Despite the almost universal ratification of the Convention on the Rights of the Child, summits and conferences organized by international and local agencies, the awareness campaigns and the immense work performed by nongovernmental organizations, too many children continue to endure hardship. It is estimated that 8.4 million children are involved in the worst forms of child labour, namely labour that involves forced or bonded labour, sexual exploitation, illicit work and armed conflicts.
The impact of such activities on the survival, health (both physical and mental) and development of children is devastating. Girls are particularly vulnerable. But children are resilient, and although longitudinal data on the validity of the programmes are not yet available, rehabilitation programs adapted to their own culture and reinsertion in their communities have shown positive results.
Along with monitoring, research, education and rehabilitation, paediatricians have the responsibility, as physicians and advocates for children, to promote the respect of children’s rights while, at the same time, searching for solutions to eradicate poverty and prevent war. There should be zero tolerance for those who violate children’s rights.
Child labour; Child prostitute; Child soldier
The Convention concerning the Prohibition and Immediate Action for the Elimination of the Worst Forms of Child Labour was adopted by the International Labour Organization in 1999. 174 countries around the world have signed or ratified the convention, which requires countries to adopt laws and implement programs to prohibit and eliminate child labor that poses harms to health or safety. Nonetheless, child labor continues to be common in the agriculture and mining sectors, where safety and environmental hazards pose significant risks. Drawing upon recent human rights investigations of child labor in tobacco farming in Kazakhstan and gold mining in Mali, the role of international human rights mechanisms, advocacy with government and private sector officials, and media attention in reducing harmful environmental exposures of child workers is discussed. Human rights-based advocacy in both cases was important to raise attention and help ensure that children are protected from harm.
Gynecological problems are common in children but training in this subject is rare during paediatric postgraduate education. Knowledge in this area is important for providing comprehensive health care to children. The article explores the gynecological examination of the child and common gynecological disorders in the paediatric and adolescent age groups. Routine examination of the external genitalia as part of a well-child physical normalizes the examination for the child and helps to inform the physician about the large variations in normal genitals. Many complaints can be dealt with by reassurance, while most others respond to medical therapy and can be dealt with easily by paediatricians. Both young children and adolescents respond positively when allowed to have control over the tempo of the interview and the examination. A positive experience associated with a genital examination will help to open lines of trust. This along with nonjudgmental, open communication, will create educational opportunities to enhance a responsible transition from child to young adult.
Gynecology; Vulvar; Paediatric
The knowledge that the environment in which we live, grow and play, can have negative or positive impacts on our health and development is not new. However the recognition that adverse environments can significantly and specifically affect the growth and development of a child from early intrauterine life through to adolescence, as well as impact their health later in adulthood, is relatively recent and has not fully reached health care providers involved in paediatric care.
Over the past 15 years, world declarations and statements on children's rights, sustainable development, chemical safety and most recently climate change, have succeeded in cultivating a global focus on children's health and their right to a healthy environment. Many international calls for research in the area, have also been able to identify patterns of environmental diseases in children, assess children's exposures to many environmental toxicants, identify developmental periods of vulnerability, and quantify the cost benefits to public health systems and beyond, of addressing environmentally related diseases in children. Transferring this information to front-line health care providers and increasing their awareness about the global burden of disease attributed to the environment and children's especial vulnerability to environmental threats is the salient aim of this commentary.
Miss Anna Freud died during the winter at the age of 86. She had been a pioneer in the understanding of children through psychoanalysis and a great champion of the rights of children. Her life began in Vienna as the youngest child of Sigmund Freud, and her early work with children was in Austria. In 1938, because of the Nazi régime and even though she was nursing her father during his terminal illness, she had to escape with him to London. Her work with homeless children and with those in residential nurseries in London during the second world war is well known, as is her work on child development and psychopathology in the postwar years. But one less well known aspect of her life that was of immense importance to a few fortunate British paediatricians was the 'paediatric group' that she ran for over a quarter of a century and which Dr Christine Cooper recalled at the memorial meeting in London earlier this year.
Women reported to child protective service agencies frequently report problems that significantly interfere with the health and well-being of their children and themselves. Behavioral treatment programs appear to be effective in managing these co-existing problems, such as domestic violence and substance abuse. However, evidence-supported interventions are rarely exemplified in complicated clinical cases, especially within child welfare settings. Therefore, in this case example, we describe the process of adapting an evidence-supported treatment to assist in managing significant co-existing health-related problems in a mother who was referred due to child neglect and drug abuse. At the conclusion of therapy, the participant reported improvements in perceived family relationships, illicit drug use, child maltreatment potential, whereas other health-related outcomes were mixed. Most improvements were maintained at 4-month follow-up. Issues relevant to implementing evidence-based treatments within community contexts are discussed, including methods of increasing the likelihood of valid outcome assessment, managing treatment integrity, and adjusting standardized treatments to accommodate co-occurring problems.
Child neglect; Substance abuse; Obesity; Family Behavior Therapy
In recent years, a large body of research has investigated the various factors affecting child development and the consequent impact of child development on future educational and labor market outcomes. In this article, we contribute to this literature by investigating the effect of handedness on child development. This is an important issue given that around 10% of the world’s population is left-handed and given recent research demonstrating that child development strongly affects adult outcomes. Using a large, nationally representative sample of young children, we find that the probability of a child being left-handed is not significantly related to child health at birth, family composition, parental employment, or household income. We also find robust evidence that left-handed (and mixed-handed) children perform significantly worse in nearly all measures of development than right-handed children, with the relative disadvantage being larger for boys than girls. Importantly, these differentials cannot be explained by different socioeconomic characteristics of the household, parental attitudes, or investments in learning resources.
Family violence, including child abuse, neglect, and domestic violence, is a public health problem. The aim of this study was to provide data on prevalence and factors of Orofacial lesions relating child abuse in Iran to lend evidence to support preventing child abuse.
Materials and Methods:
The overall approach was a case-note review of children having child abuse note, recording by personnel of social services. Research ethical approval was sought from the Central social service organization. This study was conducted in Isfahan, Iran (2011).
The mean age of children, when abuse had been occurred was 8 years (SD = 1.68), and there were approximately an equal number of boys and girls. Children had a high physical experience (66.1%).Of these children, at least 60% sustained trauma to the face and mouth. Emotional abuse was 77.1%, neglect was 64.1%, and lower experience of sexual abuse which was 4.1%. There was a strong relationship between gender and abuser which shows girls have been affected by stepfathers (P = 0.001).
Preliminary data suggest that there are strong evidence regarding the incidence of child abuse relating orofacial lesions which dentists should be aware of them. Future trials may draw on these useful baseline data to help their study design.
Child abuse; child neglect; Iran; orofacial lesions
Children in dentistry are traditionally described in terms of medical diagnosis and prevalence of oral disease. This approach gives little information regarding a child’s capacity to maintain oral health or regarding the social determinants of oral health. The biopsychosocial approach, embodied in the International Classification of Functioning, Disability and Health - Child and Youth version (ICF-CY) (WHO), provides a wider picture of a child’s real-life experience, but practical tools for the application of this model are lacking. This article describes the preliminary empirical study necessary for development of such a tool - an ICF-CY Core Set for Oral Health. An ICF-CY questionnaire was used to identify the medical, functional, social and environmental context of 218 children and adolescents referred to special care or paediatric dental services in France, Sweden, Argentina and Ireland (mean age 8 years ±3.6yrs). International Classification of Disease (ICD-10) diagnoses included disorders of the nervous system (26.1%), Down syndrome (22.0%), mental retardation (17.0%), autistic disorders (16.1%), and dental anxiety alone (11.0%). The most frequently impaired items in the ICF Body functions domain were ‘Intellectual functions’, ‘High-level cognitive functions’, and ‘Attention functions’. In the Activities and Participation domain, participation restriction was frequently reported for 25 items including ‘Handling stress’, ‘Caring for body parts’, ‘Looking after one’s health’ and ‘Speaking’. In the Environment domain, facilitating items included ‘Support of friends’, ‘Attitude of friends’ and ‘Support of immediate family’. One item was reported as an environmental barrier – ‘Societal attitudes’. The ICF-CY can be used to highlight common profiles of functioning, activities, participation and environment shared by children in relation to oral health, despite widely differing medical, social and geographical contexts. The results of this empirical study might be used to develop an ICF-CY Core Set for Oral Health - a holistic but practical tool for clinical and epidemiological use.
This article provides an overview of different types of rights to aid consideration of, and debate about, children and young people's rights in the context of paediatrics and child health. It demonstrates how children's rights may or may not differ from adult rights and the implications for practice. It shows that applying a children's rights framework can be more helpful in pursuing a public child health agenda than in reducing ethical or legal conflicts when interacting with child patients and their families.
children's rights; ethics
A team approach in the comprehensive management of children on a general paediatric ward is described. The team comprises paediatricians, nurses, a child psychiatrist, and a social worker, with a psychologist, play-leader, and teachers making important contributions. In this way members of the team learn from each other, and the paediatrician in training gains valuable experience about the management of children with emotional problems. The team approach is based on the principles of family therapy, but it also uses other forms of therapy--such as behavioural, marital, and individual. Children with severe psychosomatic problems in particular can be helped by such treatment, but other emotional problems are also suitable for management using such an approach.
While child maltreatment is recognised as a global problem, solid epidemiological data on the prevalence of child maltreatment and risk factors associated with child maltreatment is lacking in Australia and internationally. There have been recent calls for action to improve the evidence-base capturing and describing child abuse, particularly those data captured within the health sector. This paper describes the quantity of documentation of maltreatment risk factors in injury-related paediatric hospitalisations in Queensland, Australia.
This study involved a retrospective medical record review, text extraction and coding methodology to assess the quantity of documentation of risk factors and the subsequent utility of data in hospital records for describing child maltreatment and data linkage to Child Protection Service (CPS).
There were 433 children in the maltreatment group and 462 in the unintentional injury group for whom medical records could be reviewed. Almost 93% of the maltreatment code sample, but only 11% of the unintentional injury sample had documentation identified indicating the presence of any of 20 risk factors. In the maltreatment group the most commonly documented risk factor was history of abuse (41%). In those with an unintentional injury, the most commonly documented risk factor was alcohol abuse of the child or family (3%). More than 93% of the maltreatment sample also linked to a child protection record. Of concern are the 16% of those children who linked to child protection who did not have documented risk factors in the medical record.
Given the importance of the medical record as a source of information about children presenting to hospital for treatment and as a potential source of evidence for legal action the lack of documentation is of concern. The details surrounding the injury admission and consideration of any maltreatment related risk factors, both identifying their presence and ruling them out are required for each and every case. This highlights the need for additional training for clinicians to understand the importance of their documentation in child injury cases.
Child maltreatment; Clinical documentation; Data linkage; Injury surveillance; Morbidity data
Family physicians, paediatricians, nurse practitioners and all primary health care providers are well-positioned in the health care system to provide identification and intervention for developmental delay in early childhood. This can be accomplished through the promotion of healthy child development by supporting children and their parents, paying special attention to issues of attachment and parent-child interactions. Early recognition and intervention is critical for addressing all developmental, social and behavioural problems in young children. A familiarity with local community resources and services is crucial; it will assist primary health care providers in supporting families by providing extra assistance and assessment for families at risk. The present article reports on the evidence-based interventions at the 18-month visit including screening tools, resources and a case example. The importance of interdisciplinary coordination to provide a comprehensive approach to screening, assessment and intervention for developmental delays in infants and young children is highlighted.
Autistic spectrum disorder; Child development; Early intervention; Health promotion; Paediatrics; Well-child care
This article examines the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research recommendations on children as research subjects in the context of the history of American childhood. The Commission's deliberations took place during the post-World War II period of rapid changes in understandings of childhood and adolescence, brought on in part by school children's highly visible roles as risk-taking protagonists in the polio vaccine trials and the civil rights movement; by the children's rights movement and court decisions granting children and adolescents greater autonomy in divorce cases and in delinquency and mental health hearings, among other rights; and finally by a renewed movement for child protection led by parents of disabled children and by polio survivors themselves. The National Commission's final recommendations emphasized the need for parents to approve, for children above age seven to assent to research, and for children in special care (either medical, psychiatric, or because they were orphans or had committed juvenile crimes) generally to be subjects of research only if there was some direct connection between the reasons for their special care and the objectives of the research. Ultimately, in these recommendations, the National Commission charted a middle ground between the children's rights movement, which advocated enhanced self-determination for children, and the disability rights movement, which urged greater protection for children.
National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research; children as research subjects; autonomy; informed consent; research ethics; civic childhood
Parents have central and critical influence in the health, learning and development of their young children. The physician plays a key role in supporting this role of parents, and there are practical health interventions that practitioners can promote in everyday practice that are coherent with the population-based evidence related to childhood outcomes. Four child development enhancers are recognized – emotional awareness, reading books, appropriate discipline and preschool programs including appropriate play opportunities. The child’s physician can give clear messages about why each enhancer is important and what parents can do to use them to create nurturing environments for their children. The present article provides the evidence for these interventions and a series of coordinated physician activities that will enhance the early learning opportunities of the first few years of life, for improved trajectories for health and well being.
Discipline; Emotional awareness; Literacy; Parenting; Play child development; Social paediatrics
Paediatric cataract blindness presents an enormous problem to developing countries in terms of human morbidity, economic loss, and social burden. Managing cataracts in children remains a challenge: treatment is often difficult, tedious, and requires a dedicated team effort. To assure the best long term outcome for cataract blind children, appropriate paediatric surgical techniques need to be defined and adopted by ophthalmic surgeons of developing countries. The high cost of operative equipment and the uneven world distribution of ophthalmologists, paediatricians, and anaesthetists create unique challenges. This review focuses on issues related to paediatric cataract management that are appropriate and suitable for ophthalmic surgeons in the developing world. Practical guidelines and recommendations have also been provided for ophthalmic surgeons and health planners dealing with childhood cataract management in the developing world.
paediatric cataract surgery; intraocular lens; developing world
The care and protection of the estimated 143,000,000 orphaned and abandoned children (OAC) worldwide is of great importance to global policy makers and child service providers in low and middle income countries (LMICs), yet little is known about rates of child labour among OAC, what child and caregiver characteristics predict child engagement in work and labour, or when such work infers with schooling. This study examines rates and correlates of child labour among OAC and associations of child labour with schooling in a cohort of OAC in 5 LMICs.
The Positive Outcomes for Orphans (POFO) study employed a two-stage random sampling survey methodology to identify 1480 single and double orphans and children abandoned by both parents ages 6-12 living in family settings in five LMICs: Cambodia, Ethiopia, India, Kenya, and Tanzania. Regression models examined child and caregiver associations with: any work versus no work; and with working <21, 21-27, and 28+ hours during the past week, and child labour (UNICEF definition).
The majority of OAC (60.7%) engaged in work during the past week, and of those who worked, 17.8% (10.5% of the total sample) worked 28 or more hours. More than one-fifth (21.9%; 13% of the total sample) met UNICEF's child labour definition. Female OAC and those in good health had increased odds of working. OAC living in rural areas, lower household wealth and caregivers not earning an income were associated with increased child labour. Child labour, but not working fewer than 28 hours per week, was associated with decreased school attendance.
One in seven OAC in this study were reported to be engaged in child labour. Policy makers and social service providers need to pay close attention to the demands being placed on female OAC, particularly in rural areas and poor households with limited income sources. Programs to promote OAC school attendance may need to focus on the needs of families as well as the OAC.
District hospital services in Kenya and many low-income countries should deliver proven, effective interventions that could substantially reduce child and newborn mortality. However such services are often of poor quality. Researchers have therefore been challenged to identify intervention strategies that go beyond addressing knowledge, skill, or resource inadequacies to support health systems to deliver better services at scale. An effort to develop a system-oriented intervention tailored to local needs and context and drawing on theory is described.
An intervention was designed to improve district hospital services for children based on four main strategies: a reflective process to distill root causes for the observed problems with service delivery; developing a set of possible intervention approaches to address these problems; a search of literature for theory that provided the most appropriate basis for intervention design; and repeatedly moving backwards and forwards between identified causes, proposed interventions, identified theory, and knowledge of the existing context to develop an overarching intervention that seemed feasible and likely to be acceptable and potentially sustainable.
Results and discussion
In addition to human and resource constraints key problems included failures of relevant professionals to take responsibility for or ownership of the challenge of pediatric service delivery; inadequately prepared, poorly supported leaders of service units (mid-level managers) who are often professionally and geographically isolated and an almost complete lack of useful information for routinely monitoring or understanding service delivery practice or outcomes. A system-oriented intervention recognizing the pivotal role of leaders of service units but addressing the outer and inner setting of hospitals was designed to help shape and support an appropriate role for these professionals. It aims to foster a sense of ownership while providing the necessary understanding, knowledge, and skills for mid-level managers to work effectively with senior managers and frontline staff to improve services. The intervention will include development of an information system, feedback mechanisms, and discussion fora that promote positive change. The vehicle for such an intervention is a collaborative network partnering government and national professional associations. This case is presented to promote discussion on approaches to developing context appropriate interventions particularly in international health.
Interorganizational relationships (IORs) between child welfare agencies and mental health service providers may facilitate mental health treatment access for vulnerable children. This study investigates whether IORs are associated with greater use of mental health services and improvement in mental health status for children served by the child welfare system.
This was a longitudinal analysis of data from a 36 month period in the National Survey of Child and Adolescent Well-Being (NSCAW). The sample consisted of 1,613 children within 75 child welfare agencies who were 2 years or older and had mental health problems at baseline. IOR intensity was measured as the number of coordination approaches between each child welfare agency and mental health service providers. Separate weighted multilevel logistic regression models tested associations between IORs and service use and outcomes, respectively.
Agency level factors accounted for 9% of the variance in the probability of service use and 12% of mental health improvement. Greater intensity of IORs was associated with higher likelihood of both service use and mental health improvement.
Having greater numbers of ties with mental health providers may help child welfare agencies improve children's mental health service access and outcomes.
Policymakers should develop policies and initiatives to encourage a combination of different types of organizational ties between child welfare and mental health systems. For instance, information sharing at the agency level in addition to coordination at the case level may improve the coordination necessary to serve these vulnerable children.
This research examined whether additional forms of family violence (partner-child aggression, mother-child aggression, women’s intimate partner violence [IPV]) contribute to children’s adjustment problems in families characterized by men’s severe violence toward women.
Participants were 258 children and their mothers recruited from domestic violence shelters. Mothers and children completed measures of men’s IPV, women’s IPV, partner-child aggression, and mother-child aggression. Mothers provided reports of children’s internalizing and externalizing behavior problems; children provided reports of their appraisals of threat in relation to interparent conflict.
After controlling for sociodemographics and men’s IPV: 1) each of the additional forms of family violence (partner-child aggression, mother-child aggression, women’s IPV) was associated with children’s externalizing problems; 2) partner-child aggression was associated with internalizing problems; and 3) partner-child aggression was associated with children’s threat appraisals. The relation of mother-child aggression to externalizing problems was stronger for boys than for girls; gender differences were not observed for internalizing problems or threat appraisals.
Men’s severe IPV seldom occurs in the absence of other forms of family violence, and these other forms appear to contribute to children’s adjustment problems. Parent-child aggression, and partner-child aggression in particular, are especially important. Systematic efforts to identify shelter children who are victims of parental violence seem warranted.
Men’s severe intimate partner violence seldom occurs in the absence of other forms of family violence (partner-child aggression, mother-child aggression, and women’s intimate partner violence), and these different forms of family violence all contribute to children’s adjustment problems. Treatment programs for children who come to domestic violence shelters should address these different forms of family violence, especially parent-child aggression.
The effects on children of political violence are matters of international concern, with many negative effects well-documented. At the same time, relations between war, terrorism or other forms of political violence and child development do not occur in a vacuum. The impact can be understood as related to changes in the communities, families and other social contexts in which children live, and in the psychological processes engaged by these social ecologies. To advance this process-oriented perspective, a social ecological model for the effects of political violence on children is advanced. This approach is illustrated by findings and methods from an ongoing research project on political violence and children in Northern Ireland. Aims of this project include both greater insight into this particular context for political violence and the provision of a template for study of the impact of children’s exposure to violence in other regions of the world. Accordingly, the applicability of this approach is considered for other social contexts, including (a) another area in the world with histories of political violence, and (b) a context of community violence in the US.
The United Nations Children’s Fund (UNICEF) plays a leading role in the collection, compilation, analysis and dissemination of data to inform sound policies, legislation and programmes for promoting children’s rights and well-being, and for global monitoring of progress towards the Millennium Development Goals. UNICEF maintains a set of global databases representing nearly 200 countries and covering the areas of child mortality, child health, maternal health, nutrition, immunization, water and sanitation, HIV/AIDS, education and child protection. These databases consist of internationally comparable and statistically sound data, and are updated annually through a process that draws on a wealth of data provided by UNICEF’s wide network of >150 field offices. The databases are composed primarily of estimates from household surveys, with data from censuses, administrative records, vital registration systems and statistical models contributing to some key indicators as well. The data are assessed for quality based on a set of objective criteria to ensure that only the most reliable nationally representative information is included. For most indicators, data are available at the global, regional and national levels, plus sub-national disaggregation by sex, urban/rural residence and household wealth. The global databases are featured in UNICEF’s flagship publications, inter-agency reports, including the Secretary General’s Millennium Development Goals Report and Countdown to 2015, sector-specific reports and statistical country profiles. They are also publicly available on www.childinfo.org, together with trend data and equity analyses.
United Nations Children’s Fund; statistics; data collection; information dissemination; child welfare
Child psychiatrists and paediatricians are faced by a number of disturbed children and adolescents who become a major treatment challenge due to a combination of their dangerous and/or disruptive behaviour and the unavailability of resources. Paediatricians and psychiatrists in one regional health area were questioned about the number of such children and adolescents under 18 years of age seen over a 20 month period. The response rate was 44% (86/194 specialists approached). A total of 72 children and adolescents were identified. For a health district with a total population of 200,000, this represents nearly five children (about one of these identified by paediatricians and one with associated learning disability). The majority of cases were adolescents with chronic problems (over one month's duration) but most cases reported by paediatricians were acute in preadolescents. Conduct disorders, autistic spectrum, and psychotic disorders were the most common clinical problems. Seriously disruptive behaviour had been present in two thirds and marked problems with behaviour that was a physical risk to others and to the self were present in over half and nearly a third of cases respectively. Services had been universally stretched by these children's difficulties. Clinicians thought the needs of these children would have been best met either through psychiatric day hospital type facilities or in combined paediatric/child psychiatric inpatient units.
The number of integrated paediatric cochlear implantation programme are very few in the world. In U.K. this pioneering integrated paediatric chochlear implantation programme has been started in the year 1989 under the supervision of group of dedicated paediatric personnel comprising of ENT surgeons, neuro-radiologist, audiologist, speech therapist, orthophonists, teachers of the deaf and others associated with the deaf children. Only the surgical procedure of cochlear implantation is not the answer of a profound sensorineural deaf child who can not be helped by conventional hearing aids. Proper selection of the cases, pre-operative counselling, pre-operative audiological and non-audiological investigations are of immense value. Similarly the programme following surgery as a team approach is equally important for proper rehabilitation of profound sensorineural deaf child who can not be helped by conventional hearing aids.
Child and infant malnourishment is a significant and growing problem in the developing world. Malnourished children are at high risk for negative health outcomes over their lifespans. Philani, a paraprofessional home visiting program, was developed to improve childhood nourishment. The objective of this study is to evaluate whether the Philani program can rehabilitate malnourished children in a timely manner.
Mentor Mothers were trained to conduct home visits. Mentor Mothers went from house to house in assigned neighborhoods, weighed children age 5 and younger, and recruited mother-child dyads where there was an underweight child. Participating dyads were assigned in a 2:1 random sequence to the Philani intervention condition (n = 536) or a control condition (n = 252). Mentor Mothers visited dyads in the intervention condition for one year, supporting mothers' problem-solving around nutrition. All children were weighed by Mentor Mothers at baseline and three, six, nine and twelve month follow-ups.
By three months, children in the intervention condition were five times more likely to rehabilitate (reach a healthy weight for their ages) than children in the control condition. Throughout the course of the study, 43% (n = 233 of 536) of children in the intervention condition were rehabilitated while 31% (n = 78 of 252) of children in the control condition were rehabilitated.
Paraprofessional Mentor Mothers are an effective strategy for delivering home visiting programs by providing the knowledge and support necessary to change the behavior of families at risk.