Children and war

Children bear disproportionate consequences of armed conflict. The 21st century continues to see patterns of children enmeshed in international violence between opposing combatant forces, as victims of terrorist warfare, and, perhaps most tragically of all, as victims of civil wars. Innocent children so often are the victims of high-energy wounding from military ordinance. They sustain high-energy tissue damage and massive burns - injuries that are not commonly seen in civilian populations. Children have also been deliberately targeted victims in genocidal civil wars in Africa in the past decade, and hundreds of thousands have been killed and maimed in the context of close-quarter, hand-to-hand assaults of great ferocity. Paediatricians serve as uniformed military surgeons and as civilian doctors in both international and civil wars, and have a significant strategic role to play as advocates for the rights and welfare of children in the context of the evolving 'Laws of War'. One chronic legacy of contemporary warfare is blast injury to children from landmines. Such blasts leave children without feet or lower limbs, with genital injuries, blindness and deafness. This pattern of injury has become one of the post-civil war syndromes encountered by all intensivists and surgeons serving in four of the world's continents. The continued advocacy for the international ban on the manufacture, commerce and military use of antipersonnel landmines is a part of all paediatricians' obligation to promote the ethos of the Laws of War. Post-traumatic stress disorder remains an undertreated legacy of children who have been trapped in the shot and shell of battle as well as those displaced as refugees. An urgent, unfocused and unmet challenge has been the increase in, and plight of, child soldiers themselves. A new class of combatant comprises these children, who also become enmeshed in the triad of anarchic civil war, light-weight weaponry and drug or alcohol addiction. The International Criminal Court has outlawed as a War Crime, the conscription of children under 15 years of age. Nevertheless, there remain more than 300 000 child soldiers active and enmeshed in psychopathic violence as part of both civil and international warfare. The typical profile of a child soldier is of a boy between the ages of 8 and 18 years, bonded into a group of armed peers, almost always an orphan, drug or alcohol addicted, amoral, merciless, illiterate and dangerous. Paediatricians have much to do to protect such war-enmeshed children, irrespective of the accident of their place of birth. Only by such vigorous and maintained advocacy can the world's children be better protected from the scourge of future wars.

Anxious children and their parents: What do they expect?

Assigned 73 children, ages 7 to 14, to 1 of 3 groups (anxious, clinical control, and nonclinical control) according to their diagnostic status. Within the anxious group, children were assigned to 1 of 2 further groups on the basis of self-reported parental anxiety-either the child anxiety only group or the child + parent anxiety group. All children completed an experimental task (giving a brief talk in front of a video camera), which was the focus for a series of structured family discussions between the child and his or her parents. The aims of the study were to measure and compare across groups (a) the evaluations of children and their parents regarding the child's predicted anxiety and skill level and (b) the effect of the family discussion on children's expectations. Results indicated that, prior to the family discussion, anxious children's expectations of their future performance did not differ from those of control children. Similarly, there were no differences in children's expectations between the child anxiety group and the child + parent anxiety group. Second, compared to mothers in the child anxiety group, mothers in the child + parent anxiety group expected that their children would be more anxious and more likely to choose an avoidant problem solution (but not less skilled). Finally, the family discussion was found to produce no changes in anxious children's expectations of their future performance. The implications of these findings are discussed.

Accuracy of predicting a child's response to potential threat: A comparison of children and their mothers

Considerable research has indicated that children and their parents often demonstrate marked discrepancies in their reporting of anxiety-related phenomena. In such cases, the question arises as to whether children are capable of accurately reporting on their anxiety. In the present study, 50 children (aged 5 to 14 years) were asked to approach a large, German Shepherd dog. Prior to the task, both the mother and child independently predicted the closest point likely to be reached by the child and the degree of anxiety likely to be experienced. These predictions were then compared with the actual phenomena displayed by the child during the task. On the behavioural measure (closest step reached), both the child and mother demonstrated equivalent predictive accuracy. On the subjective measure (fear ratings) children were considerably more accurate than their mothers. The data were not influenced by gender, age, or clinical status. The results indicate the ability of children to accurately predict their anxious responses, and support the value of incorporating children's self-reports in the assessment of emotional disorders.

Absorption of sunscreens across human skin: an evaluation of commercial products for children and adults

Aims Topical sunscreens are routinely applied to the skin by a large percentage of the population. This study assessed the extent of absorption of a number of common chemical sunscreen agents into and through human skin following application of commercially available products. Methods Sunscreen products were applied to excised human epidermis in Franz diffusion cells with the amount penetrating into and across the epidermis assessed by h.p.l.c. for 8 h following application. Results All sunscreen agents investigated penetrated into the skin (0.25 g m(-2) or 14% of applied dose), but only benzophenone-3 passed through the skin in significant amounts (0.08 g m(-2) or 10% of the applied dose). With one exception, suncreen agents in corresponding products marketed for adults and children had similar skin penetration profiles. Conclusions Whilst limited absorption across the skin was observed for the majority of the sunscreens tested, benzophenone-3 demonstrated sufficiently high penetration to warrant further investigation of its continued application.

Cost-effectiveness of cognitive behavioural therapy and selective serotonin reuptake inhibitors for major depression in children and adolescents

Objective: To assess from a health sector perspective the incremental cost-effectiveness of cognitive behavioural therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs) for the treatment of major depressive disorder (MDD) in children and adolescents, compared to 'current practice'. Method: The health benefit is measured as a reduction in disability-adjusted life years (DALYs), based on effect size calculations from meta-analysis of randomised controlled trials. An assessment on second stage filter criteria ('equity'; 'strength of evidence', 'feasibility' and 'acceptability to stakeholders') is also undertaken to incorporate additional factors that impact on resource allocation decisions. Costs and benefits are tracked for the duration of a new episode of MDD arising in eligible children (age 6-17 years) in the Australian population in the year 2000. Simulation-modelling techniques are used to present a 95% uncertainty interval (UI) around the cost-effectiveness ratios. Results: Compared to current practice, CBT by public psychologists is the most cost-effective intervention for MDD in children and adolescents at A$9000 per DALY saved (95% UI A$3900 to A$24 000). SSRIs and CBT by other providers are less cost-effective but likely to be less than A$50 000 per DALY saved (> 80% chance). CBT is more effective than SSRIs in children and adolescents, resulting in a greater total health benefit (DALYs saved) than could be achieved with SSRIs. Issues that require attention for the CBT intervention include equity concerns, ensuring an adequate workforce, funding arrangements and acceptability to various stakeholders. Conclusions: Cognitive behavioural therapy provided by a public psychologist is the most effective and cost-effective option for the first-line treatment of MDD in children and adolescents. However, this option is not currently accessible by all patients and will require change in policy to allow more widespread uptake. It will also require 'start-up' costs and attention to ensuring an adequate workforce.

Children and economic development: Family size, gender preferences and human capital formation - theory and Indian cases

In the light of Gary Becker's economic theory of the family, considers how economic cost and benefit factors can influence the size of families that parents decide to have. Some support for the importance of such factors is found from results of structured interviews with wives in Kondh-dominated villages in western Orissa. These results are at variance with the hypothesis of Malthus about population growth. Factors that may alter the optimal family size as development proceeds are discussed. It is found in our sampling that, on the whole, there is a preference for daughters rather than sons although this is not as strong in the Kondh-dominated villages as in poor villages in the Santal tribal belt of West Bengal. While in the Kondh-dominated villages some discrimination in access to education in favour of boys compared to girls is present, little such or no such discrimination occurs in relation to access to food and medical attention. In the villages surveyed in the West Bengal Santal tribal belt, discrimination in favour of boys is more pronounced than in the Kondh-dominated area in Orissa. While economic considerations help to explain gender discrimination between boys and girls, we find that social and cultural factors also play a major role. Parents in a similar economic situation seem to display substantially different patterns of gender discrimination between children depending on their social and cultural content. It seems that the extent to which economic theories of the family explain family preferences and behaviour depend significantly on the social and cultural context in which they are to be applied.