Bioethics for clinicians: 9. Involving children in medical decisions

Medical decisions involving children raise particular ethical issues for physicians and other members of the health care team. Although parents and physicians have traditionally made most medical decisions on behalf of children, the developing autonomy of children is increasingly being recognized in medical decision-making. This poses a challenge for physicians, who must work with the child''s family and with other health care practitioners to determine the child''s role in decision-making. A family-centred approach respects the complex nature of parent-child relationships, the dependence and vulnerability of the child and the child''s developing capacity for decision-making.     

The Development of Reflection Through Learning

The article introduces a famous labyrinth task used to demonstrate children's different approaches to learning tasks. The author connects reflection to children's questions concerning personal learning tasks beyond teacher assignments. She assigns a special role in this to child's personal search in charting the limits of the unknown. Child's active exploration should focus on new methods. Development of reflection in the frame of developmental teaching sets new paradoxical requirements to teachers.     

基于心率检测的便携式儿童情绪感知系统研制

目的:检测儿童的情绪能力,从而检验儿童情绪能力发展是否正常以及协助训练孤独症儿童的情绪能力。方法:设计了一套便携式的儿童情绪感知系统,检测儿童的情绪能力。本系统由心率信号采集模块,PC机端的软件以及情绪能力数据分析组成。结果:研制的儿童情绪能力感知系统具有便携、可穿戴等优点,能够准确地检测儿童情绪能力。结论:儿童情绪能力感知系统能够检测使用者的情绪能力,也能够在儿童情绪能力干预训练中记录孤独症儿童的情绪变化,为干预训练提供帮助。     

On the Structure of Learning Activity

The child's mind develops through learning. All that a child acquires during the course of his mental development is given to him in "ideal" form and within the context of a social reality, which is the source of development. Active learning is the lynchpin.     

A Method to Quantify Visual Information Processing in Children Using Eye Tracking

Visual problems that occur early in life can have major impact on a child''s development. Without verbal communication and only based on observational methods, it is difficult to make a quantitative assessment of a child''s visual problems. This limits accurate diagnostics in children under the age of 4 years and in children with intellectual disabilities. Here we describe a quantitative method that overcomes these problems. The method uses a remote eye tracker and a four choice preferential looking paradigm to measure eye movement responses to different visual stimuli. The child sits without head support in front of a monitor with integrated infrared cameras. In one of four monitor quadrants a visual stimulus is presented. Each stimulus has a specific visual modality with respect to the background, e.g., form, motion, contrast or color. From the reflexive eye movement responses to these specific visual modalities, output parameters such as reaction times, fixation accuracy and fixation duration are calculated to quantify a child''s viewing behavior. With this approach, the quality of visual information processing can be assessed without the use of communication. By comparing results with reference values obtained in typically developing children from 0-12 years, the method provides a characterization of visual information processing in visually impaired children. The quantitative information provided by this method can be advantageous for the field of clinical visual assessment and rehabilitation in multiple ways. The parameter values provide a good basis to: (i) characterize early visual capacities and consequently to enable early interventions; (ii) compare risk groups and follow visual development over time; and (iii), construct an individual visual profile for each child.     

The child's best interest in gamete donation

Procreation with donor gametes is widespread and commonly accepted, but it involves ethical questions about the child's best interest. Understanding the historical structures of the moral discussion of gamete donation may contribute to reflecting on the child's best interest. This is why I have analysed the debate on gamete donation in the Netherlands, and this analysis has uncovered some striking discontinuities. Notions of the child's best interest have undergone a radical swing. In the past, it was considered acceptable to conceal the truth about the child's biological origin, but in the past two decades the general opinion has changed to the common belief that this information should be shared with the child. This changed notion of the child's best interest will be analysed using a framework encompassing three views of the child, which derive from the debate on children's rights. These three views each provide a different interpretation of the child's moral and political status. I conclude that the changed notion of the child's best interest results from a view of the child that focuses on autonomy and citizenship, and which frames the child's interests according to its legal status. I comment on this view and I champion an alternative one, namely ‘the embedded child’. This is a relational view based on care ethics that goes beyond what can be articulated in law, and that will help to establish a more balanced interpretation of the child's best interest at the practice and policy levels of gamete donation.     

Correlation between Evaluation of Another Person's Behavior and Choice of Response in a Chance Situation

Research in the 1970s produced further knowledge regarding the correlation between what a child perceives as provocation (attack) by another child and the response the child chooses. Repeatedly we have found that an aggressive response is very likely when the behavior of the initiator is considered aggressive [1]. Underlying the significance of what Dodge, Murphy, & Buchsbaum [2] learned in this context is the actual intention of a person causing certain negative consequences, whether identified as such or as something else. Results of Dodge and co-workers' research confirmed the hypothesis that an aggressive response by a child who was attacked was determined by the child's perception of the intention of the initiator, not by the actual intention of that person.     

Lecture 36. Thinking and Activity

An infant's communication with an adult is the basis on which the child's mental development takes place. Hence, for proper organization of the educational process in infancy, knowledge of the role of communication with adults in a child's mental development and clear notions of the nature of this communication are necessary. The present article deals with the characteristics of the stages of development of communication in the first year of a child's life and their role in the child's mental development.     

Cultural Identity and Internationally Adopted Children: Qualitative Approach to Parental Representations

Approximately 30 000 children are adopted across national borders each year. A review of the literature on the cultural belonging of these internationally adopted children shows substantial differences between the literature from English-speaking countries and that from France and Europe in general. The objective of this study is to start from the discourse of French adoptive parents to explore their representations of their child''s cultural belonging and their positions (their thoughts and representations) concerning connections with the child''s country of birth and its culture. The study includes 51 French parents who adopted one or more children internationally. Each parent participated in a semi-structured interview, focused on the adoption procedure and their current associations with the child''s birth country. The interviews were analyzed according to a qualitative phenomenological method, Interpretative Phenomenological Analysis. The principal themes that emerged from our analysis of the interviews made it possible to classify the parents into three different groups. The first group maintained no association with the child''s country of birth and refused any multiplicity of cultural identities. The second group actively maintained regular associations with the child''s country of birth and culture and affirmed that their family was multicultural. Finally, the third group adapted their associations with the child''s birth country and its culture according to the child''s questions and interests. Exploring parental representations of the adopted child enables professionals involved in adoption to provide better support to these families and to do preventive work at the level of family interactions.     

Prevention of psychosocial problems in children with chronic illness.

Children with chronic illness and disability are at considerably increased risk of psychosocial problems, such as neurosis, attention deficit and poor adjustment to school. Health care professionals, especially primary care physicians, can do a great deal to prevent such problems in these children and their families. The approach outlined here is based on an understanding of the transactional model of development, in which the child interacts with--and to some extent creates--the social environment, and on a "noncategorical" concept in which common elements in chronic illness are recognized and emphasized. The physician''s role is to inform the family of the child''s condition as soon as possible, to offer hope, encouragement and guidance, to watch the child''s development, to maintain a shared view of the child and family, and, if possible, to ensure continuity of care.     

Parental attitudes toward pediatric organ donation: a survey.

We conducted a telephone survey of parents in the National Capital Region to assess their intention to donate their child''s organs and to provide physicians with information that could help alleviate their concerns about approaching parents for consent. Of 339 parents who agreed to answer questions after being given details of their child''s "death" 288 (85%) said that they would be willing to donate their child''s organs. The degree of willingness was associated with the certainty of death, altruism and empathy toward children in need of an organ, previous discussion of organ donation with a family member and knowledge of an adolescent or adult child''s attitude toward donation. Factors that inhibited the intention to donate included uncertainty of death, insufficient information from medical professionals and fear of multilation. The child''s age was not significantly associated with intention to donate. Concordance between the results and actual donation rates in Canada and the United States supports the generalizability of the survey findings.     

Experimental Reflexological Research on the Newborn

In carrying out reflexological research on children from birth onward, the Infant Department of the Leningrad Pedological Institute found it necessary to make a most careful study of the first moments of a child's life, since it is only this period that offers the opportunity to study the child's basic, primary, "inherent" reactions that serve as the groundwork for the accumulation of "personal experience" in response to repeated stimuli from the physical and social environment. In addition, our work made clear the importance of studying the various states of a newborn child as an approach to the problem of waking and sleep.     

Adaptation of children to a chronically ill or mentally handicapped sibling.

The presence of a chronically ill or mentally handicapped child in a family can be a stress for the child''s siblings, who often are ill informed about the nature and prognosis of the illness, may be uncertain what is expected of them in the caregiving role, may feel their own identities threatened, and may experience ostracism by their friends and misunderstanding at school. Although individual reactions vary widely, feelings of anger, guilt, resentment and shame are commonly reported. Excessive responsibility and concern about one''s identity may add to these feelings and culminate in psychologic problems in the sibling. The physician caring for the family must be alert for symptoms of emotional disturbance or social maladjustment among the siblings of chronically ill or mentally handicapped children and should be prepared to counsel the family or refer them to a counsellor experienced in this area. In general, the first step is to be sure that the sibling is fully informed about the condition and to encourage frank discussion between the parents and the handicapped child''s siblings.     

Ability to taste 6-n-propylthiouracil and BMI in low-income preschool-aged children

Background: Sensitivity to the bitter compound 6‐n‐propylthiouracil (PROP) is genetically mediated. Sensitivity to PROP has been associated with weight status in both adults and children. Objective: To determine whether there is an association between PROP sensitivity and BMI in low‐income children of diverse race/ethnicity, among whom there is a high prevalence of obesity. Methods and Procedures: Eighty‐one preschool‐aged children attending Head Start tasted a solution of 560 μmol/l PROP and reported whether it tasted “like water” or “like something else”. Mothers reported child's race, age, maternal education, maternal weight and height, child's reluctance to sample new foods via the Food Neophobia Scale (FNS), and child's dietary intake using a food frequency questionnaire. Child weight and height were measured. BMI was calculated and for children, expressed in z‐scores. Regression analyses were used to evaluate the relationship between child's PROP taster status and BMI z‐score, testing covariates child's age, gender, race, maternal education and BMI, and child's FNS score. Children's dietary intake was compared by PROP taster status. Results: PROP tasters, compared with nontasters, had significantly higher BMI z‐scores (0.99 (s.d. 1.24) vs. 0.03 (1.12), P = 0.004) and had a significantly higher prevalence of overweight (31.8% vs. 5.6%, P = 0.025), but demonstrated no differences in reported dietary intake. The most parsimonious model predicting the child's BMI z‐score included only maternal BMI and the child's PROP taster status (R ² = 22.3%). Discussion: A genetically mediated ability to taste bitter may contribute to obesity risk in low‐income, preschool‐aged children.     

Socioeconomic Predictors of Cognition in Ugandan Children: Implications for Community Interventions

Background

Several interventions to improve cognition in at risk children have been suggested. Identification of key variables predicting cognition is necessary to guide these interventions. This study was conducted to identify these variables in Ugandan children and guide such interventions.

Methods

A cohort of 89 healthy children (45 females) aged 5 to 12 years old were followed over 24 months and had cognitive tests measuring visual spatial processing, memory, attention and spatial learning administered at baseline, 6 months and 24 months. Nutritional status, child''s educational level, maternal education, socioeconomic status and quality of the home environment were also measured at baseline. A multivariate, longitudinal model was then used to identify predictors of cognition over the 24 months.

Results

A higher child''s education level was associated with better memory (p = 0.03), attention (p = 0.005) and spatial learning scores over the 24 months (p = 0.05); higher nutrition scores predicted better visual spatial processing (p = 0.002) and spatial learning scores (p = 0.008); and a higher home environment score predicted a better memory score (p = 0.03).

Conclusion

Cognition in Ugandan children is predicted by child''s education, nutritional status and the home environment. Community interventions to improve cognition may be effective if they target multiple socioeconomic variables.     

Behavioral and Self-report Measures Influencing Children's Reported Attachment to Their Dog

Despite the prevalence of dogs as family pets and increased scientific interest in canine behavior, few studies have investigated charac- teristics of the child or dog that influence the child–dog relationship. In the present study, we explored how behavioral and some self-report measures influence a child's reported attachment to their dog, as assessed by the Lexington Attachment to Pets Scale (LAPS). We tested specifically whether children (n = 99; mean age = 10.25 years, SD = 1.31) reported stronger attachment to dogs that were perceived as being more supportive (mea- sured by a modified version of the Network of Relationships Inventory), that were more successful in following the child's pointing gesture in a standard two-object choice test, or that solicited more petting in a sociability assess- ment. In addition, we assessed whether children's attachment security to their parent and being responsible for the care of their dog influenced re- ported attachment to the dog. Overall, perceived support provided by the dog was highly predictive of all subscales of the LAPS. The dog's success in following the child's pointing gestures and lower rates of petting during the sociability assessment were associated with higher ratings on the General Attachment subscale of the LAPS, but not on the other subscales. Caring for the dog did not predict the child's reported attachment to the dog, but did predict the dog's behavior on the point-following task and petting during the sociability task. If the child cared for the dog, the dog was more likely to be successful on the pointing task and more likely to be petted. These results indicate a dyadic relationship in which the child's care for the dog is associ- ated with the dog's behavior on the behavioral tasks, which in turn is related to the child's reported attachment to their dog. The direction of influence and nature of this dyad will be a fruitful area for future research.     

Maternal short stature does not predict their children's fatness indicators in a nutritional dual‐burden sample of urban Mexican Maya

The co‐existence of very short stature due to poor chronic environment in early life and obesity is becoming a public health concern in rapidly transitioning populations with high levels of poverty. Individuals who have very short stature seem to be at an increased risk of obesity in times of relative caloric abundance. Increasing evidence shows that an individual is influenced by exposures in previous generations. This study assesses whether maternal poor early life environment predicts her child's adiposity using cross sectional design on Maya schoolchildren aged 7–9 and their mothers (n = 57 pairs). We compared maternal chronic early life environment (stature) with her child's adiposity (body mass index [BMI] z‐score, waist circumference z‐score, and percentage body fat) using multiple linear regression, controlling for the child's own environmental exposures (household sanitation and maternal parity). The research was performed in the south of Merida, Yucatan, Mexico, a low socioeconomic urban area in an upper middle income country. The Maya mothers were very short, with a mean stature of 147 cm. The children had fairly high adiposity levels, with BMI and waist circumference z‐scores above the reference median. Maternal stature did not significantly predict any child adiposity indicator. There does not appear to be an intergenerational component of maternal early life chronic under‐nutrition on her child's obesity risk within this free living population living in poverty. These results suggest that the co‐existence of very short stature and obesity appears to be primarily due to exposures and experiences within a generation rather than across generations. Am J Phys Anthropol 153:627–634, 2014. © 2013 Wiley Periodicals, Inc.     

Predictors of accurate maternal perception of their preschool child's weight status among Hispanic WIC participants

Childhood obesity is a growing problem in the United States. Parental perception of their children's weight status is a key factor that needs to be considered when developing prevention programs for preschool children. Using a randomly selected sample of participants of Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) in Los Angeles County, we assessed accuracy of maternal perceptions of their children's weight status by comparing children's weight classification to the mothers' response to the question “Do you consider your child to be overweight, underweight or about right weight for (his) (her) height?” Additionally, we identified possible predictors of accurate maternal perception of their children's weight status by conducting a logistic regression model with child's gender, child's birth weight, maternal age, maternal BMI, maternal education, maternal acculturation level, and maternal language preference as potential predictors. Almost all mothers in the study classified their overweight or obese child as being about the right weight (93.6% and 77.5% of mothers, respectively). Maternal BMI and child's birth weight were the only predictors of maternal perception of their child's weight. Both were negatively associated with accuracy, with higher maternal BMI and higher infant birthweight associated with less accurate maternal perception of child weight. Parents need to be educated on the importance of childhood obesity and how to identify if their children are overweight or obese. If parents fail to recognize that their overweight child is overweight, then it is unlikely that they will recognize that interventions targeting obesity are relevant to their families.     

Can children withhold consent to treatment?

A dilemma exists when a doctor is faced with a child or young person who refuses medically indicated treatment. The Gillick case has been interpreted by many to mean that a child of sufficient age and intelligence could validly consent or refuse consent to treatment. Recent decisions of the Court of Appeal on a child''s refusal of medical treatment have clouded the issue and undermined the spirit of the Gillick decision and the Children Act 1989. It is now the case that a child patient whose competence is in doubt will be found rational if he or she accepts the proposal to treat but may be found incompetent if he or she disagrees. Practitioners are alerted to the anomalies now exhibited by the law on the issue of children''s consent and refusal. The impact of the decisions from the perspectives of medicine, ethics, and the law are examined. Practitioners should review each case of child care carefully and in cases of doubt seek legal advice.