DEVELOPMENTAL MEDICINE AND CHILD NEUROLOGY. 1963, 5

while on treatment, its liability to produce tiresome side-effects, and the relapses which occurred when the drug was withdrawn are severe limitations on its usefulness. Indeed, the improvements recorded would nearly all be more justly called modifications, because there is no indication in this experiment that consistent progress towards a cure is being made in most cases, and, while it is certainly true that a wider range of fusion and a lessening of the deviation is a beneficial difference, such changes do not raise great hopes of ultimate cure. The author herself expresses disappointment that the drug fails to pro- duce a ‘predictable, measurable and all-or-none response’.

She quotes one remarkable case where paresis of both superior recti and both superior obliques disappeared while on treatment only to reappear on its cessation. This is a most uncommon type of squint, and in this particular case the mode of action of the drug is even more obscure than usual.

We still understand too little of the fundamental mechanisms involved in the early stages of concomitant strabismus in children or of why it so often deteriorates later into an irreversible state; so we can do no more than make guesses at what will eventually prevent squints or cure them by rational therapy not involving surgery. Dr. FLETCHER’S conclusion that the use of this and other drugs in the treatment of children with strabismus should be explored is undoubtedly valid and her preliminary report should encourage further efforts along these lines. PETER GARDINER

REFERENCES *Fletcher, M. C. (1961) ‘Chlordiazepoxide (“Librium”) in the treatment of strabismus; a preliminary

report.’J. Amer. med. Worn. Ass., 16, 37-44.

RESIDENTIAL TREATMENT THE publication of the papers from the International Study Group at Oxford last September on the ‘Indications for Residential Treatment in the Early Years’, shows that we are now thinking of cerebral palsied children as having feelings as well as lesions. (Three appear in this number, while papers by Ellis, Kershaw and Michell were published in February).

All six papers emphasise that these children need both family life and early treatment, and discuss obstacles in the way of providing them together. The difficulties inherent in distance from treatment centres, in tensions within the family or in the strain on parents and other children, are sympathetically explored. Milani-Comparetti helps us to further clarification by asserting firmly that when the choice makes non-residential treatment impossible, ‘these cases cannot be counted as “indications” for residential treatment’. The continuing admission that residential treatment in the early years is always second best is of primary importance, however inevitable it seems in particular cases. It underlines the need for vigilance in planning, whether for an individual child or for the development of services in general. Probably many of us know at least one family which i s both able and willing to move nearer to a treatment centre if the child’s dual needs are fairly and squarely discussed. Unfortunately, we cannot always rule out a bias towards residential care in some of us who are professionally concerned, either because, as in England, residential education is highly respectable, or because the parents are not the best co-operators. Acceptance that separation, whatever its benefits, is a bad substitute for family life plus treatment should make us look diligently at every means for avoiding it, as is clearly done in Newcastle. Is the home which, in Kershaw’s words, is ‘actively harmful to the child’ really beyond

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redemption ? Is rehousing of an overcrowded family, with the help of some of the money which would be spent on residential placement, really impossible ? Such a suggestion has been known to raise a scandalised cry of ‘subsidising families’ but is not residential care a subsidy anyhow, partly paid for in money but partly by the child in terms of emotional deprivation and impoverishment ? Or again, may not the unco-operative parent, who does not t ry because she will not accept the handicap, really need skilled psychiatric or casework help?

The second reason for continuing consciousness of the importance of roots within the family is that it might enable inadequately mothered children to be seen, throughout their school life, as children at risk. Michell lists some of the signs of distress in young children; the work of Bowlby and others has shown that the effects may be delayed beyond childhood, manifesting themselves in impoverished personality rather than as behavioural symptoms. The paper from Scandinavia excites admiration for the efforts made to defeat geography. Much detail must have been omitted in so condensed a presentation, but one would like to know how the answers to the questionnaire were evaluated. Two months is an eternity when one is under three, when one measures time in days and when any number beyond three is ‘lotsum’ and incalculable. Michell’s summary of Spitz shows that a child of three, after separation, may sleep well, play with toys, be very biddable and yet be an emotionally disturbed child. The questionnaire includes detailed enquiry of what a child does on return- ing home, but little on how he feels or, equally vital, how his parents feel towards him or about their adequacy as parents.

These admirable papers should stimulate study of, among other matters: (a) The varying needs of families with cerebral palsied children, for housing and home

help as well as for treatment. (b) The long term effect of deprivation and separation, perhaps by carefully paired

comparison with those treated while remaining within a satisfactory family. (c) The need, normal as well as neurotic, of parents for their children. This is less obvious

and less easy to study than the needs of children for their parents; it may be equally important.

NORAH GIBBS For reasons of space, comment on boarding schools for older children had to be omitted.

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