FACTORS CONTRIBUTING TO CHILD HEALTH & DEVELOPMENTAL ... · Centre for Community Child Health CHILD PUBLIC HEALTH ELECTIVE 3rd July 2012 FACTORS CONTRIBUTING TO CHILD HEALTH & DEVELOPMENTAL

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Centre for Community Child Health

CHILD PUBLIC HEALTH ELECTIVE 3rd July 2012

FACTORS CONTRIBUTING TO CHILDHEALTH & DEVELOPMENTAL OUTCOMES- A GLOBAL PERSPECTIVE

Tim MooreCentre for Community Child HealthThe Royal Children’s Hospital


OUTLINE

• Social climate change – parallels with climate change• Social climate change – changes in lives of children

and families• Consequences – impact on child outcomes• Causes – factors contributing to worsening outcomes• Causes – child development and developmental

pathways• Cures – common factors underpinning climate

change and social climate change• Cures – implications for action• Conclusions


CLIMATE CHANGE

WORSENING CLIMATE OUTCOMES

• A profound transformation of Earth’s environment is now apparent, owing not to the great forces of nature or to extraterrestrial sources but to the numbers and activities of people - the phenomenon of global change.

• Begun centuries ago, this transformation has undergone a profound acceleration during the second half of the 20th century.

• The evidence that these changes are affecting the basic functioning of the Earth System, particularly the climate, grows stronger every year

• The Earth is currently operating in a ‘no-analogue’ state: in terms of key environmental parameters, the Earth System has recently moved well outside the range of the natural variability exhibited over at least the last half million years.

Steffen et al (2004)

Steffen et al. (2004)Steffen et al. (2004)

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WORSENING CLIMATE OUTCOMES

• Geologists have subdivided the 4.5 billion year history of our planet into a timescale subdivides time into eons, eras, periods and epochs, each based on a globally significant event recognisable in the geological record, such as a mass extinction or a global geochemical anomaly.

• Like any science, geology is incredibly conservative – the geological timescale has been unchanged for more than a century.

• In 2004, the first new period was added in more than 100 years - the Ediacaran period - named after a place in the Flinders Ranges in South Australia, and ratified after more than a decade of debate.

• There is a new proposal to add a new epoch to the very end of the timescale, termed the Anthropocene. The case is that the processes now shaping the planet, and life on it, are so different from the past that they are creating a geologically distinct record. The name is reflective of the new agent responsible for this change — it's us.


WORSENING CLIMATIC OUTCOMES:THREE KEY QUESTIONS

• Is it really happening? Are there significant changes occurring in a variety of indicators of global environmental health?

• If so, did we do it? Are these changes the result of human activity?

• If so, what do we need to do now? What action can we take to prevent long-lasting damage to the global environment?


SOCIAL CLIMATE CHANGE


SOCIAL CLIMATE CHANGE

• The same factors that have contributed to climate change have also dramatically altered human societies and the conditions under which families are raising young children

• These changes have occurred over the last fifty years and have been so rapid, dramatic and unprecedented as to constitute a form of social climate change paralleling environmental climate change

• While the impact of social climate change on child development and family functioning does not appear to be as dramatic as the impact of climate change on the health of the earth, that may be because we have not fully understood what is happening

Steffen et al. (2004) Steffen et al. (2004)

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THE NATURE OF SOCIAL CLIMATE CHANGE

• One of the key features of the social changes that have occurred is that society has become more complex and interconnected

• This interconnectedness is a product of many factors, including globalisation of trade and ideas made possible by developments in transport and communication technologies, and the greater density and diversity of populations resulting from population growth and movements.

Our world, we believe, is a complex and dynamic one. Nowadays, most people live in a multitude of constantly splitting, merging and overlapping social domains that are intertwined in ever-changing ways with a wide array of equally dynamic and varied technological and technological domains

(Verweij, Thompson & Engel, 2006)


THE NATURE OF SOCIAL CLIMATE CHANGE (cont)

• One effect of this increased interconnectedness is to alter the nature of people’s relations with others: ‘

The societal drift today favours interdependence. We are able to connect in forms – and at speeds – that our forbearers could never have imagined.’ (Blau & Fingerman, 2009)

• It also alters the nature of the major social and health problems that are facing contemporary societies

• The major health problems today are ‘disorders of the bioenvironmental interface’, products of socioeconomic influences on health (such as poverty), health disparities, technological influences on health, overweight and obesity, increasing mental health concerns (Palfrey, Tonniges, Green & Richmond, 2005)


CHANGES IN THE CONFIGURATION OF CHILDHOOD HEALTH AND ILLNESS

• Classical pediatric morbidity (1900s-1950s) – focus on infectious diseases, high infant mortality rates, poor nutrition, few cures for chronic disease, epidemics (eg, influenza, polio), and diseases of overcrowding

• The new morbidity (1960s-1980s ) – focus on family dysfunction, learning disabilities, emotional disorder, functional distress, educational needs

• Beyond the new morbidity (1980s-2000s) – community efforts to efforts to prevent disease and promote health, focusing on social disarray, political ennui, new epidemics (eg, violence, acquired immunodeficiency syndrome, homelessness)

• Millennial morbidity (2000-present) – disorders of the bioenvironmental interface, including the socioeconomic influences on health (such as poverty), health disparities, technological influences on health, overweight and obesity, increasing mental health concerns

Palfrey, Tonniges, Green and Richmond (2005)

Human health in city environments is an expression of complex social and environmental interactions not previously faced in our long evolutionary history. The rising tide of 21st century public health problems, such as obesity, cardiovascular disease and depression, are different to past problems that could be directly attributed to infectious agents, toxic chemicals, poor industrial design and a lack of effective environmental management.

The new diseases of urban living arise more from the complex way we now live, eat, travel, build, play and work in urban environments, rather than from any single agency.

Our health is now an expression of a complex web of interactions that have not been previously faced during human evolution and these interactions are more subtle and indirect in their action.

Kearns, Beaty & Barnett (2007)



• Many of the most pressing policy challenges involve dealing with very complex or ‘wicked’ problems.

• These problems are ‘wicked’, not in the sense of them being evil in some way, but in the sense of them being complex and difficult to solve. They are contrasted with ‘tame’ problems where the problems are well understood and the solutions known.

• These problems share a range of characteristics:

- they go beyond the capacity of any one organisation to understand and respond to

- there is often disagreement about the causes of the problems and the best way to tackle them

- the problem is not understood until after a solution has been formulated

- the problem is never solved (completely).



Another framework for understanding difficult social problems is the distinction between problems that are simple, complicated or complex:

• Simple problems. Baking a cake is a simple problem. It involves following a recipe that gives good results every time, and there is a high degree of certainty of outcome.

• Complicated problems. Sending a rocket to the moon is a complicated problem. It involves high levels of expertise and a wide range of skills, but there is a high probability of success, because rockets are similar in critical ways, and sending one rocket increases the likelihood that subsequent attempts will also be successful.

• Complex problems. Raising a child is a complex problem. There is no recipe or precise formulae, and raising one child provides experience but no assurance of success with the next. Expertise can contribute but is neither necessary nor sufficient to assure success. Every child is unique and must be understood as an individual, and the ultimate outcome remains uncertain.

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These three types of problems differ in the extent to which cause and effect is or can be known

• In simple situations cause and effect is known so interventions and their consequences are highly predictable and controllable.

• In complicated situations cause and effect is knowable as patterns are established through research and observations over time, but the many variables involved make prediction and control more precarious.

• In complex situations, cause and effect is unknown and unknowable until after the effect has emerged, at which point some retrospective tracing and patterning may be possible.



• An example of a contemporary social problem that is both complex and wicked is social exclusion:

‘Social exclusion is a shorthand term for what can happen when people or areas suffer from a combination of linked problems such as unemployment, poor skills, low incomes, poor housing, high crime environments, bad health, poverty and family breakdown. In the past, governments have had policies that tried to deal with each of these problems individually, but have been less successful at tackling the complicated links between them, or preventing them arising in the first place.’ (UK Social Inclusion Unit)

• Other examples of wicked problems include child protection, indigenous disadvantage, health inequalities, poverty, obesity, climate change and land degradation.

• The major health and social challenges that we face are now more likely to be complex or wicked problems


NATURE AND EXTENT OF WORSENING DEVELOPMENTAL OUTCOMES

CONCERN ABOUT WORSENING DEVELOPMENTAL OUTCOMES

• Mental health - eg. depression, suicide, drug dependence

• Physical health - eg. asthma, obesity, diabetes, heart disease

• Academic achievement - eg. literacy levels, retention rates, educational outcomes

• Social adjustment - eg. employment, juvenile crime

CONDITIONS WITH COMMON ANTECEDENTS

Physical health outcomesdiabetes, cancer

respiratory conditionscardiovascular disease

Mental health outcomesADHD

depression/suicideaggression

Risk behaviour outcomessubstance use

early sexual activityteen parenting

Academic outcomestruancy

early school leavingalienation

Social outcomesindividuals in institutions

children in carecriminal behaviour

Developmental outcomespoor attachment

poor cognitive developmentpoor speech and language

Problems of human development


CONCERN ABOUT WORSENING DEVELOPMENTAL OUTCOMES (cont)

• The rates of all these developmental outcomes have risen or are unacceptably high

• The developmental pathways that lead to each of these outcomes can be traced back to early childhood

• All the poor developmental outcomes identified have associated social and financial costs that cumulatively represent a considerable drain on societal resources

• These worsening outcomes represent an unintendedconsequences of other changes and policies which in other respects have been generally successful

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WORSENING DEVELOPMENTAL OUTCOMES

• Increasing proportions of our children and youth have complex diseases such as asthma, diabetes, overweight and obesity, intellectual disabilities, and particularly psychological problems such as depression / anxiety, suicide and eating disorders.

• There have been no improvements in the proportions of our children born prematurely or underweight, or in those diagnosed with physical disabilities such as cerebral palsy.

• There have been perceived dramatic increases in a range of behaviour problems such as attention deficit disorder and hyperactivity; dangerous activities such as substance abuse; and the high levels of teenage pregnancies.

Stanley, Richardson and Prior (2005)


WORSENING DEVELOPMENTAL OUTCOMES (cont)

• Trends in behavioural and learning outcomes in schools are challenging teachers, and education departments are voicing concern at the levels of social and other problems in schools and how these may affect educational achievement.

• Not all types of juvenile crime have increased, but the most aggressive ones certainly have, such as assault and rape.

• Child abuse and neglect is reported more than ever before, although it may be that the occurrence is not really increasing, but that it is more acceptable to report it.

• Whatever the case, child protection services everywhere are in a state of crisis

Stanley, Richardson and Prior (2005)


OBESITY

• Perhaps the most observable instance of a worsening outcome is the rise of obesity in children.

• Obesity has become a pandemic, with more than a billion people affected worldwide – it has replaced malnutrition as the major nutritional problem in some parts of Africa, with overweight/obesity being as much as four times more common than malnutrition. (Chaput & Tremblay, 2008)

• Over the past 30 years, the prevalence of overweight children has tripled

• The incidence of type 1 diabetes in children shows a significant increase over a 15 year period, with the greatest increases in the 0-4 age group, pointing towards harmful changes in the environment in which contemporary children live.

Epidemiological course of biological and ecological ‘inflammatory’ processes

Egger and Dixon (2010)Centre for Community Child Health

OBESITY (cont)

• The obesity epidemic is best understood not as the outcome of individual greed or lack of discipline (an ‘unnatural response to a natural environment’) but as the outcome of an ‘obesogenic’ environment (and hence a ‘natural response to an unnatural environment’) (Egger & Swinburn, 2010).

• An obesogenic environment is one that promotes obesity through the combined effects of a range of factors, including ready access to energy-dense but nutrient-poor processed foods and reduced levels of exercise (Swinburn et al., 1999).

• Efforts to reduce levels of childhood obesity through interventions aimed at the individual level have not proved very successful so far and need to be complemented by efforts to moderate the physical, social and economic environmental factors promoting obesity.

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OTHER DEVELOPMENTAL OUTCOMES

Other indices of child health and well-being that have been nominated as worsening include:

• asthma• hay fever and other allergic reactions, such as eczema • food allergies. • onset of puberty• anorexia nervosa• self harm • attention deficit disorders• autism spectrum disorders• lupus• multiple sclerosis


OTHER DEVELOPMENTAL OUTCOMES (cont)

• Since the 1980s, the world has experienced an epidemic of allergic disease.

• The prevalence of asthma rose rapidly during the 1990s, followed by increases in the prevalence of eczema and allergic rhinitis, both of which continue to rise.

• Of great concern is new evidence that yet another allergic condition — food allergy — is also on the rise, particularly in infants and young children: an estimated 10%–15% of the population report symptoms of food allergy

Allen (2011)


WORSENING OUTCOMES

There are three general points to be made about this phenomenon of worsening outcomes.

• First is their ubiquity: every index of development and functioning appears to be affected

• Second, they occur in every developed nation, and also appear in developing nations as they acquire Western lifestyles and levels of prosperity

• Third is that it should be happening at all, given the general improvements in prosperity over the past few decades - this phenomenon has been dubbed ‘modernity’s paradox’:

‘MODERNITY’S PARADOX’

A puzzling paradox confronts observers of modern society. We are witnesses to a dramatic expansion of market-based economies whose capacity for wealth generation is awesome in comparison to both the distant and the recent past.

At the same time, there is a growing perception of substantial threats to the health and well-being of today's children and youth in the very societies that benefit most from this abundance.

(Keating & Hertzman, 1999)

Over the course of the last 50 years, there have been tremendous improvements in the physical health of children and in the life expectancy of adults. It is chastening to realise that there have not been parallel improvements in psychological functioning or mental health …On the contrary, psychosocial disorders in young people have tended to increase in frequency over the last half century.

Why has this been so? I would argue that this has to be an answerable question. If we had a proper understanding of why society has been so spectacularly successful in making things psychologically worse for children and young people, we might have a better idea as to how we can make things better in the future.

Rutter (2002)Centre for Community Child Health

WORSENING CHILD OUTCOMES:THREE KEY QUESTIONS

• Is it really happening? Are the same worsening health and developmental outcomes evident in all developed nations?

• If so, did we do it? What are the causal pathways leading to these outcomes and are they the result of various aspects of the social changes that have occurred over the last half century?

• If they are, what should we do to redress or offset them?

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FACTORS CONTRIBUTING TO WORSENING OUTCOMES

SUE PALMER (2007). TOXIC CHILDHOOD: HOW THE MODERN WORLD IS DAMAGING OUR CHILDREN AND WHAT WE CAN DO ABOUT IT.

Palmer lists 15 factors that affect children's development that have undergone considerable changes in recent decades

BERNARD RIMLAND (2007). DYSLOGIC SYNDROME: WHY MILLIONS OF KIDS ARE ‘HYPER', ATTENTION-DISORDERED, LEARNING DISABLED, DEPRESSED, AGGRESSIVE, DEFIANT, OR VIOLENT – AND WHAT WE CAN DO ABOUT IT.

Rimland identifies three main causes of ‘dyslogic syndrome’


ENVIRONMENTAL EFFECTS

You cannot treat ‘the environment’ as separate from humans (SEHN, 2007). In fact, human health depends upon three ‘environments’:

• The natural environment (air, water, soil, flora and fauna)

• The built environment (roads, power plants, suburban sprawl, chemicals, etc.)

• The social environment (relationships of trust, mutual respect, and friendship but also poverty, racism and white privilege, sexism, homophobia, insecurity, the sense that life is out of control, and so on).


FACTORS CONTRIBUTING TO WORSENING HEALTH AND DEVELOPMENTAL OUTCOMES

Natural environmental factors

• Environmental change

• Climate change

Built environmental factors

• Environmental toxins

• Changes in urban environments

• Changes to living environments

• Changes in food consumption

• Changes in food production and distribution

• Medication and vaccinationsCentre for Community Child Health

FACTORS CONTRIBUTING TO WORSENING HEALTH AND DEVELOPMENTAL OUTCOMES (cont)

Social environmental factors

• Economic and social changes

• Epidemiological transition

• Social inequities

• Changes in social values and priorities

• Changes in social environments

• Changes in levels of stimulation

• Changes in the nature and content of media

• The speed of change

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ENVIRONMENTAL DEGRADATION AND RESOURCE DEPLETION

• The ongoing degradation of Earth's ecosystems - land degradation, ozone depletion, temperature increases etc. –has potentially disastrous results for human health

• These could result in food shortages, new and intensified disease patterns, rising seas, mass refugee problems, and cancers, blindness, and immune suppression from increased ultraviolet radiation

• Although global warming and resultant climate change pose serious risks to human health, global warming is only one of a nested series of threats to the health of humankind

• These threats, acting synergistically, stress the ecological and social foundations upon which humanity relies for air to breathe, water to drink, food to eat, and disposal of waste

Over the past 50 years humans have changed natural ecosystems more rapidly and extensively than any comparable period in human history. The findings provide the strongest evidence so far of the ways in which pressures on ecosystems have resulted in the loss of vital ecosystem services, which purify and replenish water, soil and air resources essential to health, and also keep many diseases in check. Loss of these ecosystem services, in turn, affect patterns of communicable and non-communicable disease distribution and transmission.

In the future, still-increasing pressures on ecosystems could impact public health in a variety of ways that are unpredictable and potentially severe.

OECD (2005)


CLIMATE CHANGE

• Climate change poses direct and indirect risks to health:• Direct risks include physical injury because of more

frequent events such as bushfire, and increased heat-related death and disease.

• Indirect risks include more infectious diseases transmitted through vectors such as insects, and mental and physical health difficulties that typically follow social and economic disruption such as drought and flood.

• The diversity of health risks from climate change presents a direct challenge to the health sector – including acute health-care and the public health system.

• Many health-protecting activities will need to be undertaken by other sectors of government and industry, as well as by individuals and communities.


CLIMATE CHANGE (cont)

The main health risks derive from: • extreme weather events/disasters; • temperature extremes; • effects on air quality and aeroallergens, plus the (biological)

interaction of some air pollutants with meteorological conditions;

• environmental infectious diseases - water and food borne; • vector-borne infectious diseases; • altered food production, affecting yields and nutritional

quality; • social, economic and demographic dislocation (especially in

relation to mental health).

McMichael, Woodruff &

Hales (2006)Centre for Community Child Health

ENVIRONMENTAL TOXINS

• Exposure to toxins prenatally or early in life can have a devastating and lifelong effect on the developing architecture of the brain.

• Exposures to many chemicals have much more severe consequences for embryos, fetuses, and young children, whose brains are still developing, than for adults.

• Substances that can have a truly poisonous effect on the brain can be found in environmental chemicals such as lead and mercury, in recreational drugs such as alcohol, nicotine, and cocaine, and in prescription medications, such as some acne treatments.

• Even very low doses of some biologically active contaminants can alter gene expression important to learning and developmental function.

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ENVIRONMENTAL TOXINS (cont)

Environmental agents that we are confident cause learning and developmental disabilities in humans• Alcohol• Lead• Mercury• Polychlorinated biphenyls (PCBs)• Polybrominated diphenyl ethers (PBDEs)• Manganese• Arsenic• Solvents• Polycyclic aromatic hydrocarbons (PAHs)• Pesticides• Nicotine & ETS (secondhand smoke)



• We are regularly exposed to many toxic chemicals and carry them in our bodies, as evidenced by samples of human blood, breath, hair, tissue, and body fluids.

• Most of our exposures to these chemicals are not from sources traditionally regulated, such as remote waste sites and factories. Rather, the primary sources are close to us: within our indoor environments, and the personal activities, products, and materials inside those environments.

• The sources of these pollutants are largely unregulated –meaning that our environmental regulations, designed to protect and promote human health, are missing major sources of health risks.



• Exposures to environmental pollution remain a major source of health risk throughout the world, though risks are generally higher in developing countries

• Associations between environmental pollution and health outcome are complex: individual pollutants may be implicated in a wide range of health effects, whereas few diseases are directly attributable to single pollutants.

• Nevertheless, it is estimated that about 8–9% of the total disease burden may be attributed to pollution, but considerably more in developing countries.

• Unsafe water, poor sanitation and poor hygiene are seen to be the major sources of exposure, along with indoor air pollution.


CHANGES IN URBAN ENVIRONMENTS

• Reduced access to parks and safe places for children to play

• Reduced access to green spaces and natural environments

• Increased road traffic at expense of pedestrian safety and comfort

• Increased safety fears results in children doing less walking and riding to school and other places, and less risk-taking in general


CHANGES IN URBAN ENVIRONMENTS

• According to UNICEF (2012), the percentage of the world’s children living in urban areas rose from 27% in 1955 to 43% in 2005.

• During 2007, the human species became predominantly urban

• Australia is highly urbanised, and urban life is characterised by sedentariness, excess food intake, reliance on cars for transport, a high level of exposure to media and marketing messages, and a consumer culture

• These characteristics are linked to obesity, diabetes, heart disease, some cancers, chronic respiratory disease, injury, depression and anxiety.

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CHANGES TO LIVING ENVIRONMENTS

• Many allergies and immune deficiency conditions have doubled, tripled or even quadrupled in the last few decades

• Immune deficiency conditions that have increased include asthma; hay fever and other common allergic reactions, such as eczema; and food allergies.

• Others that appear to be on the increase include lupus, multiple sclerosis and other afflictions caused by misfiring immune systems.

• The cause remains the focus of intense debate and study, but some researchers suspect the concurrent trends all may have a common explanation rooted in aspects of modern living


CHANGES TO LIVING ENVIRONMENTS (cont)

• According to the ‘hygiene hypothesis’, one contributing factor is growing up in increasingly sterile homes

• Decreased exposure to viral infections in early childhood, partly as a result of multiple immunizations or cleaner environments, may provide less or less normal stimulation of the immune system, with more susceptibility to allergies in later years.

• Other contributing factors include changes in diet, air pollution, and possibly even obesity and increasingly sedentary lifestyles.


CHANGES IN FOOD CONSUMPTION

• Children’s patterns of food consumption – what they eat and drink, how much they eat and drink, and under what circumstances – have altered dramatically over the last few decades.

• The quality of neighbourhood food environments plays a part: people who live near an abundance of fast-food restaurants and convenience stores compared to grocery stores and fresh produce vendors have a significantly higher prevalence of obesity and diabetes.

• The highest rates of obesity and diabetes are among people who live in lower-income communities which have worse food environments.


CHANGES IN FOOD CONSUMPTION (cont)

• The ultimate incarnation of modern agricultural policies is the fast food meal, featuring low-quality carbohydrates and fats, few essential nutrients, little fibre, high energy density, and poor satiety value.

• These meals are very cheap, but promote over-consumption, markedly increasing risk for obesity and its complications.

‘To avoid excessive weight gain and obesity-related chronic disease, virtually all experts recommend regular physical activity and a diet based on vegetables, fruits, legumes, whole (rather than refined) grains, and high-quality proteins and fats. Unfortunately, the last half-century witnessed widening divergence, concurrent with the obesity epidemic, from these recommended behaviors … This increasingly unhealthful lifestyle is a predictable consequence of national economic, social, and policy trends of recent decades.’ (Ludwig & Pollock, 2009)


CHANGES IN FOOD PRODUCTION AND DISTRIBUTION

• Within developed nations over the past few decades, there have been significant changes in food production and in the composition of basic foods - these include increases in the amount of refined sugar in foods (Egan and Switzer, 2007)

• There have also been increases in various food additives, such as food colourings

• Artificial colours or a sodium benzoate preservative (or both) in the diet produce increased hyperactivity in otherwise normal children (McCann et al., 2007)


MEDICATION AND VACCINATIONS

• Debates about the medication of children with ADHD and behavioural regulation problems

• Debates about the link between autism and the measles-mumps-rubella (MMR) vaccine and autism

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ECONOMIC AND SOCIAL CHANGE

Over the past few decades, there have been significant changes in developed nations throughout the world:

• Adoption of free market economic policies – the globalisation of commerce

• Concurrent rise in general prosperity – dramatic increases over the last few decades

• Reduction in government control over market and in government responsibility for provision of public services

• Fall in birth rates – an international phenomenon

• Increased movement of people between countries, leading to more diverse societies

• Globalisation of ideas and culture – world wide webCentre for Community Child Health

LOCAL CHANGES

There have been significant changes in Australia’s demographic make-up:

• a drop in the birth rate – to 1.77 per woman (2.11 in indigenous women) which is below the replacement level

• a decrease in proportion of children in society - from 1:3 in 1977 to 1:4 in 2002 (but with a recent upturn)

• Children are less of a social priority – the care of the aged becomes more of a priority and takes up more and more of the public budget. (The old used to be the poorest group in society – now it’s single parents with children, followed by two-parent families with 4 or more children)

• Those who do not have (and do not intend to have) children are less keen on public investments in children and families


LOCAL CHANGES (cont)

Over the past 25 years, there have been dramatic changes in employment opportunities and conditions :

• a decline in men’s participation in the labour market and in their employment, and an increase in women’s participation and employment

• a large shift away from full-time and towards part-time work

• a rise in the proportion of workers who are employed as casuals

• a rise in long hours of work

• a fall in the proportion of the workforce employed in manufacturing (now down to 12%) and a rise in employment in service industries (now 75%)

• increased inequality in the distribution of pay – pay at the top end has risen faster than pay at the bottom, especially for men


LOCAL CHANGES (cont)

• Changes in the cost of housing as a proportion of income – Australia now has one of the highest rates in the developed world

• Changes in social mobility , with consequent weakening of the social infrastructure

It should be noted that the Australian governments of all political persuasions have done (and continue to do) much to protect families from the adverse effects of these social and economic changes.


EPIDEMIOLOGICAL TRANSITION One explanation of ‘modernity’s paradox’ lies in what is known as the epidemiological transition (Wilkinson, 2005):

• Social and psychological factors loom large among the determinants of health in the developed countries because the long history of rising living standards has drastically reduced the direct effects of material privation.

• As infectious diseases declined, many of the so-called diseases of affluence (eg. heart disease) reversed their social class distribution to become more common among poor in affluent societies.

• Health in societies that have gone through the epidemiological transition ceases to be as responsive to further rises in material living standards as it had been earlier: once you have enough of everything, it doesn't help to have much more.


SOCIAL INEQUITIES

• As prosperity has increased, there have been widening gaps between the rich and the poor in most developed nations

• These gaps, rather than poverty itself, are associated with poorer health and social outcomes

• Social gradient effects operate such that health and social problems progressively worsen the lower people are on the socioeconomic scale

• Within each of the developed countries, average life expectancy is five, 10, or even 15 years shorter for people living in the poorest areas compared to those in the richest.

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THE IMPACT OF INEQUALITY

• Psychosocial factors affect health through the extent to which they cause frequent or recurrent stress.

• Chronic stress affects numerous physiological systems, including the cardiovascular and immune systems, increasing our vulnerability to a very wide range of diseases and health conditions.

• According to Wilkinson (2005), there are three psychosocial risk factors which play a major role in triggering biological stress responses: low social status , poor social affiliations , and early childhood experiences .

• According to Marmot (2004), there are two key psychosocial risk factors: control over our lives , and opportunities for full social participation.

CHILDHOOD MORTALITY RATES AND SOCIOECONOMIC STATUS IN AUSTRALIA

Age-standardised mortality rates for children aged 0–14 years, all causes and injury mortality, 1998–2000.

Quintile 1 = least disadvantaged; quintile 5 = most disadvantaged

Draper, Turrell and Oldenburg (2004)

Centre for Community Child Health Centre for Community Child Health

Centre for Community Child Health Centre for Community Child Health

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CHANGES IN SOCIAL VALUES AND PRIORITIES

• ‘Affluenza’ – the grip of consumerism (Hamilton and Denniss, 2005; James, 2007)

• The tenuous relationship between prosperity and happiness (Eckersley, 2005)

• The search for meaning in a materialist world (McKay, 2007)

Measures of social well-being used to increase in parallel with wealth as countries got richer during the course of economic development. But now, although rich countries have continued to get richer, measures of well-being have ceased to rise, and some have even fallen back a little. Since the 1970s or earlier, there has been no increase in average well-being despite rapid increases in wealth.

Wilkinson (2005)


CHANGES IN SOCIAL ENVIRONMENTS

• Partial erosion of traditional family and neighbourhood support networks, due to factors such as increased family mobility and the search for affordable housing

• Increase in the number of parents whose own experiences of being parented were compromised, and who therefore have difficulty parenting their own children

• All these factors have contributed to an increase in the number of families with complex needs


CHANGES IN FAMILIESFamilies have become more varied in their structure, and more diverse culturally and ethnically:

• families are smaller (but houses are bigger)• extended families are also smaller – there are fewer

cousins, uncles and aunts• childlessness is increasing – there are more people who

neither have children nor intend to have children• mother’s age at first birth is increasing – from 25 in

1984 to 29 in 2004• more single parents – due principally to growth in the

number of children born to mothers without a partner, rather than to divorce or separation

• more blended families• more shared custody arrangements• more same sex couple families


CHANGES IN FAMILIES (cont)

These changes have important consequences:

• Children are growing up with fewer siblings, as well as smaller extended families

• Children see fewer examples of parenting as they grow up

• Children have fewer experiences of caring for younger children and being cared for by older children

• Because families have fewer children, parents are more intensely concerned about their welfare


CHANGES IN FAMILY CIRCUMSTANCES

The circumstances in which families are raising young children have also changed:

• more parents are working

• more mothers with babies are working • more parents are doing shift work and

working non-standard hours• more parents are working longer hours• more families are jobless• more children are being raised in poverty

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Globalisation is the critical driving force that is fundamentally restructuring the social order around the world, and families are the centre of this change. In every society, traditional notions about family life, work, identity, and the relationships of individuals and groups to one another are being transformed due to globalising forces.

Trask (2010)


CHANGES IN LEVELS OF STIMULATION

• Hallowell (2006) argues that the modern phenomenon of brain overload is a national epidemic: we are suffering from culturally induced ADHD.

• Jackson (2008) argues that our hyper-mobile, cyber-centric, attention-deficient lifestyle is eroding our capacity for deep attention

• Rosen (2008) argues that multitasking - the simultaneous use of several different media, such as television, the Internet, video games, text messages, telephones, and e-mail - has become endemic and that this is adversely affecting how we learn and contributes to the release of stress hormones and adrenaline, which can cause long-term health problems, and contributes to the loss of short-term memory


CHANGES IN LEVELS OF STIMULATION (cont)

• Laura, Marchant and Smith (2008) argue that highly technological machines are invading our lives and separating us from personal relationships: we personalize our computers and associated technologies while depersonalizing others and ourselves.

• Greenfield (2008) argues that new technologies are leading to changes in behaviour and environment that create physical changes in the brain: the result of all that screen time and addictive dopamine will be the biggest physical changes to the human brain since the Neanderthals 100,000 years ago, producing changes in behaviour and thought patterns that amount to nothing less than a different type of person.


CHANGES IN FORM AND CONTENT OF MEDIA

• Children under six are now spending more time connected to electronic media than reading books

• Impact on prolonged exposure to electronic games and TV on physical activity, hence contributing to health problems and obesity

• Impact of TV advertising on eating behaviours, identity formation, development of values etc.

• Impact of media violence on development


THE ACCELERATING SPEED OF CHANGE

• In 1904, the Wright brothers took the first controlled, powered, and human flight in a heavier-than-air vehicle, covering a distance of 120 feet at a speed of 11 kms an hour.

• Just a few months before Orville Wright’s death in 1948, Charles ‘Chuck’ Yeager flew an orange Bell X-1 jet faster than the speed of sound. (Huntington, 2010)

• In 2008, half the population of the planet became mobile telephone subscribers: in a decade, we went from half the world having never made a telephone call to half the world owning their own mobile. (Pesce, 2008)


THE SPEED OF CHANGE (cont)

• There has been rapid growth in the size of the ‘digital universe’ as a result of the explosion of social networking, online video, digital photography and mobile phones.

• In 2007, technology consultancy company IDC estimated that the digital universe was equivalent to 161,000 petabytes - each petabyte represents a million gigabytes.

• By 2010, it had grown to 8,000,000 petabytes, and a new unit –the zettabyte, equivalent to a million petabytes – had been coined to measure the ongoing expansion.

• As a result of continued rapid expansion, the digital universe is forecast to expand by a factor of 44 over the next decade.

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CHILD DEVELOPMENT AND DEVELOPMENTAL PATHWAYS: OPENING THE BLACK BOX

As Nelson (2007) points out, there is a such a proliferation of theoretical views about child development that

‘…there is no overarching conception that has won the minds of those who study development of psychological processes, nor is there a small set of strongly competing views.’

The early childhood ecology

Child

Church members

Extended family

Friends

Neighbours

Schools

Prevailing economic conditions Industrial relations

Health services

Parks

Sporting clubs

Child Care

Playgroups

Employment

Peers

Drought

Housing policies

Societal norms and attitudes

Local Govt

Child Care Policy

Safety

Specialist services

Cultural groups

The ChildTemperament

AbilityHealth

Gender

Extended Family

Early Childhood Centres

ChronosystemPatterning of environmental events and transitions over the life course: sociohistorical conditions

Community

Immediate FamilyNeighbours

Work Friends

Friends

Informal Support Network

HealthGP

Education

Formal Services

Societal Attitudes

Media

Government Policy

Culture

CHILD

FAMILYHOME

COMMUNITY

INTERPERSONALECOLOGY

PHYSICALECOLOGY

INTRAPERSONALECOLOGY

PSYCHOLOGICAL

NEUROLOGICAL

BIOLOGICAL

GENETIC

SOCIETY

WORLD

LOCAL

NATIONAL

GLOBAL THE REDUCTIONIST CAUSAL CHAIN

• According to Noble (2008), the reductionist view of genes and their function sees them as the origins or causes of life – the phenotype as ‘created by’ the genotype

• In this model, the causal chain is a one-way system from the genes to the organism

• The assumption is that if we know all about the lowest-level elements – the genes and proteins – then we would know everything about the organism

Organism��

Organs��

Tissues��

Cells��

Sub-cellular mechanisms��

Pathways��

Proteins��

Genes

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INTEGRATIONIST MODELS

• Emergent complexity (Laughlin, 2007)

• Systems biology (Noble, 2008)

• Dynamic systems theory (Fogel et al, 2008; Lickliter, 2008)

The functional significance of genes (or neural structures, hormonal levels, or social interaction) can only be understood in relation to the larger developmental system of which they are a part.

This idea of distributed control , that direction for the emergence and development of our traits resides in the nature of the relationships within and between internal genetic and non-genetic factors and external environmental variables, is a key principle in understanding how development works.

Lickliter (2008)


DEVELOPMENTAL PATHWAYS

There are three ways in which exposure to both beneficial and adverse circumstances over the life course contribute to each person’s unique life exposure trajectory, which will manifest as different expressions of health and well-being:

• Latency: There are relationships between an exposure at one point in the life course and the probability of health expressions years or decades later, irrespective of intervening experience.

• Cumulative: Cumulative refers to multiple exposures over the life course whose effects on health combine.

• Pathways: These represent dependent sequences of exposures in which exposure at one stage of the life course influences the probability of other exposures later in the life course.

Hertzman and Power (2003)

LATENCY PATHWAYS

There is a major paradigm shift taking place in scie nce that while simple is profound. It states that the root of many diseases, including reproductive diseases and dysfunctions, will not be found by examination of disease onset or etiology hours, days, weeks, or even years prior to disease onset. The new paradigm suggests that susceptibility to disease is set in utero or neonatally as a result of the influences of nutrition and exposures to environmental stressors / toxicants.

In utero nutrition and/or in utero or neonatal exposures to environmental toxicants alters susceptibility to disease later in life as a result of their ability to affect the programming of tissue function that occurs during development. Heindel (2007)


PRENATAL ADAPTATIONS: The Barker hypothesis

• During development fetuses respond to adverse conditions, mainly severe undernutrition, by favoring the metabolic demands of the growing brain/CNS and heart at the expense of other tissues

• The long-term consequences of this response are that the fetus is protected from death, is live-born, but has a low birth weight and is more prone to diseases later in life.

• Low birth weight (LBW), small for gestation age (SGA), frank intra-uterine growth retardation (IUGR) or clinically abnormal thinness at birth strongly predicts the subsequent occurrence of hypertension, hyperlipidemia, insulin resistance, type 2 diabetes, ischemic heart disease, breast or prostate cancer in adult life.

• Fetuses that are clinically malnourished during the first trimester are three times more likely to be obese as adults.


EVOLUTIONARY MISMATCH

• Gluckman and Hanson (2006) argue that we have built a world that no longer fits our bodies.

• Our genes - selected through our evolution - and the many processes by which our development is tuned within the womb, limit our capacity to adapt to the modern urban lifestyle: there is a mismatch.

• We are seeing the impact of this mismatch in the explosion of diabetes, heart disease and obesity. But it also has consequences in earlier puberty and old age.

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EPIGENETIC INHERITANCE

• Behavioural development is usually thought to result from the interplay among genetic inheritance, congenital characteristics, cultural contexts, and parental practices as they directly impact the individual

• There is another contributor - epigenetic inheritance, which is the transmission to offspring of parental phenotypic responses to environmental challenges - even when the young do not experience the challenges themselves.

• Genetic inheritance is not altered, gene expression is. Organismic pathways for such transmission exist.

• Maternal stress during the latter half of a daughter's gestation may affect not only the daughter's but also grand-offspring's physical growth

Dong et al (2004)


EARLY CHILD DEVELOPMENT (cont)

Development is ‘weakly’ determined – individual causal factors, whether genetic or environmental, rarely have a significant impact on development on their own• Risk and protective factors are multiplicative rather than

additive in their effects.

Development is multiply determined, with both direct and indirect factors within and outside the child contributing to particular outcomes• Thus, many different risk or protective factors can lead

to any particular developmental outcome, and particular risk or protective factors can lead to many different developmental outcomes.

HOW DEVELOPMENTAL CHANGE OCCURS: TRANSACTIONAL MODELS

Sameroff and Fiese (2000)

Gottlieb (2007)Gottlieb (2007)

A biodevelopmental framework for understanding the origins of disparities in learning, behavior, and

health (Shonkoff, 2010)

Examples of pathways that may link physical exposures associated with childhood and adolescent SES to adult health

(Cohen et al., 2010)

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Examples of pathways that may link psychosocial exposures associated with childhood and adolescent SES to adult health.

(Cohen et al., 2010)


BIOPSYCHOSOCIAL PATHWAYS

Our bodies work through a series of communication-and-control systems:

• Autonomic nervous system. This connects our nerve endings to our brains and interconnect the huge number of neurons in our brain so that we have thoughts, memories and conditioned reflexes

• Endocrine (or hormonal) system. This involves all of the body's hormone-secreting glands, and broadcasts messages throughout our body by means of chemicals.

• Immune system. This involves the cells and tissues that recognise and attack foreign substances within our bodies.

• Cardiovascular system. This involves the system of blood vessels, arteries and heart functions.

• Metabolic system. The metabolic system governs the chemical and physical changes that take place within the body that enable its continued growth and function.

These systems work in very different ways but are intricately connected.


BIOPSYCHOSOCIAL ACCUMULATION EFFECTS

• Bioaccumulation occurs when an organism absorbs a toxic substance (such as a pesticide) at a rate greater than that at which the substance is lost.

• Biopsychosocial accumulation is an analagous process that describes what happens when people are subjected over time to a range of toxic biopsychosocial experiences at a faster rate then their body and mind can process effectively.

• This is similar to the notion of allostatic load (McEwen, 2009): this is the cumulative wear and tear on the body caused by repeated mobilizations of multiple physiological systems over time in response to environmental demands McEwen, B.S. (1998). Protective and damaging effects of stress mediators.

New England Journal of Medicine, 338 (3), 171-179.


CUMULATIVE IMPACTS PROJECThttp://www.cumulativeimpacts.org/home.html

• ‘Cumulative impacts’ refers to the total harm to human health and the environment that results from combinations of assaults and stressors over time.

• Adverse effects can add up until they surpass the limits of an individual's or system's ability to withstand them.

• Factors that can contribute to these assaults include socioeconomic and psycho-social experiences, nutrition, toxic exposures, gene-environment interactions, infectious disease, and disruptions in climate patterns, among others.


CUMULATIVE IMPACTS PROJECT (cont)

• They seldom add up predictably but are complicated by interactions, synergism, compounding, feedback loops, and other mechanisms that create uncertainty but also suggest crosscutting, preventive solutions.

• This project pools information on cumulative impacts in three scopes:

- Ecosystems — local, planetary, climate change

- Communities — environmental justice and vulnerable populations

- Human health — multiple factors in disease and disability

• These three scopes represent different aspects of the problem of cumulative impacts and leverage points for addressing it. They also overlap and affect each other.

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COMMON FACTORS UNDERPINNING WORSENING SOCIAL AND CLIMATE OUTCOMES


COMMON FACTORS

• Climate change will itself lead to social problems –prompted by the battle for diminishing resources and the inclination of the more rich and powerful to take more of these, thereby exacerbating the tensions and toxic effects of social inequalities.

• However, social problems also as a direct result of the same forces that produce the climate changes.

• There are two main underlying factors – population growth and industrial free-market economies (Speth, 2008)

The consequences of neoliberal globalisation affect the resources for fostering optimal child development in two ways. It reduces the income, psychological and social capital of the affected families by way of job loss and its related stress, and increases the social divide which feeds into social exclusion. It also reduces the capacity of affected communities to invest in child development through infrastructure and facilities, and safe physical environments. If governments reduce social spending on health and welfare, universal access to some basic social and health services becomes increasingly jeopardised, with a large negative impact on the most vulnerable children and families.’

(Li, McMurray & Stanley, 2008 )


IMPLICATIONS AND CONCLUSIONS

‘The primary determinants of disease are mainly economic and social, and therefore its remedies must also be economic and social.’

Geoffrey Rose (1992). The Strategy of Preventive Medicine .

‘In the twenty-first century, social, economic, and environmental factors are more important than biological disorders as causes of poor health in children. …. The contribution of medical care is correspondingly modest and, for maximum benefit, health care must focus more on prevention. This involves community approaches as well as individual health care, and must take into account the physical and mental health of the adults who interact with children and young people.’

Hall and Elliman (2003). Health for All Children (4th Ed)


IMPLICATIONS FOR ACTION

• According to the WHO’s Commission on Social Determinants of Health (2008), action to promote health must go well beyond health care - it must focus on the conditions in which people are born, grow, live, work, and age, and in the structural drivers of those conditions, namely inequities in power, money, and resources.

• This will take urgent and sustained action, globally, nationally, and locally.

• It will also take a dual focus on the health of the planet and the health of human societies

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Because climate change has such profound implications for the health of the global system and for the human societies that live within it,

We need to bring the two agendas of health equity and climate change together. Our core concerns with health equity must be part of the global community balancing the needs of social and economic development of the whole global population, health equity, and the urgency of dealing with climate change.

WHO Commission on Social Determinants of Health (200 8)


IMPLICATIONS FOR ACTION (cont)

In tackling these challenges, the WHO Commission recommended three principles on which action should be based:

• Improve the conditions of daily life – the circumstances in which people are born, grow, live, work, and age.

• Tackle the inequitable distribution of power, money, and resources – the structural drivers of those conditions of daily life – globally, nationally, and locally.

• Measure the problem, evaluate action, expand the knowledge base, develop a workforce that is trained in the social determinants of health, and raise public awareness about the social determinants of health.



• Both climate change and social climate change need to be understood systemically.

• This is the point that Steffen at al. (2004) make about global climate change:

Somewhat more than a decade ago it was recognised that the Earth behaves as a system in which the oceans, atmosphere and land, and the living and non-living parts therein, were all connected. While accepted by many, this working hypothesis seldom formed the basis for global change research. Little understanding existed of how the Earth worked as a system, how the parts were connected, or even about the importance of the various component parts of the system. Feedback mechanisms were not always clearly understood, nor were the dynamics controlling the system.



• This is also true of social climate change: the social forces that result in worsening outcomes act as a system in which all factors are connected.

• Understanding how these forces interact and collectively shape the health and well-being of children and their families is the challenge that is facing us.

• The vast majority of research, however, is focused on one or other of these factors in isolation from all others, and the solutions generated seek to rectify one symptom at a time.

• At best, these solutions will provide temporary symptomatic relief only: sustainable change can only result from efforts to understand and work with the social system as a whole.


HYPOTHESES

• As the unintended consequence of recent dramatic social and environmental changes, children are experiencing worsening health and developmental outcomes

• These changes parallel and arise from the same factors that produce global climate change and constitute a form of ‘social climate change’

• Poor child developmental outcomes are the result of a process of biopsychosocial accumulation whereby children are subjected over time to a range of toxic biopsychosocial experiences at a faster rate then their body and mind can process effectively

• These accumulation processes have their effects via a limited number of biopsychosocial pathways


ANSWERING THE THREE KEY QUESTIONS

• Is it really happening? We need a collaborative international epidemiological effort to establish exactly what developmental outcomes are common to all developed nations

• What are the causal pathways? We need a collaborative interdisciplinary effort to understand the developmental pathways that lead to poor outcomes.

• What should we do? We need collaborative whole-of-government efforts to address the causal pathways.

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Dr. Tim Moore Senior Research Fellow

Centre for Community Child Health,Murdoch Childrens Research Institute, The Royal Children’s Hospital, Flemington Road, Parkville, Victoria, Australia 3052

Phone: +61·3·9345 5040Fax: +61·3·9345 5900Email: [email protected]

Website: www.rch.org.au/ccch

Documents

FACTORS CONTRIBUTING TO CHILD HEALTH & DEVELOPMENTAL ... · Centre for Community Child Health CHILD PUBLIC HEALTH ELECTIVE 3rd July 2012 FACTORS CONTRIBUTING TO CHILD HEALTH & DEVELOPMENTAL