Hall report (Health for all children) - all about surveillance and promotion. Universal but with targeting of vulnerable families, data collection. Early years (hearing, vision, language, motor), oral health, diet. Expanded school nurse role. Parent held child health record.
Partnership for Care, 2003 - early years and children both emphasized. Patient centred, locally based "one stop shop".
For Scotland's Children- 80 kids become homeless daily. 40% born to unmarried mothers. Move towards single shared assessment, key worker.
Adopted Romanian kids with development delay catch up but the earlier the better, and persistent risk of Autistic SD.
High levels of cortisol lead to impaired brain growth in animal models, presumably the mechanism of stress acting on brain development. Abused children have smaller brain volumes. Secure kids generate smaller cortisol rises on meeting strangers. High early morning cortisol seen in substance misuse & conduct disorder in foster children.
Patterns of attachment:
Adult's own attachment experience + ability to become autonomous predicts 70pc of stranger/separation responses in child. Attachment pattern also appears to be potential source of resilience - see inequalities below.
Dyad of parent-child, pattern is not specific to that child in isolation.
High grandmother involvement reduces likelihood of A+E attendance which requires no treatment other than paracetamol by a factor of 8. There's a theory that grandmothers are responsible for the evolutionary superiority of the human species - it was only when humanoids could survive long enough to care for their grandchildren that effective family groups were possible and the population really exploded.
Formal maternal education reduces likelihood of A+E attendance which requires no treatment other than paracetamol by factor of 4 (Royal Free).
After controlling for family connectedness and socioeconomic factors, adolescents in the US who shared more meals with their family had lower incidences of tobacco, alcohol, and marijuana use; higher grade point averages; fewer depressive symptoms and less suicidal ideation; and, among girls, better self-esteem and fewer suicide attempts. Arch Pediatr Adolesc Med 2004;158:792?6
The time a toddler spends watching TV is inversely related to the time spent doing parent-child activities eg shared reading. However, having a mother with mental distress (on Mental Health Inventory 5 screening, about 20% of mums) is associated with 25% more time watching TV. So consider the mental health of mothers before trying to reduce television viewing time.
In Scotland, the Reporter can take referrals from members of the public as well as professionals, and can institute legally binding conditions on children and parents. Do not, however, require proof so good where legal procedures are likely to antagonize or be difficult. Good for eg self-destructive behaviour.
=Sudden infant death syndrome, now Sudden Unexpected Death in Infancy. SIDS suggests an actual diagnosis, when really it's just a description. Unexpected rather than unexplained, pending further investigations in the child and further research into aetiology.
Some features:
Helena Kennedy (QC) report after Sally Clark etc, 2004 - joint RCPath/RCPCH group. Highlighted regional differences in medical/police handling of SIDS. 2004 Childrens Act obliges local authorities to set up panels to investigate unexpected death - aim is structured multiagency investigation, data then collated and reported to Confidential enquiry in Maternal and Child health. But exact format still being worked out. Report calls for standardized national protocol for investigation. Emphasizes an early home visit, within 24 hours, probably by paediatrician but certainly a health professional who carries authority with police. Family can then explain what happened and what they did (given that scene rarely left intact for police). Builds on project in Avon and Somerset where home visits have been done for 4 years, but most paediatricians feel very uncomfortable in that role, esp with child protection controversies. Would need special training. Specialist HV possibly? Need for more paediatric pathologists - review of SIDS suggested that essential tests had been omitted in up to 70%, and diagnosis was wrong in about 20%.
Then multidisciplinary meeting to conclude what contributed to death, report to coroner and plan support for family. Also calls for college accreditation for expert witnesses. Recognizes that doctors from child protection backgrounds may have different perspective from general paediatricians.
Retention of the brain can be very useful but tests may require 3-4 months; given that this can impede bereavement process, should only be done with explicit consent unless coroner instructs otherwise (and independent of need to retain blocks and slides of tissues).
Police may turn up in uniform due to nature of emergency, however guidelines exist (ACPOS) that emphasize appropriate handling viz special training, detective of at least inspector rank. Potential for home visit to include police questioning.
Probably no need for tests at time of death, if appropriate pathology service available.
Cot death trust in Scotland.
Procedures - prior to placement, social worker should collate medical history in the Health Record Booklet, the Essential Core Record, Placement Agreement and Essential Background Record. They should seek the completion of the Parental Authority of Medical Treatment section of Health Record Booklet and Essential Core Record. If unavailable, should be signed by the Area Services Manager. Preadmission medical should be carried out and carers provided with necessary Information. This should be done by the existing GP else the carer's GP or a Community Paed if placement has been outside Glasgow. If unplanned must be within 2 working days. (Gps tend to be resistant).
If placement will be for more than 4 weeks, a Comprehensive Health Assessment should be done within six weeks using the Summary Health Assessment Framework.
Parents position should be considered, and attendance encouraged. Annual health questionnaire to carers replaces medical examination. Care plans should include health promotion, general surveillance and assessment of development.
McKeown in 70s supported the importance of standard of living and nutrition as determinants of trends in mortality, cf Preston who claimed medical care and related technologies more important. Debate continues today. Across Europe, inequalities in mortality increased from early 80s to early 90s despite different macroeconomic performance.
NZ study showed that relative contributions of different diseases to health inequalities change over time, even as the inequalities themselves change.
Adjusting for IQ reduces differences in many indicators of health across socio-economic class by 15-58% but does not remove them. BMJ 1 Feb 2006
Health inequalities persist even in Nordic countries with strong welfare systems. The reason for this failure is to do with relative and absolute differences in death rates. Imagine that premature deaths are entirely caused by 100 different factors, each twice as common among the poor as among the rich. The result would be a two-fold difference in rates of premature death. If a welfare state then succeeded in removing half of those contributions to inequalities in premature deaths, we would still be left with a two-fold difference in death rates from the remaining causes. Now, imagine that there are, in addition, some causes of premature death that act equally in all classes, which are also reduced by stronger welfare systems. The result would then be that better welfare states would be left with larger relative differences in mortality.
The persistence of inequalities does not take away from the fact that Nordic countries have lower death rates - Sweden has the lowest mortality for manual workers in Europe. In addition, these more egalitarian societies have higher rates of social mobility: reductions in health inequalities might be partly masked by selective mobility.
The most important thing that the better welfare states do is to redistribute income. Only Japan has better health than the Nordic countries. That it has a weaker welfare system is offset by the fact that incomes before taxes and benefits start out less unequal. The same pattern can be seen in the USA: the states with the best health tend to be those that have better welfare systems. Once again, the only states that do equally well without good welfare systems are those, like New Hampshire, which are relatively egalitarian to start with.
More equal countries not only have better health, they also have lower levels of violence, better educational performance of school children, lower teenage birth rates, lower prison populations, and higher social capital.
The Lancet Volume 368, Issue 9543 , 7 October 2006-13 October 2006, Pages 1229-1230
Systematic review of health interventions to reduce inequalities: systematic, intensive delivery of effective health care (and???), improved access including reminders (aha!). Systematic review of home visiting programmes showed limited evidence of positive effect on quality of parenting and child development outcomes; where reviews have not shown benefit, may have been due to failure to provide tailored programme.
NZ RCT of home insulation – better self reported health, fewer GP visits, days off work/school. Better indoor environment or less expenditure on heating as mechanism?
Conflicting evidence on whether inequalities are more or less obvious in childhood. 2 different US studies using same data set came up with opposite conclusions! The difference is the inclusion/exclusion of young adults living alone rather than at home - when excluded, inequalities increase significantly through childhood towards adolescence. Social Science & Medicine Volume 64, Issue 4 , February 2007, Pages 757-761
Attachment style may act as a source of resilience in the face of educational disadvantage. Men in mid-life who were not burdened with anxious or avoidant attachment styles seem to have been more likely to overcome the disadvantage of a lower level of educational attainment and progress up the ladder of Civil Service grades in the English Whitehall II study. As it is not strongly related to parentsÕ social class, it can be argued that attachment style has acted as a source of upward social mobility which is also likely to reinforce better health in later life. Social Science & Medicine Volume 64, Issue 4 , February 2007, Pages 765-775
Law in Scotland changed in 2006 - now if Dad is named on birth certificate, he automatically gets rights. For children born before 2006 however, nothing changes. Dad (or anyone else) only gets rights if he is married to Mum, if he has filled out the Parental Responsibilities and Parental Rights Agreement ( PRPRA, needs mum's agreement), or if a court confers them.
25-30% of 16yr olds already sexually active, rate is rising esp girls (catching up with boys). Teenage pregnancy rate varies 10 fold by area! Besides poverty, associated with higher risk of poor adult income, supportive partner, educational achievement. But poverty multiplies the risk. Sex is about intimate relationships and cognitive development including identity, independence, planning - much more than just physical development.
DoH guidance instructs trusts to establish whether patients are lawfully living in the UK. If not, duty to charge them. Asylum seekers are exempt from charges as they are considered to be in the country for a purpose, but refused refugees are not. Treatment of some communicable diseases eg TB, STDs are exempt; diagnosis of HIV is free but not treatment. The official guidance at the DoH is now obsolete, and is yet to be replaced following consultation.
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