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to merge m u c h of our identities and functions over the next decades. This can be a joint contribution to the better delivery o f medical care in the community. In the same way as the hospital walls begin to open, so should the administration change to bring us more in harmony. We have in our National Health Service that which is in concept the best in the world. We, the oldest branch of the profession and the most numerous, are proposing to affect sweeping changes in our education and function to bring us in line with the needs o f the time, This brings our c o m m o n objectives not only nearer to identity but easier to attain. I can see the possibility, which I firmly believe should become a reality, that we have in twenty years time, much sooner if you like, a College o f Community Doctors, clinical and administrative. When we have reached such fusion then will we be delivering the best in community care. There will be as much derision or anger at this personal suggestion from my profession as from yours, but it is an idea not lightly to be discarded. Oxford, Northampton and the West Riding have shown how present public health can happily co-operate with existing general practice. How much easier will be co-operation when these beginning changes are complete.

AT RISK REGISTERS MAUREEN

J. H O D G S O N

M.B., B.S., D . C . H ,

Medical Officer, Mbdstry of Health, London I would have preferred this paper to have been entitled "'The Child at R i s k " rather than "'At Risk Registers". I have an uncomfortable feeling that by using the word register we may, unwittingly be deluding ourselves that the register is an end in itself, a list of names to show to visitors or to feed into a computer rather than the beginning o f a careful assessment and lbllow-up, and yet, it is not safe I fear, to rely on a technique which does not include some method o f ensuring that a child at risk is carefully watched until such time as he can confidently be diagnosed as falling within the limits of normal development or not. I have not infrequently heard the remark that Miss So and So lmows all the children and their families so well, that there is no need to remind her that it is time to check a child's development; but I have discovered that the Miss So and Sos are only h u m a n after all. W e know that certain detects can be cured or ameliorated by early treatment; for instance phenylketonuria, congenital dislocation of the hips, a n d deafness. M a n y believe this to be true also of cerebral palsy and strabismus. M o s t o f us are in fact convinced that early diagnosis associated with good parent guidance, training and teaching is always in the interest of the handicapped child, whether at the present time we have curative treatment for a defect or not.

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So it is for the purpose of early identification that the concept of the child at risk was evolved. Ideally, of course, we would like to feel that every child could have the careful screening, assessment and follow-up envisaged for the child K but the present shortage of trained staffmakes this impossible, although "at r~"~-" we do already have screening tests applicable to the whole infant population. For example, phenylketonuria, congenital dislocation of the hip, deafness, and the cover test for squint. It is a fact that work is at present being carried out in this field, and we can hope that further screening tests will be available in the near future. The principal criticisms of the "at risk registers" as I understand them, is that too m a n y children are included on the register and that it is insufficiently selective, and certainly, if these are to be useful tools they must not include too high a proportion of the live births and they must pick out a high proportion of the handicapped children. It has been found that in somecases with a register of 25 per cent. o f live births, only 50 per cent. of the handicapped children have been detected, Frustrating as this may be, a greater measure o f selection has been achieved with a normal size register, than would be likely to occur by chance. I do not, however, for a moment suggest that we should be satisfied with this selection, but rather consider how i t can best be improved. Details of shorter lists of "at risk" groups now being used by two local authorities were published in last year's C. M. O.'s report. Professor Illingworth (1966) has published a list of "Items in the History That A l e r t the D o c t o r " mainly designed for early detection of cerebral palsy but which might prove a very useful basis for a comprehensive at risk register. Itwould seem to me, however, that the length of the list is not a major factor, but very much mote important is the information obtainable concerning a child's "at risk status" and the s k i l l with which it is interpreted. For example if a new-born baby i s seen by a doctor skilled in developmental pa~diatrics and child neurology, his evaluation of the history and his examination will enable him to indicate the child's " a t risk potential" much more accurately t h a n would be the case if the only information available was a tick alongside a list of potential "at risk" factors made by t h e midwife a t the around time o f delivery. Professor Illingworth in his paper o n t h e diagnosis of cerebral palsy in the firstyear of life previously referred to, states ',The concept of the child at risk o f certain handicaps s u c h as severe mental subnormality, cerebral palsy, deafness, blindness or congenital dislocation o f the hip is a useful one for alerting the doctor. He will then follow up a n d make an especially careful examination o f a child where there is a history of a factor which put him at risk for one of these :handicaps." He also summarizes his paper, which gives a description of the examination of the child forcerebra! palsy, as:~follows: " A routine examination of every baby in the welfare clinic or hospital, taking a few minutes, will be enough to pick out t h e infant with cerebral palsy or mental subnormality o f any b u t the minor degrees. W h e n doubtful signs are found, more time will have to be devoted

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to study the baby more carefully." In this connection also Professor Prechtl (1965) makes the following comment: " A neurological examination in the new-born period has a sound prognostic value in respect to later neurological troubles and behaviour problems." He further states that it is clearly not possible at the moment to make acomplete neurological examination of every baby, and therefore suggest a neurological screening test which should .be part of the p~ediatric routine examination of every baby. Di: Prechtl and his colleagues believe that all babies "at risk" should have a full neurological examination. (This has been well described by Prechtl and Beintema in 1964 and Andr6 Thomas in 1960.) Professor Prechtl's screening examinations for the full-term new born infant is described as an appendix to the Little Club Clinics in Developmental Medicine No. 12 published in 1964 by the Spastics Society~Medical Education and Information Unit. I feel I simply must point out here that the originM list of "at risk" factors suggested by Dr Mary Sheridan in 1962, was compiled after numerous discussions with M. Os. H.,p~ediatricians, obstetricians, pathologists and other specialists; hence its length and possible imprecisions o f which she was fully aware. The list was intended as "'guide posts" only and not as diagnostic entities. Undoubtedly, the priority, order, and composition of the groups is still experimental and will naturally change alongside the development of knowledge and skill. It will be a long time I fear before it is purely a question of punch cards and computers. Dr Sheridan also made the point in this paper that in an effort to obtain further particulars without adding to the work of the hospital staff; some health departmems now print a list of the main risk groups on the reverse side of the usual notificatio1~, of discharge form, witl~ the request that a mark is made agMnst any appropriate item so that the health visitor and clinic medical officer may be alerted to the need to institute further enquiries. What I am attempting to say, perhaps in a roundabout way, is that the greater the involvement of medical personnel, particularly if they are especially trained, the more accurate will be the selection of the child "at risk". Ideally it would be best for a local authority doctor (or doctors) skilled in developmental p~ediatrics, to see allthe children and select on a basis of history a~d examination which of the children are "'at risk" and be responsible for deciding on the follow-up; but if this is not possible, then the doctors responsible .for the register should at least see all the children notified as possiNy being "at risk" by the midwives, health visitors etc., as soon after birth as possible, to decide whether or not they should be followed up further, or whether they require some special type of investigation. Screening tests should ideally be carried out on all children but if this cannot be achieved they then should be done on aU "at risk" children and.on as many others as is practicable: It very soon-becomes evident that wheri considering the eompihng of an "'at risk register", the examination of the potentially at risk child and its follow-up, the local authority doctor (or doctors) involved inthe work will require further training with regard to the normal and abnormal de'~elopment of infants

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and young children, and also in modern methods of developmental testing. This is to some extent now being met by in-training courses, short residential courses for general practitioners, p~diatricians, and local authority medical officers, and courses arranged by the Society of Medical Officers o f Health, and Departments of Child Health. Many more i am sure are envisaged for the future. To sum up this very short paper I would like to emphasize the. need for careful medical supervision o f the registers, in conjunction with the use of screening techniques for all children where this is possible and careful consideration given to the necessary training in developmental pediatrics for the doctors whose function it is to detect as early as possible those children who are handicapped. The term developmental pediatrics in this paper is used according to the definition given by Dr M. Sheridan which reads as follows: "Developmental P~ediatrics is concerned with maturational processes 'from foetal viability to full growth' in structure and function of normal and abnormal children; for the purpose first of promoting optimal physical and mental health, secondly of ensuring early diagnosis and effective treatment of handicapping conditions of body, mind and personality and thirdly of discovering the causation and prevention of such handicapping conditions.'" REFERENCES ILLINOWORTH. R. S. (1966). Develop. Meal. & Child Neurol., 8, 178. PRECHTI_, H. F. R. (1765). Pro¢. roy. Soc. ]~4ed., 58, 3. SHEttlDAN, M. D. (1962). ]~,Ith. BMI. ?dinist. Hlth. 21,238.

CHILD

HEALTH

POINTS

OF

CONCERN

H. W. S, F R A N C I S M.A., M.B., B.CHIR., D.P.H.

Deputy County Medical Officer, County Council of the West Riding of Yorkshire I have been asked to discuss the possibilities of growth in child care in relation to preventive psychiatry. However, I would like to widen my talk a little and deal with four points which while not unconnected with preventive psychiatry I have mainly chosen because they have been a matter of some concern to me over the last few months, These four matters are: behavioural disorder; ,child poverty;child neglect; and prevention of m_ental illness itself.

Behaviourat disorder All people concerned would agree that one o f the most difficult problems in a n y sittlation is dealing with the disturbed aggressive child. It is unusual for psychotherapy, for residerxtial placement o r for a combination of these, to completely resolve the difficulties. Recently, however, there have been two advances which suggest that some of this disturbed aggressive behaviour may have a physical basis.