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Contents

Objectives

When you have completed this chapter you should be able to:

Children’s rights

14-1 What are the rights of children?

South Africa has agreed to put children first in its constitution and in the signing of the United Nations Convention of the Rights of the Child. Child rights should play a very important role in planning and delivering social services to children. Effective interventions for improving child survival and wellbeing are known and yet the gap between what can be done and what is actually being done widens each year in many low income countries.

Under the South African constitution children have certain rights:

Children’s rights to survival and healthy development must be respected, promoted and protected.

Note
The United Nations Convention on the Rights of the Child of 1989 defines 4 principles (non-discrimination, best interests of the child, right to survival and development, and respect for the views of the child); the African Charter on the Rights and Welfare of the Child of 1990 addresses the unique problems of the African child (socio-economic inequality, cultural and traditional barriers to progress, natural disasters, armed conflict, exploitation and hunger, female circumcision, child soldiers, literacy and children of imprisoned mothers) while the South African Constitution and Bill of Rights focus on the rights of children.

14-2 What threatens children’s rights?

The greatest threat to children’s rights is a dysfunctional family. This may be due to:

Infants and young children are totally dependent on their parent/s or caregivers. Their family and social environment also have a huge influence on their wellbeing.

Note
A rights-based approach to health focuses on the whole child and the creation of an environment which promotes the realisation of these rights. It implies duties and implications by the family, community and the state.

Poverty

14-3 What is the role of poverty in child health?

Poverty, inequity, ignorance and neglect remain the main causes of ill health in children in many low-resource countries. Poverty is the single most negative influence on children. Therefore, addressing poverty is the most effective way of improving the survival and the quality of life of children. All governments must strive to reduce poverty. In many countries, grants are available to poor families.

Poverty places children at risk.

14-4 Why does poverty place children at risk?

Female education and empowerment of women improve the lives of children living in poverty.

14-5 What political factors play a role in poverty?

Inappropriate government expenditure (e.g. arms instead of housing), policies (e.g. neglecting rural and slum areas) and strategies (e.g. building expensive hospitals without adequate staffing). Corruption, lack of vision and insight, and no political will to make the changes needed. War, civil strife and refugees remain a reality in many poor countries. We know what the problems are and how to correct them; the challenge is to make the changes needed in poor communities. Migration and urbanisation lead to the breaking up of families and communities.

We know what the problems are and how to correct them; the challenge is to make the changes needed in poor communities.

14-6 What can health workers do to help obtain social grants for children?

  1. Know what grants are available to children, which children are eligible for grants, and the process of obtaining child grants.
  2. Identify children who are eligible for grants.
  3. Inform parents or caregivers about available grants.
  4. Help with the process of applying for grants by referring parents or caregivers to the social security department and by getting medical reports completed.
  5. As most grants are targeted at poor families an income means test will be needed.

In South Africa applications must be submitted through special social workers in the South African Social Security Agency (SASSA). Applications may need a medical certificate and processing through the Children’s Court.

Note
The caregiver’s identity document, the child’s birth certificate, and proof of the financial status of the household will be needed for the application.

14-7 What grants are available?

There are a number of government grants aimed at supporting poor families, families of children with special needs, and families who are fostering a child.

In South Africa the following grants are available:

  1. Child support grant: For children in very poor homes.

    Note
    For children under 14 years with a caregiver over 18 years and a monthly household income under R 800 (rural) or R 11 000 (urban).

  2. Care dependency grant: For the support of families of children with permanent handicaps.

    Note
    For children aged 2 to 18 years with a severe handicap and an annual family income below R 48 000.

  3. Foster care grant: To assist foster families of a child in need.

    Note
    For children under 18 years who live with, and are cared for by, a foster family. Requires a court order.

  4. Social relief grant: An immediate short-term grant for children and families during a crisis situation (e.g. death of the breadwinner)

    Note
    Usually food parcels or a small financial grant while other grant applications are being processed.

The types of grants and schemes to reduce poverty in South Africa are being rapidly expanded.

Social environment

14-8 What home environmental factors can affect a child’s health?

14-9 What environmental factors outside the home can affect a child’s wellbeing?

14-10 When do children not have access to health care?

Child abuse

14-11 What is child abuse?

This is the purposeful maltreatment of a child with the aim of causing harm or injury. The child is always the innocent party. Abuse is usually by a family member, guardian or child minder. Child abuse is most common in children under the age of 5 years. The younger the child the greater is the risk of severe injury or death.

Child abuse is the intentional harm or injury of a child.

14-12 What are the forms of child abuse?

Abuse may be physical, emotional or sexual and takes many forms which often overlap with each other:

14-13 When should you consider child abuse?

The most important step in making the correct diagnosis is to consider abuse. Abuse should always be thought of if any of the following occur:

The most important sign of abuse is a history that does not adequately explain the degree or nature of the injury.

Unfortunately, the diagnosis of child abuse is often missed as it is not considered. Almost half of all abused children do not have physical injuries.

The most important step in the diagnosis is to consider child abuse.

14-14 What are the clinical signs of physical abuse in children?

Child abuse often presents with:

An X-ray examination may show multiple injuries of different ages, e.g. new and old rib fractures.

14-15 What are the clinical signs of sexual abuse in children?

Sexual abuse may present with:

Often there are no obvious clinical signs. A family member may report the abuse.

Note
Special investigations may be indicated such as a full blood count and clotting profile if there is extensive bruising, skeletal survey for suspected repeated injury or brain scan if cerebral injury is suspected.

14-16 Why do people abuse children?

Adults who abuse children were often abused themselves as children. Child abuse is usually a family problem. Poverty, inadequate family and social support, alcoholism, unemployment and mental illness are risk factors for child abuse.

Child abusers were often abused themselves as children.

Physical abuse usually involves a stressed parent or caregiver, a vulnerable child, and a precipitating crisis.

Sexual abuse usually occurs when there is inadequate supervision of a child and involves bribes, threats or force.

14-17 What should you do if you think a child is being abused?

Abuse is best managed by a multi-disciplinary team who have experience with caring for abused children. Always be kind and gentle with the child, and handle the parents with support and understanding. Be non-judgmental and non-threatening as being accused of child abuse is always emotionally threatening. Stay calm and do not become aggressive with the parents. It is often very difficult to tell with certainty whether a child is or is not being abused.

  1. A careful history from the child and family is important. Children rarely lie about abuse.
  2. A full examination looking especially for unusual or unexplained injuries. The examination must not be traumatic for the child. Look for signs of malnutrition or neglect. Has the child been drinking alcohol?
  3. All past and present injuries must be carefully documented. Make good notes as they may be used in court. Always date and sign your notes.
  4. Provide any immediate physical or emotional treatment needed.
  5. Always consider the safety of the child. You may have to remove the child to a safe place until the investigation of child abuse is completed. Never allow a child to be taken home if you suspect that the abuse will be repeated. The safety and interests of the child must always come first.
  6. If at all possible the child and parents should be seen urgently by someone who has had special training in the management of child abuse. Many big hospitals have a child abuse team. If this is not possible, contact an experienced person immediately.
Note
Always examine the fundi of the eyes for retinal haemorrhages which are important indicators of physical abuse.

14-18 Should the authorities be informed?

Health workers have a specific responsibility to inform the authorities if a case of child abuse is suspected. Notify the police, a social worker or child welfare officer immediately.

All cases of suspected child abuse must be notified to the authorities immediately.

Note
The Child Care Amendment Act 96 of 1996 in South Africa states that any person who suspects that a child is being maltreated or deliberately injured must immediately notify the authorities.

14-19 What is the long term goal of managing an abused child?

The repair and reconstruction of the family, if this is possible.

14-20 How should a child be managed if sexual abuse is suspected?

  1. An examination of the anus and genital must be done only once. Younger children can be held on the parent or caregiver’s lap with their legs pulled up to expose the genitalia. Older child are best examined in the lateral position, never in the knee–chest position which is often used by abusers. This examination is usually not urgent. All signs of sexual interference (bruising, tears, swelling or scarring) will be at or external to the hymen. Therefore, an internal digital examination should not be done. However, a vaginal examination may be needed under a general anaesthetic if there is severe trauma. Describe the shape and appearance of the hymen. The findings must be carefully documented. Swabs must be taken for culture.

    Note
    A special Crime Kit to collect semen samples is available if the sexual abuse has taken place in the past 4 days.
  2. Take blood for VDRL and HIV screen.
  3. Consider prophylaxis for syphilis, Chlamydia, gonorrhoea, Trichomonas, Gardnerella and HIV.
  4. Prescribe pregnancy prophylaxis within 72 hours of rape in girls who have already started menstruating.
  5. Debrief and counsel to prevent post-traumatic stress disorder.
Note
Cefotaxime IMI once, metronidazole (Flagyl) for 7 days and erythromycin for 10 days to prevent most sexually transmitted infections. AZT and 3TC for 28 days for HIV prophylaxis in children of 35 kg or less and fixed dose combination of TDF, 3TC and FTC in children who weigh more than 35 kg.

Street children

14-21 Who are street children?

These are children under 16 years of age who live on the street. Street children have little or no contact with their family. The street is their home. They find shelter, food, security and friends on the street. Street children should not be confused with children who make a living on the street after school but return to their family and home at night.

Street children have left their home and family to make a new life on the street.

14-22 How do street children get onto the street?

Street children seek to find a better place to live. It is expected that the number of street children will increase dramatically as more and more families are affected by HIV.

14-23 How do street children survive on the streets?

They beg, scavenge, undertake simple tasks (e.g. cleaning car windscreens), steal and become sex workers. To cope with cold, hunger, loneliness and the stress of living on the street, many children abuse chemical substances (e.g. sniff glue).

Street children often suffer from malnutrition, poor hygiene, infections, trauma and sexually transmitted infections. Most have severe emotional and psychological problems due to the reasons behind leaving home as well as their experiences on the street.

Street children have many physical and emotional problems.

14-24 How should the problem of street children be managed?

Street children have the same rights and needs as other children. There are many programmes to help street children:

It would be far better for citizens to contribute to one of the agencies which assist street children rather than giving money directly to these children. Giving food and money at street corners only encourages them to beg. Street children are often used and abused by older people to collect money.

Street children should be integrated back into society.

Orphans

14-25 What are orphans?

These are children who have lost both parents. Children who have been abandoned in hospital or who have parents in jail have similar problems to orphaned children.

14-26 Are the number of orphans increasing in South Africa?

Yes. With the epidemic of AIDS and frequency of war in Africa, more and more children are becoming orphans. Everyday children are losing their parents to AIDS in South Africa. Most children born to an HIV-infected mother are not infected themselves. Therefore they are at risk of becoming orphaned if both parents die of AIDS. While many of these children are cared for by their grandparents or extended family, the number of child-led families is increasing. The support and management of these orphans is a major challenge to both government and society.

14-27 What are the risks of being an orphan?

Parents are a child’s first line of protection and guidance. Therefore, children who lose both parents are vulnerable to exploitation, violence, discrimination, child labour, malnutrition, illness and abuse. Orphaned children without support often end up as sex workers, servants and sweat shop workers or get involved in organised crime. In some countries they are used as child soldiers.

Being separated from parents by death, war or social breakdown is detrimental to a child’s development and general wellbeing. Many of these children are uneducated, unhealthy and impoverished.

Orphans are at an increased risk of deprivation and abuse.

14-28 What can be done to help orphans?

Every effort must be made to help and protect these children. They have the same physical and emotional needs as other children. Whenever possible they should remain in their extended families or within their broader society. The state must provide the financial support to make this possible. Only as a last resort should they be placed in orphanages. It is better if they can be fostered or adopted so that they can be part of a family.

Every effort must be made to care for orphans in their own family and community.

Children who are cared for outside their own family and community soon lose their family ties and sense of identity. This can be severely damaging emotionally.

Developmental screening

14-29 What is normal neurological development?

From birth to adulthood, children both grow and develop. Normal development follows a standard orderly sequence of events which can be measured. Along the path of development are critical stages called ‘milestones’. Milestones are important developmental achievements such as standing and talking. Determining the child’s milestones allows for an assessment of whether development is normal or not. Milestones are determined both from the history and examination.

Milestones are critical developmental achievements.

14-30 Do all normal children reach the same milestones at the same age?

Not all children reach the same milestones at the same age. The age at which children acquire various physical, mental and social skills varies. Some normal children develop faster than others. Therefore, there is a wide normal range around the average time most children achieve a certain milestone (i.e. some normal children talk earlier than others). It is better to look at when a range of milestones are reached rather than base a developmental assessment on a single milestone.

14-31 What is developmental screening?

Many tests are available to decide whether a child’s development is within the normal range. These are called screening tests. Some are quick and simple and are used at primary care clinics to screen all children. Others are complicated and take time and experience to perform correctly. These tests are used to screen children at high risk of developmental problems.

Basic developmental screening is part of normal primary health care. In infants born preterm, their postnatal age should be corrected for the number of weeks that they were born early. Therefore, a one month old infant born at 36 weeks gestation should behave like a full term infant.

A method for routine developmental screen is included in the Road-to-Health Booklet.

All children should have basic developmental screening.

14-32 What areas of development should be assessed?

Developmental assessment looks at the following areas:

14-33 What are the common milestones in gross motor development?

  1. Smiling socially by 6 weeks
  2. Sitting without support by 6 months
  3. Pulling to a standing position by 9 months
  4. Walking with help by 12 months
  5. Walking well by 18 months

14-34 When do children develop fine motor skills?

  1. The newborn infant will grasp anything placed in the hand.
  2. By 6 months an object will be passed from hand to hand.
  3. By 12 months a child should pick up small objects in a pincer grip between thumb and index finger.
  4. By 18 months they should be able to build a tower with 3 blocks.

14-35 Which children are at high risk of developmental delay?

14-36 What should be done if a child has developmental delay?

The child should be referred to a developmental clinic for assessment by a multi-disciplinary team. Do not simply advise the parents that the child will outgrow the problems. Causes of any developmental delay should be looked for and corrected if possible. It may be necessary to test the child’s sight and hearing. An interview with a social worker may be needed to exclude emotional or social problems at home or school. Children with developmental delay may be found to have a neurodevelopmental disability.

Neurodevelopmental disability

14-37 What is disability?

A child with disability is not able to do something which most children are able to do at that age. Neurodevelopmental disability may be intellectual or physical or both.

14-38 How is intellectual disability assessed?

By measuring the intelligence quotient (IQ). Children without intellectual disability have an IQ of 75 or above. The developmental quotient (DQ) can also be used to assess intellectual ability, especially in young children. The developmental quotient is the developmental age divided by the chronological age, multiplied by 100. 95% of children will have an IQ or DQ between 75 and 125.

14-39 What are the grades of intellectual disability?

Intellectual disability can be divided into 4 grades based on intelligence quotients (or developmental quotients):

Moderate and severe intellectual disability are usually due to brain damage.

14-40 What is cerebral palsy?

A non-progressive motor disorder with abnormalities in tone, movement and posture. It is caused by damage to the immature, developing brain (before birth or in infancy). This is the most common cause of motor disability in children. There are a number of different types of cerebral palsy and part or all of the body may be effected. The most common is spastic cerebral palsy which may present as hemiplegia (weakness on one side of the body only), diplegia (legs affected more than arms) and quadriplegia (all limbs affected). Children with cerebral palsy may also have fits, learning difficulties, visual, hearing or speech problems. Spastic cerebral palsy is usually due to hypoxic damage during labour and delivery.

Cerebral palsy is a non progressive motor disorder involving tone, movements and posture.

Note
Children with cerebral palsy may also be hypotonic (floppy) or athetoid (abnormal tone and movements).

14-41 How should cerebral palsy be managed?

Children with cerebral palsy must be referred for assessment and management by a multi-disciplinary team. Physiotherapy and occupational therapy are very helpful. The family often need support and financial help through a state grant. The involvement and co-operation of the family and community is very important. These children may be intellectually normal. If at all possible they should be cared for at home with the family and not institutionalised.

Behaviour and emotional problems

14-42 What problems are common in young children?

Most of these problems get better with time. Parents need understanding, support and advice. Refer the child if the problem does not disappear.

14-43 What problems are seen in older children?

Most of these problems need the help of experts and therefore these children should be referred.

14-44 What is the attention deficit disorder?

Children with attention deficit disorder (ADD) are more restless and impulsive than others and have difficulty concentrating on one thing at a time. They are easily bored and distracted, and have difficulty completing tasks. They do not pay attention and have difficulty learning. This leads to serious schooling and behaviour problems. If they are very hyperactive the condition is called the attention deficit and hyperactivity disorder (ADHD). Hyperactive children are disruptive in the classroom and difficult at home. They cannot sit still.

The cause is usually unknown but it is more common in boys. There may be a family history of the condition. The diagnosis is usually made at about the time schooling starts. However, the correct diagnosis is often missed and the children are regarded as naughty or intellectually disabled. Attention deficit with hyperactivity is particularly common in children with foetal alcohol syndrome. Some children are worse after eating certain foods.

These children need early diagnosis and educational help. The parents need to understand the nature of the disorder.

Note
Some, but not all, school children with attention deficit disorder respond dramatically to methylphenidate (Ritalin) taken after breakfast on school days. Recent findings suggest that the medication should be taken both during school days and holidays.

Case study 1

A very underweight child is brought to the local urban clinic by his mother who is unemployed. The mother has had little school education and relies on her boyfriend for food and shelter. Her boyfriend drinks heavily and abuses her. Unfortunately her family are far away in a rural village. The clinic nurse criticises her for not feeding her child adequately and for not bringing him to the clinic regularly.

1. What is the main problem facing this mother and child?

Poverty.

2. Why is the mother in this situation?

She is unemployed and has had very little formal education. Therefore she has to rely on an abusive boyfriend for food and shelter, both for herself and her child.

3. Why does she not seek employment?

She has no social support as her family are far away. She probably came to town looking for work, but she has little education and few work skills. Who would she leave the child with if she went to look for employment? This is a very common scenario in many poor countries which results in childhood malnutrition, ill health and delayed growth and development.

4. What do you think of the attitude of the nurse?

This will not encourage the mother to bring her child to the clinic in future. This woman needs help, advice, understanding and support.

5. What can be done to help her?

Her problem is not easily answered. Referral to a social worker would be helpful. Social grants are available for children in need.

6. What are this child’s rights?

All children have a right to basic shelter, care and nutrition. They also have a right to basic health and social services.

Case study 2

A 2-year-old child is brought to a casualty department in the early hours of the morning. The parents give a vague story of the child falling off the bed. The parents are obviously drunk. On examination the child has bruises all over her body and a cigarette burn on the abdomen. Some bruises are fresh and others are old. A skeletal survey shows both recent and old fractures of the ribs. The medical officer shouts at the parents and phones the police from a busy waiting room.

1. Why would you suspect child abuse from the history?

Because the history does not adequately explain the bruises all over the body. The fact that the child was brought to hospital so late at night and that the parents were drunk is also very suspicious.

2. Does the examination confirm your suspicions?

Yes. Both bruises of different ages and a cigarette burn are very strong evidence for abuse.

3. Are the X-ray findings typical of child abuse?

Yes. Multiple injuries of different ages are typical. It would be most unusual for a non-abused child to have rib fractures that occurred on more than one occasion.

4. What was wrong with the doctor’s actions?

It is very difficult to stay calm when you know that a child has been abused. However, it is important to behave in a professional manner. The authorities must be informed, but it is not appropriate to shout at the parents and discuss the child in a public place.

5. What would be the correct management of this child?

The child must not be allowed to return home as the abuse may be repeated. The parents need to be told of the suspected diagnosis and that the authorities have to be informed. If possible an abuse team should be notified. Very careful notes must be written to document the history and clinical findings.

6. Why do some parents abuse their children?

They were often abused themselves as children. Abuse is more common in a social background of poverty, poor education, a lack of emotional support, and alcoholism.

7. How should the child’s genitalia be examined if sexual abuse was suspected?

Children must not be hurt or frightened. It is best to examine young children on their mother’s lap. Inspection of the vulva and anus is usually all that is needed. A digital internal examination should not be done.

Case study 3

A child of 8 years is brought to a general practitioner following physical abuse by older boys. He has been living on the street for the past 6 months following the death of his mother and then his father. He does not know why they died.

1. How do children get onto the street?

Like this child, they may be orphaned. However, they may also be abandoned by their parents or run away from home.

2. What problems are common in street children?

They commonly suffer from malnutrition, poor hygiene, infections, trauma and sexually transmitted infections. They may also abuse drugs. Most have severe emotional and psychological problems due to their experiences on the street.

3. What is the aim of managing a street child?

To integrate the child back into society and, thereby, avoid all the risks of living on the street.

4. What should the general practitioner do to help this child?

Contact the local social services.

5. Where is the best place for orphaned children?

In their extended families, e.g. with a grandmother. If this is not possible, every effort should be made to get these children cared for in the community where they lived before losing their parents.

6. What factor explains many of the recently orphaned children in South Africa?

AIDS.

Case study 4

Parents bring a 1-year-old child to hospital because he is still unable to sit without support. They recognise that his development has been slower than that of their other children. On examination it is noted that the tone in his legs is much greater than that in his arms. He appears generally well. The mother says that he was very small at birth and had a gestational age of only 35 weeks. He remained in hospital for 3 months.

1. Should the parents be concerned about his slow development?

Yes. Most children are sitting without help by 6 months. One year is very late not to be sitting yet. Even with correction for his prematurity (10 weeks), he is developing very slowly.

2. Why do you think this child is developing slowly?

The increased tone in his legs suggests that he has spastic diplegia. This is a form of cerebral palsy that is typically seen in infants that were very low birth weight or preterm. The history indicates that he was born preterm and needed a long stay in hospital.

3. How can you tell whether this child also has intellectual disability?

He needs special tests to assess all aspects of development.

4. What areas of neurodevelopment should be assessed?

Gross motor, fine motor, language and communication (including vision and hearing) and social interaction. Neurodevelopment is best assessed by a multidisciplinary team.

5. Could the diagnosis have been made earlier?

Yes. Cerebral palsy can usually be detected by screening all children at regular intervals as part of primary care.

6. Can this child be helped?

He needs physiotherapy. The parents also need to be counselled about the cause, the management and the prognosis. It is very important to work with the parents.

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