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There’s no doubt that trust is ‘won’ immediately in some circumstances and in young children is the default position. Usually, though, it has to be earned: and even when deserved it isn’t always granted. I wonder whether this ‘process’ (clumsy word, but possibly the best under the circumstances) has become slower, more attritional and more grudgingly acknowledged, a symbol perhaps of societal changes we might have to accept. Taking this a step further, one spoke in the paediatric (or any medical) pathway is mutual visibility surely a predictor of the point at which a family unmanacles themselves of reservations. How long does it take for a mother to disclose (even anonymously) to researchers that every time she enters her home, she risks adding to her bruise count: how many online consultations does it take before a family feel sufficiently at ease to disinter the spectres in their history lurking stage left behind the velvet curtains? I rest my case… or maybe, teasingly, am only just hinting at it.
Neglected global diseases
No one is oblivious to the pernicious effects of intimate partner violence (IPV), but little is known about effect sizes either on the mother or children. Previous cohort studies that have had the ‘guts’ to examine this pervasive holoendemic disease might have underestimated the prevalence and effects by: using only physical violence (emotional control is more common); using unidimensional measure (conflict tactics scale, for example) or by missing the opportunity for long term follow-up. Deidre Gartland and colleagues examined close to 700 maternal-child dyads in Melbourne, Australia from the Maternal Health Study in children born between 2003 and 2005, recruitment beginning during pregnancy and repeat assessments at 3, 6 and 12 months then at 4 and 10 years. IPV was assessed with the composite abuse scale and child outcomes by the Strengths and Difficulties Questionnaire (SDQ), Developmental and Well Being Assessment (DAWBA), Spence Children’s anxiety scale, Wechsler intelligence scale NIH picture vocabulary test and the Children’s Communications Shortlist. In short, 13% of mothers of children at 1 year and 16% at 10 years reported some form of IPV. Adjusted ORs for likely psychiatric diagnosis and emotional difficulties (DAWBA and SDQ) with respect to IPV at 2.0 and 1.9 respectively were significant. Given the likely under-reporting in such studies the real effect is probably larger, a reflection of the dysfunctional parent -child relationships this sort of abuse inevitably fosters. So, what do we, and paediatricians, do about it? We ask: we ask in the same way that obstetricians do. The line ‘if there’s anything you haven’t already mentioned at home that you’d like to tell me…’ opens doors-literally and metaphorically. See page 1066
The future: part 1 – distance consultation
The pandemic reinforced the need to revisit the traditional default of all follow-upvisits needing to be in person both from medical and family need angles. Three papers examine aspects of the evolution of and drawback to this seismic (and I don’t think is an exaggeration) shift towards tele-medicine. Ronny Cheung’s Viewpoint looks at practicalities. What does an outpatient visit entail for a family? To name but a few: time off work and lost income; days out of school; lost social contact lessons and sports; a tedious gridlocked drive through the drizzle with the inherent carbon footprint; the search for the elusive car parking spot which is pounced on by another vehicle. Of course, contact is important, but the value of physical proximity surely needs to be weighed up, the default surely being ‘is there a reason for the next visit not to be online—what does the childthink?’
The notion that ‘mobile phones are wonderful because they enable parents to instantly send images to their children’s paediatricians’ is to some extent justified and predates even that hazy, carefree era before December 2019. It is, though, riddled with potholes. Potholes that are navigable, but potholes, nonetheless. These relate not only to security but also on the tacit transfer of responsibility to act on the picture (particularly if unsolicited). Mahmoud Motawea and colleagues thoughts on their use and implications (even in the face of highly secure NHS mechanisms) lends some context (but not cold water) to the wave of enthusiasm.
The issues don’t stop there as, as Robert Wheeler’s Clinical Law series piece articulately demonstrates. The reality is that a video call whether as part of a legal assessment or otherwise simply can’t (or can’t at present) replicate the sixth sense one gets (subtleties of movement, parental eye contact, signs of neglect) that being in the same room can. This isn’t always necessary, but the court precedents show there are times that it is. See pages 1041, 1044, 1056
The future: part 2 – robots
Maybe it uncovers the nascent techno-luddite in me, but the mention of robots as the future has generally tended to make me shudder and the notion of robot as anxiolytic a dismissive ‘what’s wrong with a hug/slug of midazolam/nitrous oxide?’ I think, though, I’m changing my mind, at least a bit, in no small part the result of Brenda Littler and colleagues’ narrative systematic review on the use of (social) robots in distress alleviation, some, ironically, ‘real’ teddy bears themselves. See page 1095
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Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Commissioned; internally peer reviewed.