Editor's Choice Editor's choice

Easing the spring

BMJ 2007; 334 doi: https://doi.org/10.1136/bmj.39168.549178.43 (Published 29 March 2007) Cite this as: BMJ 2007;334:0
  1. Fiona Godlee, editor
  1. fgodlee{at}bmj.com

    As the Northern hemisphere's daffodils do their thing, presaging the spring, the BMJ carries, as well as a daffodil on the cover, some good news. It is possible to improve children's antisocial behaviour by teaching their parents positive parenting skills. Not only that, but the intervention is cost effective.

    Conduct disorder is the commonest reason for referring children and adolescents to mental health services, and antisocial behaviour in childhood is a powerful predictor of public service use in adulthood (BMJ 2001;323:191; doi: 10.1136/bmj.323.7306.191). Last year we published the results of an evaluation of Sure Start in England (BMJ 2006;332:1476; doi: 10.1136/bmj.38853.451748.2F), which found that the programme may harm those children most in need. The more encouraging findings from Judy Hutchings and colleagues' pragmatic randomised trial in Wales (pp 678, 682) adds further weight to a recent assessment by NICE, which concluded that parenting programmes seem to be effective.

    In an accompanying editorial, Stephen Scott calls on NICE (the UK's National Institute for Health and Clinical Excellence) to commission practice guidelines for managing conduct disorders (p 646). We don't yet know whether the good effects of this intervention will last beyond the initial six months' follow up, but the study suggests that, as one would expect, some approaches to teaching parenting skills (such as the Incredible Years programme evaluated by Hutchings et al) may prove more effective than others. Proper implementation of the programme also looks likely to be important. It would be a shame if a useful strategy were to be diluted by ineffective implementation of ineffective techniques. Here's an opportunity for governments to commission evidence based and cost effective programmes that look likely to benefit disadvantaged children and their parents, not to mention society at large.

    Investment in unbiased information for patients would be another worthwhile call on governments' coffers. I have to declare an interest here – the BMJ Group publishes the highly rated evidence-based patient information website Best Treatments (www.besttreatments.co.uk), which was until January made available free to people in the UK by the NHS. As Hannah Brown reports (p 664) the pharmaceutical industry is keen to provide information for patients, but experience from Canada and elsewhere suggests that this can be the thin end of the wedge that becomes direct to consumer advertising.

    Direct to consumer advertising has been a feature of the rise and rise of erythropoietin for treating anaemia in people with cancer and chronic renal failure. So too, according to a recent article in the Lancet (Lancet 2006;368: 2191-3), have US health care's financial incentives to prescribe the treatment and links between clinical guidelines and industry. These have tended to encourage higher target haemoglobin concentrations than are necessary or safe. A guidance statement on erythropoietin by NICE is currently mired in appeals from industry. While awaiting the final results from several key randomised trials, clinicians may find help in David Steensma's measured appraisal of the risks and benefits of these drugs (p 649). Use only in people with severe anaemia or those likely to need transfusion.

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