Editorial Virtual Special Issue: Child Health
Frances E. Aboud, McGill University
A growing number of articles published in Social Science & Medicine concern child health. Social Science & Medicine provides a unique outlet for research that examines children's health from a social science perspective with sufficient breadth to apply internationally. A social science perspective introduces the impact of children's parents and peers who, in addition to socializing children, also provide the basis of major social institutions such as families, schools and communities. Children are influenced by and in turn influence their social environments. This is captured by the developmental-contextual perspective which views "human development as the dynamic interaction between a changing individual in a changing context" (Schoon, Sacker & Bartley, 2003: 1001; see also Hertzman & Power, 2003). The recently published studies selected to be part of this Virtual Special Issue on Children's Health provide vivid examples of healthy development within a variety of contexts.
The health determinants highlighted here include social and physical environments along with developmental and cultural dimensions. Because of the many contexts in which children live, researchers must identify the most potent social contexts as the source of health determinants. Some use Bronfenbrenner's (1979) ever-widening concentric circles to locate their social environment, namely parents, siblings and peers with whom the child interacts on a daily basis; the institutions of family or school where structures exist; the wider community with its social, human, and economic capital; and the culture. More importantly, for each concentric circle, there is a micro-theory to provide a basis for hypotheses.
Theories of parent-child socialization (Bugental & Goodnow, 1998; Siegal & Aboud, 2005) and theories of sibling and peer relations (Rubin, Bukowski & Parker, 2006) identify the quality of those relationships that influence health and health behaviour. Relationship theories converge with social support theory (e.g. Heaney & Israel, 2002) to identify positive and negative features of relationships that buffer and exacerbate stress. Likewise, relationships are known to promote and hinder healthy development in children. While studies in this Virtual Special Issue highlight parent-child interaction in the early years, they also point to the importance of siblings in these early years, and the combined influence of parents and peers in later years.
The physical environment is also a critical feature of most child health articles in this Virtual Special Issue. Limited resources arising from a family's socioeconomic position or developing country poverty create vulnerability to malnutrition, disease, behaviour problems, and injury. The rural farm environment, dangers of the urban slum, and unsafe schools and homes place children directly in harm's way. The physical environment is known to have a serious impact on children because of their immature and vulnerable state. For this reason most societies try to manage the environment to make it a safer place for children. This includes setting standards for home and farm equipment, eliminating school tuition, and providing proper sanitation and safe water. The alternative is to manage the child by constraining his or her interaction with the environment. The latter has undesirable side-effects, in particular curtailing children's exploration of the environment and their developing sense of mastery.
The articles included here generally introduce a developmental perspective as well. They recognize that children of different ages have different issues and vulnerabilities, and have selected children of an age when the potential for such a problem is most critical. Moreover, young children interact with a narrower environment than older children. Young children are more passively influenced by their environments, whereas older children take a more active role in selecting the environments that influence them (Scarr & McCartney, 1983). They select their friends, they select to a certain extent the physical activities engaged in after school, and they select how oriented they become to peers and parents. The more active role of older children depends partly on their maturing social and cognitive skills and on the role given to them by their culture.
The broader cultural context influences to a certain extent how children are valued and how parents and others interact with them. Although many aspects of development proceed similarly worldwide, as reflected in physical and mental milestones, they may be expressed differently and arouse different expectations from adults (see Norenzayan & Heine, 2005, for a fuller discussion of the different levels at which universals may exist, namely existential, functional and accessibility universals). Security of attachment appears to be a universal process in the first year of life, and most cultures provide for this in the form of environments and behaviours that keep the child close to caregivers. The importance attached to women and children and the beliefs about them, however, determine how protected the child is in the first vulnerable months, how much food he or she receives, and the roles of family members in protecting and providing. Cultures also vary in the value they place on autonomy and relatedness for the child (Kagitcibasi, 2005), and the expression of warmth and control by adults towards children. Although these dimensions are not necessarily the only ones influencing children, their centrality across cultures provides the means to compare different cultures in which children develop.
The articles in this Virtual Special Issue only hint at mechanisms by which the social environment influences children's health. Most social entities are not as clearly connected as physical dangers such as lack of good quality and sufficient food, proximity to contagious diseases, and environmental hazards. Verbal and perceptual stimulation from family apparently affect the pruning and proliferation of synapses in the brain (Nelson, 2000). Breastmilk and micronutrients affect brain development by insulating axons and supplying neurotransmitters. But social influences are many and the transfer can take place emotionally, behaviourally, and by norms that are descriptive or prescriptive, depending on the child's age, sex and other variables. The specific mechanisms of transfer are important in influencing children's current health and the stability of their developing health habits. For example, families under stress transfer the stressfulness and/or the coping skills to their children depending on the child's age. Children who grow up surrounded by their parents' network of social support benefit from its companionship and validation and then develop their own. Children are quick to pick up the rules of conduct through incidental learning, by simply observing who does what to whom and with what consequences. Modelling, reinforcement and a biological readiness to learn provide background facilitators. It is also becoming clear that individual and developmental genetics play a part in children's health such as whether they are impulsive and therefore injury-prone.
All cultures recognize that the youth of today are the shapers of the world tomorrow. So the urgency in studying children is to determine how much of the strengths and vulnerabilities are cumulative. Do the problems of malnutrition, disease, injury, anxiety and sedentary behaviour in children follow them throughout life, accumulate or dissipate? Are contemporaneous influences in adolescence and adulthood more important than early influences? Malnutrition and depression are both strong contributors to the burden of disease and both have their roots in childhood. Both also influence the child's behaviour which in turn rebuffs or invites the responsive attention of adults and peers. For example, malnutrition and low iron status make an infant irritable (e.g., Wachs, Pollitt, Cueto, Jacoby, & Creed-Kanashiro, 2005); in some cultures fussy infants draw the soothing attention of adults, whereas in other cultures such irritability provokes distancing.
The article by Ingrid Schoon, Amanda Sacker and Mel Bartley (2003) entitled "Socio-economic adversity and psychosocial adjustment: a developmental-contextual perspective" serves to provide a comprehensive theoretical framework for child health. The authors examined the developing child's psychological adjustment in relation to early contemporaneous and cumulative disadvantage. They also examined how early child behaviour sets up later disadvantaging environments. Their study used two historical cohorts and followed children longitudinally into adulthood. Thus, the analyses allowed for testing multiple competing hypotheses from different theories about the interaction between the developing child and his or her environment.
Two articles on child physical health take a similarly broad view of the family and community variables that influence developing children. Ellen Van de Poel, Owen O'Donnell, and Eddy Van Doorslaer (2007) analyzed data from 42 developing countries to answer the question of why urban children seem to be healthier than rural children. When family wealth is controlled, they are not more healthy and sometimes are considerably less healthy due to extreme urban inequalities. Another article, by Juhua Yang (2007) dispels the myth that single children in China are at risk for being overweight. Because the policy has been applied differentially, the authors are able to use cross-sectional and longitudinal data to compare children with and without siblings along with strong-policy and weak-policy communities. Sibling sex, parental input, and changing diet and leisure make more important contributions to child health.
Three additional articles included here examined aspects of child development in different contexts around the world. Deb Pal, Gautam Chaudhury, Suryanil Sengupta, and Tulika Das (2002) described how epilepsy distorted the social contexts in which children develop in India. Mainly because of social expectations about epilepsy, children of all ages had much less contact with school, peers, and community life. Girls were particularly restricted. In rural Uganda, Benjamin Atwine, Elizabeth Cantor-Graae, and Francis Bajunirwe (2005) found that age, gender, socio-economic status, and school attendance had little impact on adolescents' anxiety, depression and anger, but orphan status did. The family context of AIDS orphans differed in some but not all respects from non-orphans; the most significant loss was not only a parent but also the full support of a living parent who might be pre-occupied with survival, caring for others, and grieving. Peer support and contact with other orphans helped to maintain the positive self-concept of these children, but not their anxiety and depression. The article by Tamara Daley (2004) highlights another social context that potentially facilitates or impedes the development of autistic children in urban India. Because of parental and professional expectations about child development, many autistic children were not taken to a professional or were mislabeled as retarded. Social and emotional problems of children, such as those with autism, isolate them from important peer and adult networks that are central to life in India. The stigma surrounding epilepsy, AIDS, and autism therefore create restricted environments and cumulative continuities in curtailed healthy development.
The following three articles examined family environments with age expectations that lead to malnutrition and injury. Anna Moore, Sadika Akhter and Frances Aboud (2006) described a non-responsive feeding style among mothers in rural Bangladesh that did not take into account the psychomotor skills of a developing child. Mothers continued to feed their children long after such skills were available. Maternal control may in turn have led children to reject food, thereby confirming the mothers' expectations that young children are not ready to feed themselves. Rodolfo de Castro Ribas, Alexander Tymchuk, and Adriana Ribas (2006) found that family environments in Brazil did not take into account the often impulsive and exploring natures of young children. Mothers were unaware of the dangers in their kitchens, bedrooms, living rooms and the yard; this led to unintentional injuries. Managing the environment to be healthy, supportive and stimulating for differently aged children required a sophisticated view of development, understood by more educated mothers in Brazil. More developed countries do not leave all decisions up to mothers, but rather regulate safe environments at preschools, parks and homes. Still, Barbara Morrongiello, Trevor MacIsaac and Nora Klemencic (2007) found that when older siblings supervised younger siblings at home, while parents were doing chores, the higher level of unintentional injury was largely due to non-compliance by a temperamentally difficult child whose activity level was beyond the restraining powers of a youthful supervisor. Given the very common use of sibling supervisors around the world, the developmental-contextual framework use here has international value. The inclusion of age and activity level of an "injury-prone" child in interaction with the family's physical and social context created a more complete explanatory framework of determinants of injury.
A final paper on rape and coerced sex reveals the unsafe environments in which girl children live in southern Africa. Rachel Jewkes, Loveday Penn-Kekana, and Hetty Rose-Junius' (2005) interviews with children, adolescents, parents and health workers converged on an understanding of why child rape occurs and is widely tolerated. Age and gender status differentials within the family and society place girls in submissive, sexualized relationships with fathers and other male friends of the family. Females generally are held responsible for the outcomes, leading to stigma and self-blame. We see in this and other articles in this Virtual Special Issue, how widely-held norms on the way children are to be treated enhance or imperil their healthy development, leaving mothers in a struggle to protect them.
The messages from these ten studies are relevant to researchers and practitioners around the world. Child-unfriendly environments, sibling supervision, and social exclusion are common. Although children, families and cultures may manage them differently, the three-way interactions described here are ones we can all relate to. The selected articles are largely descriptive, analyzing in depth the social and physical environments associated with children's health. As such, they identify environmental candidates for interventions to enhance health. The Millennium Development Goals and papers from the Bellagio Child Survival Study Group (e.g., Jones, Steketee, Black, Bhutta, & Morris, 2003) are reminders that the next challenge is to evaluate change.
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