737 useful technique for identifying high risk areas or groups of children as a first step in preventive action". They concentrated on two aspects of the child’s social environment-the neighbourhood and the school. In their investigation of neighbourhood factors the researchers were unhappy about confining themselves to the electoral wards as units to be studied, because of the lack of homogeneity within a particular ward. They rather cannily, therefore, took enumeration districts (each containing about 400 households) as their units, and using cluster analysis grouped them into twenty-two clusters which were homogeneous for social and demographic factors. There was a very wide range of variation amongst the clusters, both in child-guidance and

delinquency rates (the two rates co-varying). High rates were associated with high density of population, low proportion of owner-occupied houses, and high proportion of social classes iv and v. At first sight there was nothing surprising in these findings, but closer scrutiny revealed something very interesting: the inter-cluster variation in child-guidance rates proved to be as extensive within each social-class group as within the sample as a whole. It looks, therefore, as though the district of residence can exert an influence quite independent of the social class of the child’s family. In Manchester, Reade3found that schools whose headmasters attached importance to establishing contact with the children’s families had a lower rate of delinquency than did other schools. The Croydon research, similarly, showed the schools as exercising an influer....:e on child-guidance and delinquency rates irrespective of neighbourhood factors: "Disparities between neighbouring schools were so large as to suggest that major factors must operate within the individual school". Here the question arises; to what extent does the Croydon study support Government policy for child-guidance services as outlined in the circular on child guidance? The circular is in fact less clear about the precise course of action proposed, but its message, in short, seems to be that, firstly, child-guidance clinics M at present constituted should be dismantled, and their various personnel should be returned to their parent disciplines; and that, subsequently, a cooperative network should evolve composed of the relevant services-educational psychology, social work, child psychiatry-in collaboration with child-health services. "The inter-disciplinary approach to children with behavioural disorders must not remain something that is practised only by a few from a single platform but become a way of life for all professionals specialising in services for children."4 The principal function of this network of services would be to extend the contact of child-guidance workers with teachers, general practitioners, health visitors, and others already engaged in front-line work with children. In theory, this would facilitate the earlier detection of children in difficulties, and would make help more readily available to a greater number. Clearly a radical reorganisation on these lines cannot be justified unless we can be sure it will reduce the rates of maladjustment and delinquency. The Gath study raises the suspicion that the mooted reorganisation would on its own turn out to be ineffectual: whatever 3.

Reade, A. W. Cited by Gath et al.1 4. Whitmore, K. The Contribution of Child Guidance Mind: occasional paper 2, 1974.

to

the

Community.

the changes in structure, the child-guidance system would be incapable of taking on problems relating directly to school or neighbourhood conditions. A more circumspect strategy would be to maintain the status quo whilst expediting more research into key factorsthe results, for example, of extending child-guidance contact with school and other front-line areas; and the exact features in both school and neighbourhood leading to, or militating against, maladjustment and delinquency. Without further mixed operational and epidemiological research of the Croydon type, it would be premature to embark on a major reorganisation of childguidance services to deal with what may turn out to be primarily environmental and educational concerns.

HALO-PELVIC DISTRACTION EVEN when

carefully moulded, plaster casts, jackets, spinal supports do not hold the neck or trunk securely after correction of a spinal deformity. Skeletal traction by skull callipers has been used for the cervical spine but this is only effective in one plane. In order to realign deformities associated with cervical muscle paralysis a system was devised to provide adjustable control in

or

three dimensions. Secure attachment to the skull was achieved with a metal ring called a halo, fixed by threaded pins. This was then suspended by an adjustable frame attached to a plaster jacket. The splint subsequently found wider use, in the treatment of cervical fractures and deformities of the dorsal and lumbar region : a hoop was fixed to the pelvis by two threaded rods drilled through the iliac wings in an antero-posterior direction and connected by means of four turnbuckles on upright strips of metal to the halo, thus producing the halo-pelvic distraction apparatus.2 Advantages of this technique have been early ambulation instead of months of recumbency; there is no restriction of chest movement (an important feature in scoliotic patients with reduced respiratory function) and surgical access to the front and back of the trunk is easy. Kalamchi et awl. report results with the halo-pelvic distraction apparatus in 150 consecutive patients. The average age was 15.5years (range 3’5—26-3) and the apparatus was in place for an average of 29 weeks. Diagnoses included tuberculous kyphosis and paralytic, idiopathic, and congenital scoliosis. Although the average correction of kyphotic tuberculous spines was only 20%, appearances improved, the disease was eradicated, and further progression was prevented by sound spinal fusion. With paralytic scoliosis a 46% correction was obtained and the apparatus was also effective in holding and correcting severe congenital curves. Early in the series the complication-rate was high but it fell with experience. The most disastrous complication is paraplegia. No patient in this series suffered permanent spinal-cord injury, but 11 had paraparesis and spasticity. Other neurological complications were neurapraxia of the sixth and tenth cranial nerves, brachial-plexus palsies, and irritation of the lateral cutaneous nerve of the thigh. Halo-pelvic distraction is of great value in the treatment of severe spinal deformities, but it should be applied under careful supervision. 1. 2. 3.

Perry, J., Nickel, V. L. J. Bone Jt Surg. 1959, 41A, 37. Dewald, R. L., Ray, R. D. ibid. 1970, 52A, 233. Kalamchi, A., Jau, A. C. M. C., O’Brien, J. P., Hodgson, A. R. ibid. 1976, 58A, 119.

Halo-pelvic distraction.

737 useful technique for identifying high risk areas or groups of children as a first step in preventive action". They concentrated on two aspects of...
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