Words of Wisdom Learning rather than accomplishing should be the focus of raising children.
KEY TERMS cultural competence culture
discipline enculturation ethnicity ethnocentrism family
family structure foster care genetics heredity punishment race
religion resilience social capital spirituality temperament
Learning Objectives
Upon completion of the chapter, you will be able to:
1. Discuss genetic influences on child health.
2. Compare and contrast the factors associated with health status and lifestyle that affect a child’s health.
3. Explain the concept of resiliency as it relates to children and their health status.
4. Discuss health care and its effect on child health.
5. Delineate the structures, functions, and roles of families and the influence on children and their health.
6. Differentiate discipline from punishment.
7. Discuss culture and ethnicity in relation to child health.
8. Discuss community and its effects on a child’s health.
9. Discuss the sources of violence and how exposure to violence affects children.
10. Describe the impact of poverty and homelessness on the health of children.
Miguel Delgado is a 10-month-old boy who is admitted to the pediatric unit for treatment of pneumonia. He is
accompanied by his parents and 3-year-old sister, Luisa. Miguel’s parents speak Spanish and very little English. The family is Roman Catholic. As the nurse admitting Miguel, how will you facilitate communication? What steps can you take to help ensure ongoing communication with this family despite the language barrier?
When they come into the world, children are members of a family and have already been influenced by myriad factors such as genetics and the environment. As members of a family, they are also members of a specific population, culture, community, and society. Children live, learn, and grow in an environment affected by ever-changing cultural, spiritual, community, and social factors.
For example, changes in population demographics in the United States have led to shifts in minority population groups. It is projected that over the next four decades the United States will experience a dramatic increase in racial and ethnic diversity (Ortman &
Guarneri, 2009). The Hispanic population is expected to double, the Asian population is expected to increase by 79%, and all other racial groups will see an increase with the exception of non-Hispanic whites, who are expected to decline (Ortman & Guarneri, 2009). Globalization has led to an international focus on the health of children. In addition, access to health care, and the types of health care available for children, has changed due to modifications in health care delivery and financing. Furthermore, the United States continues to grapple with issues such as violence, immigration, poverty, and homelessness. The interplay of all of these factors creates a situation unique to each child. These factors may affect the child positively, promoting healthy growth and development, or negatively, exposing the child to health risks.
Nursing care for children and their families involves astute assessment of all of the factors that may affect the health of children.
Nurses play a key role in determining the impact of these factors on children and their families. Pediatric nurses need a sound knowledge base about the individual child, including genetics, race and temperament, and overall health status and lifestyle. Family, including the different structures, roles, and functions found in today’s society, is also an important component to child health.
Knowledge of special situations such as single-parent or adopted families is important to provide individualized care. The nurse should also assess the family’s level of stress based on the demands they face and their ability to meet those demands. Do they have the coping behaviors, patterns, and strategies needed to have a positive impact on the child’s health?
Other assessments need to focus on culture, ethnicity, and spirituality and the child’s community and society, including social roles and socioeconomic status (e.g., poverty and homelessness). Information gathered from these assessments can help the nurse refer the family to community resources that may assist them with stability and health needs. Resources such as state and federal agencies and community agencies such as the United Way or Salvation Army may be of assistance to families.
Nurses work with children and their families in a variety of settings and need to be alert to subtle yet important indicators that may suggest a problem. For example, the child or family may give an inaccurate address or may give as their address a homeless shelter.
Parents or children may be embarrassed or ashamed, feeling the stigma of poverty or homelessness. Other clues to problems may include a history of repeated infectious diseases, multiple health problems, or complaints that the child is always hungry. The key is to link children and their families with community resources that will assist with financial stability and with meeting the health needs of the children.
Due to changing demographics, immigration, and the global nature of society, nurses must make sure that the care they provide is culturally sensitive. Nursing interventions need to incorporate the family’s unique values, beliefs, and actions to ensure that their needs are met. To gain the knowledge and skills needed to plan effective care for children, pediatric nurses need to understand how all these factors affect the quality of nursing care and children’s health outcomes. By doing so, nurses can create appropriate strategies and
plan interventions for achieving the best possible outcomes for children and their families.
GENETIC INFLUENCE ON CHILD HEALTH
Genetics, the study of heredity and its variations, is a field that has applications to all stages of life and all types of diseases. Heredity is the process of transmitting genetic characteristics from parent to offspring. The child’s gender and race; the child’s biological traits, including some behavioral traits or aspects of temperament; and certain diseases or illnesses are directly linked to genetic inheritance.
Gender
A child’s gender is established when the sex chromosomes join. A child’s gender can influence many key aspects, such as physical characteristics and personal attributes. In addition to the development of male or female genitalia, body development, and hair distribution, some diseases or illnesses can be gender related: for example, scoliosis is more prevalent in females and color blindness is more common in males. An early influence of gender in children involves the survival rate of premature infants: premature girls have a higher survival rate than premature boys (Lee et al., 2010).
In addition to the specific biological and physical traits related to gender, there are also social effects. The child develops specific gender attitudes and behaviors that are appropriate in his or her culture. Interactions with family members and peers as well as activities and societal values affect how children perceive themselves as a specific gender (Fig. 2.1). If confusion develops with this process, various psychological and social difficulties can arise for the child (American Academy of Pediatrics, 2010).
FIGURE 2.1 The young child learns to identify with the parent of the same sex.
Race
Race indicates membership in a particular group of humans who have biological traits that are transmitted by descent; they may share physical features such as skin color, bone structure, or blood type. Some of the physical variations may be normal in a particular race but may be considered an identifying characteristic of a disorder in other races. For example, epicanthal folds (the vertical folds of skin that partially or completely cover the inner canthi of the eye) are normal in Asian children but may occur with Down syndrome or renal agenesis in other races. In addition, specific malformations and diseases are found in specific races. For example, sickle cell anemia occurs more often in African Americans.
Temperament
Temperament is the manner in which a child interacts with the environment. The way a child experiences a particular event will be influenced by his or her temperament, and the child’s temperament will influence the responses of others, including the parents, to the child. Early on, infants demonstrate differences in their behavior in response to stimuli. These responses are an integral part of the infant’s developing personality and individuality. Although a child’s temperament is intrinsic and relatively resistant to change, it does stabilize as the child matures (Feigelman, 2007). Knowing a child’s temperament can help parents understand and accept the
characteristics of the child without feeling responsible for having caused them.
The classic temperament theory proposes nine parameters of temperament: activity level, rhythmicity, approach and withdrawal, adaptability, threshold of responsiveness, intensity of reaction, quality of mood, distractibility, and attention span and persistence (Feigelman, 2007). This theory seeks to identify behavioral characteristics that lead the child to respond to the world in specific ways.
Using the nine parameters, children’s temperaments may be categorized into three major groups: easy, difficult, and slow to warm up;
various temperaments exist that are a combination of these groups (Feigelman, 2007). Easy children are even-tempered and have regular biological functions, predictable behavior, and a positive attitude toward new experiences. Difficult children are irritable, highly active, and intense; they react to new experiences by withdrawing and are frustrated easily. Children in the slow-to-warm-up category are moody and less active and have more irregular reactions; they react to new experiences with mild but passive resistance and need extra time to adjust to new situations.
A child’s temperament may cause problems in the family if it conflicts with that of the parents (e.g., a difficult 2-year-old with slow- to-warm-up parents). If parents want and expect their child to be predictable but that is not the child’s style, parents may perceive the child to have problems; this conflict may then affect the child’s health. The key is not to label the child but to recognize the strengths and limitations of each group. Knowing a child’s temperament can help parents understand a child’s characteristics and behaviors and allow parents to adjust their parenting style.
Genetically Linked Diseases
New technologies in molecular biology and biochemistry have led to better understanding of the mechanisms involved in hereditary transmission, including those associated with genetic disorders. These advances are now leading to better diagnostic tests and management options.
Two major areas of study in genetics that are important to pediatrics are cytogenetics and the Human Genome Project.
Cytogenetics is the study of genetics at the chromosome level. Chromosomal anomalies occur in 0.4% of all live births and are the most prevalent cause of cognitive impairment and congenital anomalies or birth defects (Elias, Tsai, & Manchester, 2007); anomalies are even more common among spontaneous abortions and stillbirths. The Human Genome Project is an international research effort involving the localization, isolation, and characterization of human genes and investigation of the function of the gene products and their interaction with one another. This research project will provide information about genetic diseases to aid in developing new ways to identify, treat, cure, or even prevent them. Chapter 29 offers a more detailed discussion of genetics.
HEALTH STATUS AND LIFESTYLE
Obviously, the general health status of a child and specific lifestyles can influence a child’s health. Health status may be a factor soon after birth. For example, the incidence of multiple births has been increasing in this country due to the increased use of in vitro fertilization and other assisted reproductive technologies along with women delaying childbearing until they are older (Ben-Joseph, 2007). Potential complications of multiple births include prematurity and intrauterine growth retardation, which may lead to chronic health problems in the child. Children with chronic health conditions may also have developmental delays, especially in acquiring skills related to cognition, communication, adaptation, social functioning, and motor functioning. Thus, the beginning health status of a child may affect his or her long-term health and development.
Development and Disease Distribution
The way a child develops is the result of genetics and the environment within the context of a variety of biopsychosocial forces. The biological influences include genetics, in utero exposure to teratogens, postpartum illnesses, exposure to hazardous substances, and maturation. Chapters 3 through 7 discuss the forces affecting growth and development for each age group.
Developmental level has a major impact on the health status of children. In general, the distribution of diseases varies with age. For example, certain communicable diseases are more commonly associated with certain age groups. Roseola, which is a viral illness resulting in high fevers and rash, is most often seen in infants 6 to 15 months old, whereas scarlet fever, which is an infection from group A streptococci, is a disease that primarily affects children from 4 to 8 years old. The physiologic immaturity of an infant’s body systems increases the risk for infection. Ingestion of toxic substances and risk of poisoning are major health concerns for toddlers as they become more mobile and inquisitive. Because preschool- and school-age children are, generally, very active, they are more prone to injury and accidents. Adolescents are establishing their identity, which may lead them to separate from the family values and traditions for a period of time and attempt to conform to their peers. This journey may lead to risk-taking behaviors, resulting in injuries or other situations that may impair their health.
Nutrition
Adequate nutrition can provide a rich environment for the developing child; conversely, nutritional deprivation can seriously interfere with brain development and other functions. Nutritional requirements change over the child’s life and have a great influence on the child’s physical growth and intellectual development. Nutrition provides the essentials required to maintain health and prevent illness (Fig. 2.2). Chapters 3 through 7 discuss the specific nutritional requirements and the impact of deficiencies for each developmental stage.
FIGURE 2.2 The dietary habits established early in life can have a long-lasting impact on the health of the child and the quality of life.
Nutritional deficiencies, such as iron deficiency anemia, or excesses, such as the increasing incidence of childhood obesity, are still common problems in the United States. Some factors contributing to poor nutrition include inadequate food intake, nutritionally unsound social and cultural food practices, the easy accessibility of processed and nutritionally inadequate foods, lack of nutrition education in homes and schools, and the presence of illness that interferes with ingestion, digestion, and absorption of food. In a growing child, inadequate nutrition is associated with lower cognitive ability, poor emotional and mental health, increased susceptibility to childhood illnesses, increased risk for mortality, and stunted physical growth (Heird, 2007). “Fast food” or “junk food” diets are one cause of childhood obesity and are linked to the recent increases in the number of cases of childhood type 2 diabetes.
Lifestyle Choices
Lifestyle choices that can affect a child’s health include patterns of eating; exercise; use of tobacco, drugs, or alcohol; and methods of coping with stress. For children, the lifestyle of the parents basically is the lifestyle of the child. Inactive parents who eat poorly commonly have children with the same habits, which can result in diabetes, obesity, and early heart disease. These typically adult problems are being diagnosed more frequently in children and adolescents today. Parents should first self-evaluate their own dietary and activity habits, make changes where necessary, and then strive to encourage healthy eating habits and an appropriate level of physical activity in the child’s life through sports, hobbies such as dancing, or family activities.
Environmental Exposure
Environmental exposures can have a detrimental impact on the child. In utero, the child can be affected by poor maternal nutrition or by exposure to the mother’s use of alcohol, tobacco, or drugs or infections. It is important for pregnant women to be aware of the risks associated with certain drugs, chemicals, and dietary agents as well as maternal illnesses that may lead to problems for the child.
These agents, known as teratogens, may be linked to birth defects in children. Not all drugs or agents are associated with fetal effects, however, and research is ongoing to identify the correlations between teratogens and other variables.
The environment continues to affect a child’s health after birth. Exposure to air pollution, tobacco, and water or food contaminants
can impair a child’s health status. Safety hazards in the home or community can contribute to falls, burns, drowning, or other accidents. Exposure to secondhand smoke and other pollutants, such as from radiation or chemicals, is a health hazard for children.
Because children are smaller and still developing, environmental exposures can cause more health problems for them. For example, lead exposure is a common preventable poisoning in children, especially children younger than 6 years of age. Due to young children’s rapidly developing nervous systems, they are more sensitive to the effects of lead. Sources include lead paint, lead-contaminated dust, and lead contained in soil and water. Lead exposure can result in developmental and behavioral problems ranging from inattentiveness and hyperactivity to permanent brain damage and death, depending on level of exposure.
Take Note!
A recent study found that residual tobacco smoke and carcinogens remain after a cigarette is extinguished (referred to as third-hand smoke). These toxins cling to the smoker’s hair and clothes and can be present on any surface in the house, such as carpet and cushions. Children are particularly susceptible to third-hand smoke since they breathe near, crawl, touch, and mouth contaminated surfaces (Winickoff et al., 2009).
Stress and Coping
Children are exposed to various situations and events that can produce stress. These events can be associated with the normal problems associated with growth and development, such as entering a new classroom, learning a new skill, or being teased by a classmate. However, they can also be associated with problems such as poverty, divorce, violence, illness, or trauma. Some children can adapt and respond to the stress, while others cannot. The term resilience refers to the qualities that enable an individual to cope with significant adverse events or stresses and still function competently (Lietz, 2007).
Various internal and external protective factors promote resiliency. Internal factors include the person’s ability to take control and be proactive, to be responsible for his or her own decisions, to understand and accept his or her own limits and abilities, and to be goal directed, knowing when to continue or when to stop. External factors include caring relationships with a family member; a positive, safe learning environment at school (including clubs and social organizations); and positive influences in the community (see the discussion later in this chapter about protective factors and violence). Promoting the development of resiliency in children aids in the achievement of positive developmental outcomes (Yates & Masten, 2004).
Access to Health Care
The health care system, including the delivery and financing of this system, continues to change and evolve. In the United States, changes in the health care system result from pressures from many directions. These changes reflect shifts in the social and economic realities and results of biomedical and technological progress over the past several decades. The effects are felt by everyone who seeks health care in any form. The method of providing medical care in a high-tech environment has changed to providing health care within a limited-resource environment. Allocating the limited health care resources continues to be the theme.
Access to health care is affected negatively by lack of health insurance. Parents with uninsured children often delay care for their children, are less likely to take their children to a doctor or dentist in the last 2 years, and are five times less likely to have a usual place of care for their children (Kaiser Commission on Key Facts, 2007). The percentage of children without health insurance dropped slightly from 11.7% in 2006 to 11% in 2007 (Sherman, Greenstein, & Parrott, 2008). This decrease is attributed to states’
ability to improve enrollment in Medicaid and the State Children’s Health Insurance Program (Sherman et al., 2008). Medicaid is a joint federal and state program that provides health insurance to low-income children and their parents. It is state administered and each state has its own set of guidelines. In 1997 the US Congress passed legislation that led to the creation of the State Children’s Health Insurance Program (SCHIP) (now known as the Children’s Health Insurance Program [CHIP]). The purpose of this program is to help insure low-income children who are ineligible for Medicaid but cannot afford private health insurance. This program is also funded jointly by the federal and state governments, but administered by the individual states.
With the development of such public health insurance programs for children, the number of uninsured children declined by one third between 1997 and 2005 (Kaiser Commission on Key Facts, 2007). In 2007, 60.7% of children were insured by private or employer-based health insurance and 28.2% with Medicaid or SCHIP. Of the 11% of uninsured children, 44.8% were eligible for Medicaid, 23.6% were eligible for SCHIP, and 31.6% were not eligible for either primarily due to family income exceeding the programs’ eligibility levels (American Academy of Pediatrics, 2008). In recent years Medicaid and SCHIP have focused on increasing enrollment by increasing outreach, simplifying enrollment procedures, and retaining eligible enrollees (Kaiser Commission on Key Facts, 2007).
Despite these efforts, three quarters of children uninsured are eligible for these public programs (Kaiser Commission on Key Facts, 2007). Lack of awareness, difficulty accessing the programs, uncertainty of how to apply for the programs, discomfort related