Making Sense of Child Welfare When Regulating Human Reproductive Technologies

Policy-makers have attempted to frame the ethical requirements that are relevant to the creation of human beings via reproductive technologies. Various reports and laws enacted in New Zealand, Canada, Australia, and Britain have introduced tests for how we should weigh child welfare when using these technologies. A number of bioethicists have argued that child welfare should be interpreted as a “best interests” test. Others have argued that there are ethical reasons why we should abandon this kind of test. I will argue that at least some of the relevant policy can be interpreted as requiring those wishing to exercise their procreative liberty to have a reasonable plan to care and nurture any resulting child, thereby respecting the internal preconditions of that liberty. This interpretation of child welfare requirements answers some of the ethical worries about a child welfare test.     

ABC of child abuse. Role of the child psychiatry team.

In summary, a child psychiatrist can make an important contribution to the management of child abuse. At least one child psychiatrist in each district should take an interest in this work and should be given the time to do so. As for other professionals, child abuse is an aspect of the work of child psychiatrists that is particularly harrowing and time consuming.     

The costs of human locomotion: Maternal investment in child transport

This article investigates maternal investment in child carrying and presents a method for determining when it is energetically advantageous for a mother to carry her child rather than force her child to walk independently. I calculate maternal and child energy consumption while walking and develop correction factors to facilitate making these energy calculations for young children. In addition, I investigate the effect of maternal burdens in addition to the child and of external nutritional support on energy consumption. Since maternal energy is a finite resource, the “decision” to carry a child or force it to walk independently is especially important. This decision can be predicted from the body mass of the mother and child and the child's age. If the mother provides all of the child's nutrition, then the mother should choose to carry her child only when the energy usage of the mother carrying the child is less than the sum of the energy used when the mother and child walk independently. The critical velocity, when the two expenditures are equal, can then be determined. Several general hypotheses are also addressed. The critical velocity of a 60 kg mother with a 4-year-old child approximately equals the average walking speed of adult humans. For a lighter mother, the critical velocity is reached when her child is 3 years old, while for heavier mother this point is not reached until her child is 6 years old. The effect of burdens in addition to the child's mass is minimal. Nutritional support of the child by agencies other than the mother decreases the age at which the mother should force the child to walk independently. In some cases, especially for the lightest mothers, it is never in the mother's best energetic interest to carry her child. Am J Phys Anthropol 107:71–85, 1998. © 1998 Wiley-Liss, Inc.     

Automatic analysis of longitudinal growth data on the website willi-will-wachsen.de

Many disorders of child development can only be treated successfully when they are detected early. Thus, child development should be checked periodically. Usually, a few parameters are sufficient to check whether or not a child is developing normally in terms of growth. By making such checks publicly available on the website: willi-will-wachsen.de the authors hope to provide a tool which helps the automatization of simple check procedures and thereby detect with less effort more children with growth disorders.     

Parental Permission and Child Assent in Research on Children

Grounded on the ethical principle of respect for persons, parental permission and child assent function together to protect the child and to foster the development of the child’s self-determination. Although both parental permission and child assent involve the same components of information sharing, comprehension, and voluntariness, how these three components are understood and operationalized should differ depending on the developmental level of the child. For example, the amount of information that a child must comprehend to provide meaningful and developmentally appropriate child assent (or dissent) should be allowed to vary with the age and maturity of the child. By understanding child assent together with the important protections of parental permission, child assent does not need to be burdened with the same informational and process requirements. As a result, the age (as a proxy for developmental stage) at which a child is deemed capable of assent would be lower (i.e., 5 to 7 years old). By assuming a lack of capacity, the potential arises to dishonor and disregard a child’s wishes by failing to solicit meaningful assent or dissent. Further research needs to be done on how best to obtain truly informed and voluntary parental permission and child assent for research participation.     

Selecting potential children and unconditional parental love

For now, the best way to select a child's genes is to select a potential child who has those genes, using genetic testing and either selective abortion, sperm and egg donors, or selecting embryos for implantation. Some people even wish to select against genes that are only mildly undesirable, or to select for superior genes. I call this selection drift – the standard for acceptable children is creeping upwards. The President's Council on Bioethics and others have raised the parental love objection : Just as we should love existing children unconditionally, so we should unconditionally accept whatever child we get in the natural course of things. If we set conditions on which child we get, we are setting conditions on our love for whatever child we get. Although this objection was prompted by selection drift, it also seems to cover selecting against genes for severe impairments.
I argue that selection drift is not inconsistent with the ideal of unconditional parental love and, moreover, that the latter actually implies that we should practise selection drift – in other words, we should try to select potential children with the best genetic endowments. My endowment argument for the second claim works from an analogy between arranging an endowment prior to conception to fund a future child's education, and arranging a genetic endowment by selecting a potential child who already has it, where in both cases the child would not have existed without the endowment. I conclude with some programmatic remarks about the nonidentity problem.     

MANAGEMENT OF JUVENILE RHEUMATOID ARTHRITIS—The Problem of Long-Term Rehabilitation

A program for the management of juvenile rheumatoid arthritis should permit the child an optimal developmental experience despite the persistence of potentially crippling inflammatory disease. Drugs are useful, although no more than palliative, and all are significantly toxic. Physical measures should be directed toward the improvement of joint alignment and mobility and the restoration of muscular strength. The emotional, social and educational needs of a child with such a chronic disability deserve the most thoughtful attention.     

Effect of number, order, and spacing of siblings on child and adult outcomes: an overview of current research

The impact of the number, order, and spacing of siblings on child and adult outcomes has been the topic of research by scholars in 4 separate fields (human biology, psychology, sociology, and economics), and the barriers to communication between academic disciplines are strong. Also most researchers have had to work with data sets gathered for other purposes. This has resulted in a relative inadequacy of research. Social scientists have 3 theories concerning the relationship between the number, order, and spacing of siblings and child and adult outcomes: that an increase in the number of siblings or a decrease in the spacing between them dilutes the time and material resources that parents can give to each child and that these resource dilutions hinder the outcome for each child; that account must be taken not only of parental resources but also of the resources given to each child by his/her siblings; and that there is no causal relationship between number, order and spacing of siblings and child outcomes and that any apparent relationships are spurious. In light of these theories, the question arises as to how should the sibling variables be measured. The most important aspect of sibling number is that it is a variable over time. Yet, the proper measurement of sibling number has an additional complication. According to all existing theories, the ages of the other siblings are relevant for the outcome for the given child. All of the relevant information is now available only when it is possible to construct a matrix in which the rows present the age of the given child and the columns the age grouping of the siblings for whom a count of sibling number will be made. Many such matrices could be developed, some much more elaborate than others. For illustrative purposes, Table 1 presents the matrix of the number of siblings for a child who is the first-born among 5 children, all of whom are spaced exactly 3 years apart and all of whom are financially dependent only up to exact age 21. Table 2 presents the matrix for the last-born child among 5 children with characteristics identical to those in Table 1. It can be inferred from these tables that the oldest child in the family, as compared to the youngest child, probably will suffer from a diminution of parental resources, most likely financial resources, in adolescence. The youngest will suffer from a reduction of parental resources, probably time resources, in infancy and early childhood. Research concerned with the consequences of the number and spacing of children should be based on data sets for which some version of this matrix can be constructed.     

Relief of pain by infiltration of autonomic ganglia with steroids.

When parents are concerned about the development of stuttering in their child they often consult their pediatrician or family physician. Theories on the development of stuttering are briefly examined in this article, and guidelines are provided to help the physician determine if the child''s dysfluencies are within the normal range. Referral to a speech therapist should be considered when any of the following are noted: excessive repetition of the first syllable of words; tremor of the muscles of mouth or jaw, increase in pitch or loudness, or evidence of fear or emotion as the child struggles with a word; evidence that the child avoids certain words or situations; and excessive concern of parents, teachers or the dysfluent individual. Two approaches to therapy, traditional and behavioural, are described. The latter has resulted in significant gains in fluency among stutterers.     

The frequency of consanguineous matings due to multiple use of donors in artificial insemination.

The amount of inadvertent inbreeding as a result of donor anonymity in artificial insemination has been estimated. A child from a first-cousin mating or closer is expected approximately once every 41/2 years in the United States as a result of artificial insemination by donor. Since a child with unknown paternity seems less likely to mate with paternal relatives than is a child with known paternity, artificial insemination by donor may actually reduce the average inbreeding of the population. Nevertheless, to reduce recessive diseases, inbreeding should be kept to a minimum by limiting the number of children produced by a single donor. Formulas are presented for local risks of inbreeding based on the number of children per donor.     

Books received

While theoretical work focusing on immigrant language acculturation suggests that both parental and child's understanding of English are needed to measure acculturation, analysts have instead focused on child bilingualism. I develop a measure of familial acculturation and conceptually distinguish it from child bilingualism. I then determine whether several child and parental variables influence these measures differently, which would provide evidence supporting the conceptual distinction. Results show that child bilingualism is indeed independent of familial acculturation. Parental skills and resources significantly affect familial acculturation but not child bilingualism, whereas gender and Latino status affect child bilingualism but not familial acculturation. Additionally, modes of incorporation do not determine either child bilingualism or familial acculturation, suggesting that integrative forces external to the family may have little power to shape the internal workings that generate child or familial language acculturation. Together, these findings imply that researchers should avoid conflating child bilingualism with familial acculturation.     

PSYCHIATRIC MANAGEMENT OF INTERSEXED PATIENTS

The psychiatric management of intersexed patients stems from an awareness that sexual identity is the result of a complex mixture of somatic and psychological components. Decisions in treatment are dependent on the appearance and correctability of the anatomic defects, the age of the patient, and the potential reversibility of the identifications contributing to the manifested sexual identity. In infants and small children, following proper diagnosis of somatic sex and an evaluation of degree of correctability of anatomical defects, decision can be made whether to bring up the child in his genetic sex or not. It is very difficult to change the sexual identity after two and a half years, except possibly in persons who already have considerable question as to their maleness or femaleness.In the psychiatric treatment of children with such disorders, the child and his family should be informed in understandable language what is being done, and the child and usually the parents should be involved in psychotherapy.With the adult, if treatment is necessary, supportive therapy, not psychoanalysis, should be used.     

Childhood malignancies and decision making.

Failure to obtain "adequate" medical care for a child constitutes child neglect, which may be used as the basis for prosecution of parents, removal of the child from the home, or court-ordered medical treatment. "Adequate" care is usually construed as that which is given by a licensed physician, but, in case of dispute, courts almost never engage in choosing one medical approach over another. The principle that parents may not refuse medical care, however, is made very difficult when children have malignancies--the long-term nature of the treatment means that, if the child is left at home, court order or not, the parents may flee with their child. Removing the child from the home, however, adds that trauma to the ill child's burdens. Questions should be asked before making a request to a court to order a therapy which will prolong but not save a child's life if the parents would prefer to spare their child the side effects. Parents, however, may always refuse to permit their child to participate in research studies, no matter how promising. Adolescents are increasingly believed to be capable of medical decision making; most courts, however, would not allow an adolescent to refuse life-saving treatment.     

Assessing the utilization of maternal and child health care among married adolescent women: evidence from India

This study explores the prevalence and factors associated with the utilization of maternal and child health care services among married adolescent women in India using the third round of the National Family Health Survey (2005-06). The findings suggest that the utilization of maternal and child health care services among adolescent women is far from satisfactory in India. A little over 10% of adolescent women utilized antenatal care, about 50% utilized safe delivery services and about 41% of the children of adolescent women received full immunization. Large differences by urban-rural residence, educational attainment, religion, economic status and region were evident. Both gross effect and fixed effect binary logit models yielded statistically significant socioeconomic and demographic factors. Women's education, wealth quintile and region are the most important determinants for the utilization of maternal and child health care services. Health care programmes should focus more on educating adolescents, providing financial support, creating awareness and counselling households with married adolescent women. Moreover, there should be substantial financial assistance for the provision of delivery and child care for married women below the age of 19 years.     

Mitral Valve Replacement in a 14-Month-Old Child

In a 14-month-old child with severe congenital mitral insufficiency, the mitral valve was replaced with a Starr-Edwards valve. This resulted in dramatic improvement and the child continues to thrive one year after surgery. The authors conclude that valve replacement should be considered in a child of any age if other methods of valve repair cannot be relied upon to produce a good result.     

The Management of the Retarded Child in Practice

The management of the retarded child in general practice is discussed. The necessity of a thorough medical and psychological assessment is stressed. The problem of the parents is described from the point of view of the emotional stages through which they pass and the defence mechanisms they commonly use. The factors involved in planning the future program for the retarded child are enumerated and depend on the degree of mental and physical handicap, the socio-economic and emotional climate of the family and the available services in the area. Since a large proportion of retarded children remain at home, a systematic follow-up program by the practising physician should be encouraged.     

What Is the Association between Absolute Child Poverty,Poor Governance,and Natural Disasters? A Global Comparison of Some of the Realities of Climate Change

The paper explores the degree to which exposure to natural disasters and poor governance (quality of governance) is associated with absolute child poverty in sixty-seven middle- and low-income countries. The data is representative for about 2.8 billion of the world´s population. Institutionalist tend to argue that many of society’s ills, including poverty, derive from fragile or inefficient institutions. However, our findings show that although increasing quality of government tends to be associated with less poverty, the negative effects of natural disasters on child poverty are independent of a country´s institutional efficiency. Increasing disaster victims (killed and affected) is associated with higher rates of child poverty. A child´s estimated odds ratio to be in a state of absolute poverty increases by about a factor of 5.7 [95% CI: 1.7 to 18.7] when the average yearly toll of disasters in the child´s country increases by one on a log-10 scale. Better governance correlates with less child poverty, but it does not modify the correlation between child poverty and natural disasters. The results are based on hierarchical regression models that partition the variance into three parts: child, household, and country. The models were cross-sectional and based on observational data from the Demographic Health Survey and the Multiple Indicator Cluster Survey, which were collected at the beginning of the twenty-first millennium. The Sustainable Development Goals are a principle declaration to halt climate change, but they lack a clear plan on how the burden of this change should be shared by the global community. Based on our results, we suggest that the development agencies should take this into account and to articulate more equitable global policies to protect the most vulnerable, specifically children.     

Parent predictors of child weight change in family based behavioral obesity treatment

Family based behavioral treatment for overweight and obese children includes parenting skills targeting the modification of child eating and activity change. The purpose of this study was to examine parenting skills and parent weight change as predictors of child weight change in a sample of 80 parent/child dyads who were enrolled in a family based behavioral weight loss program for childhood obesity. Eighty overweight and obese children and their parents who enrolled in treatment in two sites were included in the study. Variables included those related to parent modeling (parent BMI), home food environment, parenting (parent and child report), and demographics. Results suggested that parent BMI change was a significant predictor of child weight, in that a reduction of 1 BMI unit in the parent was associated with a 0.255 reduction in child BMI. None of the other variables were significant in the final model. This study is consistent with other research showing that parent weight change is a key contributor to child weight change in behavioral treatment for childhood obesity. Researchers and clinicians should focus on encouraging parents to lose weight to assist their overweight and obese child in weight management.     

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.     

Ethical use of covert videoing techniques in detecting Munchausen syndrome by proxy.

Munchausen syndrome by proxy is an especially malignant form of child abuse in which the carer (usually the mother) fabricates or exacerbates illness in the child to obtain medical attention. It can result in serious illness and even death of the child and it is difficult to detect. Some investigators have used video to monitor the carer''s interaction with the child without obtaining consent--covert videoing. The technique presents several ethical problems, including exposure of the child to further abuse and a breach of trust between carer, child, and the professionals. Although covert videoing can be justified in restricted circumstances, new abuse procedures under the Children Act now seem to make its use unethical in most cases. Sufficient evidence should mostly be obtained from separation of the child and carer or videoing with consent to enable action to be taken to protect the child under an assessment order. If the new statutory instruments prove ineffective in Munchausen syndrome by proxy covert videoing may need to be re-evaluated.