Children’s place in society

Published on 21/03/2015 by admin

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2 Children’s place in society

Lisa Jackson, Nandu Thalange

Chapter contents

Introduction

The United Nations Convention on the Rights of the Child

Rights of protection 
Rights of participation
Rights of provision

Parents’ and doctors’ responsibilities and the child’s best interests

Parents’ rights and responsibilities 
Physical punishment of children

Duties of medical confidentiality

Consent

Children living in poverty and marginalized groups

An international view 

Inequalities in child health

Marginalized groups of children

Ethnic minorities 
Children in lone-parent families
Refugee and asylum-seeking children

Why is this important?

Conclusion

Introduction

An inquisitive visitor from a remote, isolated society might wonder why the Society for Protection of Animals has a royal charter whereas the Society for Protection of Children does not; why restaurants and pubs feel it is necessary to say that children will be welcomed (if they are well behaved); and why teenagers with as much interest and appreciation of the political world around them as most adults are not allowed to vote for the people that govern them. Despite lip-service being paid to the importance of children, society in western developed countries is adult-centred, and children’s place in it is defined in terms of their relations with adults.

Society’s responsibilities towards children are complex and sometimes contradictory. Children are our future and so need to be nurtured and at the same time they are vulnerable and so deserve protection. Society can discharge these responsibilities by supporting families. If families put their children’s interests first and provide a stable, loving and stimulating environment, they will ensure the child’s future health, development and social well-being. But children are also individuals and ought to be able to participate in society in their own right. Balancing these principles may be difficult.

The United Nations Convention on the Rights of the Child

A good starting point is to think in terms of children’s rights. The 1990 UN Convention on the Rights of the Child (UNCRC) is the document on which the basis of children’s rights, and their place in society, are founded (see www.unhchr.ch). It has been ratified by every country in the world with the exceptions of Somalia and the United States of America.

The UNCRC is a ‘must know’ for all doctors caring for children. It explains the responsibilities we have as health professionals caring for children, and provides a means to disentangle some of the complex ethical problems encountered in the healthcare of children.

The UNCRC begins by describing underpinning principles:

• The interests of children are paramount

• Children have the right to be supported in their own families and communities, but are not their families’ ‘property’.

It then lays out articles that cover rights of protection, participation and of provision. Below are listed some of those of relevance to child health.

Rights of protection

The right:

• To life (article 6)

• Not to be separated from their parents against their will except where to remain with them would harm the child (article 9)

• To special protection such as fostering or adoption when children are deprived of their family environment (article 20).

These rights reiterate the importance of families for the welfare of children.

The right to be protected from:

• All forms of abuse (article 19)

• All forms of sexual exploitation (article 34)

• Economic exploitation (article 32)

• Exposure to illicit drugs (article 33).

These rights reflect the vulnerability of children and the responsibility of society to protect them. The most relevant for paediatric care are the articles protecting children from abuse, which includes physical, mental and emotional abuse, neglect, and sexual abuse and exploitation. Although paediatricians have a particular role in diagnosis and management, all doctors and healthcare workers have responsibilities for identification and prevention.

Rights of participation

• The right to an identity, i.e. a name, a family and a nationality (articles 7 and 8).

These may not seem relevant to healthcare but consider how many children change their surname, how often the surname a child answers to is different from the one stated on health records, and how often we call a child by a different name to the one they are familiar with.

• The right to express their views freely (articles 12 and 13)

• To have access to information (articles 13 and 17).

These are important general principles that are also directly relevant to children’s health. Children should know about their health and contribute to decisions about their healthcare. In order to do this we need to be able to speak to children, provide them with written information, and listen to what they are saying, all in ways that are developmentally appropriate.

• The right of disabled children to enjoy life and participate actively in society (article 23).

This article describes the rights of disabled children to special provisions, but its inclusion as a right of participation reflects the view that disabled children should have the same status as any other child, or indeed as any other person. Participation is seen here as a positive property, in contrast to the negative notion of handicap (which describes how children’s participation in society is limited by disability).

Rights of provision

• The right to the highest standard of health and the highest quality of healthcare attainable (article 24).

This article is the guiding principle for all those who care for the health of children. It describes the importance not only of treatment of illness, but of preventive and anticipatory measures, public health, nutrition, health promotion and information, all with an emphasis on primary healthcare.

• The right of every child to a standard of living adequate for the child’s physical, mental, spiritual, moral and social development (article 27).

While article 24 underpins healthcare for children, this article is arguably the most important for children’s health. It reflects the fact that poverty and deprivation have a pervasive detrimental influence on almost all aspects of children’s health, well-being and development. The UK has very high rates of child poverty. Indeed, in 2008, the United Nations rebuked the UK for having unacceptably high levels of poverty for a wealthy country. Using the government’s own definition of poverty, in 2010, 21.3% of children were living in poverty. In response, the UK government passed the Child Poverty Act (2010) which seeks to abolish child poverty by 2020.

Parents’ and doctors’ responsibilities and the child’s best interests

While the UNCRC provides the basis for understanding society’s care of children, the cornerstones of family and public law in England and Wales are the Children Acts of 1989 and 2004. It is within this act that the key principles of the child’s best interests, the child’s autonomy and the parent’s responsibilities are described. These laws provide principles and guidance, but case-law will always play an important role in deciding on the best course of action in complex family problems.

Parents’ rights and responsibilities

Children’s best informed and most committed advocates are likely to be their parents. Of course, parents’ decisions about children are influenced by their own personal attitudes and feelings. In most cases this is to be welcomed; it is the result of, and perpetuates, a diverse, multicultural, and pluralist society. Hence the importance of parental responsibility being enshrined in a wide range of laws and declarations (including the Children Act and the UNCRC). But at the other extreme, parents’ own needs and desires might harm the child; this is child abuse, and society has an obligation to override the parents in order to protect the child.

The extremes are easy to understand, but there is a large grey area in the middle where the behaviour and decisions of parents conflict with the interests of the child in some way. Examples include physical punishment of children, parents condoning or encouraging truancy, cases where parents do not adhere to medical advice they have previously agreed was necessary for their child’s health, or where parents present a child for medical diagnosis and treatment excessively and unnecessarily. The balance between a parent’s rights and a child’s interests can be very hard to determine. It is not a decision that an individual doctor, however experienced, can make alone because all of us are motivated by our personal or professional prejudices.

Physical punishment of children

Corporal (physical) punishment of children is still legal in the UK, although public chastisement of children less than 3 years of age is illegal in Scotland. The arguments for and against abolishing corporal punishment are well-rehearsed.

For:

• It is technically a form of assault which is illegal where adults are concerned

• It leads to a punitive form of child behaviour management, which is ineffective and potentially harmful

• There is no distinction between physical punishment and physical abuse of children

• It models aggressive responses to children that will influence detrimentally their responses to other people and their own children (‘the cycle of abuse’)

• It is a form of domestic violence

• Countries that have made this illegal have far lower rates of physical child abuse.

Against:

• There is very little direct evidence that it is harmful

• There is a large body of public opinion in its favour

• A law against corporal punishment would be impractical to enforce.

Duties of medical confidentiality

Maintaining confidentiality is one of the fundamental duties of doctors. However, it is not absolute. There are circumstances where it is permissible, or even obligatory, to pass on medical information. Confidentiality may need to be broken if this would prevent harm to the patient or to others. This is why we have a duty to pass on information about child abuse. Even if our individual patient may be safe, there is a potential risk to others. The General Medical Council issued updated guidance on safeguarding and confidentiality in July 2012.

In contrast to other branches of medicine, where there is a direct two-way doctor–patient relationship, in paediatrics there are three parties involved: the doctor, the child and the parent(s). Occasionally a doctor can be in the uncomfortable position of being asked by the parent or child to keep some information confidential from the other, even though the doctor feels that to share that information would be in the best interests of all. Usually, discussing the benefits of sharing the information with the other party resolves the impasse. However, we must always be aware that our position as professionals and adults can seem very daunting to a child.

Consent

Similar principles apply to consent. Who should give consent to a medical intervention, whether this is a diagnostic test or some form of treatment? Going back to our first principles, children ought to have a say because they are individuals with their own rights, but, on the other hand, society endows a child’s parents with authority to make decisions on their behalf because of their vulnerability and their unrealized long-term potential.

Legally, whatever the situation, parents can consent to treatment only if it is ‘in the child’s best interests’. Doctors must apply this test as well. In order to give consent there are three requirements:

• Adequate information

• Competence

• For there to be no coercion.

How can competence be assessed in a child or young person? Judges have described three tests which are equally valid for all vulnerable individuals including those with mental health problems and learning disabilities:

• The ability to understand and retain information

• To believe the information

• And to be able to weigh up the information and arrive at a choice.

These criteria are all highly subjective. Recent research has shown that we underestimate the competence of children of different ages to make informed decisions. Even at the same age, children’s developmental abilities vary widely so we do need to make some judgement about their capacity to assimilate information and express a reasoned opinion.

After a famous court case – Gillick v West Norfolk and Wisbech Area Health Authority 1986 – the law recognized that children aged under 16 years may have sufficient understanding and intelligence to consent to a medical intervention. They may do this against the wishes of their parents or without their parents’ knowledge. For our part, it is vital that we record the evidence on which we base our assessment of the child’s competence.

The law about refusing treatment is a little different. No-one under 18 years of age, whether they are competent or not in the Gillick sense, can refuse treatment that their parents’ have agreed to. However, there are practical limits. No responsible doctor would force treatment or an investigation on a child who was violently struggling, and all doctors know young patients who refuse to take essential medications despite the best efforts of the parents and health workers to ensure that they do.

Children living in poverty and marginalized groups

An international view

In 1990, the United Nations set out its Millennium Development Goals. The fourth goal was to reduce mortality of children under 5 years by two-thirds, by 2015. Between 1990 and 2008, worldwide mortality in children under 5 years fell by 28%. Nevertheless, just under 8 million children under 5 years of age die each year, most from preventable causes. Of the 67 countries with high child mortality rates (accounting for over 95% of all deaths, worldwide), only 10 are on track to meet their Millennium Development Goal target. Many of these deaths are preventable by simple and relatively inexpensive measures, such as sanitation, immunization and oral rehydration.

This is an international scandal. In the longer term, the world economy operates in a way that keeps the poorest countries poor and does not reward expenditure on health and educational infrastructure. However, in the shorter term, it is not finance that is required, but organization and robust delivery systems – and leadership. Charismatic and outspoken leaders are making a difference with AIDS and HIV. Where are the leaders for children?

The other scourges of child health are the bedmates of poverty: war, conflict and violence. For children, these result in enormous social and health problems, including mental health problems, disrupted families and large numbers of orphaned and displaced children.

By comparison, the state of children in the UK might seem benign. However, the UK is not immune to child poverty. A survey by UNICEF in 2010 of child poverty in 21 European countries in the world placed the UK in the bottom four.

Inequalities in child health

Social inequalities exist in almost all aspects of children’s health. Babies from poorer backgrounds are born smaller, are more likely to die in infancy, and more likely to suffer from infectious diseases. In childhood, accidental injury is strongly associated with social class, as are mental health problems and suboptimal nutrition, with both obesity and poor growth being more prevalent. In young adulthood, teenage pregnancy, mental illness, drug abuse and death from injury and violence all show steep social gradients. Finally, many of the chronic degenerative diseases of old age, such as heart disease, stroke and chronic lung disease, are strongly influenced by adverse social circumstances in childhood (see Figure 2.1).

image

Figure 2.1 Social class distribution of (a) infant mortality, (b) low birth weight, (c) injury mortality and (d) mental disorders.

Marginalized groups of children

Ethnic minorities

Children from ethnic minorities are much more likely to be living in poverty, and have further disadvantages such as discrimination and racial abuse. English may not be their first language and they may have to struggle with conflicting cultural expectations.

There are other groups of children whose circumstances are detrimental to their health and well-being. These include refugees and asylum seekers, children whose parents are in prison, children from travelling families, and children being looked after by local authorities (‘in care’). Preventive healthcare is less well covered, and mental and physical health problems are more common and less well managed in these children.

Children in lone-parent families

Many children live in families headed by a lone mother. In the UK these families have a very high risk of living in poverty (although in some other countries with a social benefit system that is more supportive of lone parents, this is not necessarily the case). The children have similar health disadvantages to other children living in poverty, and many studies have shown that the economic disadvantages suffered in these families determines the poor health experiences of the children rather than any deficit in parental care, or quality of family life.

Refugee and asylum-seeking children

Children from refugee and asylum-seeking families have greater health needs than indigenous children. There may be a number of reasons for this:

Separation from, or loss of parents

– causing emotional distress, attachment disorders in younger children, anxiety and worry, lack of protection and adult support

Under-nutrition

– with effects on growth, and function of various body systems, neurodevelopment and intellectual abilities

Infections or parasitic infestations

Torture and physical abuse

– causing post-traumatic stress disorder, anxiety, depression, various physical consequences

Rape

– with risks of pregnancy, sexually transmitted infections, post-traumatic stress disorder, longer-term mental health consequences such as anxiety, depression, low self-esteem

Witness to murder, rape or violence towards others, including family members

– causing severe emotional distress, anxiety, post-traumatic stress disorder

Involvement in conflict

– children from conflict societies may be forced into participation in brutality, torture and fighting (‘child soldiers’), with severe effects on mental well-being, notably post-traumatic stress disorder.

Why is this important?

There are several reasons why doctors looking after children need to be aware of these matters.

• Many children seen in clinics or hospital will come from poor, disadvantaged or marginalized families. It is important for doctors to be aware of the social conditions of their patients

• Knowing the effect of social circumstances on children’s health will help us understand the reasons for some of their health problems, and may guide our treatments and advice

• Doctors have a duty to advocate for their patients. Knowledge of the effects of poverty and deprivation will inform the way that we advocate for individual children and their families

• Doctors have a wider duty of public health advocacy. This includes supporting measures to improve equity within society and to draw attention to the health consequences of poverty and discrimination. This is particularly relevant for paediatricians because children are a group who are not in control of their own social circumstances.

Conclusion

Children’s place in society is a paradoxical one. On the one hand they are privileged with specific laws, provisions and services that reflect their vulnerability and their future potential, while on the other hand they are under-valued by their powerlessness in an adult-oriented society. This paradox is related to the ambivalence most adults feel about children themselves. Children’s doctors have a duty to confront this ambivalence in themselves, in the general population, and in the laws and practices which govern our lives. By doing this we can make a difference to the lives of children and young people in our society and the wider world.

Further reading

United Nations Convention on the Rights of the Child. www.unicef.org/crc/

Child poverty in the UK. Joseph Rowntree Foundation. www.jrf.org.uk

Protecting children and young people: The responsibilities of all doctors. http://www.gmc-uk.org/guidance/ethical_guidance/13257.asp.

Millennium Development Goal 4 – Reducing child mortality. www.unicef.org/mdg

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