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chapter 2 the health of children: an overview
Last year's Chief Medical Officer's report emphasised the importance of children's health and well-being, not only to our current child population, but to our whole nation. There are immediate effects of poor child health in terms of the considerable strain it puts on parents and carers. Even more important is the lifelong impact of poor physical or mental health in the early years of life on the potential that child might have achieved.
We must think of health and well-being holistically as not just the absence of disease, but the positive presence of physical, mental and emotional well-being, the capacity to function independently in society, form satisfying relationships, feel a purpose in life, cope with adversity and have hope and resilience. A child's potential can be represented diagrammatically as in figure 1. Throughout life factors act to diminish that potential, whilst others act to promote and protect it. Some examples are illustrated - readers will be able to think of many more.
As a society, we need to strengthen promoting and protecting factors and, wherever possible, remove or reduce the effects of the adverse ones - and we need systems to monitor progress in both, and in eventual outcomes.
Subsequent chapters cover a number of important areas for child health, reporting progress, setting out the potential for further improvements, and identifying some gaps in our current knowledge.
Figure 1: Influences on Health from conception to Adulthood
Source: Dr Lucy Reynolds and Paula Barton
Inequality and child health
It is important to appreciate, when reading these individual chapters, that the child populations involved are not discrete. The risk factors for, and therefore the experience of, these health problems cluster in vulnerable groups. For example maternal depression may impact on an infant's development even when that mother has very strong family support, a secure income, good housing, and prompt support from primary care and specialist mental health services. Depression in a single woman, dependent on benefits and living in poor housing, with no support from partner, family or friends, and no motivation to contact health services (or even a barrier to this such as language or disability), can result in risks to her child's immediate physical well-being, as well as long-term development. A child born into disadvantage is very much more likely than his or her more privileged peer to suffer from not just one but several, or all, of the subsequent chapter topics: infections, poor nutrition, mental health problems, poor educational attainment, unintentional injuries and substance misuse.
The importance of attachment and parenting
In the early months and years it is crucial that each child has the opportunity for a warm reciprocal relationship with a small group of special adults who respond to the child's varying needs for stimulation or soothing, shape his or her later relationships and emotional self regulation, and give the capacity to learn and develop empathy.
The most dramatic changes in brain structure that take place during the early years of life are seen in the area involved in social behaviour. There is increasing evidence that children's early experiences can influence the way the brain develops.
Creating a favourable environment for Scotland's babies, toddlers and preschool children is therefore a key for society as a whole and the health service has an important part to play. Parenting programmes serve an important purpose in ameliorating some of the effects on a child of a family's vulnerability, but further efforts are required to make families less vulnerable in the first place, for example by early recognition, support and treatment of mental health or substance misuse problems, improved housing and neighbourhood environments, and improved job opportunities.
Child poverty
Child poverty damages both those who suffer it and society more generally: inequity breeds crime, vandalism, fear of crime, dependency.
The recent Poverty in Scotland 2007 report 18 highlighted the 240,000 children living in Scotland who are part of households with an income so much lower than the typical income for households in Scotland that we can consider them to be living in poverty (60% below median equivilised income). The same report also showed that nearly one in four children in Scotland (23%) live in relative poverty and almost one in eight children in Scotland (13%) live in absolute poverty. Although child poverty is still at an unacceptably high level in Scotland, it is reassuring that since 1996/97 there has been a reduction in child poverty from 33% to the 23% of today. Yet the high level of poverty suggests that thousands of our children continue to live in circumstances that have implications for their current and future health.
Figures from the 2001 Census showed that lone-parent households now make up 25% of all households with children in Scotland. In some deprived areas of Glasgow the figure is 50%. The 2002 Scottish House Condition Survey (Newhaven Research) estimated 33% of properties in Scotland to be in "urgent disrepair", and 1% (approximately 20,000 properties) below tolerable standard. The University of Glasgow Centre for Drugs Misuse Research estimated that in 2003, 6,142 children in Glasgow City were living with a parent with a substance misuse problem. Among other problems caused by problem substance use, intoxication and withdrawal symptoms are important causes of poor emotional relationships between parents and children.
"It is estimated that in 2003, 6,142 children in Glasgow City were living with a parent with a substance misuse problem."
Figure 2: Health Plan Indicators (No and %) at November 2006, for Scottish children born in 2006
Source: ISD, from Child Health Surveillance Programme - Preschool
Core | Additional | Intensive | Unknown | Total |
|---|
12,724 | 9,197 | 827 | 56 | 22,804 |
56% | 40% | 4% | 0% | 100% |
Recent policy focus on assessing and addressing needs
A number of National Policies developed or implemented during 2006 aim to set the holistic analysis of need, or risk, in context, and to direct the provision of children's services appropriately: The Education (Additional Support for Learning) Act, Health for All Children 4, and Getting it Right for Every Child.
The implementation of Health for All Children 4, is supported by a National Information Technology system, from which some early, provisional data are available. The key summary indicator, known as the HPI, is established by 2-3 months of age, after a process of assessment of risk and protective factors, involving the family, the health visitor and any other professionals involved in providing services to the family. The health visitor then records the HPI on the national Child Health Surveillance Programme - Preschool system. If it is concluded that the infant and family's needs are "core", further contacts will be scheduled for only routine immunisations and screening (such as vision screening in preschool year, height and weight at school entry). If, however, the infant and family's needs are considered to be "additional" or "intensive", then additional services and support are provided for that child and family. As the child grows older and other services such as childcare and education become involved they must work together to maintain up-to-date assessment of need of that child and family, and continue to provide additional services to meet the extra needs.
Whilst the use of HPI is still at an early stage, and not all services are yet using it, figures already show that in areas with a high concentration of deprivation, such as Greater Glasgow, higher proportions of infants warrant additional or intensive support in order to achieve their potential. However, one of the authors of the Health For All Children 4 report (David Elliman, personal communication), has stated that, if assessment is carried out appropriately, he would expect at least two-thirds of infants in a multiply-deprived urban population will be found to have additional or intensive support needs. There may be a temptation to set thresholds for additional services at the level based on our current pattern of services available. Only if we truly quantify need can we develop the services to meet it. We know that very significant numbers of Scotland's children are failing to meet their potential in all manner of ways, and hence so too is our nation. In those areas with greatest need due to high levels of social deprivation we are probably setting our thresholds too high for those in greatest need. If we fail to target our services and continue to provide only our current level of service to these children and their families, we cannot hope for an improvement.
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