1.1 Child health and disease
Setting the scene
Globally deaths in children under the age of 5 years are at their lowest level ever. They fell by over three million to 10 million deaths annually in the 15 years prior to 2006. Australian children are amongst the healthiest children in the world, generally have access to high-quality health care, and infant and child mortality rates halved between 1986 and 2006, which compares favourably with other high-income countries. However, there are significant groups of children in Australia that have relatively poor health and access to care. These include Aboriginal and Torres Strait Islander children, refugee children, children living in out-of-home care (foster or kinship care), children with disabilities, children from socioeconomically disadvantaged backgrounds, and children living in rural and remote Australia. There are also new emerging morbidities, such as the rising rates of childhood obesity, diabetes, dental decay and emotional–behavioural disorders. In addition, many of our childhood deaths are still preventable, especially those due to injuries such as motor vehicle incidents and drowning. Fortunately children are living for longer with chronic diseases and as long-term survivors of cancer. Therefore, the role of the health system in offering high-quality, child-centred care close to home is becoming increasingly important. This chapter discusses the key child health issues facing Australian children today and ways to improve the health of our children.
What do we know about children and young people in Australia today?
Children and young people (up to the age of 24 years) comprise approximately one-third of the 22.5 million population of Australia, but, as in most other developed countries, this proportion is falling.
• 19.4% of the Australian population is now aged 0–14 years (4.1 million children), compared with over 28% in 1971, although children in the Northern Territory comprise about 25% of the population.
• 4.8% of Australian children are Indigenous and 38% of the Indigenous population is aged less than 14 years. This reflects the higher birth rate amongst Indigenous women (2.1 births per 1000 compared with 1.8 per 1000 in the total population) and the younger age structure of the Indigenous population due to shorter life expectancy.
• 5.9% of Australian children were born overseas in 2009 and 33% have at least one overseas-born parent. Sudan-born had the highest proportion (21%) of residents aged 0–14 years, followed by the USA (16%), Afghanistan (14%), South Africa, Singapore, Pakistan and Zimbabwe (12–13% each). Most migrants enjoy health that is equal to or better than that of the Australian-born population, often with lower rates of death, mental illness and disease risk factors.
Almost 1% of all Australian children are refugees, nearly a quarter of them from Sudan. These children have higher health needs on arrival than the local population due to their adverse environmental circumstances and restricted access to health care in their countries of origin.
The number of children in out-of-home care has more than doubled since 1997, from 11 600 to 26 700 in 2008, with the rate increasing from 3.0 placements per 1000 children in 1997 to 6.5 per 1000 in 2008. Children enter statutory care most often because of child abuse and neglect. Some of the risk factors include low family income, parental substance abuse, mental health issues, and community and family violence. Across the country, Indigenous children are nine times more likely to be placed in out-of-home care (foster care, kinship care, residential care) than non-Indigenous children. Australian surveys have shown that the majority of these children have chronic physical, developmental or mental health conditions arising from their earlier neglect and trauma.
Where do Australian children live and why is this important?
The majority (86%) of Australian children aged 0–14 years in 2007 live in the south-eastern mainland states: almost one-third in New South Wales, a quarter in Victoria and one-fifth in Queensland.
Two-thirds of Australian children aged 0–14 years live in major cities. Three per cent of children live in remote and very remote areas. Indigenous children are eight times more likely to live in remote and very remote areas, accounting for 38% of all children in these areas, despite accounting for less than 5% of all children. Children comprise a larger proportion of the total population living in rural and remote areas. Access to high-quality health care is poorer in these areas and children experience higher death rates, higher rates of neural tube defects and lower rates of cancer survival than those in major cities.
What are the circumstances of Australian households?
Family composition
The type of family in which children live has changed minimally in the decade to 2007. Some 83% live in couple families (including 10% in blended and step families) and around 17% in one-parent families, 87% with their mother.
Family income and work
Poverty is well known to affect the health of children. Australia is ranked behind many developed countries, with 10 of 24 Organisation for Economic Co-operation and Development (OECD) countries having a lower proportion of children living in relative income poverty than Australia.
• In 1999, 12% of Australian children aged 0–17 years lived in households with equivalent income of less than 50% of the median household income (relative poverty).
• In 2005–2006, low-income households (those in the second and third income deciles) with children aged 0–12 years accounted for 421 300 households Australia-wide and received on average $347 a week ($218 a week less than median-income households with children aged 0–12 years).
• Jobless families are disproportionately likely to be reliant on welfare, to have low incomes and to experience financial stress. In 2006, 15% of Australian children aged 0–14 years lived in jobless families, a decline from 19% in 1996.
• Nearly half (42%) of Indigenous children aged 0–14 years live in jobless families, three times the proportion of all children. The higher proportion of Indigenous children living in one-parent families contributes to this higher rate, as 45% of Indigenous children live in one-parent families compared with 20% of all children. 68% of Indigenous children living in one-parent families do not live with an employed parent.
• Australia had the second highest proportion of working-age, jobless families with children aged 0–17 years of 24 OECD countries in 2000, largely due to the relatively high rate of one-parent households in Australia and the high rate of joblessness (51%) among this group.
Why does this matter?
Members of jobless households report worse physical and mental health and lower life satisfaction than members of households where someone is employed. There are causal relationships between parental joblessness and family conflict, family breakdown and child abuse. Secure employment provides financial stability, self-confidence and social contact for parents, with positive effects flowing on to children.
Childcare and early childhood education
Why are early childhood education and care important for health and wellbeing?
Most Australian children participate in child care or early education prior to school entry. Early experiences in a child’s life strongly influence the biological pathways that affect cognition, behaviour, language development, capacity to learn, memory, stress re-sponse, and physical and mental health and wellbeing throughout life. Early childhood education is important for successful transition to formal schooling. It is also associated with a lower incidence of personal and social problems in later life, such as school dropout, welfare dependency, unemployment and criminal behaviour. Preschool programmes may be especially positive in the lives of children from disadvantaged backgrounds, where children may not be receiving the stimulation they require from the home environment. An English study of over 3000 preschool children found that the increased risk of antisocial or worried behaviour among disadvantaged children at school entry can be reduced by high-quality preschool care at 3 and 4 years of age.
Australian children’s experiences of child care and early education
In 2008, 50.2% of Australian under 2-year-olds were in formal or informal child care, compared with 41% in care in 2002. Around half (47%) of children in child care spent less than 10 hours per week in care. A further 37% were in care for 10–29 hours, and 16% of children spent more than 30 hours per week in child care. It is within this latter group where British and American studies have raised concerns about the increased prevalence of disruptive behaviour in later childhood.
Overall, the most commonly used type of child care was informal care, used by 29% of all children aged 0–12 years. Care provided by grandparents was the most common type of informal care and was used by 19% of children.
Social Trends 2010 reported that the use of child care was highest (78%) for children in one-parent families where the parent was in full-time employment. Around two-thirds (64%) of children attended care if their parent was employed part-time, whereas the proportion of children attending care dropped to 40% if the parent was not employed.
The story was similar for couple families. When both parents were in full-time employment, 60% of children usually attended child care. This fell to 51% for children in families where one parent was employed full-time and the other part-time. The proportion of children in child care was lower when both parents were employed part-time (41%) or if only one parent was employed full-time (25%) or part-time (26%). The proportion of children in child care was only 17% for couple families where neither parent was employed.
It is difficult to estimate the number of children who participate in formal early childhood education programmes in the years before the first year of primary schooling owing to the varied nature of children’s services throughout Australia and differences in data collection between states and territories. According to the Australian Bureau of Statistics (ABS) 2005 Child Care Survey, 68% of children aged 3–4 years attended preschool or a long day-care centre. Nearly half (48%) of long day-care services offered a preschool (or structured educational) programme.
In terms of children’s participation in pre-primary education, Australia is one of the worst performers in the OECD, despite growing evidence that preschool education has major long-term benefits for the child’s educational and social trajectory.
Why is the proportion of children in the population declining and what does that mean for children of the future?
Since the last century there has been a general decline in fertility in Australia to the current level of 1.77 children per woman. In addition there has been a significant increase in life expectancy leading to ageing of the population. Consequently, the projected child population proportion (aged 0–14 years) will drop from almost 20% in 2010 to 12–15% in the year 2051. Whilst it can be argued that expenditure on quality, evidence-based services for children and young people is a cost-beneficial investment likely to promote better health and wellbeing in the population generally, the ageing population is likely to create pressure on the allocation of resources for children’s services in the future.
Child health
What affects child health?
The health of a child reflects a complex interaction between biological susceptibility and the child’s experience of the environment. The child’s environment affects health in both immediate and long-term ways, with physical factors such as pollution or hunger due to neglect having a short-term impact as well as possibly affecting the child’s wellbeing and health in the long term. Many factors previously thought to be short-term problems (such as low birth weight) are now known to produce adverse health effects well into adult life.
The context in which a child grows up plays a major role in that child’s lifetime health. A child’s health can be deeply affected by the family circumstances, the community in which the child is raised, and the cultural and social factors operating in society. Factors such as the protection of children’s rights in society, community support to new parents, how a society deals with poverty or discrimination, the availability of maternity leave or welfare grants to unemployed parents all affect the health of that society’s children.
There is convincing evidence that home visiting to high-risk, disadvantaged parents before and after the birth of their child and good-quality early childhood education can significantly affect the life trajectory of those children, affecting their cognitive development and successful transition to formal schooling. These interventions are associated with lower incidence of personal and social problems later in life, such as school dropout, welfare dependency, unemployment and criminal behaviour. These effects are more marked in children from disadvantaged backgrounds and therefore may be particularly effective in closing the gap between advantaged and disadvantaged children.
Greater understanding of the role of gene–environment interactions on child health outcomes (epigenetics) has demonstrated the combined impact of biological susceptibility and adverse environmental factors. For example, a Canadian study has shown that adults who have committed suicide and were abused as children have reduced NR3C1 gene expression (through methylation) and reduced total glucocorticoid expression in the hippocampus compared with those who committed suicide with no history of childhood maltreatment. This combination leads to reduced feedback inhibition and thus to higher cortisol levels in response to stress, enhancing its effects in adulthood, vulnerability to mood disorders and increasing suicide risk.
How do we describe child health?
We use rates of mortality and morbidity to evaluate the health status of a community. Mortality is a very crude index of health and is of limited value in assessing the health status and health needs of a community. Morbidity is a measure of the presence or absence of medical diseases or conditions. A widely accepted view is that to describe health adequately involves also measuring a broad range of social and economic risk and protective factors. In 1946, the World Health Organization (WHO) defined health holistically as ‘a state of complete physical, mental, and social wellbeing and not merely the absence of disease or infirmity’. A child’s physical, mental and social wellbeing is inextricably linked to the environment and social values surrounding that child. Furthermore, children and adolescents are growing and developing rapidly, and may be more susceptible than adults to adverse environmental influences (Fig. 1.1.1).
Individual and social determinants of health
Levels of health and wellbeing depend on two broad forces: determinants (factors that influence health) and interventions (interventions to improve health). There are many determinants and they interact in complex ways. They range from individual behaviours (such as smoking or drink-driving) to much broader factors such as socioeconomic background. All of these interact with our genetic makeup to produce health outcomes, such as reduced life expectancy, and increased illness or disability. Interventions can range from personal services to treat the sick to broad preventive campaigns such as encouraging breastfeeding.
Protective factors promote positive health and development and include factors such as infant breastfeeding, physical activity and sound nutrition. Factors that increase the risk of ill-health in children include overweight and obesity, exposure to tobacco smoke or alcohol use in pregnancy. From a practical point of view, complete paediatric clinical assessment requires a consideration of all aspects of the child’s life, such as the home circumstances, the access to health care, the physical and mental health of the parents, and the quality of community support available. This applies equally to every child whether they present with leukaemia, cystic fibrosis, acute bacterial meningitis, developmental delay, child maltreatment, behaviour problems or even a well-child review (Fig. 1.1.2).
Fig. 1.1.2 A conceptual framework for determinants of health.
(From Australian Institute of Health and Welfare 2010 Australia’s health 2010: the twelfth biennial health report of the Australian Institute of Health and Welfare. AIHW, Canberra, p 65, with permission.)
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