Childcare and Social Services.

[Fiona]

Sad thing is there will be a govt. initiative based on these for 'problem parents' and enforcible by the courts in 'exceptional' circumstances. Just you wait.:undecided:

I am not very sure what you mean by this Pebbles. Cards on the table - I am a social worker. It is part of my job to deal with "problem parents" and I honestly believe this needs to be done. I also know, absolutely certainly, that there are parents so ignorant or so neglectful that their babies are seriously harmed in astonishing ways. Do you not believe we have a responsibility to try to mitigate that?

[Pebble]

I am not very sure what you mean by this Pebbles. Cards on the table - I am a social worker. It is part of my job to deal with "problem parents" and I honestly believe this needs to be done. I also know, absolutely certainly, that there are parents so ignorant or so neglectful that their babies are seriously harmed in astonishing ways. Do you not believe we have a responsibility to try to mitigate that?

My worry with Govt. invovlement is that the imperative to do something, leads to actions that are not evidence based. Yes we know there are problems, many opinions exist as to the best solution but the evidence for what is effective is so limited that this cannot be parcelled up into an adequate package for action, so 'experts' opinions are relied upon. Solutions are agreed upon and become the new orthrodoxy, what is not done is to rigourously identify that which is proven, that which appears supported by objective observation, that which is one of many competing theories that could fit with the available observations and that which is pure guess work. Further, we are interefering with personal freedoms here, we must at the very least set up a progam that will challange the assumptions we are making to determine which are subsequently supported, which are not, and to ruthlessly root out the junk opinions that lead to fiasco's such as the satanic abuse nonsense in Scotland a few years ago.

[Fiona]

Can you suggest how this can be done?

[Pebble]

Can you suggest how this can be done?

Model on NICE for medicines. Independent assessment of the quality of evidence. Recommend minimum standards, recognising where those are based on opinion rather than evidence, suggesting research to fill gaps of knowledge identified. Then set audit program to assess adherence with recommendations. Police implementation to ensure that evidence based recommendations are being followed, and that where un-orthrodox practices are followed these are in the setting of properly designed research protocols.

[Fiona]

Are you involved in this field Pebbles?

[Pebble]

Are you involved in this field Pebbles?

Indirectly only, NICE.

[Fiona]

How do you think those principles contained in the social judgements document should be applied to child protection?

[Pebble]

How do you think those principles contained in the social judgements document should be applied to child protection?

Not necessarily directly applicable, but some jump out..

http://www.nice.org.uk/aboutnice/howwework/socialvaluejudgements/SVJSecondEditionConsultation.jsp

I would start with:

Principle 1
NICE should not recommend an intervention (that is, a treatment, procedure, action or programme) if there is no evidence, or not enough evidence, on which to make a clear decision. But NICE may recommend the use of the intervention within a data collection or research programme if this will provide more information about the effectiveness, safety or cost of the intervention.

Principle 2
Those developing clinical guidelines, technology appraisals or public health guidance must take into account the relative costs and benefits of interventions (their 'cost effectiveness') when deciding whether or not to recommend them.

7 Particular issues for public health guidance

Public health initiatives ....

NICE asked the Citizens Council to consider when it is legitimate for authorities to intervene in a 'mandatory' way to address a public health problem. (Mandatory means that an intervention would be legally enforced - for example, legislation to ban smoking in public places.) The Council thought that non-mandatory public health measures, such as providing education and information, are preferable to mandatory ones, provided they are effective. Non-mandatory measures are less controversial and easier to introduce, and do not breach the principle of individual autonomy. In many cases, non-mandatory measures are the only practicable way of improving public health (for example, safe sex, taking exercise and attending smoking cessation clinics).

However, although the Citizens Council thought that where possible people should have freedom of choice and be responsible for their own health, they also thought that when necessary NICE should recommend that interventions should be mandatory.

NICE should take the following issues into account when deciding whether to recommend that a measure is mandatory.
The balance of benefits and costs. In the case of a national emergency, the evidence needed to justify a public health intervention might be of lower quality.
The importance of respecting individual choice but within limits.
The proportionality of the measures relevant to the risk.
The requirement to reduce health inequalities.
Potential adverse effects on vulnerable members of society.
The need to ensure mandatory measures are monitored, evaluated and discontinued as required to avoid harmful consequences.
The importance of implementing measures in consultation with the broader community and after explaining the reasons for their introduction.I suspect that in the first instance one would have to recommend some interventions that are not evidence based. Under principle 7 replace public health with child protection. Cost efficacy would be a rather thorny issue, so more public consultation on that aspect.

[Fiona]

NICE should not recommend an intervention (that is, a treatment, procedure, action or programme) if there is no evidence, or not enough evidence, on which to make a clear decision. But NICE may recommend the use of the intervention within a data collection or research programme if this will provide more information about the effectiveness, safety or cost of the intervention.

Evidence means what in this context? You are aware that any statutory intervention has to be authorised by a court?


Those developing clinical guidelines, technology appraisals or public health guidance must take into account the relative costs and benefits of interventions (their 'cost effectiveness') when deciding whether or not to recommend them.

Heehehe. You think this is an issue in child care? There is almost no money. That is one of the fundamental problems. You seen case loads lately?



NICE asked the Citizens Council to consider when it is legitimate for authorities to intervene in a 'mandatory' way to address a public health problem. (Mandatory means that an intervention would be legally enforced - for example, legislation to ban smoking in public places.) The Council thought that non-mandatory public health measures, such as providing education and information, are preferable to mandatory ones, provided they are effective. Non-mandatory measures are less controversial and easier to introduce, and do not breach the principle of individual autonomy. In many cases, non-mandatory measures are the only practicable way of improving public health (for example, safe sex, taking exercise and attending smoking cessation clinics).

No idea what your point is here. Almost all social work is non-mandatory


However, although the Citizens Council thought that where possible people should have freedom of choice and be responsible for their own health, they also thought that when necessary NICE should recommend that interventions should be mandatory.

No idea what this point is either. You imagine these ideas are new?


NICE should take the following issues into account when deciding whether to recommend that a measure is mandatory.
The balance of benefits and costs. In the case of a national emergency, the evidence needed to justify a public health intervention might be of lower quality.
The importance of respecting individual choice but within limits.

The proportionality of the measures relevant to the risk.
The requirement to reduce health inequalities.
Potential adverse effects on vulnerable members of society.
The need to ensure mandatory measures are monitored, evaluated and discontinued as required to avoid harmful consequences.
The importance of implementing measures in consultation with the broader community and after explaining the reasons for their introduction.I suspect that in the first instance one would have to recommend some interventions that are not evidence based. Under principle 7 replace public health with child protection. Cost efficacy would be a rather thorny issue, so more public consultation on that aspect.


I don't honestly think you know anything about social work, Pebbles. Sorry

[Pebble]

I don't honestly think you know anything about social work, Pebbles. Sorry

Never claimed to know anything about social work. However, I think your responses show a lack of imagination.

My point - in respect of child abuse specifically, was that there should be clear evidence to back action. Where such evidence is not available, social workers and govt, should get off their high moral horse and acknowledge these shortcomings. The cost benefit argument is clearly essential if you want to change the funding streams available - regarding such a central issue as laughable, will never change the funding you receive. Finally mandatory intervention in peoples lives seems to outsiders to be undertaken with wholly inadequate safeguards. I am sure the reverse is true also, but changing perceptions is vital if you want to move to a position that allows you to justify the significant investent of public funds that would give you a chance of a high qulaity service.

[Fiona]

Never claimed to know anything about social work. However, I think your responses show a lack of imagination.

Probably. I do know what I am talking about, however


My point - in respect of child abuse specifically, was that there should be clear evidence to back action.

Yes. That is why it is tested in court. It is not an adequate system because our courts are adversarial and presume a contest between two equal parties: as with rape trials the evidence one would ideally like to see does not exist and cannot exist. So what is it you propose?



Where such evidence is not available, social workers and govt, should get off their high moral horse and acknowledge these shortcomings.

I have no idea whatsoever what you mean by this. It seems to me that you are the one with a "high horse" if anyone is.


The cost benefit argument is clearly essential if you want to change the funding streams available - regarding such a central issue as laughable, will never change the funding you receive.

What has begun to change the funding is attitudes like yours. The government is now finally realising that this ill informed and arrogant approach has meant that recruitment into social work, and retention there, had more or less dried up. Sadly the response is to "fast track" people through the training and reduce the content of it. So this is not likely to improve the situation.


Finally mandatory intervention in peoples lives seems to outsiders to be undertaken with wholly inadequate safeguards.

You know what? I really don't care. There has been a sustained campaign against my work on the basis of arrogance and ignorance. It started with us, as we are a small body with no professional organisation to speak back. It then moved to teachers and to the police and medicine, now that the corrosion is far advanced. It is apparently designed to destroy any confidence in the public sector, and it is very effective.


I am sure the reverse is true also, but changing perceptions is vital if you want to move to a position that allows you to justify the significant investent of public funds that would give you a chance of a high qulaity service.

I think not. A great deal of money has gone into attempts to change public perceptions already but it is not going to work because the media agenda is not impartial, IMO. Certainly there is no evidence whatsoever that they have responded to any of this. They continue to feed an infantile notion of child protection which makes the job we do in conjunction with the police that much harder.

Why don't you set out the kind of evidence you think might help? I would love to see what you propose.

[Pebble]

Fiona, first I would like to apologise for my ill tempered reply, but what really gets my goat is the view from any group of experts that outsiders need to be treated with contempt if they question the value of your actions.

The issue of child abuse has been with us for many generations, it is really only in the past couple of hundred years any attention has been paid to it at all, and much of what we now believe to be fundamental self evident facts have only been part of mainstream thought for the last 50 years. So the first conclusion is that however harrowing for the victim, however destructive for the family, society will survive the presence of child abuse.

As a society we must therefore decide how important is child abuse, how much of available resources should be ringfenced for this purpose, and what other services or benefits should we forego to ensure his happens. Cost benefit is therefore an essential argument to win.

Government can always side step such issues where the evidence is weak or readily portrayed as flawed. It is essential therefore when the evidence is less than perfect to err on the side of caution. This is terrible for the child but the impact of getting it wrong is destructive for the family, children and the image of your services. It is hardly surprising that media get very exercised about cases where the injustice is meeted out by those who are paid to protect our families.

Of course you will be hit from the other side too, if a child is killed, having been known to be at risk, then your failure to act will be equally criticised. Here I would argue that the system is what has failed, if agreed procedures are followed, and despite this children can be clearly shown to fall through the net, then those who are responsible for the system (ultimately the Govt.) can in the final analysis be made to acknowledge their responsibility and thus act. The adherence to agreed procedures also protects you from the media, since you can show that 'everything was done correctly' even if the outcome was disastrous.


The ultimate question then is how can one know that a child is at risk? This is like preventing thought crime. Unless parents have already caused physical injury to a child, I would suggest that you are on a loser. Even if research could show that in certain senarios the rate of child abuse will be 50%, then intervention will target 50% who would not have damaged their children. Research of this type could help to focus voluntary prevention campaigns, but not mandatory action.

Where injury or neglect is already suspected, then the weight of evidence is central. Unless the family members or others are prepared to 'confess' or act as witnesses the situation becomes very difficult. Indirect evidence must be very strongly supported by very high quality research from more than one source, unlike say anal relaxation.

So this is your field! My contention is that whenever social services cause an injustice by acting against someone that is later shown to be innocent, you will be villified, even if the courts and police are involved - since you undertake the investigation and present the evidence. While I understand the desire not to fail a child in need, I am simply asking when you take a family to court how would the level of evidence presented stack up to an objective independent observer. The requirement of objectivity is that the observer is not emotionally swayed by any consideration of the consequences of not removing the child.

You may feel that this is a very 'cold' approach, that is the nature of skepticism. I would put it to you that the alternative is taking chances with the lives of innocent families, and that is the reason the media attack you, and hence your funding, staff attraction and retention issues.

[Fiona]

Fiona, first I would like to apologise for my ill tempered reply, but what really gets my goat is the view from any group of experts that outsiders need to be treated with contempt if they question the value of your actions.

I am not really bothered by your tone, Pebbles. I am more than used to it. But the charge is that social work treats questioning by outsiders with contempt. The opposite is the truth and it has led to the current situation in fact. Social work never speaks for itself as other "professional" groups do through professional associations. There is never a robust or even an articulate explanation of the situation: the case is made by local authority spokespeople who are not and never have been social worker; who are informed by the tabloid press just as you are; and inquiries are conducted by judges or medical personnel with little or no knowledge of the subject at all. More than any other group we have allowed outsiders to define the work that we do and this has damaged us perhaps beyond repair. It is sadly true that in the current climate an honest statement that we may have "lessons to learn" is seen as an admission of guilt. Other professions know this and are less quick to say it publicly: they have benefitted from this otherwise regrettable stance but we do indeed have "lessons to learn" from them


The issue of child abuse has been with us for many generrations, it is really only in the past couple of hundred years any attention has been paid to it at all, and much of what we now believe to be fundemental self evident facts have only been part of mainstream thought for the last 50 years. So the first conclusion is that however harrowing for the victim, however destructive for the family, society will survive the presence of child abuse. Tell me it isn't so !::)
Can you be any more patronising?


As a society we must therefore decide how important is child abuse, how much of available resources should be ringfenced for this purpose, and what other services or benefits should we forego to ensure his happens. Cost benefit is therefore an essential argument to win.Doh!!::)


Government can always side step such issues where the evidence is weak or readily portrayed as flawed. It is essential therefore when the evidence is less than perfect to err on the side of caution. This is terrible for the child but the impact of getting it wrong is destructive for the family, children and the image of your services. It is hardly surprising that media get very exercised about cases where the injustice is meeted out by those who are paid to protect our families.Amazing! Getting it wrong causes harm to families and children. Who knew?
Later in this post I will call this kind of outcome a "type 1 error", for brevity


Of course you will be hit from the other side too, if a child is killed, having been known to be at risk, then your failure to act will be equally criticised. Here I would argue that the system is what has failed, if agreed procedures are followed, and despite this children can be clearly shown to fall through the net, then those who are responsible for the system (ultimately the Govt.) can in the final analysis be made to acknowledge their responsibility and thus act. The adherence to agreed procedures also protects you from the media, since you can show that 'everything was done correctly' even if the outcome was disastrous. I hardly know where to start with this drivel.

First: it will not be equally criticised. It will be criticised in far more practical ways because I will lose my job. Your pie in the sky complacency needs to take the real world into account
Second: it is not automatically true that the system has failed if a child dies. It is an inevitable consequence of the very caution you advocate. If a doctor acts in a reasonable and professional way, yet his patient dies, this is accepted. If a police officer shoots someone and he can be shown to have acted reasonably in the circumstances this is also accepted. (though both are finding that harder to establish now the media has turned their agenda on these far more powerful bodies). Yet this infantile notion, that if the "proper procedures" were followed no child would ever die, persists and is propagated.

I do recognise that is not the position you have outlined since you prefer to think that if the proper procedures are followed then the "blame" will fall on those responsible for the system and they will be forced to act. Trouble is there is no action which can be taken, and which is politically possible. Because action would comprise telling the public and the press to grow up.

As to protecting us from the media. well sorry to disappoint you, but I am drowning in proper procedures. The whole profession is in defensive mode and every move we make is constrained by that idea. The practical effect is to make many more of the type 1 errors you are so concerned about, since the local authorities fondly imagine that you are right. The Caleb Ness enquiry proves you are wholly wrong.



The ultimate question then is how can one know that a child is at risk? This is like preventing thought crime. Unless parents have already caused physical injury to a child, I would suggest that you are on a loser. Even if research could show that in certain senarios the rate of child abuse will be 50%, then intervention will target 50% who would not have damaged their children. Research of this type could help to focus voluntary prevention campaigns, but not mandatory action.Absolutely. So what do you suggest? This is the heart of the matter. There is no credible evidence of the sort we sceptics love;and there cannot be. Large amounts of money go into laughable "research" which tell me things like the degree to which the children of alcoholics or drug addicts are at more risk than others: that children in households where there is domestic violence are more vulnerable etc etc. How does any of that help me to decide if wee Susie X is at risk? It doesn't and it cannot. Epidemiology is useful for decisions about targetting services: clinical judgement is still the foundation for much of medicine. Social work is no different.


Where injury or neglect is already suspected, then the weight of evidence is central. Unless the family members or others are prepared to 'confess' or act as witnesses the situation becomes very difficult. Indirect evidence must be very strongly supported by very high quality research from more than one source, unlike say anal relaxation.Again I ask: what kind of research do you envisage. Unless you can make some positive suggestion this is just a mantra and does not speak to anything in the real world


So this is your field! My contention is that whenever social services cause an injustice by acting against someone that is later shown to be innocent, you will be villified, even if the courts and police are involved - since you undertake the investigation and present the evidence. Yes we will. But you don't get it, do you? Social work is called the lead agency in such matters but child protection investigations are in practice led by the police. Actions are agreed in "consultation" with them in the early stages and the timetable is determined by their shift patterns very largely. Action to protect a child is indeed based on evidence presented in court or, in an emergency, to a judge in chambers. The decision is entirely theirs. The villification of social workers is made easier by ignoring these facts. It is also made easier by the fact that the inter-agency protocols in place are largely ignored by other professionals, especially doctors. I have seldom seen a GP at a case conference: I have never seen one at a children's hearing. I have been amazed by the unwillingness of consultants to make a definitive statement about the cause of injuries. it is a case of "McCavity wasn't there"


While I understand the desire not to fail a child in need, I am simply asking when you take a family to court how would the level of evidence presented stack up to an objective independent observer. The requirement of objectivity is that the observer is not emotionally swayed by any consideration of the consequences of not removing the child.If the court is not the independent observer of your dreams then what is?


You may feel that this is a very 'cold' approach, that is the nature of skepticism. I would put it to you that the alternative is taking chances with the lives of innocent families, and that is the reason the media attack you, and hence your funding/ staff attraction retention issues.As follows from the rest of this post: no I don't think it is cold. I certainly dont' think it is sceptical. I think it is the worst form of woo. Sorry to sound harsh but you really do not have a notion about this

[Pebble]

I am not really bothered by your tone, Pebbles. I am more than used to it.

I am bothered. I don't like acting defensively.


But the charge is that social work treats questioning by outsiders with contempt. The opposite is the truth and it has led to the current situation in fact.

Please read you recent entries. It is clear you regard my views with contempt.


Social work never speaks for itself as other "professional" groups do through professional associations.

This is in your hands, set up a body to represent yourselves


There is never a robust or even an articulate explanation of the situation: the case is made by local authority spokespeople who are not and never have been social worker; who are informed by the tabloid press just as you are; and inquiries are conducted by judges or medical personnel with little or no knowledge of the subject at all.

The LA has a different agenda, defending the system they administer, nothing to do with tabloids. I never read tabloids.


Other professions know this and are less quick to say it publicly: they have benefitted from this otherwise regrettable stance but we do indeed have "lessons to learn" from them

Not the way to go. Stop admitting to your problems and you stifle improvement, I know you won't agree, but you are wrong.


Tell me it isn't so !::)
Can you be any more patronising?

I had made the point in respectof cost efficacy twice before and you did not appear to understand why I though this was important. That is why I added this introduction.


Doh!!::)

Amazing! Getting it wrong causes harm to families and children. Who knew?
Later in this post I will call this kind of outcome a "type 1 error", for brevity

Treating the legitimate concerns of others like this does you no favours.


First: it will not be equally criticised. It will be criticised in far more practical ways because I will lose my job.

And I thought your primary concern was the welfare of children


If a doctor acts in a reasonable and professional way, yet his patient dies, this is accepted.

I do recognise that is not the position you have outlined since you prefer to think that if the proper procedures are followed then the "blame" will fall on those responsible for the system and they will be forced to act. Trouble is there is no action which can be taken, and which is politically possible. Because action would comprise telling the public and the press to grow up.

So you have all the answers, simply give the SW a free hand and trust you to sort it out?


The whole profession is in defensive mode and every move we make is constrained by that idea. The practical effect is to make many more of the type 1 errors you are so concerned about, since the local authorities fondly imagine that you are right. The Caleb Ness enquiry proves you are wholly wrong.

So the LA is wrong to regard protecting those who are possible innocent from intervention?


How does any of that help me to decide if wee Susie X is at risk? It doesn't and it cannot. Epidemiology is useful for decisions about targetting services: clinical judgement is still the foundation for much of medicine. Social work is no different.

Clinical judgement is fine when treatment is by mutual consent. Remove the element of consent and a tool as error prone as clinical judgement is unacceptable.


Again I ask: what kind of research do you envisage. Unless you can make some positive suggestion this is just a mantra and does not speak to anything in the real world

In research experts in the field ome up with the question to be answered, and suggest possible ways of exploring the question. Those with a knowledge of research methodology (here I would include myself) then address whether the proposal is robust, will the primary end point be achieveable, what size and duration of study will be required, what statistical methodolgy should be used,, and what one should do about confounders. So your question is misdirected. If those in the field have no research ideas to test you cannot advance the field.


Yes we will. But you don't get it, do you? Social work is called the lead agency in such matters but child protection investigations are in practice led by the police. Actions are agreed in "consultation" with them in the early stages and the timetable is determined by their shift patterns very largely. Action to protect a child is indeed based on evidence presented in court or, in an emergency, to a judge in chambers. The decision is entirely theirs.

I stand corrected


I have seldom seen a GP at a case conference: I have never seen one at a children's hearing. I have been amazed by the unwillingness of consultants to make a definitive statement about the cause of injuries. it is a case of "McCavity wasn't there"

Are you seiously suggesting that if clinicians would only agree with you that these injuries have been inflicted by the parents even though other possibilities exist that this would improve the situation?


If the court is not the independent observer of your dreams then what is?

I was actually suggesting that you stand back and look at your evidence from this perspective, then you might feel less embattled, and begin to understand that the world is not against you, simply wary of intervening incorrectly.


As follows from the rest of this post: no I don't think it is cold. I certainly dont' think it is sceptical. I think it is the worst form of woo.

Gratuitous

[Pebble]

Have read the introduction and conclusions of Caleb Ness Inquiry. Seems a fairly even handed report, my quibble would only be that any inquiry after the fact is by definition flawed. It is easy to suggest that (a) led to (b) once the outcome is known. The real question which was dodged, is how many similar situations do not lead to an adverse outcome.

I would certainly commend to you a study of child care issues among drug addict and brain damaged parents. End point: recorded child injuries irrespective of cause. Control group: similarly disadvantaged parents without drug habit or brain injury. Size and duration: depends on how frequent you think child injury is in each of these groups.

[Fiona]

I regard your views as ignorant, Pebble, nothing more. And I agree an effective professional body would help: however this is not likely at the moment since the registration council is new and many hold out hope it will serve that purpose. Perhaps it will in time.

I did say it was an "otherwise regrettable stance".

Your point about cost efficacy rests on research I think? Where is it?

What are your legitimate concerns? Statutory intervention has always been a measure of last resort in social work. There is less non-statutory and preventive work now because of the situation we are in but it is still both professionally and legally a last resort. I assume you are aware of the "no order" principle? It is one of the three fundamental principles of child care law


And I thought your primary concern was the welfare of children Yes. But I am also human and I have other concerns as well. As I am sure you do too. Or are you really one of those who is utterly selfless?

I did not say I have all the answers. I take from your posts that you do. I live with uncertainty all the time. That is the nature of working with people in a job which is specifically geared to deal with those who do not fit in happily to universalist services. I do believe that social work practice should be judged by social workers as well as by outsiders, yes. This is common in many fields and although that is now under attack I think that there are good reasons for it


So the LA is wrong to regard protecting those who are possible innocent from intervention?They are not protecting the innocent: they are protecting the local authority. Or so they think. And as I said, it leads to more statutory intervention and less risk taking than before. It is precisely the opposite outcome than what you seem to seek


Clinical judgement is fine when treatment is by mutual consent. Remove the element of consent and a tool as error prone as clinical judgement is unacceptable.That is why the decisions are taken by the courts. On your reasoning we should dismantle the police force for they are in exactly the same position. They take their evidence to court and the court decides whether it is good enough. What system do you suggest should supercede this?

It is not and cannot be science. Some things aren't, you know


Are you seiously suggesting that if clinicians would only agree with you that these injuries have been inflicted by the parents even though other possibilities exist that this would improve the situation?Of course not.You are confounding two separate points.
1. The public seems to believe that doctors can say something about how injuries are caused. This is almost never true, but the expectation renders the court process much harder. Let me give you an example, of a case I was involved with.

An 11 year old girl was taken to A+E by her parents because she was bleeding from her vagina. They explained that she had been playing on the floor in her nightdress and the family's labrador puppy had mounted her. The doctor stitched her up and sent her home. 4 days later the consultant saw the notes and was not happy and he referred the girl to social work. He would make no statement as to the cause of the injury nor of the likelihood of the explanation given. What do you think should happen in such a case? Is there no responsibility on the doctor to say something about the reasons he made the referral ? to say something about other possible explanations? the fact is they will say nothing at all.

2. In line with recommendations from enquiries and also with the law as it now stands I am suggesting that primary care participation in multi-agency plannng would improve the situation. I can see nothing controversial about that


I was actually suggesting that you stand back and look at your evidence from this perspective And I was trying to explain that I do this all day every day.

[Pebble]

I regard your views as ignorant
Don't knock ignorance, sometimes the best questions come from children


Your point about cost efficacy rests on research I think? Where is it?If your profession has never addressed the question of cost efficacy through appropriate research, this significantly weakens your case in respect of underfunding


I did not say I have all the answers. I take from your posts that you do.I think I have made it abundantly clear that I am questioning your assumptions, not saying that the answers are known. If one recognises where the gaps in knowledge are, only then can one construct the appropriate research portfolio. This may take many years to bear fruit but that is not a reason for giving up


That is why the decisions are taken by the courts. On your reasoning we should dismantle the police force for they are in exactly the same position. They take their evidence to court and the court decides whether it is good enough. What system do you suggest should supercede this? Finger printing, DNA, video surveillence etc, the police do not act only on confessions and intuition these days


It is not and cannot be science. Some things aren't, you know Why not? I have suggested one study one could reasonably do, In many cases your complaint about the quality of studies available to you show that these studies were poorly constructed and failed to address the questions you face on a daily basis, not that such studies are impossible to conceive of and perfrom. As with police work there will still be a role for gut feelings and knowing people, but unsupported by a degree of objectivity you are in a similar position to homeopathy: no evidence base


Of course not.You are confounding two separate points.Was not evident from your entry


4 days later the consultant saw the notes and was not happy and he referred the girl to social work. He would make no statement as to the cause of the injury nor of the likelihood of the explanation given. What do you think should happen in such a case? Is there no responsibility on the doctor to say something about the reasons he made the referral ? to say something about other possible explanations? the fact is they will say nothing at all. Absolutely not! If he was concerned that the explanation given might not be valid and his expertise extended no further than that, then he must not guesstimate probabilities


2. In line with recommendations from enquiries and also with the law as it now stands I am suggesting that primary care participation in multi-agency plannng would improve the situation. I can see nothing controversial about that Does not address my primary concern, lack of any research program to address fundamentals


And I was trying to explain that I do this all day every day.Glad to hear that you try to do this, your entries suggest that you still do not understand the reasons others act as they do in these senarios (e.g. the Dr in your example)

[Fiona]

I think we are talking at cross purposes. Pebble. You are not questioning my assumptions so far as I can see: you are laying out you own

You say you have suggested a study one could reasonably do. I have read your post again and I do not see it. Can you spell it out for me please.All I can see is this
I would certainly commend to you a study of child care issues among drug addict and brain damaged parents. End point: recorded child injuries irrespective of cause. Control group: similarly disadvantaged parents without drug habit or brain injury. Size and duration: depends on how frequent you think child injury is in each of these groups.If this is what you mean can you tell me how you think this would help?

Turning to the doctor: no I do not understand why he acted as he did. How about you answer the question I asked? What should happen next ?

[Pebble]

I think we are talking at cross purposes. Pebble. You are not questioning my assumptions so far as I can see: you are laying out you own

You say you have suggested a study one could reasonably do. I have read your post again and I do not see it. Can you spell it out for me please.All I can see is this If this is what you mean can you tell me how you think this would help?

Turning to the doctor: no I do not understand why he acted as he did. How about you answer the question I asked? What should happen next ?

Cross purposes are wonderful, created amazing debates. You have asserted that there is no evidence based practice, hence my questions/doubts in respect of the wisdom of the current approach.

Study: I have suggested one possible study, many would obviously be necessary to change the situation you describe. In essence, study the strenght of association between say addicted mothers and child injury, accepting that a proportion of said injuries will be 'normal' some due to neglect and some deliberate. HAving established that there is a consistent statistically significant excess of injuries when compared to an equivalent population in a number of studies, address the issue of cost beenfit: How many families need to be screened to find a parent with drug addiciton, what is the cost of doing this. What intervention has been demonstrated in parallel studies to be effecgtive in this population, and how many child injuries are prevented by said intervention. What rhus is the total cost per child injury prevented.
This approach clearly needs replication over many situations you face on a daily basis. I do not underestimate the difficulty of achieving this.

As for you Dr. It is clear from your story that the consultant had not actually seen the child in question, merely identified that the explanation acccepted by his junior was unlikely to be correct. How in such circumstances could he reasonable offer alternate explanations, or assess who was most likely to be responsible?

[Fiona]

Cross purposes are wonderful, created amazing debates. You have asserted that there is no evidence based practice, hence my questions/doubts in respect of the wisdom of the current approach.

I do not think we are clear even yet. In child protection evidence is presented in court. How can it not be? This is where I am getting confused because this does not seem to be what you mean


Study: I have suggested one possible study, many would obviously be necessary to change the situation you describe. In essence, study the strenght of association between say addicted mothers and child injury, accepting that a proportion of said injuries will be 'normal' some due to neglect and some deliberate. HAving established that there is a consistent statistically significant excess of injuries when compared to an equivalent population in a number of studies, address the issue of cost beenfit: How many families need to be screened to find a parent with drug addiciton, what is the cost of doing this. What intervention has been demonstrated in parallel studies to be effecgtive in this population, and how many child injuries are prevented by said intervention. What rhus is the total cost per child injury prevented. I have already said there are many such studies. What good do you see them doing in my job? I see precisely no value in them. At present there is a panic on about mothers who abuse illegal drugs, and so in some areas of the country every one who uses such drugs who becomes pregnant is identified in maternity hospitals and a case conference is held. This is not an initiative from social work: it is health and social services responding to this kind of politically driven "evidence based" approach. It is a complete waste of time and money. It is not applied to alcohol dependent mothers, or those reliant on prescription drugs, or any other group where studies have shown the behaviour statistically increases the risk to children. Not all people who misuse drugs abuse children and it is positively insulting to suggest that they do. It is the antithesis of cost effective practice and it is one of the examples which make me so angry.

Please understand that, as I have already said, this kind of approach is fine for targeting services to vulnerable people as a policy and resourcing issue: it has nothing whatsoever to say to me about a particular family, and if I acted as if it did then I think I would be rightly criticised for an increase in what I called type 1 error. It is exactly the same as the justification for the over representation of black people in the stop and search debate: they are statistically more likely to commit crime and so it is proper to stop them more readily. This is a daft argument and I will not allow my practice to reflect this attack on my values and the values of my profession.




As for you Dr. It is clear from your story that the consultant had not actually seen the child in question, merely identified that the explanation acccepted by his junior was unlikely to be correct. How in such circumstances could he reasonable offer alternate explanations, or assess who was most likely to be responsible?He couldn't. So why did he make the referral? Again I ask, what do you think should happen in response ?

[Pebble]

Have made a brief attempt to see what is published. Pub med retruns 103 studies on 'child + abuse + addiction, most are studies of childhood abuse and subsequent addiction.

Google scholar returns over 15000 hits between 2000 and 2007, however mainly these are books where old research is quoted. From what I can initially glean there is no good quality research in terms of what I have outlined: if you know of any please point me in the right direction.

What I find are like the following:

http://www.questia.com/googleScholar.qst?docId=5002443136

Children of Mothers with Serious Substance Abuse Problems: An Accumulation of Risks (#).

by Nicola A. Conners , Robert H. Bradley , Leanne Whiteside Mansell , Jeffrey Y. Liu , Tracy J. Roberts , Ken Burgdorf , James M. Herrell
Although there are few reliable estimates of the numbers of children in the United States whose mothers are addicted to alcohol or other drugs, the information available suggests the number may be shockingly high. Researchers estimate that up to 15% of all American women between 15 and 44 years old abuse alcohol or illicit drugs (1). Results from the combined 2000 and 2001 National Household Survey on Drug Abuse (NHSDA) indicate 3.7% of pregnant women reported using illicit drugs in the prior month (2). Also based on the NHSDA, it has been estimated that 10% of children (more than 7 million) have at least one parent who is dependent on alcohol or illicit drugs and that 6% have at least one parent who is in need of treatment for illicit drug use (3). These estimates suggest that millions of children currently are being reared in environments characterized by maternal addiction.
Children of substance abusing parents are widely considered at high risk for a range of biological, developmental, and behavioral problems, including for developing substance abuse problems of their own. However, while much has been written about possible risks that parental substance abuse poses to children, there is almost no systematic documentation of the life circumstances of these children. Further documentation of the life experiences of such children is critically needed for both policy makers and those involved in planning health and human services. Although studies examining...

or:

1: Child Welfare. 1998 Jul-Aug;77(4):407-26.Preventing child placement in substance-abusing families: research-informedpractice.Dore MM, Doris JM.Columbia University School of Social Work, New York, NY, USA.The authors present finding from their study of a placement prevention programdesigned to facilitate addiction treatment for substance-abusing mothers andother primary caregivers reported for child maltreatment. Relationships betweeninvolvement in the program, the status of addiction treatment, and the variety ofoutcomes for caregivers and their children were tested. Findings indicate thatnearly half of the participants were able to complete addiction treatment andachieve sobriety. Those who used the program's child day care component werethree times more likely to complete treatment. Implications for confronting theproblem of substance-abusing caregivers in the child welfare system are drawn.:undecided:

I think this sort of data is not very useful, the problem is that if that is all you have 'experts' will try to come to conclusions and draw up action plans based almost entirely on their particular moral framework, this I would suggest is why authorities focus on illicit drug addicts and not alcoholics.

If you had decent comparative research showing that the likelihood of abuse was no higher among illicit addict parents when compared to alcoholics, then the authorities would have to listen.Once you have such studies, then you can begin to suggest rational targeting of research into programs of intervention and stop the media and political expediency determining your direction. Further when presenting cases to courts you can use such studies to back up the probability of your assessment being correct.


As for Dr. If he felt that the explanation accepted by his junior was incorrect. It follows that he/she thought abuse was one of the options. Referral then becomes mandatory. It does not bring him/her any closer to knowing what happened. It is for those investigating to determine that if possible.

[Fiona]

I think you make my point, really. There is no evidence which helps. There are no "experts" in the policy making arena: only politicians and a variety of interest groups, including "so called" academics who have no idea at all. A great deal is informed by a "moral framework" but this is nothing at all to do with social workers, who waste a great deal of time and energy resisting the "flavour of the month".

There is little or no relationship between those who do the work and those who do research. When we do meet, usually at training events where they present their findings it is quickly clear that the quality of research is poor and even if it were not it is useless. They do not hear this, however. I do not know who makes the decisions about such research but they are not social workers and they do not talk to social workers. I am quite happy to support more and better research, but meantime I have to do my job and it offers nothing at all at present.

Let me give you another example. I went to a training event recently where the researcher had concluded that a comprehensive inter-agency assessment should be done on every child referred to any of the relevant agencies. Who could disagree? I don't actually think we need research to know that, but hey if it helps to get the money lets waste some. He went on to say that such an assessment would take approximately 3 months if the agencies were all properly coordinated and available.

He did not seem to know that there is legislation in the form of an "assessment order", which is applied for and granted by the court (S.55 Childen (Scotland) Act 1995). It is intended to be used where there is reasonable cause to suspect a child is being "so treated (or neglected) that he is suffering, or likely to suffer, significant harm" . It goes on to say that such an order will "have effect for such period as is specified in the order, not exceeding 7days.."

But even if a family are prepared to allow an assessment, and so the order is not required, an assessment report ordered by the children's reporter must be finalised in 6 weeks: per the requirements of the Scottish Executive. This is a relatively recent requirement. It is absurd, frankly. Social workers know it is absurd. We do not need a rule of any kind. Some assessments take longer and some are relatively short. In the past it took the time it took. Not now. And this is also based on "evidence" informed by cost efficiency and the imposition of targets based on averages.

So we have the "research" and we have the law, informed by one part of the research findings and wholly at odds with another: both equally relevant. I see no hope that in this situation the law will not reflect what is cheaper

What do social workers do in this situation? They break the rules to make the system work, is what. We do it all the time. We can never be "fireproof" in terms of "following procedures" because we cannot do our jobs if we do. Just like most people in fact. A " work to rule" brings most organisations to a standstill, and we are no different.

Having said that, there are legal and procedural requirements I must follow. And the effect of this is to stop me working effectively. Recent research issued by the Scottish executive at last recognises that the most effective intervention in many situations is the relationship with the social worker (Review of social work in the 21st century - Changing Lives http://www.scottishexecutive.gov.uk/Publications/2006/02/02094408/0) and acknowledges the damage done over the last 20 years. It is a nice glossy document and it does address much of what I see as the problem. But in another part of the forest the paper work attached to social work is now such that it takes me half the week to do it. That is half the week when I am not doing my job; I am writing about doing my job. Some of it is necessary - there is an increasing demand for reports for various bodies and those are mandatory: much of it is completely useless and much of it is duplication of information or recording of information which is nothing to do with the case. This is something which all those who work with the public complain about ( teachers; civil servants etc) and it is detrimental to the service we can provide. The review also recognises this and we hope it will change but there is no sign of it yet

Despite the fact that the relationship is formally recognised as central to effectiveness, I spoke to a social worker in another team last week. She works in a child care team and she is part time, working 20 hours a week. She has 35 cases. I can tell you that a full time worker can effectively service between 8 and 20 depending on complexity. She is not unusual. Some authorities have a policy of keeping case loads manageable and the service is far better when they do: but others are informed by a "target" which insists all statutory child care cases must be allocated. And so they allocate them. On paper. And the box is ticked. Have you any idea how stressful that is for the social worker?

What you do not seem to realise is that social workers spend their lives trying to uphold the value of the individual: trying to resist the "flavour of the month" witch hunts; risking themselves to base intervention on evidence rather than prejudice ( in practice this means having cases which are very scary sitting on your desk; and waiting for something to happen and hoping it will be enough to let you take effective action and not so much that you will be pilloried in the press for not acting sooner); trying to balance a law which emphasises parental rights and lays a duty on social workers to

"(a) safeguard and promote his welfare"

and

" take such steps to promote, on a regular basis, personal relations and direct contact between the child and any person with parental responsibilitis in relation to him as appear to them to be, having regard to their duty to him under paragraph (a) above, both practicable and appropriate"

(S 17 Children (Scotland( Act 1995)

I do not know the details of the Gamor case: but I do know there is a lot of "evidence" to show that most people with schizophrenia are not violent: and that the policy is to keep the majority of mentally ill people in the community and to "normalise" their lives as far as possible. We will see when the report comes out, but it is already clear that your idea that society will live with the idea that some children will die is not on the agenda.

And turning again to the doctor. He did not see the child: his juniors did. If there was nothing he could say as to cause or likelihood then although you are right and he must refer if he is not satisfied, I ask again, what is the aim of such a referral? What do you think should happen?

[Pebble]

Fiona, what can I do but offer my sympathy?

I would say that proper research is vital and can address the problems that plague you on a daily basis. The researcher you write of was clearly not very well informed, hence the research output less helpful than needed. The primary question should have been what are the practical timelines for optimal inter agency co-ordinated care? Armed with this one can go to the LA and demand that sufficient time is given or your employers accept the consequences of cost cutting.

That academics are not addressing the questions you face on a daily basis is hardly surprising, that is why you need your own professional body, their primary purpose should be to lobby for research to address the issues that make your job impossible.

In the mean time I do not envy you, the job you do is essential, but the parameters you work with are harmful both to you and your clients. Keep positive, only by fighting for what you believe in can you get the result we all need.

[Fiona]

Sorry Pebble: it was not "less helpful": it was culpably ignorant and completely useless. It was also an insult, as much of this research is. It is predicated on the idea that we do not do good practice because we do not know what it is. I do not find it at all suprising that social workers are generally hostile to this stuff, though I do think it is regrettable.

You have still not said what kind of research you think would be helpful, Pebble. Let me return to the NICE link posted by Bindeweede in the Ritalin thread.


ADHD can only be identified by looking for certain characteristic types of behaviour..

Can you explain how this type of "diagnosis" differs from what I do? The research is related to the effectiveness of treatment but it does not help the clinician make the diagnosis: it is actually based on the clinical experience of those who drew up the criteria - nothing more


in some cases treatment may be appropriate for children and adolescents who do not fit the diagnostic criteria for HKD but are experiencing severe problems due to inattention or hyperactivity/impulsiveness.

How is this science?


Diagnosis should be made on a timely, comprehensive assessment conducted by a child/adolescent psychiatrist or a paediatrician with expertise in ADHD. It should also involve the child, his/her parents and carers and the child's school, and take into account cultural factors in his/her environment. Multidisciplinary assessment, which may include educational or clinical psychologists and social workers, is advisable for children who show signs of other significant disease or conditions.

And this is not science either. It is a description of how assessments are made in ideal circumstances and it is no different from what I do


While this wider service is desirable, any shortfall in provision should not be used as a reason for delaying the appropriate use of the medicine.

Nothing there to suggest that this approach is going to increase service provision: we are to live with that, it seems.


Access to child and adolescent mental health services is variable, with long waiting times in some areas.

Something of an understatement in my experience; child and adolescent psychiatric services are vanishingly rare: so the idea that diagnosis will be made by someone with such expertise is just laughable. But social work is the agency which gets the problems others do not deal with. That is just the way it is. If there is no appropriate service but the child is causing trouble the trouble comes to us; and we cannot pass it on: if there is a service and the input is ineffective they close the case and if the child is causing trouble the case comes to us; and we cannot pass it on.


Child/adolescent psychiatrists and paediatrician with expertise in ADHD should review their practice in line with the guidance .

There is a strong implication that these professionals do not know what good practice is. Since the "guidance" is based on what the clinicians told NICE, this is the same kind of insult which I referred to before. If the aim is to inform the public so the "sharp elbows of the middle class" can push for more service, well and good. Why the assumption that the professionals do not already follow this guidance ( with the proviso that there will be bad practitioners in any job, of course) since they provided it?


This guidance does not, however, override the individual responsibility of health professionals to make the appropriate decisions in the circumstances of the individual patient

Back to clinical judgement. It has to be so, because people are not statistics and there is never a one-to-one relationship between treatment and effect. Not in medicine: not in any field dealing with the individual. Proper controlled trials can, in the case of drugs, sort out what definitely does not work and this is great: where is the equivalent certainty in social work? It may be theoretically possible, but I sincerely doubt that. There are too many variables and too many individual differences: problems tend not to come as single spies and one cannot isolate them.

I am committed to my work, Pebble. It is frustrating and it is very irritating to face the kind of prejudice you started with. I am sorry I lost my temper but you really do not know what we do or how we do it: and I am afraid I see your organisation as part of the problem, precisely because of the unexamined assumptions you bring to this. We are unlikely to agree, and that is ok: but for me this is scientism, not science. If and when it becomes science I will be very happy

[Pebble]

I am sorry that you remain so hostile to my ideas, because I think we can acheive much more if we understand each others point of view and try to work together.

You dismiss much of what research is about. I fail to see why. Certainly there is an awful lot of crap research, as in every area. But studying the blindingly obvious is important. For example there were 11 studies showing that Vitamin E improved heart disease, there were hundreds of boodk dealing with the improtance of free radicals in heart disease. Despite it being absolutely obvious to many people that vitamin E was 'good' for the heart, when properly designed trials were performed, vitamin E was useless or worse. I do not know the details of the research this individual presented, but whether it is 'insulting' or not really depends on the quality of the study not the chosen end points.

You castigate research for studying 'good practice' if appropriate one should criticise the methodology, especially if conclusions are reached that are not justified by the quality of the data. But research into 'good practice' is essential. Only in the past 5 years has research shown clearly how attention to hand washing and other hygeine measures combine to virtually abolishe hospital acquired infection. Hospital staff have been batteling with this issue for centuraries, and were convinced that they knew how to prevent infection spread, and that they were implementing effective procedures, but felt that government interference caused overcrowding and excessive throughput, and that this was the problem, not their hygeine. No one argues that anymore.

You feel that NICE guidance on ADHD is not based on science. In much of this I would agree, but setting the standards, allows research to focus on improving that situation. ADHD is indeed 'diagnosed' based on clinical hunch, there are standardised ways of doing this, and thus opertunities for improving the current rather hit and miss approach in the future. But in any event it is clear that ritalin improves behaviour in the majority that fit current criteria, so it is less relevant whether the diagnosis is correct, only whether the process identifies those likely to benefit from treatment (this aspect is clearly science: i.e. evidence based)

You castigate NICE for recommending that children receive a trial of theray even if the appropriate personnel are not locally available to make a timely diagnosis. I agree that insisting that appropriately skilled people are made available to everyone in need would be better. But if the diagnositic algorhythm is followed, then those would are likely to benefit from treatment can be identified, even by non experts. Should those individuals continue to be ignored until Nirvana is acheived?

You castigate NICE for guiving guidance to professionals, as I have shown by example even highly trained clinical staff in hospitals need gudiance. It is not insulting to codify, standardise and publicise how professionals should behave, it is essential, we are all human and all need reminding about how we should do things again and again.

You dislike pushy parents. They are your allies, when they do not have you personally in their sights. They will agitiate and fight for what they perceive is right. Yes it is done selfishly, and they don't care once they have got their way. But what energy, harness it by directing them toward the LA and the politicians, conveince them that you believe that every child should have what they are asking for and let them do the fighting for you.

Randomised trials not appropriate for complex care packages? Yet again let me bring you back to the hospital hygeine issue. No single askect of the care package, e.g. not wearing ties in contact with patients can be shown in isolation to reduce infection. But the whole package of measures when applied together and policed rigorously reduces infection so dramatically that govt, health authorities, the media and hospital staff acknowledge that change is necessary. It is not easy; it is very possible.

I do not work for NICE. I have worked with them on a few projects (hence 'indirectly'). I know you think I am predjudiced, but I think not. I think that you have become too wary of external criticism, and the very people that you must work with to improve the situation (researchers, LA, pushy parents and Govt bodies) are your enemies. Sometimes accepting the criticism of others even if you have doubts as to the validity of said concerns is very enlightening, if give the opportunity to reflect on one's practice, and to analyse whether there might be truths other than one's own.

As to the studies: I have outlined how I think research in SW should be approached over several responses. If you are waiting for detailed specific proposals then I am sorry, that is not possible. To get to that point I would need to work on a specific question with someone such as yourself over a period of weeks or months.

[Fiona]

You dismiss much of what research is about. I fail to see why. Certainly there is an awful lot of crap research, as in every area. But studying the blindingly obvious is important. For example there were 11 studies showing that Vitamin E improved heart disease, there were hundreds of boodk dealing with the improtance of free radicals in heart disease. Despite it being absolutely obvious to many people that vitamin E was 'good' for the heart, when properly designed trials were performed, vitamin E was useless or worse. I do not know the details of the research this individual presented, but whether it is 'insulting' or not really depends on the quality of the study not the chosen end points.

I dismiss research because it is crap, yes. I think that is fair enough. I have already said that if there were good research I would be more than happy. There is not. It is politically driven ie it is based on what you earlier dismissed as "moral judgement" It is social workers who are trying to resist this and researchers who are furthering that agenda. That need not be true: it just happens that it is true.


You castigate research for studying 'good practice' if appropriate one should criticise the methodology, especially if conclusions are reached that are not justified by the quality of the data. But research into 'good practice' is essential. Only in the past 5 years has research shown clearly how attention to hand washing and other hygeine measures combine to virtually abolishe hospital acquired infection. Hospital staff have been batteling with this issue for centuraries, and were convinced that they knew how to prevent infection spread, and that they were implementing effective procedures, but felt that government interference caused overcrowding and excessive throughput, and that this was the problem, not their hygeine. No one argues that anymore.

I would like to see references for this. Hospital staff have known about the importance of personal hygiene since Florence Nightingale and they practiced it relentlessly for many years. Then the running of hospitals was taken out of the hands of doctors and nurses and handed over to managers. And the cleaning was privatised. And the bed occupancy rates were increased. And the staff complements were reduced. And there was increased dependence on agency staff. And the training of nurses took them away from core tasks to make them more involved in things which used to be doctor's tasks. And the "professionalisation" of nursing meant that the distinction between SEN's and SRN's was abolished.And young nurses were encourage to believe that basic care was beneath them. And matrons were managers drowning in paper work where they existed at all. And now we have re-invented the wheel and you think this is a plus for research? Well I am sorry, but it was research on "cost effectiveness" that caused the problem, in my humble opinion.


You feel that NICE guidance on ADHD is not based on science. In much of this I would agree, but setting the standards, allows research to focus on improving that situation. ADHD is indeed 'diagnosed' based on clinical hunch, there are standardised ways of doing this, and thus opertunities for improving the current rather hit and miss approach in the future.

You may be right. Show me.


But in any event it is clear that ritalin improves behaviour in the majority that fit current criteria, so it is less relevant whether the diagnosis is correct, only whether the process identifies those likely to benefit from treatment (this aspect is clearly science: i.e. evidence based)

I don't understand this. According to the NICE guidance this is not true. What it says it that if the clinician's assessment is that the behaviour might be improved by ritalin then try it for a while: and stop if it does not work. It is quite clearly relevant whether the diagnosis is correct, and the diagnosis is based on clinical experience. This aspect is quite clearly not science. The effectiveness of ritalin is, because one can do proper trials of drugs: but you can only do them on a sample which has been diagnosed. By clinicians. On the basis of judgement.


You castigate NICE for recommending that children receive a trial of theray even if the appropriate personnel are not locally available to make a timely diagnosis. I agree that insisting that appropriately skilled people are made available to everyone in need would be better. But if the diagnositic algorhythm is followed, then those would are likely to benefit from treatment can be identified, even by non experts. Should those individuals continue to be ignored until Nirvana is acheived?

Yes. Ritalin is a very powerful drug. I have worked with a child where it was prescribed by a GP and continued for many months: then abruptly withdrawn. The results were very bad for the child and his family. The NICE guidance specifically says that it should only be prescribed for those diagnosed by a child psychiatrist or a paediatrician with expertise in ADHD. I happen to agree with that. You, on the other hand, do not, apparently. Yet you are the one arguing in favour of this approach. I do not see any consistency in your stance, Pebble.


You castigate NICE for guiving guidance to professionals, as I have shown by example even highly trained clinical staff in hospitals need gudiance. It is not insulting to codify, standardise and publicise how professionals should behave, it is essential, we are all human and all need reminding about how we should do things again and again.

This is not science. It is a question of who is best qualified to set and maintain standards. Doctors did this for themselves through bodies like the GMC for example. I do not see any "evidence" that this was worse than the current situation where people who know nothing about it issue "guidance" at best based on what the people they are instructing tell them.


You dislike pushy parents.

I said the opposite


They are your allies, when they do not have you personally in their sights. They will agitiate and fight for what they perceive is right. Yes it is done selfishly, and they don't care once they have got their way. But what energy, harness it by directing them toward the LA and the politicians, conveince them that you believe that every child should have what they are asking for and let them do the fighting for you.

I said precisely that. The middle class parent is a very useful ally, for securing mainstream services. Once again you are basing on your own preconceptions of my stance; and it doesn't seem to matter what I say



Randomised trials not appropriate for complex care packages?
Yet again let me bring you back to the hospital hygeine issue. No single askect of the care package, e.g. not wearing ties in contact with patients can be shown in isolation to reduce infection. But the whole package of measures when applied together and policed rigorously reduces infection so dramatically that govt, health authorities, the media and hospital staff acknowledge that change is necessary. It is not easy; it is very possible.

I did not say that. I said it is not possible. It is not possible because there are too many variables and also because trials are not ethical. You are pretending to complexity where there is none, to make your case. The question in the case of hygiene is not complex. Does cleanliness reduce infection? Yes. We have known this since the 19th century. The last person to deny it was Lister, I believe. What does cleanliness comprise? That is certainly a question which can be operationalised: though in truth the questions were answered more than 100 years ago.


I do not work for NICE. I have worked with them on a few projects (hence 'indirectly'). I know you think I am predjudiced, but I think not. I think that you have become too wary of external criticism, and the very people that you must work with to improve the situation (researchers, LA, pushy parents and Govt bodies) are your enemies. Sometimes accepting the criticism of others even if you have doubts as to the validity of said concerns is very enlightening, if give the opportunity to reflect on one's practice, and to analyse whether there might be truths other than one's own.

Yes, I know what you think. It is interesting that you recommend I should consider the criticisms of others but you do not think that my criticism of this ideology is worthy of consideration. Perhaps you should analyse whether their might be truths other than one's own?


As to the studies: I have outlined how I think research in SW should be approached over several responses. If you are waiting for detailed specific proposals then I am sorry, that is not possible. To get to that point I would need to work on a specific question with someone such as yourself over a period of weeks or months.

I am sorry Pebble but you have not said anything at all useful about research in social work should be approached. You have said, for example


If you had decent comparative research showing that the likelihood of abuse was no higher among illicit addict parents when compared to alcoholics, then the authorities would have to listen.Once you have such studies, then you can begin to suggest rational targeting of research into programs of intervention and stop the media and political expediency determining your direction. Further when presenting cases to courts you can use such studies to back up the probability of your assessment being correct.

I ask again: how would this help?

For example:

http://findarticles.com/p/articles/mi_m0978/is_4_30/ai_n8582687/pg_1


Children who live with an alcohol-dependent parent also are more likely to have diagnosable childhood psychological disorders than do those who live with nonsubstance-abusing parents


Although both COAs and COSAs often experience emotional and behavioral difficulties, it is plausible that differences in psychosocial functioning would evolve in large part because of differences in the family and social environments created by alcoholic versus drug-abusing (DA) parents. For instance, Hogan (22) has persuasively argued that substantial differences exist in the home environments of children with parents who abuse alcohol versus illegal drugs. Families in which a parent abuses illegal drugs, particularly opiates and cocaine, are more likely to be living in poverty, whereas alcohol abusers are more likely to be living across a range of socioeconomic contexts (21). Because secrecy and stigma pervade the use of illegal drugs, greater social support is available for individuals who abuse alcohol than for substance abusers and their families. In addition, illegal drug use is associated with criminal activities and places the parent at risk for arrests and imprisonment and grave health risks. Although many drug-dependent individuals also abuse alcohol, children who live in homes with a parent who abuses illegal drugs may be expected to experience additional disruptive familial influences.


a significantly greater proportion of children from DA homes had clinical levels of psychosocial impairment (n = 23; 45%) compared with children living with alcohol-dependent fathers (n = 5, 10%), [chi square] = 15.95 (1), p < 0.001


It is important, based on their mothers' reports, 45% of children with DA fathers exhibited behavior defined as clinically significant.


Previous research has shown that more severe drug use is associated with illegal activities such as theft and less likelihood of full- or part-time employment (41). For men in the present study, illegal drug use was associated with greater legal difficulty and more employment problems. Illegal drug abuse appears to result in difficulty meeting the demands of full-time employment (e.g., greater unemployment, more job changes, and more absenteeism) and in many cases may deprive children of the family's main source of income. Low family income and financial problems have established negative effects on children (42,43). Noteworthy is the finding by Gillham and colleagues (44) who found a more consistent relationship between paternal unemployment and child abuse and neglect than maternal unemployment and child mistreatment. For children living with DA men, job instability appears to be an associated problem that has significant implications for children's psychosocial functioning.


In addition, several studies have shown that family-based interventions for substance abuse are more effective than individual-based treatments for drug abuse (48). For instance, Behavioral Couples Therapy (BCT), which emphasizes ways to reduce drug use and to improve dyadic functioning, is more effective than individual treatment for reducing days of drug use, increasing periods of abstinence, decreasing drug arrests, reducing partner violence, and increasing relationship satisfaction (49,50). Kelley and Fals-Stewart (51) found that couples-based treatment for men entering treatment for drug or alcohol abuse improved children's psychosocial functioning over individual-based treatment or a psychosocial attention control treatment. At present, however, many men do not want their children involved in their treatment (52). Clearly, offering a wide range of treatment options, and possibly offering individual treatment for children, may be important for families in which a DA father is living with dependent children.

My bold.

This is the kind of research which can be done. Note: the small sample size ( chi-squares, forsooth): the 45% of children who show clinical level impairment: the earlier research which has shown that poverty and unemployment are significantly associated with such impairment: the concentration of drug misusing parents in the lowest socio-economic groups ( in contrast to the alcohol misusing parents): the confounding element of criminality: the fact that best treatment options are impossible to implement because the identified client does not want the children involved.

Now can you tell me how this helps me to identify which are the 45% of children who are being damaged? Because that is what I need to know. Can you tell me how you would make the decision for compulsory intervention where the father does not want this, in light of the fact that we cannot make an assessment of the child without parental consent? Unless of course you want me to take compulsory measures to achieve that? But you are opposed to compulsory intervention without evidence of course: and so am I. Can you tell me how it is just to intervene in such circumstances, if the biggest factor in child impairment is poverty? Can you say why we should particularly scrutinise the children of those who come forward for treatment or are ordered to do so by a court?

I say again, all of this is fine for developing services: but it is nothing to do with child protection at all.

[Pebble]

Fiona. In this last reply your certainties have extended to a complete understanding of the nature of hospital management and infection control.

Here there is no shortage of evidence:

See:
http://www.his.org.uk/_db/_documents/FINAL_C_diff_report.pdf (http://www.his.org.uk/_db/_documents/FINAL_C_diff_report.pdf)


http://www.his.org.uk/_db/_documents/MRSA_Guidelines_PDF.pdf (http://www.his.org.uk/_db/_documents/MRSA_Guidelines_PDF.pdf)


http://www.clean-safe-care.nhs.uk/toolfiles/22_SL_HII_4_v2.pdf (http://www.clean-safe-care.nhs.uk/toolfiles/22_SL_HII_4_v2.pdf)

Also in respect of Lister:


http://www.nahste.ac.uk/isaar/GB_0237_NAHSTE_P0389.html (http://www.nahste.ac.uk/isaar/GB_0237_NAHSTE_P0389.html)


I suppose you will disagree with all that too. I am no longer convinced that evidence sways your opinion.

[Pebble]

Now can you tell me how this helps me to identify which are the 45% of children who are being damaged? Because that is what I need to know.

Now there is a research question: Is Drug use or poverty the confounder? I would argue that in practical terms poverty in isolation can be studied, thus the prevalence of child damage, however, measured can be addressed without the confounding impact of drug misuse. Then the other side of the equation can be studied. As for identifying apriori who will be damaged. Cannot be done ever I hope: what a world it would be if we could accurately predict psychological intactness according to a formula. But developing and testing questionnaires for teachers/SW/parents etc to identify children likely to be suffering from depression/anxiety/ADHD/etc: no reason that should be impossible

I say again, all of this is fine for developing services: but it is nothing to do with child protection at all.

Main function, but not limited to this, how to deliver care most effectively also can be addressed, how to measure impact of care given, when first line approach is not working, etc

[/QUOTE]

I am not trying to say that research solves the problems of the world, and that if you listened to what given researchers say the world would be better. Only that without research (critical assessment of what is right and what is redundant) progress is dependent on luck and is not defensible against the next new fad.

[Pebble]

Sorry top half or more of my reply got eaten by the gemlins.

But issue of how to diagnose ADHD without specialist input deserves comment. For any large scale trial standardized diagnostic techniques have to be developed: experts are too unreliable. Thus:


http://archpedi.ama-assn.org/cgi/content/full/160/1/82

Diagnosis of ADHD was based on a clinical evaluation using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)23 criteria, confirmed by structured interview (using the behavior module of the Kiddie Schedule for Affective Disorders and Schizophrenia)24 and by a Children’s Global Assessment Scale25 score of 41 to 70.

http://pediatrics.aappublications.org/cgi/content/full/109/3/e39

The diagnosis of ADHD was based on a parent interview using the National Institute of Mental Health Diagnostic Interview Schedule for Children–Version 4.0.14


This is how such questions are dealt with scientifically. The scoring systems do not rely on experts to administer, trained staff do this more consistently.

[Fiona]

Fiona. In this last reply your certainties have extended to a complete understanding of the nature of hospital management and infection control.

Here there is no shortage of evidence:

See:
http://www.his.org.uk/_db/_documents/FINAL_C_diff_report.pdf (http://www.his.org.uk/_db/_documents/FINAL_C_diff_report.pdf)


good hand hygiene by health care workers is paramount
correlations can be shown between environmental contamination and infection rates <snip> The highest standards of cleaning should be demanded
A major risk factor.....is prior antibiotic exposure.....restrictive antibiotic policy to reduce inappropriate administration ....have proven effectiveness. Prescriber education is also important
host immunity is an important determinant of CDAD, in particular that there are patients who are particularly prone to developing clinical disease following acquisition of the organsim Can't see the relevance of this at all. Seems to say we should keep hospitals clean and people clean and not overprescribe antibiotics. What else is new?


http://www.his.org.uk/_db/_documents/MRSA_Guidelines_PDF.pdf[/quote (http://www.his.org.uk/_db/_documents/MRSA_Guidelines_PDF.pdf)


Background
.....the low rates in some Northern European countries may reflect a more vigorous "search and destroy" policy combined with lower bed occupancy rates or may reflect exposure to different strains of MRSA with less propensity for spread
One of the reasons for the relative lack of success in the control of MRSA may be inadequate resources and the failure of healthcare professionals to comply with good infection control practice.....in a study of risk factors for MRSA transmission in an adult intensive care unit, staff shortages were the only significant variable associated with clusters of cases
Action To be Taken if Screening Results are Positive

....Little evidence exists to guide the details of an appropriate response, but this should be influenced by the risk group of the affected unit. by the number of newly detected MRSA-positive patients, by the adequacy of nurse numbers to staff the ward, and by the availability of isolation and cohorting facilities....

Management of the environment and equipment should be considered central.....cleaning regimens and products should be in accord with local policy, but should include the removal of organic material with a general purpose detergent.....

The Working Party emphasises that inadequate nursing staffing is incompatible with effective infection control. Infection control teams and hospital managment should bear nursing workload in mind (including staff numbers, grades and levels of experience and patient acuity ........
Improved nurse staffing levels on an affected ward may allow improved adherence to local infection control policies and should be considered as a component of a package of measures to control local outbreaks
The special difficulties and risks posed by agency and locum staff should be considered.
Control of VISA And VRSA

In the absence of randomised controlked trial data and on the basis of the descriptive studies outline above and a strong theoretical rationale, recommendations for the control of these organisms remain the province of existing best practice and professional opinion
Patient Management
Evidence to support specific interventions is lacking due to many studies employing multiple interventions in the management of these patient groups, without demonstrating the value of individual measures.

It is essential that infection control is seen as an organizational responsibility and priority, that adequatefacilities and resources are provided, and that appropriate infection control staff and support
services are available.116 The infection control team should agree a long-term strategy for control with hospital senior management, which should include provision for adequate isolation and handwashing facilities in new or upgraded units or hospitals.......

it is essential that a strong emphasis is placed on infection control being included as a core element of induction programmes for all new staff. It
should be included within undergraduate and postgraduate training, and in continuing education programmes for all staff groups.
Cleaning and decontamination

There is little evidence of the role that the environment and equipment play in the transmission of MRSA in a facility......general principles should be adopted to minimize the bacterial burden within a facility......need for dust minimization,...appropriate disposal of contaminated waste and linen...Adequate handwashing facilities and antibacterial hand rub/gel should be available for staff and visitor hand decontamination before and after contact with the patient or their immediate environment.....Instruments or equipment should preferably be single-patient use. Multiple-patient-use items should be decontaminated appropriately before use on another patient...standard cleaning
regimens are ineffective in eliminating MRSA contamination. There is a requirement for protocols to be agreed for enhanced levels of cleaning, to include additional time to enable the removal of all reservoirs of dust....MRSA-contaminated patient areas should be cleaned after the patient’s discharge with hot water and detergent...Curtains should be removed and laundered if not single-use disposable curtains. Pillows
and mattress covers should be checked for damage.Therapy beds may need specialist cleaning in accordance with the manufacturer’s/hirer’s
instructions....Finally, there should be planned, periodic and thorough cleaning of the whole ward, including bedding and curtains.Can't see any science needed there. Clean the place and control overuse of antibiotics. Don't see it supports your assertions that the issue is complex or that my ideas are much different from these, really. Didn't claim expertise at all: claimed some knowledge of the history and some common sense. Much cheaper than this


[quote]http://www.clean-safe-care.nhs.uk/toolfiles/22_SL_HII_4_v2.pdf (http://www.clean-safe-care.nhs.uk/toolfiles/22_SL_HII_4_v2.pdf)

This is no different


Also in respect of Lister:


http://www.nahste.ac.uk/isaar/GB_0237_NAHSTE_P0389.html (http://www.nahste.ac.uk/isaar/GB_0237_NAHSTE_P0389.html)

I know who Lister is, thanks. He continued with the carbolic spray for a long time before he accepted that cleanliness in hospitals did the same job far better.





I suppose you will disagree with all that too. I am no longer convinced that evidence sways your opinion. Ditto ;)

[Fiona]

This is how such questions are dealt with scientifically. The scoring systems do not rely on experts to administer, trained staff do this more consistently.

Well I think you better tell NICE then

[Fiona]

As for identifying apriori who will be damaged. Cannot be done ever I hope: what a world it would be if we could accurately predict psychological intactness according to a formula.

My point exactly: can't be done


But developing and testing questionnaires for teachers/SW/parents etc to identify children likely to be suffering from depression/anxiety/ADHD/etc: no reason that should be impossible

No reason at all. Still unethical to administer them without parental consent, however. Don't see how it helps in any case. People get anxious and depressed for an awful lot of reasons.

[seren]

OT: I heard someone today refer to NICE as the National Institute for Cock-ups and Excuses. ;D

The other day I rang them about a technology they should know about and they claimed complete ignorance of it. It appeared they were looking at their own website to find information- which of course I had already done. ::) You're not a NICE bod, are you, Pebble? I don't mean to offend....

[Pebble]

Selecting out the statements that you agree with is not the same as assesing the evidence and determining whether in toto the recommendations reflect your preconceived ideas:


Control precautions (all Category 1b)
Action to be taken on identification
of a case of VISA/glycopeptide-intermediate
S. aureus (GISA) or VRSA

e

The laboratory should immediately notify the relevant

clinician and infection control personnel.
e


The infection control team should immediately

identify where the patient is and where the patient
has been during all of the current admission,
including transfers from other healthcare
facilities.
e


The relevant national surveillance organization,

e.g. Health Protection Scotland, Health
Protection Agency in England and Wales, and
the Health Protection Agency (Communicable
Disease Surveillance Centre) in Northern Ireland,
should be notified.
If the patient is still an inpatient
e


The number of healthcare workers caring for

the patient should be reduced. This will cause
problems for those who are allocated to care
for the patient. These healthcare workers will
need support.
e


Healthcare workers with chronic skin conditions,

e.g. eczema or psoriasis, should not be
involved in direct care of the patient.
e


All staff caring for the patient should be made

aware of how the organism is transmitted and
the precautions necessary to prevent this.


e


The patient should be cared for in a single room

with toilet facilities and a wash hand basin.
e


The patient and visitors must understand the

need for isolation.
e


Fans should not be used to control the patient’s

temperature.
e


Appropriate infection control procedures

should be implemented:
1. Standard precautions should be used.
Gowns/disposable aprons and disposable
gloves should be worn by all those entering
the patient’s room. Clean, non-sterile
gloves and gowns/aprons are adequate.
Consideration should be given to use of theatre-
style greens in addition to protective
clothing to ensure that healthcare workers
do not take uniforms home to launder.
2. Disposable masks and eye protection should
be worn by carers for procedures likely to
generate aerosols/splashing. Use of closed
suction systems will help to reduce
aerosols.
3. Hand hygiene should be performed with
an antibacterial preparation before and
after patient contact. Visibly soiled hands
should be washed with soap prior to
disinfection.
4. Non-disposable items that cannot be easily
cleaned or disinfected (e.g. sphygmomanometer
cuffs) should be dedicated for use
only by the infected/colonized patient.
5. Patient charts and records should be kept
outside the isolation room.
6. Linen should be treated as infected. It must
be discarded into alginate bags within the
patient’s room and a secondary bag outside
the room.
7. All waste should be discarded into a clinical
waste bag inside the room, and bags should
subsequently be disposed of according to
hospital policy.
8. Transfers of colonized/infected patients
within and between institutions should be
avoided unless essential, and the receiving
institution should be made aware of the patient’s
colonization/infection status prior to
transfer.
9. After discharge, the room in which the patient
was cared for should be cleaned according
to local disinfection policy, with
special attention given to horizontal surfaces
and dust-collecting areas. Hot water
and detergent are usually satisfactory. Curtains
should be changed.
10. Compliance with infection control procedures
should be monitored.
Screening (all Category 1b)
Patients
e


Nose, axillae, perineum, skin lesions and manipulated

sites of the index case and all other
patients in the unit should be screened for carriage
of VISA/GISA or VRSA.
e


The infection control team should review the

admission history of the patient and determine
if screening needs to be extended to other
areas and other units alerted.
Staff
e


Agreement with staff on the need for screening

should be sought.
e


Nose, axillae and perineum of healthcare

workers and others with close physical contact
with the case should be screened for carriage
of VISA/GISA or VRSA.
e


Healthcare workers who maintain contact

with the patient will require weekly screening.
This may require significant support for
these staff.
e


Feedback of results and maintenance of confidentiality

should be considered.
Eradication (all Category 1b)
e


Eradication of colonization/carriage of patients

and healthcare workers should be attempted
(see section on eradication of MRSA
carriage).
e


Colonized staff should be excluded from work
until eradication of carriage is achieved.

That is why it is called a package!

The point I was trying to make, is that the very arguments you are advancing to assert that SW is beyond research methodology has been rehearsed adnauseum in this setting. No single aspect of the package outlined is defensible in isolation, but the package of measures has been shown time and time again to work. Further if the education drive, resporting mechanisms and policing of the package of care slips as has been shown to occur if left to the local staff, then infection levels rise again.

[Pebble]

OT: I heard someone today refer to NICE as the National Institute for Cock-ups and Excuses. ;D

The other day I rang them about a technology they should know about and they claimed complete ignorance of it. It appeared they were looking at their own website to find information- which of course I had already done. ::) You're not a NICE bod, are you, Pebble? I don't mean to offend....


Nope! Not attempting to defend NICE at all, but even they sometimes get it right! The concept is correct, its execution leaves an awful lot to be desired (e.g. alzheimer's treatment)

[Fiona]

Nope! Not attempting to defend NICE at all, but even they sometimes get it right! The concept is correct, its execution leaves an awful lot to be desired (e.g. alzheimer's treatment)


Model on NICE for medicines. ::)



The point I was trying to make, is that the very arguments you are advancing to assert that SW is beyond research methodology has been rehearsed adnauseum in this setting. No single aspect of the package outlined is defensible in isolation, but the package of measures has been shown time and time again to work. Further if the education drive, resporting mechanisms and policing of the package of care slips as has been shown to occur if left to the local staff, then infection levels rise again.



And the point I was trying to make is they have re-invented the wheel. You don't do complexity, do you Pebble?


Only in the past 5 years has research shown clearly how attention to hand washing and other hygeine measures combine to virtually abolishe hospital acquired infection.

That is not true according to the links you yourself provided. I was not quoting the bits I agree with. I was quoting the bits which show that hygiene in hospitals is important, as has been known for more than 100 years: and the bits which showed that other factors such as staff shortages and overcrowding are also important; as I said and as you did not. And we do not need research to know this because it is already known. By the average 10 year old actually. it is no wonder I am not persuaded by your approach, Pebble. First you did not support your assertion with any evidence at all: then the evidence you do post does not support what you say. It supports what I say: that you can put in a package of measures, without evidence if you already know the answer.

I have been reading back over this thread. I notice you don't actually answer any questions. It annoys me, so I am going to ask some again

1. How do you suggest a social worker should determine which child is at risk or is being abused?
2. What do you think should be done with a referral such as that made by the doctor in my example?
3. Which independent observer do you think should judge whether statutory measures are required if not the court?
4.. Are you indeed such a selfless person that the threat of losing your job would make precisely no impact on your decision making?
5. Do you really believe that the police got convictions solely on the basis of confessions and intuition before recent innovations in techonology?
6. Do you think that the over-representation of black people in stop and search figures is a good thing? And if not, why not?
7. Do you or do you not accept that the diagnosis of ADHD and the prescription of ritalin should only be done by a child psychiatrist or a paediatrician with expertise in ADHD, as NICE says?
8. Can you consider the possibility that NICE is a monumental waste of money? That in fact it is not science based, but rather a marketing and cost control body ?
9. do you understand that in the question I posed it is not a question of whether poverty or drug misuse is the confounder, only?

In any given family there may be poverty, drug misuse of one or both parents, single parenthood, alcohol misuse by another family member. domestic violence. sibling abuse. sexual abuse, alcohol abuse, social isolation, poor housing, bullying, learning difficulties which may be situational or innate, poor hygiene, criminality, and on and on and on. Your immediate idea of investigating two issues is silly, Pebble. Folk are just more complicated than that. Even if you can sort out all of those things you will still find that some children are abused and some are not: some are resilient and some are not.

Can you see why I do not see you as very scientific? You opened with blind prejudice and a great deal of ignorance and so far as I can see you have spent the rest of the time defending you profession. I have done the same but you attacked social work on no information whatsoever: I at least attack your profession from some basic experience. Far from being able to make progress in the way you suggest I honestly believe you would take us further and further from reality. Some things just are not science

[Pebble]

My worry with Govt. invovlement is that the imperative to do something, leads to actions that are not evidence based. Yes we know there are problems, many opinions exist as to the best solution but the evidence for what is effective is so limited that this cannot be parcelled up into an adequate package for action, so 'experts' opinions are relied upon. Solutions are agreed upon and become the new orthrodoxy, what is not done is to rigourously identify that which is proven, that which appears supported by objective observation, that which is one of many competing theories that could fit with the available observations and that which is pure guess work. Further, we are interefering with personal freedoms here, we must at the very least set up a progam that will challange the assumptions we are making to determine which are subsequently supported, which are not, and to ruthlessly root out the junk opinions.quote]

[quote=Fiona;31504]::)





It supports what I say: that you can put in a package of measures, without evidence if you already know the answer.


Here exactly is my point: indeed the point I started with. Of course the package is comprised of commonsense measures. The impact of applying these measures then must be studied. Over time one can root out that which is unnecessary and identify further additions required to enhance efficacy. This can only be done when one has standardized practice, and identified those aspects that meet minimum criteria for inclusion in the package. For many years individual aspects of the 'common sense' approach have been tried and failed to significantly impact the infection rate. Only having studied the impact of implementing the packages as whole units could it be demonstrated that outcomes improved, and that it was worth in effect forcing staff to accept external direction and policing of their behaviour on a day to day basis to bring about improvement. The worry I started with (predjudice to use your words) is that simply applying the 'common sense' approach without then studying the outcome is where danger lies: whose common sense? based on what belief system? what evidence?


I have been reading back over this thread. I notice you don't actually answer any questions. It annoys me, so I am going to ask some again


1. How do you suggest a social worker should determine which child is at risk or is being abused?


That would be specultation; I am not against use of a common sense approach; I only insist that its elements should be codified and tested to measure the level of efficacy achieved by and given approach. So that comparisons can be made, and false theories debunked.


2. What do you think should be done with a referral such as that made by the doctor in my example?


More speculation. I do not know the details of the case, and am not a gynaecologist. As a guess vaginal bleeding is uncommon in 9 year old girls. But presumably she could be starting puberty. So that would be the first thing to establish.


3. Which independent observer do you think should judge whether statutory measures are required if not the court?


Courts have a rather limited remit. Fine for individual cases, but in the long run you must continually gather data to confrims or refute the efficacy of your care approach. Such data must be analysed independently somewhere along the line, since we all tend to believe our own data.


4.. Are you indeed such a selfless person that the threat of losing your job would make precisely no impact on your decision making?


No. But I would be extremely loathe to ever use my tenure as the explanation why I would or would not do something. If I get to that point, then I no longer believe in the system I am working for, and will try to change it.


5. Do you really believe that the police got convictions solely on the basis of confessions and intuition before recent innovations in techonology?


Finger printing is not exactly new. A couple of hundred years ago confessions were held to be the highest level of evidence, however extracted. While the development of policing methods led to analyzing whether someones confession/withness statements fitted with known facts. I think most would agree that confessions remain central to police work even today. Not my area of expertise so I shall say no more. If you have evidence otherwise, please produce.


6. Do you think that the over-representation of black people in stop and search figures is a good thing? And if not, why not?


Not sure where this comes from: you presumably think I am a racist!


7. Do you or do you not accept that the diagnosis of ADHD and the prescription of ritalin should only be done by a child psychiatrist or a paediatrician with expertise in ADHD, as NICE says?


Yes and No. I think the area is sufficiently difficult and the longterm effects of widespread use of ritalin insufficiently understood, that more work is required to know if on balance it's long term use is justified. If it worked, and the population it worked on can be identified by a check list of symptoms and behaviours, and less highly qualified people can be shown to administer these assessments more rigorously than psychiatrics and paediatricians. Why insist on them making the diagnosis, if in that senario others have been shown to do it better.


8. Can you consider the possibility that NICE is a monumental waste of money? That in fact it is not science based, but rather a marketing and cost control body ?


Is NICE too expensive - Yes. Is it objective - No. Is it consistent - No. Is it a COMPLETE waste of money - No. Again the package approach. It is clear that many treatments used by the medical profession are a waste of time and money. Some one must codify and determine what is useful and what is not. This must be done in a co-ordinated fashion, because spending money on one treatment reduces available time and money for other treatments. Further the huge variations in access to quality care giving the best outcomes cannot be tackled by a piecemeal approach. NICE certainly needs to leard lessons from its behaviour to date. But the fundamental concept is wholly justifiable.


9. do you understand that in the question I posed it is not a question of whether poverty or drug misuse is the confounder, only?

I never suggested that it was the only confounder. Merely using the pair as a method to demonstrate how one approached confounders. Your then give a list of confounders. To suggest that the presence of counfounders puts things beyond scientific enquiry is just mad. The same argument has been put to suggest that double blind trials are useless because there are so many differences between individual patients, how can you allow for all those effects? Randomisation!


Can you see why I do not see you as very scientific? You opened with blind prejudice and a great deal of ignorance and so far as I can see you have spent the rest of the time defending you profession.


What profession?


I have done the same but you attacked social work on no information whatsoever:


What attack?




I have shown my original position for reference.

[Pebble]

I know who Lister is, thanks. He continued with the carbolic spray for a long time before he accepted that cleanliness in hospitals did the same job far better.




Ditto ;)

You obviously have a different information source on Lister than I do:

http://web.ukonline.co.uk/b.gardner/Lister.html

"Having tried methods to encourage clean healing, with little, or no success, Lister began to form theories to account for the prevalence of sepsis. He discarded the popular concept of direct infection by bad air and postulated that sepsis might be caused by a 'pollen-like dust'. Although, there is no evidence to suggest he believed this dust to be living matter he was close to the truth."

"When, In 1865, Louis Pasteur suggested that decay was caused by living organisms in the air, which on entering matter caused it to ferment, Lister made the connection with wound sepsis.
A meticulous researcher and surgeon, Lister recognized the relationship between Pasteir's research and his own. He considered that microbes in the air were likely causing the putrefaction and had to be destroyed before they entered the wound."

"Although his methods initially met with indifference and hostility, doctors gradually began to support his antiseptic techniques.
In 1870 Lister's antiseptic methods were used, by Germany, during the Franco-Prussian war saving many Prussian soldier's lives. In Germany, by 1878, Robert Koch was demonstrating the usefulness of steam for sterilizing surgical instruments and dressings."

"German surgeons were beginning to practice antiseptic surgery, which involved keeping wounds free from micro-organisms by the use of sterilized instruments and materials."

"A simple operation of wiring a fractured kneecap, entailing deliberate convertion of a simple fracture into a compound fracture, often resulted in generalised infection and death. On October 26 1877, Lister, for the first time, carried out the operation under antiseptic conditions."

Doesn't sound to me like some one who was against cleandiness!

Where is you information from?

[Fiona]

Ok, Let me have a look at your original statement, because it raises some good questions


[quote=Pebble;31162]My worry with Govt. invovlement

If you do not think Government should be involved in child protection who do you think should be involved instead? Where do you think the money should come from, if not from taxation?


is that the imperative to do something, leads to actions that are not evidence based.This is exactly what happened in the hospital hygiene issue, as shown in the links you posted. The actions taken were not based on evidence, as the report repeatedly states. The evidence of effectiveness was post hoc, only. Having said that, I repeat that the measures taken were effective because the answer was already known. You say that common sense knowledge must be tested, and of course that is true if it is nothing more than common sense: but in this, as in many cases, the common sense was underpinned by more than 100 years of clinical experience. The effectiveness of good hygiene in controlling infection was established in exactly the same way as has now been done again: by showing that it works.

The role of this "research" is two-fold. 1. It provides a fig-leaf for those who caused the problem, by implying that their decisions were reasonable and could not have been predicted to lead to an increase in hospital based infection, because the knowledge was not there: this is a lie. 2. It places the blame on hospital staff for a lack of personal hygiene, though it clearly shows that many factors are involved: for example lack of handwashing facilities; shortage of staff; inadequate cleaning etc etc etc. All of those are the result of ideology and cost/benefit analyses carried out by people who know nothing of the complexity of the organisation and who are ultimately driven by the bottom line of a balance sheet. Cost/benefit analyses do not have to be like that, but they very often are.

The research was not undertaken by impartial researchers unaffected by politics or ideology: it was done because the rates of hospital acquired infection were so shockingly high that they could not be denied: something had to be done, indeed. And whatever was done must not demonstrate that policies held to be sacrosanct were in fact disastrous. The researchers were used by interest groups in exactly the same way as social workers, so far as I can see.


Yes we know there are problems, many opinions exist as to the best solution but the evidence for what is effective is so limited that this cannot be parcelled up into an adequate package for action s so limited that this cannot be parcelled up into an adequate package for action, so 'experts' opinions are relied upon. Solutions are agreed upon and become the new orthrodoxy, what is not done is to rigourously identify that which is proven, that which appears supported by objective observation, that which is one of many competing theories that could fit with the available observations and that which is pure guess work. Further, we are interefering with personal freedoms here, we must at the very least set up a progam that will challange the assumptions we are making to determine which are subsequently supported, which are not, and to ruthlessly root out the junk opinions.Unlike hospital hygiene the solutions in child protection are not already known, so you are right. Let me accept what you appear to be saying: let us shut up shop until research can give us a "package of measures" which are evidence based. Let us imagine that we work together to do that. Where shall we start? Well you say we know there are problems. perhaps we should start with defining them. So let us define child abuse. Since, as you so rightly said, this is culturally determined, it changes all the time. But I am sure that a good researcher can come up with a definition we can all accept, which will remain consistent over time, and which can be objectively measured.
So assuming we can do that, we now need to consider the scale of the problem, do we not? Oddly this has also proved quite intractable to research. For example, most of us would at least agree that where someone deliberately kills a child, that is evidence of child abuse. And a lot of effort goes into determining cause of death when someone dies unexpectedly: and those figures are recorded. So there should not really be a problem at least in this most objective of areas. Yet it seems that there is.

http://www.nspcc.org.uk/Inform/research/Briefings/childkillingsinenglandandwales_wda48218.html

http://www.unicef.at/fileadmin/medien/pdf/repcard5e.pdf (http://www.unicef.at/fileadmin/medien/pdf/repcard5e.pdf).

Never mind, I am sure we an solve this for both child deaths and whatever other things we include in our objective definition of child abuse, once we get it. Of course there are problems with statistics too.

http://www.jimhopper.com/abstats/#s-intro

But we are all aware of those, so we should be able to solve them quite simply: especially since we will be completely free of pressure from those who pay our wages while we do this, won't we? And from the media when bad cases of child abuse come to light: we will just explain that we cannot do anything cos we are busy making an evidence base, and it would be wrong to act till we have it. I think you will have to be the person who explains this to them: I, as a social worker, have conspicuously failed to convince either group: but researchers are so much better at this.

So we have an agreed definition and we have found out the scale of the problem. Let us get to the real meat and decide on what to do about it. Of course we could decide we should not do anything at all: but let us suppose that that is not what society wants, for the moment. Let us suppose they would like child abuse to stop. Well prevention is better than cure so we need to research all the factors which contribute to make a person abuse a child. What might we look at? Well previous research gives us some clues: first, and most importantly perhaps, we should abolish poverty. That is apparently the most effective measure we can take. Mental illness is another biggy so we better ensure that adequate resources go into that too. Drug and alcohol misuse are implicated so we have to make sure those problems are dealt with. Poor housing is a problem so the housing stock will have to be radically improved. Parents who have themselves been abused are more likely to abuse so we need to find ways of identifying them and then provide evidence based therapy for all who need it. Criminality is also a factor so we need to put resource into crime prevention, and marital breakdown is a problem so we need to support people to stay together...oh wait - domestic abuse is also known to be a very big indicator so ....well we can sort that out with therapeutic interventions I am sure. Once we have done all that and of course addressed all the other factors which have a bearing we can evaluate the effectiveness of all this: and we can do a cost/benefit analysis to see if it is all worthwhile.

I am going to take a wild guess here: I do not think society will want to spend all this just to prevent child abuse. Call me cynical.

So what else can we do? Well we can accept that all those things are the most important factors in child abuse but leave them as they are. So we conclude that a certain amount of child abuse is to be expected and leave it at that. That is the rational thing to do. For myself, I do not think society is going to be very comfortable when they are told that children who die in plastic bags in bath tubs are the choice they have made, but, again, you can explain this properly. Good luck with that. We can still act after the fact and jail the perpetrators if we can find them. Of course we do not know about most child abuse: and where a child dies in the home it is often not possible to say who did it: but that is true of most crime and we live quite unhappily with the fact. This is no different.

But I do not think society will be very happy with that either, somehow. I suspect they will want "something to be done". So what is left? Well we know that even in the most adverse circumstances (ie when suffering from some or many of the factors we have identified as risk factors) some people abuse their children and some people don't. We agreed earlier that we cannot predict which ones, however, so that is not a lot of help. If we could then we could set up a research programme. We could try things which might help (as the hospitals did with hygiene) and we could evaluate which of those things were effective. But we have a problem. We have to respect individual liberty. If we did not have that constraint then we could specify criteria and identify all the people with some or many of the risk factors we have so painstakingly identified: and we could make them undergo whatever we think might be effective ( with proper hypotheses and theoretical bases and pilot studies and anything else research finds necessary); we could randomly assign them to to those different programmes; and we could evaluate the outcomes and see which ones were "effective" ( after we have identified what "effective" means, of course). And we would know what works best and we could do that. Better, we could make everybody go through those programmes, again randomly assigned: that would give us a much bigger data base. I like it!!
But there is individual liberty, thank dog, so we cannot do that :-[. And without that we have no way of judging what is effective, because we do not know which people are going to abuse children.

So what if we just take people who have already abused children? Even though we cannot identify the vast majority of them we do identify some. Course some of them are in jail; and some are subject to pesky legal orders which prevent them from going near any more children. But there are some who are not so constrained. Perhaps we could have a new law akin to a drug treatment order whereby they are allowed to live with children so long as they participate in our programmes? Then we could measure how many on which programmes abuse again, and that would tell us what is "effective". Hmmm. Our programmes are only going to take up a wee part of the day. How will we control for variables outside those programmes? This is a problem because our sample is going to be very small indeed, especially since there are so many forms of abuse and we have no idea what significance those differences have: so we will need to randomise all the different forms across all the different programmes:and the factors in play vary such a lot too: if one in the drug-misusing/paedophiliac/single parent group gets clean that could really distort the results. Well perhaps we can do this time and again over a very long time? No that won't work either, I fear, because external circumstances change a lot over 20 years.

Sorry I am stumped. But then I am not a researcher. I am sure you can think of much better ways to do this. Meanwhile I will get on with my job :)

[Fiona]

As to Lister: he pioneered antisepsis but he was not involved in the development of asepsis. I am unable to find my original source but these illustrate my point. Lister used the carbolic spray and it was reported that he did not think asepsis was particularly important for a long time

http://www.bookrags.com/research/antiseptic-and-aseptic-techniques-a-scit-051234/


By 1880, based on the work of Lister, infections and particularly post-surgical infections continued to decline. Within a generation antisepsis was refined to asepsis, meaning the absence of harmful organisms. Asepsis is achieved mainly through sterilization (http://www.bookrags.com/research/antiseptic-and-aseptic-techniques-a-scit-051234/#). German physician Ernst von Bergmann (1836-1907) made a major breakthrough in asepsis when he introduced steam sterilization of surgical instruments in 1885.

http://www.questia.com/library/encyclopedia/surgery.jsp




The Birth of Modern Surgery
With the introduction of antiseptic methods, surgery entered its modern phase. Louis Pasteur (http://www.questia.com/library/encyclopedia/101263534) established the fact that microbes are responsible for infection and disease. Using this knowledge, Dr. Ignaz Semmelweis (http://www.questia.com/library/encyclopedia/101270204) reduced postpartum infections (puerperal sepsis) in the wards of Vienna's lying-in hospitals by urging doctors to wash their hands between patients. In the 1860s Joseph Lister (http://www.questia.com/library/encyclopedia/101255585) introduced the use of carbolic acid as a cleansing and disinfecting agent, and his results in reducing infection were dramatic. It was found later that the carbolic acid spray that Lister used to cleanse the air about the patient was unnecessary, but the antiseptic (http://www.questia.com/library/encyclopedia/101229479) treatment of instruments and other articles in contact with the patient continued until antisepsis was gradually replaced by the aseptic methods employed in modern hospitals. Before the discovery of antisepsis by Lister, about 80% of surgical patients contracted gangrene.
Ernst von Bergmann is credited with introducing steam sterilization under pressure for treating instruments and all other medical equipment used for a surgical patient. William Stewart Halsted (http://www.questia.com/library/encyclopedia/101247976), the famous surgeon at Johns Hopkins Hospital, introduced sterile rubber gloves when the hands of his fiancée became irritated from constant washings and antiseptics. The development of methods of anesthesia (http://www.questia.com/library/encyclopedia/101229207), especially the discovery in the 1840s of the value of ether, has also been of immeasurable value.

[Pebble]

As to Lister: he pioneered antisepsis but he was not involved in the development of asepsis. I am unable to find my original source but these illustrate my point. Lister used the carbolic spray and it was reported that he did not think asepsis was particularly important for a long time

[/LEFT]

The more I read about this chap the more I think those criticizing him are missing the point. He may have built on the German work on asepsis, and may have quite rightly realized that asepsis on its own was not suffieicnt for safe surgery, but to say that he was against asepsis seems entirely unfounded.

http://www.fullbooks.com/Beacon-Lights-of-History-Volume-XIV6.html
Listerism has been unjustly alleged by
a few to be unworthy of the appreciation in which it is held by the
great majority of medical men of all countries; simple cleanliness, it
has been urged, is quite as efficient as the full Listerian precautions.
This is begging the question, for simple cleanliness, "chemical
cleanliness," is all that Listerism purports to accomplish. The use of
antiseptics has been decried in the interest of asepticism, as if the
whole purpose of antisepticism were not to secure asepsis. Lord Lister
is entitled to the full credit of establishing the aseptic surgery of
the present day, in spite of the facts that his doctrine followed rather
than preceded his early improvements, that aseptic procedures have been
brought nearer perfection elsewhere than in his own country, and that
the whole system rests on foundations laid by Pasteur.


http://campus.udayton.edu/~hume/Lister/lister.htm

Here Lister was able to spend more time teaching as well as furthering his research. Lister was not always met with complete acceptance and had to train his colleagues as well as the nursing staff in Edinburgh to his new methods. The nursing profession was improving a great deal at this time with the work of Florence Nightingale and her schools, however the surgeons and other physicians were set in their ways. They saw Lister's excessive cleanliness and particularly his carbolic acid sprays during surgery as a waste of time and effort. The spray burnt their hands and eyes, and cleaning tools and linens a wasted effort.
Lister did not only continue to change and experiment with new methods of asepsis, but had other influences as well.

In January 1860, Joseph and Agnes moved to Glasgow where he was appointed Regius Professor at the university there. Lister was met by extreme filth and unfavorable conditions in his wards in Glasgow, and lack of cooperation from his colleagues in keeping the area clean. Lister had noticed in Edinburgh that keeping the area clean seemed to decrease the risk of infection, although he had no answer for why this made a difference.

As to your longer reply, that will take a little work, but I think we are beginning to address the same issue rather than parallel ones now.

[Fiona]

I am not criticising him, Pebble. I made an aside that he did not at first accept the importance of general cleanliness, as is perfectly understandable. He accepted the subsequent work which showed this and also the new techniques of sterilisation etc.

[Pebble]

Lister used the carbolic spray and it was reported that he did not think asepsis was particularly important for a long time



[/left]

That looks fairly critical to me!




If you do not think Government should be involved in child protection who do you think should be involved instead? Where do you think the money should come from, if not from taxation?

Not what I said. I expressed my concern that govt. often failed to follow through with the necessary validation of their action.



This is exactly what happened in the hospital hygiene issue, as shown in the links you posted. The actions taken were not based on evidence, as the report repeatedly states. The evidence of effectiveness was post hoc, only.


The actions taken could not be fully underpinned by the highest quality of evidence, but were strongly supported by the evidence accepting that any individual aspect was open to criticism as not fully validated. Not the same as your oversimplification.


The effectiveness of good hygiene in controlling infection was established in exactly the same way as has now been done again: by showing that it works.

Not what the MRSA report says. Yes hygiene important but insufficient:



Fidteen full publications between[1982 and 2002 were adduced by the Societyof Healthcare Epidemiology of America (SHEAR','serif']Working Party 26,40,42,87, 98 in support of the value[/font]
]of active surveillance]85, 91 ]Several of these reports[/font]
[provided particularly significant additional[/font]
[information. Jernigan et al. demonstrated a 15.6-[/font]
[fold reduced rate of transmission (95% confidence[/font]
[interval 5.3 - 45.6, P <0.0001) from patients who[/font]
[were known to be MRSA carriers by surveillance[/font]
[cultures compared with those whose screening results[/font]
were not available.[/87 Later re-analysis of the[/font]
data showed that the effect was similar if patients[/font]
[who were only colonized with MRSA were studied[/font]
[relative risk 11.9, 95% confidence interval 3.25
-47.5, P< 0.00014).[


or



[]Secondly, on a Dutch ICU, Vriens[/font]
[et al. ]found a 38-fold greater rate of transmission[/font]
[]from unisolated unknown positive patients nursed[/font]
[]with universal precautions compared with identified[/font]
isolated positive patients cared for with[/font]
gown, mask and gloves.]

[A recent study in an 850-bedded community[/font]
[]hospital in Italy with endemic MRSA 50% of the[/font]
S. aureus ]infections being meticillin resistant)[/font]
[]reported the effects on MRSA bloodstream infections[/font]
[of introducing patient screening, targeted[/font]
enhanced contact precautions, feedback of MRSA[/font]
[rates to ward staff, and mupirocin clearance of[/font]
]MRSA carriage. A sustained fall in the incidence[/font]
[of MRSA bacteraemia was observed from 0.64 to[/font]
[]0.30 per 1000 admissions. Historical controls[/font]
[]were used, but the baseline was established over[/font]
[]18 months, screening and interventions were progressively[/font]
]introduced over 30 months, and this[/font]
was followed by a 24-month observation period.[/font]
]This reduction occurred despite rising usage of[/font]
[]central venous catheters. Interestingly, a rise in[/font]
[the rate of MSSA central venous catheter infection[/font]
[]was noted (0.81 to 1.59 per 1000 admissions, relative[/font]
[risk 1.96, 95% confidence interval 1.32[/font]e2.93,
[P <0.001),
[/font]



The role of this "research" is two-fold. 1. It provides a fig-leaf for those who caused the problem, by implying that their decisions were reasonable and could not have been predicted to lead to an increase in hospital based infection, because the knowledge was not there: this is a lie.

Need to read reports again there is much more meat to them that this.



2. It places the blame on hospital staff for a lack of personal hygiene, though it clearly shows that many factors are involved: for example lack of handwashing facilities; shortage of staff; inadequate cleaning etc etc etc.

No it specifically shows that hygiene alone cannot solve the problem.



The research was not undertaken by impartial researchers unaffected by politics or ideology: it was done because the rates of hospital acquired infection were so shockingly high that they could not be denied:

Much of this work was done in Sweden and Holland where this was not a large problem: why?



Unlike hospital hygiene the solutions in child protection are not already known, so you are right.

Agreed this is a much tougher nut.


Let me accept what you appear to be saying: let us shut up shop until research can give us a "package of measures" which are
evidence based.

No. I specifically said that one may have to act without an evidence base, but that the actions muct be underpinned by programs to acquire that evidence.



So let us define child abuse. Since, as you so rightly said, this is culturally determined, it changes all the time. But I am sure that a good researcher can come up with a definition we can all accept, which will remain consistent over time, and which can be objectively measured.

Just like the MRSA problem. MRSA colonisation was known to occur without causing patients any harm, MRSA caused deaths but was it just killing those who were destined to die anyway or was this a real additional problem? Years of research answered just that question.

So lets think of a parallel. Fractures in children occur. Many are not down to abuse. But serious abuse often leads to fractures. If we could show that there was a significant association between serious abuse and fractures, would the elimination of childhood fractures whatever the causse become a legitimate target. After all who wants a child with a broken bone?

Nw is that the only sort of abuse? Of course not, but other managable surrogates will exist.



[quote]Never mind, I am sure we an solve this for both child deaths and whatever other things we include in our objective definition of child abuse, once we get it. Of course there are problems with statistics too.

No one said statistics were perfect. But just because statistics can be abused, is no reason for dismissing statistics.



And from the media when bad cases of child abuse come to light: we will just explain that we cannot do anything cos we are busy making an evidence base, and it would be wrong to act till we have it.

I am simply suggesting that one codifies the actions taken and audit the outcome to determine which programs are effective.



Well previous research gives us some clues: first, and most importantly perhaps, we should abolish poverty. Mental illness is another biggy so we better ensure that adequate resources go into that too. Drug and alcohol misuse are implicated so we have to make sure those problems are dealt with. Poor housing is a problem so the housing stock will have to be radically improved. ....

I am going to take a wild guess here: I do not think society will want to spend all this just to prevent child abuse. Call me cynical.


I think you instinct is spot on here. Is that a reason for giving up?



So we conclude that a certain amount of child abuse is to be expected and leave it at that. That is the rational thing to do. For myself, I do not think society is going to be very comfortable when they are told that children who die in plastic bags in bath tubs are the choice they have made, but, again, you can explain this properly.

Now there is a message I would shout from the roof tops. Chldren are dying / suffering because you (general public) are too mean to pay for adequate support for the disadvantaged. Would need very solid evidence to show that this was the uncounfounded causative factor.


We could try things which might help (as the hospitals did with hygiene) and we could evaluate which of those things were effective. But we have a problem. We have to respect individual liberty. If we did not have that constraint then we could specify criteria and identify all the people with some or many of the risk factors we have so painstakingly identified: and we could make them undergo whatever we think might be effective ( with proper hypotheses and theoretical bases and pilot studies and anything else research finds necessary); we could randomly assign them to to those different programmes;

OK the premise here is that one must do something. Fine, but what you do is set up a number of packages of 'diagnosis', 'surveillence', 'prevention' and 'intervention' to pilot the various ideas people have. Then record and compare outcomes. Of course, direct randomisation is not possible, but f the same approach in different situations produces a consistent outcome, and this is not true of other packages, then that one is trialed further, and if results are consistent. It can ultimately be adopted as evidence based.




So what if we just take people who have already abused children? Even though we cannot identify the vast majority of them we do identify some.

Numbers too small, would only use this group to help understand the factors that led to child abuse in the first place. As is already being done but not in a veery systematic way.

II return to my quote: I have bolded the link points. I am critizising Govt failure to follow through. Not their need to or right to act.



My worry with Govt. invovlement is that the imperative to do something, leads to actions that are not evidence based. Yes we know there are problems, many opinions exist as to the best solution but the evidence for what is effective is so limited that this cannot be parcelled up into an adequate package for action, so 'experts' opinions are relied upon. Solutions are agreed upon and become the new orthrodoxy, what is not done is to rigourously identify that which is proven, that which appears supported by objective observation, that which is one of many competing theories that could fit with the available observations and that which is pure guess work. Further, we are interefering with personal freedoms here, we must at the very least set up a progam that will challange the assumptions we are making to determine which are subsequently supported, which are not, and to ruthlessly root out the junk opinions that lead to fiasco's such as the satanic abuse nonsense in Scotland a few years ago.

[Fiona]

That looks fairly critical to me!

Well I already know you have an idiosyncratic way of reading things :smiley:


Not what I said. I expressed my concern that govt. often failed to follow through with the necessary validation of their action.Not like any other body, eh?


The actions taken could not be fully underpinned by the highest quality of evidence, but were strongly supported by the evidence accepting that any individual aspect was open to criticism as not fully validated. Not the same as your oversimplification.Correction: their oversimplification

.Little evidence existsand
In the absence of randomised controlled trial data and on the basis of the descriptive studies outline above and a strong theoretical rationale, recommendations for the control of these organisms remain the province of existing best practice and professional opinion
and
evidence to support specific interventions is lacking



Not what the MRSA report says. Yes hygiene important but insufficient:I can't read your next bit, but I did not say it was only hygiene if that is what you imply: I said that the effectiveness of good hygiene was established in the same way as it was before. I also mentioned the control of antibiotic over-prescription in a previous post; and if I did not mention screening it was an oversight.

You, on the other hand, said
Only in the past 5 years has research shown clearly how attention to hand washing and other hygeine measures combine to virtually abolishe hospital acquired infection.That is what I was responding to. So tell me how "screening" is a hygiene measure if you are using ordinary english?
http://www.google.co.uk/search?hl=en&client=firefox-a&channel=s&rls=org.mozilla:en-US:official&hs=OLN&defl=en&q=define:hygiene&sa=X&oi=glossary_definition&ct=title



Need to read reports again there is much more meat to them that this.No, I dont think I will bother, unless you show me what you mean


No it specifically shows that hygiene alone cannot solve the problem.Yes it does: yet that is what you took from it ( see above). Not that I blame you since it is implicit in how the thing is written


Much of this work was done in Sweden and Holland where this was not a large problem: why?No idea. Do you? It is irrelevant to why this report was produced

< snip>



No. I specifically said that one may have to act without an evidence base, but that the actions muct be underpinned by programs to acquire that evidence.Where? I saw this


]My point - in respect of child abuse specifically, was that there should be clear evidence to back action.

and this


Where injury or neglect is already suspected, then the weight of evidence is central. Unless the family members or others are prepared to 'confess' or act as witnesses the situation becomes very difficult. Indirect evidence must be very strongly supported by very high quality research from more than one source, (my bold)

If you qualified later I missed it, and I aplogise.


Just like the MRSA problem. MRSA colonisation was known to occur without causing patients any harm, MRSA caused deaths but was it just killing those who were destined to die anyway or was this a real additional problem? Years of research answered just that question. I do not understand this. MRSA was defined: the effect of it might not have been known but the increase in hospital infection was known. That was the additional problem. It is actually nothing like child abuse: I do not think MRSA is culturally determined. But I am interested to learn if I am wrong.


So lets think of a parallel. Fractures in children occur. Many are not down to abuse. But serious abuse often leads to fractures. If we could show that there was a significant association between serious abuse and fractures, would the elimination of childhood fractures whatever the causse become a legitimate target. After all who wants a child with a broken bone?You have completely lost me. I genuinely have no idea what you are talking about. Earlier we agreed that child abuse is culturally determined. As I noted in the case of child murder there are things we can agree are abuse, and I would think that deliberately caused fractures are in the same box, since both murder and grievous bodily harm are generally frowned on. "Deliberately caused fractures" and "serious abuse" are effectively a tautology. Would the elimination of childhood fractures be a legitimate target? Nice idea. I imagine everybody in the world is trying to achieve that; and they probably always have. After all, who wants a child with a broken bone? But, you know something? Accidents happen.

<snip>


No one said statistics were perfect. But just because statistics can be abused, is no reason for dismissing statistics.And I did not say that. As the article I linked painstakingly pointed out, it is a reason for treating them with caution. Do you disagree with that?


I am simply suggesting that one codifies the actions taken and audit the outcome to determine which programs are effective.And I am simply asking how


I think you instinct is spot on here. Is that a reason for giving up?Er.....who is giving up?

Now there is a message I would shout from the roof tops. Chldren are dying / suffering because you (general public) are too mean to pay for adequate support for the disadvantaged. Would need very solid evidence to show that this was the uncounfounded causative factor.Agreed

OK the premise here is that one must do something.

If that is your premise, fine. It is not mine


Fine, but what you do is set up a number of packages of 'diagnosis', 'surveillence', prevention' and 'intervention to pilot the various ideas people have. Then record and compare outcomes. Of course, direct randomisation is not possible, but if the same approach in different situations produces a consistent outcome, and this is not true of other packages, then that one is trialed further, and if results are consistent. It can ultimately be adopted as evidence based. Do you honestly believe this has not been done? Have you never heard of "Headstart" or even "Surestart"? Children's centres? Family Centres? And a million other projects of the same sort? They do not produce conclusive results. They cannot.

But I am happy to concede that they are not well set up in the terms you set out. So tell me: let us imagine we have a "diagnostic" package. How is it to be used? Do you envisage it should be administered to the whole population and then we should wait and see how many false positives and false negatives we get? I do not think that is realistic and I do not think people would be happy to take a compulsory test. Do you? Seems a bit "big brother" to me and I thought we were both against that kind of thing

Are you seriously suggesting we should put the whole population under suveillance? Or the whole population of a street, if it is a pilot?

Let us imagine that one idea for prevention and intervention is home visits by a social worker. This is not fanciful: it is one of the things the Scottish Office acknowledges in the review I linked earlier: and I happen to believe it is right. Are you really sure you want every home in the country (or half of them if we are doing controlled trials)to be visited by a social worker regularly? Cos I am really sure I do not.

Numbers too small, would only use this group to help understand the factors that led to child abuse in the first place. As is already being done but not in a veery systematic way.Exactly. The numbers are too small. That is why statistics don't work. That is why the research is inconclusive. That is in fact why the research is crap. We are not a universalist service. We deal with small numbers and that is all there is to it

[Pebble]

Fiona, too much to take in there in one go. But taking parts of statements out of context and asserting that that defines my position is part of the problem.

Lets look at the hygeine argument:

Hospital hygiene measures had indeed been in place for many years. These were known as 'universal precautions' it was evident that this was insufficient for certain situations: e.g. outbreaks of diarrhoea type illnesses. Here 'enhanced contact packages' were required. When it came to endemic infections like MRSA the required precise balance between these approaches was unknown. It was evident that universal application of the 'enhanced contact package' (gown, gloves and mask) was not practicable or desirable. Demonstration that MRSA carriage rate was strongly associated with MRSA sepsis rate, led to concepts that if one identified all those who were carriers and applied the enhanced approach to them this greatly reduced the MRSA sepsis rate. Thus surveillence measures became and extension of the 'hospital hygiene' package.

You are of course absolutely right there is more to it than just the hygiene measured that I have focused on. The point I was addressing at the time (context is important) is that many staff were very resistent to being directed in respect of the frequency of hand washing, the wearing of gowns, gloves and masks, the isolation of patients with suspected contact, the laborous auditing of all these actions, with endless education sessions on the same boring topic. Thus creating an evidence base that was capable of overcoming this natural resistance to change was a vital step. Yet because of the complexity of the issues invovled no breakthrough trials were possible. Many of the trial results seemed on the surface contradictory, but it was evident that whole package approaches did consistently show that MRSA sepsis rates could be sustainably reduced in most settings. This was demonstrated in many centres throughout the world and finally the burden of evidence was sufficient that although there are still those who argue that what they are being asked to do is unproven, these people are now a very small minority. Introduction of the packages with a degree of enforcement has been successful in taming one of the most intractable problems in UK hospitals in a very short time frame.

The crux of the argument I was trying to address, is that even if something cannot be proven absolutely to be true, if the burden of evidence for efficacy is high enough and the outcome desirable to society, one can justify actions that require a certain amount of interference with individual freedom. I am not suggesting one takes children away from parents on this basis, but alters the contract between family and state, to work toward a new appreciation of what society expects of individual families in terms of their childcare obligations.

Now you are right to assert that I did not bother with other aspects of the package (search and destroy policies; antibiotic management systems etc) but they were not relevant to the point I was trying to make.

[Fiona]

Fiona, too much to take in there in one go. But taking parts of statements out of context and asserting that that defines my position is part of the problem.

I do not accept that is a fair charge of what I am doing. Your whole paragraph was


You castigate research for studying 'good practice' if appropriate one should criticise the methodology, especially if conclusions are reached that are not justified by the quality of the data. But research into 'good practice' is essential. Only in the past 5 years has research shown clearly how attention to hand washing and other hygeine measures combine to virtually abolishe hospital acquired infection. Hospital staff have been batteling with this issue for centuraries, and were convinced that they knew how to prevent infection spread, and that they were implementing effective procedures, but felt that government interference caused overcrowding and excessive throughput, and that this was the problem, not their hygeine. No one argues that anymore.

I do not think I have misrepresented you at all. You focussed on hygiene alone: and you said no-one argues that the other factors were relevant anymore. Bear in mind you had not posted your study then: and when you did it does not confirm any of that. I do not think it is illegitimate to point that out.


Lets look at the hygeine argument:

Hospital hygiene measures had indeed been in place for many years. These were known as 'universal precautions' it was evident that this was insufficient for certain situations: e.g. outbreaks of diarrhoea type illnesses. Here 'enhanced contact packages' were required. Yes. We knew how to control infection in hospitals long ago. So we seem to agree.


When it came to endemic infections like MRSA the required precise balance between these approaches was unknown. It is not demonstrated that previously existing practice was insufficient for prevention. As you said, MRSA was around for a long time when hospital infection rates were much lower: and when clean hospitals were the norm. Other countries did not have the problem to anything like the same extent, as you said. Nor had they made the same changes to hospital management as we did in the uk. That is a correlation but it is not unreasonable to consider a causal effect: and indeed that is precisely what the study does ( though obliquely: and you know my views about why that is: what are yours?)


It was evident that universal application of the 'enhanced contact package' (gown, gloves and mask) was not practicable or desirable.Now you are talking about dealing with the problem once it has arisen. That is a completely separate point. It put the hospitals back to something like the position they were in before Lister.


Demonstration that MRSA carriage rate was strongly associated with MRSA sepsis rate, led to concepts that if one identified all those who were carriers and applied the enhanced approach to them this greatly reduced the MRSA sepsis rate. Thus surveillence measures became and extension of the 'hospital hygiene' package. All this means is that if people are infected with a disease they will transmit it. Not exactly new, if the disease is communicable. The idea that we should take measures to put a barrier between carriers of disease and people who do not have that disease is hardly new. Typhoid Mary? Quarantine? Dont send a child with measles to school?


You are of course absolutely right there is more to it than just the hygiene measured that I have focused on. The point I was addressing at the time (context is important) is that many staff were very resistent to being directed in respect of the frequency of hand washing, the wearing of gowns, gloves and masks, the isolation of patients with suspected contact, the laborous auditing of all these actions, with endless education sessions on the same boring topic. Evidence? I am unable to read the whole article but this abstract is interesting


Abstract



An interview study was conducted among 173 nurses in two hospitals to explore their views concerning infection risks to themselves and patients and to identify any problems they perceived in safely performing infection control precautions during routine activities. Subjects were interested in the topic of Infection control and keen to perform optimally, but perceived difficulties related to lack of expert guidance whether or not they had access to an infection control nurse. In one hospital subjects identified shortages of vital equipment (gloves, appropriate handwashing agents), and this was corroborated on a checklist used independently to document the availability of resources. When the opinions of nurses working in intensive care, surgical and medical units were compared, few differences emerged other than those explained by variation in supplies of equipment, except that intensive care unit nurses were more likely to rate their patients and themselves as particularly at risk of infection, Nurses who had been qualified longer, with more than 3 years experience in their speciality, were more conscious of infection risks. Thus creating an evidence base that was capable of overcoming this natural resistance to change was a vital step.Once again you blame the staff for systemic failure. You have said you are not doing this but you really seem to be. I find it both simplistic and insulting, and I think we will have to differ on this




Yet because of the complexity of the issues invovled no breakthrough trials were possible. Many of the trial results seemed on the surface contradictory, but it was evident that whole package approaches did consistently show that MRSA sepsis rates could be sustainably reduced in most settings. This was demonstrated in many centres throughout the world and finally the burden of evidence was sufficient that although there are still those who argue that what they are being asked to do is unproven, these people are now a very small minority. Introduction of the packages with a degree of enforcement has been successful in taming one of the most intractable problems in UK hospitals in a very short time frame.I am afraid that nothing here adds anything to what you have already said. I am not persuaded it is complex: I am not persuaded the research was needed to find out how the problem arose or how to address it. We re-invented the wheel and that is a good thing. It is hardly cost effective. Again we will have to disagree.


The crux of the argument I was trying to address, is that even if something cannot be proven absolutely to be true, if the burden of evidence for efficacy is high enough and the outcome desirable to society, one can justify actions that require a certain amount of interference with individual freedom.

Yes. The difference is that you only accept one kind of evidence: and only in one direction. This is curious. In the case of hospital hygiene we could have relied on the existing evidence: we could have stuck with what was known instead of allowing managers with no knowledge of the field to change practices which had been shown to be effective over many years. And they had been shown to be effective: they were accepted as given all over the world, not because of dogma but because "the burden of evidence for efficacy [was] high enough and the outcome desirable to society". If your conception was in play the changes to that system would not have been made without an "evidence base". It is politics, Pebble, not science


I am not suggesting one takes children away from parents on this basis, but alters the contract between family and state, to work toward a new appreciation of what society expects of individual families in terms of their childcare obligations.As I said, that is what the court is for. You choose not to accept that as a legitimate way of mediating the relationship between the individual and the state: I think that is what it is for. I am certainly not going to pass that responsibility into the hands of "scientists". I do not actually think they would want it. Certainly your continued failure to answer my question about what should be done with the referral from the doctor seems to suggest they would not.



Now you are right to assert that I did not bother with other aspects of the package (search and destroy policies; antibiotic management systems etc) but they were not relevant to the point I was trying to make.Sauce for the goose, I think :smiley:

[Pebble]

Fiona, when I say you are taking my words out of context, I do not mean necessarily that you are not quoting the whole paragraph. The statements made are for the purpose of advancing an argument, or to illustrate a point. Thus my arguments in respect of hygiene are to do with evidence base in areas where there is no proof, and how in such senarios you can reach a sufficient burden of proof. The context was responding to your charge that child abuse was an area of complexity that prevented research. This is raised as an illustration.

I perhaps should have been more careful of my phraseology, but the tangents it has led you to are beyond belief. Nothing what so ever to do with the prinicple question. Only your ushakable belief that mismanagement in UK hospitals caused the problem (Spain; Ireland; Italy; USA - must be outposts of the NHS I am unaware of).

Also in respect of the evidence base for child abuse, you mis read my first statement - as I have shown. Then when I was replying to specific points of yours explaining why I though evidence was so important, us quote this out of context to support your view that I would refuse to let the Govt act without evidence.

Rather than breaking this reply into small pieces to see if you can think of a challange a number of pieces in isolation, why not take the general concept being advanced in the context of your recent entries (this is a reply after all) and tell me if in general I have a point or not?

[Fiona]

I believe I have answered that, Pebble. Many times in fact. I do not think that it is an area of complexity, as you do. I have said why I do not. You do not accept my view, and if we have nothing new to say we must leave it there.

I do not believe it has led me to tangents which are nothing to do with the principle question. You raised it and I have discussed it. I do not accept your analysis and I do not think your evidence supports your conclusion. I do not have an "unshakeable belief" that mismanagement caused the problem. I did start from this hypothesis and the evidence you have posted tends to confirm it. When you post something which shows otherwise I will consider that too. Meantime I will hold to a view which is in line with the facts I have.

I did not misread your first statement Pebble. I took you to mean what you said, not only in that first statement but elsewhere. If you do not mean what you write then I am at a loss as to how to proceed.

As to whether you have a point or not: I am wedded to the idea of basing on evidence where there is good evidence to be had. I like it when science has something solid to tell us about problems we face and I happily embrace this. I am also aware that some things are not science and never will be. This is the way the world is. As Dr S said in a different thread (if I do not misunderstand her; apologies if I did), the study of myth and the origin of religion is just such a field: there are many. It is not sceptical to asssume that such fields do not exist; it is perhaps legitimate to conclude that you do not wish to discuss them, but I do not think it is legitimate to say they have no value; or that others should not pursue them within their own terms, using their own methodology. It is true that science has advanced our knowledge in many fields, some of which were not originally seen as suitable for that approach. The phenomenal success of the method leads us to try to apply it very widely and that is a good thing. But it is also true that there is such a thing as what I have seen called "scientism": that is the over-extension of the method to areas where it is not appropriate. For example economics wears the clothes of science and adopts is vocabulary: that does not make it science. This is true of nearly all so called "social science": it is instructive to find that in those areas, despite the best efforts of honest people who are both intelligent and dedicated, we have still not falsified many of the competing theories, using data from within social science itself. You can bring forward the odd thing such as phrenology, as a counter example, I do not deny. But those are rare in comparison with the persistence of competing theories in these areas. Social science does not proceed like hard science. This may be because it is young: but I am not convinced. It seems to me that it is in need of a methodology more suited to the subject matter and that in many ways the orthodoxies which have proved so successful in other areas are in fact holding us back rather than advancing us.

I realise that may be an unpopular view on a sceptic site: but I contend that this is also a sceptical position since it questions prevailing assumptions.

[Pebble]

Fiona. If I read your reply correctly your contentions are:

1. Skepticism is questioning an orthrodox view.

2. If science cannot disprove bogus theories in a given field this is because the field is beyond science or at least its current methodology

3. Social SCIENCE will probably never be a SCIENCE.

Skepticism is usually defined rather differently:

http://dictionary.cambridge.org/define.asp?key=70265&dict=CALD

sceptic, USskeptic
nouna person who doubts the truth or value of an idea or belief

Science has such a broad remit, that to me it seems difficult to conceive of a field of human endevour where it is inapplicable, though I take your point about exploration of human psychology before recorded human history.

http://dictionary.cambridge.org/define.asp?key=70394&dict=CALD

science
noun1(knowledge obtained from) the systematic study of the structure and behaviour of the physical world, especially by observing, measuring and experimenting, and the development of theories to describe the results of these activities

My main response would be that science rarely proves a theory wrong. The role of science is support theories that explain the observed facts and predicts the results of intervention better, or removes the need for redundant assumptions. It is not its role to prove other theories wrong just to render them redundant.

No one has to date proven that angels are not responsible for keeping the stars and planets in the sky, they hide when you look for them. This theory has been on the go for over 1400 years. All that has been shown is the the laws of physics from Newton through Einsteins to Heisenberg fit better and predict future findings better.

Likewise the reason the woos won't go away is that one rarely can prove that their theoires are wrong, just that application of their theories failed to predict observations in experimental conditions or real life while other theories succeeded.

This also explains why I have not proven that hospital management is not the cause of MRSA spread, what I have done if you read the report in detail is to show that that explanation is not sufficient, and that a rather more complex theory explains the observations better. Further that application of the more complex theories in real life produced predictible results.


So if my characterisation of your beliefs are correct, observation, theory formulation and testing of theories in practice do not have a role presently in social SCIENCE. Clinical experience and recourse to the courts is the total knowledge base that is available. All non experts should get off your patch because by definition they are ignorant and do not understand, external scrutiny has no basis for an opinion, because there is no evidence they can cite.

Please tell me I am wrong!

[Fiona]

You are wrong, but there is no indication of any possibility of a meeting of minds here Pebble. I am out :smiley:

[Janot]

Science has such a broad remit, that to me it seems difficult to conceive of a field of human endevour where it is inapplicable, This is such a sad statement I hardly know where to start arguing against it. How can you deny whole fields of human endevour where science has no function? Music? Literature? Art?

Science is in my view quite limited, it has great value but only in clearly defined areas. Anyone who tries to apply a scientific analysis of, say, personal interaction (and dare I say it, especially with a woman) is doomed. >:-)

[DrS]

Science has such a broad remit, that to me it seems difficult to conceive of a field of human endevour where it is inapplicable ...

http://dictionary.cambridge.org/define.asp?key=70394&dict=CALD
sciencenoun1(knowledge obtained from) the systematic study of the structure and behaviour of the physical world ...

Would you not accept that science is concerned with the physical world, as indeed according to your quote of the definition from the Cambridge dictionary. It does indeed have a broad remit, but not beyond the physical world (in the widest sense here ... not talking quantum physics). How then does one apply it, realistically, to the world of ideas, of arts, of human interaction and development ...

I can conceive of very many fields of human endeavour where it is inapplicable.

[Pebble]

This is such a sad statement I hardly know where to start arguing against it. How can you deny whole fields of human endevour where science has no function? Music? Literature? Art?

Science is in my view quite limited, it has great value but only in clearly defined areas. Anyone who tries to apply a scientific analysis of, say, personal interaction (and dare I say it, especially with a woman) is doomed. >:-)


Would you not accept that science is concerned with the physical world, as indeed according to your quote of the definition from the Cambridge dictionary. It does indeed have a broad remit, but not beyond the physical world (in the widest sense here ... not talking quantum physics). How then does one apply it, realistically, to the world of ideas, of arts, of human interaction and development ...

I can conceive of very many fields of human endeavour where it is inapplicable.


It has obviously taken me long enough to write something truly outrageous. Personal interactions, clearly an area for scientific endeavor, results pretty useless to date. Art - depends on what is meant, appreciation etc. certainly should be studied with PET scanning to try to understand nature and responses to pleasurable stimuli and understand why certain combinations of colour/hue etc please some and leave others cold. Just because some aspects of life may have no scientific meaning in and of themselves does not of itself preclude scientific enquiry. I would venture to suggest that the human brain is a physical structure and the biochemical reactions that lead to the wonders of the world are indeed a viable area for study, though perhaps indirectly.O0

[DrS]

So how would you apply this to go about determining the meaning to fifth-century BC Athenians of, say, the Parthenon frieze.

[Janot]

Personal interactions, clearly an area for scientific endeavor Why?

Art - depends on what is meant, appreciation etc. certainly should be studied with PET scanning to try to understand nature and responses to pleasurable stimuli and understand why certain combinations of colour/hue etc please some and leave others cold. Just because some aspects of life may have no scientific meaning in and of themselves does not of itself preclude scientific enquiry. Of course it does. This to me is an insane application of science.
I would venture to suggest that the human brain is a physical structure and the biochemical reactions that lead to the wonders of the world are indeed a viable area for study, though perhaps indirectly.O0And I would venture to suggest that you are reducing all activities of the brain to some logical structure like a computer, and effectively eliminating most of meaning from life by reducing us all to some form of robot.

The application of scientific method in an area where it is not applicable is to my mind displaying an appalling lack of awareness of what science actually is. What is the point of reducing music to the study of how various parts of the brain are stimulated by it? Where would the joy of life be with such a deterministic approach?

More Between Heaven and Earth than Dreamt of in Your Philosophy.

[Pebble]

Why?
Of course it does. This to me is an insane application of science.And I would venture to suggest that you are reducing all activities of the brain to some logical structure like a computer, and effectively eliminating most of meaning from life by reducing us all to some form of robot.

The application of scientific method in an area where it is not applicable is to my mind displaying an appalling lack of awareness of what science actually is. What is the point of reducing music to the study of how various parts of the brain are stimulated by it? Where would the joy of life be with such a deterministic approach?

More Between Heaven and Earth than Dreamt of in Your Philosophy.

What is deterministic about understanding the differences between more and less creative brains? Between musicians, versus visual artists or literary artists? I see absolutely no reason why research should be precluded from looking critically at such an area. We have spent long enough trying to understand rational intelligence (not very successfully to my mind), why limit ourselves to trying to understand rational intelligence, why should we not explore emotional or artistic intelligence? Is understanding such a bad thing? I absolutely accept that such knowledge (were it readily available) may be abused and misrepresented. Some may feel that it helps move the designer baby theories forward, or might be used to predetermine how children are educated, but that to me is an entirely separate argument. Where there is a method to study, progress will eventually be made, you either join in or get left behind.

[Pebble]

So how would you apply this to go about determining the meaning to fifth-century BC Athenians of, say, the Parthenon frieze.

Not my point, please see above, what I mean by saying that no area should be excluded. I do not by that mean that all areas of endeavor are reducible to scientific explainations, but that the mind is a physical entity that we simply do not yet understand.

[Janot]

Not my point, please see above, what I mean by saying that no area should be excluded. I do not by that mean that all areas of endeavor are reducible to scientific explainations, .Well, that is what I understood you meant.

... but that the mind is a physical entity that we simply do not yet understand.If our minds were simple enough for us to understand, we would be too stupid to understand them. :cheesy::cheesy:

[DrS]

Not my point, please see above, what I mean by saying that no area should be excluded. I do not by that mean that all areas of endeavor are reducible to scientific explainations, but that the mind is a physical entity that we simply do not yet understand.
I don't really follow your meaning here, but in any case, you said:

Just because some aspects of life may have no scientific meaning in and of themselves does not of itself preclude scientific enquiry.
I asked how you would apply this (scientific enquiry) to go about determining the meaning to fifth-century BC Athenians of, say, the Parthenon frieze.

[SimonC]

I would argue that there are, indeed, many areas of life in which scientific inquiry is utterly inappropriate and quite invalid - philosophy, particularly in regard to ethics, for example. We may use ethics to guide the application of scientific discoveries but not, I think, the other way around.

Following from the fascinating converstion in this thread, I'm sure that science ( forensics, medical investigations etc ) can be used to investigate tragic familial situations. Science cannot, however, determine the morality of events that may have occured.

[Pebble]

I don't really follow your meaning here, but in any case, you said:

I asked how you would apply this (scientific enquiry) to go about determining the meaning to fifth-century BC Athenians of, say, the Parthenon frieze.

If one regards the output of the heart as blood flow, the output of the kidneys as concentrated waste products and the output of the brain as the mind (accepting that all these organs do much more), then the mind is a valid area for study. Why do we infer meaning? What are the factors that influence value? Why do one group judge that ancient artifacts are of immeasurable value in themselves and must be preserved at all costs, while others will actively destroy those same artifacts? The questions one could address are endless. I am not saying that we are any where near being able to do this systematically at present, just that I see no reason to assert that such enquiries are taboo or beyond all imaginable possibilities.
So to the meaning of the Parthenon frieze: whose meaning? those who created it (not available for direct study now) to current observers? Well if the latter why not? One may not be able to codify and rationalise the meaning itself, but one can evaluate different groups that see different meanings in the frieze.


I would argue that there are, indeed, many areas of life in which scientific inquiry is utterly inappropriate and quite invalid - philosophy, particularly in regard to ethics, for example. We may use ethics to guide the application of scientific discoveries but not, I think, the other way around.

Following from the fascinating converstion in this thread, I'm sure that science ( forensics, medical investigations etc ) can be used to investigate tragic familial situations. Science cannot, however, determine the morality of events that may have occured.

Thanks, ethics are indeed an excellent example of an area that I would have difficulty in seeing the method of study for. But lets consider this are our ethics not informed by our understanding of the world. Who would have considered it unethical to clear forrestation for human use a hundred years ago? Now that we have rational insight into climate change, ethicists have the opportunity to include scientific data into their formulation of acceptable human values. I would suggets that we no longer regard the burning of witches as ethically acceptable because of increased understanding - this did not come from philosophy or religion. Granted if you go right back to what is fundamenatlly right and wrong, I run out of options, other than to question is there really right and wrong or is this simply a product of the human mind?

[DrS]

What are the factors that influence value? Why do one group judge that ancient artifacts are of immeasurable value in themselves and must be preserved at all costs, while others will actively destroy those same artifacts? The questions one could address are endless.
I agree here, and these questions fall within the remit, properly, of archaeology, where a scientific approach is valid and useful, though not the only approach available and utilised in archaeological studies.

So to the meaning of the Parthenon frieze: whose meaning? those who created it (not available for direct study now) Yes, I referred to "determining the meaning to fifth-century BC Athenians". And here I disagree with you. It is entirely possible to reconstruct various possible meanings of this frieze for direct study from literary, archaeological, and historical sources. There are methodologies available that are both rational and rigorous to assist in interpreting these sources, but it is impossible to conceive of hard evidence that could be, or even should be, subjected to a putative scientific approach.

This is my problem with what you have been saying at times. "Not available for direct study now" implies to me that you would discard even the attempt to reconstruct a period of human genuis, with all the resultant loss for our own times that this would imply. Also, for example, when you ask why we should not explore emotional or artistic intelligence, I would contend that it depends on what you mean by explore. I would dispute that a critical scientific approach is the correct form of exploration in such fields.

[Pebble]

This is my problem with what you have been saying at times. "Not available for direct study now" implies to me that you would discard even the attempt to reconstruct a period of human genuis, with all the resultant loss for our own times that this would imply. Also, for example, when you ask why we should not explore emotional or artistic intelligence, I would contend that it depends on what you mean by explore. I would dispute that a critical scientific approach is the correct form of exploration in such fields.

I will concede on these points. My original statement was too sweeping, so pointless trying to defend. What I was trying to get at was that even where an area seems beyond scientific method, there is usually a way of reframing one's questions to permit a 'scientific' approach, i.e. of creating a consistent way of recording data for analysis and hypothesis formation and testing.

[DrS]

I completely agree, and this is routinely done in the humanities, at least in the fields of history and archaeology that I am familiar with. :smiley: