
401-03. 10. Lilford RJ, Watson
AJ. Commentary: has in vitro fertilization made salpingostomy obsolete? Br J Obstet Gynaecol 1990; 97: 557-60.
Neurological conversion disorders in childhood Conversion disorders
can
be
regarded as forms of
or as enactments of sickness2 that in present response to a predicament of which the resolution is beyond the patient’s control. Abdominal or limb pains and headaches occur without apparent organic cause in up to 20% of schoolchildren,3 but account for only 0-3% of admissions to a general paediatric hospital.The reported prevalence of conversion disorders varies from 0-5 to 10% in childhood psychiatric clinics,s°6 and is 16-7% in paediatric inpatients who are referred to psychiatrists.’That symptoms referrable to the central nervous system are the main presenting features in childhood8 accords with the observation that 65% of children seen for conversion disorders by the psychiatric service in a hospital with an active paediatric neurology department had had previous contact with neurologists.6 About 2% of paediatric neurological referrals are for conversion disorders.9,10 The most usual presentations are episodic loss of awareness such as pseudoseizures and syncope; motor dysfunction, including gait disturbances and pareses; and sensory abnormalities, mainly pain and numbness or disorders of the special senses.l,5--7,9-13 Headaches, dizziness,
body language1
sleep difficulties, eating disorders, vomiting, hiccups,
psychogenic cough, and tremors are common accompanying complaints. 11,13,14 Multiple organ systems are often involved, especially in older children.5 The most important component of assessment is observation of the child during day-today activities. This can be supplemented by videoelectroencephalography and serum prolactin measurements if pseudoseizures are suspected; by the mirror test for blindness; by Hoover’s sign when a leg is paralysed; by holding the hand over the face and letting it go, in upper limb paresis; and by sensory mapping which, in conversion disorders, reveals sharply demarcated borders that do not cross the midline or follow dermatomes.9,10 In most cases
some
investigations for organic disorder are appropriate, but such tests should be strictly limited. Non-specific electroencephalographic changes are common 5,10,11,13 and can make differentiation between epileptic seizures and pseudoseizures very difficult, especially when these conditions coexist. Conversion disorders are extremely rare in children younger than 6 years.4,5,7,9,11,13 The sex ratio is equal under the age of 10, but in adolescence females predominate in ratios up to 3:1.4-9,11-14 Pre-existing or co-existing organic disease does not preclude the presence of a conversion disorder ,11,13,15,.16 and in many cases an infection or other incident seems to trigger illness behaviour.2,6,11,16 It may be hard to identify the underlying predicament. Conventional mental state examination may not be helpful, since many of the children do not have a formal mental disorder.22 Family difficulties are often covert.5,9,13,15 A close family or social associate often acts as a model for the symptoms,7,11-13 and grief reaction is a very important precipitant.Family disharmony is common, but not more so than in other children attending psychiatric clinics.5,7 Incestuous relationships and other forms of sexual abuse are said to be precipitants of pseudoseizures in particular.13,14,17 Other stresses that have been identified are academic failure and peer conflicts.56 Once a conversion disorder is suspected, combined and neurological care and investigation allow options for diagnosis and early treatment in either or both areas.1,16,18 Up to 46% of children in a psychiatric serviceand 6% of those initially thought by paediatric neurologists to have conversion disorders 1,11,18 are found later to have organic explanations for their symptoms. Abnormalities of posture and deterioration in schoolwork are strong indicators of neurological abnormalities.18 Spinal cord tumours, epileptic seizures, and neurodegenerative diseases, especially juvenile neuronal ceroid lipofuscinosis, are the conditions most likely to be misdiagnosed as conversion disorders.10,11,18
psychiatric
1. Maisami
M, Freeman JM. Conversion reactions in children as body language: a combined child psychiatry/neurology team approach to the management of functional neurologic disorders in children. Pediatrics 1987; 80: 46-52.
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.
