Children Youth and Healthy Development

Children Youth and Healthy Development
Canada
Canada
Health
Canada
Santé
Canada
Healthy Development
of
Children and Youth
T h e
R o l e
o f
o f
t h e
D e t e r m i n a n t s
H e a l t h
Healthy Development
of
Children
T h e
R o l e
o f
o f
and
t h e
Youth
D e t e r m i n a n t s
H e a l t h
D e c e m b e r
1 9 9 9
Our mission is to help the people of Canada
maintain and improve their health.
Health Canada
Canadian Cataloguing in Publication Data
Main entry under title: Healthy development of children and youth:
the role of the determinants of health
Également disponible en français sous le titre : Le développement
sain des enfants et des jeunes : Le rôle des déterminants de la santé
Includes bibliographical references.
1.
2.
3.
4.
I.
Children — Health and hygiene — Canada.
Youth — Health and hygiene — Canada.
Child development — Canada.
Health status indicators — Canada.
Canada. Health Canada.
RJ103.C3H42 1999
305.231’0971
C99-980286-0
The analysis, views and opinions expressed are those of the authors
and do not necessarily reflect the position or policies of Health
Canada.
Permission granted for non-commercial reproduction related to
educational or service planning purposes, provided there is a clear
acknowledgement of the source.
For additional copies, please contact:
Publications
Health Canada
Postal locator: 0900C2
Ottawa, Ontario
K1A 0K9
Tel.: (613) 954-5995
Fax: (613) 941-5366
E-mail: [email protected]
This publication is also available on the Internet at the following
address: http://www.hc-sc.gc.ca/hppb/childhood-youth/spsc.html
This publication can be made available in alternative formats upon
request.
©Her Majesty the Queen in Right of Canada, represented by the
Minister of Health Canada, 1999
ISBN 0-662-28062-8
Catalogue No. H39-501/1999E
F o r e w o r d
S
trategies to influence population health status must address the broad
range of health determinants in ways that are both comprehensive and
integrated. While, in its own right, healthy child development is a crucial
determinant of future health and well-being of the population, it is also
influenced by each one of the other major determinants. Collaboration
and active support across many sectors is necessary to raise healthy, engaged,
socially responsible citizens.
This report comes at a time when there is high interest in the health and
well-being of Canadian children and youth. Governments across Canada
believe that a National Children’s Agenda, developed as a shared vision,
will help to enhance collective efforts to improve children’s lives.
The purpose of Healthy Development of Children and Youth is to contribute to
the knowledge base and stimulate discussion about the application of the
determinants of health concept to the healthy development of Canada’s
children and youth. The report offers a framework for the discussion of
child and youth development issues among all interested sectors — a vital
step in the process of applying population health.
Through this document and in collaboration with major national initiatives,
such as the Report on the Health of Canadians, the National Longitudinal Survey
of Children and Youth and the Health Behaviours in School-Aged Children Study, it
is hoped that a common evidence base will be developed to set priorities,
develop strategies, plan and implement action and measure progress related
to the health and well-being of our children. This process will increase the
understanding of the issues and their interrelationships by all sectors about
the ways in which their policies, decisions and actions have an impact on
the health and well-being of the child and youth population as a whole.
Ian Potter
Assistant Deputy Minister
Health Promotion and Programs Branch
Healthy Development
iii
of Children and Youth
A c k n o w l e d g e m e n t s
M
any groups and individuals within Health Canada and other federal
departments were involved in the development of the research frame-
work, which forms the basis of this report, identifying and selecting the
research and data to be included, as well as providing input and feedback
at various stages of the report’s development. Because of the complexity
of the task and the length of time required to develop the report, many
of the individuals involved in both the working and advisory groups have
changed since the beginning of the initiative.
Health Canada’s Childhood and Youth Division would like to thank the
following federal departments for their collaboration: Human Resources
Development Canada; Indian and Northern Affairs Canada; Justice Canada;
Environment Canada; and Status of Women Canada.
Childhood and Youth Division would also like to thank their colleagues in
other divisions and directorates of Health Promotion and Programs Branch,
Health Protection Branch, Medical Services Branch, and in Policy and
Consultation Branch. Their attention to detail and thoughtful input and
feedback have contributed immensely to this comprehensive report.
Additionally, several external experts were consulted and produced the
first drafts of either whole chapters or sections of chapters. Childhood
and Youth Division thanks: Dr. Denise Avard and Dr. Eef Harmsen of Avard
& Harmsen, Consultants; Craig Shields of Human Services Consultants; and
Dr. Peter Szatmari of the Canadian Centre for Studies of Children At Risk
at McMaster University.
Within Childhood and Youth Division, the leadership of Brian Ward in
conceptualizing the project, and Esther Kwavnick and Helen McElroy in
supporting the project and providing guidance and advice were invaluable.
The team which provided the continuing day-to-day work to bring the
project to reality consisted of Mary Johnston, Andrea Brand, Catherine
Mills and Daniel Riendeau.
Healthy Development
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of Children and Youth
Allium Consulting Group Inc. (Ottawa) was responsible for the writing,
editing, design and production. Catherine Robinson provided project
management and, together with Jane Chapman, carried out the writing
and editing of the report. Simon Alves designed the report, Jane Coghlan
provided production coordination, and Gina Marin was responsible for
desktop publishing.
The staff at Traductions Houle were responsible for the French language
translation. The revisions of the French text was done by Sylvain Topping.
Healthy Development
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of Children and Youth
T a b l e
o f
C o n t e n t s
Foreword ...................................................................................................... iii
Acknowledgements ................................................................................ v
Part A — Background and Context
Introduction ................................................................................................ 3
Purpose, Scope and Organization of the Report ...................................... 4
Through the Population Health Lens .................................................. 4
Organization of the Report .................................................................. 5
Data Sources and Limitations .............................................................. 5
The Population Health Approach .............................................................. 6
An Evolution in Thinking...................................................................... 6
The Determinants of Health ................................................................ 8
Overview of Children’s Development ...................................................... 11
About Canada’s Children .......................................................................... 14
How Many Are There? ........................................................................ 14
Where Do They Live? .......................................................................... 15
What Do Families Look Like? ............................................................ 16
How Many Children Live In Poverty? ................................................ 17
How Healthy Are They? ...................................................................... 17
References .................................................................................................. 18
Healthy Development
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of Children and Youth
Part B — A Closer Look at the Determinants
1. Income and Social Status ..............................................................21
Overview...................................................................................................... 21
Relationship to Healthy Child Development............................................ 22
Conditions and Trends .............................................................................. 22
Family Income ...................................................................................... 22
Child and Family Poverty .................................................................... 23
Food and Housing Security ................................................................ 27
Income and Social Status and Other Determinants ................................ 29
Education.............................................................................................. 29
Social Environment.............................................................................. 29
Personal Health Practices .................................................................... 29
Individual Capacity and Coping Skills .............................................. 29
References .................................................................................................. 30
2. Employment and Work Environment .................................. 33
Overview...................................................................................................... 33
Relationship to Healthy Child Development............................................ 34
Conditions and Trends .............................................................................. 35
Parents’ Labour Force Participation .................................................. 35
Working and Parenting........................................................................ 37
Child Care ............................................................................................ 38
Youth Employment .............................................................................. 40
Employment and Other Determinants...................................................... 42
Education.............................................................................................. 42
Genetic and Biological Factors............................................................ 42
Culture .................................................................................................. 42
References .................................................................................................. 43
Healthy Development
viii of Children and Youth
3. Education .............................................................................................. 45
Overview...................................................................................................... 45
Relationship to Healthy Child Development............................................ 46
Conditions and Trends .............................................................................. 47
Education Level of Parents.................................................................. 47
Role of Families .................................................................................... 50
School Readiness ..................................................................................51
Staying in School .................................................................................. 52
Education and Other Determinants .......................................................... 56
Income .................................................................................................. 56
Employment ........................................................................................ 57
Social Environment.............................................................................. 57
References .................................................................................................. 58
4. Social Environment .......................................................................... 61
Overview...................................................................................................... 61
Relationship to Healthy Child Development............................................ 62
Conditions and Trends .............................................................................. 63
Parenting and Family Functioning
(or Love and Emotional Support) ...................................................... 63
Family Structure .................................................................................. 64
Family Violence .................................................................................... 66
School and Community Networks ...................................................... 69
Community Security ............................................................................ 70
Child and Youth Crime........................................................................ 70
Social Environment and Other Determinants .......................................... 71
Income .................................................................................................. 71
Education.............................................................................................. 72
Genetic and Biological Factors............................................................ 72
References .................................................................................................. 73
Healthy Development
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of Children and Youth
5. Natural and Built Environments .............................................. 75
Overview...................................................................................................... 75
Relationship to Healthy Child Development............................................ 76
Behaviour.............................................................................................. 76
Physiology and Chemical Hazards ...................................................... 79
Development and Chemical Hazards ................................................ 79
Conditions and Trends: Natural Environment ........................................ 80
Ambient Air Quality ............................................................................ 80
Water and Food Quality ...................................................................... 83
Soil Quality .......................................................................................... 87
Radiation and Global Warming .......................................................... 88
Conditions and Trends: Built Environment .............................................. 89
Injuries: A Major Health Threat ........................................................ 89
Home Environment and Injuries........................................................ 90
Home Environment and Chemical Exposure.................................... 91
Home Environment and Biological Exposure .................................. 93
The School Environment .................................................................... 93
Transportation ...................................................................................... 93
Recreational Environment and Injuries ............................................ 95
Recreational Environment and Chemical Exposure ........................ 96
Recreational Environment and Biological Exposure ........................ 96
Environment and Other Determinants .................................................... 97
Income .................................................................................................. 97
Personal Health Practices .................................................................... 97
Culture: Aboriginal Children .............................................................. 97
Gender .................................................................................................. 98
References .................................................................................................. 98
Healthy Development
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of Children and Youth
6. Personal Health Practices .......................................................... 103
Overview.................................................................................................... 103
Relationship to Healthy Child Development.......................................... 104
Conditions and Trends ............................................................................ 107
Prenatal and Infant Health .............................................................. 107
Healthy Eating .................................................................................... 108
Body Image ........................................................................................ 109
Physical Activity .................................................................................. 110
Smoking, Alcohol and Other Drugs ................................................ 111
Injuries ................................................................................................ 114
Sexual Activity .................................................................................... 117
Personal Health Practices and Other Determinants.............................. 120
Income and Education ...................................................................... 120
Natural and Built Environments ...................................................... 120
Individual Capacity and Coping Skills .............................................. 121
Culture ................................................................................................ 121
Gender ................................................................................................ 121
References ................................................................................................ 122
7. Individual Capacity and Coping Skills ................................ 127
Overview.................................................................................................... 127
Relationship to Healthy Child Development.......................................... 128
Conditions and Trends ............................................................................ 130
Mental Disorders ................................................................................ 130
Stress.................................................................................................... 132
Suicide ................................................................................................ 134
Capacity, Coping and Other Determinants ............................................ 135
Income ................................................................................................ 135
Social Environment............................................................................ 135
Genetic and Biological Factors.......................................................... 135
Gender ................................................................................................ 135
References ................................................................................................ 136
Healthy Development
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of Children and Youth
8. Genetic and Biological Factors ................................................ 139
Overview.................................................................................................... 139
Relationship to Healthy Child Development.......................................... 141
Types of Biological and Genetic Risk Factors .................................. 141
Developmental Disabilities ................................................................ 144
Conditions and Trends ............................................................................ 145
Genetic and Biological Factors and Other Determinants .................... 147
Employment ...................................................................................... 147
Education............................................................................................ 147
Social Environment............................................................................ 147
Natural and Built Environments ...................................................... 148
Personal Health Practices .................................................................. 148
Health Services and Social Services .................................................. 148
References ................................................................................................ 149
9. Health Services and Social Services ...................................... 153
Overview.................................................................................................... 153
Relationship to Healthy Child Development.......................................... 155
Conditions and Trends ............................................................................ 158
Health Services and Social Services and Other Determinants ............ 161
Income and Social Status .................................................................. 161
Education............................................................................................ 162
Social Environment............................................................................ 162
Natural and Built Environments ...................................................... 162
Personal Health Practices and Coping Skills .................................. 163
Genetic and Biological Factors.......................................................... 163
Culture ................................................................................................ 163
Gender ................................................................................................ 164
References ................................................................................................ 164
Healthy Development
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of Children and Youth
10. Culture ................................................................................................ 165
Overview.................................................................................................... 165
Relationship to Healthy Child Development.......................................... 166
Conditions and Trends ............................................................................ 169
Language and Ethnicity .................................................................... 169
Injuries ................................................................................................ 170
Suicide ................................................................................................ 170
Education............................................................................................ 171
Culture and Other Determinants ............................................................ 171
Education and Employment.............................................................. 171
Natural and Built Environments ...................................................... 171
Personal Health Practices .................................................................. 171
Individual Capacity and Coping Skills .............................................. 172
References ................................................................................................ 172
11. Gender ................................................................................................ 175
Overview.................................................................................................... 175
Relationship to Healthy Child Development.......................................... 176
Conditions and Trends ............................................................................ 178
Gender and Other Determinants ............................................................ 180
Education............................................................................................ 180
Personal Health Practices .................................................................. 180
Individual Capacity and Coping Skills .............................................. 181
Genetic and Biological Factors.......................................................... 181
References ................................................................................................ 181
Healthy Development
xiii of Children and Youth
Part C — Challenges — Today and Tomorrow
12. Challenges ........................................................................................ 185
Overview.................................................................................................... 185
Overarching Issues for the 21st Century ................................................ 187
Child Development ............................................................................ 187
Population Health.............................................................................. 188
An Inter-sectoral Approach .............................................................. 189
Decentralization ................................................................................ 189
Globalization ...................................................................................... 189
The Information and Communication Age .................................... 190
The Aging Population........................................................................ 190
Children’s Participation .................................................................... 191
Conditions and Trends ............................................................................ 191
Income and Social Status .................................................................. 192
Employment and Work Environment .............................................. 193
Education............................................................................................ 195
Social Environment............................................................................ 196
Natural and Built Environments ...................................................... 197
Personal Health Practices .................................................................. 199
Individual Capacity and Coping Skills .............................................. 201
Biology and Genetic Factors.............................................................. 202
Health Services and Social Services .................................................. 203
Culture ................................................................................................ 204
Gender ................................................................................................ 204
Looking Ahead .................................................................................. 205
References ................................................................................................ 205
Healthy Development
xiv of Children and Youth
Part
A
Background
and
Context
Part A positions Healthy Development of Children and Youth in
context, providing an introduction to the population health approach
and an overview of child development, as well as some basic facts
and figures about Canada’s children.
I n t r o d u c t i o n
F
or the most part, our children and youth are growing up healthy, and
live, study and work in environnments that promote well-being. Not
only do young people and children represent Canada’s future, they are
also important today as members of Canadian families, communities and
the larger society. Yet, a number of significant inequalities exist in the
health status of Canadian children and youth. Some young people are
more likely to be injured, others to experience physical and mental health
challenges. Without appropriate action, these health inequalities are likely
to persist into adulthood. On both a personal and societal level, the downstream consequences of these early experiences can be overwhelming.
Current research shows that much of the ill health and injury evident
among young Canadians can be prevented. Moreover, it is now accepted
that the health status of young people in Canada is influenced by a wide
range of social, cultural, physical and economic determinants, many of
which lie outside the traditional health sector. Through research and
experience we are coming to know the power of education in improving
the life circumstances and health outcomes for young people. There is a
growing awareness of the alienation and negative consequences experienced by young people growing up in poverty. Positive social environments,
supportive family structures, a healthy and safe environment — all of these
factors interact to affect the health of Canadian children.
In fact, the research provides a glimpse of the future for Canada’s young
people, including a promise of what is possible through concerted action
on a number of important fronts. Working together, we can build a healthy
and fulfilling future for Canada’s children. But while there is cause for
optimism, there is also the need for caution. The challenges that lie ahead
are daunting and cannot be addressed in isolation. A cooperative, multisectoral approach that addresses the wider determinants of health is essential
for enhancing the health of Canadian children and youth.
Healthy Development
3
of Children and Youth
Introduction
Background and Context
Purpose, Scope and Organization of the Report
Healthy Development of Children and Youth is intended as a starting point for
discussion and action aimed at improving the prospects for Canadian children
and youth. Using a population health approach, the report compiles existing
research to explain how the various determinants of health interact to shape
healthy child development, and to depict conditions and trends relevant to
the health and well-being of children and youth in Canada.
The document is aimed at a wide range of audiences concerned with the
current and future health of Canada’s children and youth, including policy
and program developers, researchers working in all levels of government,
health and social service agencies, and research organizations. It is hoped
that the information presented here will promote broad-based thinking
about the conditions and factors that help to shape children’s health. To this
end, policy and program developers will be encouraged to look outside their
traditional areas of influence to consider the impact of their decisions on
healthy child development.
Through the Population Health Lens
The population health approach, which incorporates the broad determinants
of health and well-being, provides a useful framework for organizing evidence
about the factors that contribute to children’s health, and for highlighting
promising avenues for further research and action. While healthy child
development is itself a determinant of health, for the purposes of this report
it serves as the filter or lens through which the other determinants of health
are viewed and analyzed.
The population health approach is still in its infancy — much work
remains to be done before it will be possible to identify with any certainty
the specific causes of good health and how the various determinants interact
to shape children’s health and well-being. An important contribution to
both strengthening and broadening the field, the report draws heavily on
a plenitude of excellent work that has been carried out by researchers and
practitioners working in the field of healthy child development, as well as
on the work of those in fields related to the other determinants of health.
By drawing together highlights of the literature and presenting the research
within a population health framework, the report enables policy and program
developers to access relevant information easily and to add to their own
knowledge base on issues related to healthy child development. With this
goal in mind, key linkages among various determinants have been illustrated
throughout the report — again, with a view to encouraging readers to look
beyond their own fields and to consider the implications of the full range of
factors that influence children’s health.
Healthy Development
4
of Children and Youth
Introduction
Background and Context
The primary focus of the report is children and youth to the age of 18 years.
It should be noted, however, that many of the issues addressed relate to adults
(especially parents). So many aspects of children’s lives are beyond their
individual control that a broader examination of the settings in which they
operate — physical, social and economic — is essential to painting the full
picture of relevant conditions and trends. For some issue areas, such as income
and child poverty, a wealth of information exists; other areas, for example,
the incidence of child abuse, lack information at the national level.
Organization of the Report
The report is organized into 12 core chapters, as well as this introduction.
The Introduction provides useful background information, including basic
demographic information about Canada’s children and youth, an overview of
the population health approach and the determinants of health, and a general
description of the process of child development.
Chapters 1 to 11 make up the body of the report. Each chapter examines
a specific determinant of health, addressing its relationship to healthy child
development, summarizing current conditions and trends relevant to that
determinant, and identifying how it relates to other determinants of healthy
child development.
Chapter 12 presents a commentary by the Childhood and Youth Division
of Health Canada. It takes a broader view of the areas of concern identified
in each chapter, compiling some of the key findings about the determinants
of health to identify issues,
opportunities and priorities for
intersectoral collaboration and
Canada’s Native Population:
decision making that will improve
Defining the Terms
the health and future prospects
for Canada’s children and youth.
For the purposes of this report, the terminology
used to describe Canada’s Native populations is
Data Sources and Limitations
defined as follows:
This report draws on a wide range of
health information from a variety of
sources. Some major studies were used
extensively throughout the report,
including the National Population Health
Survey (NPHS), the 1996 Census and the
National Longitudinal Survey on Children
and Youth, 1994–95.
A range of other reliable data sources
and reports were also consulted and
credited in discussions of health issues
and trends. This has resulted in some
discrepancies and inconsistencies in how
information is presented. For example,
differing age categories may not allow
direct comparisons across studies.
Healthy Development
5
Aboriginal: includes the Indian, Métis and
Inuit peoples of Canada
First Nations: refers specifically to Status
Indians (i.e., Registered Indians)
Status Indian: is a person recorded as an
Indian in the Indian Register. Most registered
Indians are members of an Indian band.
Studies referenced throughout this report do
not necessarily use these same definitions.
of Children and Youth
Introduction
Background and Context
Similarly, differences in the time periods reported for some indicators do
not permit readers to consider relative changes over time with any degree
of precision. Many studies of Canada’s native population variously define the
different groups, making comparisons difficult (see sidebar, p. 5). Likewise,
the terms “poverty” and “poor” may be variously defined in the research.
It should be noted that while a wealth of information about the health
of Canadian children is collected and published each year, there are a
number of significant areas in which data are lacking. Several of these gaps
merit particular attention, including the lack of data on the quality of healthcare services and the fact that most health service data are hospital based.
Moreover, information on Aboriginal peoples and other cultural groups
is inconsistent or lacking altogether. Culture and ethnicity are important
determinants of health and the paucity of data makes an assessment of trends
and implications difficult.
The Population Health Approach
The population health approach explores the ways in which health is determined by the interaction of individual characteristics and endowments, the
physical environment, and social and economic factors. As a field of study,
it shifts the focus from individual health to the health of the population as
a whole and to subgroups of the population. Consistent with this shift is a
change of emphasis from individual actions and attributes (such as personal
behaviour and knowledge) to collective, societal factors that affect health and
well-being.
The following passage describes the approach and its focus:
The population health approach focuses on the entire range
of individual and collective factors and conditions, and the
interactions among them, that determine the health and
well-being of Canadians. Strategies are based on an assessment
of the conditions of risk and benefit that may apply across the
entire population or to particular subgroups within the
population (Health Canada, 1996a, p. 3).
An Evolution in Thinking
The population health approach builds on a 20-year legacy of Canadian
advancements in how to best promote and maintain the health of a nation.
Since the early 1970s, Canada has gained international renown for its work
in the area of health promotion. This reputation relates to the development
of a number of important initiatives, including community action programs
for health promotion, health advocacy and healthy public policy.
Healthy Development
6
of Children and Youth
Introduction
Background and Context
The release of the highly acclaimed
Population Health in Action
Lalonde report, A New Perspective on
the Health of Canadians (1974), was a
Health Canada’s Community Action Program
turning point in broadening Canadians’
for Children (CAPC) is an innovative,
understanding of the factors that concommunity-based program that is designed to
tribute to health as well as the role of the
government in promoting the health of
ensure children living in conditions of risk get
the population. The report identified
a healthy start in life.
human biology, environment, lifestyle
One CAPC initiative, the Trinity Conception
and health-care organizations as the four
principal elements affecting health.
Family Resource Program in Newfoundland,
By the mid-1980s, there was growing
offers a range of programs to support children
recognition of the limitations of many
from conception to age 6 and parents. There
health promotion efforts. It was argued
are parenting programs and children’s programs,
that the health and behaviour of people
as well as support groups, discussion groups on
were also determined by conditions such
as income, employment, social status,
budget management and a clothing exchange.
housing and other environmental factors.
The emerging focus on these non-medical
determinants of health, as well as the
release of both Achieving Health for All (1986) (which added social justice and
equity to the mix) and the Ottawa Charter for Health Promotion (1986) began
to shift attention to the societal (population) level — essentially pointing to
factors that were beyond the immediate control of individuals, professionals
and communities.
Both Achieving Health for All: A Framework for Health Promotion and the Ottawa
Charter for Health Promotion provided important frameworks for guiding policy
and program development, not only in Canada but also internationally. They
continue to be relevant today and have served as the basis for key developments
in health policy over the past 15 years.
Specifically, Achieving Health for All set out a plan for putting health
promotion strategies into action and reiterated the need for positive, holistic
perspectives on health. In addition to identifying national health challenges,
the framework presented a set of health promotion mechanisms (self-care,
mutual aid and healthy environments) and a series of implementation
strategies (fostering public participation, strengthening community health
services and coordinating healthy public policy).
Similarly, the Ottawa Charter was an important stage in the progression
towards a more comprehensive view of health. It included a clear working
definition of health promotion action, specifying the need to build healthy
public policy, create supportive environments, strengthen community action,
develop professional skills, and reorient health services.
In the early 1990s, population health researchers began to publish findings
and articulate a model of the determinants of health that provided additional
evidence for many of the fundamental principles and activities initiated by the
health promotion agendas in many government and health policy circles.
Healthy Development
7
of Children and Youth
Introduction
Background and Context
In 1994, the population health approach was officially endorsed by the
Federal/Provincial/Territorial Ministers of Health in the report Strategies for
Population Health: Investing in the Health of Canadians. The report summarized
what is known about the broad determinants of health and articulated a
framework to guide the development of policies and strategies to improve
population health.
The Determinants of Health
The population health approach identifies the broad range of factors that
interact to affect personal health and well-being. “Determinants of health”
is the collective label given to the multiple factors that are now thought
to contribute to the health of populations. An overview of these factors —
including a brief description of their
relevance to health and healthy child
development — is provided below. Each
Population Health in Action
determinant is addressed in greater
depth in the following chapters, in terms
“Healthy kids learn better.” Since it was first
of how it relates to children’s health
initiated in 1993, Calgary’s Comprehensive
directly and how it interacts with other
determinants of health.
School Health Initiative has grown to include
88 area schools. The approach, which partners
the health and education sectors, as well
Income and social status
as schools within the broader community,
Income and social status are the most
addresses a range of health issues such as
important determinants of health. There
is conclusive evidence that people at each
mental/emotional health, nutrition, physical
level of the income scale are healthier and
activity, healthy sexuality, tobacco use and
live longer than those at the level below.
substance abuse prevention, and injury
Moreover, countries in which incomes are
prevention.
more evenly distributed have a healthier
population in terms of life expectancy,
quality of life and mortality rates. Family
income has a direct influence on children’s health outcomes: inadequate
income can negatively affect children’s physical and mental health, cognitive
and social development, and academic achievement.
Employment and work environment
Unemployment, underemployment and stress at work are associated with poor
health. Generally, people who have more control over their work and fewer
stress-related job demands are healthier and live longer than those who are
unemployed or have high-stress jobs. Conversely, employment contributes
to better health for parents and children. Employment status and working
conditions affect parents’ economic opportunities as well as their ability
to carry out family responsibilities and to develop healthy relationships with
their children. Not surprisingly, these factors affect the health of the parents’
offspring.
Healthy Development
8
of Children and Youth
Introduction
Background and Context
Education
Health status improves with level of education. Education affects income
level and job security, and equips people with a sense of control over their
life circumstances — all key influences on health. Many factors contribute
to how long children stay in school and how well they perform in school,
including parents’ education level and involvement in the child’s schooling,
and a child’s overall readiness for school. In addition, the development of
health literacy skills is important in knowing how to access the information
needed to make responsible decisions about using the health-care system, as
well as those about maintaining and improving personal and family health.
Social environment
Living in safe, supportive communities and having the support of families,
friends and neighbours can help to reduce stress and contribute significantly
to positive health outcomes. These primary and secondary supports are
essential for children and can help parents cope with the stress of raising
a family.
Natural and built environments
Physical factors in the natural environment (e.g. air and water quality) can
have a direct impact on health. Factors in the human-built environment
(e.g. housing, community and road design) also influence health, quality
of life and well-being. For example, living in substandard housing may pose
a threat to the safety of children and their families, while the design of
communities (e.g. common space, lighting, density) can influence social
interaction and safety.
Personal health practices
People’s health practices — ranging from the amount of physical activity they
engage in and the kind of food they eat to whether they smoke and practise
safe sex — play a key role in determining health. Environments that support
and enable healthy lifestyle choices can have a positive effect on people’s overall health. Many of the practices that will contribute to health and well-being
in adulthood are established during childhood and adolescence.
Individual capacity and coping skills
Psychological characteristics such as personal competence and sense of
control and mastery over one’s life play an important role in supporting
mental and physical health. They influence people’s susceptibility to such
health problems as cancer and cardiovascular disease, and affect their risk
of mental disorders and suicide. There is strong evidence that coping skills
are acquired primarily in the first few years of life and that resilience to stress
and negative circumstances is profoundly influenced by the experiences of
early childhood.
Healthy Development
9
of Children and Youth
Introduction
Background and Context
Genetic and biological factors
The basic biology and genetic make-up of the human body is a fundamental
determinant of health. Inherited predispositions to a wide range of health
conditions and diseases can affect health status given particular social, physical
and environmental circumstances. Additionally, maternal exposure to a variety
of microbial and chemical compounds during pregnancy can have an impact
on the fetus and thus on the future health of a baby.
Health services and social services
Health services contribute significantly to health, in particular those services
designed to maintain and promote health, to prevent disease and to restore
health and function. For children, young people and their families who are
disadvantaged in some way, social services are also key to ensuring basic needs
and other necessities that serve as a foundation to good health. These services
help to keep children on healthy developmental pathways and to reduce
the risk of negative consequences for young people who are disadvantaged in
some way. Many other community facilities and services such as recreation,
transportation, parks, schools and libraries play key roles in helping families
raise healthy, socially engaged children.
Culture
Some people in society face additional health risks due to marginalization,
stigmatization and lack of access to culturally appropriate services. Culturespecific practices can also have an impact on the overall health of a population.
New immigrant and refugee children, as well as children from other ethnic
groups and Aboriginal children (including First Nations, Inuit and Métis), are
likely to experience unique stresses that can negatively affect their physical and
mental health.
Gender
Gender refers to the array of socially determined roles, personality traits,
attitudes, behaviours and values that society ascribes to being male or female.
Many health issues such as dieting, smoking and sexually transmitted diseases
(STDs) are a function of these gender-based roles, the majority of which are
established in early childhood and adolescence.
Healthy Development
10
of Children and Youth
Introduction
Background and Context
Overview of Children’s Development
Good health does not happen automatically. On the contrary, ongoing positive
investments are needed for an infant to grow and develop into a competent,
participating adult member of society. When such investments are not made
(for whatever reason), many children will carry into adulthood physical and/or
emotional disabilities that could have been prevented.
Children and young people are particularly vulnerable to conditions in
their social and physical environments. As they pass through infancy and early
childhood to the teenage years, they are susceptible to a wide range of positive
and negative influences. To grow and mature into healthy adults, they require
support, care, understanding and nurturing from their family, peers, school
community, and community groups. At each developmental stage, the type
and source of the support children require may vary considerably.
Traditionally, the course of childhood development has been seen as a
progression through a series of predictable stages, each with its own tasks and
accomplishments. Health at later stages and in adult life has been thought to
be partially determined by the events, conditions and successes at preceding
stages. These models have presented development as a ladder-like progression,
assuming similar life experiences for all and implying a single route to
adulthood (Rutter, 1989).
The nature of the tasks within the different stages is given a different
emphasis in different models. Jean Piaget’s model, for instance, emphasizes
the cognitive ability to adapt to the environment; Eric Erikson’s concept
concentrates on personality development through conflict resolution at each
stage; and Robert Havighurst’s framework outlines various developmental
tasks that must be mastered at each stage.
Longitudinal studies are offering support for a less rigidly defined line
of development, shifting the model to one of pathways. While an individual’s
growth — physical, psychological and social — does progress through stages
marked by important life transitions, these transitional events, their meaning,
and their impact seem to be varied, and personal. There may be various routes
and detours in a child’s movement through life and immense individual
variability in important life transitions. Adverse past experiences may be
offset by “recuperative” experiences occurring later in life or by the present
environment and/or circumstances. A single negative event does not necessarily
and inevitably lead to a single effect. Childhood development is less a ladder
of linear steps than a series of pathways with innumerable routes and outcomes.
What is shared and vitally important in all these models is that chain effects
in development are common. The past does affect present health, albeit in
individualized ways. If we are to make a difference in the healthy lives of
children and the adults they become, we must acknowledge the variety of
individual experience and consider them in personal terms; we must see the
complex links in causal chains and how they interconnect; and we must search
for the unifying principles underlying the diversity of pathways from childhood
to adult life.
Healthy Development
11
of Children and Youth
Introduction
Background and Context
The early years
More recent research indicates that the period from pre-conception to age
5 is much more important than previously thought (Guy, 1997, p. 6). It is an
extremely sensitive and critical time in the development of the child, laying
the groundwork physically, mentally and socially for later health, forming
resources that may be drawn on later in life or deficits that must be overcome.
During this “investment phase,” children develop language skills, the ability
to learn, to cope with stress, to have healthy relationships with others, and to
have a sense of self. The effects can be physically based; poor nutrition before
or during pregnancy and during a child’s infancy can seriously interfere
with brain development. The effects can also be socially or emotionally
based; secure attachment to a nurturing adult, positive sensory stimulation,
and positive social interactions are crucial to ensure future well-being
(Federal, Provincial and Territorial Advisory Committee on Population
Health, 1998).
How the Brain Develops
Recent research on the development of the brain has reinforced the belief that the first few years
of life are vitally important to healthy development, and that impacts felt early on may well have
consequences throughout life.
By the time a baby is born, it will have approximately 100 billion brain cells and will have the
ability to learn through the general pathways connecting regions of the brain. If development
goes well, so does the ability to learn.
The baby’s neurons begin to form a dense network of interconnections, with each cell sending
messages out to other brain cells and receiving input from others. With the help of special
chemicals, they travel from cell to cell, creating connections. Repeated activation of these
networks strengthens the connections so that by the time the child reaches age 2 or 3, each
neuron has formed an average of 15,000 connections. This network of connections provides the
child with built-in flexibility, allowing her to respond successfully to stimulae in her environment.
For example, in order to learn language, a child must be physiologically ready for sound
structures and grammar.
Children retain these neural connections until about age 10 or 11, after which time pathways
that have not been repeatedly stimulated will gradually atrophy and die. Various factors — for
example, disease, toxic substances and alcohol — can place a child’s developing brain at risk.
Social experience is also critical to the process of development; the workings of the brain are
profoundly shaped by children’s experiences, in particular, their relationships with family and
peers (Nash, 1997).
Healthy Development
12
of Children and Youth
Introduction
Background and Context
The middle years
In the middle years (to age 12), children experience rapid changes socially,
intellectually, psychologically and emotionally, contributing to their personal
adjustment and social acceptance. It is a time of expanded social relationships
and demands during which they develop values, enhance problem-solving skills,
achieve greater independence, and form a framework of attitudes towards
society and behaviour towards others. Physical changes decelerate while cognitive intellectual development speeds up. During this period, developmental lags
experienced in the early years may be overcome through the mediation of
the family, community and school (Federal, Provincial and Territorial Advisory
Committee on Population Health, 1998, p. 7).
The adolescent years
During adolescence, from age 12 on, the child acquires more abstract cognitive
abilities and develops a social, more gender-based role. Physical changes
accelerate at this time; cognitive development continues through puberty, but
tends to level off afterwards. Peer influence becomes even more important
while the child is shaping an ethical system to guide behaviour in society.
During this stage, family and community become important as the adolescent
prepares for the transition to adult responsibilities and experiences: work,
marriage, and child bearing.
Childhood mediators
As Rutter (1989) points out in “Pathways from Childhood to Adult Life,”
longitudinal research indicates that while events or conditions in childhood
or adolescence may set off a chain reaction of experiences or choices that
affect the well-being of the adult, the outcomes are not always the same. Several
factors appear to “mediate,” strengthening or weakening the link in the
potential chain. For example, the nature of a causal factor alone does not
determine its effect: timing also appears to be important. Neural structure
and functioning may be adversely affected during periods of high neural
development, but not after. Infants and babies may not be affected by separation from their parents, while toddlers will be. Timing may also determine
societal responses to incidents, influencing how they are experienced, as in
the case of teenage pregnancies. As another example, the occurrence of an
event in itself is not enough to assess its outcome — how it is experienced and
its meaning to that individual may determine its impact on the well-being of
the individual. To illustrate, unwanted parenthood at an early age will not be
the same experience as the welcome birth of a child to a young, happily
married couple.
Healthy Development
13
of Children and Youth
Introduction
Background and Context
A dynamic process
The influences in the life of a child or young adult that contribute to their
health and future well-being are rich and complex. Their biological conditions
(genetically or non-genetically determined), their physical, social and economic
environment, the cognitive and social skills they develop, their sense of
self and self-esteem, and their habits and coping styles are only a few of the
interconnected forces working in their development. The route along the
pathway from childhood to adulthood is a dynamic one, characterized by a
“continuing interplay over time between intrinsic and extrinsic influences
on individual development” (Rutter, 1989, p. 24).
About Canada’s Children
Canadian children and youth are a diverse group that make up almost one
third of the population. They come from varied ethnic, religious and linguistic
backgrounds; they live in a variety of family structures in both urban and
rural settings; and they grow up in families with disparate levels of social and
economic resources. For the purposes of this report, and in keeping with the
United Nations Convention on the Rights of the Child, a child is defined as
a person who is 18 years old and under.
This section presents a broad overview of Canada’s children. It establishes
a general context for the more specific discussion in the remaining chapters
of key variables that influence children’s health, and provides the reader with
basic information about who Canada’s children are and how they live. More
detail on many of the points below is included in the following chapters of
this report.
How Many Are There?
• In 1997, there were slightly more than 8 million children aged 0 (newborn)
to 19 years in Canada — 51.2% of these were boys and 48.8%, girls. Children
in this age group made up 26.5% of the Canadian population (Statistics
Canada, 1998a). The number of children has declined steadily since 1961
(Ross, Scott and Kelly, 1996, p. 17). See Exhibit 1.
1
Population of children and youth, by sex and age, Canada, 1997
Both sexes
Male
Number
Female
Both sexes
Male
% of total population
Female
30,286,596
14,999,677
15,286,919
26.5
27.4
25.6
0–4
1,915,801
981,837
933,964
6.33
6.55
6.11
5–9
2,049,449
1,049,529
999,920
6.77
7.00
6.54
10–14
2,027,130
1,035,369
991,761
6.69
6.90
6.49
15–19
2,024,088
1,037,276
986,812
6.68
6.92
6.46
All ages
Source: Adapted from the Statistics Canada Web site: www.statcan.ca
Healthy Development
14
of Children and Youth
Introduction
Background and Context
• In 1996, there were 280,415 Aboriginal children under the age of 15 living
in Canada; they accounted for 35% of all Aboriginal people identified in
the census that year (Statistics Canada, 1998b).
• Canada’s natural growth rate accounted for 47% of the population’s growth
in 1996, while immigration accounted for the remaining 53%. The natural
growth rate declined substantially between 1990 and 1995, from 7.7 to 5.7
per 1,000 population (Statistics Canada, 1998c).
Where Do They Live?
2
• The proportion of children aged 0 to 14
years in terms of total population varies
by province/territory, ranging from a
low of 19% in Quebec to a high of 32%
in the Northwest Territories (Statistics
Canada, 1998a). See Exhibit 2.
Children aged 0–14 years as a proportion of
the total population, by province/territory,
1997
%
Canada
19.8
British Columbia
19.2
Alberta
22.1
Saskatchewan
22.5
Manitoba
• The majority of the Canadian
population lives in urban settings.
However, this proportion varies
considerably across the country.
For example, in 1996, more than
half of all residents of the Northwest
Territories, Prince Edward Island and
New Brunswick lived in rural settings,
while the same could be said of only
17% and 18% of residents in Ontario
and British Columbia, respectively
(Statistics Canada, 1997a, p. 183).
See Exhibit 3.
21.5
Ontario
19.9
Quebec
18.5
New Brunswick
18.9
Prince Edward Island
20.9
Nova Scotia
19.1
Newfoundland
18.9
Yukon
22.7
Northwest Territories
32.3
Source: Adapted from the Statistics Canada Web site: www.statcan.ca
• In 1996, 6 out of 10 Registered Indians
lived on reserve, a drop from 7 out of
10 in 1982, and this trend is expected
to continue. See Exhibit 4. Overall, the
Registered Indian population is expected
to increase at a rate of 2.1% per year over
the next five years — compared with
a growth rate of 1.2% for the general
Canadian population over the same
period (DIAND, 1998, pp. 4–5).
3
Proportion of population living in urban and
rural areas, by province/territory, 1996
Province/Territory
Canada
British Columbia
Alberta
Saskatchewan
Manitoba
Ontario
Quebec
New Brunswick
Prince Edward Island
Nova Scotia
Newfoundland
Yukon
Northwest Territories
Urban (%)
Rural (%)
77.9
82.1
79.5
63.3
71.8
83.3
78.4
48.8
44.2
54.8
56.9
60.0
42.5
22.1
17.9
20.5
36.7
28.2
16.7
21.6
51.2
55.8
45.2
43.1
40.0
57.5
Source: Adapted from Statistics Canada (1997). A National
Overview: Population and Dwelling Counts. Catalogue No. 93-357XPB. Ottawa: Statistics Canada.
Healthy Development
15
of Children and Youth
Introduction
4
Background and Context
Current and projected registered Indian population growth on and off reserve,
Canada, 1982–2006
Thousands
On reserve
Off reserve
Total on and off reserve
800
600
400
200
0
1982
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
2001
2006
Year
Source: Department of Indian Affairs and Northern Development (1998). Basic Departmental Data
1997. QS3575-000-BB-A1, Catalogue No. R12-7/1997. Ottawa: DIAND, p. 4.
What Do Families Look Like?
• In 1996, the average family size in husband-wife families was 3.0 persons;
in lone-parent families, 2.5 persons (Statistics Canada, 1998a).
• In 1996, 73 of every 100 children lived in married-couple families, down
from 78 children of 100 in 1991 (Statistics Canada, 1997b). See Exhibit 5.
• The proportion of children living in common-law families is on the rise.
As of 1996, 8 out of 100 children lived in common-law families, a 52%
increase over 1991 (Statistics Canada, 1997b). See Exhibit 5.
• Almost one in every five children in Canada lived with a lone parent in 1996,
compared with one in six children in 1991; 84% of these children lived with
a female lone parent (Statistics Canada, 1997b).
5
Proportion of children living in selected family
structures, Canada, 1996
Married couple
73.3%
Female lone-parent
15.9%
Common-law
7.9%
Male lone-parent
3%
Note: Numbers do not total 100% due to rounding
Source: Adapted from Statistics Canada (1997). The Daily,
Catalogue No. 11-001, October 14, 1997.
Healthy Development
16
of Children and Youth
Introduction
Background and Context
How Many Children Live in Poverty?
• In 1996, 20.9% of children under 18 years of age lived below Statistics
Canada’s low income cut-off (LICO) compared with 14.9% in 1980 (National
Council of Welfare, 1998, p. 12).
• In 1994–95, more than one quarter (25.7%) of children in Canada lived
in households with incomes of less than $30,000 per year; 41.6% were in
households with total incomes ranging from $30,000 to $60,000 per year;
and almost one third (32.8%) lived in higher-income households, those with
annual earnings of more than $60,000. (Ross, Scott and Kelly, 1996, p. 33).
• While an accurate poverty rate for Aboriginal children is not available, some
authorities consider that many Aboriginal children in Canada experience
living conditions similar to those in Third World countries (CICH, 1994,
p. 140).
How Healthy Are They?
• Almost 10% of children included in the 1996 National Longitudinal Survey
of Children and Youth (NLSCY) were born prematurely (i.e. before 259
days’ gestation) (Ross, Scott and Kelly, 1996, p. 19).
• In 1996, 5.8% of babies were considered to be of low birthweight (below
2,500 grams), declining slightly from 5.9% the previous year (Statistics
Canada, 1998d).
• In 1998, life expectancy at birth was 81 years for women and 75 years for
men for the general Canadian population (Health Canada, 1998). The most
recent figures available (1995) for the First Nations population show life
expectancy to be 76.2 years for women and 69.1 for men (Health Canada,
1996b).
• In 1996, the infant mortality rate was 5.6 deaths per 1,000 live births,
declining from 6.1 per 1,000 live births in 1995 (Statistics Canada, 1998d).
The most recent data available for First Nations indicate a higher and
increasing infant mortality rate — 12 deaths per 1,000 live births in 1994,
up from 10.9 per 1,000 in 1993 (Health Canada, 1996b).
Healthy Development
17
of Children and Youth
Introduction
Background and Context
References
Canadian Institute of Child Health (1994). The Health of Canada’s Children: A CICH Profile,
2nd edition. Ottawa: Canadian Institute of Child Health.
Department of Indian Affairs and Northern Development (1998). Basic Departmental Data
1997. QS-3575-000-BB-A1, Catalogue No. R12-7/1997. Ottawa: Department of Indian
Affairs and Northern Development.
Erikson, E.H. (1963). Childhood and Society, 2nd edition, New York: W.W. Norton. Cited
in M. Rutter (1989). “Pathways from Childhood to Adult Life.” Journal of Child Psychology,
Psychiatry and Allied Disciplines, Vol. 30: 23–51.
Federal, Provincial and Territorial Advisory Committee on Population Health (1998). Building
a National Strategy for Healthy Child Development. Catalogue No. H39-424/1998E. Ottawa:
Health Canada.
Guy, K.A., ed. (1997). Our Promise to Children. Ottawa: Canadian Institute of Child Health.
Health Canada (1996a). Towards a Common Understanding: Clarifying the Core Concepts of Population
Health — A Discussion Paper. Catalogue No. H39-391/1996E. Ottawa: Health Canada.
Health Canada (1996b). Indian Health Information Library, electronic database. Ottawa:
Medical Services Branch, Health Canada.
Health Canada (1998). Health Canada Web site: http://www.hc-sc.gc.ca
Nash, J.M. (1997). “Fertile Minds.” Time, Vol. 149(5) (February 1997): 45–54.
National Council of Welfare (1998). Poverty Profile 1996. Ottawa: National Council of Welfare.
Ross, D.P., K. Scott and M.A. Kelly (1996). “Overview: Children in Canada in the 1990s.” In
Growing Up in Canada: National Longitudinal Survey of Children and Youth. Catalogue No. 89550-MPE, No. 1. Ottawa: Human Resources Development Canada and Statistics Canada,
pp. 15–45.
Rutter, M. (1989). “Pathways from Childhood to Adult Life.” Journal of Child Psychology, Psychiatry
and Allied Disciplines, Vol. 30: 23-51.
Statistics Canada (1997a). A National Overview: Population and Dwelling Counts. Catalogue No.
93-357-XPB. Ottawa: Statistics Canada.
Statistics Canada (1997b). The Daily, October 14, 1997.
Statistics Canada (1998a). Statistics Canada Web site: http://www.statcan.ca
Statistics Canada (1998b). The Daily, January 13, 1998.
Statistics Canada (1998c). The Daily, June 24, 1998.
Statistics Canada (1998c). The Daily, July 8, 1998.
Healthy Development
18
of Children and Youth
Part
B
A Closer Look
at the
Determinants
Part B examines the determinants of health in turn, and for each one addresses
its relationship to healthy child development, and current conditions and trends
relevant to that determinant.
C h a p t e r
1
Income and Social Status
Overview
Higher socio-economic status is associated with better health — in fact,
income and social status seem to be the most important determinants of
health. People at each level of the income scale are healthier and live
longer than those at the level below. Countries in which incomes are
more evenly distributed have a healthier population in terms of life
expectancy, quality of life and mortality rates.
In addition to enabling people to cover basic needs, a higher income
provides people with more choices and a feeling of greater control over
decisions. This feeling of control is basic to good health.
Family income influences children’s outcomes — children are dependent
on their parents or guardians for food, shelter, clothing and recreational
and social activities. For children, inadequate income can be harmful.
Physical and mental health, cognitive and social development, and
academic achievement can all be negatively affected by low income.
While average family income has been relatively stable through the 1990s,
lower income families experienced decreases in income, while upper
income families experienced increases. In particular, lone-parent families
headed by women have persistently experienced low incomes.
Most children in Canada have access to adequate food and live in adequate
housing. However, in 1995, close to 1 million children received food from
a food bank.
While the causal relationship between income and health status is not clearly
understood yet, it is widely accepted that raising family incomes is critical
to raising child health outcomes.
Healthy Development
21
of Children and Youth
Income and Social Status
A Closer Look at the Determinants
Relationship to Healthy Child Development
Income affects all aspects of child health.
Socio-economic status does not only determine how children do during the
preschool years, but it also appears to set the stage for health and well-being
throughout life (Bertrand, 1998, p. 6).
A child’s socio-economic status — determined by parents’ income,
occupation and education level (the latter two are the focus of other chapters
in this report) — strongly influences development. For example, both infant
mortality and low birthweight rates improve with each income level (CICH,
1994, p. 123).
Poverty is strongly correlated with increased risks of illness. The detrimental
impacts of poverty on children are clear and show up across a wide range of
child outcomes. Poor children face a greater risk of death, hospitalization and
disability. They are more likely to have mental health disorders (CICH, 1994,
p. 113), and to die as a result of injuries than their wealthier counterparts
(Wilkins, Adams and Brancker, 1994, as cited in CICH, 1994, p. 122).
Conditions and Trends
The relationship of socio-economic status and health has been the focus of
extensive research in Canada and other countries. In this section, three key
issues are examined: family income, child and family poverty, and food and
housing security.
Family Income
The average Canadian family needs 77 weeks’
worth of work to cover basic annual expenses
— meaning that most families must have two
wage-earners (Vanier Institute of the Family,
1998, p. 25).
Average family income has been relatively
stable in the 1990s; the 1996 figure of $56,629
is up $1,500 from 1993. However, despite little
change in average income overall, between 1995
and 1996, average family income for families
with the lowest income declined 3%. Conversely,
average family income for those with the highest
income increased almost 2%. The longer term
picture shows that average family income has
decreased $2,300 (3.9%) since 1989 (Statistics
Canada, 1997a). See Exhibit 1.1.
Healthy Development
22
Low Income
Estimates of the number of families with
low income are derived using Statistics
Canada’s low income cut-offs, or LICOs
(1992 base). These cut-offs were selected
on the basis that families with incomes
below these limits usually spend more than
55% of their income on food, shelter and
clothing, and so they may be considered to
live in straitened circumstances. Although
the cut-offs are commonly referred to as
“poverty lines,” Statistics Canada does not
endorse them for this purpose.
of Children and Youth
Income and Social Status
A Closer Look at the Determinants
1.1 Average family income, Canada, 1978 to 1996
Total income
Income before transfers
60,000
$58,910
58,000
$56,629
$55,901
56,000
$55,154
54,000
52,000
$53,080
$52,931
$51,500
$49,988
50,000
48,000
$48,054
$47,325
46,000
1978
1980
1982
1984
1986
1988
1990
1992
1994
1996
Source: Adapted from Statistics Canada (1997). The Daily, Catalogue No. 11-001, December 22, 1997.
Generally speaking, changes in family income can be attributed to labour
market conditions, as almost 80% of total family income comes from employment. Canada’s Labour Force Survey indicates that employment grew 1.3%
in 1996, contrasting with the more robust growth of 2.1% in 1994, the most
recent year of significant improvement in income (Statistics Canada, 1997a).
Government transfers are declining.
In 1996, government transfers declined, particularly
Employment Insurance and social assistance payments (Statistics Canada, 1997a). Government
transfers are an important source of income (Vanier
Institute of the Family, 1998, p. 47). This made 1996
the third straight year that the proportion of family
income from transfers decreased; in 1996, transfers
accounted for 11.7% of total income, down from the
peak of 12.9% in 1993. For the 20% of Canadians with
the lowest income, 59% of their 1996 income was in the
form of government transfers (Statistics Canada, 1997a).
Cost of Raising a Child
Manitoba Agriculture provides annual
pricing of the basic costs related to
raising a child. For 1998, the total
estimated cost of raising a child to
age 18 was $159,376 (Manitoba
Agriculture, 1998, as cited in CCSD,
1998, p. 19). See Exhibit 1.2.
Child and Family Poverty
Child poverty rates (using low income cut-off, or LICO, as the measure of
poverty) are a reflection of parental poverty rates and tend to rise and fall
as economic conditions deteriorate or improve. Low-income families live on
incomes substantially below the average. In 1991, the average income of lowincome couples with children under 18 years was $18,800 — just 32% of the
$58,761 average income for all couples with children under 18 years. This
proportion was relatively unchanged five years later. In 1996, the average
income of low-income couples with children was $19,915 — more than 30% of
the $63,981 average income for all couples with children (Statistics Canada, 1998a).
Healthy Development
23
of Children and Youth
Income and Social Status
A Closer Look at the Determinants
The depth of poverty for working age one-parent families has
declined. In 1980, the average gap
between “poverty line” income and
“average” income of poor, working
age lone parents was $10,284,
declining to $9,604 by 1996. For
working age two-parent families, the
gap increased slightly from $8,474
to $8,866 (National Council of
Welfare, 1998, p. 53). The benefits
of the decreasing risk of poverty for
children has been more than offset
by the growth in the proportion of
children under age 7 in lone-parent
families. In 1975, 8.7% of children
lived in lone-parent families; by
1992, nearly 1 million children
(14.7%) lived in lone-parent
families (HRDC, 1996, p. 2).
1.2 Estimated cost of raising a child to age 18, by type
of expenditure, Canada, 1998
Transportation
$2,897
(2%)
Personal care
$2,662
(2%)
Health care
$5,144
(3%)
Recreation, reading,
gifts, school
$13,433
(8%)
Child care
$52,029
(33%)
Clothing
$15,933
(10%)
Shelter,
furnishings,
household needs
$36,998
(23%)
TOTAL $159,376
Food
$30,281
(19%)
Note: These numbers are in current 1998 dollars.
Source: Prepared by the Canadian Council on Social Development using
data from Manitoba Agriculture’s Family Finance: The Cost of Raising a
Child: 1998. In Canadian Council on Social Development (1998). The
Progress of Canada’s Children — 1998. Ottawa: CCSD, p. 19.
“Deep” poverty rates are high.
However, during this same period (between 1975 and 1992), there was virtually
no improvement in deep poverty rates for children under age 18. (The “deep”
poverty line is defined here as 75% of the 1986 LICOs). In fact, during that
time, deep poverty rates for young children (under age 7) increased 1.6%. The
incidence of deep poverty among children in lone-parent families declined
significantly during the 18-year period (from 51.3% to 41.6%); however, the
incidence is still very high (Zyblock, 1996, pp. 9–10).
Of Canadians who identify with an Aboriginal (First Nations, Inuit and
Métis) group, 54% reported income of less than $10,000 in 1991, compared
with 35% of all Canadian adults (Statistics Canada, 1993, p. xiv).
Government transfers appear to have played a major role in reducing the
poverty gaps (i.e. between average income and poverty line) for all families
— most strikingly for lone-parent families
(Zyblock, 1996, p. 14). See Exhibit 1.3.
1.3 Proportion of income from government transfers
The overall decline in government
for poor families, by family type, Canada,
transfer payments is of particular
1975 and 1992
significance for lower income families
1975
1992
Family type
since more than half of their income
59.7
71.3
Lone parent, children < 18
(59% in 1996) comes from this source.
Overall, average family income for this
63.3
78.9
Lone parent, children < 7
group declined 3% in 1996, the result
26.7
42.9
Two parent, children < 18
of both lower earnings and lower transfer
24.6
47.7
Two parent, children < 7
payments. Female lone-parent families
account for one in four families in this
Source: M. Zyblock (1996). Child Poverty Trends in Canada: Exploring
group (Statistics Canada, 1997a).
Depth and Incidence from a Total Money Income Perspective, 1975 to
1992. Catalogue No. W-96-1E. Ottawa: Human Resources Development Canada, Applied Research Branch, p. 14. Reproduced with the
permission of the Minister of Human Resources Development
Canada, 1999.
Healthy Development
24
of Children and Youth
Income and Social Status
A Closer Look at the Determinants
Number of poor children on the rise.
In fact, the number of poor children is increasing — it grew from 1.1 million
in 1990 to 1.5 million in 1996 (National Council of Welfare, 1998, p. 12). This
means that the proportion of children living in low-income families was 21.1%
in 1996, little changed from 21.0% in 1995, but substantially above the low of
15.3% in 1989. The 1996 estimate was 47% more than in 1989. See Exhibit 1.4.
During the same period, the total number of children increased 7% (Statistics
Canada, 1997a).
“Young” families are
hit hard.
Between 1986 and 1996, the
incidence of low income among
“young” families (i.e. those headed
by a person aged 25 to 34 years)
increased from 16% to 21.2%.
During the same period, the
incidence of low income among
“older” families (i.e. those headed
by a person over the age of 34
years) increased at a much
slower rate and remained
substantially lower (Statistics
Canada, 1997b, pp. 182–183).
1.4 Proportion of children in low-income families,a Canada,
1978 to 1996
%
35
30
25
Children under 18 years of age
20
15
Total persons
10
0
1980
1982
1984
1986
1988
1990
1992
1994
1996
a. Living under Statistics Canada’s low income cut-offs (LICOs).
Source: Adapted from Statistics Canada (1997). The Daily, Catalogue
No. 11-001, December 22, 1997.
Many female-headed lone-parent families experience
long-term poverty.
In 1994–95, one-quarter (24.6%) of children in Canada aged 0 to 11 years
lived in households considered poor (Ross, Scott and Kelly, 1996a, p. 33).
Younger children (ages 0 to 11) living in lone-parent families were much more
likely to be poor than children living in two-parent families (68% compared
with 16.5%). See Exhibit 1.5. Very
young children are more likely to
live in poverty than older children —
Children with Lone Female Parents
in 1994–95, infants (under 2 years)
The majority of low-income children (56% in 1995)
were 20% more likely to be poor than
11-year-olds (Ross, Scott and Kelly,
are in two-parent families, yet the risk of low income
1996a, p. 34).
is much higher for children of single mothers (CCSD,
More than two-thirds (69.5%) of
1996, p. 21). In 1996, 60.8% of female lone-parent
families headed by female lone parents
families had low incomes, compared with 11.8% for
in 1982, and who remained lone
parents from 1982 until 1987, had
two-parent families (Statistics Canada, 1997a).
market incomes below the LICOs in
every year during that time span.
Persistent low market incomes were
also experienced by 11.7% of two-parent families (whose structure stayed the
same) with dependent children. Between 1988 and 1993, these percentages
dropped to 66.9% for female lone parents and to 11.5% for couples with
children (Finnie, 1997, p. 42). See Exhibit 1.6.
Healthy Development
25
of Children and Youth
Income and Social Status
A Closer Look at the Determinants
Many Aboriginal families are poor.
1.5 Distribution of poora children aged 0 to 11
In 1995, among Aboriginal children aged
6 to 14, the incidence of low income was 48%,
more than double the national rate of 22%
(Statistics Canada, 1998b).
In 1995, average employment income of
Aboriginal people ($17,382) was 34% below
the national average of $26,474. One out of
every four Aboriginal earners lived on a
reserve. Aboriginal people who lived on a
reserve reported average employment income
of $14,055, which was 24% below the $18,463
reported by those who lived off reserve
(Statistics Canada, 1998b).
Among urban Aboriginal families headed
by lone females, between 40% and 76%
(depending on the city) lived below the poverty
line in 1991. Rates were as high as 90% in some
western cities — Winnipeg, Regina and Saskatoon
(Clatworthy, 1994, as cited in Frankel, 1997, p. 6).
by family type, Canada, 1994–95
Family type
Poora
(%)
Non-poor
(%)
Two-parent family
16.5
83.5
Single-parent family
68.0
32.0
Female single parent
70.9
29.1
Male single parent
30.7b
69.3
a. Poverty is measured using Statistics Canada’s low income cut-offs (LICO).
b. Estimate less reliable due to high sampling variability.
Source: Adapted from D.P. Ross, K. Scott and M.A. Kelly
(1996). “Overview: Children in Canada in the 1990s.” In
Growing Up in Canada: National Longitudinal Survey of
Children and Youth. Catalogue No. 89-550-MPE, No. 1.
Ottawa: Human Resources Development Canada and
Statistics Canada, p. 34.
1.6 Proportion of families that experienced low market income,a by selected number of years
of low income, Canada, 1982 to 1993
Number of years of low market
income 1982–1987
Number of years of low market
income 1988–1993
0
1–5
6
0
1–5
6
Couples with children
55.9
32.5
11.7
58.9
29.4
11.5
Female lone parent
11.4
19.0
69.5
13.4
19.7
66.9
Male lone parent
37.2
33.3
29.4
33.1
32.5
34.4
Family type
a. Market income refers to income before government transfer payments.
Source: R. Finnie (1997). “Earnings Dynamics in Canada: A Dynamic Analysis of Low Market Incomes (Market
Poverty) of Families With Children, 1982-1993.” Applied Research Bulletin, Vol. 4, No. 1. Catalogue No. W-97-3E.d.
Ottawa: Human Resources Development Canada, Applied Research Branch, p. 30. Reproduced with the permission
of the Minister of Human Resources Development Canada, 1999.
Social Assistance
In 1994–95, 85.4% of children under age 12 lived in households whose principal source of income
was wages and salaries or self-employment earnings. Ten percent of children under age 12 lived in a
household whose main source of income was social assistance (Ross, Scott and Kelly, 1996a, p. 35).
See Exhibit 1.7. In 1996, almost half (46%) of poor, lone-parent mothers under age 65 reported
income from paid employment (National Council of Welfare, 1998, p. 67). However, lone-parent
families derived 31.9% of their income from government transfers in 1994 (Statistics Canada, 1996).
In 1995–96, 43% of registered Indians living on reserve — including those with children —
received social assistance (DIAND, 1998).
Healthy Development
26
of Children and Youth
Income and Social Status
A Closer Look at the Determinants
Food and Housing Security
Elements of food and housing security are closely related to income. In broad
terms, households spent 17 cents of every dollar in their 1996 budgets on
shelter, and 12 cents on food (Statistics Canada, 1998c). Expenditures on
both food and housing as a percentage of total expenditures are significantly
higher for low-income families than for high-income families.
Food costs are stable.
Expenditure on food remained
relatively stable between 1992 and
xpenditure on food
1996, with the average household
spending $112.09 a week on food
remained relatively stable
purchased in grocery stores or
between 1992 and 1996, with
restaurants in 1996 — an increase
of $1.65 from 1992 (Statistics
the average household spendCanada, 1998d).
ing $112.09 a week on food
In 1996, households in the lowest
income quintile spent 32% of their
purchased in grocery stores
budgets on shelter and 19% on food, while
or restaurants in 1996 — an
households in the highest income quintile spent 13% and 10%,
respectively. In dollar terms, households with the lowest incomes
increase of $1.65 from 1992
reported spending an average of $5,200 on shelter, compared with
(Statistics Canada, 1998d).
$12,800 for households with the largest incomes (Statistics Canada,
1998c).
In 1996–97, 6.4% of Canadian households, including families with children,
1.7 Distribution of children aged 0 to 11, by main
reported running out of money to buy
source of household income, Canada, 1994–95
food on at least one occasion in the
previous 12 months (Health Canada,
Main source of household income
% of
children
1998). In 1995, some 900,000 children
received food from one of approximately
Wages and salaries
74.6
460 food banks across the country
Self-employment
10.8
(Canadian Dietetic Association, 1996,
Social assistance
10.1
Unemployment insurance
1.5
p. 4).
a
Miscellaneous
1.0
There is a high level of food
Child tax benefit
0.9
insecurity in northern communities
Pensionsb
0.4
(primarily Inuit) due to the very high
Worker’s compensation
0.3c
cost of food and inconsistent supply
Child support
0.3c
of good quality, nutritious foods (Lawn
Dividends and interest
†
and Langner, 1994).
Alimony
†
E
Total
100.0
a. Includes other government assistance, rental income, scholarships, etc.
b. Includes Canadian and Quebec Pension Plans, Old Age Security and Guaranteed
Income Supplement, retirement pensions, supperannuation and annuities.
c. Estimate less reliable due to high sampling variability.
† Estimate too unreliable to publish.
Source: Adapted from D.P. Ross, K. Scott and M.A. Kelly (1996).
“Overview: Children in Canada in the 1990s.” In Growing Up in
Canada: National Longitudinal Survey of Children and Youth.
Catalogue No. 89-550-MPE, No. 1. Ottawa: Human Resources
Development Canada and Statistics Canada, p. 35.
Healthy Development
27
of Children and Youth
Income and Social Status
A Closer Look at the Determinants
Housing is not secure for all.
Food Security
Most Canadian families live in housing
Most simply defined, food security is the absence
that meets or exceeds all of today’s
standards for suitability (including
of hunger and malnutrition. Food security exists
number of bedrooms), adequacy (e.g.
when all people, at all times, have physical and
plumbing facilities) and affordability (costs
economic access to sufficient, safe and nutritious
less than 30% of the household’s income).
food to meet their dietary needs and food
In 1991, 68% of family households met
preferences for an active and healthy lifestyle
these national standards. Of the 32% of
families whose housing was substandard,
(Agriculture and Agri-food Canada, 1998, p. 5).
more than one half (54%) spent at least
30% of their income on housing. Research
conducted by Canada Mortgage and
Housing Corporation and Statistics Canada shows that low income is a major
contributing factor behind substandard housing for Canadians (CMHC, 1993).
That year, one in 10 households — which included 548,000 children
under age 16 — were unable to obtain housing that met or exceeded housing
standards. These families are defined as being in “core housing need.” We
also know that in 1991:
• Lone-parent households were 11 times more susceptible to core housing
need than two-parent households (CMHC, 1993, p. 2). Sixty-two percent
of Aboriginal lone-parent families (CMHC, 1997a, p. 1) and 40% of Inuit
lone-parent families are in core housing need (CMHC, 1997b, p. 1).
• Families that rent housing are six times more likely to have core housing
need than families that own their housing (CMHC, 1993, p. 2).
• One out of every two lone-parent families that rent experienced core
housing need (CMHC, 1993, p. 2).
• Household income for families with core housing need was only a quarter
of the income of families not in need (CMHC, 1993, p. 3).
Aboriginal housing is improving.
On-reserve Aboriginal families do not fare as well. In 1996–97, 48% of onreserve dwellings required renovations or replacement (DIAND, 1998, p. 47).
Crowded living conditions are more frequent for on-reserve Aboriginal families
as well; in 1991, 21% of on-reserve dwellings housed more than one person
per room compared with only 1% of dwellings for the general population
(DIAND, 1997). Crowding is particularly problematic for Canada’s Inuit people;
in 1991, 26% of Inuit households were in core housing need and were
crowded (CMHC, 1997b).
Housing conditions for Aboriginal people are improving, with fewer
on-reserve dwellings without water delivery systems (3.9% in 1996–97, down
from 17.7% in 1987–88), and fewer dwellings without sewage disposal systems
(8.5% in 1995–96, down from 27.8% in 1987–88) (DIAND, 1998, p. 48).
Urban-dwelling Native households are much more likely to live in belowstandard housing (26.9% in 1991) than non-Native urban-dwellers (17.1% in
1991) (CMHC, 1995).
Healthy Development
28
of Children and Youth
Income and Social Status
A Closer Look at the Determinants
Income and Social Status and Other Determinants
Education
Literacy is a determinant of income. Close to 50% of adults at the lowest
level of literacy live in households with low income, compared with only 8%
of those at the highest level of literacy. Over half (55%) of those at the lowest
scale of literacy were unemployed in 1994 and, if they did work, they earned
less than $15,000 (Shalla and Schellenberg, 1998, p. 14).
People with fewer than nine years
of education are more likely to have
unrewarding, low-paying jobs. MoreIncome Plays a Pervasive Role
over, growing up in persistent or
Children in low-income families have poorer health,
concentrated poverty is related to
school failure, truancy, dropping out
lower levels of educational attainment, live in
of school, behaviour problems and
riskier environments (e.g. no household smoke
delinquency (Evans, 1995, pp. 19, 24).
detector, poor housing conditions), and partake
Income also affects school readiness
in riskier behaviours (e.g. smoking, alcohol use,
and academic performance — children
disregard for contraceptives). Compared with
who live in poverty are more likely to
non-poor teens, twice as many poor teens aged
experience lower levels of educational
16 and 17 drop out before they complete high
attainment (CCSD, 1997, p. 20).
school (Ross, Scott and Kelly, 1996b, pp. 8, 13).
Social Environment
Poverty is strongly associated with family or neighborhood violence and
aggressive behaviour patterns. As well, child abuse and neglect can be
attributed to a number of factors including “inadequate monetary support,
unemployment or underemployment and a lack of social services” (Advisory
Committee on Children’s Services, 1990, p. 22).
Personal Health Practices
Children and youth living in the poorest neighbourhoods of urban Canada
are more likely than those in richer neighbourhoods to die as a result of
injuries (Wilkins, Adams and Brancker, as cited in CICH, 1994, p. 122). High
rates of teen pregnancy are also associated with low income — rates are almost
five times higher in the lowest income neighbourhoods than in the highest
income neighbourhoods (Health Canada, 1999, p. 4).
Individual Capacity and Coping Skills
There is growing evidence that competence and resiliency are undermined by
the combined effects of multiple environmental stresses and the psychological
deprivations that often co-exist with poverty (e.g. maternal depression, parental
substance abuse and violence, and paternal criminality, rather than just low
income (Steinhauer, 1998).
Healthy Development
29
of Children and Youth
Income and Social Status
A Closer Look at the Determinants
References
Advisory Committee on Children’s Services (1990). Children First. Toronto: Ontario Ministry
of Community and Social Services.
Agriculture and Agri-food Canada (1998). Canada’s Action Plan for Food Security. Ottawa:
Agriculture and Agri-food Canada.
Bertrand, J. (1998). “Enriching the Preschool Experiences of Children.” In Canada Health Action:
Building on the Legacy — Volume 1, Children and Youth. Ottawa: National Forum on Health,
Health Canada, pp. 3–46.
Canada Mortgage and Housing Corporation (1993). Research and Development Highlights. Issue 12.
Canada Mortgage and Housing Corporation (1995). Research and Development Highlights. Issue 21.
Canada Mortgage and Housing Corporation (1997a). Research and Development Highlights. Issue 34.
Canada Mortgage and Housing Corporation (1997b). Research and Development Highlights. Issue 35.
Canadian Council on Social Development (1996). The Progress of Canada’s Children — 1996.
Ottawa: Canadian Council on Social Development.
Canadian Council on Social Development (1997). The Progress of Canada’s Children — 1997.
Ottawa: Canadian Council on Social Development.
Canadian Dietetic Association, Joint Steering Committee Responsible for Development of
a National Nutrition Plan for Canada (1996). Nutrition for Health: An Agenda for Action.
Toronto: Canadian Dietetic Association.
Canadian Institute of Child Health (1994). The Health of Canada’s Children: A CICH Profile, 2nd
edition. Ottawa: Canadian Institute of Child Health.
Clatworthy, S. (1994). Migration and Mobility of Canada’s Aboriginal Population (Research report
prepared for Royal Commission on Aboriginal Peoples). Cited in S. Frankel (1997). “The
Well-Being and Social Conditions of Aboriginal Children and Youth: An Assessment of
Current Knowledge and A Proposal for Knowledge Development.” Winnipeg: Child and
Family Services Research Group, Faculty of Social Work, University of Manitoba.
Department of Indian Affairs and Northern Development (1997). Customized 1991 Census
Tabulation. Unpublished raw data prepared for Indian and Northern Affairs Canada by
the Census Operations Division, Statistics Canada.
Department of Indian Affairs and Northern Development (1998). Basic Departmental Data 1997.
QS-3575-000-BB-A1, Catalogue No. R12-7/1997. Ottawa: DIAND.
Evans, P. (1995). Children and Youth at Risk. In Organisation for Economic Cooperation and
Development (1995). “Our Children at Risk.” Paris: Organisation for Economic
Cooperation and Development, pp. 13–50.
Finnie, R. (1997). Earnings Dynamics in Canada: A Dynamic Analysis of Low Market Incomes
(Market Poverty) of Families With Children, 1982–1993. Catalogue No. W-97-3E.a. Ottawa:
Human Resources Development Canada.
Health Canada (1998). National Population Health Survey (NPHS), 1996–97. Unpublished data.
Health Canada (1999). A Report from Consultations on a Framework for Sexual and Reproductive
Health. Ottawa: Health Canada.
Human Resources Development Canada (1996). Applied Research Bulletin, Vol. 2, No. 2
(Summer/Fall 1996).
Lawn, J., and N. Langner (1994). Air Stage Monitoring Program: Final Report — Volume 2: Food
Consumption Survey. Ottawa: Department of Indian Affairs and Northern Development.
Healthy Development
30
of Children and Youth
Income and Social Status
A Closer Look at the Determinants
Manitoba Agriculture Ministry (1998). Family Finance: The Cost of Raising a Child: 1998. Cited in
Canadian Council on Social Development (1998). The Progress of Canada’s Children — 1998.
Ottawa: Canadian Council on Social Development.
National Council of Welfare (1998). Poverty Profile, 1996. National Council of Welfare.
Ross, D.P., K. Scott and M.A. Kelly (1996a). “Overview: Children in Canada in the 1990s.”
In Growing Up in Canada: National Longitudinal Survey of Children and Youth. Catalogue
No. 89-550-MPE, No. 1. Ottawa: Human Resources Development Canada and Statistics
Canada, pp. 15–45.
Ross, D.P., K. Scott and M. Kelly (1996b). Child Poverty: What Are the Consequences? Ottawa:
Canadian Council on Social Development.
Shalla, V., and G. Schellenberg (1998). The Value of Words: Literacy and Economic Security in Canada.
Catalogue No. 89-552-MPE. Ottawa: Statistics Canada.
Statistics Canada (1993). Schooling, Work and Related Activities, Income, Expenses and Mobility: 1991
Aboriginal Peoples Survey. Catalogue No. 89-534. Ottawa: Statistics Canada.
Statistics Canada (1996). The Daily, August 14, 1996.
Statistics Canada (1997a). The Daily, December 22, 1997.
Statistics Canada (1997b). Income Distributions by Size in Canada, 1996. Catalogue No. 13-207-XPB.
Ottawa: Statistics Canada.
Statistics Canada (1998a). 1992 and 1997 Survey of Consumer Finances. Custom data. Ottawa:
Statistics Canada, Income Statistics Division.
Statistics Canada (1998b). The Daily, May 12, 1998.
Statistics Canada (1998c). The Daily, February 12, 1998.
Statistics Canada (1998d). The Daily, February 4, 1998.
Steinhauer, P.D. (1998). “Developing Resiliency in Children from Disadvantaged Populations.”
In Canada Health Action: Building on the Legacy — Volume 1. Determinants of Health: Children
and Youth. Ottawa: National Forum on Health, Health Canada, pp. 47–102.
Vanier Institute of the Family (1998). From the Kitchen Table to the Boardroom Table: The Canadian
Family and the Work Place. Ottawa: Vanier Institute of the Family.
Wilkins, R., O. Adams and A. Brancker (1994). Unpublished data, as cited in The Health of
Canada’s Children: A CICH Profile, 2nd edition. Ottawa: Canadian Institute of Child Health,
1994.
Zyblock, M. (1996). Child Poverty Trends in Canada: Exploring Depth and Incidence from a Total
Money Income Perspective, 1975 to 1992. Catalogue No. W-96-1E. Ottawa: Human Resources
Development Canada, Applied Research Branch.
Healthy Development
31
of Children and Youth
C h a p t e r
2
Employment and
Work Environment
Overview
Employment status and conditions in the work environment can affect
the health of parents and their children. Generally speaking, people are
healthier when they are employed, have a high degree of control over their
work circumstances, and have fewer stress-related job demands. Stable
employment and adequate salary determine child and family income and
social status. Chronic unemployment or excessive work-related stress for
parents can negatively affect the mental and physical health of all family
members.
The increased participation of women in the paid labour force has had a
profound effect on the organization of family life, including the necessity
or requirement that care arrangements be made for children while their
parents are at work. For this reason, the availability and quality of childcare services are of paramount concern.
Employment, unemployment and workplace social supports are important
to youth as well as adults. A high proportion of Canada’s teenagers are
employed — many work on a part-time basis, gaining valuable experience
as they complete school and earning money towards their future education
expenses.
Healthy Development
33
of Children and Youth
Employment and Work Environment
A Closer Look at the Determinants
Relationship to Healthy Child Development
Employment contributes to better health for parents and children.
Employment can be a protective health factor for parents and children.
Employment status and working conditions strongly influence the economic
opportunities of parents. These factors can affect their ability to carry out
parenting responsibilities and, consequently, to develop healthy relationships
with their children.
Conversely, unemployment is associated with poorer health. A major review
by the World Health Organization found that high levels of unemployment
and economic instability in a society adversely affect the mental and physical
health of unemployed individuals, their families and their communities
(Wescott et al., 1985). Similarly, a Canadian study found unemployed people
have significantly more psychological distress, anxiety, depressive symptoms,
disability days, activity limitations, health problems and hospitalization visits
than do those that are employed (D’Arcy, 1986, p. 127).
In turn, these factors can have a negative impact on the health of children,
who may encounter mental health problems, lowered self-esteem and a decreased
ability to manage stress. They may also be less sociable and distrustful during
such a difficult family time.
A healthy workplace means better health.
People who have control over their work circumstances and few stress-related
demands of the job (e.g. fast work pace, frequent deadlines) are healthier
and tend to live longer than those in more stressful or riskier work activities.
In addition, people who have strong workplace social support (measured by
the number and quality of interactions with co-workers) are more likely to be
healthier than those without this type of support (Federal, Provincial and
Territorial Advisory Committee on Population Health, 1994, p. 18).
A supportive workplace — coupled with workplace policies that recognize
and support the needs of parents — can reduce stress and improve parents’
ability to meet the demands of both working and parenting.
Healthy Development
34
of Children and Youth
Employment and Work Environment
A Closer Look at the Determinants
High-quality, accessible child care is vital.
The entry of increasing numbers of women into the paid labour force
over the past several decades has resulted in a dramatic shift in child-care
arrangements. Accessible child-care services are essential in supporting and
promoting employment. They also give parents the opportunity to complete
or continue their education and/or to participate in job training programs
(Lero and Johnson, 1994, p. 31).
Moreover, the quality of child-care services is important. “When child
care providers are responsive and warm, have some understanding of child
development and are not responsible for too many children, child care can
be just as beneficial, or more beneficial, than parent care — particularly in
social and language skill development. When caregivers are neglectful or
harsh, unable to give individualized attention because they are responsible
for too many children and there is inadequate stimulation, research shows
that non-parental care can be harmful to children” (Guy, 1997, p. 81).
Conditions and Trends
The literature identifies a number of employment-related issues that have
strong links to healthy child development. This section provides recent data
describing four of these issue areas: parents’ labour force participation, working
and parenting, child care, and youth employment.
Parents’ Labour Force Participation
Most parents of young children are in the labour force, a situation that both
benefits children and presents challenges to family life and healthy child
development. Some of the facts about parents’ labour force participation
are provided below.
Many parents are working.
Working parents are the norm in most families, but not all. The National
Longitudinal Survey of Children and Youth (NLSCY) shows the breakdown
for two-parent and lone-parent families. In 1994–95, more than a third (35.5%)
of children under age 12 lived in families where both parents were employed
full time, and another third (33.2%) lived in two-parent families where one
parent was employed. The situation was strikingly different for children in
lone-parent families. More than one half (54.9%) lived in families where the
parent was not employed, while for just over one third, the parent worked
full time (Ross, Scott and Kelly, 1996, p. 35). See Exhibit 2.1.
Two-parent families with children under 18 have increased their combined
weeks of employment an average of 5.7 weeks — from 72.6 weeks in 1984 to
78.3 weeks in 1994 (CCSD, 1996, p. 15).
Healthy Development
35
of Children and Youth
Employment and Work Environment
A Closer Look at the Determinants
2.1 Distribution of children aged 0 to 11, by labour market status of parent(s),
Canada, 1994–95
Two-parent
families (%)
Both full-time (except single-parent)
One full-time, one part-time
One full-time, one not employed
Part-time onlya
Not employed
Single-parent
families (%)
35.5
21.8
33.2
2.9
6.6
34.1
n/a
n/a
10.9
54.9
a. Includes two-parent families in which one parent is employed part-time and the other is employed part-time or not employed.
n/a Not applicable
Source: Adapted from D.P. Ross, K. Scott and M.A. Kelly (1996). “Overview: Children in Canada in
the 1990s.” In Growing Up in Canada: National Longitudinal Survey of Children and Youth. Catalogue
No. 89-550-MPE, No. 1. Ottawa: Human Resources Development Canada and Statistics Canada, p. 36.
More women are working.
Analysis of 1991 census data shows that the participation rate of women in
the labour market more than doubled between 1961 and 1991, increasing
from 29% to 60%. The participation rate for men declined over the same
period, dropping from 81% to 76% (Gunderson, 1998, p. 23).
Women with young children have higher participation rates than women
in general. Looking back to 1976, only 50% of mothers with children under the
age of 3 were in the labour force (CICH, 1994, p. 7). See Exhibit 2.2. While
1991 data show that more than 70% of women with a preschooler and 78%
with a child between 6 and 14 years old participated in the labour force
(Gunderson, 1998, p. 28). In 1995, most married fathers (94%) were in the
labour force, regardless of the age of their children (Marshall, 1998, p. 73).
Unemployment is higher among
Aboriginal and lone-parent families.
2.2 Labour force participation of women,a by age
of youngest child, Canada, 1976 to 1992
The percentage of families with at least one
parent unemployed for more than six months
increased from 7.1% in 1981 to 12.2% in 1994
(CCSD, 1996, p. 19).
In 1994–95, 6.6% of children aged 0 to
11 years in two-parent families lived in homes
where neither parent was employed, while
54.9% of children in lone-parent homes lived
with a parent who was not employed (Ross,
Scott and Kelly, 1996, p. 35). See Exhibit 2.1.
In 1991, 10% of Canadians were unemployed compared with 25% of all Aboriginal
peoples. Aboriginal people living on reserve
have the highest rate of unemployment at
31% (Statistics Canada, 1993, as cited in CICH,
1994, p. 138).
Healthy Development
36
Less than 3
3–5
6–15
76
69
61
56
52
50
68
62
61
%
44
41
32
1976
1981
1986
1992
a. Includes full-time and part-time participation.
Source: Canadian Institute of Child Health (1994). The
Health of Canada’s Children: A CICH Profile, 2nd edition.
Ottawa: CICH, p. 7.
of Children and Youth
Employment and Work Environment
A Closer Look at the Determinants
Working and Parenting
Increased participation of women in the labour force has created new
challenges for parents, employers and communities pertaining to the
integration of work and family responsibilities. Regardless of their employment
status, women still play the primary role in child care and housework. This
dual role has been linked to significant stress and health problems for women
(Marshall, 1994, pp. 27–29).
Women do more “home” work.
Women are twice as likely as men to describe their main activity as caring
for a family and working, and half as likely to describe it as simply working
for pay or profit (Federal, Provincial and Territorial Advisory Committee
on Population Health, 1996, p. 46). See Exhibit 2.3.
2.3 Main daily activity of adults, by selected activity and sex, Canada,
age 15+, 1994–95
%
53
Male
24
19
Female
26
15
10
15
12
11
1
Working
for pay
Caring for
family/
working
Caring for
family
Retired
Going to
school
5
2
Looking
for work
Source: Federal, Provincial and Territorial Advisory Committee on Population Health
(1996). Report on the Health of Canadians: Technical Appendix. Catalogue No. H39385/1-1996E. Ottawa: Health Canada, p. 48.
In fact, the work that primarily benefits children is done mostly by women,
even when women are employed full time, and regardless of whether their
husbands are also employed full time. In 1992, in households with young
children where the mother and father are both employed full time (in the
paid labour force), women did almost twice as much child-related work. For
every hour men spent doing child-oriented work, women spent almost two
hours (1.86 hours) (Federal-Provincial/Territorial Ministers Responsible for
the Status of Women, 1997, p. 29).
The same study also shows that in 1992, women worked a half hour more
every day (including paid and unpaid work) than men — the equivalent
of five weeks per year at a full-time paid job (Federal-Provincial/Territorial
Ministers Responsible for the Status of Women, 1997, p. 21).
Healthy Development
37
of Children and Youth
Employment and Work Environment
A Closer Look at the Determinants
Working mothers experience high levels of stress.
Recent research reveals that striving to balance work and family demands is
closely linked to significant stress and mental health problems, particularly
for women. In The Progress of Canada’s Children — 1996, the Canadian Council
on Social Development (1996, p. 15) found that working mothers report:
• high levels of work/family conflict (40%),
• high levels of stress (50%), and
• high levels of depressed mood (40%).
The stress experienced by working mothers seems to be particularly high
among employed lone mothers. A 1993 study reported that this group was
more likely to experience high levels of work–family tension than employed
married mothers (Vanier Institute of the Family, 1998, p. 29). Lone fathers
are likely to experience similar high stress levels.
Research suggests that employers seldom consider the responsibilities
of employees who have family obligations as having an impact on their work.
Employees are often stressed and in poor health, turn down promotions and
transfers, yet feel guilty about the quality of their parenting. Employers tend
to focus on the negative effects on work performance, absenteeism, turnover
rates and employee morale (Vanier Institute of the Family, 1998, pp. i–ii).
Flexibility is key.
Women with children were more likely than women without children to work
part time (26% and 18%, respectively), to be self-employed (17% versus 12%),
to have flextime (32% versus 29%) and to have flexible working arrangements
(27% versus 16%) (Fast and Frederick, 1996, p. 16).
Child Care
With more and more women entering the labour force, accessible high-quality
child care is increasingly important. There is evidence to suggest that childcare arrangements are not meeting the changing needs of Canadian families.
Child-care services and subsidies are in high demand.
In 1994–95, 32.4% of children under age 12 (1.5 million children) were in
some form of non-parental child care while their parents worked or studied.
Of these, just over one third (34.2%) received unregulated care in the home
of a non-relative, and slightly more than one quarter (26.9%) were in regulated
Healthy Development
38
of Children and Youth
Employment and Work Environment
A Closer Look at the Determinants
care. Almost one quarter (23.9%) were cared for by a relative (including
a sibling), or cared for themselves (Ross, Scott and Kelly, 1996, p. 25). See
Exhibit 2.4. We also know that in the same year:
• There were 360,000 regulated child-care spaces for children under age 13;
for the 1 million preschool children whose parents were working or studying more than 20 hours per week, there were an additional 270,000 such
spaces (HRDC, 1994, p. 53).
• Approximately 42% of regulated day-care spaces in Canada were subsidized
for low-income families (HRDC, 1994, p. 53).
Between the early 1970s and the
late 1980s, the annual growth of childcare spaces Canada-wide ranged from
10% to 16%. However, there has been
a slower growth rate since 1990. In
1995, the rate of growth was 4.7%,
which is fairly typical of growth rates
during this decade (HRDC, 1995 and
1996, pp. 3, 9).
In recent years, both the number
of child-care subsidies for low-income
parents and operating or wage grants
to child-care providers were reduced
in many provinces. Some provincial
governments have also lowered
standards for child-care facilities and
have cut back on monitoring and
enforcement of regulations (CCSD,
1997, p. 30).
2.4 Distribution of children aged 0 to 11, by type
of non-parental child-care arrangement, Canada,
1994–95
Primary care arrangement
Unrelated family home day care, unregulated
Care by relative, in child’s or someone else’s home
Child-care centre, regulated
In child’s home by non-relative, unregulated
Unrelated family home day care, regulated
Before and/or after school program regulated
Sibling or self-care
Other
Source: Adapted from D.P. Ross, K. Scott and M.A. Kelly (1996).
“Overview: Children in Canada in the 1990s.” In Growing Up in Canada:
National Longitudinal Survey of Children and Youth. Catalogue No. 89550-MPE, No. 1. Ottawa: Human Resources Development Canada and
Statistics Canada, p. 25.
In 1988, 23% (340,000) of children in Canada aged 6 to 12 years who required
care spent at least some time alone or with a sibling under age 13 while parents
worked at a job or business. Self-care or care by a sibling was the primary care
arrangement for 7% of children aged 6 to 9, and 21% of children aged 10 to
12 (Lero and Johnson, 1994, p. 33).
First Nations communities have limited access to child-care services.
Very little national data exist concerning child-care services in First Nations
communities. It is understood that Aboriginal peoples’ conceptions of child
care tend to be more holistic and involve extended family than is the case for
the general Canadian population. The most recent data indicate that there
are only 68 child-care centres in more than 1,000 First Nations communities
in Canada (National Inquiry into First Nations Child Care, 1989).
39
34.2
21.4
15.7
14.2
7.2
4.0
2.5
0.7a
a. Estimate less reliable due to high sampling variability.
Siblings play an important role.
Healthy Development
% of children
of Children and Youth
Employment and Work Environment
A Closer Look at the Determinants
Changing needs require changing services.
Supply of regulated day-care spaces has not kept pace with demand. Demand
for licensed child care is not being met. A 1994 national study drew attention
to the fact that less than half (45%) of children for whom licensed care was
preferred by their parents received such care. Parents surveyed cited several
reasons why alternatives were used:
• licensed care was unavailable or in short supply (70%),
• licensed care arrangements were too expensive (22%), and
• hours when care was available did not match parents’ work schedules (8%)
(Lero and Johnson, 1994, pp. 34–35).
There are other indications that child-care services are not meeting the
needs of a changing workplace. Because most child-care centres are open
during “standard” hours only, parents who work evenings or weekends may
have considerable difficulty finding non-parental child care (Lero et al., 1992,
p. 63).
Youth Employment
Youth unemployment is higher than in the general population, even though
young people are more highly educated than in the past. The outlook for
young people with post-secondary education is good, while females who
drop out of high school may have more difficulty finding a job than do male
drop-outs.
Youth unemployment is increasing.
Between 1989 and 1995, the number
of working 15- to 24-year-olds fell
about 500,000, while adult employment numbers rose 1 million. This
difference has been largely attributed
to the lack of experience or seniority
of youth (HRDC, 1996, p. 3). With
increased computerization and demand
for highly educated employees, youth
are often the ones to be turned away
from prospective jobs (CCSD, 1997, p. 51).
Leaving high school may have more serious consequences
for females than for males. According to the 1995 School Leavers
Follow-up Survey, 30% of young women high school drop-outs
are unemployed, compared with 17% of young men (HRDC
and Statistics Canada, 1996, p. 5). Interestingly, two thirds of
high school drop-outs are male.
I
n 1995, approximately
four out of five people who
graduated from university
or college in 1990 were
employed full time, with less
than 10% working in jobs
unrelated to their education.
Healthy Development
40
of Children and Youth
Employment and Work Environment
A Closer Look at the Determinants
Young people are working in part-time, low-paying jobs.
More young people are working part time. In 1994, 40% of teenagers (including students and non-students) were employed — 80% on a part-time basis
(CCSD, 1996, p. 54). In 1996, 20% of all non-student employment was part
time, up from 6% in 1976 (Statistics Canada, 1997, p. 30).
Youth are likely to find work in low-paying, service sector jobs. Of 15to 18-year-old secondary school students who worked in 1995, most (89%)
were employed in service jobs. Two thirds worked in accommodation, food
and beverage services, or in a retail trade (Greenon, 1998, p. 86).
In 1995, secondary students earned an average of $6.66 an hour, while their
post-secondary counterparts averaged $8.13 per hour (Greenon, 1998, p. 87).
Post-secondary education contributes to employability.
In 1995, approximately four out of five people who graduated from university
or college in 1990 were employed full time, with less than 10% working in
jobs unrelated to their education. More than two thirds of trade/vocational
graduates had full-time jobs (HRDC, 1998, p. 1). See Exhibit 2.5.
Both employment and earnings for post-secondary graduates have
remained stable since 1982. Three HRDC/Statistics Canada studies of
1982, 1986 and 1990 graduates, five years after graduation, show that the
proportion of college and university graduates with full-time jobs remained
fairly constant (HRDC, 1998, p. 2).
2.5 Unemployment rates for youth aged 15 to 24, by educational attainment, Canada,
selected years, 1980 to 1995
Year
Primary
education
(0–8 years)
Some or
completed
high school
Some
Post-secondary
post-secondary certificate or
diploma
University
degree
1980
1985
22.2
27.4
14.0
18.9
9.3
11.7
8.7
10.3
7.0
9.7
1990
1995
25.0
27.0
14.6
18.7
9.3
12.4
8.7
11.0
6.6
8.6
Source: Prepared by the Canadian Council on Social Development using data from Statistics Canada Labour
Force Annual Averages, Selected Years. In Canadian Council on Social Development (1997). The Progress of
Canada’s Children — 1997. Ottawa: CCSD, p. 52.
Healthy Development
41
of Children and Youth
Employment and Work Environment
A Closer Look at the Determinants
Employment and Other Determinants
Education
Employment interacts with education to affect health outcomes. For instance,
the more education people have, the less likely they are to be unemployed
at any time in their lives. Furthermore, people with fewer than nine years
of education are more likely than those with higher education levels to have
unrewarding, low-paying jobs. They are also more likely to have jobs that are
characterized by a high rate of occupational injuries, to experience periods of
unemployment, and to rely on social assistance (Chevalier et al., 1995, as cited
in Working Group on Community Health Information Systems, 1995, p. 72).
Parents’ education has been linked to work status and household income
— those with higher educational qualifications are more likely to hold higherpaying jobs (Ross, Scott and Kelly, 1996, p. 36).
Education greatly affects young people’s chances of being employed.
Nearly 19% of youth aged 15 to 24 with high school education or less were
unemployed in 1995, compared with less than 9% of those with a university
degree. These rates are similar to those in 1985, but higher than those in 1990
(CCSD, 1997, p. 10). See Exhibit 2.5.
Working teens are less likely to drop out of school. However, teenagers who
work more than 20 hours a week are at risk for leaving school early (CCSD,
1996, p. 54). In 1993, teens 14 to 17 years old made a significant contribution
to their family incomes, earning more than $2 billion dollars collectively
(CCSD, 1996, p. 54).
Genetic and Biological Factors
As more and more children with genetic, developmental and psychiatric disorders enter adulthood, there will be an increased requirement for suitable
jobs — those that provide dignity and remuneration, and are geared to their
special abilities.
Culture
It has been established that culture has an impact on the education and
occupation of an individual, as well as the education and occupation of the
person’s spouse. This affects income, knowledge of support structures, access
to informal support and personal coping skills (Erickson, 1991, p. 4).
Healthy Development
42
of Children and Youth
Employment and Work Environment
A Closer Look at the Determinants
References
Canadian Council on Social Development (1996). The Progress of Canada’s Children — 1996.
Ottawa: Canadian Council on Social Development.
Canadian Council on Social Development (1997). The Progress of Canada’s Children — 1997.
Ottawa: Canadian Council on Social Development.
Canadian Institute of Child Health (1994). The Health of Canada’s Children: A CICH Profile,
2nd edition. Ottawa: Canadian Institute of Child Health.
Chevalier, S., et al. (1995). Cited in Community Health Indicators: Definitions and Interpretations.
Ottawa: Working Group on Community Health Information Systems, Canadian Institute
for Health Information, 1995.
D’Arcy, C. (1986). “Unemployment and health: Data and implications.” Canadian Journal of
Public Health, 77 (Supp. 1): 124–131.
Erickson, B. (1991). Families and the Transmission of Culture. Report submitted to the Demographic
Review Board. Ottawa: Health and Welfare Canada.
Fast, J.E., and J.A. Frederick (1996). “Working Arrangements and Time Stress.” Canadian Social
Trends, Vol. 43 (Winter 1996): 14–19. Catalogue No. 11-008E. Ottawa: Statistics Canada.
Federal, Provincial and Territorial Advisory Committee on Population Health (1994). Strategies
for Population Health: Investing in the Health of Canadians. Catalogue No. H39-316/1994E.
Ottawa: Health Canada.
Federal, Provincial and Territorial Advisory Committee on Population Health (1996). Report
on the Health of Canadians: Technical Appendix. Catalogue No. H39-385/1-1996E. Ottawa:
Health Canada.
Federal-Provincial/Territorial Ministers Responsible for the Status of Women (1997). Economic
Gender Equality Indicators. Catalogue No. SW21-17/1997E. Ottawa: Status of Women.
Greenon, L. (1998). “Juggling Work and School.” In Work Arrangements in the 1990s. Catalogue
No. 71-535-MPB, No. 8. Ottawa: Statistics Canada, pp. 85–89.
Gunderson, M. (1998). Women in the Canadian Labour Market: Transitions Toward the Future.
Catalogue No. 96-321-MPE, No. 2. Ottawa: Statistics Canada.
Guy, K.A., ed. (1997). Our Promise to Children. Ottawa: Canadian Institute of Child Health.
Human Resources Development Canada (1994). Agenda: Jobs and Growth: Improving Social
Security in Canada. Catalogue No. SC-035-09/94E. Ottawa: Human Resources Development
Canada.
Human Resources Development Canada (1995 and 1996). Status of Day Care in Canada.
Catalogue No. H74-14/1996E. Ottawa: Human Resources Development Canada.
Human Resources Development Canada (1996). Applied Research Bulletin, Vol. 2, No. 2: 3–5.
Human Resources Development Canada (1998). Applied Research Bulletin, Vol. 4, No. 1: 1–3.
Human Resources Development Canada and Statistics Canada (1996). After High School:
The First Years — The First Report of the School Leavers Follow-up Survey, 1995. Catalogue
No. MP78-4/12-1996. Ottawa: Human Resources Development Canada and Statistics
Canada.
Lero, D., et al. (1992). Canadian National Child Care Studies: Parental Work Patterns and Child
Care Needs. Catalogue No. 89-529E. Ottawa: Statistics Canada.
Lero, D.S., and K. Johnson (1994). 110 Canadian Statistics on Work and Family. Ottawa:
The Canadian Advisory Council on the Status of Women.
Healthy Development
43
of Children and Youth
Employment and Work Environment
A Closer Look at the Determinants
Marshall, K. (1994). “Balancing Work and Family Responsibilities.” In Perspectives on Labour
and Income. Catalogue No. 75-001E. Ottawa: Statistics Canada, pp. 26–30.
Marshall, K. (1998). “Balancing Work and Family.” In Work Arrangements in the 1990s. Catalogue
No. 71-535-MPB, No. 8. Ottawa: Statistics Canada.
National Inquiry into First Nations Child Care (Canada) (1989). Report of the National Inquiry
into First Nations Child Care. Summerstown, ON: National Indian Brotherhood, Assembly
of First Nations.
Ross, D.P., K. Scott and M.A. Kelly (1996). “Overview: Children in Canada in the 1990s.”
In Growing Up in Canada: National Longitudinal Survey of Children and Youth. Catalogue
No. 89-550-MPE, No. 1. Ottawa: Human Resources Development Canada and Statistics
Canada, pp. 15–45.
Statistics Canada (1993). Schooling, Work and Related Activities, Income, Expenses and Mobility:
1991 Aboriginal Peoples Survey. Catalogue No. 89-534. Ottawa: Statistics Canada. Cited in
The Health of Canada’s Children: A CICH Profile, 2nd edition. Ottawa: Canadian Institute
of Child Health, 1994.
Statistics Canada (1997). Labour Force Update: Youths and the Labour Market (Spring 1997).
Catalogue No. 71-005-XPB. Ottawa: Statistics Canada.
Vanier Institute of the Family (1998). From the Kitchen Table to the Boardroom Table: The Canadian
Family and the Work Place. Ottawa: Vanier Institute of the Family.
Wescott, G., et al. (1985). Health Policy Implications of Unemployment. Copenhagen: World Health
Organization.
Healthy Development
44
of Children and Youth
C h a p t e r
3
Education
Overview
Education level is positively associated with health status and health
behaviours. Moreover, educational attainment is widely acknowledged as
an important determinant of socio-economic status and income, which
are both key determinants of health.
Many factors contribute to how well children perform in the formal
education system. Parents’ education level and involvement in their child’s
schooling, as well as overall readiness for school are all contributors to the
child’s level of achievement in school and to how long he or she stays in
school. Early school leavers fare poorly in the job market compared with
youth with high school or university education.
Healthy Development
45
of Children and Youth
Education
A Closer Look at the Determinants
Relationship to Healthy Child Development
Education is a tool for life.
Education contributes to health and prosperity by equipping people with the
knowledge and skills needed for problem solving and by giving them a sense
of control over their life circumstances. Education also improves people’s
ability to access and understand information that can keep them healthy
(Federal, Provincial and Territorial Advisory Committee on Population Health,
1994, pp. 17–18). In fact, research
demonstrates a two-way connection
between health and learning — doing
3.1 Proportion of adults aged 15+ with selected
poorly and/or expecting to do poorly in
health risk factors, by number of years of
school are associated not only with school
education, Canada, 1994–95
failure, but also with such behaviours
Years of education
as delinquency, substance abuse and
Less than 12
12–15
16 or more
%
teen pregnancy (Dryfoos, 1990, p. 94).
50
40
More education means better health.
Health status improves with level of
30
education. In general, as education
20
increases, “self-rated health status improves,
while activity limitation and the number
10
of workdays lost due to illness or injury
decreases. People with a university degree
0
are about half as likely to have high blood
High blood
High blood
Overweight
pressure
cholesterol
pressure, high blood cholesterol, or
to be overweight, as are those with less
Source: Federal, Provincial and Territorial Advisory Committee
on Population Health (1996). Report on the Health of Canadians.
than high school education” (Federal,
Catalogue No. H39-385/1996-1E. Ottawa: Health Canada, p. 29.
Provincial and Territorial
Advisory Committee on
Population Health, 1996,
3.2 Poverty ratesa among adults aged 15+, by highest level of
p. 29). See Exhibit 3.1. The
education completed, 1996
highest educated group is
also the least likely to live
Heads of families
Unattached persons
%
in poverty (National Council
55.4
of Welfare, 1998, p. 44).
45.8
44
See Exhibit 3.2.
34.7
29
19.2
21
12.4
15.6
0–8
years
Some high
school
19.8
18.9
High
school
graduate
7.7
Some postsecondary
Postsecondary
diploma
University
degree
a. As defined by Statistics Canada’s low income cut-offs.
Source: National Council of Welfare (1998). Poverty Profile, 1996. Ottawa:
National Council of Welfare, p. 44.
Healthy Development
46
of Children and Youth
Education
A Closer Look at the Determinants
Children need to be ready for school.
There is good evidence that early childhood intervention programs can be
successful in promoting children’s capacity to learn, their social success and
their success in school. The effects of these programs are most dramatic with
disadvantaged children (Hertzman, 1996).
The impact of school readiness goes well beyond
early academic and social accomplishments. Children
Literacy and Age
who have the appropriate level of cognitive,
People with high literacy skills are
emotional, language and physical skills are more
more likely to hold high-paying jobs.
likely to stay in school, graduate from high school,
find employment, and contribute to society as
A 1997 international study on adult
caring individuals and taxpayers (Doherty, 1996).
literacy shows a dramatic link
Preschool ability sets the stage for children’s
between age and literacy levels. This
transition into the formal school system. Children who
link is largely accounted for by
have not learned skills such as colour naming, sorting,
counting, letters and the names of everyday objects
differences in education levels
are at a disadvantage compared with children who have
attained. In addition, for young
mastered these skills. Teachers tend to rate children
people (aged 16 to 25 years),
in these skills early on (Entwistle and Alexander, 1989).
mothers’ education level and fathers’
Young people need to stay in school.
occupation are both strong predictors
of literacy levels (Willms, 1997).
A positive and supportive learning environment is
essential for acquiring the skills and social capacities
children need to make their way through
adolescence. Youth who do not complete
school are more likely to be at a disadvantage regarding employment,
income and life opportunities
(Statistics Canada, 1993a, p. 2).
The personal costs of premature
departure from school are an
increased likelihood of poor health,
delinquency, crime, substance abuse
and economic dependency, and a
lower quality of life (Statistics Canada,
1993a, p. 4).
A
positive and
supportive learning
environment is essential
for acquiring the skills
and social capacities
Conditions and Trends
children need to make
their way through
adolescence.
Education Level of Parents
Parents’ education — together with income and labour-market status — is
associated with a variety of child outcomes, including academic achievement
(Ross, Scott and Kelly, 1996, p. 36). Generally speaking, children’s early
educational performance is influenced by the education level of their mothers
(Willms, 1996, p. 73).
Healthy Development
47
of Children and Youth
Education
A Closer Look at the Determinants
The education level of Canadians is increasing.
The number of people 15 years of age and older without a Grade 9 education
fell from more than 30% in 1971 to just less than 14% in 1991 (Federal,
Provincial and Territorial Advisory Committee on Population Health, 1996,
p. 37). See Exhibit 3.3. In 1971, nearly one quarter of 15- to 24-year-olds had
at least some post-secondary education — this rose to well over one third
(39%) by 1996 (Statistics Canada, 1998a).
3.3 Population aged 15+, by highest level of education completed, Canada, selected years
1976
1981
1986
1991
1996
Number
16,890,350
18,609,285
19,634,100
21,304,740
22,628,925
Less than Grade 9
4,285,390
3,851,285
3,473,640
3,051,900
2,812,015
Grades 9 to 13
7,440,765
8,122,465
8,354,030
9,071,580
9,131,775
Some post-secondary
4,077,825
5,145,355
5,927,950
6,761,505
7,684,435
University degree
1,086,370
1,490,180
1,878,480
2,419,750
3,000,695
Total
Source: Adapted from the Statistics Canada Web site: www.statcan.ca
While there have been steady improvements in educational achievement
over the years, Aboriginal peoples still have lower education levels than nonAboriginal Canadians. According to the Aboriginal Peoples Survey, in 1991,
17% of 15- to 64-year-old Aboriginal people had fewer than nine years of
schooling, 50% had completed high school, and one third had some postsecondary education (Statistics Canada, 1993b, p. 2). See Exhibit 3.4.
3.4 Highest level of educational attainment achieved, adults aged
15 to 64, by Aboriginal peoples and all Canadians, Canada, 1991
Less than Grade 9
%
High school
53
49
50
Some post-secondary
43 43
38
34
33
33
36
26
17
16
14
12
All
Aboriginal
Indian
Métis
Inuit
All
Canadians
Source: Statistics Canada. Schooling, Work and Related Activities, Income, Expenses and
Morbidity, 1991 Aboriginal Peoples Survey, 1993. Cited in Canadian Institute of Child Health
(1994). The Health of Canada’s Children: A CICH Profile, 2nd edition. Ottawa: CICH, p. 137.
Healthy Development
48
of Children and Youth
Education
A Closer Look at the Determinants
Women’s overall level of education is increasing. In 1992–93, women represented 53% of all
undergraduate students, 46% of full-time master’s
degree students and 35% of full-time doctoral
students, an increase from 43%, 27% and 19%,
respectively, in 1972–73 (Normand, 1995, p. 19).
Immigrant Children
and Education
Immigrant youth often experience
disruptions in their education. In some
cases, they may be too old to enter the
school system in Canada and, at the
Parents’ education level affects children’s
academic achievement.
same time, be unqualified to begin work
(Multiculturalism and Citizenship Canada,
The National Longitudinal Survey of Children and
Youth (NLSCY) found that the education level of
the person most knowledgeable about the child
(most often the mother) was a significant predictor
of children’s verbal ability at ages 4 and 5, and of
children’s mathematics achievement in grades 2
and 4 (Willms, 1996, p. 73).
Parents’ level of education is also associated
with the value placed on education within the
family. “Parents with higher levels of education
tend to place a greater value on the importance of
academic achievement and are likely to spend more
time reading to their children and helping them do
their homework.” In 1994–95, the vast majority
(83.7%) of children under age 12 lived with parents
who had at least a high school diploma (Ross, Scott
and Kelly, 1996, p. 37). See Exhibit 3.5.
1988, p. 65).
More than half of immigrant children
between 4 and 17 years of age who came
to Canada between 1981 and 1988 did
not speak either official language. While
these children may obtain lower marks in
English than do Canadian-born children,
they perform very well in mathematics
(Samuel and Verma, 1992, pp. 53–56).
3.5 Distribution of children aged 0 to 11, by mothers’ and fathers’ education
level, Canada, 1994–95
Level of education
Mother’s
education (%)
Father’s
education (%)
Less than high school
16.3
16.3
High school graduate
46.4
40.5
Diploma/certificate from trade or business school
8.9
13.2
Degree/diploma from university or college
28.3
29.9
100.00
100.00
Total
Source: Adapted from D.P. Ross, K. Scott and M.A. Kelly (1996). “Overview: Children in Canada in
the 1990s.” In Growing Up in Canada: National Longitudinal Survey of Children and Youth. Catalogue
No. 89-550-MPE, No. 1. Ottawa: Human Resources Development Canada and Statistics Canada, p. 37.
Healthy Development
49
of Children and Youth
Education
A Closer Look at the Determinants
Role of Families
Parents’ involvement in preparing their children for school provides children
with a stronger base for learning from their school experience, while continued
parental interest in schooling can have a positive effect on children’s academic
performance. School-aged children whose parents are involved in such activities
as helping with homework and assisting in the classroom tend to do better
academically. We know that:
Most parents are involved in preparing their children for school.
In 1994–95, parents of more than half of infants and toddlers up to age 2
showed their youngsters picture books daily, and most (94%) read aloud to
their children every day. See Exhibit 3.6. The parents of more than 50% of
children aged 2 to 5 also helped them with writing every day, while another
30% did so a few times a week (CCSD, 1997, pp. 45–46).
Teachers surveyed in 1994–95 as part of the NLSCY reported that two
thirds of their students had parents who were “very involved” in their children’s
education, suggesting that these parents recognize the vital role they play in
their children’s learning (CCSD, 1997, p. 46).
Parents’ involvement affects children’s achievement.
Children whose parents had little interest in their schooling were seven times
more likely to have repeated a grade than children whose parents placed a great
deal of importance on education. Children who failed at math were more likely
to have parents who did not take an active interest in their education (CCSD,
1997, p. 46).
3.6 Distribution of parent(s) who read to their children aged 2 to 5,
by frequency of reading, Canada, 1994
Do you read out loud
to your child regularly?
How often do you
read to your child?
7% Less than once a week
Yes
94%
26% Few times a week
No
6%
55% Daily
11% Many times a day
Source: Prepared by the Canadian Council on Social Development using data from Statistics
Canada’s National Longitudinal Survey of Children and Youth, 1994. In Canadian Council on
Social Development (1997). The Progress of Canada’s Children — 1997. Ottawa: CCSD, p. 46.
Healthy Development
50
of Children and Youth
Education
A Closer Look at the Determinants
School Readiness
Being ready for school helps to set the stage for success in school as well as
in future work and social life. Children who do well in school often approach
school “ready to learn.” These children have already been exposed to books and
numbers, they have been introduced to problem-solving techniques, and they
have developed the social skills needed in group settings (Ross, Scott and
Kelly, 1996, p. 24).
Overall, most children who enter school are “ready to learn.” Children
from higher income families, and those whose parents have more education,
tend to be ready more so than other children.
Children with Disabilities and Education
“In April 1991, almost 90% of 5- to 14-year-old children with disabilities were in school. Of the
9,550 (3.1%) who were not in school or being tutored, 6,325 had never attended school and 3,225
had attended school before April 1991” (CICH, 1994, p. 158). See Exhibit 3.7.
According to the NLSCY, 4% of Canadian children under age 12 have a learning disability (CCSD,
1997, p. 50). The Health and Activity Limitation Survey (HALS) estimates that learning disabilities
are the most common disabilities among children under age 15 (Statistics Canada, 1994, p. xxxv).
Yet these disabilities often are undiagnosed until a child has failed at school. The school drop-out
rate for children with learning disabilities is 35% — twice that of their non-disabled peers
(Bullivant, 1997, pp. 1–2).
Parents’ education and income have an impact on school readiness.
Results of the NLSCY show no significant differences between boys and girls
on one measure of school readiness — the Peabody Picture Vocabulary Test
(PPVT). However, there were differences among
children according to the educational
attainment of their parents. Exhibit 3.8
shows that children who lived with one
or two highly educated parents were
more likely to do well on the PPVT
than children who lived with one or
two parents who had not graduated
from high school (Ross, Scott and
Kelly, 1996, p. 24).
Compared with their peers from
the highest socio-economic group,
children from the lowest socio-economic
group are more likely to be at the bottom of
their class in reading, writing and math abilities
(Lipps and Frank, 1997).
Nationally, one quarter of children from low-income families were
verbally delayed in their development, compared with one sixth of the
children in middle-income families, and less than one tenth of those from
families with the highest incomes (Ross, Scott and Kelly, 1996, p. 42).
Healthy Development
51
of Children and Youth
I
n April 1991,
almost 90% of 5- to
14-year-old children
with disabilities
were in school.
Education
A Closer Look at the Determinants
3.7 Distribution of children with disabilities aged 5 to 14,
by those attending school or being tutored, Canada,
April 1991
Being
tutored
Attended
school
previously
7.4%
34.0%
Not attending
school or being
tutored
3.1%
Never attended
school
66.0%
Attending school
89.5%
Source: Canadian Institute of Child Health using Statistics Canada’s
Health and Activity Limitation Survey (HALS) 1991 unpublished data.
In Canadian Institute of Child Health (1994). The Health of Canada’s
Children: A CICH Profile, 2nd edition. Ottawa: CICH, p. 158.
3.8 Distribution of children aged 4 to 5, by child’s school readinessa and parents’b education, 1994–95
Child outcome on PPVT c
(4 to 5 years)
Less than
high school
graduate
(%)
High school
graduate
7.6 d
57.4
35.0
Advanced development
Normal development
Delayed development
(%)
Diploma/certificate
from trade or
business school
(%)
Degree/diploma
from university
or college
(%)
10.4d
73.1
16.6
12.0 d
72.6
15.4
22.5
66.0
11.6d
a. As measured by the Peabody Picture Vocabulary Test (PPVT) or the Échelle de vocabulaire en images Peabody (EVIP).
b. Based on the spouse with the highest education credential (in two-parent families).
c. Peabody Picture Vocabulary Test.
d. Estimate less reliable due to high sampling variability.
Source: Adapted from D.P. Ross, K. Scott and M.A. Kelly (1996). “Overview: Children in Canada in the 1990s.” In Growing Up
in Canada: National Longitudinal Survey of Children and Youth. Catalogue No. 89-550-MPE, No. 1. Ottawa: Human Resources
Development Canada and Statistics Canada, p. 24.
Provincial governments play a role.
Funding for kindergarten programs is being cut in many provinces; therefore,
fewer children aged 3 to 5 have access to high-quality preschool learning
programs. Ontario’s government has made junior kindergarten optional, and
some school boards have cancelled the program altogether. The Newfoundland
government has “frozen” funds for kindergarten programs, while Alberta
has reduced the number of kindergarten program hours from 480 to 400.
In Nova Scotia, half-day rather than full-day kindergarten programs are
provided (CCSD, 1996, p. 29).
Staying in School
More young people are attending school, which is a positive trend particularly
in light of the fact that it is becoming increasingly difficult for young people
who drop out of high school to succeed in a highly competitive job market.
Healthy Development
52
of Children and Youth
Education
A Closer Look at the Determinants
More young people are staying in school.
The proportion of young men and women
(aged 15 to 19) attending school has been
steadily increasing in Canada. In 1961, 62%
of young men and 56% of young women were
attending school. By 1991, the percentages had
risen to 79% and 80%, respectively (Normand,
1995, p. 20).
Young people (aged 18 to 20 years) who stay
in school are more likely than their counterparts
who drop out to believe that school is relevant
to their lives (Statistics Canada, 1993a, p. 28).
Who’s Ready for School?
School readiness refers to a child’s ability to
meet the demands of school and to learn the
content of the curriculum that is appropriate
for his or her grade at the time of entry into
the school system (Kagan, 1992). Research has
identified five components of school readiness:
• physical well-being and motor development,
• emotional health and positive approach to
Some people are more likely than others
to drop out of school.
new experiences,
• social knowledge and competence,
• In 1991, poor1 youth were almost three
times more likely to drop out of school than
non-poor youth (CICH, 1994, p. 122). See
Exhibit 3.9.
• language skills, and
• general knowledge and cognitive skills
(Kagan, 1992, p. 50).
• The school drop-out rate in 1991 among 20year-olds was 22% for males and 14% for females
(Statistics Canada, 1993a, p. 17).
• Aboriginal youths experienced particularly high rates of early school leaving;
in fact, 40% of all 18- to 20-year-olds in this group drop out of high school
(Statistics Canada, 1993a, p. 23).
• The school drop-out rate for children with learning disabilities (the most
common long-term disability suffered by children under age 15) is 35%
(Bullivant, 1997, pp. 1–2).
• Young people who drop out of school
are more likely: to be living with neither
parent; to come from single-parent
homes; to have parents who have low
levels of education or blue-collar jobs;
to be married; to have children; or to
have disabilities (Statistics Canada,
1993a, p. 24).
3.9 School drop-out rates for poor a and non-poor
youth aged 16 and 17, Canada, 1987 to 1991
%
Non-poor
Poor
17
12
8
1987
14
13
8
1988
8
1989
7
1990
13
5
1991
a. Youth living below Statistics Canada’s low income cut-offs.
Source: Prepared by the Canadian Council on Social Development,
Centre for International Statistics on Economic and Social Welfare
for Families and Children, Newsletter No. 1, July 1993. In Canadian
Institute of Child Health (1994). The Health of Canada’s Children:
A CICH Profile, 2nd edition. Ottawa: CICH, p. 122.
1. Based on the CICH definition of “poor” child — a child who lives in a family whose total income is below
Statistics Canada’s low income cut-off (LICO).
Healthy Development
53
of Children and Youth
Education
A Closer Look at the Determinants
W
omen’s enrollment in first-year medical
school programs has been steadily increasing.
The Gender Barrier
Young women remain underrepresented in physical science courses, including physics
and chemistry, and are underrepresented in undergraduate engineering and applied
sciences. In 15 major trades, just 1% of all apprentices registered in 1992 were women.
At the community college level, in 1991–92, women accounted for only 32% of
enrollment in natural science and primary industry programs, 30% in maths/computer
science, and 12% in engineering and other technologies. In contrast, women made up
96% of enrolees in secretarial science, 89% in nursing and 90% in education and
counselling services (Statistics Canada, 1995, pp. 59–61).
Women’s enrollment in first-year medical school programs has been steadily increasing.
In the 1996–97 academic year, women composed 50.5% of first-year medical school
enrolees, up from 45.5% in 1990–91, 40% in 1980–81, and 21% in 1970–71 (Association of Canadian Medical Colleges, 1997, Table 18).
Dropping out costs money.
3.10 Unemployment rates among high school
A 1992 study calculated that, over their
collective lifetimes, all children dropping
out of school in Canada in 1989 would
cost Canadian taxpayers a cumulative
total of $4 billion (Lafleur, 1992).
Young women who drop out of high
school are more likely than young male
leavers to be unemployed; in fact, 30%
of young female drop-outs were
unemployed in 1995, compared with
17% of male drop-outs (HRDC and
Statistics Canada, 1996, p. 5). See
Exhibit 3.10.
Healthy Development
54
graduates and leavers, by sex, Canada, 1995
%
30.2
Men
Women
Total
20.9
17.3
14.1
12.9
11.3 10.4 10.8
11.2
High school
graduates (with
further education
or training)
High school
graduates (no
further education
or training)
High school
leavers
Source: Adapted from Human Resources Development Canada and
Statistics Canada (1996). After High School: The First Years — The
First Report of the School Leavers Follow-up Survey, 1995. Catalogue
No. MP78-4/12-1996. Ottawa: Human Resources Development Canada
and Statistics Canada, p. 5.
of Children and Youth
Education
A Closer Look at the Determinants
More on-reserve Aboriginal children are in school.
The total number of on-reserve children enrolled in kindergarten programs
and elementary and secondary schools increased 33% between 1987–88 and
1996–97, from 84,271 to 112,060 (DIAND, 1998, p. 30).
The percentage of Registered Indian school-aged children on reserve
enrolled in kindergarten programs and elementary and secondary schools
increased marginally, from 80.9% in 1987–88 to 82% in 1996–97 (DIAND,
1998, p. 30). See Exhibit 3.11.
Moreover, on-reserve Indian children are remaining in school longer. The
proportion of Aboriginal children who remain in school until Grade 12 almost
doubled between 1987–88 (37%) and 1996–97 (71%) (DIAND, 1998, p. 31).
See Exhibit 3.12.
3.11 Proportion of on-reserve registered Indian population aged 4 to 18
enrolled in kindergarten, elementary and secondary schools, Canada,
1987–88 to 1996–97
% aged 4–18
83
82
81
80
’87–’88 ’88–’89 ’89–’90 ’90–’91 ’91–’92 ’92–’93 ’93–’94 ’94–’95 ’95–’96 ’96–’97
School year
Source: Department of Indian Affairs and Northern Development (1998). Basic Departmental
Data 1997. QS3575-000-BB-A1, Catalogue No. R12-7/1997. Ottawa: DIAND, p. 30.
3.12 Proportion of on-reserve students remaining until Grade 12 for
consecutive years of schooling, Canada, 1987–88 to 1996–97
%
80
70
60
50
40
30
’87–’88 ’88–’89 ’89–’90 ’90–’91 ’91–’92 ’92–’93 ’93–’94 ’94–’95 ’95–’96 ’96–’97
School year
Source: Department of Indian Affairs and Northern Development (1998). Basic Departmental
Data 1997. QS-3575-000-BB-A1, Catalogue No. R12-7/1997. Ottawa: DIAND, p. 31.
Healthy Development
55
of Children and Youth
Education
A Closer Look at the Determinants
University enrollment is decreasing — slightly.
From 1993 to 1996, full-time post-secondary enrollment in university
declined for males, from 272,644 in 1993–94 to 260,436 in 1997–98. However,
during the same period, full-time enrollment for females steadily increased
— from 301,670 in 1993–94 to 312,663 in 1997–98 (Statistics Canada,
1998b).
For Registered Indians and Inuit, the story is different. The number of
Registered Indians and Inuit enrolled in post-secondary institutions almost
doubled between 1987–88 and 1996–97, rising from 14,242 to 27,487. In
1996–97, enrollment increased an additional 304 from the previous year
(DIAND, 1998, p. 32).
University Tuition Fees
Over the last decade, every province has increased university tuition fees in response to funding
constraints. As a result, more students are seeking financial assistance from federal and provincial
loans programs, and the average debt load for a four-year graduate has grown from $8,700 in 1990 to
$22,000 in 1997. Access to post-secondary education could be constrained by rising costs and concerns
about student debt (CCSD, 1997, p. 49).
Undergraduate enrollment at Canadian universities has declined over the past five years (8.6% between
1992–93 and 1997–98). This decline is due entirely to the sharp drop in enrollment of part-time
undergraduates. Full-time undergraduate enrollment has remained steady (Statistics Canada, 1998c).
Education and Other Determinants
Income
The results of teachers’ assessments of reading, writing and mathematical
abilities revealed that children from families in the lowest quintile of socioeconomic status fared worse than children from the highest quintile. They
also showed that when children in elementary schools were ranked by socioeconomic group, those in the lowest income group were three times more
likely to be placed in remedial education classes and twice as likely to repeat
a grade. Conversely, children from families with the highest socio-economic
status were twice as likely to be in gifted education programs (Lipps and Frank,
1997, p. 56). See Exhibit 3.13. Another study demonstrated that growing up
in persistent or concentrated poverty is related to school failure, which in
turn can lead to truancy, dropping out of school, behaviour problems and
delinquency (Evans, 1995, pp. 19, 24).
A 1998 study showed the poverty rate for families led by single-parent
mothers with less than a high school education was 87.2% — by far the highest
rate among all those who did not graduate from high school. Single-parent
mothers who did graduate had a poverty rate of 51.8% — again the highest
of any family type (National Council of Welfare, 1998, p. 43).
Healthy Development
56
of Children and Youth
Education
A Closer Look at the Determinants
There is evidence that people with
fewer than nine years of education are
more likely to have unrewarding, lowpaying jobs. They are also more likely
to have jobs that are characterized by
a high rate of occupational injuries, to
experience periods of unemployment,
and to rely on social assistance (Chevalier
et al., 1995, as cited in Working Group
on Community Health Information
Systems, 1995, p. 72).
3.13 Proportion of children aged 4 to 11 scoring in the
top 20% of mathematics computation test scores,
by socio-economic status group, Canada, 1994–95
%
30
25
20
15
10
5
Employment
0
Upper
Lower
A 1995 study revealed that young people
Lowest
Middle
Highest
middle
middle
aged 22 to 24 without a high school
Socio-economic status group
diploma were more likely to be
Source: Adapted from G. Lipps and J. Frank (1997). “The National
unemployed than high school graduates.
Longitudinal Survey of Children and Youth, 1994–95: Initial results from
The unemployment rate among those
the school component.” Education Quarterly Review, Vol. 4, No. 2: 43–57.
Catalogue No. 81-003-XPB. Ottawa: Statistics Canada, p. 56.
without a high school diploma was 21%,
compared with 13% for those with a high
school diploma but no further education. Individuals with both a high school
diploma and further education had the lowest unemployment rate (11%)
(HRDC and Statistics Canada, 1996, p. 5).
Social Environment
The family environment appears to play an important role in preparing
children for school. The NLSCY reports that positive parenting is associated
with normal and advanced scores on school readiness tests (Ross, Scott and
Kelly, 1996, p. 42).
On-Reserve Enrollment and First Nations Control of Education
According to federal government data, the government’s commitment to increased First Nations
control of on-reserve education is reflected in enrollment trends. The proportion of children enrolled
in band-operated elementary and secondary schools is increasing while the proportion enrolled in
schools operated by federal or other authorities is declining. More specifically:
• The proportion of children enrolled in band-operated schools increased from 31.4% in 1987–88
to 57.3% in 1996–97.
• The proportion of children enrolled in federal schools dropped to less than 2% in 1996–97 from
20.6% in 1987–88.
• The proportion of students enrolled in provincial/private schools dropped from 48% in 1987–88
to 41% in 1996–97 (DIAND, 1998, p. 36).
Healthy Development
57
of Children and Youth
Education
A Closer Look at the Determinants
References
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Disabilities Association of Canada.
Canadian Council on Social Development (1996). The Progress of Canada’s Children — 1996.
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Chevalier, S., et al. (1995). Cited in Community Health Indicators: Definitions and Interpretations.
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Entwistle, D.R., and K.L. Alexander (1989). “Early Schooling as a ‘Critical Period’ Phenomenon.”
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Evans, P. (1995). Children and Youth at Risk. In Organisation for Economic Cooperation and
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Kagan, S.L. (1992). “Readiness Past, Present and Future: Shaping the Agenda.” Young Children
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Healthy Development
59
of Children and Youth
C h a p t e r
4
Social Environment
Overview
The relationships we have in our lives — including the support we receive
from our family, friends and community — are directly associated with
general health. Effective responses to stress and the support of family and
friends seem to act as buffers against health problems. Conversely, studies
have shown that low levels of emotional support and low social participation
have a negative effect on health and well-being.
Primary supports (family and friends) and secondary supports (school
and community) contribute significantly to healthy child and adolescent
development. Parents themselves need a supportive environment in which
to raise their children. Support from family, friends and neighbours is
important in helping parents to cope with the stress of raising children.
A safe and violence-free environment within which children and youth
can live, learn and grow is crucial to their optimal development. However,
a significant number of men, women and children in Canada live with
violence or with the fear of violence. Child maltreatment and abuse have
devastating long-term outcomes for children and serious social and
economic costs for society.
Healthy Development
61
of Children and Youth
Social Environment
A Closer Look at the Determinants
Relationship to Healthy Child Development
Strong family and social support protects children.
Children’s social support is determined by their experiences with parents and
caregivers, how their family functions, the nature of their whole community,
and other factors in the broader society.
It is widely recognized that children need a significant and continuous
relationship with at least one caring adult. Other factors contribute to children’s
health and well-being, including adults setting high expectations and expressing
belief in children’s ability, and their acknowledgement of children as valued
participants in the life and work of their school, family and community
(Benard, 1991).
The impact of positive early nurturing carries on into later life. Children
who have a solid base of emotional security created by the experience of
sensitive and responsive early nurturing will be more likely to have strong and
enduring personal relationships later in life (Guy, 1997, p. 66).
Poor social support has negative consequences.
Just as strong support networks contribute to healthy child development,
inadequate social support for children and their families is potentially
very damaging. For example, children with a troubled home life in which
supportive, caring relationships are lacking
may suffer the consequences of poor
social knowledge. In turn, these children
may have difficulties maintaining stable
and fulfilling relationships with others
(Guy, 1997, pp. 64–65).
Schools and community play a role.
Secondary support networks include the
school and community, which provide
hildren who have the opportunity to
support for children and their families,
take part in a wide variety of activities
leisure and cultural activities, and safe and
nurturing environments. Children’s participation in
and programs are more likely to view
school and community activities is important. Children
themselves as capable human beings
who have the opportunity to take part in a wide variety
of activities and programs are more likely to view
and will seek out additional challenges.
themselves as capable human beings and will seek
out additional challenges (Guy, 1997, p. 86).
Children’s intellectual growth is stimulated by their relationships with the
adults who guide their learning. A long-term mentoring relationship with at
least one successful adult is also beneficial for healthy development (Werner
and Smith, 1982).
C
Healthy Development
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of Children and Youth
Social Environment
A Closer Look at the Determinants
Fear and violence have a negative impact on children.
Fear and violence in children’s wider social environment have a significant
influence on their health and well-being. Children are at risk of developing
serious problems when they witness violence or are direct victims of abuse.
Resulting physical, emotional and developmental problems can last a lifetime
(Statistics Canada, 1997a, p. 2).
Among all forms of maltreatment, witnessing spousal violence appears to
have the strongest influence on young people’s subsequent risk behaviours,
including substance abuse and criminal behaviour (Manion and Wilson, 1995,
pp. 28–29). Family violence, school difficulties, impoverished communities
and high rates of youth unemployment have been cited by the National
Crime Prevention Council as underlying risk factors for delinquency (CCSD,
1997, p. 23). The most common form of family violence — including both
physical violence and verbal abuse (e.g. teasing, name calling and isolation)
— is between siblings (CCSD, 1997, pp. 42–43).
The values and norms of the broader society have a profound influence
on the physical, mental, spiritual, social and economic health and well-being
of children and adults alike. By extension, the services and policies that reflect
norms and values related to issues such as culture and ethnicity, the place of
women in society, and the importance placed on children and families, all
have an impact on children’s health (Health Canada, 1996a, pp. 15–16).
Conditions and Trends
Parenting and Family Functioning
(or Love and Emotional Support)
A key requisite for healthy child development is
attachment to an adult who consistently provides
direction, understanding and support. According
to the National Longitudinal Survey of Children and
Youth (NLSCY), in 1994–95, most children aged 2 to
11 had fairly positive interactions with their parents and received
consistent parenting (Ross, Scott and Kelly, 1996, p. 39).
In a study of 10- and 11-year-olds in step-families, the NLSCY found
that while the majority of step-children reported moderate to good
experiences, approximately 33% of children felt they lacked emotional
support from their parents. Only 27% of children in intact families
that comprise the birth parents felt this way (Cheal, 1996, p. 98).
See Exhibit 4.1.
There are indications that many children and youth are looking to
sources outside their family for help. For example, an average of 3,000
children and youth per day call the Kids Help Phone, a national 24-hour
counselling service (CCSD, 1997, p. 10).
Healthy Development
63
of Children and Youth
A
key requisite
for healthy child
development is attachment to an adult who
consistently provides
direction, understanding
and support.
Social Environment
A Closer Look at the Determinants
4.1 Selected residential parenting arrangements and negative perceptions of family life
of children 10 to 11 years old, Canada, 1994–95
Lack of
emotional support
Erratic
punishment
Difficult family
relationships
Biologicala mother and biological father
26.8%
33.1%
28.1%
Biological mother and no father
30.2%
34.2%
60.7%
Biological mother and step-father
33.8%
49.9%
45.2%
a. Biological parents include adoptive parents.
Source: Adapted from D. Cheal (1996). “Stories About Step-families.” In Growing Up in Canada: National Longitudinal
Survey of Children and Youth. Catalogue No. 89-550-MPE, No. 1. Ottawa: Human Resources Development Canada and
Statistics Canada, p. 98.
Family Structure
While the dominant family structure remains married couples with children,
Canadian families are more diverse than ever before. The result is that children
today face a complex world of new social relationships — custodial and noncustodial parents, step-parents, members of common-law relationships, full
siblings, half siblings and step-siblings (CCSD, 1996, p. 14).
Most children live in families with married parents.
In 1994–95, most (84.2%) children lived in families with two parents (Ross,
Scott and Kelly, 1996, p. 29). See Exhibit 4.2. While divorce rates have dropped
since reaching an all-time high in 1987, current rates are significantly higher
today than they were a generation ago. The number of divorces per 100,000
people increased from 54.8 in 1967 to 273.9 in 1991 (Richardson, 1996, p. 229);
in 1994, the rate declined slightly to 269.7 (Statistics Canada, 1996a, p. 4).
Legal frameworks for divorce have changed significantly in recent years, and
statistics on family formation and dissolution were not necessarily reliable in
the past when separations and common-law unions were underreported.
There are more common-law families.
The percentage of families that include common-law spouses in Canada
doubled between 1981 and 1995, from 6% to 12%. Roughly half of these
families include children (CCSD, 1996, p. 13).
The NLSCY data suggest that common-law unions
provide a less stable family environment for
Kids with Teen Moms
children than marriages. In 1994–95, 63% of 10Contrary to popular perception, a
year-olds with parents living in a common-law
relatively small proportion of teens
union had seen their parents separate, compared
with only 14% of children whose parents were
in Canada are having babies. In
married and had not previously lived in common
1994, less than 1% of all Canadian
(Statistics Canada, 1998a).
children lived with a teen mother
(CCSD, 1997, p. 13).
Healthy Development
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of Children and Youth
Social Environment
A Closer Look at the Determinants
4.2 Distribution of children aged 0 to 11 by family type, Canada, 1994–95
Number of children aged 0 to 11 years
4,673,000
100%
Children with two parents
3,934,000
84.2%
Children with a single parent
734,000
15.7%
With a female single parent
681,000
14.6%
With both
biological parentsa
3,678,000
78.7%
Children not with
a parent
Less than 1%
With a male single parent
53,000
1.1%
With one biological parent
and one step-parent
200,000
4.3%
With otherb
two-parent families
55,000
1.2%
a. Includes 182,000 children living with step-siblings.
b. Includes children with two adoptive parents, one biological and one adoptive parent, two foster parents, two step-parents, and one adoptive and
one step-parent.
Source: Adapted from D.P. Ross, K. Scott and M.A. Kelly (1996). “Overview: Children in Canada in the 1990s.”
In Growing Up in Canada: National Longitudinal Survey of Children and Youth. Catalogue No. 89-550-MPE,
No. 1. Ottawa: Human Resources Development Canada and Statistics Canada, p. 29.
The number of step-families and lone-parent families is increasing.
In 1994, approximately 9% of Canadian children under the age of 12 lived in
a step-family, the majority of which were blended families, with both parents
bringing children from a previous relationship into their current union
(Statistics Canada, 1997b, p. 9).
Approximately 20% of all families
Who Are Kids with Problems?
with children were lone-parent families
in 1996. The number of lone-parent
Results of the 1994–95 NLSCY show that most
families as a percentage of all families in
children with behavioural, academic or social
Canada almost doubled between 1961 and
1991 (from 11% to 20%) (CCSD, 1996,
problems are from dual-parent families. For
p. 10). Eight out of 10 lone-parent families
example, almost three quarters (71.1%) of
are headed by women (CCSD, 1997, p. 12).
children with conduct disorders came from twoparent families, while 28.9% were from lonemother families (Lipman, Offord and Dooley,
1996, p. 86). This split reflects family structure
trends: most children live in dual-parent families.
Healthy Development
65
of Children and Youth
Social Environment
A Closer Look at the Determinants
The proportion of lone-parent
families is even higher among Aboriginal
people. In 1996, 32% of Aboriginal
children under the age of 15 living
in Census families1 were lone-parent
families — twice the rate of the general
population. See Exhibit 4.3. In urban
areas, the rate was even higher at 46%
(Statistics Canada, 1998b).
4.3 Proportion of children aged 0 to 14 in Census
families, by family structure, Canada, 1996
%
Total population
Aboriginal identity populationa
73.6
43.2
10.5
Married couples
Most people have family
responsibilities.
32.1
24.7
Common-law couples
16.4
Lone parents
Family type
a. The population who reported identifying with at least one Aboriginal group: North
American Indian, Métis or Inuit.
A 1992 survey of more than 5,000
Source: Adapted from Statistics Canada (1998). The Daily,
employees in eight Canadian workCatalogue No. 11-001, January 13, 1998.
places revealed that 31% of respondents had caregiving responsibilities
for dependents under 19 years of age,
20% had only elder care responsibilities, and 26% had responsibility for
both child care and elder care. Fewer than one in four employees (23%)
had neither child care nor elder care responsibilities (Work and
Eldercare Research Group of CARNET, 1993,
pp. 3–5).
Families are smaller.
The majority (81%) of all families in Canada have either one or two children
(CICH, 1994, p. 5). Smaller families mean fewer relatives (Vanier Institute of
the Family, 1994, p. 10) and fewer sources of social support for members.
Since Canada is a country of mobility and immigration, extended support
networks are often drawn from outside the family.
Family Violence
Child welfare is an area of provincial jurisdiction, and there are significant
variations in the types of data collected and the manner in which they are
reported. For these reasons, national child abuse data are currently not
available. However, development of a national database — the Canadian
Incidence of Reported Child Abuse and Neglect — is under way. We do
know that, on a national scale, children are frequently the victims of family
violence. Girls are most often the victims of sexual assault.
1. “Census family” is defined by Statistics Canada as a now-married couple (with or without never-married sons
or daughters of either or both spouses), a couple living common-law (again with or without never-married sons
or daughters of either or both spouses), or a lone parent of any marital status, with at least one never-married
son or daughter living in the same dwelling. Families of now-married and common-law couples together
constitute husband-wife families.
Healthy Development
66
of Children and Youth
Social Environment
A Closer Look at the Determinants
Reported violence against children is increasing.
Maltreatment assessments, complaints, and the number of children in need
of protection appear to be increasing in most Canadian provinces. Moreover,
it is generally accepted that substantial numbers of cases still go unreported
in many jurisdictions (Wachtel, 1989, pp. 7–8). At the same time, public
education programs across the country aimed at sensitizing the public to the
full impact of violence against children are resulting in increases in reports
of violence.
A survey of selected police agencies in 1996 showed that children under
18 years of age were the victims in 22% of all reported violent crimes. A much
higher proportion of these assaults were sexual (60%) than physical (18%)
(Statistics Canada, 1997c).
Family members are accused in one fourth
of all assault cases against children under age
Children of Violence
18. Very young children (under age 3) are more
Children who witness their mother
likely to be assaulted by family members than
being abused by their father or other
non-family members — almost 70% of victims
under the age of 3 were assaulted by members
male partner display higher rates of
of their own family (Statistics Canada, 1997c).
emotional problems, low self-esteem,
withdrawal and depression. They also
Girls are most at risk from sexual abuse.
tend to have lower levels of school
It has been estimated that 25% of girls and 10%
of boys will be sexually abused before the age of 16
(Finkel, 1987, p. 245). Results of a 1998 study by
Statistics Canada showed the following:
achievement (National Clearinghouse
on Family Violence, 1996, p. 3).
• Overall, girls are the primary victims of sexual assaults by family members,
and represent four in every five victims of sexual assault by a family
member (79%). Girls were also the victims in more than half of physical
assaults (56%) (Statistics Canada, 1998c, p. 22).
• Girls and boys appear to be vulnerable to abuse by family members at
different stages of their development. Higher numbers of girls were sexually
assaulted by a family member at 12 to 15 years of age. In contrast, boys were
more likely to be sexually assaulted between the ages of 4 and 8 (Statistics
Canada, 1998c, p. 3).
• Of all reported child abuse cases committed by family members, 20% were
physical assault. Parents were the most likely perpetrators in 64% of these
cases; 73% were committed by fathers and 27% by mothers. Thirty-two
percent of all reported sexual abuse cases were committed by a family
member. In 43% of these sexual assault cases, one of the parents was the
most likely perpetrator. In almost all of these cases (98%), the father was
responsible; responsibility for the other 2% rested with the mother. The
remaining 57% of sexual assault cases involved a sibling (28%), an extended
family member (27%) or a spouse (1%). (Statistics Canada, 1998c, p. 22).
Healthy Development
67
of Children and Youth
Social Environment
A Closer Look at the Determinants
Wife assault and child abuse
often co-exist.
Costs of Violence
There are many social costs associated with
One in three Canadian women has been
assaulted by her partner, with many of these
assaults being witnessed by children (Statistics
Canada, 1994, pp. 4, 14). There is a 30% to
40% overlap between children who witness
wife assault and children who experience
direct physical or sexual abuse themselves
(Jaffe, Wolfe and Wilson, 1990, pp. 21–22).
family violence: children and adolescents with
histories of maltreatment are more likely to
engage in risky behaviours and to come into
contact with the justice system. Adolescents
who have experienced neglect, physical, emotional or sexual abuse, or exposure to interparental violence are more likely to run away
Violence is a problem in Aboriginal
families.
from home and to use tobacco and other
There are currently no national data on the
incidence of family violence in Aboriginal
communities. However, existing research
indicates that abuse pervades these communities. For example:
adjust to life changes and are more likely to
drugs. These adolescents are often less able to
contemplate suicide, suffer from mental illness
and engage in criminal behaviour (Manion
and Wilson, 1995, pp. 7, 28).
It is estimated that the public spends
• 39% of Aboriginal adults say that family
violence is a problem in their community, and
a large proportion state that unemployment,
alcohol, sexual abuse and suicide are significant problems (Statistics Canada, 1993,
p. 114). See Exhibit 4.4.
US$169,029 on each child sexual abuse
offender. The expenditure for each victim
is estimated at US$14,304 (Prentky and
Burgess, 1990, pp. 106–120).
• In some northern Aboriginal communities, it is believed that between 75%
and 90% of women are battered. One study found that 40% of children in
these communities had been physically abused by a family member (Health
Canada, 1996b).
4.4 Proportion of Aboriginal people, aged 15+, identifying selected social issues
as a problem, Canada, 1991
Indians on reserve
Indians off reserve
%
78
75
Métis
Inuit
73
67
60
56 59 58
59
43 45
49
44
36 39
44
29
Unemployed
Alcohol abuse
Drug abuse
Family violence
35
35
41
22 23
20 22
Sexual abuse
Suicide
Social issues
Source: Statistics Canada (1993). Language, Tradition, Health, Lifestyle and Social Issues: 1991 Aboriginal
Peoples Survey. Catalogue No. 89-533. Ottawa: Statistics Canada.
Healthy Development
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of Children and Youth
Social Environment
A Closer Look at the Determinants
School and Community Networks
As seen earlier, the relationships that children and youth establish and
the experiences they have in their school and community are critically
important to their development. A child’s secondary support network is
the local community, which offers developmental opportunities through
informal play, organized recreation, schooling and cultural experiences.
A supportive school environment is important.
Schools can provide a variety of positive influences on children. They can
promote self-esteem, provide opportunities to experience success, and enable
students to develop both social and problem-solving skills (Rutter, 1987).
A supportive school environment can also act as a buffer against potentially
harmful conditions in the home and in other non-school environments
(Dubois et al., 1992).
“Successful” schools are characterized by a number of common elements
related to social support: higher levels of parental involvement; higher teacher
expectations of student achievement; relevant curriculum content with emphasis
on specific literacy skills; collaboration among administrators, teachers and
students; a positive school climate where students feel safe and have a sense
of belonging; integration of students from differing social class backgrounds
and ability levels; and an emphasis on prevention over remediation (Willms,
1999).
According to the NLSCY, most children are involved in sports outside of
school; however, only 30% attended music, dance or art lessons or participated
in Brownies or Scouts (CCSD, 1997, p. 47).
Cost is a factor.
While most Canadian cities provide recreational programs for children and
youth, almost all charge user fees (CCSD, 1997, p. 32). According to the
Canadian Council on Social Development, nearly half of poor families say a
barrier to participation is the cost of physical recreation (CCSD, 1997, p. 9).
Almost 70% of 4- to 11-year-olds from
families earning less than $20,000 a year
4.5 Average yearly expenditures on physical activities
did not participate in organized sports
for children aged 0 to 18, Canada, 1995
such as hockey or gymnastics; however,
Equipment
approximately two thirds of children from
$258
Clothing
households with a family income of
33%
$133
17%
$40,000 or more did participate (NLSCY
data cited in CCSD, 1997, p. 47). See
6% Other
Transportation 14%
Exhibit 4.5.
$46
$108
10%
Membership
and user fees
$87
20%
Instruction
and coaching
$160
Source: Canadian Fitness and Lifestyle Research Institute (1996).
“The Economics of Participation.” Progress in Prevention, Bulletin
No. 10, p. 2.
Healthy Development
69
of Children and Youth
Social Environment
A Closer Look at the Determinants
Community Security
The majority of Canadian children live in neighbourhoods that their parents
believe to be safe; however, one in four children lives in an area that their
parents believe is unsafe after dark (CCSD, 1997, p. 8). See Exhibit 4.6.
Children and youth themselves are fearful — a 1996 study of 15-year-olds
found that one half of the boys and one quarter of the girls felt that bullying
was a problem (CCSD, 1997, p. 10).
4.6 Proportion of children aged 0 to 11 whose parents report selected safety
issues in their neighbourhood, Canada, 1994–95
A. Extent to which selected issues are reported by parents as problematic
“Big problem”
“Somewhat of a problem”
%
“No problem”
87
86
73
61
34
23
11
11
5
3
Burglary
4
2
Drugs
Public drinking
Trouble with
young people
B. Proportion of parents who agree/disagree with selected statements
about neighbourhood safety
“It is safe to walk alone in the
neighbourhood after dark.”
“It is safe for children to
play outside during the day.”
Strongly
agree 37%
Strongly
agree 27%
Strongly
disagree 5%
Strongly
disagree 2%
Disagree
18%
Agree
50%
Agree
51%
Disagree
10%
Source: Prepared by the Centre for Internatinal Statistics at the Canadian Council on Social Development
using Statistics Canada’s National Longitudinal Survey of Children and Youth, 1994 and 1995. In Canadian
Council on Social Development (1997). The Progress of Canada’s Children — 1997. Ottawa: CCSD, p. 23.
Child and Youth Crime
While the overall rate of Criminal Code offences among youth declined between 1991 and 1996, there has been an increase in the proportion of young
offenders charged with violent crime. For all offences, the 1996 youth rate
Healthy Development
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of Children and Youth
Social Environment
A Closer Look at the Determinants
was down 4% from that of 1991. Of
these 118,000 youth, 56% were charged
with property offences and approximately
20% were violent crimes. Over the past
decade, the rate of violent crimes has more
than doubled from 9% in 1986. This may
seem alarming, but the rising rate is due
to the increased proportion of common
assaults, the least serious form of assault
(Statistics Canada, 1997d, p. 7).
In 1996–97, 12- and 13-year-olds
accounted for 12% of cases in youth court,
while 16- and 17-year-olds accounted for 49%
of cases (Statistics Canada, 1998d). Youth
court statistics (Statistics Canada, 1998d)
show that:
Street Youth
Although the exact numbers of street youth
in Canada are not known, estimates are high.
For example, between 3,000 and 5,000 youth
lived on the streets in Toronto in 1990. The
same study of Toronto’s street youth revealed
that about two thirds had been physically
abused and one fifth had been sexually abused
by someone living with them. Over half (58%)
of those surveyed reported that the abuse
contributed to their decision to live on the
street (Smart et al., 1992, p. 24).
• The overall caseload decreased 8.5%
between 1992–93 and 1996–97.
• Property crime (which accounts for about one
half of all youth court cases) dropped 20.6% over
the same period, while violent crime increased very
slightly and drug cases doubled.
• Since 1992–93, about one half of all cases heard
involved minor assaults. Murder/manslaughter cases
accounted for less than 1% of youth court cases.
A 1994 public opinion survey showed that most (four
out of five) Canadians felt that Canada’s justice system
was too lenient (Angus Reid Group Inc., 1994, p. 18).
A
lthough the exact
numbers of street youth
in Canada are not known,
Social Environment and Other Determinants
estimates are high. For
example, between 3,000
and 5,000 youth lived on
Income
the streets in Toronto
in 1990.
Divorce affects children emotionally and economically. Children
of divorced parents are more likely to live in poverty, be exposed to
ongoing inter-parental conflict, and see less of their non-residential
parent. At the same time, the mothers of these children experience
increased social support (Mandell and Duffy, 1995, p. 227).
Poverty is a significant risk factor for exposure to family or neighbourhood
violence and the development of aggressive behaviour patterns. In 1995, the
National Council of Welfare reported that about 2.6 million Canadian households were living in poverty (CCSD, 1997, p. 29).
Healthy Development
71
of Children and Youth
Social Environment
A Closer Look at the Determinants
Child abuse and neglect can be attributed to a number of factors — one
of which is poverty. “Family factors include substance abuse, a history of family
violence, high levels of family discord and inadequate parenting in the previous
generation. Social and economic factors include inadequate monetary support,
unemployment or underemployment and a lack of social services” (Advisory
Committee on Children’s Services, 1990, p. 22).
Education
According to the NLSCY, positive parenting is associated with normal and
advanced scores on school readiness tests (Ross, Scott and Kelly, 1996, p. 42).
Genetic and Biological Factors
Biological and genetic risk factors can limit the kinds of environment in which
children are able to participate. For example, some schools and recreational
facilities may not be able to accommodate children with disabilities. Children
with this type of risk factor may have their health further impaired by being
in an inappropriate environment.
Role of the Media
Either explicitly or implicitly, the media convey socializing messages that influence
children’s values, attitudes and social behaviour patterns.
Accessibility to new technologies is increasing the potential for exposure to violent
media messages. Violence is very much a part of the entertainment culture —
including television, video, films, video games and comic books (CPHA, 1994, p. 12).
Cable TV subscriptions increased from 47% in 1977 to nearly 74% in 1994 (Frank,
1995, p. 5). In 1996, nearly one third (31.6%) of households owned a personal
computer — three times as many as in 1986 (Statistics Canada, 1996b). Television
watching is cited as the most common extra-curricular activity of children (CCSD,
1997, p. 10).
Each year, the average Canadian child is exposed to 12,000 acts of violence and
more than 1,000 rapes on television. By the time that same child graduates high
school, he or she will have been exposed to 18,000 television murders and 800
television suicides (Chance, Avard and Thurm, 1995, p. 2).
Healthy Development
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of Children and Youth
Social Environment
A Closer Look at the Determinants
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Statistics Canada (1997a). “Assaults Against Children and Youth in the Family, 1996.” Juristat
Service Bulletin, Vol. 17, No. 11. Catalogue No. 85-002-XPE. Ottawa: Statistics Canada.
Statistics Canada (1997b). “Canadian Children in the 1990s: Selected Findings of the NLSCY.”
Canadian Social Trends, Vol. 44 (Spring 1997): 2–9. Catalogue No. 11-008XPE. Ottawa:
Statistics Canada.
Statistics Canada (1997c). The Daily, November 6, 1997.
Statistics Canada (1997d). “The Justice Data Fact Finder.” Juristat Service Bulletin, Vol. 17, No. 13.
Catalogue No. 85-002-XPE. Ottawa: Statistics Canada.
Statistics Canada (1998a). The Daily, June 2, 1998.
Statistics Canada (1998b). The Daily, January 13, 1998.
Statistics Canada (1998c). Family Violence in Canada: A Statistical Profile 1998. Catalogue No. 55224-XPE. Ottawa: Statistics Canada.
Statistics Canada (1998d). The Daily, April 30, 1998.
Vanier Institute of the Family (1994). Canadian Families. Ottawa: Vanier Institute of the Family.
Wachtel, A. (1989). Child Abuse: Discussion Paper. Ottawa: National Clearinghouse on Family
Violence, Health and Welfare Canada.
Werner, E.E., and R.S. Smith (1982). Vulnerable but Invincible: A Longitudinal Study of Resilient
Children and Youth. New York: McGraw-Hill.
Willms, J.D. (1999). “Quality and Inequality in Children’s Literacy: The Effects of Families,
Schools and Communities”. In Developmental Health and the Wealth of Nations: Social, Biological
and Educational Dynamics. Edited by D.P. Keating and C. Hertzman. New York: Gilford Press,
pp. 72–93.
Work and Eldercare Research Group of the Canadian Aging Research Network (CARNET)
(1993). Work and Family: The Survey. Guelph, ON: Gerontology Research Centre, University
of Guelph.
Healthy Development
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of Children and Youth
C h a p t e r
5
Natural and Built
Environments
Overview
The physical environment — both natural and that modified or built by
humans — plays a crucial role in the development of a healthy child. It
includes the housing in which children live, the air they breathe, the water
they drink, the food they eat, the consumer products they use, and the parks
and communities in which they play. Children are exposed to different
hazards, within both natural and built environments.
These hazards can be divided into four areas.
Hazards caused by the physical environment: These hazards cause
unintentional injuries of many types, including traffic-related injuries,
drowning, animal attacks, suffocation, burns, falls, and poisoning. They
are the leading cause of death and a major cause of hospitalization for
children. They can also cause long-term disabilities.
Biological hazards: Infections caused by pathogenic micro-organisms are
termed biological hazards. They are spread through direct contact, food,
air, soil and water, and can impair child health. The consequences of these
infections range from mild gastro-intestinal discomfort to death.
Chemical hazards: Chemicals released into the environment may be present
in air, water, soil and food. In some situations, these chemicals may present
a risk to children.
Global environmental degradation: Children face serious threats to their health
from the effects of global warming and the thinning of the ozone layer.
Healthy Development
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of Children and Youth
Natural and Built Environments
A Closer Look at the Determinants
There is a definite interconnection between the natural and built environments. For instance, the quality of air — an important component of the
natural environment — is strongly influenced by human activities, such as
the operation of vehicles and industrial plants. The quality of drinking
water is influenced by the type of water used and the purification processes.
The quality of food is affected by agricultural practices such as the use
of pesticides, fertilizers, supplements and additives and the methods of
storage and preparation.
Indoor air, however, is even more affected by human activity. Its quality is
not only influenced by outdoor air pollutants, but also by indoor activities
such as cooking and by the quality of the housing (highly energy-efficient
housing with insufficient ventilation will increase indoor air pollutants).
In addition, the habits of residents, such as smoking, contaminate indoor
air. Environmental tobacco smoke (ETS) is a persistent indoor air contaminant. Damp houses and classrooms are breeding grounds for moulds,
which are strong allergens.
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Natural and Built Environments
A Closer Look at the Determinants
Relationship to Healthy Child Development
Children are highly vulnerable to their physical environment. They are more
sensitive to toxicants and hazardous conditions than their adult counterparts.
This enhanced vulnerability is caused by their behaviour, their physiology and
their early stage of development (Chance and Harmsen, 1998).
Behaviour
Several behavioural characteristics of children increase their exposure to physical,
biological and chemical hazards in both the natural and built environments.
Children’s behaviour and injury
Infancy is a time of increased mobility and discovery. However, this puts
children at increased risk of falling, suffocating, and accidental poisoning.
Preschool children have an increased vulnerability because of their curiosity,
their growing sense of independence, and because they do not have the
reasoning skills to understand danger. They are vulnerable to a wide range
of injuries, particularly from falls, ingesting poison, and water- and trafficrelated incidents. School-age children experience fewer injury deaths and
injury hospitalizations compared with toddlers; however, these older children
are involved in other injury incidents, such as those related to bicycles and
playgrounds. As teenagers strive to achieve more and more independence,
they experiment and take risks, which increases their chances of sustaining
severe injuries (Rivara, 1994).
Children’s behaviour and exposure to chemical and biological hazards
Children and infants in particular eat up to three times more food and drink
up to four times more fluids per kilogram of body weight than older children
or adults. The diets of children tend to be less varied; for example, children
have unique food preferences, eat more apples, and drink more juice (National
Research Council, 1993, pp. 167–192). This concentrated consumption of
particular foods may mean that children have a higher exposure to chemical
hazards, such as pesticide residues, than adults. In addition, young infants
are likely to ingest toxic or infectious agents in dust or soil because they play
on the ground, and because of their hand-to-mouth activity and teething
behaviour (Calabrese, Stanek and Gilbert, 1991).
Infants and young children spend, on average, 85% to 90% of their time
indoors (Samet et al., 1993). Indoor air contaminants tend to concentrate
at the floor level; because children are physically smaller and spend much
time on the floor, they may be exposed to higher concentrations of these
contaminants than adults. Ventilation clears the air at adult heights, but
children playing close to the floor won’t benefit from this (Fenske, 1992).
See Exhibit 5.1 and Exhibit 5.2. Children often sit near or on adults and are
therefore closer to the source of second-hand smoke.
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of Children and Youth
Natural and Built Environments
A Closer Look at the Determinants
Also, children are at greater risk of exposure to air pollutants (both
indoors and outdoors) because they spend more time engaged in vigorous
activities compared with adults. They breathe more rapidly and inhale more
pollutants per kilogram of body weight. Children engaging in vigorous activities
at swimming and skating facilities may be exposed to higher concentrations
of chlorinated compounds in swimming pools and carbon monoxide (CO)
and nitrous dioxide (NO2) in ice arenas (Aggazzotti et al., 1993).
5.1 Chlorpyrifos air concentrations in the breathing zone of a crawling child
and sitting adult in a non-ventilated room, Canada, 1987
Child zone (25 cm)
µg/cu meter
Adult zone (100 cm)
100
80
60
40
20
0
.5
1
1.5
3
5
7
10
24
Time interval (hours post-application)
Source: R.A. Fenske (1992). “Differences in Exposure Potential for Adults and Children Following
Residential Insecticide Application.” In P.S. Guzelion et al. (eds.). Similarities and Differences
Between Children and Adults, p. 217. Used with permission. ©1992 International Life Sciences
Institute, Washington, D.C., U.S.A.
5.2 Chlorpyrifos air concentrations in the breathing zone of a crawling child
and sitting adult in a ventilated room, Canada, 1987
Child zone (25 cm)
µg/cu meter
Adult zone (100 cm)
100
80
60
40
20
0
.5
1
1.5
3
5
7
10
24
Time interval (hours post-application)
Source: R.A. Fenske (1992). “Differences in Exposure Potential for Adults and Children Following
Residential Insecticide Application.” In P.S. Guzelion et al. (eds.). Similarities and Differences
Between Children and Adults, p. 218. Used with permission. ©1992 International Life Sciences
Institute, Washington, D.C., U.S.A.
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of Children and Youth
Natural and Built Environments
A Closer Look at the Determinants
Physiology and Chemical Hazards
It is now known that the fetus is exposed to toxicants, which pass through
the placenta, either as a result of maternal behaviour during pregnancy (such
as smoking, or alcohol and drug use) or because toxicants such as persistent
organic pollutants or heavy metals are already present in the bodies of pregnant
women. Although the known benefits of breastfeeding outweigh the uncertain
risks associated with contaminants in human milk, the presence of elevated
levels of some persistent organic chlorine contaminants such as polychlorinated
biphenyls, dioxins and furans in the milk of Inuit women has raised concern.
Since compounds such as lead or organochlorine (OCs) can accumulate in
body tissues, exposure prior to pregnancy contributes to the overall amount
stored in the mother’s body and also results in exposure to the developing
fetus during pregnancy (DIAND, 1997, pp. 411–412).
Small children can absorb more toxicants from ingested food, water, air,
dust or soil than adults (Plunkett, Turnbull and Rodricks, 1992). For instance,
children are able to absorb a greater percentage of ingested lead because
their system is up to five times more efficient. In addition, an immature blood
brain barrier in infants is less selective in its permeability and hence will pass
lead more easily (Rodier, 1995).
A child’s ability to metabolize, detoxify and eliminate toxicants can be
different from an adult’s. For example, an infant may be more susceptible
to toxic chemicals because the detoxification enzymes in the liver and the
excretion capabilities of the kidney are immature, especially in the first year
(Chance and Harmsen, 1998).
Development and Chemical Hazards
Growing tissue is susceptible to interference; consequently, developing organs
are more prone to functional damage. Organ development begins in the fetal
stage and continues into adolescence. The growth of the organs is not linear,
occurring instead in spurts. If toxic exposure occurs during these critical growth
stages, the system can sustain permanent damage.
The brain is the most complex organ, needs the longest time to develop,
and hence is potentially the most vulnerable to environmental influences.
At all phases of growth, the brain is vulnerable to environmental influence.
The brain’s developmental phases are particularly crucial because of the finite
nature of neural tissue growth. Critical growth periods missed or critical cell
systems lost will not be replaced, unlike in some other organs such as liver or
muscles, which can regenerate easily (Rodier, 1995). This disturbed neural
tissue growth may cause neurological abnormalities later on in life.
Even low exposure levels of toxicants can affect organ development (Rice,
1998). The so-called hormonal or endocrine disruptors can interfere with
growth at concentrations which are up to 10,000 times lower than those needed
for acute toxicological effects (Colborn, Dumanoski and Peterson Myers, 1996,
pp. 110–121). As yet, there is no hard evidence that endocrine disruptors
have caused adverse health effects in people at levels typically found in our
environment (Health Canada, 1997a, pp. 126–127).
Healthy Development
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Natural and Built Environments
A Closer Look at the Determinants
Conditions and Trends: Natural Environment
Ambient Air Quality
The major sources of air pollution are both natural and human-made. Air
pollutants arise from the combustion of fossil fuels for energy generation
in industrial processes, transportation and heating. Air pollutants can be
transported over long distances. For example, a reddish-brown haze present
in the Arctic originated in Europe and Asia (Environment Canada, 1996,
p. 10-13). In the Windsor–Quebec corridor, ground level ozone originates
in the United States, while Ontario’s SO2 emissions affect the air quality in
the eastern United States and the Atlantic provinces (Environment Canada,
1996, p. 10-11). Other compounds, such as lead, as well as pesticides, dioxins
or PCBs are transported through the air over long distances. For instance,
pesticides used in Latin America, Mexico and the United States have contributed substantially to the pesticide levels in the Great Lakes and the Arctic
(Environment Canada, 1996, pp. 9-14–9-20).
Because children breathe faster than adults, the amount of inhaled air
relative to a child’s size and weight is substantially higher (Plunkett, Turnbull
and Rodricks, 1992). Children’s lungs are vulnerable; during infancy and
up to age 8, the number of alveoli is still increasing and growing. Effects of
air contaminants on children range from coughing, wheezing and asthma
to diminished lung function. These effects, in turn, result in increased
hospitalizations.
Outdoor airborne contaminants that impact on children’s health are
sulphur dioxide, small airborne particles, ground-level ozone and lead.
See Exhibit 5.3.
5.3 Trends in common air contaminants, Canada, 1979 to 1993
% of maximum acceptable level
60
50
Total suspended particles
40
30
Ground-level ozone
20
Nitrogen oxide
Carbon monoxide
10
Sulphur dioxide
0
‘79
‘80
‘80
‘81
‘82
‘83
‘84
‘85
‘86
‘87
‘88
‘89
‘90
‘91
‘92
‘93
Year
Note: Maximun acceptable levels are 82 parts per billion (ppb) for ozone (1h), 344 ppb for sulphur dioxide (1h), 213 ppb for nitrogen
dioxide (1h), 13 parts per million (ppm) for carbon monoxide (8h), and 120 µg/m3 for total suspended particles (24h). Data plotted
are average annual levels at all monitoring stations.
Source: Government of Canada (1996). The State of Canada’s Environment — 1996. Ottawa: available
from Environment Canada, p. 10-10. Reproduced with the permission of the Minister of Public Works
and Government Services, 1998.
Healthy Development
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of Children and Youth
Natural and Built Environments
A Closer Look at the Determinants
Sulphur dioxide
SO2 is a highly water-soluble, irritating gas that originates from the burning
of sulphur and sulphur-containing coal, gas and oil. Maximal SO2 levels occur
in winter. About 73% of the SO2 responsible for air pollution comes from
industry, specifically the metal ore industry; 23% results from the combustion
of fuel from power generators, while 4% comes from heavy vehicles that
burn diesel fuel. Levels of SO2 have decreased over the years (Environment
Canada, 1996, p. 10-10).
Increased levels of SO2 affect children’s health and cause acute irritation
of the upper respiratory tract (i.e. the nose and throat), as well as the eyes.
At higher concentrations, SO2 may cause bronchoconstriction and ultimately
a decline in lung function. Children with asthma are more sensitive to SO2
than non-asthmatic children. It is estimated that 1% of the hospitalizations
of children in Ontario result from high levels of SO2 in ambient air (Burnett
et al., 1994).
Airborne particles
Airborne particles are small particles that stay suspended in air. They vary in
size and, in general, the smaller the size of the particle, the greater the health
risk. Airborne particles are produced by a variety of sources both natural
and synthetic. In Canada in 1992, 65% of the total emission of particles was
released into the air by mining, coal, wood, and pulp and paper industries,
while 22% was derived from fuel combustion, either from power generation
or from residential heat production, such as wood burning. Transportation
accounted for 10% of the small particle emissions. Naturally occurring events
such as soil erosion, forest fires and dust from windstorms also contribute
to airborne particles. Over the last 10 years, industrial particulate emissions
have declined, but emissions from residential wood burning have increased
(Environment Canada, 1996, pp. 10-12–10-13).
Particles smaller than 10 µm (called particulates) are not filtered by the
nose and can reach the bronchial area and be deposited in the lungs. They
can damage the lungs and affect the health of children. Increases in airborne
particulate levels have been associated with an increase in children’s coughing,
hospitalizations, and impaired lung function in both healthy and asthmatic
children (Dockery and Pope, 1994; Koren, 1995). Children with asthma are
more sensitive to particulates than non-asthmatic children. The mechanisms
by which inhaled particles injure the lung are diverse, but inflammation of
the lung plays an important role (Koenig, Covert and Pierson, 1989).
Ground-level ozone
Ground-level ozone is formed when sunlight and warm temperatures interact
with oxides of nitrogen (NOX) and volatile organic compounds (VOCs).
Ground-level ozone is highest during daylight in the summer and is a major
constituent of summer smog. In 1992, high annual averages of ground-level
ozone were found in the Windsor–Quebec corridor, the Lower Fraser Valley
and the southern Maritimes (Environment Canada, 1996, p. 10-12).
Healthy Development
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Natural and Built Environments
A Closer Look at the Determinants
Ground-level ozone poses a unique problem for children because ozone is
formed on sunny days, when children are more likely to be active and playing
outside. Ground-level ozone affects children with asthma as well as children
with no known pulmonary diseases. In Ontario during the summers from 1983
to 1988, it is estimated that about 15% of total hospital admissions of infants
were attributable to the effect of ozone (Burnett et al., 1994). See Exhibit 5.4.
This effect did not show a threshold, which could indicate that no safe level
of ozone exists. In addition, ozone in young children may have an impact on
alveoli surfaces of young children, which could affect future lung development
(Richards and Brooks, 1995). Several studies have reported a decline in lung
function of children after exposure to ozone (Spektor et al., 1988).
5.4 Hospital admissions for respiratory conditions — relationship
to selected air quality factors, Ontario, 1983 to 1988
A. Relationship between daily respiratory admissions and daily
maximum one-hour ozone levels (ppb) on the previous day,
Ontario hospitals, 1983 to 1988
Daily respiratory admissions
114
112
110
108
106
104
102
10
20
30
40
50
60
70
80
90
Daily maximum one-hour ozone level (ppb)
(recorded on previous day)
100
B. Relationship between daily respiratory admissions and daily
average sulphate levels (µg/m3) on the previous day, Ontario
hospitals, 1983 to 1988
Daily respiratory admissions
114
112
110
108
106
104
102
0
2
4
6
8
10
12
14
Daily average sulfate level (µg/m3)
(recorded on previous day)
16
20
Source: R.T. Burnett et al. (1994). “Effects of low ambient levels of ozone and
sulphates on the frequency of respiratory admissions to Ontario hospitals.”
Environmental Research, Vol. 65: 172–94.
Healthy Development
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of Children and Youth
Natural and Built Environments
A Closer Look at the Determinants
Atmospheric lead
Atmospheric lead is derived mainly from vehicles burning leaded gasoline, with
minor contributions from smelters and battery plants. Since the elimination
of leaded gasoline in 1990, exposure to lead through ambient air is less of
a concern. In Canada, levels of atmospheric lead have declined 95% since
unleaded gasoline became available (Environment Canada, 1996, p. 13-11).
See Exhibit 5.5. Over the last 25 years, the mining industry has also reduced
its lead emissions (Environment Canada, 1996, p. 11-64).
The developing brain and nervous system of the fetus and young child
are particularly vulnerable to lead. Adverse effects include IQ deficiencies,
reading and learning disabilities, hyperactivity, and hearing problems. Even
lead blood levels as low as 10µg/100 ml are associated with adverse effects;
no obvious threshold for lead seems to exist (Needleman and Gatsonis, 1990).
5.5 Total lead content of gasoline sold in Ontario and mean annual airborne
lead concentrations in Toronto, 1971 to 1993
1.0
0.5
0.0
1971
1975
1977
4
2
Lead content
in gasoline
lowered
1973
6
1979
1981
1983
1985
1987
1989
1991
Total lead content of gasoline sold
(g. billions)
Airborne lead
concentration
Lead content in gasoline
lowered
Total lead in gasoline
1.5
Lead eliminated gasoline
in December 1990
8
Lead-free gasoline
introduced
Mean annual airborne lead
concentration (µg/m3)
2.0
0
1993
Source: Government of Canada (1996). The State of Canada’s Environment — 1996. Ottawa: available
from Environment Canada, p. 13-11. Reproduced with the permission of the Minister of Public Works
and Government Services, 1998.
Water and Food Quality
Quality food and drinking water are essential for the growth and health of
children. In Canada, the quality of food and water in general is very good;
however, biological and chemical contamination of these necessities does
occur, with possible acute and long-term health effects (Health Canada, 1997a,
pp. 84–85).
Some pollutants found in the water can bioaccumulate in the food chain.
Substances such as persistent chlorinated compounds (PCCs) and metals such
as mercury are in water at low concentrations. However, these compounds
can accumulate in the food chain at incredibly high levels — 10,000 times
higher in fish than in water, and in even higher concentrations in mammals
and birds (Colborn, Dumanoski and Peterson Myers, 1996, pp. 87–109).
Healthy Development
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of Children and Youth
Natural and Built Environments
A Closer Look at the Determinants
Because children eat and drink three to four times more food and fluids
than adults per kilogram of body weight and eat a less varied diet, they
experience higher doses of contaminants than adults per kilogram of body
weight (National Research Council, 1993, pp. 172–192).
However, the Government of Canada, through Health Canada, Agriculture
and Agri-Foods Canada, Fisheries and Oceans Canada and Environment
Canada, has programs in place aimed at safeguarding Canada’s food supply
for Canadians.
Biological contamination
Rate per 100,000
Both food and water are occasionally contaminated by biological agents
including bacteria, viruses and protozoa. Children are more vulnerable than
adults to biological contaminants. Recent data from British Columbia show
that preschoolers aged 1 to 4 have the highest rates of intestinal infections.
(B.C. Provincial Health Officer, 1998, pp. 65–78). See Exhibit 5.6. Giardia is
the most commonly implicated
protozoan parasite in outbreaks
5.6 Reportable intestinal disease rates, by selected age groups,
of water-borne disease.
British Columbia, 1987 to 1996
Cryptosporidium, also a
protozoan parasite and even
700
more chlorine-resistant than
600
Giardia, was implicated
Ages 1–4
in recent outbreaks. Half
500
of the people affected by
400
Cryptosporidium were children
Under age 1
under 14 years of age (B.C.
300
Provincial Health Officer,
200
1998). Food-borne illnesses
Ages 5–14
Age 15+
result primarily from improper
100
food handling, preparation
0
and storage. Salmonella and
1987 1988 1989 1990 1991 1992 1993 1994 1995 1996
Campylobacter bacteria are
associated with these outbreaks
Source: B.C. Provincial Health Officer (1998). The Health and Well-being of
(Health Canada, 1997a,
British Columbia’s Children: Provincial Health Officer’s Annual Report 1997:
Victoria: B.C. Ministry of Health, p. 73.
pp. 110–112).
Chemical contamination
The most common pathways of exposure to contaminants include breathing
indoor air and ingesting food, water and other materials. In food, one can find
heavy metals such as lead and mercury, pesticides, organochlorine compounds,
and organic compounds such as mycotoxins. Vegetables and fruits may contain
many natural compounds, which when tested under laboratory conditions,
are found to be carcinogens. The effects of many of these natural toxicants
are quite hazardous and detrimental to the health of children (Ames and
Gold, 1992).
Healthy Development
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Natural and Built Environments
A Closer Look at the Determinants
Breast milk
Breastfeeding is widely accepted as the optimum method of feeding for the
first year of life. Many toxicants are found at low levels in human breast milk,
including prescription drugs, methyl mercury, lead, and estrogen mimickers
(Kacew, 1993). Fat-soluble and persistent compounds (e.g. PCBs, DDT, lindane,
hexachlorobenzene) absorbed by the mother over her lifetime are also
accumulated in breast milk and transferred to the infant during breastfeeding
(Mes et al., 1993). See Exhibit 5.7.
In general, the levels of these chemicals in breast milk are low. It is difficult
to determine whether any related health effects originate while the fetus is in
the womb or during the course of breastfeeding. There have been suggestions
that exposure of infants to PCBs or dioxins in breast milk may be associated
with (small) neurological and immunological abnormalities, although frequently
these effects were transient (Rogan and Rogan, 1994). Since the 1970s, the
levels of PCBs and organochlorine pesticides in human breast milk have dropped
(Mes et al., 1993). Nevertheless, both Health Canada and the World Health
Organization, among others, have concluded that human breast milk is generally
the safest, most nutritious food available for human infants.
5.7 DDT and PCBs in human breast milk, Quebec, Ontario and Canada,
selected years, 1967 to 1992
Mean total DDT level (ng/g)
A. Levels of DDT in human breast milk: Quebec, Ontario and
Canada, selected years, 1967 to 1992
Quebec
Ontario
1982
1986
Canada
200
180
160
140
120
100
80
60
40
20
0
1967
1975
1992
Mean total PCB level (ng/g)
B. Levels of PCBs in human breast milk: Quebec, Ontario and
Canada, selected years, 1975 to 1992
Quebec
Ontario
Canada
35
30
25
20
15
10
5
0
1975
1982
1986
1992
Source: Government of Canada (1996). The State of Canada’s Environment — 1996.
Ottawa: available from Environment Canada, p. 6-49. Reproduced with the permission
of the Minister of Public Works and Government Services, 1998.
Healthy Development
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of Children and Youth
Natural and Built Environments
A Closer Look at the Determinants
Lead
Lead compounds can be found in vegetables, cereals and drinking water.
Especially when vegetables are grown in soil containing lead, levels can be
high and can become a dangerous source of lead in the diet (Health Canada,
1997a, p. 134). However, since lead in the environment is declining, this
issue is of minimal importance in the Canadian food supply.
Methyl mercury and PCBs in fish
Inuit infants of Nunavik have high levels of mercury and PCBs in the umbilical
cord blood; the mercury levels are nearly 14 times higher than those recorded
in newborn babies in the general population. Their mothers had consumed
large amounts of fish and fat from marine mammals, which contained increased
levels of methyl mercury. Although the health effects at this level of exposure
are not known, this level of exposure is a concern (Muckle, Dewailly and
Ayotte, 1998, pp. 22–23). See Exhibit 5.8.
5.8 PCBs and mercury in umbilical cord blood, selected populations, 1993–96
A. Concentrations of PCBs* (µg/L) in umbilical cord blood
N
Average†
Range
480
62
66
47
101
111
125
656
2.0
1.0
1.7
0.2
2.0
1.0
0.3
0.5
0.2–18.6
0.2–5.1
0.4–28.3
0.0–2.3
0.3–15.0
0.1–8.2
0.0–1.9
0.1–3.9
Population
Nunavik (Quebec), Inuit‡
MacKenzie/Kitikmeot (NWT), Inuit¶
Baffin Region (NWT) Inuit§
NWT Déné/Métis¶
Lower and Mid-North Shore Montagnais††
Lower and Mid-North Shore coastal population††
NWT non-Aboriginal¶
Southern Quebec general population‡‡
* Aroclor 1260 is made by combining PCB congenerics numbers 138 and 153 and then multiplying the result by 5.2.
† Geometric average ‡ ref. no. 37
¶ ref. no. 38
§ ref. no. 39
†† ref. no. 40
‡‡ ref. no. 41
B. Concentrations of mercury (µg/L) in umbilical cord blood
Population
Nunavik (Quebec), Inuit‡
MacKenzie/Kitikmeot (NWT), Inuit¶
Baffin Region (NWT) Inuit§
NWT Déné/Métis¶
Lower and Mid-North Shore Montagnais††
Lower and Mid-North Shore coastal population††
NWT non-Aboriginal¶
Southern Quebec general population‡‡
n/a = not available
† Geometric average
‡ ref. no. 37
¶ ref. no. 38
Year
N
Average†
Range
1993–96
1994–95
1996
1994–95
1993–95
1993–95
1994–95
1993–95
475
62
67
47
102
111
121
1109
14.2
5.7
10.4
1.9
2.1
2.3
1.7
1.0
1.0–104.0
n/a
0.6–75.8
n/a
0.2–14.0
0.4–15.8
n/a
0.2–13.4
§ ref. no. 39
†† ref. no. 40
‡‡ ref. no. 41
Source: G. Muckle, E. Dewailly and P. Ayotte (1998). “Prenatal Exposure of Canadian Children to Polychlorinated Biphenyls
and Mercury.” In Canadian Journal of Public Health, Vol. 89, Supplement 1, p. S22.
Healthy Development
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of Children and Youth
Natural and Built Environments
A Closer Look at the Determinants
Nitrates
High levels of nitrates are found in certain vegetables and fruits, especially
when fertilizers are used extensively to grow the food. In addition, a 1993 survey
in Ontario found that up to 40% of all rural wells may be contaminated with
high nitrate levels and/or fecal coliform bacteria (Environment Canada, 1996,
p. 11-17). High levels of nitrates in drinking water, once converted to nitrite,
can give rise to serious health problems for infants. This contaminant will impair
the transportation of oxygen from the lungs to the tissues of the infants, a
condition known as methemoglobinemia (Bruning-Fann and Kaneene, 1993).
Pesticides
Pesticides are products registered by the federal government. One objective
is to minimize applicator, bystander and consumer exposure to the pesticides
and their by-products. Children may be exposed to pesticides from residues on
the food and in the drinking water they consume, as well as through contact
with pesticides when they are used around the home and in recreational areas
such as parks. As well, children can accidentally ingest pesticides when they
are improperly stored or discarded. The susceptibility of infants and children
to pesticides in the diet was examined by a committee from the U.S. National
Research Council (National Research Council, 1993). It identified age-related
variation in susceptibility, toxicity and exposure to pesticides.
Soil Quality
Soil can become contaminated through waste disposal, pesticide use and
industrial pollution. Soil contamination is usually confined to sites where
chemicals have been dumped, either intentionally (e.g. at an isolated industrial
site) or accidentally (e.g. from a leaking oil tank). Hazardous waste disposal
sites are of special interest because many sites are located close to urban areas.
Unfortunately, the scale and nature of the contaminants in old dump sites are
unknown because permits, regulatory controls and records were not kept
(Environment Canada, 1996, p. 12-23).
Infants and toddlers are particularly at risk from contaminated soil because
they frequently place their hands in their mouth while playing and eating. The
amount of soil ingested while playing outside is age dependent. It is estimated
that on average, a child will consume approximately 35 mg to 50 mg of soil
per day. Children with an abnormal craving or appetite for non-food substances,
known as “pica,” will eat between 5 g and 10 g of soil per day (Calabrese, Stanek
and Gilbert, 1991). A study correlating the levels of metals in soil with metal
blood levels in children found a weak association between the two (Jin and
Teschke, 1995).
Waste disposal sites
It has been difficult to assess the effects of hazardous waste disposal sites on
health. The famous Love Canal case, in which industrial waste from a chemical
lindane plant was deposited into the canal, has been widely studied. After the
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plant was closed and the old canal bed turned into a housing development,
the area became a major research site. Several studies concerning this site
have indicated an association between maternal exposure and low birthweight
and chromosomal abnormalities (Gochfeld, 1995).
Radiation and Global Warming
UV radiation
The ozone layer is situated in the stratosphere, between 18 km and 35 km
above ground level, and shields us from excessive ultraviolet (UV) radiation.
However, since the 1960s, the ozone layer has become thinner because of the
release of chlorinated fluorocarbons (CFCs). These compounds are non-toxic,
very stable and used extensively as cleaning fluids, refrigerants and propellants.
They accumulate in the stratosphere, slowly depleting the ozone layer
(Environment Canada, 1996, p. 15-19).
Exposure to UV radiation is beneficial because it produces vitamin D.
However, excessive exposure causes skin burns. Infants especially have a thin
skin and are prone to sunburn. Just a few sunburns in early life can increase
the risk of developing skin cancer as an adult (Health Canada, 1997a, p. 75).
Radon
Radon is a naturally occurring, radioactive gas originating from uranium in
the soil. It can accumulate in basements through cracks in the foundation
and contaminate the indoor air. Exposure to high levels of radon is linked
to lung cancer, especially in miners (Axelson, 1995); exposure to indoor
radon is also associated with myeloid cancer, cancer of the kidney, melanoma,
and certain childhood cancers (Henshaw, Eathough and Richardson, 1990).
Henshaw, Eathough and Richardson (1990) plotted the provincial mean radon
concentrations against the incidence in childhood leukemia, and found
a dose-response effect. A study in Winnipeg did not find an increased risk
of indoor air radon and lung cancer in adults (Letourneau et al., 1994).
Global warming
Increases in carbon dioxide (CO2) levels in the atmosphere play a key role in
the greenhouse effect; they trap energy from the sun, thereby causing a slow
increase in the global temperature. (CO2 is released by the combustion of
fossil fuels.) In Canada, the average temperature has increased more than
1oC over the last century (Environment Canada, 1996, p. 15-11).
Although a warmer climate for Canada sounds appealing, the effect of
a higher average temperature on child health is not clear. Global warming
may contribute to more extreme weather conditions with a subsequent
increased risk of storms and flooding. In addition, children can be exposed
to an increasing number of infectious diseases, specifically those which are
now mainly confined to more tropical areas (Health Canada, 1997a, p. 77).
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Conditions and Trends: Built Environment
The built environment has a major impact on the health and development of
children. It includes the buildings, parks, businesses, schools, road systems, and other
infrastructures that children encounter in their daily lives. Children need protection
and a safe physical environment. Protection from physical injuries is a key aspect
of a healthy physical environment. Well-designed homes, streets, transportation
systems and playgrounds promote the safety and health of children and youth.
Injuries: A Major Health Threat
Injuries are a major environmental health threat. In 1990 alone, about 1,500
children in Canada died from injuries and 81,000 were hospitalized because
of injuries (Health Canada, 1997b, p. 17). Injuries are the leading cause of
death for children and youth after age 1 and the second leading cause of
hospitalization (respiratory illnesses are number one) (Health Canada, 1997b,
pp. 16–17). While traffic injuries are the leading cause of injury death, falls are
the main type of injury for which children are admitted to hospital (Health
Canada, 1997b, pp. 20–21). For each child who dies from an injury, many
more require hospitalization, emergency room care and follow-up visits to
health professionals. The financial cost to taxpayers is great (Angus et al.,
1998), and the personal cost, the residual disability and continued suffering
are substantial. Injury-related deaths have continued to drop in Canada —
from 31.5 per 100,000 in 1981–83 to 20.6 per 100,000 in 1990–92 (Health
Canada, 1997b, p. 22). See Exhibit 5.9.
There is a correlation between injuries and a child’s developmental stage
and daily activities.
a
by sex, 0- to 19-year-old children
5.9 Injury-related death rates for selected years,
b
and youth, Canada, 1951–53 to 1990–92
Mean annual ratec per 100,000
80
58.2
60
47.0
Boys
65.9
63.4
43.8
56.8
42.5
56.4
56.4
40.5
42.1
41.3
26.4
27.1
54.2
54.1
40.4
28.9
55.7
47.3
45.1
41.7
39.3
36.4
34.8
26.0
24.6
31.5
27.7
25.9
25.5
Total
58.7
40
30.0
Girls
27.8
23.9
22.0
17.1
20
28.7
20.6
15.0
13.9
12.2
1985
1988
1991
0
1952
1955
1958
1961
1964
1967
1970
1973
1976
1979
1982
Mid-period year
a. ICD, 9th revision codes E800 to E999. This grouping includes intentional and unintentional injuries and injuries of undetermined intent.
b. Three-year periods: January 1, 1951 to December 31, 1992.
c. Denominator: Population aged 0–19, Canada.
Source: Health Canada (1997). For the Safety of Children and Youth: From Injury Data to Preventive
Measures. Catalogue No. H39-412/1997E. Ottawa: Health Canada, p. 22.
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Injury and infants
Infancy and preschool is a time of increased exploration and a time when
children are likely to spend a large proportion of their time at home. Their
hand-to-mouth activity increases the likelihood that they may ingest harmful
substances or suffocate. For infants, suffocation is the leading cause of injuryrelated death while for other preschool children, traffic injuries are the leading
cause of injury death (Health Canada, 1997b, p. 20). Falls are the major
cause of hospitalization for infants and preschoolers (Health Canada, 1997b,
p. 21). Other important causes of injuries for infants and preschoolers are:
burns and scalds from sources such as hot tap water and hot beverages;
suffocation/choking on foods or small objects; and poisoning (Health Canada,
1997b, p. 21; Rivara, 1994).
Injury and school-age children
By the time children reach school age, they feel competent to head to school
on their own and are keen to learn, gain independence and begin to make
decisions. School-age children experience fewer injury deaths and injury
hospitalizations compared with toddlers and youth. While the leading
cause of hospitalization is respiratory illnesses, motor vehicle crashes
and bicycle mishaps are notable causes of unintentional injuries in
this age group (Health Canada, 1997b, pp. 20–21).
Injury and adolescents
Adolescence is a period of rapid growth, high expectations,
and a time of significant risk taking, increasing the
likelihood of serious injury for this age group. In
the 1990–92 period, traffic incidents were the major
cause of unintentional injury death, accounting for
nearly 83% of the deaths, while drownings contributed
another 9%. During the same period, hospitalizations
resulted from non-intentional injuries caused by traffic
collisions (60%) and falls (30%) (Health Canada, 1997b,
pp. 20–21).
A
dolescence is a period of rapid
growth, high expectations, and a time
of significant risk taking, increasing
the likelihood of serious injury for this
Home Environment and Injuries
age group.
Housing standards and availability
Most Canadians are housed in good quality homes. According to 1991 data,
the majority (68%) of Canadian households met federal adequacy and affordability standards (CMHC, 1991; CCSD, 1996, p. 29). However, the remaining
families lived in substandard houses, classified as such because they needed
repair, were too small for the family, or were too expensive for the family
budget (CCSD, 1996, p. 30). Poor housing conditions have a direct effect on
injuries because many substandard houses are often in a poor state of repair.
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Safety in the home
Injuries are most likely to occur in the home. About 80% of the children
under 4 years of age are injured at home (Health Canada, 1997b, p. 29).
As children grow up they spend less time at home, and statistics reveal that
injuries increasingly occur outside the home.
Three quarters of home-based injuries to children happen in the house
while the other one quarter occur in the garden or garage (Health Canada,
1997b, p. 72). In 1993, some of the leading causes of injuries at home were
falls (46.3%), burns (3.4%) and accidental poisonings (3.2%) (Health Canada,
1997b, p. 73).
Many household products including cleansers, disinfectants, medicines,
alcohol, solvents, cosmetics and mothballs are potential hazards for small
children and should be kept out of their reach and in child-resistant containers.
Garages and basements often contain items such as paint or paint thinner,
bottled or liquid gas, glue, gasoline, and other automotive products. Very
young children do not have the ability to judge what is harmful, and for this
reason it is not surprising that 97% of the poisonings in this age group occur
while children are exploring their own homes (Health Canada, 1997b, p. 162).
Home Environment and Chemical Exposure
Indoor air
Indoor air quality is critical to children’s health because they spend so much
time indoors. Numerous sources of indoor contaminants influence the quality
of indoor air, including exposure to second-hand smoke (ETS). Volatile organic
compounds (VOCs) are released from furnishings made with pressed wood
products, from household cleansers, and from personal care and pest control
products. Biological agents such as moulds, dust mites and pet dander are
common indoor contaminants. This “cocktail” of indoor air pollutants is
further aggravated by a number of factors including the number of smokers
and levels of humidity and ventilation. Adequate ventilation and the position
of vents can significantly reduce the pollution levels in a house or building
(Fernandez-Caldas et al., 1995). For instance, open windows will reduce
indoor air pollutants efficiently at the height of a sitting adult; however, closer
to the floor — the space toddlers occupy while playing — the ventilation is
less efficient (Fenske, 1992).
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Environmental tobacco smoke
Environmental tobacco smoke (ETS), or second-hand smoke, is one of the
most common indoor air pollutants (Raizenne, Dales and Burnett, 1998, p. 45).
Almost 2.8 million Canadian children under the age of 15 are exposed to ETS
at home. ETS contains more than 4,000 chemicals, including benzene, tar,
nicotine, particulates and other cancer-causing agents (Health Canada,
1997a, p. 60).
Children exposed to a smoke-filled environment experience numerous
negative health effects (Stoddard and Miller, 1995). They are at greater risk
of death from respiratory diseases and sudden infant death syndrome (DiFranza
and Lew, 1996). They have more visits to the physician and are hospitalized
for more lower respiratory tract infections such as bronchitis and pneumonia
(DiFranza and Lew, 1996). They have a reduced lung function (Cunningham,
Dockery and Speizer, 1994) and an increased susceptibility to infections from
viruses and bacteria (Wjst et al., 1994). Second-hand smoke also triggers asthma
attacks and increases the frequency and severity of the attacks in children
(Shephard, 1992).
Volatile organic compounds
VOCs are a varied mixture of compounds, consisting of aldehydes, aromatic
hydrocarbons and chlorinated compounds, to name a few. Formaldehyde is
an eye and throat irritant and results from outgassing of pressed wood, urea
formaldehyde foam insulation (UFFI) and glues. Other VOCs such as methylene
chloride and toluene may also be released when painting (Fernandez-Caldas
et al., 1995; Raizenne et al., 1998). Benzene is present in indoor air from
cigarette smoke and in fumes from adjacent garages. Chloroform and 1,2
dibromoethane are derived from evaporation of tap water, especially during
showering. Dichlorobenzene is derived from mothballs. If pets or pests are
in the house, pesticides may be used (Raizenne, Dales and Burnett, 1998).
It is difficult to assess the health impact of the complex mixture of pollutants
found in houses, schools and public buildings. Many of these compounds are
carcinogenic and may increase the risk of cancer in children. In addition, some
VOCs can increase the risk of neurological and behavioural abnormalities and
may affect respiration (Fernandez-Caldas et al., 1995).
Water quality
For children, two important routes of exposure to lead in the house are lead
in water pipes and paint. Houses built before 1950 are connected to the water
mains by lead pipes; houses built before 1988 may contain copper pipes with
lead solder (Health Canada, 1997a, p. 93). The adverse health effects of lead
are well recognized, as discussed earlier (Needleman and Gatsonis, 1990). Tap
water is a minor source of exposure to lead, with levels in untreated water
generally below 1µg/L (Health Canada, 1997a, p. 93).
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Home Environment and Biological Exposure
Moulds, dust mites and pet dander are very common biological contaminants
in the home. These allergens can cause a number of reactions in children,
especially in infants and young children who both still have an immature
immune system (Bessot, de Blay and Pauli, 1994; Dales et al., 1991). Their
systems may respond to allergens by developing hypersensitivity, allergies or
asthma. About 25% of children have allergies (Chad, 1995).
Asthma is more frequent in younger children than older children. In boys
0 to 4 years of age, the prevalence of asthma is 15% and drops to 5% by 10
to 15 years of age (CICH, 1994a). See Exhibit 5.10. Development of asthma
is associated with house dust mites and moulds (Marks et al., 1995), while in
poorer inner-city areas, a hypersensitivity to cockroach allergens may be involved
(Kang, 1996). If young children are protected from dust or pet allergens, asthma
and allergies may be reduced or avoided (Bessot, de Blay and Pauli, 1994).
5.10 Trends in asthma-related hospitalization rates for
Since children spend a great deal of
their day in school, a number of the
issues mentioned above apply in this
setting as well. Children in classrooms
with insufficient air circulation could
be exposed to numerous harmful compounds, which may cause sick building
syndrome (Chester and Levine, 1994).
This exposure may be made worse in
school settings in which chemicals are
used, such as laboratories and art and
technical classrooms.
children, by sex and age, Canada, 1985 to 1989
A. Boys
1,800
Hospitalization rate per 100,000
The School Environment
1,600
Ages 1–4
1,400
1,200
1,000
800
600
Ages 5–9
400
Ages 10–14
200
0
1985
Transportation
1986
1987
1988
1989
B. Girls
1,800
Hospitalization rate per 100,000
For most families, transport and mobility
are essential parts of modern day life. In
1993, there were 12 million registered
vehicles in Canada, respresenting almost
one for every two Canadians (Environment Canada, 1996, p. 2.18). See Exhibit
5.11. Vehicles pose a risk because the
exhaust pollutes outdoor air which in
turn impacts on the respiratory health
of children. Although cars are important
in modern society, they place children
and youth at risk of injury and death.
1,600
1,400
1,200
1,000
800
Ages 1–4
600
Ages 5–9
400
200
Ages 10–14
0
1985
1986
1987
1988
1989
Source: Canadian Institute of Child Health (1994). The Health
of Canada’s Children — A Statistical Profile. Vol. 1, I–II8, Vol. 2,
IV–14. Ottawa: CICH.
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5.11 Total passenger car registrations, Canada, 1980 to 1992
Number of registrations (‘000s)
14,000
12,000
10,000
8,000
6,000
4,000
2,000
0
1980 ‘81
‘82
‘83
‘84
‘85
‘86
‘87
‘88
‘89
‘90
‘91
‘92
Source: Government of Canada (1996). The State of Canada’s Environment — 1996.
Ottawa: available from Environment Canada, p. 2-18. Reproduced with the permission
of the Minister of Public Works and Government Services, 1998.
Independence and mobility
The opportunity to gain independence during childhood is an important
expression of growing up. To cycle, to walk, to use the public transportation
— these are all opportunities that enhance children’s daily lives. For children
with disabilities, mobility and access to their environment are major factors in
their ability to acquire independence. Special aids and public transportation
are largely accessible to children with disabilities in major urban centres. About
7% of children 0 to 14 years old with disabilities and 4.5% of youth with disabilities have difficulty leaving their residences to take short trips. Of those in
the 0 to 14 age group, almost 9% have difficulty getting together with children
their own age (CICH, 1994b, pp. 158–162).
Safety on the roads
In 1990–92, on average, two children died per day as a result of motor vehicle
accidents (MVAs), while more than 38 children were hospitalized. The rate
of MVA injuries is age dependent, with the highest rate observed in the 15to 19-year-old age group (Health Canada, 1997b, pp. 42, 44, 76). See Exhibit
5.12. For teenagers, driving is both a means of transportation and recreation.
Because they are new and inexperienced drivers and have an exaggerated
sense of their driving abilities, young males have a much greater risk of being
in motor vehicle crashes (DeJoy, 1992). Drivers with at least five years’ driving
experience have half the mortality or morbidity rate compared with drivers
with less than two years’ experience (Health Canada, 1997b, p. 82).
In 1990–92, 116 children died as pedestrians and an additional 1,793
children were hospitalized following a collision with a motor vehicle. Those
5 to 9 years of age are the most vulnerable to this injury (Health Canada,
1997b, pp. 95–96).
In 1990–92, 46 children who were cycling died as a result of a motor vehicle
collision, and an additional 3,644 were hospitalized. Most injuries occurred
among children aged 5 to 14, accounting for 70% of the cycling-related deaths
and 77% of the hospitalizations (Health Canada, 1997b, p. 109). It is estimated
that 70% of fatal collisions were due to cyclist error (Health Canada, 1997b,
p. 108).
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5.12 Death and hospitalization rates for injuries related to motor vehicles
and other road vehicles,a by sex and period, children and youth aged
0 to 19 years, Canada,b 1951–53 to 1990–92c
Girls’ hospitalization rate
Girls’ death rate
40
400
33.9
29.3
30
27.0
23.0
21.2
19.8
20
11.0
10
27.2
355.3
350.6
338.7
28.7
298.5
22.2
20.3 20.6
10.3 10.3 10.2
11.7
13.7 13.1
15.4
300
243.2
17.4 17.3
200
171.4
13.1
180.9
12.3 12.2
174.0 170.2
9.2
142.8 100
8.0 7.8
6.0
0
Mean annual hospitalization rated
per 100,000
Mean annual death rated per 100,000
Boys’ hospitalization rate
Boys’ death rate
0
1952 ‘55 ‘58 ‘61 ‘64 ‘67 ‘70 ‘73 ‘76 ‘79 ‘82 ‘85 ‘88 ‘91
Mid-period year
a. ICD, 9th revision, codes E810 to E829. Excludes any accident involving an aircraft or spacecraft (E840 to E845);
a watercraft (E830 to E838); a train (E800 to E807).
b. Data unavailable for Prince Edward Island, New Brunswick, Yukon Territory and Northwest Territories.
c. Deaths, three-year periods: January 1, 1951 to December 31, 1992. Hospitalizations, two-year periods: April 1,
1982 to March 31, 1992.
d. Denominator: population aged 0–19, Canada, 1991 Census. For hospitalization rates, denominator excluded
population from Prince Edward Island, New Brunswick, Yukon Territory and Northwest Territories.
Source: Health Canada (1997). For the Safety of Children and Youth: From Injury Data to
Preventive Measures. Catalogue No. H39-412/1997E. Ottawa: Health Canada, p. 62.
Recreational Environment and Injuries
Other important environments for children and youth are playgrounds, parks
and recreational buildings such as pools, gyms and arenas. Most injuries to
children and youth that occur outside the home environment happen during
play and leisure activities.
Playground equipment and sports settings
Playground equipment is designed to help
children’s development, but it can also
be dangerous. Although standards for
playgrounds and equipment have been
established by the Canadian Standards
Association (Canadian Standards Association,
1990), and were updated in 1998, playground
standards are often loosely interpreted and
implemented (Health Canada, 1996, p. 71). Every
year, thousands of youngsters are treated at hospital
emergency rooms or are hospitalized after being injured on a
playground or during a sporting event. Nearly 42% of playground injuries
occurred in public playgrounds and 34% at school and/or in a child-care
setting. For children under 5 years of age, 50% of playground injuries
happened in public playgrounds. School-age children are more likely to be
injured either at school (41%) or while playing in public recreational spaces
(39%) (Health Canada, 1997b, p. 201).
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of Children and Youth
M
ost injuries
to children and
youth that
occur outside
the home
environment
happen during
play and leisure
activities.
Natural and Built Environments
A Closer Look at the Determinants
5.13 Distribution of injuries related to the 10 leading sports and recreation
activities,a by mode of practice, children and youth aged 0 to 19, Canada, 1993
Organized
Type of sports and
recreation activity
Informal
% of injuries
0
20
40
60
80
100
Basketball
42.2
57.8
Ice hockey
95.5
4.5
Soccer
45.4
54.6
Football
41.5
58.5
Baseball
38.5
61.5
Ice hockey derivatives
9.6
90.4
Gymnastics
25.9
74.1
Ice skating
3.6
96.4
Downhill skiing
0.2
99.8
Volleyball
45.1
54.9
a. Excludes drownings, near drownings and other water-related injuries, playground equipment injuries, cycling injuries and
off-road vehicle injuries.
Source: CHIRPP, unpublished data, 1993.
Sports injuries are also very common. CHIRPP (Canadian Hospitals Injury
Reporting and Prevention Program) data included 16,665 visits by children
under 20 years of age to the emergency department in one year because of
sports injuries. These injuries accounted for about 36.4% of all visits to the
emergency department in the 10 to 14 age group and 40% in the 15 to 19 age
group (Health Canada, 1997b, p. 221). See Exhibit 5.13.
Recreational Environment and Chemical Exposure
At ice rinks, children may be exposed to increased levels of carbon monoxide
(CO) or nitrous oxide (NO2) (Lee et al., 1994). At swimming facilities, children
are exposed to high chlorine levels in water and air (Levesque et al., 1994).
In addition, children in classrooms with insufficient air circulation could be
exposed to numerous harmful compounds (sick building syndrome) (Chester
and Levine, 1994).
Recreational Environment and Biological Exposure
Polluted beaches and other polluted recreational waters are a source of gastrointestinal, respiratory and skin infections. Swimmers at several of Ontario’s
beaches were 2.3 times more likely to develop an infection than non-swimmers
(Seyfried et al., 1985). In addition, windsurfers on the St. Lawrence River
were 5.5 times more likely than observers to suffer gastrointestinal illnesses
and 2.9 times more likely to develop ear, eye and skin infections (Dewailly,
Poirier and Meyer, 1986).
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Environment and Other Determinants
Income
Poverty increases a child’s risk of injury. A study by Health Canada showed
that poor children are more likely to die of injuries than other children and
that children living in the lowest income neighbourhoods are at the greatest
risk of dying from injuries. The rate of injury-related deaths for the poorest
children and youth was 40% higher than the rate for the wealthiest children
and youth (for many types of injuries) (Health Canada, 1997b, p. 54).
The children with the greatest exposure to the effects of environmental
pollution are those that are poor. Poor children live in social and low-rent
housing located close to industrial sites, highways and interchanges and on
sites previously used for toxic waste disposal. Children in families with low
incomes are at risk because they are more likely to live in houses that have
not been well maintained and have faulty design. These factors contribute
to the increased likelihood of poor indoor air quality from sources such as:
moulds; lead (from chipping paint); and contaminants (e.g. pesticides to
control cockroaches) (Chaudhuri, 1998, p. 27).
Personal Health Practices
Among the most important sources of indoor air contamination is environmental tobacco smoke (ETS). Infants and young children whose parents
smoke in their presence are particularly susceptible to a number of health
risks including lower respiratory infections and asthma. Thirty-nine percent
of children under the age of 6 live with one or more people who smoke; 46%
of Canadian households include one or more smokers (Health Canada, 1997c).
Culture: Aboriginal Children
Aboriginal children are at greater risk of injury than all other children in
Canada. Injuries are a major cause of mortality for Aboriginal children and
youth. Their infant injury rate is almost four times that of other Canadian
infants (Health Canada, 1997b, p. 55). The injury death rate for Aboriginal
teenagers is more than three times the rate for Canadian teenagers (CICH,
1994b, p. 143).
Aboriginal children are at greater risk of exposure to contaminants than
other Canadian children. Risk factors such as poor housing, contaminated
food sources, water supply and sanitation, and indoor and outdoor environmental contaminants make Aboriginal children especially vulnerable to the
toxic effects of environmental contaminants (Postl, MacDonald and Moffat,
1994; Young, Bruce and Elias, 1991).
Aboriginal families are more often housed in accommodation that is
substandard than are non-Aboriginal households. In 1996–97, 48% of the
dwellings on reserves required renovations or replacement. During this same
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period, 4% of the homes did not have hot or cold running water (a decrease
from 17.7% 10 years ago) and 9% were without sewage disposal systems (down
from 28% 10 years earlier) (DIAND, 1998, p. 48).
Gender
For every kind of injury and at every stage of development beyond age 1,
boys are more likely to die or be injured than girls. Depending on the injury,
boys have between two and four times more injuries than females, especially
for injuries involving speed and sports (Health Canada, 1997b, p. 221).
The explanation for these differences is difficult to ascertain and complex
(Morrongiello, 1998).
References
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Healthy Development 101 of Children and Youth
C h a p t e r
6
Personal Health Practices
Overview
Personal health practices, such as smoking, use of alcohol and other drugs,
healthy eating, physical activity, and sexual practices have a profound
effect on the health and well-being of Canadians. Unintentional injuries
— related to motor vehicle accidents, falls, aquatic mishaps and fires —
are the largest single cause of death for children and youth.
There is strong evidence that early childhood experiences influence the
adoption of healthy practices in childhood and later in life. Infants born
at a normal birthweight and young children who enjoy quality child care,
good nutrition and plentiful opportunities for stimulation are more likely
to practice health-promoting behaviours in later life. Similarly, children
who develop strong coping skills, competence and self-esteem tend to
engage in health-promoting behaviours.
Personal health practices exert an influence on children’s health. Low
birthweight, which increases the risk of developing certain health problems
and disabilities, may be associated with a number of undesirable maternal
behaviours during pregnancy, including poor nutrition, smoking, and
alcohol and drug use.
Health practices are learned within the context of family, community and
society — beginning at an early age and continuing through the transition
from primary school and puberty to secondary school and the work force.
Parents’ modelling of behaviours such as smoking and physical activity
can influence the adoption of these behaviours by their children. Societal
values and attitudes influence health behaviours and choices, as do social
and emotional support from families, friends and communities.
Healthy Development 103 of Children and Youth
Personal Health Practices
A Closer Look at the Determinants
Relationship to Healthy Child Development
Early experience sets the stage.
Two of the critical periods of child development occur during pregnancy and
adolescence. Behavioural risks during these times can have a negative effect
on development. For example, during the prenatal period, risk behaviours of
the mother, such as smoking or alcohol consumption, have the potential to
exert adverse effects on the fetus such as low birthweight or premature birth.
Another critical period is during the adolescent years when youth are becoming
increasingly independent. At this stage in development, adolescents may be
faced with tremendous pressure to engage in activities and behaviours that
could have serious and potentially lasting implications (e.g. unprotected sex,
alcohol and drug use). In both of these stages, such challenges are influenced
by the individual’s sense of values, knowledge and societal expectations.
While progressing through the various developmental stages from
conception to adulthood, children and youth may encounter many challenges
and situations that entail risk. In addition to protecting children from potential
dangers, parents (and society) need to guide children through these pressures,
giving them the skills, knowledge and confidence to face these challenges in
a responsible, productive way (Guy, 1997, p. 46).
The health status and behaviour of pregnant women have a major impact
on the health, well-being and long-term development of their children. In
extreme cases, a woman’s health status or behaviour can result in severe problems for her child, such as very low birthweight, neurological abnormalities
or developmental delays (Health Canada, 1996a, p. 4).
Babies with low birthweights are at a significantly increased risk of illness
and death. In fact, low birthweight is the determining factor in about 15% of
all deaths among newborns; those who survive are at greater risk of developing
health problems and disabilities (CICH, 1994, pp. 21, 27).
Breastfeeding safeguards infants’ health.
Breastfeeding is widely recognized as the best way to feed infants. It provides
nutritional and emotional nurturing as well as immunological benefits, all of
which enhance an infant’s growth and development. There is strong evidence
that infants who are breastfed have increased protection against respiratory,
ear and intestinal infections (Canadian Dietetic Association, 1998). Breastfeeding may also supply some protection against sudden infant death syndrome
(SIDS) (Health Canada, 1999a, p. 2).
Healthy Development 104 of Children and Youth
Personal Health Practices
A Closer Look at the Determinants
Positive parenting plays a role.
Early stimulation and positive parenting are essential for children’s healthy
development. New evidence shows that brain development before age 1 is more
rapid and critical than was previously realized. There is widespread agreement
that the first two years of life represent a “window of opportunity” for providing
the stimulae for certain kinds of brain development. If this crucial period
passes, the full potential for certain aspects of brain development may be lost
(Kalil, 1989).
Exposure to unhealthy physical and social environments in early childhood
may have health implications for children and youth. For example, children who
are raised in a family that is unable to provide the basic physical and emotional
necessities for optimal development may be at increased risk of negative health
outcomes — emotionally, behaviourally and academically. This risk increases
exponentially with each additional condition of risk (e.g. exposure to abuse,
exposure to substance abuse present in the household).
Healthy eating and physical activity contribute to better health.
While the overall nutritional health of Canadians is good, the eating patterns
of some Canadians contribute to the high incidence of such nutrition-related
chronic diseases as cardiovascular disease, diabetes, osteoporosis and cancer
(Canadian Dietetic Association, 1996, p. 4). The development of most of
these diseases is a gradual process which often begins in childhood or youth.
Food choices play an important role in nutritional health and significantly
influence health status.
Physical activity has been directly linked to health outcomes for children
and adults. People who have an active lifestyle reduce their risk of disease
and chronic conditions, and are better able to resist stress and depression.
Evidence also suggests that participation in various types of physical activity
leads to increased self-esteem and a pattern of healthy eating, including eating
foods that contain more fibre and are lower in fat and higher in complex
carbohydrates (Stephens and Craig, 1990).
Children are susceptible to injury.
Unintentional injuries are the leading cause of death for children over the
age of 1 (CCSD, 1996, p. 24). The natural course of growth and development
places children at higher risk for certain types of injuries at different stages
in their lives. Most injuries to infants and young children (age 5 to 9) result
from falls and other incidents occurring in the home (38%); older children
(age 10 to 14) are injured in the home too (23%), as well as during outdoor
play (15%) and on roadways (15%) (CICH, 1994, pp. 70–71).
Healthy Development 105 of Children and Youth
Personal Health Practices
A Closer Look at the Determinants
Children need to make informed decisions about smoking, alcohol
and drugs.
Childhood experiences have a lasting impact. For example, people who grow
up with an alcoholic parent are more likely to abuse alcohol themselves. Those
who begin smoking in early adolescence also tend to be more addicted than
people who begin later in life (Statistics Canada, 1998).
The health effects of smoking are widely known. Smoking (and environmental tobacco smoke), the leading cause of lung cancer, has also been linked
to leukemia, as well as to cancer of the sinuses, brain, breast, uterus, and thyroid
and lymph glands (Health Canada, 1999b). Babies of women who smoke or
who were exposed to second-hand smoke during pregnancy are, on average,
smaller at birth than babies of smoke-free mothers (Health Canada, 1995a).
Generally, continued excessive use of alcohol can damage the liver and
eventually lead to cirrhosis of the liver. Alcohol is also a risk factor for the
development of some cancers.
Native youths, including both Aboriginal and Métis youth, are between
two and six times greater risk for every alcohol-related problem than youth
in the general Canadian population (McKenzie, 1997, p. 135).
Adolescents are at risk for pregnancy and sexually transmitted
diseases.
The development of intimacy and trust, gender identification and positive
sexual and sensual experiences begin in early childhood and influence
healthy sexuality and sexual decision making throughout life. Gender is an
important issue in sexual health. While sexual and reproductive health is
important to both men and women, the onus for preventing pregnancy most
often falls on young women. There is strong evidence to suggest that teen
parents have lower lifetime earnings and more social problems throughout
life (Health Canada, 1999c, p. 4).
Sexually active youth are more vulnerable to the transmission of diseases
such as hepatitis B, acquired immune deficiency syndrome (AIDS) and sexually
transmitted diseases (STDs) — in part because about half of 15- to 19-year-olds
believe they have no risk of contracting STDs (Williamson, 1993, p. 197).
Research has shown that most youth are either unaware of or unconcerned
about the consequences of STDs, which include pelvic inflammatory disease,
infertility, ectopic pregnancy, and chronic pelvic pain (Health Canada,
1999c, p. 14).
Healthy Development 106 of Children and Youth
Personal Health Practices
A Closer Look at the Determinants
Conditions and Trends
Prenatal and Infant Health
The incidence of low birthweight, stillbirths, perinatal death rates and SIDS
has either remained stable or declined in recent years. More Canadian mothers
are breastfeeding and most women abstain from smoking during pregnancy.
Most babies are healthy.
While most babies in Canada are born at a healthy weight, in 1990, 21,963
babies — 5.5% of all babies born in Canada — were low in birthweight. The
rate of low birthweight has not changed significantly since the 1980s (Statistics
Canada, 1992a, pp. 14–15). Rates of low birthweight are virtually the same
for the First Nations population as for the general Canadian population.
However, high birthweight is a concern
in First Nations communities, where
a
6.1 Perinatal, neonatal, post-neonatal death rates,
18% of babies are born at a high
Canada, 1971 to 1990
weight, compared with 12% for
the general population (Health
Perinatal
Rate/1,000 live births
Canada, 1996b).
Neonatal
20.1
The number of stillbirths (as well
Post-neonatal
as hospitalization rates for
spontaneous, unspecified abortions)
12.4
dropped dramatically across Canada
10.7
between 1974 (38,973) and 1993
7.7
6.4
5.2
(21,984) (Statistics Canada, 1996, p. 2).
4.6
3.2
Perinatal death rates dropped steadily
2.2
between 1971, when the rate was
1971
1981
1990
20.1 per 1,000 live births, and 1990,
reaching a low that year of 7.7 per
a. No data available for perinatal mortality from 1975.
b. Deaths occuring during the period between 28 weeks gestation and 7 days of life.
1,000 live births; these figures have
c. Deaths occuring in the first month of life.
d. Deaths occuring between 1 month and 1 year of life.
levelled off since 1985 (Statistics
Source: Canadian Institute of Child Health (1994). The Health of
Canada, 1992b, p. 40). See Exhibit 6.1.
b
c
d
Canada’s Children: A CICH Profile, 2nd edition. Ottawa: CICH, p. 25.
SIDS is a major cause of death for babies.
Sudden infant death syndrome (SIDS) is the leading cause of death for infants
between one month and one year of age. In 1995, 252 cases of SIDS were
recorded — a decrease from the 266 reported in 1993 (CFSID, 1997). Although
the number of deaths due to SIDS has declined overall since 1978, the risk
for Aboriginal infants is higher than the risk for non-Aboriginal infants
(Health Canada, 1996b). In fact, it is estimated that the incidence of SIDS
is approximately three times higher among Aboriginal infants (Canadian
Paediatric Society, 1996). Factors contributing to SIDS include sleeping in a
prone (tummy down) position, exposure to environmental tobacco smoke,
and overheating of the baby (Health Canada, 1999a; Health Canada, 1995b).
Healthy Development 107 of Children and Youth
Personal Health Practices
A Closer Look at the Determinants
What Contributes
to Low Birthweight?
More mothers are breastfeeding.
In Canada, the proportion of new mothers who
initiated breastfeeding their babies had increased
from 38% in 1963 (Health and Welfare Canada,
1990, p. 1) to 73% in 1994–95 (Health Canada,
1998a, p. 8). Data for 1994 show that 31% of
mothers were breastfeeding their 6-month-old
babies (Health Canada, 1998a, p. 25).
Factors contributing to low
birthweight include: poor nutrition,
smoking or alcohol and drug use
during pregnancy; low pre-pregnancy
weight; very young maternal age and
multiple births (Federal, Provincial
One in five pregnant women smoke.
and Territorial Advisory Committee on
While the majority of Canadian women abstain
from smoking cigarettes during pregnancy, 19%
of women aged 20 to 44 who had been pregnant
in the five years preceding a 1994 study smoked
regularly during their most recent pregnancy
(Health Canada, 1995c). See Exhibit 6.2.
Population Health, 1996a, p. 11).
Healthy Eating
No current comprehensive national data
are available on the eating patterns of
children and youth, or on the incidence
of obesity among children. However, it is
known that infants and growing children
are most vulnerable to the adverse impact
of nutritionally poor eating patterns.
While most Canadian children eat well,
Aboriginal children are at higher risk
for some nutritional deficiencies (e.g.
iron, vitamin D) (Canadian Dietetic
Association, 1996, p. 4).
6.2 Proportion of women aged 20 to 44 and their
partners who smoke regularly during pregnancy,
Canada, November 1994
68%
12%
Neither
smoked
Both smoked
7%
Only woman
smoked
13%
Only partner
smoked
Source: Health Canada (1995). Survey on Smoking in Canada —
Cycle 3. Ottawa: Health Canada, Chart 7.2.
Most children have healthy eating patterns.
Research has shown that four in five children aged 10 to 14 eat in accordance
with Canada’s Food Guide to Healthy Eating, at least partially (CICH, 1994,
p. 79). See Exhibit 6.3. A qualitative study carried out in 1995 of children’s
and parents’ perceptions of healthy eating showed that most of the children
aged 6 to 12 believed they were healthy eaters. Parents of 6- to 9-year-olds also
reported that their children ate healthily; however, parents of 10- to 12-yearolds were much less likely to label their children’s eating patterns as healthy
(Health Canada, 1995d, pp. 10, 12).
Healthy Development 108 of Children and Youth
Personal Health Practices
A Closer Look at the Determinants
Not everyone has healthy eating patterns.
Intakes of vitamin A, calcium and folacin
are frequently below recommended levels
in northern and isolated Aboriginal
communities (Lawn and Langer, 1994).
While the rate of vitamin D deficiency
rickets in children decreased after fluid
milk began to be fortified with vitamin D
in 1975 (Health Canada, 1998b), the risk
is still present, though minimal. Children
in northern communities and those with
dark skin are at greatest risk for vitamin D
deficiency (Canadian Paediatric Society,
Dietitians of Canada and Health Canada,
1998, p. 19).
6.3 Proportion of 10- to 14-year-olds reporting
use of selected strategies to eat well, by sex,
Canada, 1988
78%
Male
Female
80%
55%
60%
15%
Adhere to Canada’s
Food Guidea
Limit fat
consumption
15%
Limit sugar
consumption
a. Partial and high adherence to Canada’s Food Guide.
Source: Canadian Institute of Child Health (1994). The Health of
Canada’s Children: A CICH Profile, 2nd edition. Ottawa: Canadian
Institute of Child Health, p. 79.
Body Image
Body weight, which is largely determined by eating patterns and exercise, is
a significant contributor to children’s self-image, which in turn has important
effects on their mental health, sense of competence and control over life
circumstances. Adolescence is a particularly difficult time for young people
— adolescent girls, especially, are at risk for eating disorders.
Girls are concerned with body image.
In 1993–94, an international study showed that 77% of 15-year-old Canadian
girls wanted to change something about their body, compared with 57% of
Canadian boys (King et al., 1996).
Many female adolescents struggle to maintain a positive self-image.
Physical appearance and acceptance figure prominently in their thoughts
and self-perceptions. For example, in a study conducted by
the Canadian Teachers’ Federation, 48.2% of girls “strongly agreed”
or “agreed” with the statement “being popular is a big worry for me
right now.” In addition, 85% of girls “strongly agreed” or “agreed” that
they worry a lot about how they look (Canadian Teachers’ Federation,
1990, p. 11). A 1998 study showed that more than one third (41%) of
13-year-old girls and almost half (44%) of 15-year-old girls felt that they
needed to lose weight or were dieting to lose weight (King, Boyce and
King, 1999, p. 70).
E
ven though girls are less
active than boys, the activity
level of young women aged 18
to 24 increased substantially
between 1981 and 1995.
Healthy Development 109 of Children and Youth
Personal Health Practices
A Closer Look at the Determinants
Eating disorders are a cause for concern among young people.
Young women with negative body image have a higher risk of engaging in
disordered eating behaviours (e.g. bingeing and purging, self-induced vomiting,
refusal to eat) than those who are not concerned with their body image. Males
are not immune to negative body image. Low self-esteem has been linked with
obsessive attempts to gain weight among boys and young men — sometimes
with the help of anabolic steroids (Health Canada, n.d., p. 2). In 1998, 5% of
13-year-old boys and 4% of 15-year-old boys used anabolic steroids (WHO, 1999).
Among teens and young adults, 1% to 2% suffer from anorexia nervosa,
and 3% to 5% from bulimia (Health Canada, 1995e, p. 1). The prevalence
of obesity in children has increased dramatically in the past decade — from
14% to 24% among girls and from 18% to 26% among boys (Canadian
Dietetic Association, 1996, p. 4).
Physical Activity
Participation in physical activity has far-reaching health impacts. Boys are more
likely to be physically active than girls, although there are indications that girls’
activity level is increasing.
There is room for improvement.
A 1995 study revealed that approximately one third of Canada’s children and
youth were physically active enough to meet the energy-expenditure standard
for optimal health and development (six to eight kilocalories per kilogram of
body weight per day). Another one fifth came close to meeting the standard
and one fourth met the minimum energy standard — the equivalent of walking
for one hour per day (CFLRI, 1997, pp. 1–2). See Exhibit 6.4.
Notably, however, one quarter of Canadian children and youth are sedentary
— girls, in particular. Adolescent boys spent 50% more energy on physical
activities than did girls (CFLRI, 1997, pp. 1–2).
Young women are getting
more active.
Even though girls are less active than
boys, the activity level of young women
aged 18 to 24 increased substantially
between 1981 and 1995 (CFLRI, 1996a,
p. 3 of chart). Parents’ level of physical
activity and their belief in the value
of being physically active has a strong
influence on their children’s activity
level (CFLRI, 1996b, pp. 2–3).
6.4 Number of hours per week spent in physical
activities, 1- to 17-year-olds, by sex and age,
Canada, 1995
Hours per week
Boys
Girls
24
20
17
14
1 to 4 years
14
5 to 12 years
12
13 to 17 years
Age
Source: Prepared by the Canadian Council on Social Development using
data from Canadian Fitness and Lifestyle Research Institute, Progress
on Prevention, Bulletin No. 8, 1995. In Canadian Council on Social
Development (1997). The Progress of Canada’s Children — 1997. Ottawa:
Canadian Council on Social Development, p. 38.
Healthy Development 110 of Children and Youth
Personal Health Practices
A Closer Look at the Determinants
Smoking, Alcohol and Other Drugs
Adolescents are particularly at risk for such negative health practices as
smoking, drinking and using drugs. Despite public health messages warning
of the consequences, many young teens try smoking. Alcohol appears to be
the “drug of choice” among teenagers, although there are indications that
the use of cannabis is increasing.
Smoking, Drinking
and Drugs
Smoking is on the rise among
some groups.
A 1994 study showed that more than
Data from 1994 reveal that one in six teens had
40% of 15- to 19-year-old smokers
tried smoking by age 11. By age 13, 46% of girls
and 41% of boys had tried smoking; by age 15,
engaged in heavy drinking, compared
these numbers had risen to 64% and 58%
with 13% of non-smoking teenagers.
respectively. Almost 10% of 12- to 14-year-olds
Smokers were also more apt to be users
reported being regular smokers (CCSD, 1996, p. 45).
of marijuana and hashish (Canada’s
While the total number of Canadians who
smoke has decreased since 1981 (Statistics Canada,
Alcohol and Other Drug Survey, 1994,
1995a, p. 39), the number of young women who
as cited in Clark, 1996, p. 6).
smoke continues to increase. The HBSC data show
that in 1998, 21% of 15-year-old girls smoked daily,
the same proportion as in 1994 but a rise from 18%
in 1990 (King, Boyce and King, 1999, p. 95). See Exhibit 6.5.
The rate of smoking among Aboriginal people is significantly higher than
the rate for the Canadian population. Nine percent of First Nations youth
aged 10 to 14 smoke daily, and an additional 21% smoke occasionally. Rates
of smoking increase rapidly with age: at age 10, 23% of First Nations youth
smoke at least occasionally, while by age 14 more than half (53%) do so (Saulis,
1997, pp. ii, 41). On average, Aboriginal people started smoking between the
ages of 11 and 15 (Health Canada, 1996c, p. 20).
6.5 Proportion of students (aged 11, 13 and 15 years) who smoke
daily, by sex and grade, Canada, selected years, 1990 to 1998
%
Male
21
Female
18
15
1994
1998
13
9
2
1
0.4 1
1990
1994
Grade 6
1
9
5
6
1990
1994
8
21
16
8
1
1998
Grade 8
1998
1990
Grade 10
Source: A.J.C. King, W. Boyce and M. King (1999). Trends in the Health of Canadian Youth.
Catalogue No. H39-498/1999E. Ottawa: Health Canada.
Healthy Development 111 of Children and Youth
Personal Health Practices
A Closer Look at the Determinants
A small percentage of youth also use chewing tobacco. In 1994, 7% of
children aged 10 to 14 reported having tried chewing tobacco, including
1% who reported use in the week prior to the survey (Adlaf and Bondy, 1996,
p. 51). A 1995–96 survey of First Nations youth showed that 4.5% of youth
between the ages of 10 and 14 reported having used the smokeless tobacco
product (Saulis, 1997, pp. 45).
Second-hand smoke affects young people.
Almost half (45%) of non-smoking teens aged 15 to 19 had daily contact with
second-hand smoke. The home is the most common source of second-hand
smoke for non-smoking teenagers (Clark, 1998, pp. 3–4).
Alcohol — the teenager’s
“drug of choice.”
A 1994 study showed that among
11-year-olds, 3% of girls and 6%
of boys said they were regular
drinkers (CCSD, 1997, p. 41).
See Exhibit 6.6. Twenty percent of
teens are heavy drinkers (Federal,
Provincial and Territorial Advisory
Committee on Population Health,
1996b, p. 202). (Heavy drinking is
defined as five or more drinks per
drinking session.) See Exhibit 6.7.
According to The Ontario Student
Drug Use Survey: 1977–1995,
drinking and driving among
Ontario youth is on the decline.
The percentage of youth in
grades 7, 9, 11 and 13 driving
within an hour of consuming two
or more drinks dropped from
58.1% in 1977 to 24.4% in 1995
(Adlaf et al., 1995, p. 124).
While alcohol is still a primary
factor in many road collisions
involving young drivers, the
proportion of drivers under
the age of 21 with illegal blood
alcohol content who were fatally
injured in motor vehicle accidents
has decreased more than 20%
since 1977 (CICH, 1994, p. 105).
6.6 Alcohol use (drinking) among 10- and 11-year-olds,
Canada, 1994
Have you ever tried alcohol?
How often do you drink?
2% Regular
drinker
46% Infrequent
drinker
Yes
19%
No
81%
51% Tried only
once or
twice
Source: Prepared by the Canadian Council on Social Development using
data from Statistics Canada’s National Longitudinal Survey of Children
and Youth, 1994. In Canadian Council on Social Development (1997). The
Progress of Canada’s Children — 1997. Ottawa: Canadian Council on Social
Development, p. 41.
a
6.7 Regular heavy alcohol use (drinking) among adults
(aged 15 to 75 years), by age, Canada, 1994–95
%
30
25
20
15
10
5
0
15–19
20–24
45–64
25–44
65–74
75+
Age
a. Drinking five or more drinks on one occasion 12 or more times in the previous year.
Source: Federal, Provincial and Territorial Advisory Committee
on Population Health (1996). Report on the Health of Canadians.
Ottawa: Health Canada, p. 57.
Healthy Development 112 of Children and Youth
Personal Health Practices
A Closer Look at the Determinants
FAS/FAE
Fetal alcohol syndrome (FAS) is one of the leading causes of preventable birth defects and
developmental delay (Health Canada, 1996a, p. 4). Fetal alcohol effects (FAE) refers to
children with prenatal exposure to alcohol who manifest only some FAS characteristics. It is
estimated that one to three children in every 1,000 in industrialized countries will be born
with FAS; the rate for children born with FAE may be several times higher (Health Canada,
1996a). Limited studies suggest that the rate of FAS among Aboriginal people may be at least
10 times higher than the rate for the non-Aboriginal population (CCSA National Working Group
on Policy, 1994).
The NPHS found that 16% of women under age 25, 24% of 24- to 35-year-olds, and 31%
of women over age 35 consumed alcohol during their last pregnancy (Health Canada, 1998c).
Some young people are using other drugs.
Drug use among Canadian youth declined steadily since reaching its peak in
the late 1970s. One study of Ontario students in 1995 found that 22.7% of
students in grades 7, 9, 11, and 13 reported using cannabis at least once in
the year prior to the survey, up from 12.7% in 1993. Between 1993 and 1995,
cannabis use increased significantly among those in Grade 9 (8.7% to 19.6%)
and Grade 11 (from 22.3% to 40.7%). Despite these recent increases, the
1995 rate of cannabis use among Ontario youth (22.7%) was well below the
1979 rate (31.7%). See Exhibit 6.8. The study also found that the percentage
of students reporting injection drug use increased from 5.4% to 8.8% in the
same period (Adlaf et al., 1995, various pages).
6.8 Proportion of students who have ever taken marijuana, by selected levels of use, by sex and age,
Canada, selected years, 1989 to 1998
13 years
15 years
13 years
15 years
1989–1990
Never
Experiment (once or twice)
Regular use (three or four times)
89.1%
6.0%
4.9%
73.8%
10.5%
15.7%
90.1%
5.8%
4.1%
76.4%
10.8%
12.8%
1993–1994
Girls
Never
Experiment (once or twice)
Regular use (three or four times)
87.5%
6.7%
5.9%
69.5%
11.4%
19.0%
89.5%
5.4%
5.1%
72.6%
10.7%
16.7%
1997–1998
Boys
Never
Experiment (once or twice)
Regular use (three or four times)
78.9%
8.3%
12.8%
55.9%
12.6%
31.5%
82.3%
8.4%
9.2%
59.4%
11.5%
29.1%
Source: WHO (1999). Health Behaviour in School Age Children Survey, A World Health Organization Cross-National Study, 1997–98.
Healthy Development 113 of Children and Youth
Personal Health Practices
A Closer Look at the Determinants
Information from Health Canada’s Bureau of Drug Surveillance shows
that, in a 10-year period, the number of charges for all drug-related offences
for the 15 to 19 age group increased 62%, from 844 charges in 1985 to 1,368
charges in 1994 (Health Canada, 1996d).
Young people have more experience with cannabis than other age groups.
One third of 15- to 24-year-olds have used this drug in their lifetime (Hewitt,
Vinje and MacNeil, 1995, p. 32).
Injuries
During 1992, 1,452 out of a total of 4,838 deaths among Canadians under
age 20 resulted from injuries (Health Canada, 1997a, p. 2). In simple terms,
almost one in three deaths were attributed to injury, as were one in six
hospitalizations. The proportion of injuries as a cause of death increased
with age (Health Canada, 1997a, p. 14). There has been a slow but steady
decrease in injury occurrence during recent years. Injury mortality rates
among children under 20 years of age decreased 35% between 1982 and
1991, and the hospitalization rate decreased 13% (Health Canada, 1997a,
pp. 22–23). While these trends are encouraging, injuries remain the leading
cause of death for Canadian children (Statistics Canada, 1995b, pp. 5–12).
According to national longitudinal and other health survey data, at least
10% of Canadian children are injured each year seriously enough to either
seek medical attention or be restricted for a period of time in their daily
activities (Health Canada, 1999d). About 1 in every 18 male children and
1 in every 29 female children aged 1 to 4 are hospitalized for injury; in the
toddler years, the cumulative risk for injury is about one in five for boys and
one in seven for girls (Canadian Red Cross Society, 1994, p. 4). In all age
groups, boys have higher death and hospitalization rates than girls; in
particular, the mortality rate for boys aged 15 to 19 was nearly three times
higher than for girls in 1995 (Statistics Canada, 1995b, pp. 11–12).
Aboriginal children have a much higher injury-related death rate than
non-Aboriginal children. The rate for infants is four times the national rate;
for pre-schoolers, five times; and for teens, three times (CICH, 1994, p. 143).
Traffic-related injuries are the leading cause of death.
Although the trends have been declining in recent years, motor vehicle crashes
remain the leading cause of injury-related deaths among children 1 to 19 years
of age and the third leading cause of injury-related deaths among infants
under age 1 (Health Canada, 1997a, p. 14). In 1995, 611 Canadian children
(birth to 19 years old) died of motor vehicle-related injuries (Mackenzie, 1997,
p. 5). Motor vehicle crashes are also an important cause of injuries among
children, resulting in 7,489 hospitalizations each year (CIHI, 1998).
Healthy Development 114 of Children and Youth
Personal Health Practices
A Closer Look at the Determinants
Children die as passengers.
In 1995, 309 child passengers died in motor vehicle crashes (Mackenzie,
1997, p. 5). Most victims who suffer motor vehicle-related injuries (fatal and
non-fatal) are occupants of a vehicle as opposed to pedestrians or cyclists. The
injuries sustained are more serious among children and youth unprotected
by a restraint system. Occupant injuries are generally due to ejection from
the vehicle or to collision of the occupant with the interior of the vehicle or
with another occupant. Periodic surveys indicate that use of seat belts among
back seat passengers, most of whom are children, is less than 60%.
The annual number of injuries increases with each age group, peaking
among 15- to 19-year-olds. Young drivers aged 16 to 19 sustain a disproportionate
number of injuries. Risk factors for this group include speeding, alcohol use
and inexperience in driving itself (Health Canada, 1997a, pp. 82–83).
In 1995, 84 children and youth from birth to age 19 were killed as
pedestrians — struck by motor vehicles (Mackenzie, 1997, p. 5). After age 9,
the number of pedestrian fatalities is inversely related to a child’s age (Health
Canada, 1997a, p. 95). Childhood and youth pedestrian injuries represent
37% to 41% of all road vehicle injury-related deaths for those 1 to 4 and 5
to 9 years of age. The proportion falls to 18% for those aged 10 to 14 years
(Health Canada, 1997a, p. 94).
Bicycle helmets reduce the risk of injury for cyclists.
Between 1990 and 1992, 96% of bicyclists who suffered fatal
injuries were struck by motor vehicles, whereas only 20% of
hospitalized bicyclists were involved in collisions with motor
vehicles (Health Canada, 1997a, pp. 108–109).
Head injuries are sustained by more than half of
hospitalized bicyclists and are the single most serious injury
incurred by 30%, with higher rates among younger bicyclists
(Health Canada, 1997a, p. 108). Bicycle helmets reduce the
severity of head injuries, and their ever-increasing use in the
past decade represents a major improvement in the safetyrelated behaviour of Canadian children and youth (Health
Canada, 1997a, p. 113). In rural areas, where the risk of serious
and fatal bicycle injury is higher, observed helmet use is lower
than in non-rural areas (Health Canada, 1997a, p. 114).
B
icycle helmets reduce the
severity of head injuries, and
their ever-increasing use in the
past decade represents a major
improvement in the safety-
Drownings are a leading cause of death.
related behaviour of Canadian
In 1995, there were 113 drownings among those from birth
children and youth.
to age 19 (Mackenzie, 1997, p. 5). That year, for children and
youth overall, drownings were the third leading cause of injuryrelated death at 8.2%. One- to four-year-olds appear to be at
greatest risk; in this age group, drownings accounted for more than 20% of
injury-related deaths, second only to motor vehicle accidents (Health Canada,
1997a, pp. 14, 182). Studies of water-related injuries of children and adolescents
aged 5 to 19 indicate many are related to diving, jumping or being pushed with
resulting collisions injuring the head, spine and extremities. Many of these
injuries have the potential to cause permanent impairment and disability.
Healthy Development 115 of Children and Youth
Personal Health Practices
A Closer Look at the Determinants
Younger children are more at risk during bath time or from falls into water.
Older children and youth are more at risk while participating in aquatic and
boating activities.
The drowning rate for Aboriginal children is higher than for nonAboriginal children. For example, the rate for infants is about eight times
higher; toddlers, nine times higher; and 5- to 9-year-olds, six times higher
(Health Canada, 1997a, p. 185).
Falls cause serious injury.
For those under age 20, falls are not a major cause of death; rather, they
produce injuries serious enough for hospitalization. During the period 1990
to 1992, for every fall-related death, there were about 800 hospitalizations.
Falls from playground equipment, falls on stairs, falls during sports activities,
falls from a chair or bed and falls from a building accounted for 40% of these
hospitalizations (Health Canada, 1997a, pp. 136–137).
In the 1 to 4 age group, most falls occur in the home. Data from the
1990–92 period show that infants generally fell off adult beds, change tables,
and down stairs, or from high chairs or child seats. Toddlers mostly fell down
stairs, tripped while running or playing and fell onto a hard or sharp object,
and occasionally fell out a window. Fall-related injuries for 5- to 9-year-olds
resulted from falls from bunk beds or during play. Older children fell during
play, or off structures upon which they were perched (Health Canada, 1997a,
pp. 138–141).
Playground falls are serious for young children.
Between 1992 and 1997, 16 children died after being strangled with drawstrings
or loose clothing caught on equipment or fencing, or by skipping ropes that
had been tied to playground equipment (Lockhart, 1997, p. 1). The majority
of playground injuries are the result of falls. The hospitalization rate for 5- to
9-year-old children following falls from playground equipment was three times
higher than for 1- to 4-year-olds and 10- to 14-year-olds (Health Canada, 1997a,
p. 198). Almost 42% of playground equipment injuries occurred on public
playgrounds, with 33.9% occurring at schools or daycares. The main types of
equipment involved were climbers (38.2%), swings (25%) and slides (25%).
Fractures from falls were the most common type of injury reported.
Fire-related injuries and burns affect children of all ages.
During the period 1990 to 1992, fire-related injuries and burns were associated
with an annual mean of 77 deaths and approximately 1,680 hospitalizations
of Canadians under the age of 20. For each child or youth who died, about
23 others were hospitalized. Children under the age of 5 composed the group
with the highest number of fire- and burn-related deaths and hospitalizations.
Healthy Development 116 of Children and Youth
Personal Health Practices
A Closer Look at the Determinants
With the exception of those in the 15- to 19-year-old age group, boys sustained
a greater proportion of fire-related injuries and burns (Health Canada, 1997a,
p. 146). During this period, residential fires were responsible for 92% of firerelated deaths and 5% of fire-related hospitalizations of Canadians under age
20 (Health Canada, 1997a, p. 149).
The primary source of scalds for children under age 20 is hot liquids.
A great many incidents involved hot tap water, particularly during baths. For
older children, mishaps with hot beverages and while cooking caused scalds
(Health Canada, 1997a, p. 149).
Children are at risk for unintentional poisoning.
During the period 1990 to 1992, poisonings in children and youth under the
age of 20 ranked third among all hospitalizations for unintentional injury
(Health Canada, 1997a, p. 160). Hospitalization rates for poisonings are much
higher among 1- to 4-year-olds than any other age group. These poisonings
are mainly attributable to ingestion of medication and biological products.
According to a 1995 study of Canadian Poison Control Centres, approximately
100,000 Canadian children and youths under the age of 15 fall victim to
poisoning every year (Health Canada, 1997a, p. 161). For those aged 0 to 9,
11% of children poisoned were admitted to hospital, compared with 6.3%
for other injuries; the figures for those aged 10 to 19 are 42.6% and 5.2%,
respectively (Mackenzie, 1995, p. 5). According to Canadian Hospitals Injury
Reporting and Prevention Program (CHIRPP) data, the majority of poisonings
(92.4%) occurred in the home, particularly among children aged 4 or younger,
for whom the percentage was 97.1% (Health Canada, 1997a, p. 161).
Sexual Activity
Adolescence is a time of experimentation
with newly discovered sexuality. Consequently,
teenagers are at risk for pregnancy and infection
from sexually transmitted diseases (STDs).
Many adolescents do not practise safe sex.
Results of more than 30 studies in Quebec show
that between 12% and 23% of students in early
high school years have had at least one sexual
experience involving vaginal or anal penetration.
Researchers estimate that between 47% and 69%
of students in late high school years have had at
least one sexual experience (Otis, 1995, as cited
in Godin and Michaud, 1998, p. 368).
According to a national survey, 17% of sexually
active girls aged 12 to 14 did not use birth control;
14% used the pill in combination with a condom
(CICH, 1994, p. 77). See Exhibit 6.9.
Who Uses Condoms?
Recent studies conducted in Quebec show
that adolescents are more likely to use
a condom than older Canadians. Characteristics associated with those who are
increasingly using condoms are listed
below:
• male
• from a linguistic group other than
Francophone
• lives in a large urban centre
• drinks alcohol and uses drugs less often
• has had fewer sexual partners
(Otis, 1995, as cited in Godin and
Michaud, 1998, p. 369)
Healthy Development 117 of Children and Youth
Personal Health Practices
A Closer Look at the Determinants
6.9 Sexual activity and method of birth control among girls
aged 12 to 14, Canada, 1992
Never had sex
85%
Have had sex
15%
Number of times had sex
Method of birth control
Condoms
69%
Once
44%
2–5
times
33%
> 5 times
24%
Pill and
condom
14%
None
17%
Source: Canadian Institute of Child Health (1994). The Health of Canada’s
Children: A CICH Profile, 2nd edition. Ottawa: Canadian Institute of Child
Health, p. 77.
It is estimated that more than half of young people (50% to 76%) use a
condom the first time they have sex (Otis, 1995, as cited in Godin and Michaud,
1998, p. 369). According to the 1994–95 National Population Health Survey,
among sexually active 15- to 19-year-olds, 51% of females and 29% of males
reported having had sex without a condom in the previous year (Galambos
and Tilton-Weaver, 1998, p. 13). Less than one in five sexually active girls
report using the pill and condom combination as a method of birth control
(Insight Canada Research, 1992, p. 8).
HIV, AIDS and STDs are a risk for teens.
Epidemiological information regarding HIV shows that the median age of
people with AIDS has decreased from 32 years of age (before 1982) to 23 years
of age (between 1985 and 1990). This indicates that many people are becoming
infected as teenagers (Health Canada, 1995f).
Despite the fact that the number of reported cases as well as the incidence
rates for some STDs have been falling, STDs are important contributing factors
to morbidity among Canadian men and
women (Health Canada, 1998e). Rates for
Paediatric AIDS
both chlamydia and gonorrhea are well
above average for young women (aged 15
Since 1988, a total of 131 AIDS cases have
to 19 years) (Health Canada, 1998f). See
been reported in Canada for children aged 0
Exhibit 6.10 and Exhibit 6.11.
to 14. Perinatal transmission is the most
Between 1988 and 1995, 559 children in
common form of HIV transmission in children.
Canada were known to have been exposed
Encouragingly, the number of new cases
perinatally to HIV. Women in their
childbearing years represent an increasing
reported each year is declining: in 1997, there
proportion of people infected with HIV. The
were just five new cases — half the number
transmission from mothers to babies creates
reported in 1996, and down from 24 in 1995
serious implications for both the woman and
(Health Canada, 1998d, pp. 22, 26).
child (Goldie et al., 1997).
Healthy Development 118 of Children and Youth
Personal Health Practices
A Closer Look at the Determinants
6.10 Reported gonorrhea: incidence per 100,000 by age and sex, Canada, 1995
Rate per 100,000 population
Male
Female
100
90
80
70
60
50
40
30
20
10
0
<1
1–4
5–9
10–14
15–19
20–24
25–29
30–39
40–59
60+
Age group
Source: Health Canada Web site: http://www.hc-sc.gc.ca
6.11 Reported genital chlamydia: incidence per 100,000 by age and sex, Canada, 1995
Male
Female
Rate per 100,000 population
1,200
1,000
800
600
400
200
0
<1
1–4
5–9
10–14
15–19
20–24
25–29
30–39
40–59
60+
Age group
Source: Health Canada Web site: http://www.hc-sc.gc.ca
Teen Pregnancy
In 1994, there were an estimated 46,800 pregnancies among 15- to 19-yearolds — marking the continuation of an almost steady rise from 1987, when
39,300 teen pregnancies were recorded. There has also been an increase in
the number of teenage pregnancies that end in abortion (Wadhera and
Millar, 1997, pp. 11–12). See Exhibit 6.12.
Healthy Development 119 of Children and Youth
Personal Health Practices
A Closer Look at the Determinants
6.12 Distribution of outcomes of teenage pregnancy,
by selected age groups, Canada, 1974 and 1994
Age group
Total
15–19
Year
Outcome (distribution)
Live birth
Abortion
Miscarriage/
Stillbirth
1974
1994
66.3
50.7
25.8
45.0
7.9
4.3
15–17
1974
1994
58.3
46.1
34.2
49.5
7.5
4.4
18–19
1974
1994
71.2
53.4
20.7
42.4
8.1
4.2
Source: Adapted from S. Wadhera and W.J. Millar (1997). “Teenage Pregnancies,
1974 to 1994.” Health Reports, Vol. 9, No. 3 (Winter 1997): 9–16. Catalogue
No. 82-003-XPB. Ottawa: Statistics Canada, p. 11.
Personal Health Practices and Other Determinants
Income and Education
Lower socio-economic status is associated with higher rates of injury, and with
more severe and often fatal injury (Rivara and Mueller, 1987). For example,
in 1991, the rate of injury-related deaths for the poorest children and youth
was 40% higher than the rate for the wealthiest children and youth (Health
Canada, 1997a, p. 53).
Income is also associated with various health behaviours and negative
health outcomes. For instance, low income and smoking during pregnancy
are two of the factors associated with an increased incidence of low
birthweight (Ross, Scott and Kelly, 1996, p. 21). See Exhibit 6.13.
Teen pregnancy is almost five times more common in the lowest income
neighbourhoods than in the highest income neighbourhoods (Health
Canada, 1999c, p. 4).
Education also plays a role, influencing decisions about sexual behaviour.
For example, young people who have high investment in their education are
more likely to use contraception (Health Canada 1999c, p. 12).
Natural and Built Environments
Environmental tobacco smoke is an important source of indoor air pollution.
Infants and young children whose parents smoke in their presence are more
susceptible than others to a number of health risks including respiratory
infections and asthma. Almost two-fifths of children under the age of 6 live
with one or more people who smoke (Health Canada, 1997b).
Healthy Development 120 of Children and Youth
Personal Health Practices
A Closer Look at the Determinants
6.13 Distribution of children aged 0 to 3 years by birthweight, household
income and mother’s smoking during pregnancy, Canada, 1994–95
Normal birthweight
(> 2,500 g)
(%)
Low birthweight
(< 2,500 g)
(%)
Family incomea
< $30,000
$30,000–$60,000
> $60,000
93.5
93.7
95.8
6.5
6.3
4.2
Smoking during pregnancyb
Smoked
Did not smoke
92.2
94.8
7.8c
5.2
a. Distribution of children aged 0 to 3 years by family income.
b. Distribution of children aged 0 to 2 years by mother’s smoking during pregnancy.
c. Estimate less reliable due to high sampling variability.
Source: Adapted from D.P. Ross, K. Scott and M.A. Kelly (1996). “Overview: Children in Canada
in the 1990s.” In Growing Up in Canada: National Longitudinal Survey of Children and Youth.
Catalogue No. 89-550-MPE, No. 1. Ottawa: Human Resources Development Canada and Statistics
Canada, p. 21.
Individual Capacity and Coping Skills
Personal capacities such as coping skills and sense of control are key contributors to sexual and reproductive health. Young people who have a good
sense of their own worth and strong coping skills are likely to make more
sound decisions about sex. At the same time, supportive social environments
are necessary to enable and sustain healthy choices (Health Canada, 1999c,
pp. 12–13).
Culture
The prevalence of smoking is high among Inuit and
Francophone women and low among most immigrant
women (Maritime Centre of Excellence for Women’s
Health, 1997). With respect to alcohol consumption,
alcoholism is virtually unheard of as a social or medical
problem in Chinese society (Lin T.-y., 1983, p. 864) and
has been noted as more prevalent among the Irish than the
Jewish (Henderson and Primeaux, 1981, p. xix).
S
Gender
upportive social
environments are
Young women are more likely to engage in disordered
eating behaviours than young men. Among boys and
young men, low self-esteem has been linked with the
use of anabolic steroids (WHO, 1999).
Healthy Development 121 of Children and Youth
necessary to enable and
sustain healthy choices.
Personal Health Practices
A Closer Look at the Determinants
References
Adlaf, E., et al. (1995). The Ontario Student Drug Use Survey 1977–1995. Toronto: Addiction
Research Foundation.
Adlaf, E.M., and S.J. Bondy (1996). “Smoking Behaviour.” In Youth Smoking Survey, 1994:
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Healthy Development 125 of Children and Youth
C h a p t e r
7
Individual Capacity
and Coping Skills
Overview
Individual capacity and coping skills include psychological characteristics
such as personal competence and a sense of control and mastery over one’s
life. These characteristics play an important role in supporting mental
and physical health — influencing people’s vulnerability to such health
problems as cancer and cardiovascular disease, and affecting their risk of
unintentional injuries, mental disorders and suicide.
Coping skills enable people to be self-reliant, solve problems and make
informed choices that enhance health. They help people to deal with the
events, challenges and stresses in their day-to-day lives, without resorting
to health risk-taking behaviours such as alcohol and drug abuse. People
with a strong sense of their own effectiveness and ability to cope with the
circumstances in their lives are likely to be most successful in adopting
and sustaining healthy behaviours and lifestyles.
There is strong evidence that coping skills are acquired primarily in the
first few years of life. Children are born with an innate ability to cope,
meaning that they are resilient to stress and negative circumstances. However, this ability is profoundly influenced by early childhood experiences.
Developing these skills to their fullest potential depends on a variety of
protective and risk factors in the individual, family and community. Factors
such as gender, temperament, parenting styles and family functioning,
interaction with peers and significant adults, and the nature of community
support interact to hinder or enhance children’s mental health outcomes.
Healthy Development 127 of Children and Youth
Individual Capacity and Coping Skills
A Closer Look at the Determinants
Relationship to Healthy Child Development
Early nurturing is important.
Children’s early experiences contribute significantly to their ability to cope with
stress. Effective parenting, which includes providing children with emotional
security and strong and sensitive nurturing, is essential if children are to learn
the coping skills they will need throughout their lives (Steinhauer, 1998). In
the period from birth through the toddler years, it is likely that the strongest
single familial factor protecting the potential for resiliency is the establishment
of a secure attachment to a primary caregiver (Steinhauer, 1998, p. 57).
Findings of the National Longitudinal Survey of Children and Youth
(NLSCY) support the theory that effective parenting skills and family functioning are important to young children’s mental health. When parents have
difficulty coping with life, work, family or parenting, they may be unable to
provide their children with the necessary emotional, social and physical
support (CCSD, 1996, p. 16; Landy and Tam, 1996).
Consistency in parenting is especially important for building social
relationships for children in at-risk families (McKinnon and Ahola-Sidaway,
1997, pp. 38–39).
Ongoing support and stimulation from family, peers and significant
others contribute to positive mental health.
Establishing trust and safety through caring relationships, providing guidance
and challenge, and ensuring opportunities for meaningful participation in
family and community are all protective factors in a child’s environment.
These factors can alter or even reverse negative outcomes and help children
to develop resilience and positive coping skills (Benard, 1991).
Adults outside the immediate family also
influence children’s healthy development.
Supportive adults in the school, neighbourhood and community are important
protective factors in helping to offset
the negative effects of perinatal stress,
chronic poverty, parental psychopathology and disruptions in the
family (Werner, 1993).
Peers become an important source
of support as children grow older.
Successful peer relationships can provide
children with the models and experience that
help them develop coping mechanisms to
counteract excessive anxiety (Manassis and Bradley, 1994). Conversely,
peers can play a negative role by encouraging participation in high-risk
behaviours (e.g. drinking and driving, drug experimentation) that may
have long-term negative health and other consequences.
Healthy Development 128 of Children and Youth
S
uccessful peer
relationships can
provide children
with the models and
experience that help
them develop coping
mechanisms to
counteract excessive
anxiety.
Individual Capacity and Coping Skills
A Closer Look at the Determinants
Stimulation and challenge are essential to healthy child development. As
they move through the stages of childhood and adolescence, children require
a certain amount of stress and risk taking. Achieving despite obstacles, competition, and coping with traumatic life events such as death or divorce can help
children adapt and develop (McKinnon and Ahola-Sidaway, 1997, p. 44).
Physical and mental well-being are related.
How well people cope with the challenges in their living and working environments appears to be an important influence on their vulnerability to health
problems. Although the exact pathways and mechanisms are not yet clear,
there is strong evidence of a link between the central nervous system and the
immune system (Dantzer and Kelly, 1998). Responding poorly to challenges
can lead to persistently elevated steroid levels, which depress the host defence
system and other body functions; this increases vulnerability to negative health
outcomes (Keating and Mustard, 1996, p. 9).
Recent observations have created a better understanding of the mind-body
relationship and of how the development of competence and coping skills in
early life can influence a wide variety of causes of death in adult life (Keating
and Mustard, 1996, pp. 8–9).
Children are born with innate
resilience.
All children have the innate capacity
for “self-righting,” meaning that they
can develop traits such as social
competence, effective problem solving,
autonomy and a sense of purpose and
belief in a positive future. In fact, longterm studies show that 50% to 70% of
children born into high-risk conditions
(e.g. abusive families, war-torn communities) develop social competence and
lead successful lives (Benard, 1996).
This in-born resilience to stress
is not static; it varies over time as an
individual’s circumstances change.
The level of resiliency depends on
many environmental factors and
requires support both internally and
externally in order to contribute to
healthy human development (Benard,
1991).
Resilience and Teens
Resilience has been defined as “... the process of
healthy human development — a dynamic process
in which personality and environmental influences
interact in a reciprocal, transactional relationship”
(Benard, 1996, p. 9).
Adolescents who overcome adversity, manifesting
resilience despite the odds against them, typically
have access to three sources of “protection”: a
cohesive and stable family, external support, and
certain personal resources (Garmezy, 1983). The
latter includes the following: personality assets
such as self-esteem and autonomy; intellectual
skills such as problem-solving abilities; social
skills such as cooperation, social engagement and
responsiveness; a sense of self-efficacy; and an
easygoing temperament (Garmezy, 1983; Rutter,
1983).
Healthy Development 129 of Children and Youth
Individual Capacity and Coping Skills
A Closer Look at the Determinants
Other factors affect capacity and coping skills.
Culture and ethnicity can also affect people’s social and economic well-being,
which in turn can impact their physical and mental health. For example,
members of cultural and ethnic minorities may experience harassment in
school or in the workplace; language differences can isolate parents and
children; prejudice may deny people educational and employment opportunities, or access to housing; misunderstandings based on cultural or linguistic
differences can interfere with access to social services and other benefits, and
these people may feel cut off or isolated from the community (Health Canada,
1996, p. 19).
Coping mechanisms can be positive or negative.
Well-being, or positive health, consists of those physical, mental and social
attributes that permit an individual to cope successfully with the challenges
to their health and functioning. People use a variety of coping mechanisms
to meet life’s challenges; some contribute to health and equilibrium, while
others place the individual at even greater risk of negative health.
For example, physical activity contributes to physical and mental health:
in addition to being more physically fit, active people tend to have greater
self-esteem and a positive body image (Health Canada, 1999). Similarly, hobbies
such as music and art provide a positive outlet for stress and teach children
practical skills for coping.
Negative coping mechanisms include smoking and drug and alcohol use.
An early reliance on these behaviours often persists into adulthood and may
result in associated health problems.
Conditions and Trends
Children’s lives can be stressful. They experience rapid physical, emotional
and mental change and must face the challenges of academic requirements,
peer relationships and entry into the work force. While most gain the necessary
skills and tools for coping, some experience a range of mental disorders that
may affect them well into their adult lives.
Mental Disorders
Most Canadian children are free of psychiatric disorders. Yet, research in this
field suggests that between 17% and 22% of Canadian children and adolescents
suffer from one or more psychiatric disorders (Davidson and Manion, 1996,
p. 42). A survey of Ontario youth revealed that 25% of youth aged 15 to 24
reported having a mental health disorder (Ontario Ministry of Health, 1994,
p. 10).
Healthy Development 130 of Children and Youth
Individual Capacity and Coping Skills
A Closer Look at the Determinants
Children are at risk of a range of mental disorders.
The onset of some psychiatric disorders in children may generate later negative
psychosocial outcomes. For example, research suggests that children with
conduct disorder or antisocial behaviour may have increased tendencies
towards criminal and substance abuse behaviours and psychological difficulties
in adolescence and adulthood (Offord, Boyle and Racine, et al., 1992; Offord
and Bennett, 1994).
Attention deficit disorder (ADD) and attention deficit hyperactivity
disorder (ADHD) appear to be most prevalent during preschool and early
elementary years (Loeber and Keenan, 1994). These conditions, along with
learning disorders, can compromise social development as a result of learning
problems at school and difficulties in interpersonal relations (McKinnon and
Ahola-Sidaway, 1997).
Gender plays a role.
There are significant gender and age differences in children’s emotional and
behavioural disorders. According to the NLSCY, in 1994–95, the highest rate
of emotional and behavioural problems was among boys aged 8 to 11 (26%)
and the lowest was among girls aged 4 to 7 (16%). Among boys of both age
groups, hyperactivity was the most common disorder, followed by conduct
disorder. The incidence of emotional disorders increased significantly from
younger to older boys (from 6.1% to 11.8%). In girls, conduct disorder was
more common than hyperactivity for both age groups, but the occurrence of
emotional disorder was most prevalent among 8- to 11-year-olds (11.3%). All
prevalence rates of disorders were higher for boys than for girls (Offord and
Lipman, 1996, p. 123). See Exhibit 7.1.
7.1 Frequency of emotional and behavioural problems among 4- to 11-year-olds, by age and sex,
Canada, 1994–95
Emotional and behavioural problems
A.
Conduct
disorder
(%)
B.
Hyperactivity
(%)
C.
Emotional
disorder
(%)
D.
One or more
disorders
(%)
E.
Repeated
a gradea
(%)
F.
G.
Impairment One or more
in social
problemsa
relationships
(E. or F.)
(%)
(%)
Boys
4–7
8–11
4–11
10.6
11.3
11.0
14.0
14.0
14.0
6.1
11.8
9.0
21.9
26.0
24.0
2.9
8.1
6.5
2.7
4.2
3.5
27.4
31.0
29.9
Girls
4–7
8–11
4–11
8.3
8.2
8.3
6.1
6.7
6.4
5.8
11.3
8.6
16.0
18.8
17.4
2.1
5.8
4.6
1.5
2.9
2.3
19.1
24.0
22.4
Boys and girls
4–7
8–11
4–11
9.5
9.8
9.6
10.2
10.4
10.3
6.0
11.6
8.8
19.0
22.4
20.7
2.5
6.9
5.6
2.1
3.6
2.9
23.3
27.5
26.2
a. Data available for 6- to 11-year-olds only.
Source: Adapted from D.R. Offord and E.L. Lipman (1996). “Emotional and Behavioural Problems.” In Growing Up in Canada:
National Longitudinal Survey of Children and Youth. Catalogue No. 89-550-MPE, No. 1. Ottawa: Human Resources Development
Canada and Statistics Canada, p. 123.
Healthy Development 131 of Children and Youth
Individual Capacity and Coping Skills
A Closer Look at the Determinants
Females are much more likely than males to experience “internalized
disorders.” For example, young women aged 15 to 19 are the most likely of
any age-sex group to exhibit symptoms of depression (14%); women aged
20 to 24 are also well above average (10%) in their experience of depression
(Federal, Provincial and Territorial Advisory Committee on Population
Health, 1996, p. 317).
Other factors affect mental health.
Environment also appears to influence behavioural problems. In Ontario, the
rates of all psychiatric disorders were higher for children living in an urban
environment (16.7%) than for those living in rural areas (12.3%) (Offord,
Boyle and Racine, 1989, p. 4).
A shortage of mental health services is a problem in many areas of Canada.
It is estimated that only one in six Canadian children with mental health
problems is reached by mental health services (Children’s Hospital of Eastern
Ontario, 1993).
Stress
Adolescence can be a time of high stress. The rapid physiological changes of
puberty interact with other stress factors, with potentially significant effects on
the mental health of adolescents.
Sources of Stress
Many children have experienced events that cause anxiety and worry. Findings
of the NLSCY show that, according to the parents surveyed, roughly one third
of the children under age 12 had experienced great unhappiness. The most
common causes cited, regardless of the age or sex of the child, are listed below:
•
•
•
•
•
•
•
•
death in the family — 27%
parents’ divorce or separation — 25%
family move — 8%
family member’s illness or injury
— 8%
child’s illness or injury — 6%
conflict between parents — 6%
hospital stay — 5%
abuse or fear of abuse — 4%
• change in household members — 4%
• separation from parents, excluding
divorce — 4%
• death of a parent — 3%
• alcoholism or mental health
disorder in the family — 2%
• a stay in a foster home — 1%
• other — 29%
(CCSD, 1997, p. 38).
Healthy Development 132 of Children and Youth
Individual Capacity and Coping Skills
A Closer Look at the Determinants
Young people can experience a high degree of social, academic and
work stress.
Changes in family structure
cause stress.
Death and family break-up can also
be sources of stress for children. Data
from the NLSCY reveal that, based
on parents’ reports, roughly 33%
of the children under age 12 had
experienced “great unhappiness.”
The most common causes, regardless
of the age or sex of the child, were
death in the family (27%) and parents’
divorce or separation (25%) (CCSD,
1997, p. 38).
Males and females are different.
There is evidence that males and
females experience stress differently
during adolescence. Adolescent
females are less likely to feel good
about themselves and more likely to
perceive their lives as stressful than
adolescent males (CICH, 1994, p. 96).
See Exhibit 7.3.
14
% very satisfied
Mean work stress score (0=low)
School was cited as the greatest source of stress by 65% of youth respondents
to the 1992 Canadian Mental Health Survey, a joint effort of the Canadian
Psychiatric Association and Canadian Mental Health Association (Canadian
Psychiatric Association, 1993, p. 15). Adolescents and young adults also
experience higher levels of work stress than do older workers, with work
stress and job satisfaction being inversely related. Youth aged 15 to 24 are
the least likely to indicate that they are
“very satisfied” with their job (Federal,
Provincial and Territorial Advisory
7.2 Work stress and job satisfaction of employed persons
Committee on Population Health,
age 15+, by age, Canada, 1994–95
1996, p. 242). Work stress is highest
100
among employed teens and declines
24
Work
stress
with age, reaching its lowest level
80
22
among employed seniors (Federal,
20
Provincial and Territorial Advisory
60
Committee on Population Health,
18
1996, p. 314). See Exhibit 7.2.
40
16
Very satisfied with job
20
12
0
10
15–19
20–24
25–44
45–64
65–74
75+
Age group
Source: Federal, Provincial and Territorial Advisory Committee on Population Health (1996). Report on the Health of Canadians: Technical Appendix.
Catalogue No. H39-385/1-1996E. Ottawa: Health Canada, p. 315.
7.3 Perceived level of stress,a of 15- to
19-year-olds, by sex, Canada, 1985
and 1990
1985
1990
53%
43%
37%
30%
Male
Female
a. Very stressful and somewhat/fairly stressful.
Source: Canadian Institute of Child Health (1994).
The Health of Canada’s Children: A CICH Profile,
2nd edition. Ottawa: CICH, p. 96.
Healthy Development 133 of Children and Youth
Individual Capacity and Coping Skills
A Closer Look at the Determinants
Suicide
Young people are at increased risk for suicide.
From 1970 to 1992, there was a steady
and significant increase in the suicide
7.4 Numbers and rates of suicide, by age and sex,
rate for 15- to 19-year-olds, from a low
and by province/territory, Canada, 1992
of 7 per 100,000 population to a peak
Suicides
of 14 per 100,000 in 1983. The rate of
Number
Rate
(per 100,000
13 per 100,000 in 1992 was almost twice
population)
that of 1970.
Youth between the ages of 20 and
Canada, all ages
3,709
13
Male
2,923
21
24 have a higher rate of suicide than
Female
786
5
15- to 19-year-olds, but they have not
Age, total
34
1
experienced the same increases as the
Male
26
1
younger cohort. The rate for the former
Female
8
0
group has remained at 18 per 100,000
Age 5–19, total
249
13
Male
198
20
since 1989 (Federal, Provincial and
Female
51
5
Territorial Advisory Committee on
Age
20–24,
total
374
18
Population Health, 1996, p. 328).
Male
306
29
See Exhibit 7.4.
Female
68
7
There are limited data on the
Source: Federal, Provincial and Territorial Advisory Committee
incidence of suicide among younger
on Population Health (1996). Report on the Health of Canadians:
children. Suicides among children aged
Technical Appendix. Catalogue No. H39-385/1-1996E. Ottawa:
0 to 9 are rarely recorded. For males
Health Canada, p. 330.
aged 10 to 14, the rate rose from 0.6 to
2.6 per 100,000 between 1960 and 1992; for females, the increase was much
less significant, rising from 0.1 to just 0.8 during the same period (Health
Canada, 1994).
Rates for attempted suicide vary greatly. It has been estimated that for
every suicide there are between 10 and 100 attempted suicides (Dyck, Mishara
and White, 1998, p. 311).
More teenage males than females die from suicide attempts.
While young women are more likely to attempt suicide, young men are much
more likely than women to complete a suicide attempt (CICH, 1994, pp. 75,
89). The leading cause of hospitalization for females 15 to 19 years old is
suicide attempts — in 1989–90, their rate of hospitalization was more than
twice that of males the same age (295 per 100,000 compared with 127 per
100,000) (CICH, 1994, p. 93).
Suicide rates are higher among Aboriginal youth.
Aboriginal youth are at a higher risk of suicide than are young people in the
general population. The suicide rate for Status Indians (aged 0 to 19) is almost
five times higher than the national average (Health Canada, 1997, p. 55).
Healthy Development 134 of Children and Youth
Individual Capacity and Coping Skills
A Closer Look at the Determinants
Capacity, Coping and Other Determinants
Income
Evidence is mounting that it is both the combined effects of multiple environmental stresses and the clustered effects of psychosocial deprivations that often
coexist with poverty (particularly maternal depression, parental substance abuse,
parental violence and paternal criminality) that undermine competence and
resiliency, rather than just low income (Steinhauer, 1998).
Youth from families that receive family benefits are less likely to feel good
about themselves than youth from families that do not receive such benefits.
In Ontario, young people between the ages of 12 and 19 whose families receive
benefits were less likely to rate themselves as happy (Ontario Health Survey
analysis in CICH, 1994, p. 125).
Social Environment
Spousal abuse may affect children’s mental health. Children who witness familial
violence are at risk for many emotional and behavioural problems. These difficulties may include anxiety, depression, peer conflicts, non-compliance and,
in extreme cases, post-traumatic stress disorder (Suderman and Jaffe, 1997).
Genetic and Biological Factors
Research suggests that children who experience chronic illness or functional
disability are at higher risk of mental health problems (Cadman et al., 1986).
Gender
The results of the NLSCY show that in 1994–95 the highest rate of emotional
and behavioural problems was among boys aged 8 to 11 and the lowest was
among girls aged 4 to 7. In fact, all prevalence rates for disorders were higher
for boys (CICH, 1994, pp. 75, 89).
Healthy Development 135 of Children and Youth
Individual Capacity and Coping Skills
A Closer Look at the Determinants
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Cadman, D., et al. (1986). “Chronic Illness and Functional Limitation in Ontario Children:
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McKinnon, M., and J. Ahola-Sidaway (1997). Gender Issues and Young Children’s Mental Health:
Final Report. Ottawa: Health Canada.
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Intervention Effectiveness.” Journal of the American Academy of Child and Adolescent Psychiatry,
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Healthy Development 137 of Children and Youth
C h a p t e r
8
Genetic and
Biological Factors
Overview
The basic biology and the dynamic, organic nature of the human body
are fundamental determinants of health. These scientific perspectives
focus on the genetic endowment of an individual, the functioning of the
various body systems and the processes of development and maturation.
Genetic endowment represents the inherited variations in DNA that form
the building blocks of the body. Our genetic background can predispose
us to develop inherited disorders or conditions (e.g. Tay Saks disease,
autism) and can influence resistance to diseases and promote general
healthiness. Once an embryo has been conceived, its genetic endowment
cannot be changed.
Biological risk factors can be either innate (e.g. Down syndrome) or
acquired (e.g. brain damage from a severe head injury). Innate conditions
can be caused by chromosomal abnormalities which are not preventable,
while acquired conditions may result from teratogenic influences during
pregnancy or biological changes during and after birth. These biological
factors may be permanent or may be modified by the environment or by
the processes of maturation. For example, once treated with medication,
children suffering from attention deficit disorder (ADD) may often be able
to function normally and would not be considered as having a disability.
Teratogenic effects are caused by outside agents such as alcohol, medications
or other chemical or biological agents that influence the growth and
development of the embryo or fetus. Examples of teratogenic effects are
the birth defects seen in infants born to mothers who, during pregnancy,
were infected with rubella, drank alcohol excessively, or took thalidomide.
Healthy Development 139 of Children and Youth
Genetic and Biological Factors
A Closer Look at the Determinants
The biological processes of body system functioning and of development
and maturation can be influenced both positively and negatively by other
determinants of health such as personal health practices, the physical and
social environments, education, and economic and social status.
These risk factors influence child development in a variety of direct and
indirect ways, interacting with environments that also affect health. Many
of these biological/genetic risk factors also respond to interventions that
can minimize their impact and effects. For example, programs that promote
healthy child development or remedial programs that help children get
ready for school can minimize the impact of biological risk factors related
to cognitive development.
With advances in medical science, opportunities for significant new biomedical tests and treatments that can identify, prevent and treat conditions
are anticipated. Medical breakthroughs that will extend the life span of
persons with disabilities combined with the reality of an aging population
of people with disabilities will signal changes in two areas: an increased
demand for specialized clinical and social services to meet the needs of
this population at all stages of life and greater recognition of the rights
of persons with disabilities.
Healthy Development 140 of Children and Youth
Genetic and Biological Factors
A Closer Look at the Determinants
Relationship to Healthy Child Development
Broadly defined, biological risk factors are those innate or acquired characteristics of the child that place a child at risk of poor health. These factors can affect
healthy child development at several levels: from the simple biological fact of
the sex of the child, to genetic variants that are relatively common, such as
those associated with attention deficit disorder, to brain damage, which can
result from any number of causes, such as severe head injury.
It is impossible to talk of nature and nurture as separate entities with
respect to child development. Risk factors are not independent variables
operating in a vacuum but may interact synergistically or in an additive fashion
(Szatmari et al., 1994). Some environmental risk factors may lead to biological
outcomes that put children at risk for ill health. For example, lead in the
environment can result in lead poisoning which in turn is a risk factor for
low IQ, learning disabilities and attention deficit disorders; unemployment
and cultural displacement may lead to alcohol abuse which, for a pregnant
woman, may translate later into fetal alcohol syndrome for her child. Fetal
alcohol syndrome has been associated with learning problems, poor growth
and disruptive behaviours.
Biological/genetic risk factors may steer children towards certain environments (e.g. special schools, delinquent peers, detention centres) that place
them at further risk of poor health broadly defined. These causal chains are
multifaceted, dynamic and complex. As such, intervening anywhere in the
chain may have dramatic effects on several levels of health outcomes.
The interaction of biological/genetic factors within the environment is
dynamic — constantly changing over time. Interventions aimed specifically
at changing the genetic endowment of a child are difficult to implement and
few options are available. More potential exists for preventing teratogenic
effects and other health-related outcomes from physiological and biological
risk factors. Also, interventions aimed at finding and designing environments
that promote optimal development are well-known and can be put in place if
appropriate resources are available. Early intervention for children at risk or
with developmental delays or autism are well-known examples (Zoritch, Roberts
and Oakley, 1998; Rogers, 1998).
Types of Biological and Genetic Risk Factors
The following are some examples of biological and genetic risk factors. The
list is not meant to be exhaustive but rather to illustrate the broad range of
risk factors in this domain that affect child development.
Genetic and chromosomal syndromes
There are many examples of genetic and chromosomal syndromes including
Down syndrome, fragile X syndrome, and tuberous sclerosis. Individually,
these disorders may be rare, but there are many single-gene disorders and
chromosomal abnormalities that affect the brain. Collectively, these conditions
carry a very heavy burden of suffering (Costa, Scriver and Childs, 1985).
Healthy Development 141 of Children and Youth
Genetic and Biological Factors
A Closer Look at the Determinants
Many of these conditions are associated with severe learning disabilities and
several syndromes are characterized by specific behaviours that may place a
child at risk of further health problems (Dykens, 1996). For example, LeschNyhan syndrome is a genetic disorder characterized by self-mutilation (Nyhan,
1997). This can lead to many other health problems both physically and
emotionally, not only for the child, but also for the entire family.
Drug abuse during pregnancy
More and more substances are being identified as potentially having a harmful
effect on the developing fetus. These include low doses of alcohol, tobacco
and illegal and prescription drugs (Mattson and Riley, 1998; Singer, Garber
and Kliegman, 1991; Slotkin, 1998). These drugs can affect physical as well as
cognitive development (Singer et al., 1997), however the effects on learning
and behaviour may not be evident for many years. Fetal alcohol syndrome is
a particular problem among those living in severe low-income circumstances
(Abel and Skol, 1987; Sampson et al., 1997).
External influences on brain development
There is now accumulating evidence that stress during pregnancy as well as
maternal and early infant nutrition can affect the development of the fetal
and infant brain. For example, animal models suggest that stress during
pregnancy can affect the intrauterine hormonal environment which may then
place the infant at later risk of depression (Schneider et al., 1998; Sandman
et al., 1997; Anisman et al., 1998). Animal models also show that a stressful
intrauterine environment can affect nerve connections in the brain and the
architecture of brain development (Hayashi et al., 1998). The effects of early
malnutrition on learning and cognition are well known (Richards et al.,
1998; Morgan, 1990).
“Women need more folate, a B vitamin, during pregnancy to support their
expanding blood volume and the growth of maternal and fetal tissues, and to
decrease the risk to the fetus of neural tube defects (NTDs)” (Health Canada,
1999, p. 28). “NTDs result from the improper development and closure of
the neural tube during the third and fourth week of gestation. Pregnancies
affected by an NTD may result in a miscarriage or stillbirth, and children born
with an NTD may have mild to severe disability or die in early childhood. NTDs
include spina bifida, anencephaly and encephalocele” (Health Canada, 1999,
p. 28). There is evidence that increasing folate intake during the peri-conceptual
period via a daily supplement containing folic acid (a form of folate found in
supplements) and a healthy eating pattern can reduce the risk of NTDs (Health
Canada, 1999, p. 29).
“It is important that pregnant and nursing women consume adequate
amounts of essential fatty acids (EFAs), linoleic acid and alpha-linoleic acid
in their daily eating patterns for proper fetal neural and visual development”
(Health Canada, 1999, p. 35). The fetus and infant are dependent on the
mother to supply sufficient EFAs for their healthy development, especially
during periods of rapid growth such as the last trimester of pregnancy and
the first months of postnatal life (Health Canada, 1999, p. 35).
Healthy Development 142 of Children and Youth
Genetic and Biological Factors
A Closer Look at the Determinants
Prematurity
Premature births are defined as births occurring before 36 weeks gestation.
With significant advances in perinatal care, more premature babies are
surviving than ever before (Saigal et al., 1989; Roth et al., 1996; Lorenz et al.,
1998). Newborns that weigh less than one kilogram now regularly “graduate”
from neonatal intensive care units (Lorenz et al., 1998). Most of these children
do very well and have minimal disabilities (Saigal et al., 1990; Lorenz et al.,
1998). However, some have very special needs in terms of learning problems,
physical disabilities, sensory deficits and attention deficit (Saigal et al., 1991a,
1991b; Szatmari et al., 1990). For this reason, many graduates of neonatal
intensive care units require follow up and long-term care.
Sex
It is well known that boys may be at greater risk than girls for the development
of several developmental disorders, such as autism (Bryson, Clark and Smith,
1988) and certain types of behavioural conditions as well, such as attention
deficit and conduct disorder (Offord, 1987). The mechanism for this genderbased predisposition to these conditions is not well understood as
little research has been carried out on the links between sex,
other related biological risk factors and the environment.
While some work has shown that boys have a greater
vulnerability to brain dysfunction than girls (Waugh et
al., 1996), more research is needed to fully understand
the interplay of biological sex and social roles related
to gender.
On the other hand, girls are at much greater risk
of developing depression and eating disorders in
adolescence, particularly after 13 to 15 years of age
(Cicchetti and Toth, 1998). The mechanism for this is
probably multifactorial and involves hormonal factors
during puberty as well as experiences in socialization
irls are at much greater risk of
and gender roles unique to adolescent girls. More
research is needed to understand the complex interdeveloping depression and eating
play between biology and gender and healthy child
disorders in adolescence, particularly
development.
G
after 13 to 15 years of age.
Acute and chronic medical illnesses
Medical illnesses place children at risk of further health difficulties in terms
of emotional and behavioural problems (Cadman et al., 1987; Stein, Westbrook
and Silver, 1998). Even diseases such as cystic fibrosis, diabetes and childhood
cancers that do not affect the brain are associated with an increased risk of
emotional and behavioural problems (Thompson et al., 1998; Kovacs et al.,
1997; Dunitz et al., 1991). These problems are often a secondary consequence
of the functional limitations and social isolation associated with the illness
(Cadman et al., 1986). The illness may also affect the child’s ability to attend
school and so have an effect on educational outcomes in the long term
(Gortmaker et al., 1990).
Healthy Development 143 of Children and Youth
Genetic and Biological Factors
A Closer Look at the Determinants
Acute and chronic conditions of the brain and nervous system
Examples of conditions that affect the developing brain include cerebral palsy,
head injuries, neural tube defects, and meningitis. These disorders carry a
high risk of secondary problems pertaining to adaptation and everyday living
(Rutter, Graham and Yule, 1970; Breslau, 1990). Some of these conditions also
affect the person’s ability to speak, think, perceive and learn, which, in turn,
may affect opportunities for achieving school success and securing long-term
employment. Disorders of the central nervous system may also marginalize
the child and lead to social stigmatization that further impairs health.
Developmental Disabilities
These disorders have a biological basis with strong genetic causes. Mental
retardation and pervasive developmental disorders (PDDs), such as autism
and specific learning disabilities, fall into this category. In general, these
disorders are characterized by delayed acquisition of certain skills and an
uneven pattern of development. Mental retardation refers to a general delay
in the acquisition of cognitive skills in a variety of abilities and a lower than
expected level of adaptation. The pervasive developmental disorders are
characterized by impairments in social interaction, communication and play,
and are associated with a very high burden of suffering.
Both mental retardation and PDDs are more common in boys (Bryson,
Clark and Smith, 1988), but reading disabilities are found equally among
boys and girls (Shaywitz et al., 1992). There is currently no cure for these
developmental disorders, although treatments are available that improve
functioning (Rogers, 1998; Lovett, Ransby and Barron, 1988).
Attention deficit disorder (ADD) and attention-deficit hyperactivity
disorder (ADHD)
These disorders first become apparent in the toddler years and are characterized by overactivity, impulsivity and difficulty in information processing. Both
maladies often persist into adolescence or even adulthood (Hechtman, 1991).
Although the causes of ADHD and ADD are not known,it is clear that genetic
factors, prematurity, and developmental immaturity are significant risk factors
(Thapar, 1998; Zametkin and Liotta, 1998; Szatmari, Offord and Boyle, 1989a).
If the parents and school cannot adapt to the child’s problems of impulsivity
and short attention span, other conditions that affect health and development
may occur, including aggression, early school leaving, and perhaps later
substance abuse (Mannuzza et al., 1993). These outcomes can further impair
health and make it less likely that the child will find a health-promoting
environment in which to flourish. Effective treatments for ADHD and ADD
include medication and psycho-social intervention (Goldman et al., 1998;
Pelham, Wheeler and Chronis, 1998).
Healthy Development 144 of Children and Youth
Genetic and Biological Factors
A Closer Look at the Determinants
Other psychiatric disorders
The causes of anxiety, mood and behaviour disorders in children are clearly
multifactorial. Although psycho-social risk factors (e.g. abuse, parental
psychiatric illness, severe poverty) may be important for understanding
disruptive behaviour disorders, many biological and genetic risk factors come
into play (Rutter, 1997; Offord and Fleming, 1996), particularly for the anxiety
and mood disorders of childhood and adoloscence. All of the psychiatric
disorders of childhood have a strong genetic component, although more
research is needed to establish exactly how these genetic factors operate (Rutter
et al., 1990; Plomin and Rutter, 1998). Moreover, the developmental disabilities
referred to above (mental retardation, PDDs and specific learning disorders)
are also significant risk factors for these conditions (Beitchman and Young,
1997).
Emotional and behavioural disorders are associated with a poor long-term
outcome (Offord et al., 1987) and high economic cost in terms of treatment
and lost productivity at school and in the working world. Many adult psychiatric
disorders such as substance abuse, alcoholism, depression and schizophrenia
are also caused, in large part, by genetic factors; the onset of these conditions
often takes place in childhood or adolescence (Rutter, 1995; Fombonne, 1998).
Conditions and Trends
This section summarizes what is known, in the Canadian context, of the prevalence of conditions or disorders caused at least in part by biological and genetic
risk factors. It also presents the foreseeable trends that will have an impact on
the health of children with disabilities in the future.
The prevalence of biological- and genetically-based disorders is
significant.
The prevalence of serious medical conditions of childhood is relatively
stable. For example, in 1992 the rate of leukemia for children between ages
0 and 19 was 4.56 per 100,000 population. Despite slight fluctuations, this
rate had remained relatively stable since 1985 when the rate was 4.41 per
100,000 population (Huchcroft et al., 1996, p. 92). It is likely that more
effective medical treatments will become available in the future for children
with acute and chronic medical disorders. As a result, children with diseases
such as cystic fibrosis and cancer will live longer and require more intensive
care, even into adulthood.
With the significant advances in perinatal care, more premature babies
are surviving in Canada today than 20 years ago (Saigal et al., 1989). In recent
years, there has been little variation in the prevalence of prematurity: in 1991,
3.7% of babies born in the Canadian population were born prematurely
(Statistics Canada, 1993, pp. 18–19), and in 1995, the percentage had remained
relatively unchanged at 4.0% (Statistics Canada, 1997, p. 21). With increased
chances of survival, the number of babies with disabilities due to prematurity
will rise, as will the proportion of severe cases.
Healthy Development 145 of Children and Youth
Genetic and Biological Factors
A Closer Look at the Determinants
It is estimated that, in industrialized countries, between 1 and 3 children
in every 1,000 will be born with fetal alcohol syndrome (FAS); however, the
rate for children with fetal alcohol effects (i.e. children with prenatal alcohol
exposure but only some FAS characteristics) may be several times higher
(Health Canada, 1996, p. 4). In Canada, the rate of FAS for the Aboriginal
population may be 10 times higher than that for the non-Aboriginal population
(CCSA National Working Group on Policy, 1994).
Each year in Canada, approximately 400 babies are born with neural tube
defects (NTDs), which represents about 1 of every 1,000 births (McCourt,
1995). Because many cases of NTD are spontaneously aborted or detected
antenatally and therapeutically aborted, it is estimated that there may be at
least 800 NTD-affected conceptions each year (McCourt, 1995). Between 90%
and 95% of NTDs occur in families with no family history of the condition
(Cohen, 1987).
As a group, developmental disabilities are common. For example, the
prevalence of autism in Canada is estimated at 0.1% (Bryson, Clark and Smith,
1988), mental retardation at about 3%, and specific learning disabilities at
approximately 10% (Beitcham and Young, 1997). Although there is no evidence
that actual prevalence is increasing, the number of children receiving these
diagnoses is increasing, leading to a greater demand for services.
The prevalence of ADD is estimated at between 5% and 10% and is more
common in boys than girls (Szatmari, Offord and Boyle, 1989b). The rate of
occurrence does not appear to be affected by factors such as place of residence
(urban versus rural) or socioeconomic class.
The psychiatric disorders of childhood are also common, with combined
prevalence rates of between 10% and 20% among school-aged children (Offord
et al., 1987). Some data indicate that the prevalence of substance abuse,
depression, suicide and antisocial behaviour is increasing (Fombonne, 1998).
Disorders such as depression and anxiety are more common in adolescence
than childhood, but more research is needed to chart the appearance and
disappearance of emotional and behaviour symptoms over time.
Advances in biomedical research raise serious issues.
With the recent advances in molecular genetics and the anticipated completion
of the Human Genome Project by 2002, the genes for many inherited, developmental and psychiatric disorders of childhood will eventually be identified.
These medical breakthroughs will raise controversial issues about family planning, disability insurance, confidentiality and genetic stigmatization. Policies
will need to be developed to deal with these important ethical questions based
on sound empirical research (Dickson, 1998). Moreover, with the revolution
currently underway in molecular biology, it is anticipated that the identification
of genetic variants responsible for many conditions that affect child health will
lead to important advances in drug treatment and possibly even to gene therapy.
Healthy Development 146 of Children and Youth
Genetic and Biological Factors
A Closer Look at the Determinants
Genetic and Biological Factors and Other Determinants
Employment
As more and more children with genetic, developmental and severe psychiatric
disorders mature into adults, there will be a need for an increased number
of jobs that benefit people with disabilities: jobs that provide the person with
dignity and appropriate remuneration, and are suited to their capabilities
so that they can be productive members of society.
Education
Both early diagnosis and intervention are essential to ensuring a positive longterm outcome for at-risk children. Evidence indicates that early intervention
with a significant educational component has both short- and long-term
benefits for disadvantaged children (Zoritch, Roberts and Oakley, 1998).
Early intervention for children with developmental disorders has also been
shown to be effective (Rogers, 1998).
The education system has at its disposal remedial programs for children
with various forms of learning disabilities (Lovett, Ransby and Barron, 1988)
that may improve long-term outcome. Children with physical disabilities
due to a variety of conditions can now be fully educated in mainstream and
integrated settings. This will lead to improved educational outcomes for these
children and to better health in the long term.
Social Environment
Biological and genetic risk factors may also limit the kinds of environments
in which some children can participate. For example, some schools and
recreational facilities may not be able to accommodate children with disabilities.
A child with a biological/genetic risk factor in an inappropriate environment
may have her/his health further impaired.
A chronic health problem may also lead to emotional difficulties. By itself,
a chronic medical illness is not associated with emotional, behavioural, or
learning problems; it can, however, lead to difficulties in everyday living that
impair the child’s ability to participate fully in the community (Cadman et al.,
1986). In addition, the actions and reactions of people in the child’s social
environment can moderate the impacts of the child’s limitations and enhance
the degree to which the child can cope within the environment.
Children with biological- or genetic-based disabilities may also be deprived
of the opportunity to use their innate resilience and coping skills. For example,
the tendency is to move children with aggressive behaviour from less restrictive
settings (e.g. those in which they are integrated with other children) to more
restrictive settings (e.g. segregated classrooms, home schooling). However,
these latter environments may be less appropriate for dealing with challenging
behaviour because they may lead to labelling, negative peer influences and
Healthy Development 147 of Children and Youth
Genetic and Biological Factors
A Closer Look at the Determinants
fewer opportunities to use positive coping strategies. Some central nervous
system diseases (Lesch-Nyhan syndrome) and developmental disorders (autism)
may lead to specific behaviours that are maladaptive in themselves, such as
self-mutilation, rituals and obsessions.
Natural and Built Environments
More children with severe physical and developmental disabilities will be living
in the community as a result of the closing of institutions and the desire of
parents to keep their children with disabilities at home. The increase will
have an impact on the demand for appropriate housing in the community
and the need for community resources to address this population of clients
at the various stages of life.
Personal Health Practices
It is becoming increasingly apparent that preparing for pregnancy increases
the chances of a safe and successful pregnancy outcome. A striking example
of this is the potential for reducing the risk of neural tube defects with the
consumption of a supplement containing folic acid prior to conception.
Health Services and Social Services
The degree and severity of a disability are in part
determined by the access to services for the condition, the effectiveness of those services, and
the accommodations made by the child’s parents,
school and community. For example, while
children with attention deficit may not be able
to be cured, they can be treated effectively with
medication so that they may no longer exhibit
symptoms. Likewise, for a child with cerebral palsy,
access to physiotherapy is crucial as this type of
treatment can positively influence the degree and
severity of the condition.
As more children with disabilities are cared for at home,
a heavy burden is placed on parents to navigate the system, act
as advocates for their children and arrange for special services.
Eventually these children will grow into adults, which will result
in demands being placed on aging parents and on services for
adults with developmental disabilities.
T
he degree and severity
of a disability are in part
determined by the access
to services for the
condition, the effectiveness
of those services, and the
accommodations made
by the child’s parents,
school and community.
Healthy Development 148 of Children and Youth
Genetic and Biological Factors
A Closer Look at the Determinants
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Healthy Development 152 of Children and Youth
C h a p t e r
9
Health Services and
Social Services
Overview
Health and social services comprise a very broad and diverse set of
influences on healthy child development. Health services include those
services and supports provided by doctors, nurses, pharmacists, dentists
and other health-care professionals that focus upon both the physical and
mental health of children and, at times, their primary caregivers. Social
services consist of a wide variety of programs, services and supports that
address both the basic needs of children (including the need for
protection) and aspects of their social and psychological development
(such as awareness, judgment, feelings, behaviour and relationships).
These services are important for two reasons. Throughout childhood,
there are opportunities to provide the conditions and supports that keep
children on healthy developmental pathways. Health and social services
are important primarily in that they can contribute to promoting this
positive development. And second, if these opportunities are missed, or if
children are disadvantaged in some way, services can help reduce the risk
of negative consequences, and in many instances partially or wholly
ameliorate those that do occur.
There is a significant difference, however, in the availability of health
services compared with social services. Health services are available to all
children, including those at risk and those with special needs.1 That is,
they are more or less universal, with elastic public funding that largely
1. Availability is not the same as accessibility. Services may be available but not accessible if people
are not aware of them, cannot get to them, or have beliefs, languages, or cultures that are not
compatible with them.
Healthy Development 153 of Children and Youth
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A Closer Look at the Determinants
reflects usage. For example, a family physician can order tests or refer to
specialists in an effort to diagnose a child’s health condition, and the costs
of those services will be covered, for the most part, by the health-care system.
Social services, on the other hand, are not universally available to young
people and their families. They tend to be targeted towards those at risk
and those with special needs and are restricted in availability by fixed levels
of funding. So if, in the above example, the family physician’s concern was
about a child’s mental rather than physical health, the physician could
refer to a children’s mental health program for assessment, but there is
no assurance that the child will be seen. Assuming that the service even
existed, access would largely depend upon factors such as severity of need
and competing demands on the assessment service.
Despite these differences in funding and availability, both service sectors
share the experience of having undergone restructuring in most provinces
over the past 10 years, with a resulting reduction of public expenditures
for many programs — despite increases in the demand for some services.
Healthy Development 154 of Children and Youth
Health Services and Social Services
A Closer Look at the Determinants
Relationship to Healthy Child Development
Health and social services contribute to healthy child development in a variety
of ways. They provide services and supports at all stages of childhood, from
preconception through young adulthood. They also provide services and
supports in response to changing life circumstances and health status, ranging
from wellness through to illness or other negative health conditions. And they
provide services and supports at different points of intervention, from promotion and prevention through treatment and rehabilitation.
Health and social services contribute to healthy child development
in different ways at various life stages.
Health services and social services play a particularly important role in getting
children off to a good start in life. Their contributions can begin even prior
to conception through a variety of services for non-pregnant women. These
include services that diagnose and treat general health problems — organic
medical problems, nutritional status, sexually transmitted diseases, immune
status, gynecological, anatomic and functional disorders, occupational
exposures, and genetic risk — that could adversely affect future pregnancy,
fetal development and maternal health.
They also include services that diagnose and treat mental health disorders
and problem behaviours such as smoking, alcohol and other substance abuse.
And finally, they include services that promote responsible and effective
parenting such as comprehensive family planning
programs, which provide education and
counselling, physical exams and lab tests,
and information and instruction on
family planning methods (Carnegie
Corporation, 1994, p. 80).
Health and social services
also provide invaluable supports
for women once they become
pregnant, and to a lesser degree,
for prospective fathers. Medical
services provide early diagnosis of
pregnancy. Counselling services support
the continuation of pregnancy through
referrals to prenatal care, childbirth preparation
classes, and adoption services. Good prenatal care ensures a whole host
of benefits including requisition of appropriate laboratory tests, diagnosis
and treatment of general and/or mental health problems, assessment of
nutritional status, screening for infectious diseases, and identification and
management of high-risk pregnancies.
Prenatal counselling and anticipatory guidance services promote healthy
choices and behaviours during pregnancy, early detection of possible abnormalities, preparation for labour, information on infant nutritional needs and
feeding practices (including breastfeeding), and awareness of the emotional
and social changes brought on by the birth of a child.
Healthy Development 155 of Children and Youth
H
ealth services and
social services play a
particularly important
role in getting children
off to a good start
in life.
Health Services and Social Services
A Closer Look at the Determinants
Once a child is born, health and social services can contribute to its early
development by providing evaluation and support immediately after delivery,
linkage to continuous and comprehensive pediatric care after discharge,
diagnosis and treatment of maternal health problems including postpartum
depression, nutritional assessment and supplementation, infant stimulation
programs, home-visiting programs that support effective parenting and parentchild attachment, and quality child care.
As a child moves towards school age, the contributions of health and
social services often become more situation-specific. If a child is developing
normally, parents may only draw upon the occasional health service to diagnose
and treat the usual childhood maladies. As well, they may use some of the more
competency-based social services, such as family resource centres or other
parenting support programs.
However, for children who are living in circumstances that place them
at risk, or for those who have unique characteristics that translate into special
needs, a whole host of preventive and special services may come into play.
These include a variety of child and family services such as mental health
and child protection services, developmental and rehabilitative services
(e.g. physical therapy, language therapy), and school readiness programs.
The same pattern holds true for school-aged children and adolescents.
Those who are developing normally tend to use health and social services
on an as-needed basis. Those who are at risk or have special needs draw
upon a variety of specialized services. Health and social services can make
a significant contribution to young people approaching adolescence by
providing both good information about personal health and programs that
promote positive life skills.
These can be provided in a variety of ways, including: programs that build
social support networks, especially those addressing factors that predispose
young people to engage in risky behaviour; adult mentoring programs that
foster a stable, supportive bond between a young person and a caring adult;
well-developed peer-mediated counselling and peer tutoring programs; and
life skills programs that stress interpersonal, decision-making and coping
skills (Carnegie Corporation, 1996, p. 19).
Services for Children with Special Needs
In 1991, 7.2% of children and youth between 0 and 19 years of age living at home had at least one
disability (including physical, psychological and mental disabilities). The rate was higher among
boys (7.9%) than girls (6.3%). Most (85%) children with disabilities had mild disabilities; 11%
had moderate disabilities; 4% had severe disabilities. The rates of moderate and severe disabilities
were higher among 15- to 19-year-olds (19% and 5% respectively) (CICH, 1994, pp. 151–152).
See Exhibit 9.1.
Almost 50% of all children and youth with disabilities had specialized transportation services
available in their communities; however, more than 13,000 children and youth with disabilities
had a need for transportation services but did not have them in their communities. Few (1.5%)
children with disabilities needed speciliazed accommodation features (e.g. ramps, widened doors,
automatic doors, elevators), but did not have them (CICH, 1994, pp. 162–163).
Healthy Development 156 of Children and Youth
Health Services and Social Services
A Closer Look at the Determinants
Health and social services contribute to healthy child development
in response to changing life circumstances and health status.
Most children get off to a good start in life, and then grow and develop in
a reasonably normal way. There are numerous health and social services
(described in the next section) that promote and support this well-being
and positive development.
But health status can change at any point
9.1 Distribution of children aged 0 to 19 years
in time, as can the conditions or circumstances
with disabilities, by severity of disability,
that contribute to it. For this reason, there are
Canada, 1991
a number of health and social services that
Mild 85%
respond to changing health status and life
circumstances. Most of these services are
designed to lessen the impact of what are
Severe 4%
hoped to be temporary setbacks in states and
Moderate 11%
conditions of well-being. They range from
direct services to young people and their
caregivers, through to programs, services and
other supports that are intended to strengthen
Source: Canadian Institute of Child Health (1994). The
Health of Canada’s Children: A CICH Profile, 2nd edition.
the conditions in which these young people
Ottawa: CICH, p. 152.
and caregivers find themselves.
For example, there are a variety of primary,
secondary and tertiary health-care services that diagnose and treat the full
spectrum of childhood diseases and other health conditions. Similarly, there
are all kinds of social services that attempt to offset difficult life circumstances
(e.g. parental illness or injury, unemployment, and changes in family structure).
These include respite services, food banks, mediation services, counselling
services, child welfare services, family income security programs, employment
training programs, and subsidized housing.
For those with long-term or chronic health or developmental concerns,
such as disabling conditions, there are also a number of special health
and social services, ranging from rehabilitative services (e.g. physiotherapy
and speech and language therapy) to long-term services and supports
(e.g. attendant care).
Immunization is Key
Many childhood diseases are preventable. These include diptheria, tetanus, measles,
rubella and congenital rubella syndrome, mumps, pertussis, poliomyelitis and
invasive infections due to Haemophilus influenza.
For some diseases, the risk of long-term consequences is greater if infection is in
early childhood. Major blood-borne pathogens such as hepatitis B and hepatitis C
cause long-term persistent infections in children. The risk of chronic hepatitis B
infection is 90% to 95% if exposure occurs in infancy, but only 6% to 10% if
acquired in adulthood (Health Canada, 1998, p. 90). Hepatitis C may lead to
chronic infections in up to 70% to 80% of cases (WHO et al., 1999, p. 36).
Healthy Development 157 of Children and Youth
Health Services and Social Services
A Closer Look at the Determinants
Health and social services contribute to healthy child development
at different points of intervention.
A true system of health services and
social services is comprised of a variety
Child-care Subsidies
of services and supports that lie along
High-quality child care contributes to greater
a continuum of points of intervention.
This continuum ranges from promotion
social competency, higher levels of language
and prevention at one end, to treatment
development, higher developmental levels of play,
and long-term care at the other. Having
better ability to self-regulate and fewer behaviour
such a continuum of services and
problems.
supports enables health and social
services to contribute to healthy child
While all provinces have fee subsidies for lowdevelopment at all points of well-being.
income families, most provinces limit their
For example, health and social
availability (CCSD, 1996, pp. 30–31). In fact, in
services can promote good health and
recent years, the number of child-care subsidies
normal development through services
such as well-baby clinics and parent
for low-income parents along with operating or
education programs. They also can conwage grants to child-care providers were decreased
tribute to reducing risk and preventing
in many provinces (CCSD, 1996, pp. 30–31). In
illness or other negative health conditions
1993, the income cut-off for child-care subsidies
through immunization programs and
early identification programs that screen
was less than $21,000 for a two-parent family with
for developmental anomalies or genetic
two children in seven provinces and one territory
disorders.
(CCSD, 1996, pp. 30–31).
Where a concern is already evident,
health and social services can intervene
early before the situation worsens,
through strategies such as home-visiting programs and child development
programs. In more serious situations, they can treat illness or other negative
health conditions through resources such as neonatal trauma units, programs
that treat postpartum depression, and primary care services for childhood
diseases.
And finally, for situations in which there is a long-term concern, health
and social services can contribute to healthy child development by providing
support (e.g. counselling and anticipatory guidance) to parents of children
with chronic illness or disabling conditions.
Conditions and Trends
In Canada, health and social services are by and large the responsibility
of provincial/territorial and local governments. Given this decentralized
approach, there is considerable diversity across the country with regard to
legislation, funding, administration and availability of these services. Along
with this diversity, however, there appear to be a few common themes.
Healthy Development 158 of Children and Youth
Health Services and Social Services
A Closer Look at the Determinants
Fiscal restraint and systems change.
Perhaps the two most common themes across all jurisdictions are those of fiscal
restraint and systems change. With the persistent concerns about deficits and
debt, all levels of government have been seeking ways to contain costs and
restructure service systems to be more efficient and effective. These two trends
have had a significant impact on the funding, organization and delivery of
health and social services across all categories of service: universal, targeted,
and special services. And with the current uncertainty about the state of the
international economy, the concerns — at least about cost — are not likely
to go away.
In 1994, for the first time in 20 years, health expenditures showed a
decline, per person and as a percent of GDP (Health Canada, 1996, p. 26).
See Exhibit 9.2.
Health care spending on children accounts for less than 10% of all
spending, even though children under the age of 15 make up about 20%
of the population (CCSD, 1996, p. 30). Since 1980, the growth in per capita
expenditure on health has been about the same for all age groups. See
Exhibit 9.3.
9.2 Real per capita health expenditures, Canada, selected years,
1975 to 1994
1988 dollars
Total
2,000
1,600
Public sector
1,200
800
Private sector
400
0
1975 1977 1978 1981 1983 1985 1987
1989 1991 1993
Source: Health Canada (1996). National Health Expenditures in Canada 1974–1994: Summary
Report. Catalogue No. H21-99/1992-2. Ottawa: Health Canada, p. 26.
9.3 Per capita total health expenditures by age group,
Canada, selected years, 1980 to 1994
Dollars per capita
10 ,000
65+
8,000
6,000
4,000
45–65
15–44
2,000
0–14
0
1980 1982 1984 1986 1988 1990 1992
1994
Source: Health Canada (1996). National Health Expenditures in Canada 1974–1994:
Summary Report. Catalogue No. H21-99/1992-2. Ottawa: Health Canada.
Healthy Development 159 of Children and Youth
Health Services and Social Services
A Closer Look at the Determinants
Increased emphasis on population health and early child development.
There has been a growing appreciation
of the population health perspective,
Reduced Spending and Care
particularly at the federal and
provincial/territorial levels of
In recent years, spending cuts on health care and
government. Population health,
overall reform of the health care system have
with its emphasis on broad health
resulted in a shift away from traditional services
determinants, has become a very useful
and settings. There are some indicators that
framework for understanding both the
continuity of care has been affected by the shift
factors that influence health and the
opportunities for improving health
away from hospital care without alternative infrastatus of the population as a whole.
stucture and supports being made available. For
One consequence of this improved
example, non-voluntary short hospital stays have
understanding of the factors that
been associated with infant re-admission, problems
influence population health has been
a renewed emphasis on early child
breastfeeding, parents’ difficulty adjusting and
development.
maternal dissatisfaction (Rush, 1996, p. 6).
There has always been a strong
emphasis on getting children off to a
good start; but in the past, much of the
rationale for this emphasis was tied to preparing children for successful
transition into the formal education system. Now we understand that in
addition to promoting school readiness, investing in the early development
of children holds other benefits as well, particularly in terms of adult health
status. As a result of this growing awareness, governments at all levels have been
either introducing new programs to support early child development or, in
some cases, shifting the use of existing resources.
System level emphasis on inter-sectoral action.
Given the variety of factors that influence health and well-being, and the fact
that some of the most powerful of these influences lie outside the traditional
health-care sector, the best way to improve population health is through a
multi-sectoral approach. For this reason, governments at all levels have been
searching for ways to connect the contributions of various sectors including
health, social services, education, finance, justice, recreation, and housing.
These inter-sectoral efforts have both “horizontal” dimensions (in that
they connect different partners and sectors) and “vertical” dimensions (in
terms of layers of organizations and levels of government). Both of these
dimensions are important to varying degrees depending upon the type of
inter-sectoral action.
Many jurisdictions have tried to strengthen the connections between sectors
within government through reorganization. The two most common approaches
have been to integrate responsibilities under one ministry or department, and
to create some form of inter-sectoral committee or structure. These are examples
of efforts to promote inter-sectoral action along a horizontal dimension.
Healthy Development 160 of Children and Youth
Health Services and Social Services
A Closer Look at the Determinants
But there also are increasing efforts to stimulate inter-sectoral action along
the vertical dimension. Among other benefits, this should help alleviate situations in which there have been disagreements over who should be providing
what, which resulted in children and families falling through the cracks of an
uncoordinated system.
The emphasis on inter-sectoral action has had very real implications for
the providers of health and social services, particularly in terms of heightened
expectations that they take an integrated and collaborative approach to the
planning and delivery of services.
Service level emphasis on holistic and customized packages of support.
The other side of the “inter-sectoral action coin” is an increased emphasis on
comprehensive and customized packages of services at the consumer level.
For the same reasons that it is important to be able to draw upon the contributions of different sectors at a systems level, it is also important to be able
to translate those inter-sectoral contributions into packages of services and
supports that respond to the unique circumstances and needs of individuals
and families.
As a result, funders and consumers are putting increased pressure on
service providers to find approaches that respond to the full range of unique
needs of those that require health and social services. In the health sector,
this has resulted in public health units joining other sectors in communitybased initiatives, with particular emphasis on providing multi-faceted supports
to those at risk. In social services, it has given rise to more comprehensive
and customized approaches to provision of services and supports such as
wrap-around services, family preservation programs, and service brokerage.
Health and Social Services and Other Determinants
Income and Social Status
Income and social status are powerful influences on health and well-being
at all stages of life, but they are particularly influential on the life chances
of children. There are troubling correlations between low income status and
the need for health services, particularly in relation to getting children off
to a good start. The same holds true for certain social services; for example,
child protection agencies report disproportionate numbers of poor women
and children among their caseloads.
The National Longitudinal Study of Children and Youth (NLSCY)
found that “single-mother family status and low income significantly and
independently influenced child well-being” (Lipman, Offord and Dooley,
1996, p. 89).
Healthy Development 161 of Children and Youth
Health Services and Social Services
A Closer Look at the Determinants
Education
Health and social services can provide a variety of
supports that help young people stay in school. For
example, health services strive to maintain health,
but they also diagnose and treat illness or other
health conditions, which might interfere with
school attendance. A vast array of social
services assess and treat emotional,
behavioural or social concerns that could
interfere with school attendance and
performance. Social services also provide
supports, such as child care, which allow young
parents to continue on with their education.
Health and social services also promote healthy early
development, and otherwise ensure that children are
ready for school. Health services such as primary care,
immunization programs and injury prevention programs
contribute to healthy early development, readiness to
learn, and eventual school attendance. Social services —
particularly those that support responsible and effective
parenting, and early development — also contribute to
getting children off to a good start and to making a
successful transition into the formal education system.
S
ocial services — particularly those
that support responsible and effective
parenting, and early development —
contribute to getting children off
to a good start and to making a
successful transition into the formal
education system.
Social Environment
Health and social services link to the immediate social environments in a variety
of ways. For example, some health services (such as home-visiting programs
and parenting programs) and many social services (including family resource
centres, mutual aid groups, parent and child drop-in programs, child-care
centres, and family preservation programs) include in their design the strengthening of social networks to overcome the negative effects on parents and
families of social isolation.
Other services — including community health programs, community
development programs and local economic development programs — attempt
to strengthen local social environments by working not just with individuals
and families, but with local groups and broader communities as well.
Natural and Built Environments
Health and social services link primarily with natural and built environments
through surveillance and regulatory functions, but also through awareness
and public education activities. For example, public health departments play
a leading role in the monitoring and enforcement of standards related to the
natural environment, such as air and water quality. They also play a similar
role with regard to public health standards for built environments for children,
Healthy Development 162 of Children and Youth
Health Services and Social Services
A Closer Look at the Determinants
including parks, schools, housing units, child-care programs, and residential
care settings. Social services play a smaller role, but try to ensure that local
built environments are safe and welcoming to children and youth, and are
supportive of their developmental needs (e.g. youth programs at malls and
in high-density housing areas).
Personal Health Practices and Coping Skills
A variety of services are intended to promote healthy life choices and improve
coping skills in relation to child development. In the health sector, services
include: comprehensive family planning programs; health education programs;
programs that diagnose and treat health problems that could affect pregnancy
or birth; programs that diagnose and treat mental health problems; and
counselling and anticipatory guidance for parents of children with a chronic
illness or disabling condition.
In the social services sector, these include: family resource programs;
parent and child drop-in programs; individual, couple and family counselling
services; child and family mental health programs; child protection services;
respite programs; and community-based programs to prevent family violence.
Genetic and Biological Factors
Health and social services have a small but growing link to biology and genetics
as contributors to healthy child development. Most of the services that have
relevance for these two fields include a counselling component. For example,
prenatal health services provide genetic screening, diagnosis and counselling,
as well as diagnosis and treatment of gynecological anatomic and functional
disorders that could adversely affect pregnancy, fetal development, or maternal
health. Both health and social services also counsel with regard to pregnancy
continuation and positive health behaviours related to pregnancy.
Culture
Some health and social services are intended to be bridging services (i.e. they
assist people from varying cultural backgrounds to become more familiar and
comfortable with mainstream health and social services). In addition, health
and social services are increasingly being designed and delivered in a manner
that is both sensitive and responsive to the cultures of those they serve. In some
instances, such as social services within Aboriginal communities, the actual
governance and delivery of services is being turned over to the communities
themselves.
Healthy Development 163 of Children and Youth
Health Services and Social Services
A Closer Look at the Determinants
Gender
Health and social services link to gender in a number of ways. Health services
link with the biological dimension of gender (e.g. reproductive health), while
social services may have more links with the social dimension of gender —
parental roles, societal attitudes, receptiveness to services, and gender-related
patterns of behaviour and service (e.g. sole-parent led families, risk-taking
behaviours).
References
Canadian Council on Social Development (1996). The Progress of Canada’s Children — 1996.
Ottawa: Canadian Council on Social Development.
Canadian Institute of Child Health (1994). The Health of Canada’s Children: A CICH Profile, 2nd
edition. Ottawa: Canadian Institute of Child Health.
Carnegie Corporation of New York (1994). Starting Points: Meeting the Needs of Our Youngest
Children. New York: Carnegie Corporation of New York.
Carnegie Corporation of New York (1996). Great Transitions: Preparing Adolescents for a New Century
(Abridged Edition). New York: Carnegie Corporation of New York.
Health Canada (1996). National Health Expenditures in Canada 1974–1994: Summary Report.
Catalogue No. H21-99/1992-2. Ottawa: Health Canada.
Health Canada (1998). Canadian Immunization Guide. Catalogue No. H49-8/1998E. Ottawa:
Canadian Medical Association.
Lipman, E.L., D.R. Offord and M.D. Dooley (1996). “What Do We Know about Children from
Single-mother Families? Questions and Answers from the National Longitudinal Survey of
Children and Youth.” In Growing Up in Canada: National Longitudinal Survey of Children and
Youth. Catalogue No. 89-550-MPE, No. 1. Ottawa: Human Resources Development Canada
and Statistics Canada, pp. 83–91.
Rush, J. (1996). “Early Hospital Discharge of Mothers and Newborns.” Child Action, Vol. 2(1).
Ottawa: Canadian Institute of Child Health.
WHO and Viral Hepatitis Prevention Board (1999). “Global surveillance and control of
hepatitis C.” Journal of Viral Hepatitis, Vol. 6: 35-47.
Healthy Development 164 of Children and Youth
C h a p t e r
10
Culture
Overview
The concept of culture refers to a shared identity based on such factors
as common language, shared values and attitudes, and similarities in
ideology. In terms of health, some cultural groups face additional risks
because of dominant cultural values that contribute to conditions such
as marginalization, stigmatization, loss or devaluation of language and
culture, lackof access to culturally appropriate health care and services,
and lack of recognition of skills and training.
Racism and discrimination have direct impacts on health, as well as indirect
impacts mediated through various forms of social, political and economic
inequity. For example, the factors that contribute to the major health
disparities between First Nations, Inuit and Métis communities and other
communities (including education, income, culture, and social and physical
environment) are rooted in a long history of prejudice and racism.
Healthy Development 165 of Children and Youth
Culture
A Closer Look at the Determinants
Relationship to Healthy Child Development
Minority groups often experience “acculturative stress.”
New immigrants and refugees, as well as Aboriginal people and other ethnic
group members are likely to experience stress from a variety of sources —
including their economic circumstances, social and personal isolation, negative
attitudes, and threatened or actual violence (Berry, 1980). This “acculturative
stress” can have significant health impacts, both physical and mental. For
example, Aboriginal people in Canada often experience stress when they move
from an area of relative isolation or a smaller community to a large urban
centre. This stress may result in problems of alcoholism, family disruption and
physical illness (Masi, 1989a, p. 72).
One significant source of stress among members of immigrant groups is
the conflict between adults and children. Immigrant children tend to integrate
more quickly into the dominant culture (Baptiste, 1990; Kim, 1980), often
learning the language and cultural mores before their parents. As a result,
children become the family’s translators and cultural interpreters, with a
consequent reversal of roles and destabilization of normal lines of community
and authority in the family (Baptiste, 1993).
Minority cultural groups may also feel conflicting desires and expectations
for their children — on the one hand, fearing that their children will acquire
undesirable aspects of the new culture and, on the other, wanting them to
obtain the characteristics that will equip them for
success (Wakil, Siddique and Wakil, 1981;
Xenocostas, 1991; Markowitz, 1994). The
potential for conflict is particularly high during
adolescence, when issues of separation,
individuation and identity rise to the surface
(Baptiste, 1993). It is important to note that
while families play an important role in passing
along culture, the importance of the family has
declined relative to the impact of other sources
of cultural influence, such as the marketplace and
boriginal people in
schools (Erickson, 1991, p. 1).
A
Canada often experience
Migration can affect physical health.
There is some evidence that migration poses a
threat to physical health because of dietary changes
and exposure to local pathogens against which migrants have
no immunity (Beiser et al., 1995, p. 68).
Healthy Development 166 of Children and Youth
stress when they move
from an area of relative
isolation or a smaller
community to a large
urban centre.
Culture
A Closer Look at the Determinants
Refugees face unique stresses.
There is some evidence that voluntary migrants (e.g. immigrants) experience
less stress than those who expose themselves to cultural change involuntarily
(e.g. refugees and Aboriginal people) (Berry et al., 1987). Poverty, combined
with uncertainty about the outcome of their refugee claim and negative attitudes
in the host country, can create enormous stress for refugees. As well, refugee
children are likely to have experienced violence in their homelands and may
be at high risk for post-traumatic stress disorder (Beiser et al., 1995, p. 68).
The context of resettlement plays a mitigating role.
While the experience of migration and resettlement itself may result in significant stress for families, there are a number of mitigating factors that determine
whether or not immigration is necessarily followed by maladaptation. These
factors include selection policies, pre-migration experiences and the welcome
accorded by the host country (Beiser et al., 1995, p. 67).
Stress, personal strengths and social resources interact in complex ways
to determine health risks for minority cultural groups. Factors such as maternal
loss, depressed mothers and general family instability contribute increased
vulnerability among refugee and immigrant children. These factors also
contribute to lower scholastic achievement levels and a higher delinquency
rate (Rumbaut and Ima, 1988, as cited in Beiser et al., 1995).
Children who are separated from family members during the early years of
resettlement are at an increased risk for negative mental health consequences,
particularly if they are placed with a family of a different ethnic origin (Porte
and Torney-Purta, 1987).
Racism and discrimination
contribute to stress.
Many minority groups in Canada report
experiencing racism and discrimination.
For example, half of Indo-Canadian men
and women living in South Vancouver
reported experiencing some form of racial
hostility, ranging from verbal abuse and
physical harm to work force discrimination
(Nodwell and Guppy, 1992). In the 1980s,
testimonies of racial minorities before the
House of Commons Special Committee
on Participation of Visible Minorities
in Canada revealed many instances of
differential treatment. One study of the
Chinese community in Toronto found that
perceived discrimination correlated with
various psychological symptoms, such as
nervousness, sleep problems, headaches,
mood and degree of worry (Dion, Dion
and Pak, 1992).
Intercultural Adoptees
One study found that intercountry adoptees are
as well-adjusted as children in the population as
a whole. These children are well integrated, have
high self-esteem and positive peer relations. The
only area of concern is with respect to ethnic and
racial identity (Westhues and Cohen, 1994).
Furthermore, there is evidence that children of
parents who maintain their ethnic pride and
cultural identity perform better than children
whose parents assimilate fully (Rumbaut and
Ima, 1988, as cited in Beiser et al., 1995).
Cultural kinship — identifying with the language
and history, religious and ceremonial rituals, and
codes of behaviour of a culture — contributes to
children’s sense of identity, security and selfesteem (Haka-Ikse, 1988, p. 1113).
Healthy Development 167 of Children and Youth
Culture
A Closer Look at the Determinants
Cultural differences affect life changes.
The life changes (e.g. education, occupational status and employment income)
for immigrants vary according to their country of origin. For example,
European immigrants fare better in the Canadian labour market than their
Black and Asian counterparts (Reitz and Breton, 1994, pp. 112–114).
Cultural background, including ethnicity, can have an effect on academic
success (Farkas et al., 1990, p. 3). Despite some emphasis on multicultural
education, Canadian schools generally reproduce the cultures and values of the
dominant group (Hébert, 1992; Shamai, 1992). Language and communication
problems cause a disproportionate number of children from certain cultural
groups to be placed in special and vocational education classes (Toronto Board
of Education Consultative Committee on the Education of Black Students in
Toronto Schools, 1987). The result has been that the future education and
careers of these children are seriously limited (Masi, 1989a, p. 71).
Another study found that immigrant children whose mother tongue is
neither English nor French initially obtain lower marks in English compared
with Canadian-born children; however, they eventually catch up in their
ability to speak French or English, as well as in many other areas of school
performance (Samuel and Verma, 1992, pp. 55–56).
Cultural ties also help to maintain occupational segregation (Reitz, 1990).
Lack of recognition of diplomas and training received by immigrants in their
homeland decreases their access to work, resulting in occupational ghettoizing
and low socio-economic status (Maritime Centre of Excellence for Women’s
Health, 1997).
Culturally sensitive health and social services are important.
There is considerable evidence that physicians’ awareness of cultural issues
can positively affect the patient–physician relationship and contribute to
patient compliance and positive health outcomes. For example, an evaluation of Aboriginal health services suggested that their effectiveness was often
compromised by the cultural differences between those giving and those
receiving the services (Gibbons, 1992). Family physicians — often the first
Female Genital Mutilation
Generally performed prior to puberty, female genital mutilation (FGM) involves the removal of
part or all of the female genitalia and, in the most severe cases, the clasping together of the labia.
FGM is based on traditional practice rather than religion, and is employed in some cultures as a
way of controlling women’s attitudes towards sex, their sexuality, and of reinforcing the belief that
it is necessary to ensure their virginity and marriageability. FGM is most commonly practised in
Africa but is also experienced by women in parts of Asia and some countries in the Middle East.
Some women and girls who emigrate to Canada were subjected to FGM prior to their arrival. In
Canada, FGM is forbidden under the general provisions of the Criminal Code, and recent
amendments to the Criminal Code have made it illegal to transport a child out of Canada with the
intention of performing FGM.
Healthy Development 168 of Children and Youth
Culture
A Closer Look at the Determinants
point of contact with the Canadian health system — are under particular
pressure to become familiar with the special needs of clients from different
cultures (Hamilton, 1996, p. 585).
Other factors play a role, including traditional beliefs about the causes
of illness, attitudes towards caregivers and family values about care. Some
cultural groups routinely involve members of the extended family in providing
care. For example, people from developing countries often have a health-care
network that includes parents, relatives and non-relatives as health-care provider
(Masi, 1989b, p. 252). Moreover, language difficulties can cause misunderstandings by both physicians and immigrants, affecting diagnosis and treatment.
While large urban areas may have access to language interpretation services, the
lack of such services in smaller communities is a concern (Masi, 1989a, p. 71).
The issue of wife abuse must be addressed in a sensitive manner. Generally,
immigrant women and those from some ethnic groups who are battered have
little recourse. In some cases, community members may be more likely to
support the husband. Often, there are few outside resources available to these
battered women because of language or cultural barriers (Masi, 1989b, p. 253).
As seen in Chapter 4, witnessing spousal violence appears to have the strongest
influence on young people’s risk factors, including substance abuse and criminal
behaviour (Marion and Wilson, 1995, pp. 28–29).
Conditions and Trends
The conditions and trends listed here are not intended to be comprehensive,
but rather to provide examples of how cultural differences exist in some key
areas related to health.
Language and Ethnicity
• In the 1996 Census, 28% of the population identified themselves as having
a background other than British Isles, French or Canadian (Statistics
Canada, 1998a).
• In 1996, Canada’s visible minority population totalled 3,197,480,
representing 11.2% of the total population (28,528,125) (Statistics Canada,
1998b). See Exhibit 10.1.
• In 1996, Statistics Canada reported that about 16% of Canadians had a
mother tongue other than English or French (Statistics Canada, 1998b).
• About one quarter of all migrant children younger than age 12 enter
Canada as refugees (Beiser et al., 1995, p. 67).
• Traditionally, the sources of the majority of Canadian immigrants have
been Europe and the United States. More recently, Asia, Africa, the Middle
East and Latin America account for about three quarters of Canada’s new
immigrant population (Beiser et al., 1995, p. 68).
Healthy Development 169 of Children and Youth
Culture
A Closer Look at the Determinants
10.1 Distribution of visible minority population a by age, Canada, 1996
Total
0–14
15–24
25–44
45–64
65–74
75+
Number
Total population
28,528,125
5,899,200
3,849,025
9,324,340
6,175,785
2,024,180
1,255,590
3,197,480
778,340
521,060
1,125,730
581,275
129,415
61,655
Black
573,860
170,870
96,895
186,995
94,520
16,025
8,555
South Asian
670,590
168,585
107,465
230,245
127,355
26,425
10,505
Chinese
860,150
171,110
135,580
299,815
177,980
50,680
24,990
Korean
64,840
12,115
15,525
19,475
14,610
1,765
1,340
Japanese
88,135
12,545
11,830
20,850
14,670
5,280
2,965
Southeast Asian
172,195
49,295
28,380
68,210
20,195
4,895
1,785
Filipino
234,195
50,985
33,995
90,100
45,370
8,845
4,900
Arab/West Asian
244,665
60,850
37,040
95,005
39,995
8,185
3,630
Latin American
176,975
46,530
31,575
68,500
25,190
3,670
1,500
Visible minorityc
69,745
15,065
11,015
27,690
12,995
2,160
915
Multiple visible
minority d
61,575
20,385
11,755
18,945
8,425
1,480
575
Total visible minority
populationb
a. The Employment Equity Act defines the visible minority population as persons, other than Aboriginal peoples, who are non-Caucasian in race or non-white in colour.
b. The visible minority groups are based on categories used to define the visible minority population under the Regulations to the Employment Equity Act.
c. Not included elsewhere. Includes Pacific Islander group or another write-in response likely to be a visible minority (e.g. West Indian, South American).
d. Includes respondents who reported more than one visible minority group.
Source: Adapted from the Statistics Canada Web site: www.statcan.ca
Injuries
• Injury-related mortality rates among young Status Indians (0 to 19 years old)
are three times the national average (Health Canada, 1997, p. 55).
• Drowning rates are about eight times higher among First Nations and Inuit
children and youth aged 0 to 19 years (Health Canada, 1997, p. 185).
Suicide
Children and youth aged 0 to 19 in Aboriginal reserve communities have
a suicide rate almost five times that of children and youth in the general
population (Health Canada, 1997, p. 55).
Healthy Development 170 of Children and Youth
Culture
A Closer Look at the Determinants
Education
The majority of immigrant children aged 4 to 17 who came to Canada between
1981 and 1988 did not speak either official language (Samuel and Verma,
1992, pp. 53–54).
Culture and Other Determinants
Education and Employment
Culture affects a person’s education and occupation, as well as the education
and occupation of the person’s spouse; this, in turn, has considerable consequences for income, knowledge of support structures, access to informal
support in social networks, and personal coping skills (Erickson, 1991, p. 4).
Natural and Built Environments
Aboriginal children face a number of risks related to the natural and built
environment. For example, Aboriginal children have an injury rate almost
six times that of other Canadian infants (Health Canada, 1997, p. 55). They
are also at greater risk of exposure to contaminants because of poor housing
conditions, contaminated food sources, water supply and sanitation, and
indoor and outdoor environmental contaminants (Postl, MacDonald
and Moffat, 1994; Young, Bruce and Elias, 1991).
Personal Health Practices
There is evidence that culture affects personal health practices. For example,
the prevalence of smoking is high among Inuit and Francophone women
and low among most immigrant women (Maritime Centre of Excellence for
Women’s Health, 1997). Alcoholism has been
noted as more prevalent among the Irish
he majority of
than the Jewish (Henderson and
Primeaux, 1981, p. xix), and is
immigrant children aged
virtually unheard of as a social or
4 to 17 who came to
medical problem in Chinese society
(Lin T.-y., 1983, p. 864). There are
Canada between 1981
strong indicators that these differand 1988 did not speak
ences are due to cultural factors,
such as the degree of tolerance of
either official language.
alcohol use in a given community
(Masi, 1989b, p. 253).
T
Healthy Development 171 of Children and Youth
Culture
A Closer Look at the Determinants
Individual Capacity and Coping Skills
The incidence of suicide is higher among Aboriginal youth than among other
Canadian young people. One recent study reported a suicide rate for Status
Indians (aged 0 to 19) almost five times higher than the national average
(Health Canada, 1997, p. 55).
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Discrimination-Related Stress in Members of Toronto’s Chinese Community.” Canadian
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Erickson, B. (1991). Families and the Transmission of Culture. Report submitted to the Demographic
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Hamilton, J. (1996). “Multicultural Health Care Requires Adjustments by Doctors and Patients.”
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Women’s Health, Centres of Excellence for Women’s Health Program, Women’s Health
Bureau.
Markowitz, F. (1994). “Family Dynamics and the Teenage Immigrant: Creating the Self Through
the Parents’ Image.” Adolescence, Vol. 29, No. 113: 151–161
Masi, R. (1989a). “Multiculturalism, Medicine, and Health. Part IV: Individual Considerations.”
Canadian Family Physician, Vol. 35 (January 1989): 69–73.
Masi, R. (1989b). “Multiculturalism, Medicine and Health. Part V: Community Considerations.”
Canadian Family Physician, Vol. 35 (February 1989): 251–254.
Nodwell, E., and N. Guppy (1992). “The effects of publicly displayed ethnicity on interpersonal
discrimination: Indo-Canadians in Vancouver.” Canadian Review of Sociology and Anthropology,
Vol. 29, No. 1: 87–99.
Porte, Z., and J. Torney-Purta (1987). “Depression and Academic Achievement Among Indochinese Refugees, Unaccompanied Minors in Ethnic and Non-ethnic Placements.” American
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Postl, B., S. MacDonald and M. Moffat (1994). “Background Paper on the Health of Aboriginal
Peoples in Canada.” In Bridging the Gap: Promoting Health and Healing for Aboriginal Peoples in
Canada. Canadian Medical Association, pp. 19–56.
Reitz, J.G. (1990). “Ethnic Concentrations in Labour Markets and Their Implications for Ethnic
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Reitz, J.G., and R. Breton (1994). The Illusion of Difference: Realities of Ethnicity in Canada and the
United States. Toronto: C.D. Howe Institute.
Rumbaut, R.G., and K. Ima (1988). “The Adaptation of Southeast Asian Refugee Youth: A
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Canadian Journal of Psychiatry, Vol. 40 (March 1995): 67–72.
Samuel, J., and R.B.P. Verma (1992). “Immigrant Children in Canada: A Demographic Analysis.”
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Shamai, S. (1992). “Ethnicity and Educational Achievement in Canada — 1941–1981.”
Canadian Ethnic Studies, Vol. 24, No. 1: 42–57.
Statistics Canada (1998a). The Daily, February 17, 1998.
Statistics Canada (1998b). Statistics Canada Web site: http://www.statscan.ca
Toronto Board of Education Consultative Committee on the Education of Black Students in
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Healthy Development 173 of Children and Youth
C h a p t e r
11
Gender
Overview
Gender refers not only to the biological sex of an individual, but also to the
“array of roles, personality traits, attitudes, behaviours, values, relative power
and influence that society ascribes to men and women on a differential
basis” (Health Canada, 1996, p. 16).
The biological component to gender cannot be overlooked. For example,
girls are physiologically more likely to contract sexually transmitted diseases
(STDs) after exposure than males. Any risks associated with pregnancy or
problems related to menstruation are exclusive to females. Boys, however,
because of their later development, are at greater risk for some early
childhood diseases and conditions.
Gender is strongly influenced by the social environment in which we live.
Early socialization by parents, peers and educators can temper or enhance
the influence of biological determinants. Parents are likely to treat their
children differently, encouraging or discouraging certain behaviours depending on the sex of the child. Peers reward sexually “appropriate” behaviours
and punish “inappropriate” ones, shaping how children adopt and internalize socially constructed views of gender. The media also plays a role,
reinforcing many stereotypes of male and female behaviours and capabilities.
Many health and social conditions can be attributed to gender-based social
status or roles. For example, young women are more likely than young men
to achieve lower education levels, earn low income, experience single parenthood, and to have lower levels of both self-esteem and feelings of personal
competence. Females are also at higher risk for STDs, physical, sexual and
dating abuse, smoking, and physical inactivity. All of these factors interact
to negatively affect women’s health. On the other hand, boys have higher
mortality rates than girls — primarily from injury and suicide — and higher
rates of learning and conduct disorders.
Healthy Development 175 of Children and Youth
Gender
A Closer Look at the Determinants
Relationship to Healthy Child Development
Biology and genetic endowment set the stage.
A variety of biological and genetic differences between males and females
exert an influence on their health and development over the course of early
childhood and adolescence.
Because of physiological differences, males and females have different
sexual and reproductive experiences and risks. For example, the greater
vulnerability of the female reproductive tract to organisms transmitted during
unprotected sex places women at greater risk of acquiring certain sexually
transmitted diseases (STDs). A man with a gonorrheal infection will infect
about half of his female partners, while an infected woman will infect only
25% of male partners (Baird et al., 1993, p. 207). Females also carry an extra
burden for sexual and reproductive health; menstruation, pregnancy and
contraception are associated with numerous risks and side effects — both
physical and emotional.
Overall, girls develop more quickly than do boys. From the time they
are born, girls are more physically developed than boys, an advantage that
continues throughout early childhood. By the time they enter school, girls
are an average of one year ahead of boys in physical development (Eme and
Kavanaugh, 1995). There is some evidence to suggest that this phenomenon
may contribute to the higher incidence of birth defects among boys, and
to the fact that boys appear to suffer more from the effects of Fetal Alcohol
Syndrome (FAS) (Eme and Kavanaugh, 1995).
While girls aged 6 to 7 exhibit better coordination skills than boys (Prior
et al., 1993), this advantage appears to change over middle childhood and
adolescence. One reason may be that, as girls get older, they are less likely
to participate in physical activities that promote the development of motor
skills — including running, catching and throwing (McKinnon and AholaSidaway, 1997).
Socialization is key.
Early socialization — including the influence of parents, peers, teachers and
other significant adults — plays an important role in the acquisition of genderbased behaviours and attitudes among children.
Research has found that young boys and girls interact differently with their
parents. For example, boys are more likely to be in conflict with their parents,
to be punished and to see their parents in conflict. In addition, their family
ties are not as strong as those of girls (Prior et al., 1993).
Similarly, parents often display different behaviours depending on the
sex of the child. In father-child relationships, fathers appear to respond
more positively to daughters’ prosocial behaviour than to sons’ behaviour
(Kerig, Cowan and Cowan, 1993). They are also less tolerant of internalizing
behaviours among girls and more tolerant of physical aggression in boys.
Mothers, on the other hand, do not see the internalizing behaviour as
problematic (Webster-Stratton, 1996). Mothers are also more likely to talk
Healthy Development 176 of Children and Youth
Gender
A Closer Look at the Determinants
about emotions with their daughters than with their sons (Eisenberg, Martin
and Fabes, 1996), and may encourage their daughters to have concern for
others (Keenan and Shaw, 1997) and to problem solve (Nolen-Hoeksema et
al., 1995). Girls are often socialized to assume caring and nurturing roles,
despite the increased likelihood that they will pursue employment objectives.
Peer influences affect the development of gender-based behaviours and
attitudes. Children tend to segregate themselves according to sex — particularly
in play groups — and there is some evidence to suggest that girls and boys
learn and practise different social and cognitive skills within these groups
(Keenan and Shaw, 1997). Peers reinforce gender-typed play and punish
cross-gender play and non-normative forms of aggression (e.g. girls who are
physically aggressive, boys who are relationally aggressive) (Golombuk and
Fivush, 1994; Crick, 1997).
Early childhood educators are important socializing agents for children.
Educators’ assumptions about gender help to shape children’s perceptions
of, and interactions with, boys and girls. While there is increasing awareness
among teachers and other educators about the impact of early gender-based
expectations on children’s development, a number of studies have found
that teachers tend to react differently to boys’ and girls’ problem behaviours
(Keenan and Shaw, 1997).
The media, including children’s literature, help to enforce gender
stereotypes. Several researchers have found that the content of much TV
programming is “heavily male-oriented, and depicts sex roles that are often
stereotyped and distorted” (Luecka-Aleksa et al., 1995, p. 774). The same
may be said of sex-role portrayals in children’s literature (Golombuk and
Fivush, 1994).
The mass media also play an important role in creating and reinforcing
attitudes and values about gender roles, sexual attractiveness and body ideals.
For example, media images cast the female body ideal as tall, extremely thin
and attractive, and foster an internalization of often unattainable ideals in
girls and young women.
O
verall, girls develop more quickly than
do boys. From the time they are born, girls
are more physically developed than boys,
an advantage that continues throughout
early childhood.
Healthy Development 177 of Children and Youth
Gender
A Closer Look at the Determinants
Gender, power and violence.
Gender roles and the gender “script” imposed by society have a powerful
impact on youth behaviour, especially concerning issues such as safe sex and
coercive or early sexual activity. Women are often conditioned to assume a
submissive role and may not feel able to insist on safe sex practices. At the same
time, women are given most of the responsibility for preventing pregnancy
and STDs (Kinnon, 1994). The situation may be exacerbated when cultural
factors are present. According to one study, one third of Aboriginal women
said they were afraid of being abused if they refused to have sex with a partner
(Aboriginal Nurses Association of Canada, 1996, p. 34).
The effects of violence may be exhibited differently between the sexes.
One study suggested that, in terms of social-emotional development, physically
abused boys show more “externalizing” behaviour, such as aggression, while
girls demonstrate more “internalizing” behaviour. Young girls who are sexually
abused may also be more likely than young abused boys to exhibit cognitive
and academic difficulties (Trickett and McBride-Chang, 1995).
A recent review of the literature on children and youth who witness familial
violence has revealed gender differences in children’s reactions. Boys tend to
react with more overt violence, whereas girls tend to become more dependent
and timid. Furthermore, children who witness violence in the home are more
likely to be involved in violent relationships as adults. Whereas girls may be more
accepting of violence in their relationships, boys are more likely to be the
perpetrator (Suderman and Jaffe, 1997).
Conditions and Trends
Males have higher rates of injury, death and disability.
A variety of gender-related differences in health status have been demonstrated
among Canadian children and youth. Mortality rates are higher for males
than for females in all age groups, but particularly among 15- to 19-year-olds,
where the rates are 96 per 100,000 and 34 per 100,000 respectively (CICH,
1994, p. 87).
Hospitalization is more frequent for males of all ages. During adolescence,
the most common reason for hospital admission for males is injury (32%);
for females, it is pregnancy (39%) (CICH, 1994, p. 91). Although females are
more likely to attempt suicide, males are much more likely to die from their
attempts (CICH, 1994, p. 97).
In general, disability rates among young people under age 20 are higher
for males (7.9%) than for females (6.3%) (CICH, 1994, p. 151). The gap is
wider for young people with learning disabilities, which are twice as common
in males than in females, and with behavioural and emotional conditions,
which are three times as common in males (CICH, 1994, p. 154).
Healthy Development 178 of Children and Youth
Gender
A Closer Look at the Determinants
Females rate lower on well-being and body image.
Female adolescents consistently score lower
than males on all indicators of well-being.
11.1 Proportion of students in grades 6 to 10
who report feeling “very happy” about their
Rates of depression are higher among
lives, by grade and sex, Canada, 1997–98
females than males (52.4% vs. 35.9%)
%
(Fleming, Offord and Boyle, 1989). Among
56
Male
Female
13- to 16-year-olds, 55% of females and 48%
48
of males reported feeling stressed (CICH,
44
42
38
1994, p. 74; Holmes and Silverman, 1992,
37
35
33
p. 22). A study by the Canadian Advisory
26
26
Committee on the Status of Women found
that more males than females reported
feeling good about themselves (45% versus
30%), having a number of good qualities
(43% versus 31%), and being self-confident
Grade 6
Grade 7
Grade 8
Grade 9
Grade 10
(33% versus 22%) (Holmes and Silverman,
Source: A.J.C. King, W. Boyce and M. King (1999). Trends in the
1992, pp. 12–13). A study of students in
Health of Canadian Youth. Catalogue No. H39-498/1999E.
grades 6 to 10 found that, for every grade,
Ottawa: Health Canada, p. 45.
more males than females felt happy about
their lives (King, Boyce and King, 1999,
p. 45). See Exhibit 11.1. Comparisons with results from the mid-1980s show
that the gender gap on these measures widened in the early 1990s (CICH,
1994, p. 96).
Girls are particularly concerned with body image. Adolescent girls are much
more likely to report wanting to lose weight than are adolescent boys. One
recent study revealed that 29% of girls aged 11 wanted to lose weight, compared
with 19% of boys at the same age. At age 13, the gender gap widened, with
41% of girls and 21% of boys expressing a desire to lose weight (King, Boyce
and King, 1999, p. 70).
There are differences in personal health practices.
Differential health practices play a role in the
overall health of males and females. Boys are
more likely than girls to engage in physical
activity. In fact, adolescent boys spend about
50% more energy on physical activities than
do girls (CFLRI, 1997, p. 2). As Exhibit 11.2
shows, a higher proportion of male students
than female students in grades 6 to 10 said
they exercise four or more times a week
(WHO, 1999). However, there is evidence
that girls’ level of activity is on the rise
(CCSD, 1997, p. 37).
The incidence of smoking among 15-yearold women has increased in recent years, from
18% in 1990 to 21% in 1998. This trend
suggests that young women are increasingly
experiencing severe social strains (King,
Boyce and King, 1999, p. 95).
11.2 Proportion of students in grades 6 to 10
who report exercising four or more times a
week, by grade and sex, Canada, 1997–98
%
51
Male
48
47
31
46
45
31
26
Grade 6
Female
Grade 7
Grade 8
23
24
Grade 9
Grade 10
Source: WHO (1999). Health Behaviour in School Age Children
Survey, A World Health Organization Cross-National Study,
1997-98.
Healthy Development 179 of Children and Youth
Gender
A Closer Look at the Determinants
The risk of abuse is higher for girls.
It has been estimated that 25% of girls and 10% of boys will be sexually abused
before the age of 16 (Finkel, 1987, p. 245). Girls are more often the victims of
assault by family members than are boys. In one study, girls were the victims
in almost 80% of the cases of assault in which the perpetrator was a family
member (Statistics Canada, 1998, p. 22).
Gender not only influences the likelihood of a child being victimized,
but also the nature of that victimization. A 1995 study of self-reported
maltreatment revealed that physical abuse was reported by 44% of female
adolescents (14 to 18 years of age), compared with 33% of male adolescents.
Moreover, a further 28% reported experiences of sexual abuse compared
with 0% of male adolescents (Manion and Wilson, 1995, p. 15).
More boys than girls drop out of school.
Adolescent males are more likely to drop out of school than adolescent females
(17% and 11%, respectively). The three most common reasons for school
drop-out for both males and females are boredom, preferring work to school,
and problems with school work and teachers (Statistics Canada, 1993, p. 27).
However, girls are more likely than boys to “drop” in level of school performance as they move into adolescence, especially in maths and sciences.
Gender and Other Determinants
Education
In 1995, 30% of young women (aged 22 to 24) without a high school diploma
were unemployed, compared with 17% of men (HRDC and Statistics Canada,
1996, p. 5). Overall, women’s level of education is increasing — in 1992–93,
they represented 53% of all undergraduate students, 46% of all master’s
degree students and 35% of all doctoral students (Normand, 1995, p. 19).
However, young women remain underrepresented in physical science courses,
undergraduate engineering and applied sciences.
Personal Health Practices
Physical appearance is a key concern for many female adolescents struggling
to maintain a positive self-image. Young women with negative body image
have a higher risk of engaging in disordered eating behaviours than those
who are not concerned with image. Low self-esteem among boys and young
men has been linked with the use of anabolic steroids (King, Boyce and
King, 1999).
Healthy Development 180 of Children and Youth
Gender
A Closer Look at the Determinants
Individual Capacity and Coping Skills
According to the NLSCY, in 1994–95 the highest rate of emotional and
behavioural problems was among boys aged 8 to 11 and the lowest was among
girls aged 4 to 7. In fact, all prevalence rates of disorders were higher for boys
than for girls. While more young women than men attempt suicide, young
men are much more likely to complete the attempt (CICH, 1994, pp. 75, 89).
Genetic and Biological Factors
Boys and girls are at different risk for certain types of disabilities and disorders.
For example, boys are at greater risk than girls for developmental disorders
such as autism (Bryson, Clark and Smith, 1988) and behavioural conditions
such as attention deficit and conduct disorder (Offord, 1987). However, girls
are at much greater risk of developing depression and eating disorders in
adolescence (Cicchetti and Toth, 1998).
References
Aboriginal Nurses Association of Canada (1996). HIV/AIDS and Its Impact on Aboriginal Women
in Canada. Ottawa: Health Canada.
Baird, P., et al. (1993). Proceed with Care: Final Report of the Royal Commission on New Reproductive
Technologies. Vol. 1. Ottawa: Minister of Supply and Services Canada.
Bryson, S.E., B.S. Clark and I. Smith (1988). “First report of a Canadian epidemiological study
of autistic syndromes.” Journal of Child Psychology and Psychiatry and Allied Disciplines, Vol. 29:
433–446.
Canadian Council on Social Development (1997). The Progress of Canada’s Children — 1997.
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Progress in Prevention, Bulletin No. 13.
Canadian Institute of Child Health (1994). The Health of Canada’s Children: A CICH Profile, 2nd
edition. Ottawa: Canadian Institute of Child Health.
Cicchetti, D., and S.L. Toth (1998). “The development of depression in children and
adolescents.” American Psychology, Vol. 53: 221–241.
Crick, N.R. (1997). “Engagement in Gender Normative versus Non-normative Forms of
Aggression: Links to Social Psychological Adjustment.” Developmental Psychology, Vol. 33(4):
610–617.
Eisenberg, N., C.L. Martin and R.A. Fabes (1996). “Gender Development and Gender Effects.”
In Handbook of Educational Psychology. Edited by D. Berliner and R. Calfee. Toronto: Simon
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Eme, R.F., and L. Kavanaugh (1995). “Sex Differences in Conduct Disorder.” Journal of Clinical
and Consulting Psychology, Vol. 24, No. 4: 406–426.
Finkel, K.C. (1987). “Sexual Abuse of Children: An Update.” Canadian Medical Association
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Fleming, J.E., D.R. Offord and M.H. Boyle (1989). “Prevalence of Childhood and Adolescent
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Healthy Development 182 of Children and Youth
Part
C
Challenges — Today and Tomorrow
Part C addresses some of the key challenges Canada will face in the 21st
century — many of which already call for action — as well as core
requirements for addressing the challenges.
C h a p t e r
12
Challenges
Overview
We all want the best for our children. However, in a changing world that is
growing more and more complex, achieving this is neither predictable nor
assured. Our children’s world holds much promise: the United Nations
Convention on the Rights of the Child, the electronic revolution, longer
life expectancies, and access to the world through telecommunications and
travel. At the same time, children in our society face the threat of exposure
to environmental pollutants, violence, pressures of time and money, and
an increasingly global economy that demands a highly skilled work force.
Today, as in most generations, children at all income levels and in all ethnic
groups face a combination of opportunities, stresses and threats that were
inconceivable just 50 years ago.
The purpose of this section is twofold: to provide a summary of and
stimulate thinking around trends selected from among those presented
in the previous chapters that will likely affect the future of child health.
Understanding the forces that shape young people’s health involves a
look at the determinants of health, including the physical, family, school,
community and workplace environments, and the obstacles presented by
poverty. As a starting point, several crosscutting issues will be considered:
child development, the population health model, the inter-sectoral
approach, decentralization, globalization, the Information Age, aging of
the population, and children’s perspectives. These issues are complex and
far reaching; in fact, our understanding of the effects of some of these
issues may take years to emerge.
Healthy Development 185 of Children and Youth
Challenges
Today and Tomorrow
Although most children grow up healthy, and numerous indicators of
their well-being reveal many successes — including infant mortality rates
that are at a record low and test scores in reading and science that are
among the highest in the world — a number of other indicators paint a
picture of shortcomings, such as increased violence and suicide among
youth. The isssues and problems related to the healthy development of
children and youth are magnified for the Canadian Aboriginal population.
Our grasp of the future of young people’s health needs to be grounded in
an understanding of a wide range of influences or determinants that may
support or compromise their health. This understanding is key to our being
able to take action and make decisions that will lead to the improvement
of the situation for Canada’s children and youth and their families.
Healthy Development 186 of Children and Youth
Challenges
Today and Tomorrow
Overarching Issues for the 21st Century
Child Development
Research shows that an adult’s health is strongly linked to his or her early
childhood experiences (Federal, Provincial and Territorial Advisory Committee
on Population Health, 1998, p. 2). It follows, then, that getting off to a good
start is critical to a child’s general well-being. The two decades of transition from
the helpless newborn baby to the independence of an adult are characterized
by periods of enormous change. Each of these transitions can be viewed as
windows of opportunity for influencing future development. It has long been
acknowledged that early health promotion and protection reap benefits later
on in a person’s life. An extensive body of knowledge regarding child development is available which allows us to plan ways and means of influencing optimal
development (Keating and Hertzman, 1999).
We are learning more and more about how the environment affects brain
development. For instance, sophisticated scanning technologies are increasingly
shaping our capacity to visualize the way the brain is “wired.” This has shed new
light on the vulnerability of brain development to environmental influences
— it is more so than we ever suspected (Guy, 1997, p. 6). While heredity and
genes do play a role, the subtle interplay between genes and the environment
means that the developing brain of a fetus is susceptible to damage from
environmental factors ranging from maternal malnutrition, drug abuse, toxic
substances (alcohol and environmental tobacco smoke), metals, and chemicals
(pesticides) to viral infections. We now know that the brain development
that takes place from conception onward is more rapid and extensive than
previously realized and the influence on later brain development is long lasting.
Clearly, investment in early child development is critical as these experiences
have a long-lasting impact and contribute to lifelong health. Healthy children
who become healthy adolescents are likely to become healthy adults.
Children are often referred to as a homogenous group. However, the
experience of growing up is immensely varied and individual and is punctuated
with several sensitive and critical developmental phases (Federal, Provincial and
Territorial Advisory Committee on Population Health, 1998). It is generally
agreed that children’s physical, emotional, intellectual, social and moral
development is a gradual process that begins in the early years and continues
well into adulthood (Guy, 1997). The period before birth and early childhood
is referred to as “the investment phase” for healthy child development, and is
marked by opportunities to build language skills, coping skills, a sense of self,
and physical and mental health (Hertzman, 1994). The period between ages
6 and 18 is referred to as “the enhancement phase,” during which physically,
socially, intellectually, psychologically and emotionally young people develop
their own values, attitudes, beliefs and behaviour patterns and strengthen their
sense of identity. During this phase, intervention may be required if problems
arise (Federal, Provincial and Territorial Advisory Committee on Population
Health, 1998, p. 7). In addressing a child’s health, it is important to be clear
about the stages of growth and development attained by the child. To ignore
the complex aspects of development would be a disservice to the child.
Healthy Development 187 of Children and Youth
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Today and Tomorrow
Population Health
The idea of population health has come of age in the latter part of this century,
and with it tremendous implications for the future of child health. Over the
last decades there has been competition between those who believe that the
resources and programs to achieve health should be allocated to medical care
or to those at-risk and those who advocate for prevention and the promotion
of optimal health for all. For example, there are those who strive to find the
latest technology to cure a child with a disability, and those who work to promote
a healthy environment for child development and to prevent the existence of
children with disabilities. A good case in point is the improved survival of low
birthweight infants, many of whom are born premature. Some argue that the
survival of these infants is gained by means of expensive medical technologies
and at the expense of efforts to prevent low birthweight (Miller, 1984).
The population health approach suggests that the health of our children
cannot be achieved by concentrating on the health-care system alone, but must
also be associated with changes in larger societal issues. The health of children
is profoundly influenced not only by the health-care system but also by factors
or determinants of health such as income and social status, social support
networks or social environments, education, employment, physical environment, genetic endowment, coping skills, gender, culture, child development
and individual health behaviour.
It is important to note that the population health model extends beyond
the notion that individuals are responsible for their behaviour and health.
Earlier concepts of health held this premise — it is our fault if we smoke,
do not parent well, are under stress from work, or can’t find a job. Although
we are responsible for our deeds, influences upon our health are much
more complex. For instance, one cannot blame a parent alone for allowing
her/his children to have sweets and empty-calorie foods, while failing to hold
accountable the supermarket for placing candies at the checkout counter,
the advertiser for creating the demand, and the manufacturer for making
the product. Similarly, we cannot hold a single parent solely responsible for
the well-being of her/his children if she/he lives in a neighbourhood with no
green spaces, no grocery store, limited public transportation and recreation
facilities and overcrowded classrooms for her/his children.
According to the population health model, what allows a person to flourish
and be healthy extends beyond individual behaviour and includes a wide range
of societal determinants. Individual actions can be singled out, but there is a
need to look past individual behaviour and broaden our approach to include
all the other determinants of health discussed in this document.
Societal beliefs that the health-care system is the major contributor to determining healthy children are gradually changing. In fact, the whole concept
of health is undergoing a rethinking. The perspective is shifting from viewing
health as the absence of disease to a dynamic equilibrium created by a balance
of the factors or determinants. However, in the current health system — which
is based on the traditional medical model — the financing of health care and
professional training still dominate. We need better balance in the system —
with prevention playing a greater role — in order to achieve a truly comprehensive approach to addressing child health needs.
Healthy Development 188 of Children and Youth
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Today and Tomorrow
An Inter-sectoral Approach
To address the health of children a broad, collective effort is required that
involves multiple stakeholders from all sectors that deal with children. Children’s
health issues reach into every aspect of a child’s life and, considering the
vast domain of health determinants, the list of partners is extensive. These
include, for example, parents and families, the school system, the judicial
system, health and social agencies of provincial, federal and municipal
governments, religious, recreational, child-serving and community organizations,
and the business community. Many of these partners have not traditionally
worked together and will need to overcome the challenges of different
philosophies, different priorities and different constituencies.
Decentralization
A discussion of children’s health in the coming decade (or in any decade) must
include political decisions. The impact on child health of decentralization of
power to the provinces and in turn from the provinces to the municipalities
is not clear; however, it is likely to weaken the federal government’s ability to
influence healthy child development. Also, the introduction of the Canada
Health and Social Transfer (CHST) — a block transfer of money to the
provinces for health, post-secondary education and social services — has
been described as a threat to the health, development and future productivity
of Canada’s children and youth (Steinhauer, 1995). And while coping with
the challenges of controlling deficits and eliminating debts, it will be difficult
for agencies and municipalities to respond to social, health and educational
demands. As devolution from the federal government continues, forcing
provincial and municipal restructuring, the future of community and social
services may remain uncertain. However, as deficits come under control and
debts are reduced, governments at all levels may be able to strategically reinvest
in key services to support the healthy development of children and youth
and their families.
Globalization
The trend towards globalization and free trade is likely to have many positive
developments, such as increased educational and economic opportunities for
the children of today. However, it will also generate new hazards to the health
of children. One example is the increased availability of imported consumer
products that have not passed certain standards designed to protect children
from unsafe items. Examples include imported miniblinds (containing lead) and
vinyl toys (containing phthalates). As our economy becomes more integrated
into the global economy, consumer product protection for children and their
special vulnerabilities must be provided consistently. Also, in a market-driven
economy it will be important to ensure that the rights of children to protection,
education and play are adequately respected, and that children in other
countries are not exploited for economic reasons (Canadian Heritage, 1991).
Healthy Development 189 of Children and Youth
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The Information and Communication Age
Advances in information communication offer numerous benefits including
rapid communication and information retrieval. Technologies such as the
computer and the Internet are transforming the way we live, work, learn and
relate to others. Computers have markedly increased capacity to process and
analyze data; however the capacity of the human mind to absorb and process
this information has not changed.
Given the rapid permeation of computers into children’s lives, both in and
out of school, the possible impact of technology on children’s health is not fully
understood. Computers have the capacity to reshape the traditional nature
of learning. As these tools become part of a child’s life in public institutions,
libraries and the home, we will need to develop a better understanding of the
risks against which children must be protected. For example, advertising is
increasingly targeted at children; the Internet may lead to increased exposure
to pornography and sexual exploitation, hate literature and violence. New
technologies will radically change the way children spend their leisure time,
the way they learn and the way they communicate with others. Increased time
in front of the computer may mean fewer hours of physical activity or less
social interaction.
Also, these technologies have the potential to create a gap between families
that are information poor and those that are information rich because children
from poor families are less likely to have access to computers, E-mail and the
Internet. However, increased availability and accessibility of computers in the
school and the community may be able to compensate somewhat for this trend.
The Aging Population
Due to increased life expectancy and
a declining birth rate, the growing
proportion of persons aged 65 or
older in the Canadian population
will have a profound effect on
society and children. By the mid21st century, it is predicted that
seniors will outnumber children and
youth, which may increase competition
between the two groups for public funds.
Societal beliefs view the needs of seniors as a
collective responsibility that is shared by family and government,
whereas the upbringing of children is seen as a private matter left
to the family.
Perhaps concerns for children appear less prominent because
seniors, unlike children, are a political force represented by lobbying
groups. Unfortunately, concern for children and elders in our society
quite often focuses on issues of separation and isolation. An intergenerational response is a good antidote to the tendency to segregate
people by age. Bringing the generations together should be based on
the values of equity and social justice and not on economic and
political lobbying forces (Good, 1995).
Healthy Development 190 of Children and Youth
D
ue to increased life
expectancy and a declining
birth rate, the growing
proportion of persons aged
65 or older in the Canadian
population will have a
profound effect on society
and children. By the mid21st century, it is predicted
that seniors will outnumber
children and youth.
Challenges
Today and Tomorrow
Children’s Participation
Until recently, asking children what they will need in the future to become
healthy adults has not been a priority. Children’s views are infrequently sought
and they rarely participate in the planning and development of policies and
programs that address their needs. This oversight occurred because children
traditionally have not been consulted even about matters that concern them
and because children are among the most powerless of social groups (Mullen,
1981): they don’t sit on influential committees, most of them cannot vote, they
lack lobbying clout, and attempts to involve them as active participants are few.
But it is important to realize that children have insight into the behaviour
of other children and see the world as other children see it (Mayall, 1997). In
addition, they have views on what makes them healthy (Health Canada, 1993),
and on what makes their communities, schools and streets safe and better
places in which to live (Guerin, 1988).
Having signed (1989) and ratified (1991) the United Nations Convention
on the Rights of the Child, a comprehensive international children’s rights
instrument, Canada agreed to provide children with the right to express their
views and have their views considered, to recognize their capacity, motivation
and ability and to encourage them to become active participants in our society
(Canadian Heritage, 1991). In the coming years, a key goal is to encourage
all sectors of society to be responsive to the views of children and youth and
increase their meaningful participation in their communities and in the
programs targeted at their health and well-being. The report The Progress of
Canada’s Children (CCSD, 1998a, p. 5) shows that more communities are
attempting to find a way to involve youth in their communities in a meaningful
manner when planning programs and services targeted at children and youth.
Conditions and Trends
At the beginning of the 21st century, a logical vision for the future is to
ensure that Canadian children and youth see an improvement in their health
and well-being. Although this may sound fresh and innovative, valuing all
children and youth in Canada and sharing responsibility for their healthy
development is not a new concept (Health Canada, 1995; Federal, Provincial
and Territorial Advisory Committee on Population Health, 1998). As in the
past, a number of overarching issues may create barriers to realizing this
vision, despite our best efforts. Collaborative efforts between various sectors
remain critical to effecting this vision as we approach the millenium and
grapple with a changing and increasingly complex world.
The following section serves to highlight some of the key trends contained
within this document and to identify areas where collaborative efforts could
be focused.
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Income and Social Status
Child and family poverty
One child in five lives in poverty, and poverty rates among children and families
have increased 60% since 1989 (Campaign 2000, 1998). Whether poverty is
defined by income, occupation, social class or education, there is a direct link
between those factors and youth and child health and development (Hertzman,
1999). The poverty literature is replete with statistics linking poverty to greater
risk of health problems, disability and death (CICH, 1994; Vanderpool and
Richmond, 1990; Evans and Stoddart, 1990). Children who grow up in poverty
are often less likely to be able to learn, are more likely to be rated as performing at a lower level by teachers, and are more likely to drop out of school, have
conduct disorders, emotional problems, trouble with the law, and engage
in risk-taking behaviour. In fact, poverty is recognized as the single most
significant determinant of health status of children (Evans and Stoddart, 1990).
Conclusion: Child poverty impacts on the present and future health and well-being of
children and their families. Children are poor because their parents are poor. Therefore,
efforts that support adequate income, employment opportunities, appropriate training
and/or post-secondary educational opportunities, and accessible and comprehensive
health and social programs will be essential to promoting the healthy development of
children. Addressing child poverty will be a key challenge in the 21st century.
Income distribution
In a similar way, the health and well-being of a population is determined by
the way society distributes its wealth. The way in which income and wealth are
distributed in Canada is far from equitable. There has been a trend of growing
inequalities between high- and low-income earners in Canada (Statistics
Canada, 1997). The population health literature shows that the populations
of countries in which the gap between the rich and the poor is smaller have
longer life expectancies (Evans, Barer and Marmor, 1994). Conversely,
countries with wider social inequalities have a less healthy population. Studies
in industrialized countries show that mortality rates for children are related
not only to poverty but also to widening social inequalities in wealth (Krieger,
Williams and Moss, 1997).
Conclusion: In order to promote the optimal healthy development of Canadian children
and their families, initiatives will be needed to redress the income inequalities between
high- and low-income families.
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Housing and food security
Although most Canadian families live in housing that is suitable, safe and
affordable, and have access to a secure food supply, there remain issues of
concern. Housing and food security are particularly fragile for Aboriginal
populations, particularly for those living on reserve. In general, low-income
families continue to spend a significantly higher percentage of their total
expenditures on both food and housing than high-income families. Almost
1 in 10 households is unable to find housing that meets or exceeds national
standards (CMHC, 1993). In 1995, approximately 900,000 children received
foods from one of approximately 460 food banks across the country
(Canadian Dietetic Association, 1996).
Conclusion: The availability and accessibility of adequate, safe, secure and affordable
housing, in addition to a safe and nutritious food supply for all Canadian families
are essential elements to fostering healthy child development.
Employment and Work Environment
Parents’ labour force participation
Paid employment is central to our society. Increasingly, though, people with
children are likely to find themselves engaged in part-time employment,
typically characterized by low wages, few benefits and high insecurity.
Unemployment rates are likely to stay relatively high as the Canadian economy
continues to experience tough competition for low-skilled jobs in the world
market. Continued economic uncertainty will likely be detrimental to the
health of children and their family members and may contribute to poorer
physical and mental health as well as increased drinking, aggression, divorce
and child abuse (Dooley, Fielding and Levi, 1996).
Conclusion: Availability of stable, adequately paid employment with adequate benefits
for Canadian families and availability and accessibility to appropriate education
and training opportunities for future employment will be a major challenge for the
next century. Providing accessible supports to those outside of the labour market will be
important in supporting families in the task of raising healthy, socially engaged
children.
Working and parenting
An important change in Canadian family life relates to the amount of time
parents spend in the workplace. Today, families frequently need two incomes
to survive, which has led to an increase in women’s participation in the work
force. According to the most recent statistics, more than two thirds of women
with preschool children were working outside the home, as were more than
three quarters of the mothers of school-age children (Gunderson, 1998). Over
the last decade, these figures have not levelled off and will likely continue
to increase. Families in which both parents work are facing stresses, fatigue
and the double burden of balancing job and family responsibilities. These
difficulties are disproportionately experienced by women.
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The response to date of government, business and communities to the
need for child-care services has been slow (Paris, 1989). While the federal
government has considered expansion of child-care spaces, pending agreement from the provinces, there is no national child-care program. If the lack
of support from the governmental, private and public sectors continues, fewer
children will receive the appropriate support, nurturing and stimulation they
require during the earliest and most critical years of their development and
will lack the foundation for later school and work success.
Conclusion: Since it is likely that the majority of Canadian families will continue to
have both parents working in the 21st century, parents, and particularly women, will
need a supportive environment in order to have healthy, well developed families. Efforts
will need to be directed to overcoming the parental “time-crunch” by promoting more
flexible and balanced, family friendly work places and by developing a variety of quality
child-care services and family resource programs accessible to all.
Youth employment
The unemployment rate is much higher among the youth population than the
general population. Unemployment is most noticeable among young people
who do not complete secondary school, and is particularly problematic for
young female high school drop-outs (Human Resources Development Canada
and Statistics Canada, 1996). A clear link has been established between higher
education and employment. Individuals who attain post-secondary education
are more likely to obtain higher paying and secure jobs, which may also
improve their chances of more positive health outcomes.
Youth participation in the work force is at its lowest point in 25 years;
youth employment rates are affected by business cycles and structural changes
in the economy. Given the economy of the 1990s, young people express discouragement about employment opportunities and are acutely aware of the
importance of education and adequate skill development in preparing for
future success. While students who work more than 15 to 20 hours per week
are at increased risk of poor school performance and unhealthy lifestyles, those
who work a moderate number of hours per week or who work only summer
jobs seem to flourish (CCSD, 1998b). There is concern that, increasingly, teens
have fewer opportunities to acquire job skills, to earn their own spending
money, or to earn funds for their post-secondary studies. On the positive side,
volunteer rates among teens and young adults have increased dramatically
over the last 10 years, providing many with job-like experience (CCSD, 1998b).
Conclusion: Since youth employment develops employability skills and experience for
future employment, the availability and accessibility of entry level jobs on a part-time
and short-term basis will continue to be critical for their future employment prospects.
Creating supportive links among the education communities, workplaces and community
organizations may help give youth greater opportunities to gain both work experience
and contribute to their community. In addition, opportunities for young people to return
to the formal education system in order to complete, upgrade or change the direction of
their education will continue to be important for improving future prospects for their
health and well-being and that of their families.
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Today and Tomorrow
Education
Education provides one of the best paths to increase a person’s chances of
achieving full participation in society and increased economic security, and
of gaining meaningful and adequate employment.
The trend toward a knowledge-based economy will have a decisive influence
on the need for higher education. Without this higher education, the future
success of the young will be compromised and some groups will be left behind.
Aboriginal people and people raised in a low-income family are at increased
risk of lagging behind. Although Aboriginal children have experienced substantial gains in their education, they still experience inequalities compared
with non-Aboriginal students (Statistics Canada, 1993).
School readiness
The first years of life are vital. Early childhood is a critical time to acquire the
basic language, intellectual, interpersonal, and social skills that will determine
the well-being of a child and determine adult competence. While most children
who enter school are ready to learn, some children, such as those living in
poverty, are less well equipped. Likewise, while most children arrive at school
ready to learn every day, those who are hungry, tired, afraid, or stressed over
family, personal, school or financial problems will often have difficulty concentrating and learning.
Early and preschool learning opportunities should be encouraged and
effective programs extended to equip children with basic learning skills, selfesteem, and social abilities before school entry. Investing in preventive and
remedial measures for children in early life is more effective than measures
introduced in adulthood.
Conclusion: Since school readiness is an indicator of future school achievement, employment status and subsequent socioeconomic level, measures will be needed to ensure that
all children have the opportunity to participate in stimulating early and pre-school
learning activities. Early identification, intervention and remediation initiatives are
required for children and youth with school and learning-related problems to address
challenges and ensure healthy development.
Staying in school
Staying in school is a good passport for life and more and more children are
choosing to do so. Early school leaving has declined over the past few decades
suggesting that today’s youth will be more employable and better able to meet
both their needs and those of the global market (Normand, 1995). Unfortunately, given the steady increase in tuition fees of higher learning institutions,
many of these young people may not be able to continue their post-secondary
studies. In addition, the reduction in student grants in favour of loans means
that those who decide to pursue higher education will also accumulate a
substantial debt after the completion of their degree.
Healthy Development 195 of Children and Youth
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Today and Tomorrow
Conclusion: Since educational attainment, employment and socioeconomic status are
such closely interrelated determinants of health, availability of and equitable access to
educational institutions will continue to be critical for the future health and well-being
of Canada’s children and their families. Children from some population groups, such
as Aboriginal children, those from low-income groups or immigrant groups, may need
extra support to be able to stay in school.
Social Environment
Family health and well-being are at the heart of healthy child development.
The love and affection parents give their children in the early years will often
have a great impact on a child’s developmental outcome. Similarly, early intellectual stimulation such as being spoken to and read to will influence a child’s
learning abilities and language skills. Children who have someone to play with
are less likely to have difficulty adjusting socially. Whatever parenting approach
is employed, children need love and consistent attention from their parents.
Children whose parents participate in their development (attend school
performances, help with homework, attend sports events) tend to have higher
scholastic achievement, higher aspirations, and more positive relationships
with teachers (CCSD, 1997).
Family environment
Remarkable social and demographic changes
have transformed the family. While the dominant family structure still consists of a married
couple with children, and most children live
in families with married parents, an increasing
number of children live with one parent
and more families are breaking up or being
reconstituted. Over the last three decades,
hildren whose parents
Canada’s divorce rate has increased more than fivefold. These
rates will continue to increase if the patterns observed in other
participate in their development
countries occur in Canada (Richardson, 1996). For instance,
(attend school performances,
approximately 30% of Canadian marriages end in divorce,
compared with about 44% of American marriages (Dumas,
help with homework, attend
1997).
sports events) tend to have
Child development literature is replete with evidence that
the family environment is a key influence on a child’s health
higher scholastic achievement,
and well-being and that parental love and attention, stability
higher aspirations, and more
and consistency in the home are tremendously important
in determining what happens to a child. Parental break-ups
positive relationships with
impact on the family — how members relate to each other,
teachers.
and how parents cope with the developmental, educational and
recreational needs of their children. Although most children of
divorced parents show normal patterns of growth and development, for some
children, the experience will undermine their development. It seems that,
as a group, children of divorced parents have more problems with respect
to mental health, self-esteem, school performance and confidence in their
future performance compared with children who come from intact homes
C
Healthy Development 196 of Children and Youth
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Today and Tomorrow
or live with a widowed parent (McClosky, 1997). Divorced fathers can lose
contact with their children; research in this field shows that when fathers are
absent, their children can experience a considerable range of effects such as
dropping out of school, becoming a teen mother, or experiencing longlasting feelings of betrayal, rejection, rage, guilt, and pain that can lead to
depression and suicide (Hewlett and West, 1998). Rising divorce rates and
family breakdowns may lead to instability among those children at risk of
poor adjustment.
Conclusion: Strengthening and supporting various family formations in their childraising roles will continue to be a key challenge. School and community-based programs
that offer information on parenting, child development and support services available,
as well as early intervention programs, will remain essential. Moreover, initiatives
that affirm that parenting is not the sole responsibility of families, but also a societal
responsibility, will become more important.
Family violence
Child abuse and neglect, emotional abuse and sexual abuse are manifestations
of violence against children. While national data are not currently available,
measures are under way to establish a better estimate of incidence (Phaneuf
and Tonmyr, 1998). A recent study suggests that current statistics probably
underestimate the true level of sexual abuse suffered by children in Canada
(Holmes and Slap, 1998). It is estimated that violent behaviour against children
is high and the rates are likely to increase if children grow up in situations
that involve poverty, inadequate housing, dysfunctional families, substance
abuse, and pervasive violence in the schools and on television.
Conclusion: Reducing violence against children through community awareness and
prevention programs will remain a key challenge in the new millennium. Some positive
steps in addressing violence for those in greatest need could be community-based parenting
programs and home visiting programs that focus on positive parenting skills and
socialization in early childhood. In addition, conflict resolution, violence prevention
and social skills development programs, along with community supports, could help
children and families at risk of violence develop in a healthier manner.
Natural and Built Environments
Exposure to chemical and biological hazards
The effect of environmental contaminants on children’s health is attracting
more and more attention. Environmental issues are increasingly gaining public
attention, scrutiny and active participation (International Joint Commission,
1997; Slovic et al., 1993). While there is recognition that children are at special
risk compared with adults, testing for the effects of chemicals upon children
is still in the early stages (Committee on Pesticides, 1993).
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Today and Tomorrow
Environmental health threats to children include contaminants in the
ambient and indoor air, food, water and soil. The following are examples of
these contaminants: second-hand smoke, biological contaminants such as
moulds and house dust mites, heavy metals such as lead, and chemicals such
as pesticides and PCBs. Children exposed to such contaminants may be at
greater risk of health problems including respiratory diseases and asthma,
behavioural and learning problems, and delayed development (Committee
on Health, Safety and Food, 1997).
Conclusion: Governmental standards to control and monitor pollutants in air, water,
food and the built environment need to be developed and set with the enhanced
vulnerability of children in mind.
Information programs for parents which stress the importance of a healthy indoor
environment and the need to reduce exposure in the home to second-hand smoke,
chemicals and biological allergens from dust, pets, pests or moulds need to be available
and accessible to all Canadian parents, including those with low literacy skills and
disabilities. Regulations, standards and policies in place for other public spaces such as
schools, recreation facilities, transportation facilities, parks and playgrounds will need to be
enhanced, monitored and enforced.
Unintentional injuries
The built environment, which includes the home, schools, parks, playgrounds
and playing fields, carries a significant risk of occurrence of injuries for children.
Definite improvements have been made regarding injury death and hospitalization rates compared with prior years. Nevertheless, injuries, including those
resulting from falls, drownings and traffic accidents are the leading cause of
death among children above the age of 1 (CICH, 1994). Injury deaths should
be thought of as the tip of the “injury iceberg”; although they represent only
a small portion of total injury-related outcomes, they are the most obvious
and perhaps most dramatic consequence of injury; the majority of the iceberg,
however, is the less obvious, submerged portion — the non-fatal injuries, which
result in higher health-care and personal costs (Angus et al., 1998).
An important risk factor that contributes to childhood injuries is poverty.
Children who are poor are at higher risk of injury because they typically are
exposed to a more hazardous environment (e.g. living in firetrap houses, playing in the streets) (Rivara, 1994). There are dangers that widening income gaps
and deepening child poverty in Canada may be associated with increasing rates
of injury.
Most injuries can be prevented and success in injury prevention has been
noted (Health Canada, 1997). However, there is an unfinished agenda and
the problem remains of epidemic proportion.
Conclusion: Since more unintentional injuries occur at home than anywhere else,
particularly for very young children, increased governmental regulation to enhance
the safety of products and toys found in households and increased parental awareness
of safety at home are needed. Outside the home, promoting safety standards in schools,
parks, playgrounds, in traffic areas and other spaces where children live and play is
equally important. Educating children and youth about traffic safety, from an early
age, may further decrease traffic-related injuries.
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Personal Health Practices
Positive, health-promoting behaviours are a major determinant of child and
youth health and are also important for the future health of our children as
adults. Many disabilities and chronic health problems of adults can be traced
to negative health behaviours entrenched during childhood and adolescence
(Committee on Health, Safety and Food, 1997). Adolescence is the period most
likely associated with the onset of smoking, alcohol and drug consumption,
early and/or unprotected sexual intercourse, and a more sedentary lifestyle.
Smoking in childhood and adolescence
The total number of Canadians who smoke has decreased since 1981 (Statistics
Canada, 1995). While the prevalence of smoking has been declining in the
adult population, it has been increasing in the teenage population (Statistics
Canada, 1995). In recent years, the incidence of smoking among women aged
15–19 increased, from 18% in 1990 to 21% in 1998 (King, Boyce and King,
1999).
Unfortunately, despite many efforts to restrict youth access to tobacco,
peer disapproval of cigarette smoking and the proportion of students who see
smoking as dangerous have both declined (Forster and Wolfson, 1998). The
tobacco industry continues to advertise in magazines and to glamorize tobacco
use through the popular culture, sports and films. We may expect to see a
continued increase in smoking rates among youth as long as government
initiatives lack effective enforcement. As a result, over the long term, lives lost
to heart disease, low birthweight babies, and asthma rates will likely continue
to increase or remain steady.
Conclusion: Efforts to prevent smoking among pregnant women, and children and youth
— in particular teenage girls — will require a comprehensive approach involving all
levels of government from all relevant sectors, including families, schools, the business
community, community organizations and youth themselves. While government initiatives
such as setting and enforcing age limits for purchasing tobacco products, preventing young
people from being exposed to all forms of tobacco advertising, and increasing the price of
tobacco to discourage young people from smoking are of key importance, these initiatives
need to include not only policies and legislation, but the whole continuum of policies and
programs from health promotion and primary prevention programs to cessation and the
enforcement of current regulations.
Early and unprotected sex
Major changes in the sexual behaviours of adolescents have occurred over the
past several decades. Sexual activity is occurring at younger ages. The average
age of the initiation of sexual activity is now below age 13. It is estimated that
12% of young women have engaged in sexual intercourse at least once before
the age of 15. The figure increases to 83% of young women (those aged 15
to 19) who report having had one sexual partner in the past year (CICH, 1994).
It is estimated that more than half of young people use a condom the first time
they have sex (Otis 1995, as cited in Godin and Michaud, 1998). But it is
somewhat alarming that the majority of young women do not use a condom
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Today and Tomorrow
(Galambos and Tilton-Weaver, 1998); moreover, one in four women between
12 and 14 years of age who are sexually active use no form of birth control,
increasing the risk of pregnancy (CICH, 1994).
Conclusion: Efforts to address the impact of early onset of sexual activity and unprotected
sex include adequate, age appropriate sex and reproductive health education that is both
biologically and skills based. It is important to provide accessible information about methods
of contraception that is adapted to promote healthy adolescent development. It is equally
important to focus on the various social and emotional aspects of a sexual relationship
such as communications and mutual respect and understanding.
Teenage pregnancy
Although the teenage pregnancy rate in Canada is lower than it was 20 years
ago, the rate has remained relatively stable since the 1980s (CICH, 1994). Of
concern, however, is that the rate in Canada continues to be higher than that
of many other industrialized countries (CICH, 1994). This is cause for concern
given its association with adverse social, economic and health outcomes. For
example, a teenage mother is less likely to seek prenatal care (the absence of
which may lead to adverse birth outcomes) and is more likely to drop out of
high school and live in poverty.
In addition, the reproductive health needs of adolescents as a group have
been largely ignored. For example, young women may be reluctant to seek
birth control due to the stigma of promiscuity associated with contraceptive
preparedness. Moreover, accessibility to birth control is sometimes restricted
if the physician must obtain consent from the young woman’s parent or
guardian to prescribe contraceptives.
Conclusion: Young people need to be educated about healthy sexuality
and the biological, physiological, social, emotional and economic
risks associated with pregnancy during adolescence. In addition,
it is essential to provide a range of education and support services
to teenage mothers before, during and after the child is born to assure
optimal child development.
P
hysical activity during childhood
regulates weight, increases selfesteem, knowledge, influences
patterns of healthy eating and
Physical activity in childhood
and adolescence
sleeping, and helps establish positive
The relationship between regular physical
activity and positive health outcomes is
well established (Simons-Morton et al.,
1988). Regular exercise protects against a
number of chronic diseases. In addition,
physical activity during childhood
regulates weight, increases self-esteem,
knowledge, influences patterns of healthy
eating and sleeping, and helps establish
positive attitudes and behaviours that are
likely to persist into adulthood (SimonsMorton et al., 1988).
likely to persist into adulthood.
Healthy Development 200 of Children and Youth
attitudes and behaviours that are
Challenges
Today and Tomorrow
It is generally accepted that physical education programs within the school
curriculum help children learn, value and develop an interest in physical
activity. Unfortunately, current cuts in physical education and increases in
user fees for community programs will likely impact negatively on the risk of
chronic illnesses such as cardiovascular diseases, and affect the risk of shortterm outcomes such as obesity and poor self-esteem.
Conclusion: Efforts need to be directed toward the development and implementation
of strategies that encourage children at a very young age and their adult role models
to adopt a physically active lifestyle and maintain that lifestyle throughout their
development. Families need to have affordable activities available and accessible within
their communities in order to encourage participation in regular physical activity. In
addition, relevant and interesting physical activities need to be available and accessible
to young people throughout their development, even through the adolescent years. At
minimum, quality daily physical education at primary and secondary schools needs
to be maintained.
Individual Capacity and Coping Skills
Mental well-being
Health threats to children have changed dramatically over the past 50 years.
We have traded the biological concerns such as infectious diseases for “quiet
conditions” that do not rush children to the emergency departments. Once
dismissed as a parental responsibility, mental well-being problems include
behaviour problems, learning disabilities, and depression/suicide (Vanderpool
and Richmond, 1990). Mental disorders are inextricably linked to a range of
disruptive determinants such as family distress and dysfunction, lack of social
supports, economic insecurity, and poor parenting.
Most Canadian children are free of psychiatric disorders. However, an
estimate of the magnitude of mental health problems suggests that about
one in every five children has an emotional or behavioural problem as well
as feelings of depression and sadness, and it seems the problems are getting
worse (Offord et al., 1992). These health concerns are likely to need greater
attention through the next decade. Moreover, once identified, these problems
are poorly treated in the current heath-care system; it is not designed to serve
children’s complex health needs and rarely includes developmentally appropriate and comprehensive interventions that emphasize community-based
prevention strategies (Halfon, Inkelas and Wood, 1995).
Conclusion: Addressing children’s mental health will be a major challenge in the next
decade. Rates of mental health problems seem to be increasing significantly; therefore
there is a need for efforts to be directed toward the development and implementation of
community-based mental health promotion and primary prevention strategies and
programs that address family functioning, child socialization, parenting skills, effective
life skills and support to high-risk families who experience multiple environmental stresses.
In addition, it is essential that there are sufficient resources to provide the needed services
to prevent, detect and treat mental health problems in the school and in the social and
health-care systems.
Healthy Development 201 of Children and Youth
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Suicide
Many youth and children manage to navigate adolescence with relative success.
For others, adolescence is a time characterized by low self-esteem, lack of
confidence, loneliness and, for some, depression. The Health of Canada’s Children:
A CICH Profile (CICH, 1994) reported that depression or the percentage of
those reporting that they felt depressed once a week or more was widespread
and varied considerably by gender and age. Many children have mental health
problems that have been identified clinically. They report feelings of stress,
low self-esteem, unhappiness with their body, and loneliness. Deaths from suicide
are increasing and the rate of attempted suicide is estimated to be 10 to 100
times higher than for completed suicides (Federal/Provincial/Territorial
Committee on Population Health, 1996; Dyck, Mishara and White, 1998). Of
particular concern are persistently high rates of suicide among young men
and Aboriginal youth — they are nearly five times higher than the national
average (Health Canada, 1997). These rates are a clear indicator of distress
experienced by youth today.
The number of reported suicides likely represent the tip of the iceberg;
suicide deaths are currently under-reported due to a tendency to group them
under accidental deaths or deaths due to unknown causes. To prevent increases
in suicide, depression or other manifestation of adolescent turmoil, appropriate
measures must be taken. One example of stress experienced by youth is the
increasing uncertainty that their education will someday lead to employment.
Youth need to be given the opportunity to be included in the real world
beyond the school. Some of them can vote, they can drive, yet there are few
opportunities to actively participate in community activities with adults (Ontario
Premier’s Council on Health, 1997).
Conclusion: Measures need to be developed that would train professionals and individuals who work with children and youth in both the identification of young people
with mental and emotional health problems and their referral to appropriate programs
and services. Concomitantly, efforts will need to be made to provide accessible and
relevant interventions that can reduce mental health problems and suicide among
youth, particularly in groups at high risk such as young men and Aboriginal peoples.
Youth need to be involved in planning and developing these services, interventions
and supports in the settings where they live, learn, work and play.
Biology and Genetic Factors
Biological and genetic factors continue to increase in importance partly because
of vast improvements in medical sciences and partly because of the remarkable
progress in molecular biology, both of which have revolutionized our knowledge about genetics. Improved knowledge and technology has meant that
more children survive with chronic disabilities such as cystic fibrosis, muscular
dystrophy and cerebral palsy. The number and level of services required to
address the needs of these children and their families will likely increase as
they seek to live normal lives. Consequently, there may be an increased demand
for society to create an environment that is as integrated and stimulating as
possible to help families support the optimal development of their children.
Healthy Development 202 of Children and Youth
Challenges
Today and Tomorrow
In addition, improved knowledge of early fetal and infant development
is likely to lead us toward identifying more and more genetic and biological
links with developmental disabilities. Accordingly, we need to set safeguards
against the potential dangers of genetic screening and genetic therapy. Possible
concerns include freedom of choice of the individual and privacy. The ethical
and legal aspects of confidentiality should be addressed because genetic information is not only an individual matter — it is also a family concern.
Conclusion: There will be a need to consult on and develop safeguards against the
potential dangers of genetic screening and genetic therapy which are accepted within
society and address possible concerns, such as freedom of choice and privacy as well
as the ethical and legal aspects of confidentiality. In addition, the demand for services
required to address the needs of these children and their families will likely increase as
they seek to live normal lives and participate in society.
Health Services and Social Services
In Canada, the management and delivery of health and social services is the
responsibility of each province or territory. The federal government’s role
in these sectors involves the setting and administration of national standards
for the health system (e.g. the Canada Health Act), assisting in the financing
of provincial and territorial health and social services through fiscal transfers
(e.g. the Canada Health and Social Transfer), fulfilling other functions for
which it is constitutionally responsible, and participating in other health-related
functions such as health protection, health promotion and disease prevention.
Canada’s health and social service systems provide a wide range of services
that are designed to promote and maintain health. However, both systems
will continue to experience a wide range of challenges, including economic
restrictions and changing federal/provincial/territorial demands, as the trend
towards a coordinated, multi-sectoral approach in addressing children’s health
and well-being is adopted. As services are increasingly centralized, children
and youth and their families will hopefully be treated more as a complete
family unit or as a complete person, rather than compartmentalizing them
according to a specific desired service. In doing so, these sectors will need
to agree on definitions of shared problems, define the process of working
together, and develop multi-skilled service providers. More importantly, as
systems of service delivery become more integrated during the restructuring
process, mechanisms through which to monitor the efficiency and effectiveness of these newly configured systems will need to be established and the
results reported to the public.
Conclusion: Ultimately, our health and social service systems must make a difference
at the front line of service delivery and support the healthy development of all children
and youth in Canada and their families. Measures need to be promoted that encourage
and ensure collaboration among the many sectors addressing the needs of children and
their families in an integrated, holistic manner.
Healthy Development 203 of Children and Youth
Challenges
Today and Tomorrow
Culture
Culture is an important, though often ignored, determinant of health.
Influences ranging from barriers to needed services and loss or devaluation
of language and culture to racism and discrimination have direct impacts on
health outcomes; these have been outlined in Chapter 11. What is apparent
upon review of this chapter is the lack of available information regarding
cultural impacts on health outcomes. Given Canada’s increasingly diverse
population, cultural influences on health will remain an important consideration
for practitioners, researchers and policy makers within many sectors.
Conclusion: Canada’s challenge in the future will be to ensure that culture, as a
determinant of health, receives equal consideration beside other determining influences.
An important first step requires that adequate data and information be collected
and made available. This will allow us to broaden our understanding of cultural
influences on health outcomes and take appropriate actions toward maintaining and
improving health outcomes for all children and youth in Canada. All those working
with children, young people and their families need to be aware of their own cultural
values and beliefs, and be conscious of and open to learning about, understanding
and accepting those of the families with whom they work.
Gender
Developing a gender identity is a very complex process, which begins in the
womb and evolves throughout childhood. Although a person’s sex is biologically
determined and hormonally regulated, his or her concept of gender and
gender roles is influenced through the interaction of peers, parents, media
and other socio-cultural factors.
Behaviour
It may be that the gender roles we communicate to young people are in
themselves a source of stress. For example, social expectations about “male”
behaviour include aggression and risk taking, both of which are evidenced
in drinking and driving; deviant behaviour is seen as “manly.”
Body image
A similar case could be argued for the pressure to be feminine and “beautifully
thin”; hence the prevalence of anorexia and depression (Tipper, 1997).
Society’s obsession with weight and appearance and the value society places
on female thinness — a value which is confirmed by the appearance of ultrathin models and actresses on television, the fashion industry, and a barrage
of diet commercials — is very powerful. Eating disorders have become a
common problem in some industrialized countries. In Canada, it is unclear
exactly what percentage of young women suffer from these disorders. It is
known, however, that 41% of 13-year-old girls and 44% of 15-year-old girls felt
that they needed to lose weight or were dieting to lose weight (King, Boyce
and King, 1999). Once considered rare, eating disorders such as overeating,
Healthy Development 204 of Children and Youth
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Today and Tomorrow
bulimia and anorexia nervosa are likely to continue to increase as long as the
media continue to promote thinness as a desired state and society accepts
the message.
Conclusion: Measures need to be adopted at all ages and stages of development and
by all those working with children and young people to encourage them to develop a
positive, healthy sense of self and healthy attitudes about their bodies. Young people
need to be encouraged to critically examine the gender roles and stereotypes of their
culture groups, society in general and the settings in which they function daily such
as family, school, media, work and recreation.
Looking Ahead
It is important to recognize that children determine neither the circumstances
of their birth nor the environments in which they grow up. With this in
mind, it is important to realize that the determinants of health described in
this report shape children’s health, health beliefs and their behaviour. One
of the most effective ways to promote healthy child development is through
the support of entire communities.
The challenges were introduced with a number of overarching issues that
raise important policy and research issues as we address child health in the next
century. Other future challenges can be seen by examining the trends noted
across the entire range of determinants. Health, according to the determinants
of health framework, is determined by the complex interaction of individual
characteristics, social and economic factors and the physical environment.
Strategies to improve the health of children must therefore address all the
determinants of health. There is increasing recognition that improving health
is a collective responsibility that requires a broad, coordinated approach to
children’s policy issues.
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