Sexually abused girls: patterns of psychopathology and exploration of risk factors

This paper studies the patterns of psychopathology in sexually abused girls. It also explores some environmental risk factors for psychopathology including abuse characteristics and environmental experiences. The data are derived from the baseline assessment of 81 sexually abused girls referred to the London Child Sexual Abuse Psychotherapy Outcome Study (collaborative Tavistock and Maudsley project). Data about abuse were collected from the parent or foster parent using a standardised, semi-structured interview format. The girls' psychopathology was assessed using the Kiddie-SADS schedule. Widespread and serious psychopathology in sexually abused girls attending a psychotherapy clinic previously reported in a small-scale study was confirmed; so, too, was the extent of comorbidity and impairment of psychosocial functioning. Further, a significant association was found between children looked after away from home and high rates of Separation Anxiety Disorder. No such significant associations were found for Major Depressive Disorder nor impairment of functioning. Multivariate prediction analysis revealed that significant predictors of Major Depressive Disorder consisted of seriousness of abuse, the abuser not being a parent figure, and the abuse not being recent; the only significant predictor of Separation Anxiety Disorder was that the abuser was not a parent figure; finally, impairment of general functioning was strongly predicted by the greater seriousness of abuse and also by the abuser/s not being a parent figure. Theoretical explanations advanced for the reported associations have a sense of face validity: that girls abused by strangers will be at risk of developing Separation Anxiety Disorders; that serious sexual abuse is followed by the development of a Major Depressive Disorder and a high level of impairment of social functioning.

Psychotherapy for sexually abused girls: psychopathological outcome findings and patterns of change

BACKGROUND

Controversy exists about the efficacy of psychotherapy for the mental health problems of sexually abused children.

AIMS

To compare the relative efficacy of focused individual or group therapy in symptomatic sexually abused girls, and to monitor psychiatric symptoms for persistence or change.

METHOD

A multi-centre psychotherapy outcome study recruited 71 sexually abused girls aged 6-14 years who were randomly assigned to focused individual psychotherapy (up to 30 sessions) or psychoeducational group therapy (up to 18 sessions). Changes over the course of the study were monitored.

RESULTS

Both treatment groups showed a substantial reduction in psychopathological symptoms and an improvement in functioning, but with no evident difference between individual and group therapy. However, individual therapy led to a greater improvement in manifestations of post-traumatic stress disorder (PTSD).

CONCLUSIONS

The beneficial effects on PTSD support the use of individual therapy. However, the small sample size and lack of a control group limit conclusions about changes attributable to treatment.

Specialist adult physicians in the top end of the Northern Territory: an analysis of their number and roles

The optimal way of delivering specialist services to rural and remote Australia, and particularly to remote Aboriginal and Torres Strait Islander communities, is a matter of keen debate at present, and is being considered by the Australian Medical Workforce Advisory Committee. This paper contributes to that debate by considering one specialist medical group, namely adult physicians, and discusses both their role and optimal number in the Top End of the Northern Territory, in light of the general workforce literature and recent changes to the organisation of physician services in the Northern Territory. Models of specialist service delivery need to be explicit, and organisational methods transparent, if the service is to be equitable, flexible and accountable to primary care practitioners.

"Painting a Leonardo with finger paint": medical practitioners communicating about death with aboriginal people

This article describes 19 semi-structured interviews with medical practitioners working in the Northern Territory of Australia. The interviews explored the practitioners' perceptions of the differences between Aboriginal and Western beliefs about disease causation and death. The interviews further explored how these perceptions affected the practitioners' communication of mortality information and their response to the practical and legal tasks of reporting deaths to the coroner, requesting postmortems and certifying death. Two key themes emerged. The first was the variety of interpretations placed by medical practitioners on the concept of "respect", and the difficulty they had in showing that respect in light of competing Western legal and professional obligations. The second theme was that medical practitioners felt that Aboriginal people's notions of "blame" did not match their own; this led some medical practitioners to become despondent, whilst others negotiated this tension creatively. Use of the word "blame" almost solely to refer to the Aboriginal discourse served to exoticise the Aboriginal process and obscure its areas of similarity with the Western discourse of "responsibility".

The Quality in Australian Health Care Study (QAHCS)--a review

The author reviews the politics, publicity, methods and findings of the Quality in Australian Health Care Study, which was released to a blaze of media attention in 1995. The study is a significant contribution to the growing literature on the identification and categorisation of preventable adverse events, using expert retrospective review of medical records, and a mix of explicit and implicit criteria. However, its potential impact has been lessened by the way its findings were released.

Land, body and spirit--talking about adult mortality in an aboriginal community

The aim of this article is to describe a classificatory framework, 'Land, body and spirit', which addresses the underlying causes of disease and which has proved useful in discussing with Northern Territory Aboriginal communities the causes and possible responses to premature adult deaths. Pie charts displaying proportional mortality ratios according to underlying cause of death, age and sex have also proved useful in such discussions.

Towards a direct definition of an alcohol-related death: an analysis in Aboriginal adults

This paper addresses the conceptual and methodological difficulties in obtaining reliable information on alcohol-related mortality in Aboriginal communities. A working definition is proposed; this requires an alcohol-positive history together with a consistent mode of death, and is applied retrospectively to a series of 29 adult deaths in a large Aboriginal community. An informant history of alcohol abuse was found to be the most sensitive indicator of an alcohol-positive history and correlated well with autopsy findings and medical records. Alcohol-positive histories were found for 17 of 29 deaths by informant history, for 9 of 29 by autopsy findings, and for 12 of 29 by medical record review. These indicators were combined with a mode of death categorisation to arrive at an estimate of 5 of 29 definite, 5 of 29 probable, and 1 of 29 possible alcohol-related deaths. We conclude by examining the process by which such a definition might be further developed and the context in which resulting information might then be used.

Death certification in Western Australia--classification of major errors in certificate completion

We aimed to develop a method to classify those errors in the completion of death certificates arising from misunderstanding of the certification process. We reviewed 430 Western Australian death certificates registered in March 1990 using a method devised to differentiate between major and minor errors. Major errors were found in 16 per cent of certificates (95 per cent confidence interval 12 to 20 per cent). The error rate did not vary significantly between city and country areas, nor between teaching hospitals and other locations. The method was validated on a separate sample of 120 certificates. It has potential as a tool to monitor a critical but neglected step in the production of mortality statistics and to assess understanding of the process of death certification.

Necrobacillosis--primary anaerobic septicaemia due to Fusobacterium necrophorum

Necrobacillosis is a severe septicaemic illness caused by an anaerobic Gram-negative bacillus, Fusobacterium necrophorum. It occurs predominantly in young people and is characterised by oropharyngeal infection and subsequent metastatic complications, frequently involving the lungs and/or large joints. We report four recent cases in previously healthy young men, describing the clinical features of the disease (including autopsy findings), and the problems associated with diagnosis and treatment.

Surgical treatment and survival from cutaneous malignant melanoma

Varied methods of primary surgical treatment of 189 cases of cutaneous malignant melanoma studied in Western Australia had no statistically significant effect on prognosis. The results indicate that wide excision is not justified as the standard treatment of cutaneous malignant melanoma.