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Confrontational TV Programme Harms Children
19 November 1999
Sir
I congratulate Harvey Marcovitch on his exposition of the methods
used by some activists to hound those paediatricians who are prepared to
consider that parents do not always act invariably in the best interests
of their children.
Marcovitch draws attention to the Panorama Programme last Monday on
the equally contentious subject of chronic fatigue syndrome (CFS) in
children. This was a particularly biased and pernicious account of an area
where balance and reason are needed, not polemic and distortion.
Contrary to the message of the programme, the management of CFS in
children is in practice not contentious. Programmes of rehabilitation
rather similar to those now shown to be effective in adults, including
some form of support, encouragement, behavioural management and
activation, are now the mainstay of treatment in virtually all centres
helping such children and their families. Indeed, it is hard to find
dissenting voices in the professional literature.
Such programmes, including the one we run at King's College Hospital,
necessarily involve collaboration, not confrontation, with both the child
and family. We will shortly be presenting the results of an uncontrolled
case series, adding to the literature demonstrating both the effectiveness
and acceptability of such approachs, and have just commenced a randomised
controlled trial as part of the normal process of demonstrating efficacy
in the most scientific fashion.
Any parent who watched the one sided Panorama Programme might be
forgiven for thinking that the management of CFS in children involves
coercion and the Courts, and be discouraged from seeking help. Of course
cases of parents harming their children, even occasionally with good
intentions, do exist. Some appear nowadays under the guise of CFS or
bizarre allergic disorders (1), and when a doctor believes this is
happening, he or she has Statuatory duties to fulfil. But such cases are
fortunately extremely rare - we have not yet encountered such a problem
here at King's - and tell us little or nothing about the general
management of CFS.
(1). Taylor D. Outlandish Factitious Illness. In: David T, ed. Recent
Advances in Paediatrics. Edinburgh: Churchill Livingstone, 1992: 63-76.
Simon Wessely, Professor of Liaison and Epidemiological Psychiatry
King's College Hospital
Children with ME and Doctors
4 December 1999
There is a strange illogicality permeating much of the argument put
forward by Harvey Marcovitch (1) on the question of the treatment of CFS
or ME in children, and in some of the subsequent responses. He writes of
the hatchet job performed by Panorama (8th. November), and, in this
context, refers to the Washington Posts policy that news requires
corroboration. One of the responses to his review states contrary to the
message of the programme, the management of CFS in children is in practice
not contentious (2). Yet there was an omission in Dr. Marcovitchs
reference to a case reported by Panorama in which, he states, ...
parents views and those of the local medical team were in conflict. The
programme made it clear that the dispute was between the parents supported
by their own medical advisers and the local medical team, so perhaps there
is more divergence of view in this area than has been asserted.
Dr. Marcovitch discussed at length Munchausen syndrome by proxy,
which is relevant because one of the cases of ME reported by Panorama was
labelled as such. Neither doctors nor anyone else like being on the
receiving end of emotional, intemperate outbursts, even from people who
think they have been wrongly accused. But what is sauce for the goose is
surely also sauce for the gander. Nobody is infallible, and even doctors
make mistakes at times, yet there is no recognition in Dr. Marcovitchs
review that this is even a remote possibility. He gives no credence to the
possibility that some of those accused, knowing themselves to be innocent
of the allegations, may feel themselves to have been in receipt of exactly
the same type of vituperative attack that he objects to strongly when
doctors are on the receiving end. Allegations of this nature turn on
questions of historical fact, rather than simply being matters of clinical
opinion, so should be subject to Dr. Marcovitchs own Washington Post
test of corroboration.
It is hardly surprising that innocent people feel very angry when
accusations are levelled at them that, if made without justification in
any other context, could end in an action in defamation in the High Court.
It is also not surprising that innocent people will react vigorously to
such accusations, in order to give paramount importance to the interests
of their children, which means, in this context, fighting to preserve the
integrity of their families. The fact is that clinical opinion may at
times be highly speculative in nature, and does not enjoy the same status
as fact. Yet alone of all professionals, some doctors seem to think that
their opinions should be treated as paramount, even when they fly in the
face of the facts. Lawyers, for example, may form professional opinions
about cases, but expect to see them challenged adversarially by other
lawyers in the course of legal proceedings. Journalists, as Dr. Marcovitch
himself has suggested, should be subject to a stringent test of
corroboration in the views they express. As far as doctors are concerned,
much of the heat could be taken out of the situation if some doctors would
approach the care of children with ME with greater humility and
understanding, and attempt to build the type of partnership between
professionals and parents that is clearly best practice, and in line with
the intentions of the current child care legislation.
1)Marcovitch, H. Diagnose and be damned. BMJ (1999): 319 1376.
2)Wesseley, S. Confrontational TV programme harms children. e-BMJ,
19th. November 1999.
Competing interests: None declared
Derek Pheby, Director, Unit of Applied Epidemiology,
University of the West of England, Coldharbour Lane, Bristol, BS16 1QY.
Where was the BMJ's peer review process
20 December 1999
Dear Sir or Madam,
I write to suggest that the thoughtful response of Dr.
Derek Pheby which I have read on the eBMJ should be
published in the paper journal.
The British record of paediatricians in the field of child
abuse is not above scrutiny. There are clear examples of
doctors having done more harm than good, despite what may
well have been good intentions as illustrated by the
excesses of the "rectal tone" paediatricians in Cleveland in
1987.
The BMJ should be seeking more balance before publishing
articles like the one from Harvey Marcovitch
sincerely
Douglas Newberry, Consultant Physician
Ashford & St. Peter's Hospital, UK
Just because he doesn't eat livers with faava beans,
Imaginary Wessely said:Certainly, having a brain injury is bad, but how people respond to it is the most important thing. It's really important that we stop people from seeing themselves as victims who deserve compensation from powerful people - we should be carefully managing them to adopt a more positive approach, in which they take control of their own problems.*
* My research is funded by powerful people who are responsible for the brain injury of people and don't want to pay out compensation - but they've been very good at just letting me get on with my work without interference... No, I don't know why they decided that I should lead their research in this area - perhaps because of the great success I've had with CFS, Gulf War Syndrome, etc?
Simon Wessely, Professor of Epidemiological and Liaison Psychiatry at the Institute of Psychiatry, King’s College London, said:
"This study adds significantly to our knowledge about what serious or repeated concussion does to the brain. The animal work is impressive, particularly showing the importance of accelerating/decelerating injury.
"However, we need to remember that this is not the same as mild concussion. Nor is this the same as post-traumatic stress disorder, with which mild traumatic brain injury is sometimes confused.
"Finally, it cannot explain why mild traumatic brain injury/concussion seems to be more common in US than UK Forces, despite fighting the same enemy on the same terrain and, at least in recent years, sustaining the same rate of casualties."