• What happens when Mommy and Daddy (or appropriate partner names) argue/fight? Is there any hitting, pushing, etc.?
• How do you feel when Mommy and Daddy (or appropriate partner names) fight?
• What happens to you when you get in trouble?
If hitting or other physical forms of discipline occur, ask the following:
• What are you hit with? Where on your body? Does it ever leave a mark/bruise?
• Who hits/kicks you? How often does it happen? buffer children from the effects of violence and reduce the risk that the child will develop violent behaviors (Holt et al., 2008). Examples of protective factors include:
• Feelings of connectedness or a secure attachment to a nonviolent parent or caregiver
• Strong commitment to school and academic performance
• Involvement in social activities
• Social and community support
• Positive sibling and peer relationships
• Ability to discuss problems with parents or a supportive adult
• Consistent presence of a parent at least once during the day, such as in the morning on awakening, when getting home from school, at dinnertime, or when going to bed
Thus, interventions need to focus on reducing children’s exposure to violence and fostering protective factors.
SOCIETY
Society has a major impact on the health of a child. Major components of a society that influence children and their health include social roles, socioeconomic status, the media, and the expanding global nature of society. Each of these areas may influence children’s self-concept, the communities they live in, their choice of lifestyle, and their health. Pediatric nurses need to assess these areas and their influence on the child and family so that individualized strategies can be designed and implemented to enhance the positive effects and minimize the negative effects on the child’s and family’s health.
Social Roles
Society often dictates that specific people behave in specific ways: certain behaviors are permitted and others are prohibited. These patterns are identified as social roles and can be an important factor in the development of self-concept, and a person’s self-concept can have a very positive or a very negative influence on his or her health.
For children, social roles influence their ideas about themselves. Box 2.3 lists some typical roles children have in our society. These social roles are generally carried out in groups, such as the family, school, peers, or church or community organizations. At times there may be a conflict in how the different groups expect a child to behave. There also may be conflict for parents related to childrearing practices. For example, the child’s family may believe in creationism, while the school the child attends is teaching evolution. Thus, the child may feel confused as he or she tries to practice the behaviors expected by the different groups.
BOX 2.3
EXAMPLES OF SOCIAL ROLES FOR CHILDREN
• Daughter or son
• Brother or sister
• Granddaughter or grandson
• School or day care roles, such as first-grader, honor student
• Ethnic community member
• Church roles, such as acolyte, altar server
• Specialized roles such as developing musician, artist, or athlete
Socioeconomic Status
An even more important influence on children is the family’s socioeconomic status (relative position in society), which takes into account the family’s economic, occupational, and educational levels. Children are raised differently by parents of different educational levels, occupations, and incomes. Despite advances and improvements in quality and access to health care, discrepancies in health status between socioeconomic classes have continued (National Institute for Health Care Management [NIHCM], 2007). Income inequality is an important factor in explaining this variation. Lowerclass parents may need to work long hours to provide basic necessities and have little time or money to enrich the child’s life or make healthy lifestyle choices. However, lower-class families may have stronger family relationships if they need to rely on a family network to meet some of their physical and emotional needs.
Lifestyle characteristics, such as cultural norms for health behaviors, may help buffer some lower-class children from health problems (Chen, Martin, & Matthews, 2006).
Low socioeconomic status can have an adverse influence on children’s health. Some families may not be able to afford health insurance or health care. Meals may be unbalanced or irregular. The family’s house or apartment may be overcrowded and may have poor sanitation or lead paint. These families may not understand the importance of preventive care or may not be able to afford it, and as a result the children may be inadequately immunized against communicable diseases. Studies have documented that children who come from low socioeconomic status are more likely to suffer from acute and chronic conditions and experience more limitations from these, as well as injuries and mental health conditions (Currie & Lin, 2007).
Poverty
Basic financial stability enhances the general health and well-being of children, and thus an important negative influence on children’s health is poverty. Children living in poverty are more likely to have poor health, be retained in a grade or drop out of school, become teen parents, experience violent crimes, and become poor adults (Stanton & Behrman, 2007). They have greater rates of death and
illness from almost all causes, except suicide and motor vehicle accidents (Stanton & Behrman, 2007).
The poverty threshold is based on the family’s size and income and is used to determine whether a family is living in poverty (Table 2.6). According to the U.S. Census Bureau in 2007, approximately 12.5% of individuals and 9.8% of families were living below the poverty level (Denavas-Walt, Proctor, & Smith, 2008). Overall, 18% of children younger than age 18 years were living in poverty (Denavas-Walt et al., 2008). Over the past decade the number and rate of children living in poverty have risen. According to the Children’s Defense Fund (2008), 1 in 6, or 13.3 million, American children lives in poverty, with 1 in 13, or 5.8 million, living in extreme poverty. The rate of poverty is closely tied to the overall health of the economy; therefore, in times of recession, a rise is usually seen.
Family structure is an important factor associated with poverty rates for children. The poverty rate for married-couple families is much less than that for families headed by a single parent. Of the families living below poverty level, 28.3% were single-mother families with no husband present, 13% were single-father families with no wife present, and only 4.9% were married couples (Denavas-Walt et al., 2008). Educational level is another important factor: as education increases, unemployment declines and annual income rises. However, a chronic physical or emotional problem in any wage earner may lead to unemployment, and this can cause the family to spiral downward into poverty.
The effects of poverty on children’s health can be wide-ranging. The family may be able to afford only substandard housing or a house or an apartment in a dangerous neighborhood (e.g., unsanitary conditions, toxins, violence). Poverty may also lead to homelessness.
Homelessness
According to the National Law Center on Homelessness and Poverty, approximately 1.35 million children are likely to experience homelessness in a given year (National Coalition for the Homeless, 2008a). Families with children represent 23% of the homeless population, with half of these being children younger than 5 years of age (National Coalition for the Homeless, 2008b). It is impossible to measure homelessness with 100% accuracy. Therefore, looking at trends is important to demonstrate whether or not progress is being made. Recent research suggests that homelessness among families is increasing (National Coalition for the Homeless, 2008b).
The typical homeless family is headed by a single mother in her late 20s with two children, one or both younger than age 6, and ethnic minorities are at the greatest risk (Rog & Buckner, 2007).
Homelessness occurs not only in large urban areas but also in midsize cities as well as suburban and rural areas. The principal causes of homelessness in families are poverty and lack of affordable housing. Other causes include cutbacks in public welfare programs, mental health issues, and traumatic events such as unemployment, illness, or accidents and personal crises such as divorce, domestic violence, or substance abuse. Children may be forced out of their houses or choose to run away and become homeless because they have been abused or neglected, lived in foster homes, or were placed in residential treatment or juvenile detention centers.
In homeless children, the basic need for a stable shelter goes unmet. Homelessness is not conducive to appropriate growth and development in children. Homeless children are more likely to suffer behavioral and emotional problems, be diagnosed with a mental illness, be victims of physical and sexual abuse, and suffer educational disabilities. They also have a higher incidence of acute and chronic health problems, such as an increased rate of asthma, ear infections, gastrointestinal disorders such as diarrhea, and speech
problems, and increased mental health problems, such as anxiety, depression, and withdrawal. They may be exposed to environmental hazards in homeless shelters or overcrowded housing, or, if they live on the street, there may be exposure to the elements, lack of sanitary facilities, and an increased risk of injuries. An unbalanced diet may place homeless children at risk for nutritional deficits, which can lead to delayed growth and development. Homeless teens often engage in risky behaviors such as drug use or unprotected sex with multiple partners, so they are more likely to need emergency care, be depressed, and become pregnant (American Academy of Pediatrics, 2005). They may also become teen parents, continuing the cycle of financial instability and homelessness.
Homeless children may have limited access to health care services, especially preventive care such as immunizations, dental care, and well-child services. Lack of immunizations can lead to delayed enrollment in school, and education is vital for these children to help break the cycle of homelessness. When the families do have money, often they need it for food and shelter instead of health care.
If they do seek health care, it is usually in an emergency department or a free clinic and such sporadic care is not conducive to the ongoing health needs of a growing child. The family may not follow through with care because they cannot afford it, lack health insurance, or do not have transportation to the clinic or pharmacy.
Some of these children do not go to school or go to various schools because the family moves from place to place. The stress experienced by the family provides an environment that is not conducive to learning. As a result, children present with learning problems, socialization issues, or other behavioral issues.
Media
Today’s children are inundated with various forms of media, such as television, video and computer games, iPods, the Internet, movies, magazines, books, and newspapers (Fig. 2.7). Media has both positive and negative effects on the development of children and much depends on the content to which they are exposed (Wilson, 2008). Some of the images and information are not always in the best interests of children. Children may identify with, and mimic, characters who engage in risk-taking behaviors or lifestyles.
Health risk behaviors, such as excessive caloric intake, physical inactivity, smoking, underage drinking, and violent behavior, have been linked to media exposure (Escobar-Chaves & Anderson, 2008). Research has established a very strong link between media violence and violent, aggressive behavior (Escobar-Chaves & Anderson, 2008). If an image or type of behavior is portrayed as the norm, children may view this as acceptable behavior without examining the potential health risks or other long-term consequences.
For example, thinness is portrayed as the body type that is identified with beauty, leading some children to develop unhealthy dieting or other behaviors to develop that body type. For the child who has a body type that does not fit the ideal, depression or self-esteem issues may develop.
FIGURE 2.7 Computer games can be fun and educational, but the child should be monitored while using the computer or other forms of media to minimize negative effects.
Overall, the images children view every day will affect their behavior and possibly their health, and pediatric nurses should take this into account when working with children and their families.
The media’s influence relates not only to the content but also to the total viewing time. For example, excessive TV viewing has been linked to obesity, poor cognitive skills, and irregular sleep patterns. Overuse of computer or video games may lead to poor school performance. The media can be a positive influence, such as when it offers educational programming or public service messages on the negative effects of substance abuse, smoking, or gang involvement. Also, public broadcasting networks offer valuable programming.
Take Note!
The American Academy of Pediatrics discourages any screen media before the age of 2 (American Academy of Pediatrics, 2001).
Widespread access to the Internet has fostered a connection to other areas of the world that would not have been possible in previous years. Children are no longer limited to their immediate surroundings, and they have access to a wealth of information. The Internet can be a valuable resource for parents and children to access information, learn new things, and communicate with friends and family. However, online threats exist that can affect the child’s health and safety, such as sexual predators, pornography, violence, and racism. Parents need to be alert to these hazards and set up safety guidelines (see Teaching Guidelines 2.2).
Teaching Guidelines 2.2
TEACHING TO PROMOTE SAFE INTERNET USE
• Determine a time limit that your child can spend online each day or week and maintain consistency in enforcing this time limit.
• Ensure that use of the Internet does not replace or interfere with homework, friends, or household or school activities.
• Tell your child NEVER to share personal information with anyone online unless you are sure of the person and the child has your permission to do so.
• Urge your child NEVER to share his or her password with anyone, even friends.
• Review Internet sites with your child, and explain which sites are appropriate. Use the safety and parental controls offered by your Internet service provider.
• Avoid placing the computer in the child’s room. Rather, place the computer in a public area of your home, such as the den or kitchen, so that you can monitor your child’s use.
• Discuss with your child the need for safety while using the Internet. Explain potential hazards in terms the child can understand.
• Advise your child to immediately close any sites or stop any communication that makes him or her confused or uncomfortable.
Tell your child NEVER to arrange any face-to-face meetings with persons met online. Urge your child to tell you if he or she encounters such a situation.
• Teach the child NEVER to open e-mail from any unknown senders.
• Be aware of computer use policies in your child’s school.
Global Society
The world is connected in many ways today: people travel from one nation to another easily, new products and immigrants arrive each day, and the Internet makes worldwide communication simple. The United Nations Children’s Fund and the WHO lead the world in dealing with the issues for the children of the world. Every year 10 million children die around the world, over 26,500 every day (Shah, 2008). Hundreds of thousands of children born in developing countries are moving to more developed nations such as the United States as refugees, immigrants, or international adoptees. These children become part of this nation.
Pediatric nurses need to be aware of the impact of worldwide events on children. The population explosion and health problems in developing nations and natural and man-made disasters around the world affect the United States and the world in terms of productivity, economics, and politics (WHO, 2004). Children can be displaced by events such as hurricanes or wars, placing them at increased risk for problems such as infectious diseases, malnutrition, and psychological trauma.
According to the United Nations Children’s Fund (UNICEF, 2008), young children bear the brunt of the global burden of disease.
These organizations have identified major problems affecting child growth and development and survival:
• Malnutrition, including micronutrient deficiency
• HIV/AIDS
• Acute respiratory infections, such as pneumonia
• Diarrhea related to lack of clean water and sanitation
• Vaccine-preventable diseases such as measles
• Malaria
• Poor health care of pregnant and nursing mothers (UNICEF, 2008)
These organizations work to propose ways to eradicate these conditions by improving the case management skills of providers with adapted guidelines; improving the health systems with good district health planning and management as well as appropriate supplies, medications, information systems, and referral systems; and improving the family and community practices (WHO, 2011).
Today, society as a whole, families, and children have concerns over world threats and safety. Disasters such as the terrorist attacks of Sept. 11, 2001, and the killings at Columbine High School, and devastating weather events such as Hurricane Katrina can have a significant impact on the well-being of children. The increase in stressors such as war, terrorism, school violence, and natural disasters puts children at risk for experiencing mental health difficulties. Children who have experienced these events are at risk for issues such as posttraumatic stress disorder, behavioral problems, depression, anxiety, sleep disturbances, physiologic responses such as gastrointestinal symptoms, changes in academic performance, and safety and security concerns (American Psychological Association Online Public Policy Office, 2008). Children’s coping abilities may be reduced and alterations in growth and development may be seen. Children’s reactions depend on age and developmental level and are highly influenced by the emotional state of their caregivers. Pediatric nurses must be aware of the effects of world threats on children so that they can assess for alterations and intervene to promote security and stability.
KEY CONCEPTS
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.
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.
Developmental level has a major impact on the health status of children. Generally, the distribution of diseases varies with age.
Adequate nutrition can provide a rich environment for the developing child; conversely, nutritional deprivation can seriously interfere with brain development and other functions.
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. With advances in medicine, most chronic health problems today arise due to a person’s lifestyle. In the case of children, the lifestyle of the parents basically is the lifestyle of the child.
Environmental exposures can have a detrimental impact on the child.
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).
Internal factors that promote resiliency 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 that promote resiliency 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.
Access to health care is affected negatively by lack of health insurance.
Medicaid and the Children’s Health Insurance Program (CHIP) are both public programs available to provide health insurance to low-income children and their parents.
Even with the public programs available to assist children and families, barriers to appropriate, cost-effective, coordinated, and timely health care remain. Barriers can be financial, sociocultural, or ethnic, or part of the health care system itself.
The family is considered the basic social unit. The family into which a child is born will greatly influence his or her development and health. Children learn health care activities, health beliefs, and health values from their family.
Typical family roles include nurturer, provider, decision maker, financial manager, problem solver, health manager, and gatekeeper.
Four major parenting styles are seen: authoritarian; authoritative; permissive; and uninvolved, rejecting, or neglecting. Each represents the amount of support and control exerted over the child by the parent.
Discipline is a process that has as its goal increasing desirable behavior and decreasing or eliminating undesirable behavior.
Punishment involves a negative or unpleasant experience or consequence for doing or not doing something.