108

PREDICTING AND PREVENTING CHILD ABUSE

SiR,—Dr Lealman and colleagues (June 25, p 1423) confirm that itis possible to describe factors predictive of families at high risk ofchild abuse. However, they conclude, on the basis of their work, that"supportive measures did not prevent abuse". On this score theysay very little; perhaps much more was done than they outline. Theycorrectly state that nobody should "underestimate the complexityof this difficult social and medical phenomenon". All the moresurprising then that such sketchy facilities might have been

pictured as "supportive": they could be tantalising and provocativefor people who require sustained assiduous attention on a regularbasis.

A supportive service must be able to provide both help in crisis atany time and planned supervisory contact, which can be briefprovided it is regular. The first component appears to have beenprovided in Bradford but Lealman et al seem unaware of the needfor the second. A "drop-in" centre open one day a week cannot beexpected to retain and support people who are impulsive,unpredictable, and very dependent. Their relationships are fragileand need active support; such people are incapable of dropping inprecisely when they need support most. Would physicians advocatea weekly drop-in centre for the management of diabetes? What isneeded in child abuse is regular surveillance and responsible follow-up rather than reliance upon parents walking in when they feel "atrisk".

We would not want therapeutic nihilism, based on scantyevidence, to deter others from doing the useful work which is

possible with limited resources, provided there is determination andflair. It is "an empty hope" to expect good results from inadequatetreatment. The issues are complex and, as Lealman et al say, theproblem of child abuse has no simple answer. Indeed, we believethat those working with such disturbed families themselves requirea support group if more skilled supervision is an unattainableideal. ],2

Perinatal Bereavement Unit,Adult Department,Tavistock Clinic,London NW 3 5BA

E. LEWISS. BOURNE

SOCIAL AND HEALTH SERVICESFOR MULTIPLE SCLEROSIS

SIR,-Dr Elian and Dr Dean (May 14, p 1091), in their survey ofmultiple sclerosis patients, make a point that is familiar to mostneurologists-namely, that these patients often fail to benefit fromall the social services and support provided. This is precisely whysome neurologists regularly see such patients in follow-up clinics.In my experience, it often falls to the neurologists to initiate referralto social workers, particularly as the disease progresses. Whether welike it or not, many patients would rather deal with doctors thanwith social workers in the first instance.

Elian and Dean perpetuate the all too prevalent view that"nothing can be done for a multiple sclerosis patient". Neurologistsconcerned with the management as well as with the diagnosis ofmultiple sclerosis still see patients too late with dreadful flexioncontractures, bedsores, and urinary problems because of the

philosophy that nothing can be done. Multiple sclerosis can be aprogressive disease and the patient (and relatives) need continuingsupport. The philosophy should be "nearly always something canbe done". Putting the patient on a register may simply be asubstitute for real action.

Younger Disabled Unit,Mangan Lodge,Ladywell Hospital,Salford M5 2AA A. C. YOUNG

1. Mattinson J. Reflection process in casework supervision. London Institute of MaritalStudies, 1975

2. Westheimer IJ. Practice of supervision in social work London: Ward Lock

Educational. 1977

PRIVATE NURSING HOMES ANDNHS GERIATRIC SERVICES

SIR,-In publishing the Secretary of State’s paper on cooperationbetween the National Health Service and the private sector (June 11,p 1323) it was not, I am sure, your intention to trigger in yourcolumns a wide-ranging debate on ideology. However, it might beworth looking more carefully into the use of private nursing homesas a means of enhancing geriatric provision.A recent thesis for a higher diploma, which it was my privilege to

read, compared and contrasted long-stay patients in geriatrichospitals and in private nursing homes, and it was possible to makereasonable evaluations of the level of disability, dependency, andnursing staff levels. It was not so easy to compare the quality of careand the outcome. Few, if any, nursing homes have ready access tospeech therapy, physiotherapy, or occupational therapy-whichmay be fine for patients who do not need these services, but then dosuch patients need residential care within the NHS?In looking at costs like must be compared with like, and we must

be aware of the probability that the cheaper solution is the oneoffering a reduced range of services. One geriatric physician hascoined the term "warehousing" to describe the non-therapeuticprovision of institutional care. The danger is that by advancingpurely economic solutions to the problems of the rising number ofdisabled, frail, and elderly in our population, standards of care willfall in the name of increased efficiency.

East Suffolk Health Authority,St Clement’s Hospital,Ipswich IP3 8NN M. F. H. BUSH

CLONED GENE PROBES FOR CARRIER DETECTIONIN MUSCULAR DYSTROPHY

SiR,-Dr Wieacker and others (June 11, p 1325) state that ourcloned gene probe .RC8 can be for carrier detection for Duchennemuscular dystrophy. One of us (K. E. D.) appeared as an author ofthis letter without her knowledge. The statement that a woman"must be a carrier of the DMD gene because of her high CK levels"is incorrect. The analysis of the genotypes depends upon themother being a carrier, which may not be the case. We and ourcollaborators deal with these questions in detail in two papers, onein press’ and one in preparation (Pembrey et al), in which wedemonstrate that the probe is fully informative for carrier status inonly a small number of cases.

Biochemistry Department,St Mary’s Hospital Medical School,London W2and Welsh National School of Medicine,

Cardiff

K. E. DAVIESP. S. HARPERR. WILLIAMSON

**This letter has been shown to the Freiburg workers, whose replyfollows.-ED. L.

SIR,-We apologise that the letter published in your issue of June11 was submitted by one of us (P. W.) without giving notice to theco-authors. We agree with Dr Davies and her colleagues that a womanwith high CK levels is not necessarily a carrier of the DMD gene. Incontrast, non-carriers with an affected son and very high CK levelsare certainly very rare. As to the heterozygote referred to in ourletter, it should have been made clear that her carrier status wasestablished not only by very high CK activity but also by clinicalsigns consisting of cramps, weakness upon walking, and

asymmetrical enlargement of the calves.

Institute for Human Geneticsand Anthropology,

D-7800 Freiburg, West Germany

P. WIEACKERH. H. ROPERS

1 Harper PS, O’Brien T, Murray JM, Davies KE, Pearson P, Williamson R. The use oflinked DNA polymorphisms for genotype prediction in families with Duchennemuscular dystrophy J Med Genet (in press).