Taking the pulse of Canadian children – A health report card for the millennium

The Health of Canada’s Children: A CICH Profile was published for the first time in 1989 by the Canadian Institute of Child Health (CICH) (1). In the mid-1990s, reviews of the second edition of the CICH profile (2) that was published in 1994 appeared in the journals Canadian Family Physician (3) and Paediatrics & Child Health (4). The nationwide picture of child and youth morbidity and mortality called attention to many disturbing trends in health determinants, indicators and outcomes for children. In August 2000, the third CICH profile was released under the direction of Dr Graham Chance (5). As Canadians enter the new millennium, what progress have we made, what issues remain and what new concerns have emerged with respect to the health of Canada’s children?

The 2000 CICH profile is the result of cross-country consultation and collaboration by leading experts on child health, including representatives from both the Aboriginal sector and youth groups. In the profile, the term ‘health’ is used in its broadest, holistic sense to encompass physical, emotional, intellectual and spiritual facets. Although the available data in some areas are local or anecdotal, the National Longitudinal Survey of Children and Youth (6) and the First Nations Inuit Regional Health Survey (7) substantially add credibility to the current edition of the profile.

The profile confirms that most of Canada’s children are healthy and remain an ethnically diverse, multicultural group, with 84.2% of the children living in two-parent families. Among the youngest of Canada’s population, the infant mortality rate is at an historic low. There has been a dramatic improvement in Aboriginal neonatal health, and the incidence of neural tube defects and sudden infant death syndrome has declined. Immunization rates have risen, and the death rate in all age groups has fallen.

Though the report gives room for optimism, we can hardly be complacent about the progress that has been made. In l989, there was a unanimous all-party decision to end child poverty by 2000. How are we doing? Sadly, child poverty rates have actually increased in the past 10 years, with poverty affecting as much as 20% of all children. Canada ranks ninth among industrialized nations on the Human Poverty Index-2 (8), with Sweden having the best record in this regard. Greater income inequity translates into poorer population health, that is, increased rates of low birth weight and its attendant morbidity, increased rates of emotional disturbance, decreased academic performance, and diminished involvement in activities with a positive impact on mental health such as sports, music and the arts.

According to the 2000 profile, during their pregnancies, 23% of women continue to smoke, and low birth weights have not changed appreciably in the past 10 years. Only 50% of women breastfeed their children for the recommended six months. Almost 63% of women with children younger than 12 years of age are in the workforce, increasing the demand for quality child care and community supports. Despite the drop in overall death rates, the most significant single cause of mortality among children and youth remains injury (particularly falls) and poisoning, most of which occur in the home or at school and are largely preventable. Shouldn’t we invest in a national injury prevention strategy?

Many markers point to health concerns involving Canadian youths. The 2000 profile shows that a substantial minority of adolescents are engaged in high risk behaviours; 20% of 14-year-old youths have engaged in sexual intercourse, and less than one-half of the youths used condoms. Teen pregnancy rates are higher than they were in the l980s (49/1,000 in the 15 to 19 years of age group), and there is still no widespread comprehensive approach to this problem. Almost one-third of adult smokers began to smoke at age 12 years or younger. Bicycle helmet use declines to a mere 17% to 18% by grade 10, and more than one-third of adolescents do not regularly use a seatbelt. Youth aged 15 to 19 years are second only to the 20- to 24-year age group in the proportion who drink and drive. To increase health promotion opportunities, physicians can consciously make encounters with adolescents more ‘youth friendly’, that is, open and non-judgmental, empowering, and respectful of their goals and objectives. Given that this group consults a physician infrequently, we need to reinforce healthy behaviours during every encounter.

The number of children with complex health care needs is unknown, but such children have a profound impact on families. Most parents believed that their employment status was affected, and they had difficulty finding child care. Ninety-three per cent of parents experienced moderate to severe tension juggling work, family and child care. There is little financial support for caregivers of children with disabilities and a lack of respite care.

Two new chapters that highlight mental and environmental health were added to the 2000 profile. Nationally, parental perceptions of emotional, hyperactivity and behavioural symptoms in the eight- to 11-year-old age group are disturbingly high (in the range of 30%, 40% and 10%, respectively). Though these statistics do not necessarily indicate a disorder, they clearly identify emotional and behavioural issues as being a priority. Other Canadian statistics are equally sobering. Twelve per cent of females aged 15 to 19 years have experienced a major depressive episode, and males in the same age group committed suicide at the rate of 18.5/100,000. In an Ontario survey of adult past experiences (5), 31% of males and 21% of females had been physically assaulted as children. Despite the lack of national data, what we do know about the health issues that face street youth and children with disabilities causes concern. Street youth have higher rates of attention deficit disorder and other learning difficulties. Almost all of them have experienced some form of abuse, and they are at higher risk of suicide. Children with disabilities are also more likely to report emotional distress, low self-esteem and abuse. Similarly, the First Nations Inuit Regional Health Survey (7) indicates that Aboriginal youth have high rates of depression and alarmingly high rates of suicide. In addition, they are one of the fastest growing segments of the human immunodeficiency virus-positive population.

As physicians, we must promote resilience to improve mental health in children. As was previously mentioned, participation in sports, recreation and leisure encourages community involvement, the development of new skills and, hence, self-esteem. Spirituality, defined as a connection to music, culture, arts and the community, is emerging as an important determinant of health. Access to such programs should be universal. Children and youth who have a close and caring relationship with at least one adult, and competency in at least one area are less likely to engage in risk-taking behaviour.

The environment is another health determinant. Even though questions concerning its health implications are largely unanswered, the impact of environmental toxins on children is greater than on adults because children have increased vulnerability due to their physiological and developmental characteristics. The dramatic rise in the prevalence of asthma may be a symptom of environmental toxins, including active and passive smoking, an expression of multiple viral exposures at a younger age or a reflection of improvements in diagnosis. Concerns about the effect of environmental hazards have prompted the development of the ‘precautionary principle’ – when evidence suggests that an activity may threaten health, measures should be taken, even if cause and effect relationships are not fully established. On one hand, proponents have an obligation not to create unfounded fear in the population and to continue building scientific evidence. On the other hand, opponents need to ask themselves how much risk they are willing to accept.

The 2000 profile has raised as many questions as it answers. Many of these questions are directly relevant to medical practice. What is the prevalence of children requiring complex medical care, and what skills and resources do we need to care for them properly? What is the effect of delayed diagnosis of disability, and how can we improve early diagnosis and intervention? Which early childhood programs are successful? How do the Internet and television influence children’s physical and mental health? What is the true status of our children’s community integration?

With this daunting list of health issues before us, what can we as physicians do? We can advocate for and support social policy that enables the essential work of families regardless of incomes, parental leave with income protection, universal access to programs that support child development and quality child care services. We can promote local injury prevention programs. We can emphasize the importance of positive parenting, help a child to discover his or her area of competence, and encourage community and school involvement for children. We need to be sure that our youth receive the easily accessible, friendly attention that they deserve. We should reach out to high risk groups in our communities. Alcohol and tobacco exposure are environmental contaminants that we can directly influence throughout the life cycle because there is evidence that physicians can have a positive effect in these areas. We should support and work collaboratively with our community partners in the development of programs and resources that provide assessments, information and resources to fill identified gaps and decrease the impact of inequities. We must pursue research efforts and provide answers to some of the important questions posed by the 2000 profile.

In l991, Canada ratified the United Nations Convention on the Rights of the Child (9). It appears from the data presented in the most recent CICH profile that Canadian children still lack several basic human rights. All of us who are interested in the holistic promotion of health for children and youth can be a resource to our communities and help to improve our benchmarks. We are in an ideal position to play a part in the nationwide responsibility to our children – our future.

To obtain a copy of The Health of Canada’s Children: A CICH Profile, 3rd edition, contact: Canadian Institute of Child Health, 300–384 Bank Street, Ottawa, Ontario K2P 1Y4. Telephone 613-230-8838, fax 613-230-6654.