MODULE 11

Childhood poverty associated with chronic disease, quality of health

1.CHILDREN are among the poorest populations in the U.S., with more than 21 percent living in
poverty as of 2014

2. The health risks associated with childhood poverty range from higher infant mortality risks to
inadequate nutrition to a higher incidence of chronic disease, all of which contribute to a child's
school readiness, opportunity to learn and future health trajectory. For example, children living in
low-income families are more than twice as likely to have asthma, a major contributor to school
absenteeism, than children in higher-income families.

3. he study found that a $1 increase in the minimum wage above the federal level was associated
with a 4 percent decrease in infant death during the first year of life. In fact, the study found that if all
states had boosted their minimum wages by $1 in 2014, more than 500 infant deaths and nearly
3,000 low-weight births could have been prevented.

4 Another study, released in July from the National Bureau of Economic Research that examined
birth data over 25 years, found that increases in the minimum wage were associated with higher
birthweights as well as an increase in prenatal care utilization and a decline in smoking during
pregnancy.

Health Equity and Children's Rights

The American Academy of Pediatrics (AAP)

1.The American Academy of Pediatrics (AAP) is dedicated to reducing health

disparities and increasing health care equity for children and adolescents .
2. The fundamental determinants of children’s health and well-being, and
subsequently the health and well-being of the adults they will become, are rooted
in social, environmental, and behavioral factors that lie beyond the purview of the
health care system.

3. Differences between groups in status and outcomes are referred to as disparities.

Disparities are often described in relation to socioeconomic position, ethnicity,
race, geography, gender, and age or in the context of a combination of these and
other factors.
4. Whereas the term “disparity” only defines differences between groups,
“inequity” describes the causes of disparities in the context of the social, economic,
civil-political, cultural, and environmental conditions that are required to generate
parity and equality.

5. Inequities result in disparities in health status that are “unfair, unjust, avoidable
and unnecessary.”

6. Disparities in the well-being of children in the United States are growing.These

racial, ethnic, gender, and class-based disparities have profound implications for
the welfare of children in the United States and for the adults they will become.
The sources of these disparities are deeply rooted in inequities in social and
environmental determinants of health (eg, poverty, income inequality,
maldistribution of educational and other resources, racism, and environmental
injustice) and the failure of public policies to address them.

7. Pediatricians and pediatrics have important roles to play in these endeavors,

which will require substantive changes in our approach to training, clinical
practice, child advocacy, policy formulation, and research.

8. There seem to be critical periods in the life course, most notably during
pregnancy and early childhood, when risk and protective exposures have the
greatest effect on health.

9. Child health equity, as conceptualized in this policy statement, is composed of 4

elements: children’s rights, social justice, human capital investment, and health
equity ethics.

10. The Convention references the family as the fundamental group of society,
affirms the principle of respect for family autonomy, and obligates societies to
fulfill the rights of children by providing famIlies with access to the resources they
require to meet the needs of their children.
11. Capital investment in children reflects the moral and ethical commitment of
society and communities to invest resources required to improve the health and
well-being of all children and decrease disparities.
12. Capital investment in children is conceptualized as being composed of 5 forms
of capital: social, economic, environmental, educational, and personal capital .
13. Social capital relates to social relationships in the family, institutions, and
communities (eg, schools, clubs, and faithbased institutions) and among peers that
positively influence the health and well-being of children.
14. Newly developed tools and approaches to care, including the medical
home,71,80 family centered care,72 psychosocial and environmental screening,
Bright Futures,81 and social capital scales,72 can help pediatricians and others
understand the concept of social capital and integrate its principles into practice
15. Economic investment of a country or community’s wealth in children has a
direct effect on the health and wellbeing of children.
16. Income inequality also seems to have a negative effect on child and adult health.
Public policies that transfer wealth directly to families, and in particular to
children, in the form of cash subsidies or services (eg, child care, medical care,
food support, extended paid maternity leave, child allowances, housing subsidies)
have a positive effect on children.
17. Personal Capital Investment in the dignity of children and ensuring that all
children, without discrimination, have a legitimate and realistic expectation to
enjoy optimal health and fulfill their dreams and aspirations depends on equitable
public policy.
18. charter adopted by the European Association for Children in Hospital should
be developed and displayed by all practices and institutions that care for children.
ARTICLE No 3

Social determinants of health and the future well-being of Aboriginal children

in Canada

1.Aboriginal children experience a greater burden of ill health compared with other
children in Canada.

2. Social determinants of health increasingly explain the most pressing

global inequities. They are defined as “the conditions in which people are
born, grow, live, work and age – conditions that together provide the
freedom people need to live lives they value”

3. These determinants, among others, include peace, income, shelter,

education, food, a stable ecosystem, sustainable resources, and social
justice and equity .

4. They are shaped by the distribution of money, power and resources at the
global, national and local levels, and their relationship to health;

5. UNICEF reports that Aboriginal children fall well below national health
averages for Canadian children (7). In Canada, Aboriginal children experience
higher rates of infant mortality (8), tuberculosis (9), injuries and deaths (10),
youth suicide (11), middle ear infections (12–14), childhood obesity and
diabetes (15), dental caries (16) and increased exposure to environmental
contaminants including tobacco smoke

6. Aboriginal children are born into a colonial legacy that results in low
socioeconomic status (21), high rates of substance abuse (22) and increased
incidents of interaction with the criminal justice system (23). These are linked
with intergenerational trauma associated with residential schooling (24) and
the extensive loss of language and culture.

7. Aboriginal children’s health, then, necessitates understanding three

interrelated dimensions. First, there are proximal determinants of health.
These have a direct impact on the physical, emotional, mental and or
spiritual health of an individual, and include employment, income and
education. Second are intermediate determinants, the origin of proximal
determinants, inclusive of community infrastructure, cultural continuity
and health care systems. Third are the distal determinants, which include
colonialism, racism, social exclusion and self-determination; these
comprise the context in which intermediate and proximal determinants
are constructed and are the most difficult to change.

8. Distal determinants that require attention, including potentially by

paediatricians, include ongoing colonial structures, racism, and the lack
of Aboriginal peoples’ sociocultural and political sovereignty.

9. Colonialism, as a distal determinant of Aboriginal peoples’ health, is

complex and far from over.

10. Children’s right to cultural continuity is affirmed in the Canadian

Constitution, as well as at the international level by the UN Convention
on the Rights of the Child that highlights the fact that “traditional cultural
values are essential for the protection and harmonious development of
children”
11 For Aboriginal people, the right to identify as an Indigenous person,
the right to practice Indigenous ceremonies, and the right to speak an
Indigenous language, are all crucial to identity and health, both of which
are also especially linked to spirituality 
12 Language and cultural revitalization are viewed as health promotion
strategies (43). If Aboriginal children are provided opportunity for
growth and development that fosters and promotes cultural strengths
and citizenship, health disparities resulting from the impacts of
colonialism may be lessened. This may, in turn, lead to self-
determination, which is a distal determinant of Aboriginal children’s
health.
13 Interventions and practices designed to foster and enhance the health
and well-being of Aboriginal children require holistic concepts of health
that move beyond biomedical realms and, instead, address and focus
upon social determinants
14 Approaches must be flexible, while also addressing historical and
contemporary determinants and should include decolonizing strategies.
These approaches must underpin all medical and psychosocial
interventions aimed at bettering Aboriginal children’s health and well-
being.
15  Instead, interventions should account for broader contexts and distal
determinants that continue to influence the context and, thus, the health
of the child. These broad contexts require collaborations across and
between sectors and disciplines; medical or even health sectors alone
cannot address or influence these determinants of health and must work
in concert with other sectors such as education, child welfare, housing
and justice, among others.
16 intervention research aimed at improving the lives of Aboriginal
children is also necessary. This type of research demands collaborative
partnerships with Aboriginal communities based on respectful, equitable
relationships. 
ARTICLE 3

The social determinants of early child development: An

overview
1. Social determinants act at different levels of influence, interact with one
another, and represent a broad array of characteristics that are not of a
biological or genetic basis but rather are entrenched in the interactions
between individuals and social and physical environments: living conditions;
interpersonal relationship between children, parents and peers; socio-
demographics of the family; learning environments of day cares and schools;
access to green spaces; neighbourhood safety; and socio-political context are
examples of some of the most important social determinants of child
development.

2. Sensitive periods in brain and biological development start prenatally and

continue throughout childhood and adolescence.

3. Thus, the social environment is a fundamental determinant of early child

development, and, in turn, early child development is a determinant of
health, well-being, and learning skills across the balance of the life course.

4. Three separate processes have been proposed to influence

children’s development – latency, pathways and cumulative
processes –

5. ‘Cumulative effects’ refer to the accumulation of positive and negative

exposures over the life course, influencing health and development based on
duration and intensity of exposure to these risk factors.

6. Latent, cumulative and pathway effects interact with daily experiences to

‘explain’ health status across the life course at various levels of social
aggregation.
 7. ‘Latent effects’ occur when the effect of early exposure to biological or
environmental factors becomes manifest years and decades later regardless
of intervening experience.

8 Finally, ‘pathway effects’ refer to the way that early events set individuals on
well-worn life pathways that, in turn, lead to particular social destinations that
influence health and well-being.

9 both life course and societal factors need to be considered together in order to
fully understand children’s developmental trajectories of education and health.

10. ‘Barker’s hypothesis’. Barker18 observed that low-birthweight infants had

greater likelihood for developing coronary heart disease in their late middle age.

11 This hypothesis has given rise to a whole field of study of the developmental
origins of adult disease.

12. Poverty and malnutrition have been shown to negatively affect both maternal
and fetal health and are two major factors responsible for higher infant and child
mortality rates observed in developing countries.

13. conception to school age is a critically important time in brain development.

14. theprocess of development is influenced not only by a child’s nutritional and

health status but also by the kind of interactions – beginning in utero – an
infant/child develops with caregivers in their environment. The notions of
biological embedding and neuronal sculpting highlight the importance of
contextual influences upon physiological development, the association between
psychosocial environments and immune responses, as well as bonding/ attachment
and neuroendocrine responses.
15. A key requisite for optimal child development is secure attachment to a trusted
caregiver, with consistent caring, support and affection early in life.

16. The advantages of breastfeeding in the first year of life are well documented.
Not only is breastfeeding associated with healthier physical, brain and social
development but in developing countries exclusive breastfeeding can be protective
of several types of diarrhoeal disease which is one of the primary causes of infant
and child mortality. Breastfeeding also encourages important attachment processes
with the caregiver, providing children with feelings of security.
17. Families are the first environments with which children interact from birth.
They are critically important in providing children with stimulation, support and
nurturance.

18. Over three decades ago North American researchers began observing that
children who lived in families with very low income did not acquire the same level
of verbal and cognitive skills as children who did not live in poor families.

19. Brooks-Gunn studied the effects of family income on behaviour and IQ and
found that psychological resources such as family networks of support, high
maternal education and positive maternal mental health mediated children’s
scores.

20. In turn, maternal depression is associated with language and cognitive problems, poor social skills,
and behavioural problems in infancy and early childhood.

21, Neighbourhood safety, cohesion, and crowding are a few of the factors that may influence family
practices, family psychological well-being, and thus children’s development.

22. Reviews showed that neighbourhood effects are stronger for cognitive and academic indicators than
for behavioural and mental health measures,92,93 while Drukker et al.’s84 research suggests that
children’s mental health was associated with the degree of informal control in the neighbourhood.
23. The socio-political context refers to the national wealth and the economic trajectory of a given
society, income distribution, patterns of employment and migration, and longstanding attitudes to
mothers and children, all of which directly or indirectly influence the conditions under which children
grow up, live, and learn.

24 For example, one of the greatest challenges for countries such as Canada, the United States,
Australia, and New Zealand is the elimination of the gap between the health and educational outcomes
of Aboriginal children and those same outcomes among non-Aboriginal children.

MODULE 7
1. A child life specialist is a healthcare professional that applies
this knowledge to support the psychosocial care of children and
parents while in hospital. As advocates of children's rights, child
life specialists support child-centred care and acknowledge the
autonomy and strengths of children.

Offering opportunities for play regardless of the child's physical

abilities is an essential part of providing developmentally
appropriate and ethically-based care. 

1. Assess and meaningfully interact with infants, children, youth

and families.
2. Provide a safe, therapeutic and healing environment for infants,
children, youth and families.
3. Assist infants, children, youth and families in coping with
potentially stressful events.
4. Provide teaching, specific to the population served, including
psychological preparation for potentially stressful experiences,
with infants, children, youth and families.
5. Continuously engage in self-reflective practice that includes
awareness of current research in the field.
 6. Forming supportive relationships early in the diagnosis is vital
to building relationships.

7. Trust is a critical feature of relationship building with children

and families. 

8. Learning about the child's likes, dislikes, temperament, past

medical history, typical behaviour and parental concerns allows
child life specialists to get to know the family. 

9. Operating from the assumption that parents know their child

best, sets the framework for effective communication (Vilas,
2009). When communication between healthcare professionals
and families is clear, it creates conditions for effective coping
and better health outcomes for the child.

10.Vilas (2009) recommends the following techniques be used by child life

specialists when working with hospitalized children:

 Using language that conveys respect and self-worth.

 Offering choices only when a choice is available.
 Using appropriate pronouns such as “I”, “you” and “me” to be direct.
 Speaking to children in an appropriate tone (avoiding “baby talk”).
 Being aware and respecting non-verbal cues from the child.
 Using positive directions that tell the child what they can do instead of what
they can't do.

11.Play in healthcare settings offers a child freedom of choice, where

in many situations, they have no control (tests, procedures, etc.). Play
can also serve as a safe outlet for aggression, hostility and negative
feelings.
12. In particular for children who are young, nonverbal or have
disabilities, play is essential as a form of communication (Vilas, 2009

13. Child life specialists often engage children in free choice

normative play, medical play and other forms of therapeutic play
such as expressive arts and physiologically enhancing play. These
play opportunities allow child life specialists to assess the child's
learning styles, emotional needs and coping skills (Burns-Nader &
Hernandez-Reif, 2016).

14. For example, a child newly diagnosed with cancer may receive
medical play as part of a preparation for upcoming procedures,
normative play between procedures to have some fun, and
therapeutic play to express some frustration about being separated
from school and peers” (Burns-Nader & Hernandez-Reif, 2016).

THERAPEUTIC PLAY

15.Therapeutic play gives children a way to express their feelings and

overcome difficult situations or experiences. While supervised by an
adult, children are often prepared for medical procedures using
therapeutic play. However, this type of play can also be non-directed
and initiated by the child which allows the adult to observe and
assess (Burns-Nader, & Hernandez-Reif, 2016).

16. Therapeutic play offers the child an opportunity to gain control of

a situation in a comfortable and non-threatening environment. As an
outcome, healthcare professionals can better understand and
identify the child's fears and emotions. From this understanding,
comes an identification of best practices to deal with a particular
child's trauma or stress. The availability of therapeutic play to
children who are dealing with illness, trauma or stressful life events
is essential for their learning and emotional well-being. 
Taken together, the benefits of therapeutic play for the hospitalized
child include:

 Reduced emotional distress and anxiety.

 Increased coping during challenging medical experiences.
 Increased cooperation for medical procedures and willingness
to go to the hospital.
 Reduced negative physiological responses to medical
experiences.
 Adaptation to illness and hospitalization.
 Facilitate trusting relationships with healthcare professionals

17. Siblings can also benefit from medical play by providing a

platform to ask questions and learn about their siblings illness and
treatment (Child Life Council and Committee on Hospital Care, 2014).

MODULE 8

An accurate assessment can lend valuable information to the

healthcare professional that can allow for an individualized
preparation (Dolidze, Smith, & Tchanturia, 2013).

According to the World Health Organization (WHO) inter-professional

collaboration refers to the practice of multiple healthcare providers
working together with patients, families and communities to create a
comprehensive plan of care. (Framework, 2010)
Examples of healthcare providers include nurses, physicians, social
workers, physiotherapists, occupational therapists, child life
specialists, chaplains, psychologists, dieticians and discharge
planners.

The assessment of a child in particular, requires the professional to

have knowledge of child studies and play interventions. Play, in this
case, becomes the primary mode of observation and risk
assessment. 
A child’s ability to cope with a medical procedure and how they may
react is influenced by many variables. Assessment variables can
include:

 Developmental vulnerability
 Child’s temperament (Koller, 2008)
 Age
 Mobility
 Culture and language
 Social and family status
 Diagnosis
 Family support (Thompson, 2009)

Child and Family Variables

The family variables examine:

 Parental presence in the hospital

 Access to support systems and resources
 Cultural beliefs and values
 Parental anxiety level and emotional state
 Ability to process information and communicate with
healthcare team (Gaynard et al., 1990)
  Awareness of child needs and concerns

One of the strongest pieces of evidence that informs best practices is

the assessment of parental stress. Parental levels of anxiety and
distress are consistent predictors of a child’s overall well-being
(Morawska et al., 2015).

The child variables include:

 Temperament and associated coping styles

 Chronological and developmental age
 Responses to previous separations from home
 Previous healthcare experiences
 Ability to communicate and function independently
 Access to family and other supportive resources
 Cultural values and beliefs

Illness and Medical Variables

 Diagnosis
 Anticipated treatment and procedures
 Physical responses to illness and treatment
 Previous healthcare experiences
 Number, personalities and values of healthcare professionals
involved (Gaynard et al., 1990).

Family Variables
 Parental Presence in hospital
 Access to support/resources
 Cultural beliefs/values
  Parental anxiety/emotional state
 Information processing
 Communication and healthcare team
 Awareness of child's needs/concerns

Even for minor medical procedures, Koller (2007) notes that children
and adolescents can experience negative effects associated with the
medical procedures, such as heightened feelings of stress and
anxiety, sleep disturbance, and fear of separation. 
Literature on pediatric preparation reveals a variety of approaches to
preparation including:

 The use of role play and rehearsal

 Puppet shows
 Orientation and tours of operating and other treatment rooms
 Educational books, videos and pamphlets
 The teaching of relaxation and coping skills
(Koller, 2007)

Koller and Goldman (2012) note a cyclical relationship exists between

anxiety and pain. 
Distraction techniques can offer ways to reduce the anxiety
associated with pain and help a child cope (Koller & Goldman, 2012).
Distraction is a cognitive coping strategy and can be either passive or
active. Passive distraction involves observation of an activity or
stimulus, rather than active participation. Examples include:

 Watching television
 Listening to music
 Listening to a story
Active distraction on the other hand, engages the child directly with an activity or
task. Examples include:

 Games (electronic, board)

 Virtual reality
 Guided imagery
 Controlled-breathing exercises
For best practices, Koller and Goldman (2012) note that taking account of a child's
temperament and their right to choose the activity promotes successful coping and
desired health outcomes. 
How to help parents face bereavement?

It is very difficult for parents to face death of their children. Professionals can
prepare them to accept this reality in advance. Following strategies can be used
to support the parents

1. Talk to the parents about their fares and concerns.

2. Child life specialist can also use distraction technique to divert the
parents’ focus from grief and bereavement to something that can
reduce their stress like he/she can recommend book reading,
visiting library.
3. They should attend special intervention programs which can help
them to relieve their depression and reduce their stress.
4. They should attend counselling session where they are given
suggestions to overcome their sorrow and start a new life.
5. Life specialist can also talk to them on phone or arrange zoom
meeting to support them in difficult time and address their
concerns.
6. Parents should be invited meet other parents who are going through
similar situation that will help them relax their anxiety and sorrow.