attrition rates have been high." 12 .... in west Africa, Russia, and other states of the former Soviet ... are printed on lighter paper to keep postal coststo a minimum.
Although quality of life improves for most people with learning disabilities, this setting is a demanding one for staff dealing with people with severe learning disabilities, who can be difficult to engage in social, occupational, and community activities.'0 Preliminary results from the all Wales strategy have been modestly encouraging, but progress has been slow, there are significant implications for funding, and staff attrition rates have been high." 12 As the move to community care gains impetus general practitioners will increasingly have to identify and treat much of the less severe psychiatric disease-for which they may need extra training and experience. They may have to call on learning disability teams in the community, with their nursing, psychiatric, psychological, and social work skills. Access to specialist day hospitals will also be needed. These places can provide people with severe learning disabilities with integrated training in communication and motor skills through speech therapy, occupational therapy, and physiotherapy; programmes of behavioural management; basic training in self care (hygiene, toileting, and personal cleanliness); intensive training in social skills; family psychotherapeutic support; and the management of drug treatment. They also have much to offer people with less severe learning disabilities and can act as a focus for court diversion schemes and community supervision orders, and for counselling in acceptable sexual and drinking behaviour. A comprehensive psychiatric service for people with learning disabilities will also require inpatient facilities: for patients with intercurrent mental illness or mental illness resistant to treatment, those requiring respite care, and
those with more severe personality disorders with forensic implications who can nevertheless be managed in a locally based service with modest levels of security."3 For the few patients who offend repeatedly and seriously, secure or semisecure provision is needed. Some places provide inpatient facilities in the setting of a specialist psychiatric service for learning disabilities, whereas the Mansell report looks more to mainstream psychiatric services to meet these needs. Local services should find their own way forward and should evaluate their results. ANDREW H REID Consultant psychiatrist
Royal Dundee Luff Hospital, Dundee DD2 5NF 1 Cole G, Neal JW, Fraser WI, Cowie VA. Autopsy findings in patients with mental handicap. J Intellect Disabil Res 1994;38:9-26. 2 Rutter M, Graham P, Yule W. A neuropsychiatric study in childhood. London: Spastics International Medical, Heinmann Medical, 1970. 3 Fraser, WI, Nolan M. Psychiatric disorders in mental retardation. In: Bouras N, ed. Mental health in mental retardation: recent advances and practices. Cambridge: Cambridge University Press, 1994: 79-92. 4 Turner TH. Schizophrenia and mental handicap-an historical review and implications for future research. Psychol. Med 1989;19:301-14. 5 Reid AH. The psychiatry of mental handicap. London: Blackwell Scientific, 1982. 6 Day K, Jancar J. Mental and physical health and ageing in mental handicap: a review. J Intellect
DisabilRes 1994;38:241-56. 7 Day K. Male mentally handicapped sex offenders. BrJ Psychiatry 1994;165:630-9. 8 Holt G. Challenging behaviour. In: Bouras N, ed. Mental health in mental retardation: recent advances and practices. Cambridge: Cambridge University Press: 1994: 126-32. 9 Maxwell J. Services for people with learning disabilities and challenging behaviour or mental health needs. London: HMSO, 1993. (Mansell report.) 10 Emerson E, Beasley F, Offord G, Mansell J. An evaluation of hospital-based specialised staffed housing for people with seriously challenging behaviours. J Intelect Disabil Res 1992;36: 291-307. 11 Evans G, Todd S, Beyer S, Felce D, Perry J. Assessing the impact of the all-Wales mental handicap strategy in a survey of four districts.3Intellect Disabil Res 1994;38:109-33. 12 Emerson E, Hatton C. Moving out: the impact of relocation from hospital to community on the quality of
life ofpeople with learning disabilities. London: HMSO, 1994. 13 Reid AH. Psychiatry and leaming disability. BryPsychiatiy 1994;164:613-8.
The BA family The "BMJ" comes in 22 editions Some readers will be reading this editorial not in English but in Greek, Hungarian, Polish, Portuguese, Romanian, or Spanish. Indeed, some readers may never have even seen any of the weekly editions of the BMJ published in English from London. This is because the BMJ has 22 editions, several of them published in languages other than English. The aim of all of the editions of the BMJ is to publish rigorous, accessible information that will help doctors improve their practice and influence the international debate on health. But publishing the BMJ in different editions allows us to serve the different needs of different readers. The BMJ published its first local edition-in India and the Netherlands-in 1985. These local editions are published by local publishers in association with the BMJ Publishing Group, and most of them are monthly. Editors and editorial boards from the country concerned select material from the weekly BMJ that they think will be most suitable for their audience. Local editions are published in Brazil, Bulgaria, Greece, Hungary, India, Mexico, the Netherlands, the Middle East, Pakistan, Poland, Portugal, Romania, Scandinavia, South Africa, and Spain.* In addition, we expect this year to start editions in Central America, China, the Czech Republic, and Turkey, and we hope eventually to start editions in west Africa, Russia, and other states of the former Soviet Union. Existing local editions are sent to 147 000 readers, but local editions are usually read by more than one readerand we estimate their total readership to be about half a million. The aim of the local editions is to make the BMJ available to those who cannot read English, cannot afford the weekly 1550
BMJ, or live in countries where there is little tradition of subscribing to journals. Doctors and others are thus given access to an international medical journal, and we hope as well to support the publication of local journals by local publishers. Our Hungarian partners publish not only the Hungarian edition of the BMJ but also Lege Artis Medicianae, one of the best read medical journals in Hungary. The local editions include original scientific papers only if they have been published in the weekly BMJ, but the editors of the local editions submit any original research papers that they receive to the weekly BMJ. The local editors do, however, include some local news, comment, editorials, book reviews, and the like. All the editors and publishers of the local editions will be meeting in London next week, and our aim is to build a family in which we support, encourage, train, and criticise each other. The weekly BMJ is sent to 112 000 readers and comes in four different editions, all of them identical editorially. Only the advertising and paper are different. The "clinical research" edition is sent predominantly to hospital doctors and the "general practice" edition to general practitioners. The "compact" edition, which is sent mostly to retired doctors, and the international edition carry little or no advertising and are printed on lighter paper to keep postal costs to a minimum. The Student BMJ comes out monthly and comprises material selected from the weekly BMJ by a team of students and material submitted by students or commissioned specially. The Student BMJ began in 1992 with the aims of getting students into the habit of reading journals, helping BMJ voLuME 310
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them to make the difficult transition from student to doctor, providing them with types of educational material that are often lacking in medical schools, and giving them a forum in which to debate the issues that are particular to students. The journal has proved a great success: the BMA student membership has grown by 80% to 9300, and the journal has 1000 subscribers, many of them from outside Britain. We also now have a local edition of the Student BMJ in South Africa, with a circulation of about 4000. Local publishers are keen to start editions, not least because the Student BMJ can be an effective way to help students learn English. Finally, the BMJ is also available in electronic form on the internet (http://www.bmj.com/bmj/).' The internet BMJ contains only some of the material published in the weekly BMJ (the contents pages, structured abstracts, editor's
choice, and "This week in BMJ" plus some other articles), but it may well prove the most effective way to reach out to readers worldwide. In doing this we might further the dream of the editors of the BMJ a century ago, who wrote (in language we cannot hope to match): "Those whom seas sever and distances divide the BMJ now joins in close communion and frequent converse on common social and scientific interests." *See advertisement opposite p 161 1 in Clinical Research edition and p 1603 in General Practice edition.
BMJ, London WC 1H 9JR
RICHARD SMITH Editor TONY DELAMOTHE Deputy editor
1 Delamothe T. BMJ on the internet. BMJ 1995;310:1343-4.
Family mediation Doctors should consider refeming divorcing couplesfor this service The government's recent white paper on divorce, Looking to the Future. Mediation and the Grounds for Divorce, puts family mediation at the heart of a new one year, no fault procedure of "reflection and consideration." Family mediation has been developing in Britain for 15 years as a process for resolving disputes between separating and divorcing couples. Its defining characteristic is that a third person, the mediator, who has no personal stake in the outcome, is responsible for conducting a joint decision making process by the participants, who are invited to cooperate with each other to find mutually satisfactory agreements. The process works by the mediator moving the couple stage by stage from identifying the issues to be resolved to jointly considering and eventually choosing options. The issues can include arrangements for the children (where they should live and how they should see the parent with whom they are not resident), financial settlements, accommodation and ownership of the house, the division of assets, and the sharing of liabilities. Mediation is a voluntary and confidential process and, as an alternative to a legally conducted dispute, is accorded privilege by the courts so that the attempt to find agreement does not prejudice any later court hearing. Many courts also provide a family court welfare officer at the court as a late attempt to achieve a settlement or to report to the court on the interests of children in an unresolved dispute. Because family mediation is primarily used at the time of the breakdown of a marriage or long term relationship, family mediators are trained to work in the context of intense distress and conflict. They attempt to redress imbalances of power and to focus on the children's wellbeing. Mediation is contraindicated when either participant is too afraid to sit down with the other because of either actual or threatened violence. Family mediation has developed in response to 20 years of a rapidly increased divorce rate (1993 saw the highest number so far) and a decade of research into the effects of divorce on children. In Britain a quarter of children under 16 now experience their parents' divorce. Evidence suggests that it is the process by which parents part that is more predictive of harm than the fact of separation,' particularly when there is continuing conflict.' Children's needs are rarely fully met by parents in the throes of divorce,'4 and the effects of parental conflict can last into adulthood. A key protective factor seems to be the maintenance of the child's self esteem.5 BMJ VOLUME 310
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Given these findings, family mediators try to reduce conflict, help parents cooperate to meet their children's short and long term needs, and ensure that the voice of the children is heard by parents. This can contribute to the formation of a more positive interpretation of events by the children-a factor found by Rutter to contribute to their resilience and self esteem "in the face of adversity."6 Children can also be referred for counselling. Research into the effects of divorce on adults has focused more specifically on their health. For example, the risk of admission for psychiatric care was early found to be four to six times higher for divorced people than for those who were married.7 More than 100 studies have shown that married people tend to be happier and healthier than divorced people,8 and Walker has charted an aetiological pathway leading from the continuous episodic stress of divorce to ill health.9 Research has shown that clients particularly value family mediation, which has been shown to improve communication and reduce conflict and distress for adults and children,'0 whereas mediation of children's arrangements, which is often urgently needed and successful, can be undermined by continuing conflict over money." Doctors are often the first professionals whose help is sought during divorce. Even when a doctor is treating only one person or one parent and children, it is helpful to make a referral so that a mediator can invite the other party to participate-and he or she frequently does. This can be at any stage of the reparation and even after dicrorce. THELMA FISHER
National Family Mediation, London WC1H 9SN 1 Cummings EM, Davies P. Children and marital conflict: the impact offamily dispute and resolution. New York: Guilford, 1994. 2 Cockett M, Tripp J. The Exeter study: children living in re-ordered families. Exeter: University of Exeter, 1994. 3 Mitchell A. Children in the middle: livingthrough divorce. London: Tavistock, 1985. 4 Walczak Y, Burns S. Divorce: the child's point of view. London: Harper and Row, 1984. 5 Elliott BJ, Richards M. Parental divorce and the life chances of children. Family Law 1991 Nov:481-4. 6 Rutter M. Resilience in the face of adversity. BrjPsychiatty 1985;147:598. 7 Cochrane R, Stopes Roe M. Women, men, employment and mental health. Br Y Psychiatty
1981;139:373. 8 Lauer RH, Lauer JC. Marriage and family: the quest for intimacy. Dubuque, Iowa: Wm C Brown Communications, 1994. 9 WalkerJ. The cost of communication breakdown. London: Burston-Marsteller, 1995. 10 Walker J, McCarthy P, Timms N. Mediation: the making and remaking of co-operative relationships. Newcastle upon Tyne: Centre for Relate Family Studies, Newcastle University, 1994. 11 Lord Chancellor's Department. Report on the costs and effectiveness of conciliation in England and Wales. Newcastle upon Tyne: University of Newcastle, 1989.
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