- Email: [email protected]
Protecting children and prioritising evidence
Perspectives
Book Protecting children and prioritising evidence The failure to convince medical authorities of concerns regarding the reality of child abuse has been a feature since Ambroise Tardieu first described haemorrhage over the brain in abused children in 1860. This distinguished French forensic physician described 32 abused children, 18 of whom had died. This work, however, failed to make an impact and was rejected by his successors in France; as Jean Labbé has observed, “fearing a miscarriage of justice, they were not willing to consider the clinical signs described by Tardieu as diagnostic of physical or sexual abuse” (Child Abuse and Neglect 2005; 29: 311–24). It was not until nearly a century later, in 1946, when John Caffey again described infants with subdural haematoma together with multiple fractures of long bones in the American Journal of Radiology. He reported six cases, but initially thought the “causal mechanism obscure”; however, he later recognised that the cause of these injuries was shaking (Am J Dis Child 1972; 124: 161–69). This follows a pattern in recent history that alternates between denial of the existence of child abuse and outrage when it is not dealt with. I have just retired, but during my career in child health I have read many reports, starting with Maria Caldwell in 1975, that express horror at the failure of systems that should have protected children. All these reports expressed concern that professionals were not working together and often blamed the junior members of staff dealing with the case. Encouragingly, the more recent Laming Enquiry, after the death of Victoria Climbée, put the blame largely not on hapless junior social workers but on the senior managers who had not put enough priority and resources into child protection. My experience in the UK is that despite all these reports, progress in really working together has been slow. There www.thelancet.com Vol 368 July 22, 2006
also has been little progress in having joint budgets between social services and the Department of Health. Recently, much of the concern of paediatricians has been focused on the difficulties their colleagues have had in giving evidence in court, with some high-profile cases being put before the UK’s General Medical Council. The key to some of this concern has been
“Systematically analysing the evidence in child protection should be one of the highest research priorities for child health and for the interface between child health and the legal system.” the quality of the scientific evidence that was available to paediatricians. Following on from this, is the problem of translating the scientific evidence in a way that can be assessed, understood, and used by the court. This is true in various types of child abuse, but is especially so in the case of head injury to children and particularly the so-called “shaken baby syndrome”. The whole scientific basis for the existence of shaking as an aetiological factor in non-accidental head injury to children has been brought together in Shaking and Other Non-accidental Head Injuries in Children. This book is edited by Robert Minns and Keith Brown, who have an extensive experience of diagnosing and dealing with such injuries. There is no doubt that this volume adds to the sum of knowledge that is available to paediatricians in their clinical work and in court. Although the book draws strongly on primary evidence, it does not undertake a critical appraisal of the work and so lacks the evidential weighting of a systematic review. Nonetheless, the book is impressive in the way that it attempts to formulate
a uniform hypothesis about different mechanisms of brain injury. There are valuable chapters on retinal injury, radiology, and on epidemiology by a large group of contributors. I found the section that outlines the evidence that shaking can cause severe head injury especially useful. I was, however, left with the feeling that a standard textbook, good as this one undoubtedly is, is inadequate when dealing with the profound challenges that are going to be presented to a doctor who has to make clinical judgments, give evidence in court, and often talk publicly in the media after these cases. I was fortunate to train with Christine Cooper in Newcastle and her work was pivotal in the recognition of abuse as a major problem of childhood. She also gave evidence to courts from her experience as a paediatrician. Few people argued with her opinion. That is far from the truth today, and every paediatrician has to base his or her clinical opinion on the best evidence available. This is essential if the interests of the child, and if the interests of justice, are to be preserved. A little later in my career I was fortunate to meet Archie Cochrane and the revolution that he started in the assessment of medical evidence has had profound effects on us all. Today, we would not think of introducing a new treatment without a thorough systematic evaluation. However, this process has left child protection largely untouched. Research into the medical aspects of diagnosing child abuse is a Cinderella in the priority for funding. We seem to be quite happy to study “process” in the management of child protection cases and channel this through departments of social administration, but quite unwilling to fund work on actually diagnosing the problem and on its basic epidemiology. About 3 years ago, we started a programme in Wales of systematic
Shaking and Other Non-accidental Head Injuries in Children Robert A Minns, J Keith Brown, eds. Cambridge University Press, 2006. Pp 526. £95·00. ISBN 1-898-68335-2.
277
Perspectives
For more on the work of the Welsh Child Protection Systematic Review Group see http://www.core-info.cf.ac.uk.
review of diagnostic evidence in physical child abuse (Welsh Child Protection Systematic Review Group). Our experience has been revealing. We have confirmed some worthwhile findings, such as that accidental bruising in non-mobile babies is very rare. However, we have also found that some long-held propositions, such as that one can age bruises accurately, have little basis in the literature (Arch Dis Child 2005; 90: 186–89). Yet I can remember being told when a junior doctor that the way to tell abuse was that the bruises were of different ages. How often has one been asked in court how old the bruises were? Quite often we have found that evidence from single case reports have gone
into review articles or textbooks without any case-control studies to back them up. An example of this is the torn frenum, often said to be pathognomonic of abuse but with no case-control evidence to back that up. Systematically analysing the evidence in child protection should be one of the highest research priorities for child health and for the interface between child health and the legal system. Indeed, the Royal College of Paediatrics and Child Health has recognised this through its initiatives with the UK’s National Society for the Prevention of Cruelty to Children. However, we must also work hard on the basic epidemiology of abuse. The contributors to this book have been
among the leaders of this work in the UK and their epidemiological work is fully outlined in this book. These head injuries are predominately a problem for babies: particularly very young babies. We know that babies are especially vulnerable in other ways too, and if returned home after abuse they are often at high risk of further abuse. Shaking and Other Nonaccidental Head Injuries in Children provides important information for protecting such vulnerable children. Hopefully, in the future books on child protection will be able to be based on systematic reviews.
Jo Sibert [email protected]
In brief Book Fighting fast food
Chew on This: Everything You Don’t Want to Know About Fast Food Eric Schlosser, Charles Wilson. Puffin Books, 2006. Pp 272. £6·99. ISBN 0-141-31844-9.
278
It is somewhat ironic that the publication of Eric Schlosser and Charles Wilson’s Chew on This coincided with the launch of the Best Food Nation website. This website, which is supported by some of the biggest players in the fastfood industry, is part of a public relations exercise to counteract the wave of protest against fast food led by critics such as Schlosser. Based on his 2001 international bestseller, Fast Food Nation, Schlosser’s latest book sends out the same message, but this time aimed at 11–15-yearolds—who are often the target of advertising campaigns from the fast-food industry. In a no-holds-barred narrative, Schlosser exposes the alarming growth of the fast-food industry. We learn about the evolution of the hamburger, culminating in the current shoddy living conditions of cattle and chicken, and of the appalling treatment of workers in slaughterhouses and meat-packing warehouses. One of the most
worrying aspects of this industry is the way it targets children in an attempt to embed brand loyalty during an individual’s developing years—part of the cradle-tograve strategy. Schlosser raises an important issue about the ethics of advertising aimed at such a vulnerable population and refers to studies that show young children are unable to distinguish a television advertisement from a television show. This is even more troubling when one considers that in the USA a child can watch up to 40 000 television advertisements per year, half of which are for junk food. With the limited edition “bigger” Big Mac introduced last month to celebrate the FIFA World Cup, the fast-food industry is doing little to dispel the charge that they are promoting obesity among young people. Although Chew on This is a well written and researched account of the formidable growth of the billion-dollar fast-food industry, I do wonder how many adolescents will actually read it. Nonetheless,
the message of the book is worthy of discussion—the obesity epidemic is an important public-health issue worldwide, and this book helps to inform the public about how to avert this situation. It is heartening that journalists like Schlosser, and other advocates of healthy eating such as the UK chef Jamie Oliver, put in the effort to keep preaching the same message. Ultimately, we as individuals are accountable for the current situation. Fast-food chains are only successful because people enjoy eating at them and believe the food is value for money. While people continue to eat at these restaurants, there is no pressure on the companies to change. As a McDonald’s spokesman says of Schlosser, “His opinion is outvoted 45 million to one every single day, because that’s how many customers around the world choose to come to McDonald’s for our menu of variety, value, and quality.”
Seema Kang [email protected]
www.thelancet.com Vol 368 July 22, 2006
Book Protecting children and prioritising evidence The failure to convince medical authorities of concerns regarding the reality of child abuse has been a feature since Ambroise Tardieu first described haemorrhage over the brain in abused children in 1860. This distinguished French forensic physician described 32 abused children, 18 of whom had died. This work, however, failed to make an impact and was rejected by his successors in France; as Jean Labbé has observed, “fearing a miscarriage of justice, they were not willing to consider the clinical signs described by Tardieu as diagnostic of physical or sexual abuse” (Child Abuse and Neglect 2005; 29: 311–24). It was not until nearly a century later, in 1946, when John Caffey again described infants with subdural haematoma together with multiple fractures of long bones in the American Journal of Radiology. He reported six cases, but initially thought the “causal mechanism obscure”; however, he later recognised that the cause of these injuries was shaking (Am J Dis Child 1972; 124: 161–69). This follows a pattern in recent history that alternates between denial of the existence of child abuse and outrage when it is not dealt with. I have just retired, but during my career in child health I have read many reports, starting with Maria Caldwell in 1975, that express horror at the failure of systems that should have protected children. All these reports expressed concern that professionals were not working together and often blamed the junior members of staff dealing with the case. Encouragingly, the more recent Laming Enquiry, after the death of Victoria Climbée, put the blame largely not on hapless junior social workers but on the senior managers who had not put enough priority and resources into child protection. My experience in the UK is that despite all these reports, progress in really working together has been slow. There www.thelancet.com Vol 368 July 22, 2006
also has been little progress in having joint budgets between social services and the Department of Health. Recently, much of the concern of paediatricians has been focused on the difficulties their colleagues have had in giving evidence in court, with some high-profile cases being put before the UK’s General Medical Council. The key to some of this concern has been
“Systematically analysing the evidence in child protection should be one of the highest research priorities for child health and for the interface between child health and the legal system.” the quality of the scientific evidence that was available to paediatricians. Following on from this, is the problem of translating the scientific evidence in a way that can be assessed, understood, and used by the court. This is true in various types of child abuse, but is especially so in the case of head injury to children and particularly the so-called “shaken baby syndrome”. The whole scientific basis for the existence of shaking as an aetiological factor in non-accidental head injury to children has been brought together in Shaking and Other Non-accidental Head Injuries in Children. This book is edited by Robert Minns and Keith Brown, who have an extensive experience of diagnosing and dealing with such injuries. There is no doubt that this volume adds to the sum of knowledge that is available to paediatricians in their clinical work and in court. Although the book draws strongly on primary evidence, it does not undertake a critical appraisal of the work and so lacks the evidential weighting of a systematic review. Nonetheless, the book is impressive in the way that it attempts to formulate
a uniform hypothesis about different mechanisms of brain injury. There are valuable chapters on retinal injury, radiology, and on epidemiology by a large group of contributors. I found the section that outlines the evidence that shaking can cause severe head injury especially useful. I was, however, left with the feeling that a standard textbook, good as this one undoubtedly is, is inadequate when dealing with the profound challenges that are going to be presented to a doctor who has to make clinical judgments, give evidence in court, and often talk publicly in the media after these cases. I was fortunate to train with Christine Cooper in Newcastle and her work was pivotal in the recognition of abuse as a major problem of childhood. She also gave evidence to courts from her experience as a paediatrician. Few people argued with her opinion. That is far from the truth today, and every paediatrician has to base his or her clinical opinion on the best evidence available. This is essential if the interests of the child, and if the interests of justice, are to be preserved. A little later in my career I was fortunate to meet Archie Cochrane and the revolution that he started in the assessment of medical evidence has had profound effects on us all. Today, we would not think of introducing a new treatment without a thorough systematic evaluation. However, this process has left child protection largely untouched. Research into the medical aspects of diagnosing child abuse is a Cinderella in the priority for funding. We seem to be quite happy to study “process” in the management of child protection cases and channel this through departments of social administration, but quite unwilling to fund work on actually diagnosing the problem and on its basic epidemiology. About 3 years ago, we started a programme in Wales of systematic
Shaking and Other Non-accidental Head Injuries in Children Robert A Minns, J Keith Brown, eds. Cambridge University Press, 2006. Pp 526. £95·00. ISBN 1-898-68335-2.
277
Perspectives
For more on the work of the Welsh Child Protection Systematic Review Group see http://www.core-info.cf.ac.uk.
review of diagnostic evidence in physical child abuse (Welsh Child Protection Systematic Review Group). Our experience has been revealing. We have confirmed some worthwhile findings, such as that accidental bruising in non-mobile babies is very rare. However, we have also found that some long-held propositions, such as that one can age bruises accurately, have little basis in the literature (Arch Dis Child 2005; 90: 186–89). Yet I can remember being told when a junior doctor that the way to tell abuse was that the bruises were of different ages. How often has one been asked in court how old the bruises were? Quite often we have found that evidence from single case reports have gone
into review articles or textbooks without any case-control studies to back them up. An example of this is the torn frenum, often said to be pathognomonic of abuse but with no case-control evidence to back that up. Systematically analysing the evidence in child protection should be one of the highest research priorities for child health and for the interface between child health and the legal system. Indeed, the Royal College of Paediatrics and Child Health has recognised this through its initiatives with the UK’s National Society for the Prevention of Cruelty to Children. However, we must also work hard on the basic epidemiology of abuse. The contributors to this book have been
among the leaders of this work in the UK and their epidemiological work is fully outlined in this book. These head injuries are predominately a problem for babies: particularly very young babies. We know that babies are especially vulnerable in other ways too, and if returned home after abuse they are often at high risk of further abuse. Shaking and Other Nonaccidental Head Injuries in Children provides important information for protecting such vulnerable children. Hopefully, in the future books on child protection will be able to be based on systematic reviews.
Jo Sibert [email protected]
In brief Book Fighting fast food
Chew on This: Everything You Don’t Want to Know About Fast Food Eric Schlosser, Charles Wilson. Puffin Books, 2006. Pp 272. £6·99. ISBN 0-141-31844-9.
278
It is somewhat ironic that the publication of Eric Schlosser and Charles Wilson’s Chew on This coincided with the launch of the Best Food Nation website. This website, which is supported by some of the biggest players in the fastfood industry, is part of a public relations exercise to counteract the wave of protest against fast food led by critics such as Schlosser. Based on his 2001 international bestseller, Fast Food Nation, Schlosser’s latest book sends out the same message, but this time aimed at 11–15-yearolds—who are often the target of advertising campaigns from the fast-food industry. In a no-holds-barred narrative, Schlosser exposes the alarming growth of the fast-food industry. We learn about the evolution of the hamburger, culminating in the current shoddy living conditions of cattle and chicken, and of the appalling treatment of workers in slaughterhouses and meat-packing warehouses. One of the most
worrying aspects of this industry is the way it targets children in an attempt to embed brand loyalty during an individual’s developing years—part of the cradle-tograve strategy. Schlosser raises an important issue about the ethics of advertising aimed at such a vulnerable population and refers to studies that show young children are unable to distinguish a television advertisement from a television show. This is even more troubling when one considers that in the USA a child can watch up to 40 000 television advertisements per year, half of which are for junk food. With the limited edition “bigger” Big Mac introduced last month to celebrate the FIFA World Cup, the fast-food industry is doing little to dispel the charge that they are promoting obesity among young people. Although Chew on This is a well written and researched account of the formidable growth of the billion-dollar fast-food industry, I do wonder how many adolescents will actually read it. Nonetheless,
the message of the book is worthy of discussion—the obesity epidemic is an important public-health issue worldwide, and this book helps to inform the public about how to avert this situation. It is heartening that journalists like Schlosser, and other advocates of healthy eating such as the UK chef Jamie Oliver, put in the effort to keep preaching the same message. Ultimately, we as individuals are accountable for the current situation. Fast-food chains are only successful because people enjoy eating at them and believe the food is value for money. While people continue to eat at these restaurants, there is no pressure on the companies to change. As a McDonald’s spokesman says of Schlosser, “His opinion is outvoted 45 million to one every single day, because that’s how many customers around the world choose to come to McDonald’s for our menu of variety, value, and quality.”
Seema Kang [email protected]
www.thelancet.com Vol 368 July 22, 2006