- Email: [email protected]
Adolescent health: an opportunity not to be missed
Correspondence
*Rob Butler, James Wainwright
Pratima Jain
[email protected]
[email protected]
*Department of Cardiology, City General Hospital, University Hospital of North Staffordshire, Stoke on Trent ST4 6QG, UK (RB); Keele University, Keele, UK (JW)
Public Health Department, West Midland Deanery, Bloxwich Lane, Walsall WS2 7JL, UK
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Science Photo Library
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The printed journal includes an image merely for illustration
Moon JC, Bogle RG, Minas R. Statins audit: wrong question, wrong conclusions. Lancet 2007; 369: 640. Butler R, Wainwright J. Cholesterol lowering in patients with CHD and metabolic syndrome. Lancet 2007; 369: 27. Thomas M, Mann J. Increased thrombotic vascular events after change of statin. Lancet 1998; 352: 1830–31. Wiviott SD, de Lemos JA, Cannon CP, et al. A tale of two trials: a comparison of the postacute coronary syndrome lipid-lowering trials A to Z and PROVE IT-TIMI 22. Circulation 2006; 113: 1406–14. Waters DD. Safety of high-dose atorvastatin therapy. Am J Cardiol 2005; 96: 69F–75F.
ADHD: from childhood to adulthood Your editorial (March 17, p 880)1 rightly highlights the increased diagnosis and medical treatment of attention-deficit hyperactivity disorder (ADHD). However, it is important to highlight concerns related to this disorder that were not addressed in the editorial. ADHD is fast becoming one of the most commonly diagnosed behavioural disorders in children and young people2 that can persist into adulthood.3 The biggest concern is what happens to children who still need treatment in adolescence and adulthood. Who should provide this care? Should it be the paediatrician, or a paediatric psychologist or psychiatrist, or should their treatment be transferred to an adult psychologist or psychiatrist? The need for referral to an adult psychiatrist raises the issue of appropriate diagnosis. Also, does a patient who has grown up with ADHD have a behavioural problem or a mental illness? Health professionals must be aware of the far-reaching repercussions of diagnosing and treating ADHD, including its secondary effects at later stages in a person’s life. I declare that I have no conflict of interest.
1788
1
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The Lancet. Promoting optimum management for ADHD. Lancet 2007; 369: 880. Attention deficient and hyperkinetic disorder in children and young people: a national guideline. Scottish intercollegiate network, 2001. http://www.sign.ac.uk/pdf/sign52.pdf (accessed April 25, 2007). Spencer TJ, Biederman J, Mick E. Attentiondeficit/hyperactivity disorder: diagnosis, lifespan, comorbidities, and neurobiology. Ambul Pediatr 2007; 7 (suppl 1): 73–81.
Adolescent health: an opportunity not to be missed We support your effort to raise the issue of adolescent health and to strive for youth-friendly health services worldwide. But to state that “little progress has been made in the past 4 years” (March 31, p 1057)1 fails to recognise some important steps. Within the UK we have recognised the importance of a multidisciplinary, multifaceted approach to adolescent health. This was set out in the National Service Framework for Children and Maternity Services2 and the Public Health White Paper, “Choosing Health”.3 Hence we should use the normal activities within young people’s lives as opportunities to improve their health. The Healthy Schools Programme is recruiting all schools in England to offer a strong focus on emotional health and wellbeing: a programme of personal, social, and health education alongside physical activity programmes and healthy eating. We are on track to recruit 55% of all schools to the programme by December, 2007, and all schools by 2009. Through the Extended Schools programme, schools are providing such services as health drop-ins and wider sports activities for young people. Through implementing the “You’re Welcome” criteria,4 health
services are starting to improve the quality of their provision to make them more young-people friendly. Managing more effective transitions from adolescent to adult services is a key component within the National Service Framework and we are supporting a programme of development in this area, supported by Royal Colleges and the Care Services Improvement Partnership. We are also funding four Teenage Health Demonstration sites in Portsmouth, Hackney, Bolton, and Northumberland to assess how effectively they can improve the information, advice, and service offered to young people in a range of different settings. Through these sites we are also looking at how better to support young people with chronic disorders (a key issue raised in the fifth paper in your series5). To ensure further sustainability and improvement, we are funding the Royal College of Paediatrics and Child Health to produce an intercollegiate postgraduate training programme in adolescent health. This will mean that in the future any doctor or nurse working with adolescents will know how to do so more effectively. We are also supporting the College in establishment of a special interest group in adolescent health. Alongside that, we are funding the National Youth Agency to identify the health standards that need to be part of all youth workers’ training—these will then be a part of every undergraduate and postgraduate training programme and of within national vocational qualifications. We hope and expect that this coordinated, long-term effort will contribute significantly to the change that we are all striving to achieve. I declare that I have no conflict of interest.
Sheila Shribman [email protected] National Clinical Director for Children, Young People and Maternity Services, Room 153, Department of Health, 79 Whitehall, London SW1A 2NL, UK
www.thelancet.com Vol 369 May 26, 2007
Correspondence
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Kleinert S. Adolescent health: an opportunity not to be missed. Lancet 2007; 369: 1057–58. Department of Heath. National Service Framework documents. http://www.dh.gov. uk/en/Policyandguidance/Healthandsocialcare topics/ChildrenServices/Childrenservicesinfor mation/DH_4089111 (accessed May 9, 2007). Department of Health. Choosing health: making healthy choices easier. http://www. dh.gov.uk/en/Publicationsandstatistics/ Publications/PublicationsPolicyAndGuidance/ DH_4094550 (accessed May 9, 2007). Department of Health. You’re Welcome quality criteria: making health services young people friendly. http://www.dh.gov.uk/en/Publication sandstatistics/Publications/PublicationsPolicy AndGuidance/DH_073586 (accessed May 9, 2007). Sawyer SM, Drew S, Yeo MS, Britto MT. Adolescents with a chronic condition: challenges living, challenges treating. Lancet 2007; 369: 1481–89.
A code of ethics for scientists As Ching Ling Pang notes (March 31, p 1068),1 codes of conduct and ethics for scientists have been formulated in recent years, with Sir David King’s the most recent. To be useful, such codes need to be effectively enforced, and it might indeed be necessary to add another “R” to Sir David’s “rigour, respect and responsibility”—restrict. In medicine, research on biotechnology can help to prevent epidemics or to create biological weapons; on neuroscience, to better understand mental illness or for chemical weapons; on genomics, to understand the genetic basis of disease or to investigate the possibility of ethnic weapons.2 Eminent scientists, including Nobel laureates and past and present Presidents of the UK’s Royal Society,3–5 have suggested that limits to scientific research might be unavoidable. Such considerations should be part of the remit of local and national ethics committees, and ethics committees should be attached to the Organization for the Prohibition of Chemical Weapons and to proposed similar back-up bodies for the Biological and Toxin Weapons Convention and the (proposed) Nuclear Weapons Convention. To be www.thelancet.com Vol 369 May 26, 2007
effective they should be given access to the International Criminal Court and the United Nations Security Council. I declare that I have no conflict of interest.
Douglas Holdstock [email protected] Medact, The Grayston Centre, 28 Charles Square, London N1 6HT, UK 1 2
3
4
5
Pang CL. A code of ethics for scientists. Lancet 2007; 369: 1068. Holdstock D. Chemical and biological warfare: some ethical dilemmas. Camb Q Healthcare Ethics 2006; 15: 356–65. Atiyah M. The social responsibility of scientists. In: Bruce M, Milne T. Ending war: the force of reason. Houndmills: Macmillan, 1999: 151–64. Rotblat J. Remember your humanity. In: Bruce M, Milne T. Ending war: the force of reason. Houndmills: Macmillan, 1999: 165–71. Rees M. Our final century: will the human race survive the twenty-first century? London: Heinemann, 2003: 73–88.
research reveals is that the youngest women are the ones with a recurrent pattern of heavy drinking in particular group settings in which unprotected sex is also likely to proceed.5 The women most at risk also seem to be those with low “health literacy” with respect to alcohol use and reproductive health. Their formative experiences of intercourse are likely to be in early adolescence, while drunk; for some young people, exploitative or abusive relationships also become associated with this pattern. Unsafe sex, of course, also causes pregnancy. A complex chain of events can cause fetal alcohol effects. I am an honorary consultant at Essex Children’s Trust.
Woody Caan [email protected] Anglia Ruskin University, Cambridge CB1 1PT, UK 1
Remember the links in the causal chain of fetal alcohol effects Raja Mukherjee and colleagues (Apr 7, p 1149)1 are to be commended for recognising the need for a sustained and scientific public health debate on hazardous alcohol use in pregnancy. Potentially there is a constellation of effects of fetal alcohol exposure: on child development, on attachment to parents, and on wider patterns of relationships and resilience that only emerge during the school years.2,3 The iconic features listed in Mukherjee and colleagues’ panel seem to represent an atypical presentation: low birthweight, maternal depression and self-harm, malnutrition and child neglect, and social isolation or homelessness might, for professionals, obscure the developmental problems they do see in many families. The key challenge to understanding (and reducing) risks to health from alcohol is to explore both upstream and downstream links to dangerous drinking behaviour, and the explicit context in which a person is most exposed to risk.4 What community
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Mukherjee R, Eastman N, Turk J, Hollins S. Fetal alcohol syndrome: law and ethics. Lancet 2007; 369: 1149–50. Caan W. Being of sound mind, in the beginning… Mental Health Promotion Update 2005; 2: 13–15. Booth KJ, Caan W. Poverty and mental health. BMJ 2005; 330: 307. Caan W, Hillier D. How do we perceive risks? In: Hillier D, ed. Communicating health risks to the public: a global perspective. Aldershot: Gower Publishing, 2006. McMunn V, Caan W. Chlamydia infection, alcohol and sexual behaviour in women. Br J Midwifery 2007; 15: 221–24.
Pelvic organ prolapse: don’t forget developing countries Although pelvic organ prolapse is a significant problem in affluent countries (March 24, p 1027),1 the situation in developing countries is far worse. This is mainly a result of high fertility with early marriage and childbearing, many vaginal deliveries, and in certain countries such as Nepal, frequent heavy lifting.2 In Nepal, fertility until recently was very high and most deliveries take place at home, with only 14% in a health facility and less than 3% by caesarean section.3 In developing countries, the extent and effects of morbidity associated 1789
*Rob Butler, James Wainwright
Pratima Jain
[email protected]
[email protected]
*Department of Cardiology, City General Hospital, University Hospital of North Staffordshire, Stoke on Trent ST4 6QG, UK (RB); Keele University, Keele, UK (JW)
Public Health Department, West Midland Deanery, Bloxwich Lane, Walsall WS2 7JL, UK
1
2
2
3
4
Science Photo Library
5
The printed journal includes an image merely for illustration
Moon JC, Bogle RG, Minas R. Statins audit: wrong question, wrong conclusions. Lancet 2007; 369: 640. Butler R, Wainwright J. Cholesterol lowering in patients with CHD and metabolic syndrome. Lancet 2007; 369: 27. Thomas M, Mann J. Increased thrombotic vascular events after change of statin. Lancet 1998; 352: 1830–31. Wiviott SD, de Lemos JA, Cannon CP, et al. A tale of two trials: a comparison of the postacute coronary syndrome lipid-lowering trials A to Z and PROVE IT-TIMI 22. Circulation 2006; 113: 1406–14. Waters DD. Safety of high-dose atorvastatin therapy. Am J Cardiol 2005; 96: 69F–75F.
ADHD: from childhood to adulthood Your editorial (March 17, p 880)1 rightly highlights the increased diagnosis and medical treatment of attention-deficit hyperactivity disorder (ADHD). However, it is important to highlight concerns related to this disorder that were not addressed in the editorial. ADHD is fast becoming one of the most commonly diagnosed behavioural disorders in children and young people2 that can persist into adulthood.3 The biggest concern is what happens to children who still need treatment in adolescence and adulthood. Who should provide this care? Should it be the paediatrician, or a paediatric psychologist or psychiatrist, or should their treatment be transferred to an adult psychologist or psychiatrist? The need for referral to an adult psychiatrist raises the issue of appropriate diagnosis. Also, does a patient who has grown up with ADHD have a behavioural problem or a mental illness? Health professionals must be aware of the far-reaching repercussions of diagnosing and treating ADHD, including its secondary effects at later stages in a person’s life. I declare that I have no conflict of interest.
1788
1
3
The Lancet. Promoting optimum management for ADHD. Lancet 2007; 369: 880. Attention deficient and hyperkinetic disorder in children and young people: a national guideline. Scottish intercollegiate network, 2001. http://www.sign.ac.uk/pdf/sign52.pdf (accessed April 25, 2007). Spencer TJ, Biederman J, Mick E. Attentiondeficit/hyperactivity disorder: diagnosis, lifespan, comorbidities, and neurobiology. Ambul Pediatr 2007; 7 (suppl 1): 73–81.
Adolescent health: an opportunity not to be missed We support your effort to raise the issue of adolescent health and to strive for youth-friendly health services worldwide. But to state that “little progress has been made in the past 4 years” (March 31, p 1057)1 fails to recognise some important steps. Within the UK we have recognised the importance of a multidisciplinary, multifaceted approach to adolescent health. This was set out in the National Service Framework for Children and Maternity Services2 and the Public Health White Paper, “Choosing Health”.3 Hence we should use the normal activities within young people’s lives as opportunities to improve their health. The Healthy Schools Programme is recruiting all schools in England to offer a strong focus on emotional health and wellbeing: a programme of personal, social, and health education alongside physical activity programmes and healthy eating. We are on track to recruit 55% of all schools to the programme by December, 2007, and all schools by 2009. Through the Extended Schools programme, schools are providing such services as health drop-ins and wider sports activities for young people. Through implementing the “You’re Welcome” criteria,4 health
services are starting to improve the quality of their provision to make them more young-people friendly. Managing more effective transitions from adolescent to adult services is a key component within the National Service Framework and we are supporting a programme of development in this area, supported by Royal Colleges and the Care Services Improvement Partnership. We are also funding four Teenage Health Demonstration sites in Portsmouth, Hackney, Bolton, and Northumberland to assess how effectively they can improve the information, advice, and service offered to young people in a range of different settings. Through these sites we are also looking at how better to support young people with chronic disorders (a key issue raised in the fifth paper in your series5). To ensure further sustainability and improvement, we are funding the Royal College of Paediatrics and Child Health to produce an intercollegiate postgraduate training programme in adolescent health. This will mean that in the future any doctor or nurse working with adolescents will know how to do so more effectively. We are also supporting the College in establishment of a special interest group in adolescent health. Alongside that, we are funding the National Youth Agency to identify the health standards that need to be part of all youth workers’ training—these will then be a part of every undergraduate and postgraduate training programme and of within national vocational qualifications. We hope and expect that this coordinated, long-term effort will contribute significantly to the change that we are all striving to achieve. I declare that I have no conflict of interest.
Sheila Shribman [email protected] National Clinical Director for Children, Young People and Maternity Services, Room 153, Department of Health, 79 Whitehall, London SW1A 2NL, UK
www.thelancet.com Vol 369 May 26, 2007
Correspondence
1 2
3
4
5
Kleinert S. Adolescent health: an opportunity not to be missed. Lancet 2007; 369: 1057–58. Department of Heath. National Service Framework documents. http://www.dh.gov. uk/en/Policyandguidance/Healthandsocialcare topics/ChildrenServices/Childrenservicesinfor mation/DH_4089111 (accessed May 9, 2007). Department of Health. Choosing health: making healthy choices easier. http://www. dh.gov.uk/en/Publicationsandstatistics/ Publications/PublicationsPolicyAndGuidance/ DH_4094550 (accessed May 9, 2007). Department of Health. You’re Welcome quality criteria: making health services young people friendly. http://www.dh.gov.uk/en/Publication sandstatistics/Publications/PublicationsPolicy AndGuidance/DH_073586 (accessed May 9, 2007). Sawyer SM, Drew S, Yeo MS, Britto MT. Adolescents with a chronic condition: challenges living, challenges treating. Lancet 2007; 369: 1481–89.
A code of ethics for scientists As Ching Ling Pang notes (March 31, p 1068),1 codes of conduct and ethics for scientists have been formulated in recent years, with Sir David King’s the most recent. To be useful, such codes need to be effectively enforced, and it might indeed be necessary to add another “R” to Sir David’s “rigour, respect and responsibility”—restrict. In medicine, research on biotechnology can help to prevent epidemics or to create biological weapons; on neuroscience, to better understand mental illness or for chemical weapons; on genomics, to understand the genetic basis of disease or to investigate the possibility of ethnic weapons.2 Eminent scientists, including Nobel laureates and past and present Presidents of the UK’s Royal Society,3–5 have suggested that limits to scientific research might be unavoidable. Such considerations should be part of the remit of local and national ethics committees, and ethics committees should be attached to the Organization for the Prohibition of Chemical Weapons and to proposed similar back-up bodies for the Biological and Toxin Weapons Convention and the (proposed) Nuclear Weapons Convention. To be www.thelancet.com Vol 369 May 26, 2007
effective they should be given access to the International Criminal Court and the United Nations Security Council. I declare that I have no conflict of interest.
Douglas Holdstock [email protected] Medact, The Grayston Centre, 28 Charles Square, London N1 6HT, UK 1 2
3
4
5
Pang CL. A code of ethics for scientists. Lancet 2007; 369: 1068. Holdstock D. Chemical and biological warfare: some ethical dilemmas. Camb Q Healthcare Ethics 2006; 15: 356–65. Atiyah M. The social responsibility of scientists. In: Bruce M, Milne T. Ending war: the force of reason. Houndmills: Macmillan, 1999: 151–64. Rotblat J. Remember your humanity. In: Bruce M, Milne T. Ending war: the force of reason. Houndmills: Macmillan, 1999: 165–71. Rees M. Our final century: will the human race survive the twenty-first century? London: Heinemann, 2003: 73–88.
research reveals is that the youngest women are the ones with a recurrent pattern of heavy drinking in particular group settings in which unprotected sex is also likely to proceed.5 The women most at risk also seem to be those with low “health literacy” with respect to alcohol use and reproductive health. Their formative experiences of intercourse are likely to be in early adolescence, while drunk; for some young people, exploitative or abusive relationships also become associated with this pattern. Unsafe sex, of course, also causes pregnancy. A complex chain of events can cause fetal alcohol effects. I am an honorary consultant at Essex Children’s Trust.
Woody Caan [email protected] Anglia Ruskin University, Cambridge CB1 1PT, UK 1
Remember the links in the causal chain of fetal alcohol effects Raja Mukherjee and colleagues (Apr 7, p 1149)1 are to be commended for recognising the need for a sustained and scientific public health debate on hazardous alcohol use in pregnancy. Potentially there is a constellation of effects of fetal alcohol exposure: on child development, on attachment to parents, and on wider patterns of relationships and resilience that only emerge during the school years.2,3 The iconic features listed in Mukherjee and colleagues’ panel seem to represent an atypical presentation: low birthweight, maternal depression and self-harm, malnutrition and child neglect, and social isolation or homelessness might, for professionals, obscure the developmental problems they do see in many families. The key challenge to understanding (and reducing) risks to health from alcohol is to explore both upstream and downstream links to dangerous drinking behaviour, and the explicit context in which a person is most exposed to risk.4 What community
2
3 4
5
Mukherjee R, Eastman N, Turk J, Hollins S. Fetal alcohol syndrome: law and ethics. Lancet 2007; 369: 1149–50. Caan W. Being of sound mind, in the beginning… Mental Health Promotion Update 2005; 2: 13–15. Booth KJ, Caan W. Poverty and mental health. BMJ 2005; 330: 307. Caan W, Hillier D. How do we perceive risks? In: Hillier D, ed. Communicating health risks to the public: a global perspective. Aldershot: Gower Publishing, 2006. McMunn V, Caan W. Chlamydia infection, alcohol and sexual behaviour in women. Br J Midwifery 2007; 15: 221–24.
Pelvic organ prolapse: don’t forget developing countries Although pelvic organ prolapse is a significant problem in affluent countries (March 24, p 1027),1 the situation in developing countries is far worse. This is mainly a result of high fertility with early marriage and childbearing, many vaginal deliveries, and in certain countries such as Nepal, frequent heavy lifting.2 In Nepal, fertility until recently was very high and most deliveries take place at home, with only 14% in a health facility and less than 3% by caesarean section.3 In developing countries, the extent and effects of morbidity associated 1789