“Developmental health and wellbeing” is a term used to describe the developing human’s response to experiences and environmental circumstances.¹  It is concerned with individuals achieving their maximal competencies intellectually, physically and emotionally as a result of interactions within a positive social environment and avoidance of poor health, educational, behavioural and criminal outcomes and the resulting huge social and economic cost to society.²

The health status of Australian children has improved over the past few decades as demonstrated by decreases in the incidence of vaccine preventable diseases and infant mortality rates.³    However on measures of developmental wellbeing such as mental health and obesity, our children and young people have demonstrated a significant deterioration in outcomes. The long-term cost burden of these adverse outcomes is enormous and will increase with time. However despite this, most resources within the health sector continue to be spent on the management of disease and disability rather than on early intervention or preventative measures.

There are significant populations of children and young people at risk of poor developmental outcomes in our society. They include children born into poverty, children with mental health problems, children affected by homelessness as well as Indigenous children. In particular the health and well being of Aboriginal and Torres Strait Islander children and young people has been identified as being significantly worse than that of other Australians.  Poor health outcomes linked to poverty and reduced life chances generally commence at birth and continue throughout the life cycle. Aboriginal and Torres Strait Islander children are twice as likely to be of low birth weight, and have average death rates (between 0-14 years) of 2.5 times those of other Australian children.⁴  The link between poor health and impaired educational opportunity is well established.⁵  

There are many interventions that have been shown to effectively promote the wellbeing of children and young people. Risk and protective factors provide a useful framework for developing and analysing the effectiveness of these programs to influence children’s developmental outcomes. Important risk factors that have been identified include: ‘prenatal stress; difficult temperament; poor attachment; harsh parenting, abuse or neglect; parental mental illness or substance abuse; family disharmony, conflict or violence; low socioeconomic status; and poor links with community. Important protective factors include: easy temperament; at least average intelligence; secure attachment to family; family harmony; supportive relationships with other adults and community involvement.’ ⁶ 

Resilience is the positive adaptation of humans in circumstances where personal, family or environmental difficulties are such that we would expect a person's cognitive or functional abilities to be impaired.⁷   By investing in interventions that address risk factors and increase protective factors, society maximises the potential for individual resilience to develop.

‘There is powerful evidence to indicate that the early years of development set the base for competence and coping skills that will affect learning, behaviour and health throughout life. This evidence expands our understanding of the interplay between nature and nurture in brain development by demonstrating: the extensiveness of brain development in utero and the early years of life; the links between nutrition, care and nurture in directly affecting the wiring of the pathways of the brain; and the degree to which negative experiences in the early years, including severe neglect or absence of appropriate stimulation, are likely to have decisive and sustained effects’.⁸

Some configurations of risk at an early age have multiple consequences later in life⁹ with evidence showing that failure to intervene can have a detrimental affect on an individual’s learning capacity, their behaviour, and their ability to regulate emotions and their risks for disease in later life.¹⁰

2. Trajectory of development

Developmental approaches to health and wellbeing see life as a complex pathway involving a series of life phases or transition points where intervention can occur most effectively. This emphasis on pathways and on aspects of time and timing provides opportunities to affect determinants of ill health across the trajectory of development from early childhood, through to late childhood and youth.

2.1 Early childhood

This period of life is as important for an educated, competent population as any other period. To enhance the development of Australia’s children it is important to support the roles of early childhood services, schools, social services and health services to address behaviour and learning problems in early life. Evidence suggests that interventions at a later stage are less effective and many children may not reach their full potential.

Social capital including social cohesion is thought by many to be a key factor in long-term economic growth and the maintenance of tolerant democratic societies. Initiatives such as childcare centres, family day care, and pre and postnatal support programs can create a more coherent system of early child development, responsive to the needs of society.¹¹  Such centres engage children in play-based problem-solving activities that seek to improve outcomes for children and / or families. Evidence indicates an association between quality universal early childhood services and positive outcomes.

2.2 Childhood and Youth

While it may be most useful to intervene before children are 3 years of age, interventions for preschool and for school age children can also be effective. Therefore this earlier time period should not be emphasised at the expense of interventions aimed at older children and young people.

Adolescence is characterised by the growth of the child towards cognitive and physical maturity.  Attitudes towards health behaviours may be particularly malleable in late childhood and early adolescence when decisions relevant to involvement in risky behaviours, such as binge drinking, are being made.¹²  ‘Experience testifies to the potential, both at targeted and universal levels, of interventions to support patients and families through the adolescent phase’.¹³

In Australia the justice system is particularly interested in the cost benefits of early intervention. Research shows that this is more effective in the long-term than responses that are targeted at resolving an immediate crisis. These programs involve intervention at critical points in a young person's development and attempt to ensure that they are given the maximum opportunity to lead productive and law abiding lives.¹⁴

3. The impact of socioeconomic change on children and families 

Developed countries around the world are going through a complex socioeconomic transition. This change has caused the income gap between rich and poor socioeconomic groups to increase over the past two decades. In tandem with this phenomenon has been the emergence of a gradient of marked health inequalities. People in lower socio-economic groups suffer disproportionately from ill health, have higher rates of death and are more likely to have unhealthy behaviours such as inactivity, substance abuse and poor diet.¹⁵    There is evidence to suggest that those countries with a more equal distribution of income have better health outcomes.

Policies that aim to reduce inequalities in health must therefore address inequities in income distribution.

Families with low socioeconomic status often lack the financial, social, and educational supports that characterise families with high socioeconomic status. Poor families also may have inadequate or limited access to community resources that promote and support children’s development and school readiness.¹⁶  Poor children are at greater risk than those from higher income families for a range of problems, including detrimental affects on IQ, poor academic achievement, poor socio-emotional functioning,¹⁷  developmental delays, behavioural problems,¹⁸  poor nutrition, low birth weight, and respiratory disease.¹⁹

The evidence is clear that good early child development programs that involve parents or other primary caregivers of young children can influence how they relate to and care for children in the home, and can vastly improve outcomes for children's behaviour, learning and health in later life. The earlier in a child's life these programs begin the better. These universal programs will benefit children and families from all socioeconomic groups in society however the greatest return will be derived from interventions targeting families at risk.²⁰

4. Aboriginal and Torres Strait Islander children and young people

Aboriginal and Torres Strait Islander communities are among the most disadvantaged in Australian society.  Specific risk factors for impaired development and health for Indigenous children must be viewed in the context of the history of dispossession and intergenerational poverty. Risk factors identified by Watson include those at the social level, such as unemployment and low socio-economic status, inadequate and overcrowded housing, and geographic isolation for those living in remote locations with poor access to services and to affordable healthy food.20

Parenting skills are likely to have been influenced by the effects of disadvantage. Family risk factors may include a high proportion of single parent families, mental health problems and substance abuse, having a father in gaol and early exposure to violence.  Early childhood illness itself is a further risk factor for later development. In Aboriginal and Torres Strait Islander families, strong family networks and community involvement may act as a protective factor and promote resilience in the face of disadvantage.  In some communities, however, this may be undermined by other risk factors such as violence. 

5. Role of the medical profession

Efforts to maximise a child’s potential require a whole-of-community approach.  Policies and practices need to be informed by collaborative research involving medicine, health, education, welfare and justice.  National policy focusing on the early years of child development and the effects on learning, behaviour and health throughout the life cycle, which involves all stakeholders, is essential.

Such an approach requires improved coordination between all medical practitioners involved in child and youth health and development, particularly community based General Practitioners and paediatricians as well as hospital specialists.

6. The AMA’s position

The AMA, recognising the importance of the early years on human development, believes that:

6.1 A competent population that can cope with socioeconomic change is crucial for future economic growth. The developmental health and wellbeing of Australia’s young people needs to be a national priority.

6.2 General Practitioners play a pivotal role in the early recognition of problems and identification of at risk children and young people.

6.3 It is necessary to take steps to provide better circumstances in and outside the home for child and youth development. Learning in the early years must be based on quality, developmentally attuned interactions with caregivers and opportunities for play-based problem solving with other children that stimulates brain development.

6.4 Investment in the early years should match our investment in education, with society giving at least the same amount of attention to this period of development as it does to the school and post-secondary education periods of human development.

6.5 Research indicates that early intervention strategies are cost effective when compared to strategies to manage these problems at a later stage. This provides a compelling argument for investment in these programs.

6.6 Interventions that seek to improve the outcome for Australia’s children must be adequately resourced. Culturally appropriate pre-school education should be available to all children including those children with learning, language, behavioural, physical or developmental difficulties.

6.7 Programs must incorporate early identification of problems and have the capacity to adapt the setting to meet the needs of the individual child. This will require specialised expertise and resources and good links with specialised services and the health care system.

Because the challenges of work, family and child rearing are a shared responsibility among governments, employers, communities and families, the AMA calls on Federal and State governments to:

6.8 Develop government policy that recognises the evidence of significant stress on families and early child development in the present period of major economic and social change. These policies must address inequities in income distribution, as this is significantly associated with health disadvantage.

6.9 Ensure that programs are implemented to facilitate effective intervention at all stages in the developmental process.

6.10 Ensure that funding priorities are determined according to need. It is critical that populations at risk, particularly Indigenous children and young people, are allocated funding at a level that recognises their relative disadvantage.

6.11 Establish culturally appropriate programs to build on existing strengths within Indigenous communities. This will involve collaborating with key community leaders on program design and implementation. Effective preventative programs should target the whole community to avoid stigma and employ Indigenous workers wherever possible.

6.12 Support continued professional development for the medical profession in the area of developmental health and wellbeing.

6.13 Continue to develop and apply outcome measures for early child development, by linking health data for children to the larger population.

6.14 Improve access to medical services for children and families, particularly recognising the central position General Practitioners play in coordinating services and identifying needs for children and young people.

References:

1. Hertzman, C. (1999). Population Health and Human Development. Developmental Health and the Wealth of Nations: Social, Biological, and Educational Dynamics. D.P. Keating and C. Hertzman. New York, The Guilford Press: 21-40.

2. The Prime Minister's Science, Engineering and Innovation Council (2001). Developmental Health and Wellbeing: Australia’s future. Department of Education, Science and Training Canberra. Website: www.dest.gov.au/science/pmseic/publications.htm (17.01.03)

3. The Australian Institute of Health and Welfare (2002). Australia’s Health 2002. Australian Institute of Health and Welfare, Canberra.

4. Al-Yaman, F., Bryant, M. ,Sargeant, H. (2002). Australia’s children: their health and wellbeing. Australian Institute of Health and Welfare, Canberra.

5. AMA Position Statement on The Links Between Health and Education For Indigenous Australian Children (2001). Website: www.ama.com.au (17.01.03)

6. Department of Family and Community Services (2000). A Review of the Early Childhood Literature. Centre for Community Child Health, Melbourne.

7. Masten, A.S., Coatsworth, J.D. (1998). The development of competence in favourable and unfavourable environments: Lessons from research on successful children. American Psychologist, 53(2): 205-220.

8. McCain, M.N., Mustard J.F. (1999). Reversing the Real Brain Drain: Early Years Study, Final Report. Publications Ontario, Toronto.

9. National Crime Prevention (1999) Pathways to prevention: Developmental and early intervention approaches to crime in Australia. Attorney-General’s Department, Canberra.

10. The Prime Minister's Science, Engineering and Innovation Council (2001). Developmental Health and Wellbeing: Australia’s future. Department of Education, Science and Training, Canberra. Website: www.dest.gov.au/science/pmseic/publications.htm (17.01.03)

11. Deutsch, R.. (1998). How Early Childhood Interventions Can Reduce Inequality: An Overview of Recent Findings - Best Practice Study. Inter-American Development Bank, Washington, DC.

12. Dielman, T. (1994), School-based research on the prevention of adolescent alcohol use and misuse: methodological issues and advances. Journal of Research in Adolescence, 4: 271-293.

13. Toumbourou, J., Gregg, E. (2001). Working with families to promote healthy adolescent development. Family Matters, 59: 55-60.

14. National Crime Prevention (2003). National Crime Prevention Program: Early Intervention, Youth Crime & Families Strategy. Attorney-General’s Department, Canberra. Website: http://www.ncp.gov.au/ (17.01.03).

15. The Royal Australasian College of Physicians (1999). For Richer, for Poorer, in Sickness and in Health: The Socio-Economic Determinants of Health. RACP, Sydney.

16. Zill, N, Collins, M., West J., Germino Hausken E. (1995). Approaching Kindergarten: A Look at Preschoolers in the United States. Young Children 51: 35-38.

17. Geltman, P. L., Meyers, A. F., Greenberg, J., Zuckerman, B. (1996). Commentary: Welfare reform and children’s health. Center for Health Policy Research, Washington, DC:

18. McLoyd, V. C. (1998). Socioeconomic disadvantage and child development. American Psychologist, 53: 185-204.

19. Parker, S., Greer, S., & Zuckerman, B. (1988). Double jeopardy: The impact of poverty on early childhood development. Pediatric Clinician, North America, 35: 1227-1240.

20. Watson, J. (2002). Determined to be Self-Determined. Paper presented at the conference Frozen Futures: A conference exploring the effects of early stress on later outcomes. 14th-16th November 2002, University of Sydney. Sydney