9.2.3. Data description and analysis

 

Infants and child (1–4 years) deaths have decreased in most European countries in recent years (see Chapter 4.1). Congenital malformations are the main cause of mortality in neonates (see Chapter 4.2), and accidents for 5-14 year olds (see Chapter 7).

 

Cancer: Tumors recognized in children include mainly Hodgkin’s and non-Hodgkin’s lymphoma as well as leukaemias (Figures 9.2.1a and b). Leukaemia is often successfully treated in children.

 

Figure 9.2.1a. Age-standardised mortality rates by cancer in children aged 0-14 in selected EUGLOREH Countries – Boys

 

Figure 9.2.1b. Age-standardised mortality rates by cancer in children aged 0-14 in selected EUGLOREH Countries – Girls

 

Asthma: It is evident that childhood asthma has grown significantly over the decades, as reported by individual countries’ practitioners, but yet again there are no the statistical systems available to provide comparable Europe-wide data. Studies and registers are in the process of development, such as the International Study of Asthma and Allergies in Childhood (ISAAC) project run between New Zealand and Europe, but though this project is valuably indicating the scale of the growing problem it has not yet been developed enough to provide representative data for all countries of Europe. However, for the WHO European Health Report (WHO 2005b), the prevalence rates of “ self-reported asthma symptoms” for children aged 13-14 for those countries which could supply data ranged from 3.0% in Romania and 3.7% in Greece to 29.1% in Ireland and 32.2% in the United Kingdom. On the other hand, self reported current wheezing is not diagnostic of asthma in an individual. Wheezing is not a symptom specific to the diagnosis of asthma and there is no agreed way of grading the severity or frequency of wheezing symptoms to identify the presence of asthma. Such a consideration may explain why much lower asthma rates are reported for UK by other sources. In fact, Asthma UK gives a figure of 10% for childhood asthma, whilst the National Institute of Clinical Excellence (NICE) guidance on prescribing corticosteroids states “ Asthma is the most common chronic disease in children, with a prevalence between 17 and 23%”. Moreover, “The Global Burden of asthma” (Masoli et al, 2004?), a report developed for the Global Initiative for Asthma (GINA), gives prevalence rates of clinical asthma2 in 13- to 14-year-old children as high as 18.4% for Scotland, 16.8% for Wales, 15.3% for England, and 14.6% in Ireland, which rank among the highest in the monitored countries.. The worrying element is how little is known about the prevalence, aetiology and effects of such a comparatively common condition in childhood with likely enduring effects.

 

Disabilities: We cannot identify the number of children with impairment or disability, or the number with special educational needs of any type (through physical, intellectual, or behavioural causes). There is a common public vision of happy and healthy children, balanced with concern about individual disabled or hospitalised children, but no public health data on the latter. Though the World Health Organization (2002) has recently introduced a new international scheme for categorising limitations to functioning and ability – i.e. the International Classification of Functioning, Disability and Health - and has also developed a children’s version of it, there is currently no means of seeking public health reporting of the number of children in society with various types of impairing problems. There is no effective means of monitoring special requirements and disabilities across the whole of childhood.

 

Injuries: As already indicated earlier in this section, injury is the greatest cause of childhood death. Of this, a quarter is the result of intentional injury. Physical injuries are the main cause of death in children aged 1-14 in Europe. Over 40% of 11–15-year-olds sustained injuries requiring medical attention once or more in the previous 12 months (HBSC, 2004). Unintentional injuries include road traffic accidents, poisonings, falls and drowning. Road traffic accidents represent the primary cause of childhood injuries in Europe. One in three deaths from traffic accidents involves a person under 25 years of age. Every year, some 9.000 children and young people under 19 years of age die in traffic accidents and 335.000 are injured. These figures represent about 10% of all deaths and 15% of all injuries from traffic accidents (WHO, 2007a).

 

However, fatal injury is just the tip of the iceberg, while for non-fatal events there is little available data. Recording systems have been developed for presentations to hospital trauma units, and/or hospital admissions. However, these data are incomplete – a condition which may be treated in one type of location in one setting or country may be handled in a different one in another setting. A large amount of trauma will also be managed in primary care, from which reporting statistics are very limited. Thus, the totality of childhood injury cannot regularly be measured.

 

Violence, bullying and fighting: Accidental injuries are but one aspect of violence, as defined by the WHO. Intentional injuries include child abuse and neglect, self-inflicted injuries, bullying, psychological violence and street violence. Sadly, very little is known about the incidence of these issues, though their effect is insidious. The WHO has active programmes on violence (WHO, 2008), and within the European Commission the DAPHNE programme is charged with addressing problems of violence in society. In the Young People’s Health in Context study (HBSC, 2004) bullying occurring on average at least twice a month was found to be higher among boys and girls, and to increase slightly between 11 and 15 years of age. The Czech Republic, Ireland, Malta, Scotland, Slovenia, Sweden and Wales have consistently low levels, while Austria and Lithuania have consistently high levels of bullying. Levels of children perceiving that they were being bullied show similar patterns, although the gender difference is smaller. There is cross-national variation and marked gender difference in levels of physical fighting, with very low levels of fighting reported among girls (WHO/HSBC, 2004). Bullying is one specific aspect of violence, and one which adversely affects mental health and development.

 

Abuse: Intentional abuse has other forms than physical injury, however. A worrying situation in many countries is child physical and emotional abuse, neglect, economic exploitation and bullying. Abuse may vary from physical assault and injury, to sexual abuse (both of boys and girls), psychological abuse, or general neglect. It is extremely difficult to obtain any even crude measure of the comparable incidence across Europe - this is one of the unmet information needs highlighted by the CHILD report in 2002, but it still remains unaddressed. Therefore, European society is not only unaware of how many children are being abused and neglected in its midst, it is also unable to take action to measure it. This is valid also for the worrying phenomenon of child-on-child violence.

 

Sexual behaviour: General information on sexual behaviour in adolescents can be found in chapter “9.3.3. Sexual health”

 

Sexually transmitted infections: Sexually transmitted infections are an important health problem for young girls because of the risk of infertility, ectopic pregnancy, pelvic inflammatory disease and chronic pelvic pain. Adolescents tend to underestimate, downplay or deny their risks of HIV and other STIs. Feelings of invincibility, combined with the lack of awareness of the consequences of risky behaviour, can make them less likely to take precautions to protect their health (WHO 2005c)(see also Chapter 9.3).

 

The incidence rate of syphilis is low and seems to be decreasing in all Member States except Finland (European Commission, 2003), although in November 2006 the UK Health Protection Agency warned of a dramatic increase in the number of cases in the UK (from 137 in 1996 to 3 000 in 2005) (HPA 2006). However, trends in fluctuation are difficult to establish, as many countries have very low reporting rates (or may be under-reporting rates of infection).

 

HIV/AIDS: In Europe as a whole, 30–40% of all reported HIV/AIDS cases are among those under 25 years of age (WHO/HSBC, 2004). For both biological and social reasons, women are becoming infected with HIV/AIDS at significantly younger ages than men. Girls are more likely than boys to be informed about HIV, to be coerced or raped, or enticed into sex by someone older, more powerful, or wealthier (UNICEF, 2002). Increased incidence of HIV/AIDS in young women has also led to an increase in the transmission of the virus from mother to child (UNICEF, 2002). UNICEF’s Young Voices poll (2001) found that a significant number of children in transition countries (53%) and Western Europe (40%) are reported as saying they have very little or no information about HIV/AIDS. Thirteen per cent of those who claim to have some or very little information about HIV/AIDS say they do not know what needs to be done to avoid infection and many children are unclear about the ways HIV is transmitted (UNICEF, 2001).

 

Other infectious disease. Europe is one of the parts of the world where there has been a welcomed reduction in infectious diseases, particularly those categorised as ‘vaccine preventable’. However, with the development of new vaccines, the definition of what can be considered ‘vaccine preventable’ is not static, as actually it is expanding. Yet at the same time, given the success in virtually eradicating conditions such as tuberculosis and poliomyelitis in children, there is a greater risk of complacency. Furthermore, the cause of immunisation has not been helped by the controversy about alleged damage caused by MMR (measles, mumps and rubella) vaccine. The apparent scientific evidence brought into this controversy is now seen to be deeply flawed. Nevertheless, confidence in immunisation over and beyond MMR, and immunisation protection rates, have been compromised.

 

In areas with stable, high vaccination coverage, disease has declined, with benefits lasting through adolescence and adulthood. It has been noticed, however, that in the absence of disease, immunisation loses priority, and outbreaks of diseases such as measles continue to occur in Europe. A result of inadequate uptake of measles-mumps-rubella vaccine during childhood means that increasing numbers of women are reaching child-bearing age without immunity to rubella (WHO 2005b). The resurgence of tuberculosis (TB) in recent years has apparently largely been associated to foreign-born people migrating from countries with a high prevalence. The disease seems to be predominantly urban and occurs frequently in specific groups of frequently socially marginalised people, such as the foreign-born and intravenous drug users. It is also thought that outbreaks may be due less to lack of immunisation than to unusual or multidrug-resistant (MDR) strains of Mycobacteria, reinjection and/or reactivation, and the spread of conditions affecting immune competence, e.g. AIDS.

 

Overweight and obesity: It is generally known and accepted that Europe has a growing crisis with the rapid increase in obesity in the population. This is particularly worrying in children, as not only does obesity jeopardise their current health and wellbeing, and in many cases their self esteem, but it also impacts their future health in adulthood, their economic and caring capacity - including health parenthood - and longevity. Thus, the very future of society is threatened by the rapid increase of child obesity. At the same time, related diseases are manifesting themselves in the childhood years, including an increase in type two diabetes(see also Chapter 5).

 

Excess body weight is the most common childhood disorder in the European Region. The extent of dissatisfaction with body size is consistently higher among girls than boys. The gender gap widens with age (Fig. 2). On average, approximately a quarter of 11-year-old girls consider themselves to be too fat, with this figure increasing to over 40% in 15-year-old girls. National variations can be seen, with over 50% of 15-year-old girls in Belgium (both Flemish and French), Germany and Slovenia thinking they are too fat. However, the highest rates of dieting among girls of 15 (almost 30% or over) are found in Denmark, Hungary and Wales. Fewer than 11% of boys report dieting (WHO/HSBC, 2004). In several countries of Western Europe, its prevalence rose from around 10% in the early 1980s to around 20% by the end of the 1990s, while in some areas in Southern Europe, one child in three is overweight (WHO 2005b). Overweight in children leads to low self-esteem, depression and social exclusion. It is associated with a number of conditions such as poor glucose tolerance, increased risk of non-insulin-dependent diabetes, hypertension and sleep apnoea, and can lead to increased rates of non-communicable disease in adulthood such as cerebro-vascular disease, diabetes, certain types of cancer, osteoarthritis, gall bladder and endocrine disorders (WHO/HSBC 2004). Malta and Wales have among the highest rates of overweight in Europe. There are concerns in the EU that the number of overweight children is rising each year by 400 000 (European Commission, 2006d). Recent estimates indicate that more than 27 000 children in the EU have type 2 diabetes, more than 400 000 have impaired glucose tolerance. About 1.1 million suffer from hypertension; and 1.2 million suffer from metabolic syndrome (presenting 3 or more of the following: hypertension, central adiposity, raised HDL blood cholesterol, raised blood triglycerides, and raised blood glucose levels (Lobstein and Jackson-Leach, 2006)).

 

The World Health Organisation is so concerned that in 2006 it organised a conference of Health Ministers to address this topic (WHO 2007b). Thus, all European states, including the European Union, have signed up to urgently address the problem. However, though in general terms this crisis is known about, in detail there is remarkably little standard public health information available, particularly about children. This in turn means that Europe-wide comparable data are not available. However, by any individual measure under most European countries the situation is known to be worsening. Whilst a small proportion of obesity will be caused by genetic or metabolic conditions, the greatest majority is a combination of nutritional and physical exercise behaviours. This in turn is influenced by determinants ranging from parental attitude to breast feeding and childhood nutrition through to children’s patterns of physical exercise – practical public health issues which are not currently being measured systematically or universally.

 

Eating disorders. Male and female adolescents tend to evaluate their bodies differently. Girls may have a stronger emphasis on the attractiveness of their body to others, while boys give greater emphasis on their bodies as a means of operating effectively in the external environment including sport and work (Lerner et al 1976). Adolescents find it difficult to classify themselves appropriately in terms of weight (Figure 9.2.2). Girls often perceive themselves to be overweight, while boys are more likely to perceive themselves as underweight and to engage in weight-gaining and muscle-enhancing activities (WHO/HSBC 2004). Self-assessment of BMI may be influenced by socio-economic or educational factors, where an individual may not be certain of their actual weight or height.

 

Figure 9.2.2. Young people dissatisfied with their body weight (%)

 

Physical pubertal changes, triggering teasing about weight from friends or family, are thought to be an important causal factor in eating disorders. Weight control methods such as dieting can instigate negative physical and psychological outcomes. Those who diet are more prone to irritability, concentration problems and sleep disturbances. In extreme cases, dieting may also affect menstrual regularity and growth (Pesa 1999). There also appears to be a correlation between unhealthy weight control behaviours and infrequent shared family meals; otherwise viewed as a high level of snacking. A recent report found that 18.1% of girls who reported only 1-2 family meals per week engaged in extreme weight control behaviours, compared with 8.8% of girls who reported having 3-4 family meals/week (Neumark-Sztainer et al 2004).

 

Mental Health: Mental illnesses pose an increasing burden of disability on children. Mood disorders such as depression are known to be associated with academic, social and behavioural problems during childhood and adolescence. Attention deficit hyperactivity disorder (ADHD) is linked to development delay. Mental health policy concerning children and adolescents needs to be better developed and integrated into the overall healthcare system in order to close the treatment gap in this area. The EU Green Paper on Mental Health makes only limited mention of children, though those references are strong and underline their individual and societal significance (European Commission, 2005a). It is also important to promote preventive interventions, as they have been shown to cause sustained reduction of depression, aggressive and delinquent behaviour as well as of alcohol, tobacco and illegal drug use (WHO, 2005a).

 

Good mental health, as much as good physical health, is a right for European children. A short summary of the situation shows that we do not know well the mental health of European children. This again is a truly worrying situation, and one which cannot be justified. But mental health is not well represented – if represented at all – in national or European data sets. The HBSC study covers aspects of feelings of well-being, and of feeling able to seek support from a parent or friend when anxious, in older school children, but leaves many other aspects of children’s mental health uncovered. As an outcome measure of service failure, suicide data are available from mortality statistics, but the accuracy and completeness of these are inevitably questionable as there are many reasons for under-reporting (see below).

 

There are frequently documented complaints of difficulty of access, very limited service provision and long waiting lists for child psychiatry services of various types. Equally known to be difficult is access by older children to mental health and counselling services – in many locations a crisis has to occur before a service is available. Young people have every reason to expect access to good mental health services when they need it, and indeed this can be seen as a basic right. It is impossible to tell the number of times per year European children are being denied this right at a time of need. The European Commission has now published a Green Paper on Mental Health. Although the paper contains some reference to children’s mental health needs and services, there is clearly a long way to go (European Commission, 2006c).

 

Feelings of wellbeing and support, and peer and parental support, are the means of seeking to ensure good mental health, according to the WHO definition. Data from the Health Behaviour in a School-aged Children (HBSC) study, covering the 11-15 years of age group, shows that by no means all children feel a sense of wellbeing. Whether the causes are population movement, breakdown of the traditional nuclear family, or pressures on modern society, the study identifies that a worrying proportion of children do not feel able to obtain help when they need it.

 

Suicide: Suicide can be seen as an ultimate marker of adverse mental health, and is becoming a complex social phenomenon. Suicide rates among people under 20 years of age have increased in many countries over the last two decades. Due to under–reporting, the true rates of suicide are difficult to establish.

 

School based suicide prevention programmes are associated to a lower rate of suicide attempts but no single intervention appears to be effective in reducing the suicide rate. Services and staff in many countries are often poorly prepared to deal with developmental and age-related psychological problems (WHO 2005b).