Module 1: Module 1 - Childhood and children’s rights

Introduction to Module 1

This is the first module in a course of five modules designed to provide health workers with a comprehensive introduction to children’s rights. While the modules can be studied separately, they are designed to build on each other in order.

Module 1: Childhood and children’s rights

Module 2: Children’s rights and the law

Module 3: Children’s rights in health practice

Module 4: Children’s rights in the wider environment: the role of the health worker

Module 5: Children’s rights: planning, monitoring and evaluation

Module 1 of the curriculum provides an overall introduction to childhood and the idea of children’s needs and rights. An understanding of these issues will be necessary in order to make sense of the following modules on how to respect children’s rights in your role as a health worker. The module comprises three study sessions, each designed to take approximately two hours to complete. The sessions provide you with a basic introduction to the subject and are supported by a range of activities to help you develop your understanding and knowledge. The activities are usually followed by a discussion of the topic, but in some cases the answers are at the end of the study session. Please compose your own answer before comparing it with the answer provided. We have provided you with space to write your notes after an activity, however if you wish, you can use a notebook.

• Study Session 1 explores what we mean by childhood, how it is understood in different societies and some of the characteristics of being a child. It examines how children can be treated differently depending on whether, for example, they are a boy or a girl, or if they have a disability. And it provides you with an opportunity to explore your own attitudes towards childhood and how children should be treated. By the end of the session, you should have developed some insight into different approaches to understanding childhood, have a better understanding of your own views and behaviours towards children and be able to recognise some of the ways in which childhood is a unique and distinctive phase of life.
• Study Session 2 builds on the learning about childhood from the previous session and introduces you to the different stages of development in a child’s life. It provides an overview of some of the key changes that take place in children’s development from birth through to adolescence. It also examines the factors that influence how well children develop, such as social and economic conditions, the opportunities for children to learn and play, and the encouragement provided by key adults in the child’s life. By the end of the session, you should have a broad understanding of the different aspects of child development and at roughly what ages children should acquire different skills, knowledge and capacities. You should also have a clear idea of why knowledge of child development is important for you as a health worker, and how to use that knowledge.
• Study Session 3 explores the different needs children have if they are to grow up healthy and well. It examines how, although all children have the same needs, the way those needs must be met will change gradually as children grow older. The session then introduces you to the idea that there is wide international agreement that all children have the same needs and that adults have responsibilities for making sure those needs are met. This has led to a recognition that children are entitled to have needs met – in other words, they have rights. By the end of the session, you should have a clear understanding of children’s needs, the obligation of adults to meet those needs and the relationship between needs and rights.

1 Understanding childhood

Key words: child, childhood, dependency, evolving capacities, resilience, risk, vulnerability

1.1 Introduction

Both national laws in East Africa and international agreements define a child as anyone up to 18 years of age. They recognise childhood as a period of nurturing, care, play and learning in the family, school and community. However, every society and culture also has its own understanding of childhood and who it considers to be a child. This session will examine how children and childhood are understood in East Africa, the factors that influence how childhood is defined and some of the key characteristics of childhood. It will help you explore your own attitudes and values in relation to children and look at how those attitudes differ towards different groups of children. As a health practitioner it is important to understand and re-evaluate how your own views on children and childhood influence your day-to-day practice.

1.2 Learning outcomes

When you have studied this session, you should be able to:

• define and use correctly the key words
• define who is a child
• describe the key characteristics of childhood
• understand how different cultures influence childhood
• reflect on and re-evaluate your own understanding of childhood.

1.3 Who is a child?

Having explored some memories from your own childhood, this section moves on to explore what we mean by childhood, and how we define ‘a child’.

Although the law clearly states that a child is anyone who is under 18 years of age, this is not the way many people would define a child. The way a child is defined depends, to a very large extent, on the social, economic and cultural factors in a society. Factors such as tradition, community ideas, behaviour, physical development, place of residence, or the conditions a child is living in, can all determine whether or not a person is considered a child.

In most societies in East Africa, children are defined by their physical development, ability, responsibilities in the household and social status, rather than by the number of years they have lived. In the biological sense, a child is any person regardless of age and station in life. In a social sense, a woman or an unmarried/uninitiated man may remain a child for ever. A man may only be considered an adult when he marries and produces children. A woman is no longer seen as a child when she has given birth yet she may be considered a ‘perpetual minor’ and not be recognised as an independent individual without reference to her father, husband or male relatives.

The passage to adulthood is frequently marked by ritual or initiation around the time of puberty; however, these practices vary widely. In some cultures, male adolescents are required to be circumcised before they are regarded as adults; however, the age of circumcision can range from under 16 to over 26 years old. Even after this, full adulthood is not attained until marriage and the establishment of a family. In cultures where male child circumcision and female genital mutilation are practiced as initiation into adulthood, once boys or girls are circumcised, they are no longer regarded as children but rather as adults ready to marry and have children, regardless of their age. Examples of such cultures in East Africa are the Bagisu and Kukusabin of Uganda and the Karengin and Babukusu of Kenya. Among the Bagisu and Babukusu, for example, it is offensive to refer to a circumcised male as a boy (Musinde), even when he is as young as 14 years, because this means uncircumcised. The circumcised male builds himself a grass thatched hut (Simba) and no longer lives in the same house as his parents.

Some initiation practices, however, do have other serious consequences. Female genital mutilation is associated with many devastating physical, emotional and psychological implications for girls throughout their lives, particularly in relation to childbirth. It is in recognition of this that there are laws in most countries limiting these practices. You will look more at the importance of the law in Module 2.

Some African families or communities tie the concept of child to the physical ability to carry out specific tasks. These decisions are influenced by any of several factors, which may include economic status, level of education or location (rural or urban). Children from poor families and low educational status are seen in their societies to reach adulthood earlier than those from affluent and educated homes. It is not surprising therefore to find one 12-year-old child being deemed old enough to be an ‘adult’ for purposes of babysitting younger siblings, while another child of the same age may be deemed too young to be left alone, let alone responsible for another child. In some circumstances someone under 18 might have become the head of the household. In summary then, there are widely differing views on the definition of a child even within East Africa.

Activity 1.2: Definition of a child

(a) Child bride in Ethiopia. (b) Going to school Kasese. (c) Fishing in Zanzibar.

Look at the images above and spend at least 15–20 minutes answering the following questions:

1. Would you define the people in the photographs as children?
2. What determines whether you think they are a child or an adult?
3. List the positive and negative consequences for children caused by the way they are defined.

If you are working in a group compare your views. If your answers are different why do you think that is?

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Discussion

Your responses to whether the people are seen as adults or children may depend on your own cultural background and education. If you are not from the same community as the children in the images, you may view them differently from how they are seen within their own community. Factors that determine how they are viewed might include whether or not they are married, whether they have been circumcised, whether they are a boy or a girl, how physically strong they are, whether they have children. The purpose of the activity is for you to start thinking about why there are variations in the way people define a child. It is important in these study sessions that you question your own assumptions about children, how they are defined and how they are treated. This includes the difference between girls and boys.

The extent to which you see the positives and negatives of how children are defined will also be influenced by your own experiences and beliefs. As a health professional you need to understand the harm that children can experience if they are exposed to hazardous work or to marriage too early, and the benefits of allowing a more extended period of protected childhood and education. Because of this understanding, some of these practices such as early marriage, are now prohibited by law or, as in the case of education, actively promoted. Just because something is common or part of a long-established culture does not mean it is acceptable or inevitable.

1.4 How is childhood understood?

In both Western societies and some sections of African societies, childhood is commonly considered to be a period of extended economic dependence, protected innocence and rapid learning through schooling. Childhood describes a period of life when young people are vulnerable both in the physical and mental sense, and hence ‘suffer’ from immaturity, a weak intellect and the inability to make decisions in their own best interests. Children are viewed as relatively helpless and dependent on adult protection and control.

By contrast, in many rural or otherwise traditional African societies, childhood is seen as a period of ‘training’ in preparation for a child’s entry into the harsh world of adulthood. Rather than a period of total dependency in which the child receives adult protection, childhood is understood in terms of obligations of support between generations. So, a child is always a child in relation to his or her parents who expect, and are traditionally entitled to, all forms of support from the child in times of need. Childhood in Africa also tends to be a period of internalised and rigorously enforced obedience to authority. The family is not only responsible for training and socialising children into adulthood, but is also entitled to determine what a child can and cannot do, and what processes need to be undertaken before they graduate to adulthood.

So views on the nature of childhood vary widely. In one place it will be seen as preferable to protect a 10-year-old from economic or domestic responsibilities. In another, such responsibilities are not only the norm, but are deemed beneficial for both the child and the family.

It is clear from this exploration of children and childhood, that these issues are more complex than we often assume. The way we think about them may differ significantly from the way people in other communities think about them. And the way we think will influence our attitudes towards children, and how we treat them. Some of these attitudes in East Africa derive from traditional cultures, while some are beginning to change as communities are increasingly exposed to different ideas.

Childhoods – tradition and change

Below are some examples of traditional and changing childhood experiences in East Africa.

Naming and birth rituals

One of the first activities in all societies is giving a name to a baby. In some cultures, parents choose the name but in others, naming is an important ceremony conducted by elders and followed by feasting. Cultures vary considerably in the way they decide on names: children might be named after the dead, according to birth order, based on events, according to biblical or religious characters, or even celebrities. Whatever the origin, a name carries a lot of meaning and it is a lifelong form of identity. The umbilical cord is so significant in some cultures that a baby will not be taken outside the house until it breaks off. Some cultures in Africa expect the mother to jealously protect the umbilical cord after it breaks off because it is used by elders to prove the true belonging of a baby to a clan. In Buganda, a tribe in Uganda, newly born babies are washed with herbs (kyogero) rather than soap for the first month. The reason is to give a baby a smooth skin, avoid rashes and for the child to be blessed with luck for the rest of the its life.

The role of work

Children often have major work roles within families

In many cultures in East Africa, children, especially those in rural settings, carry the responsibility of fetching water from the well and collecting firewood. They take care of their younger siblings, are in charge of washing dishes, and helping with cooking. Children may also be involved in the cultivation of both cash and food crops. They will be allowed to play only after the parents are satisfied with the work done. However, it is important to note that there are gender differences particularly in the allocation of domestic chores. Girls are normally assigned chores like cooking and taking care of children while boys are more likely to be expected to do chores like slashing the compound.

Discipline and behaviour

If children in Africa openly oppose or question adult opinion, they are considered ‘bad mannered’. They are not allowed to be involved in decisions that concern them, and cannot say no to instructions. Most African communities view the husband as the head of the household who is responsible for making all decisions on behalf of the women and children. Some consider that corporal punishment is the right of parents and that they should not ‘spare the rod and spoil the child’. In many African cultures, children, especially girls, are supposed to be ‘humble’, and are not expected to express their feelings, talk out openly, or oppose adult ideas. Children who do so are considered rebellious or disrespectful.

Education

Basic formal education is compulsory throughout East Africa. In Kenya, for example, all children of primary and secondary school age are entitled to education. However, although there is growing recognition of the importance of formal education within the region, it does create some challenges for children. Many children are still not in school, especially those from poor families. Girls are less likely to attend secondary school, as are children with disabilities. Most children in rural settings walk long distances to school. Many children have to walk to school without adult protection, which often puts them at risk of abduction or sexual assault. Some children go to primary boarding schools from the age of six, which results in separation from their parents as they spend nine months of the year at school and only about three months at home.

The growing importance of education is contributing to a diminished role for community elders who traditionally held a significant role in providing guidance and wisdom. This erosion is being compounded by the internet and social media, which are becoming major sources of information for children, leading to a reduced level of influence by families and local community members.

Responsibility for children

In East African societies, a child traditionally belonged to the community rather than to individual parents. Children, therefore, were a shared responsibility. This meant that many aspects of the child’s training and learning, including, for example, communication about sexual reproductive issues, were the responsibility not only of parents, but also of aunts, uncles and grandparents. However, with changes in familial settings and society today, raising children is more often the responsibility of parents alone. This can create challenges, as they are often too busy to have time for their children. There are increasing rates of parental separation and divorce, and parenting traditions are also eroding. Some children are looked after by house girls who are themselves often very young; others are put in day care centres.

All these factors are having an impact on children’s social, physical, social, emotional and moral development.

1.5 Characteristics of childhood

As you can see from this study session so far, our understanding of childhood varies significantly from country to country and culture to culture. Similarly, our understanding of what children need in order to experience fulfilling childhoods and to grow up healthy varies across cultures. No universal consensus can be found as to what children need for their optimum development, what environments best provide for those needs, and what form and level of protection is appropriate for children at any specific age. These definitions are influenced by personal experience, working practices, local knowledge, law, and cultural influence.

As you consider characteristics of children, you need to recognise that every child is unique and special in its own way. There are, however, some common characteristics of the period of childhood, which should guide you in the way you look at and work with children. Three of the most important are: dependency, vulnerability, and resilience.

It is important to recognise that these three characteristics are influenced by both external and internal factors. Children do not just acquire competencies and skills according to pre-determined biological or psychological forces. Of equal significance are environmental factors and the ability of children to make an active contribution to their social environments. And, of course, childhood is not a uniform period. A 17-year-old has profoundly different needs and capacities from a 6-month-old baby.

1.6 Dependency

Children start life as dependent beings that are totally reliant on others for survival, well-being and guidance. They need to grow towards independence. For example, babies need someone to feed them; a school-going child will need financial and moral support to access education. But as they develop, they become more independent. Such nurture is ideally found in adults in children’s families, but when primary caregivers cannot meet children’s needs, it is up to society to fill the gap.

This is a gradual process that is influenced both by the biological changes taking place, and also the social, cultural, economic and political environment in which the child is living. Children may have many responsibilities put upon them at a young age. As children grow up and acquire both the capacity and the desire to take greater responsibility for themselves, they seek greater autonomy and more involvement in decisions affecting them. This process of gradual development and emergence from dependency is known as the child’s evolving capacities.

1.7 Vulnerability

The fact that children are still developing means they are especially vulnerable to harm. For example, they are more at risk than adults from poverty, inadequate health care, poor nutrition, unsafe water, inadequate housing, environmental pollution or violence. Because of this vulnerability, adults have responsibilities to provide appropriate protection to ensure their safety and well-being. This includes parents and other caregivers, professionals working with children, and local communities as well as governments.

The degree of vulnerability for each child varies according to the age of the child, their individual characteristics and the circumstances they live in. For example, a teenager who is visually impaired is at a higher risk of rape than a teenager who is not. Very young children are particularly vulnerable when they are sick because their small bodies will dehydrate very quickly. Children, especially girls, can be vulnerable to rape, child labour and other forms of abuse because of their living environment. Children living in slums may be particularly vulnerable to poor hygiene and sanitation, pollution, and exposure to violence. The culture of silence and secrecy surrounding sexuality in many African cultures exposes children to sexual abuse, and poor management of body changes.

1.8 Resilience

Although children are both more dependent and more vulnerable than adults, they can display resilience in the face of adversity, risks and challenges, such as family problems, serious health problems, or workplace and financial stresses. In other words, children are not simply passive victims of what happens to them. They can exert influence and shape their own lives. It means that children are not always overwhelmed when they experience hardship but can recover or bounce back. Children do not all react in the same way to traumatic and stressful life events. A number of factors contribute to resilience. Children are most likely to display resilience if they have caring and supportive relationships within and outside the family. These relationships can offer love and trust, provide role models, and provide encouragement and reassurance. A child’s culture might also have an impact on how he or she deals with adversity. Resilience is not only influenced by the characteristics of a child (including age, temperament, sense of humour, reasoning, sense of purpose, belief in a bright future, and spirituality) it also involves behaviours, thoughts and actions that can be learned and developed by any child.

Children’s individual responses to adversity can be understood in terms of ‘risk’ as well as ‘resilience’. Risk refers to factors in a child’s life that mean they are more likely to suffer harm. Risks might include poverty or war, harassment and abuse, neglect and parental problems, all of which inhibit a child’s healthy development.

As a health worker, it is important to be sensitive to all these characteristics of children. You need not only to understand and respond appropriately to children’s vulnerabilities and to their evolving capacities, but also to recognise the competencies, skills and strengths they bring to their own lives and to the decisions that affect them. The following study sessions will look in more detail at the particular needs of children at different ages, and how those needs are recognised as rights of children.

Activity 1.4: Dependency, vulnerability and resilience in African childhoods

A girl caring for a younger sibling

Boys working on the land

1. To what extent do you think that these children are recognised as dependent?
2. To what extent do you feel they are vulnerable? What harm might they be at risk of in their daily lives?
3. What factors might result in these children having resilience to protect themselves against the risks they might experience?

Compare your own answers with the suggestions at the end of the study session.

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1.9 Summary

This session was designed to introduce you to ideas about children and childhood, and to enable you to examine some of your attitudes towards children and childhood. In the session, you have learned that:

• International agreements and national law state that a child is a person up to the age of 18. In practice, the definition of a child varies significantly across different cultures. Economic, social and cultural factors all contribute to how different communities define who is a child.

• Accepted cultural practices around childhood can be important and positive but this should not be taken for granted. Some practices may be harmful to children, and practitioners such as health workers should be prepared to see what is in the best interest of children.

• The period of childhood is treated very differently in different cultures. In East Africa, traditionally it has been viewed as a period of training for adulthood, although that is beginning to change as more children are in formal education. It is now increasingly viewed as a period of extended dependency in which children are entitled to protection.
• Childhood is characterised initially by dependency and vulnerability, but as children grow up they become less dependent and strive for greater autonomy. They gradually develop the capacity to contribute to decisions that affect them, and to contribute actively to their social environments.
• Children are not passive victims of risk and harm. They can acquire resilience to deal with adversity. Factors that contribute to resilience include being healthy, growing up in loving families, and safe communities.

1.10 Self-assessment questions

1.11 Answers to activities

2 Child development

Key words: benchmarks, development, evolving capacities, milestones, well-being

2.1 Introduction

In session 1 of this module, you explored how a child is defined in different cultures and how childhood is understood. In this session we will explore in more detail the different stages of development that a child goes through as they mature from birth to 18 years. Childhood is a period of very rapid development. Although there is growing acceptance internationally that childhood lasts until a child is 18 years old, obviously the capacities of a small baby are very different from those of a 17-year-old. The session will examine the different stages of children’s growth and development. It will also explore the fact that, although all children pass through common processes of development, the ages at which children develop different capacities is informed not just by biological and physiological factors. Social, cultural, economic and individual factors also play a significant role in determining how well children are able to grow up. The session will provide guidance as to what to expect of children at different ages, and explore your role as a health professional in supporting children’s development.

2.2 Learning outcomes

At the end of this study session, you will be able to:

• define and use correctly all of the key words
• describe the major stages and characteristics of child development
• describe the factors that influence child development
• apply your understanding of child development to your role as a health worker.

2.3 Recognise why an understanding of child development is relevant and important for health workers

We will come back to these questions later in the session.

2.4 Why understanding stages of child development is important

From the moment of birth, a baby is in the process of extraordinarily rapid growth and development. As they grow up, children develop many different capacities. These capacities influence how they communicate, make decisions, exercise judgement, absorb and evaluate information, take responsibility, and show empathy and awareness of others. It is recognised in all societies that there is a period of childhood during which children’s capacities are perceived as developing or evolving rather than developed or evolved. When babies are born, they are completely dependent on their caregivers for food, warmth, shelter, cleanliness, and protection from harm. Nevertheless, even small babies are capable of communicating their needs. Through crying, facial expressions, body language, eye contact, they are able to engage with those caring for them, and to convey their feelings, moods and needs. As children grow up they gradually acquire an increasing range of capacities and skills and are able to take increasing control over their own needs.

As a health worker it is important to have some understanding of this process of children’s development. This will enable you to assess whether or not a child is developing appropriately, to understand what they are and are not capable of doing, and to respond to each child’s needs and rights more effectively.

2.5 The different stages of development

The first two years

From birth through to the second year of life is the fastest period of a child’s development. During this time, there are a number of major milestones that children pass through as they achieve new skills and competencies. Although it is possible to provide a general guide as to when these milestones are reached, you need to recognise that every child is different, and will not necessarily progress at exactly the same speed. Many factors will influence the child’s development. Children need emotional warmth and stability, freedom from hunger, and a safe and secure environment in which to learn and to be stimulated, with opportunities to explore and discover. If these needs are not met, the child’s development can suffer.

The pre-school years

The period between 2–5 years is a period of discovery and emerging independence for children when they will begin to explore new forms of play and new environments. As with babies, children do not all develop at exactly the same rate, but there are some benchmarks that provide a general guideline of when children will acquire new capacities, behaviours and skills. It is probably less helpful to describe these processes as milestones as they happen more gradually than in the first two years of life.

Middle childhood 6–10 years

Progress during the ages of 6–10 years in the major areas of development is more gradual than in the first few years of life.

Adolescence

Between 11 and 18 years of age, young people undergo rapid changes in body structure and physiological, psychological and social functioning. Growing research on the adolescent brain has provided a better understanding of typical adolescent development. Even though changes in puberty follow a predictable sequence, there is a great deal of variation between adolescents, in both the timing of changes and the quality of the experience. Hormones are the primary influence during these years and enable the transition from childhood to adulthood. However, gender as well as the life experiences of the child will affect their development – what kind of family and community they live in, the attitudes of people around them, whether they are living in poverty or a more affluent family.

2.6 Understanding stages of development

2.7 Promoting children’s evolving capacities

We have learned that it is possible to identify broad patterns of development that take place across given age spans. However, children’s evolving capacities are significantly affected by their particular experiences. As you saw in Study Session 1, the process of gradual development and emergence from dependency is known as the child’s evolving capacities. There is growing recognition that children’s development is not a pre-determined process that takes place automatically. Rather it is a cultural process, which is affected by the social, economic and cultural factors in the life of the child, as well as the opportunities available to them.

It is necessary to build an understanding of what factors are known to have a positive or negative influence on children’s lives, and which contribute to their development or evolving capacities (see Figure 2.1).

Figure 2.1 Factors that influence a child's evolving capacity

2.8 Creating the necessary physical environments for children to thrive

Children are entitled to grow up to reach their optimum development. Adults, therefore, have a responsibility to create the necessary environments to enable this to happen. This involves not only parents, but also professionals such as teachers and health workers, local communities, and governments. But what does this look like?

Without access to basic standards of physical care and provision – such as food, shelter, clothing, health care, and clean environments – children’s development will suffer. Many physical and intellectual disabilities are linked with material factors such as poor diet, environmental pollution, and exposure to risk of accidents, and are made worse by inadequate access to health care. For example, iodine deficiency in pregnant women can lead to severe intellectual disabilities in children. Pre-natal and post-natal health care as well as health care for children in general is important for their development.

2.9 Creating the opportunities for development of children’s capacities

Family life

Children are most likely to thrive if they are brought up in a family environment and an atmosphere of happiness, love and understanding. The family is the group in society most capable and responsible for meeting the needs of children. Families in different cultures can take many different forms, and they can all provide quality care for their children. In Africa, for example, it is often argued that it takes a village to bring up a child, but the importance of stability and the need to be loved and valued are universally accepted for children in all cultures. There is growing evidence of a direct relationship between children’s development outcomes and the quality of care they receive.

Education

Education should provide all children, including those with disabilities, with the opportunities to develop optimum levels of competence to be able to play a full part in their society, as well as to achieve their personal ambitions. However, the actual experience of education for many children is very different. Schools often fail to provide an effective learning environment. They are often authoritarian, poorly managed, inadequately resourced or offer a curriculum that is irrelevant to children’s lives. Many schools are too focused on testing and exams. Research evidence compiled by the Africa Child Policy Forum, a pan-African organisation, also paints a bleak picture as to the levels of violence perpetrated against children, particularly girls, both within schools and when travelling to school. Too often, children are beaten, threatened and humiliated by teachers. Girls may be sexually violated or faced with demands from teachers for sex in return for grades. Children cannot learn effectively in abusive environments (ACPF, 2001).

Play

Play is essential to the health and well-being of children. They learn through play. In addition, play:

• promotes creativity, imagination and self-confidence
• contributes to children’s physical health
• builds social skills
• provides fun and pleasure
• contributes to building children’s capacities to negotiate, achieve emotional stability, resolve conflicts, and make decisions
• enables children to explore the world around them, experiment with new ideas, roles, and experiences.

So, you can see that it is a very important part of children’s development. However, many children are denied the opportunity for play. Parents and teachers often fail to recognise the importance of play in children’s lives and view it as time being wasted. Many children with disabilities are denied any real chance for play as a result of discrimination, social exclusion and the physical barriers imposed by the environment. Girls, in particular, are denied chances to play because of the burden of domestic work that falls on them. Excessive formal demands on children’s time, whether through paid employment or long hours spent at school and doing homework, can also deny children the chance to play.

2.10 Respecting children’s capacities to participate

There is a tendency across East Africa, as in other regions of the world, to deny children the opportunity to take responsibility for decisions and actions that they are competent to take. Children are expected to listen and do as they are told. They are not expected to contribute their own ideas, influence their own communities, or contribute to decision-making. Yet they are often capable of understanding and engagement far beyond the assumptions that adults have. For example, it is a common concern of children that health professionals fail to acknowledge their ability to be involved in decisions about their own health care. However, children should be encouraged to take responsibility and participate in those decisions and activities over which they do have competence. And like adults, children build competence and confidence through direct experience – doing things rather than just being told about them. It is a ‘virtuous circle’ – in other words, the more children participate the more skills they acquire and the better they are able to participate in the future. The more children are recognised and encouraged to be involved in decisions and take responsibility, the more they will acquire the capacities to do so effectively. For example, you can actively engage children and young people in discussions about how to protect themselves from infection, managing pain relief, approaches to sexual health or how to change dressings.

2.11 Balancing participation and protection

Although it is important to respect children’s capacities to take responsibility for their own lives, it is also important to recognise that children are still developing and that they are entitled to protection to ensure they are not forced to take on adult responsibilities too early. No universal rules exist to determine what level of protection children need at any given age or stage of development. Indeed, if you look at the situations to which children are exposed in different cultures, you will see that it varies widely indeed. These differences highlight the fact that, to a large extent, children develop capacities to cope with challenging situations in accordance with the opportunities they are given and the expectations placed upon them.

There is no simple way to decide the levels of protection needed by children or to decide the most effective means of providing protection. Respect for children’s evolving capacity to take responsibility for decision-making must be balanced against their relative lack of experience, the risks encountered, and the potential for exploitation and abuse. It is also important to recognise that protection is not just a one-way process, with adults as protectors and children as recipients. The reality is more complex: children can contribute significantly to their own and other children’s protection.

The extent to which children are likely to be at risk of harm from any potential activity or situation will be affected by a number of factors:

• Whether the expectations of children are widely similar within the community – for example, in a society where all girls are expected to undertake child care responsibilities from an early age, or where young boys or girls are expected work on the land, the negative impacts on the child are likely to be far less than if this was being demanded of a child in a society where this was not normally expected. However, this needs to be balanced against the harm that might be caused by denying girls or boys opportunities for education and play.
• Level of support provided by the key adults in the child’s life – for example, where parents provide appropriate and positive guidance and encouragement to support the child’s engagement in a particular activity and help a child to learn from its mistakes, rather than using threats and punishment.
• Degree of control experienced by the child in coping with the situation – for example, if children feel they are in control of a situation, and can make informed choices about what they are able to undertake and how, this will help them feel confident and better able to cope in the future.
• Child’s personality and strengths – the child’s individual personality will influence how much responsibility he or she can take. Children who are healthy, strong, self-confident and with high self-esteem can cope better with adversity and challenges.

2.12 Summary

1. Child development consists of a range of different types of development – all are important and interlinked.
2. Every child should have the opportunity for the fullest possible cognitive, social, emotional and physical development. This requires that the needs of children are supported and fulfilled, both in terms of their well-being at the present time and in terms of their future potential.
3. Children go through stages of development that take place at roughly similar ages. It is important to understand these levels of development in order both to identify if the child is experiencing problems or not developing appropriately. Understanding these stages also helps adults to respond appropriately to children at given ages.
4. Development is not a given. Many factors can contribute to or impede the extent to which children are able to develop to their optimum potential, for example:
   • physical, psychological, social, economic, environmental and cultural factors, as well as the family, peers, community, society, and government
   • children’s own individual capacities, context and culture, and their active involvement in decisions affecting their lives.
   The role of families, communities and governments is, therefore, very important in providing an environment in which children can develop fully.
5. One of the challenges for parents and caregivers is to balance the child’s right to take growing responsibilities for decisions affecting them as they develop with their continuing right for protection from harm. Over-protection of children denies them the opportunity to begin to understand risk and how to make safe choices. On the other hand, under-protection can expose children to dangers that they are not fully aware of or sufficiently experienced to handle.

2.13 Self-assessment questions

2.14 Answers to activities

3 Children’s needs and rights

Key words: interdependence, needs, realisation, rights

3.1 Introduction

In Study Session 2 of this module, you will have learned about child development, and the stages that all children go through from the time of their birth to the time they reach adulthood. Children have needs that change over time, with age, maturity and experience. All societies recognise that children require nurturing and protection from harm in order to develop and grow as healthy people who are capable of reaching their full potential. Parents or guardians have the responsibility to ensure that children are adequately taken care of and enabled to thrive.

In this study session, we will look firstly at the needs that children have if they are to grow up healthily. It will focus both on those needs that are common to all children, and also how the fulfilment of those needs differs depending on a child’s age and other circumstances. We will also discuss how human rights, and children’s rights in particular, provide the basis for ensuring that these needs are met.

3.2 Learning outcomes

At the end of this study session, you will be able to:

• define and use correctly the key words above
• understand what needs children have
• recognise the importance of understanding how to meet children's needs in ways that are appropriate to their ages and abilities
• explain the relationship between children’s needs and children’s rights.

3.3 Understanding children’s needs

We will come back to this activity at the end of the session.

What is a need?

A need can be described as something that is necessary, very important, or essential for a person to live a healthy and productive life. Needs are different from wants. Wants are things that are desirable, but not necessary or essential. Children, for example, have a need for food, because without food, they will not grow or be healthy, will be unable to learn well, work or play, and ultimately will die. People need food to survive. On the other hand, a person may want a particular type of food, preferring perhaps to have fish rather than vegetables. However, although they may want fish, they do not need fish to survive. Food is a ‘need’. Fish is a ‘want’.

Another way of distinguishing between needs and wants is that people have a limited number of needs. It is usually possible to identify all of a person’s needs, whereas people can have an infinite number of wants, which differ from person to person.

Human needs can be categorised in many different ways. Figure 3.1 shows one way of categorising them.

Figure 3.1 Categorising human needs

• Physical needs: shelter, health care, water and sanitation, protection from environmental pollution, adequate food, adequate clothing, and protection from violence, exploitation and abuse, exercise for strength-endurance-coordination, opportunities for development of physical skills.
• Social, economic and cultural needs: knowledge of and respect for one’s own language, religion and culture, stable social and economic environment, access to appropriate guidance and support, access to quality education, play and friendships, freedom from discrimination and prejudice, meaningful empowering work, and opportunities for service.
• Psychological, including intellectual and emotional needs and the need to be able to exercise choices: a stable and loving family environment, a sense of belonging and identity, age appropriate information, stimulation, and opportunities to be listened to and taken seriously, models for problem solving and critical thinking, a sense of worth, being valued by others, being able to contribute to or positively affect your world, opportunities to make choices and develop cognitive talents and creative potentials.
• Spiritual needs: exploration, understanding and appreciation of the nature of life, humankind and the universe – of what lies beyond time and material world, and the possibilities to connect with the infinite and ultimate.

Human needs can often be categorised under more than one heading. A child has, for example, a need for appropriate health care, which is a social need. At times, this need may be related to serious injury or illness, which is a physical need, or related to a mental health condition, which is a psychological need. A person may rely on prayer during a period of illness, exercising the need for spiritual support.

All children have the same needs. However, the way they require those needs to be met will be different in different circumstances, and at different stages of their development. For example, while children of all ages need emotional care and support, the form that this will take will necessarily be different for a 2-year-old than a 17-year-old. All children need opportunities to learn but a child who is blind will need provision of education that is differently adapted to that provided to a sighted child. An adolescent will need greater opportunities to make independent choices than a 5-year-old.

If needs, such as food, good sanitation, education and access to health care are not met, children will not be able to enjoy their childhood, or achieve their optimum level of development as they grow up.

Interdependence of children’s needs

All these needs are inter-related and equally important. As a health worker it is important to know, for example, that a child’s emotional needs are as important as his or her physical needs. Very often, emphasis is placed on physical needs, whereas a child’s need for praise, to play, or to have the opportunity for increasing levels of responsibility is disregarded.

Children’s needs should, therefore, be considered together. In order to ensure that children can reach their full potential, attention must be paid to how physical, psychological, social, economic, cultural, and spiritual factors interact and impact on children’s health and well-being.

Responding to children’s needs as they grow older

We have already discussed the idea that children have different needs at different ages. The concept of ‘evolving capacities’ was introduced in Study Session 2 of this module. It recognises that as children grow, they are able to take increasing responsibility for their own health in line with their physical, emotional, cognitive and social development. For example, a pre-school child has only a limited understanding of cause and effect and will need adults to set safe limits. By adolescence, he or she is capable of engaging in abstract reasoning and should therefore be allowed greater independence in decision-making.

It is important to note that these changes do not take place at the same age and same rate for all children. Children’s talents, their environment, the level of support they receive, opportunities for creative and active involvement, as well as cultural expectations will all influence their capacities for decision-making and taking responsibility for their needs.

Other factors, such as, for example, gender or disability, will have a significant effect on how children’s needs must be met. It will also often affect the extent to which they are met.

Privacy, respect for confidentiality and capacity for decision-making are needs that become more and more important to older children. As children experience puberty, they may become sexually active and develop emotional attachments beyond the family. They need information relating to sexual and reproductive health. Very often young people look to their peers to obtain information and they develop their own ideas about relationships through observing others. Some of this may be helpful, but some of it may be based on myths or stereotypes. Parents, caregivers and teachers should be a source of age-appropriate information about sex, relationships and growing up to help young people become more self-aware and better informed, and allowing them to make healthy choices. However, too often they fail to provide young people with the information they need. They may provide incorrect information or are simply in denial that children are sexually active. A consultation with young people undertaken for the development of this curriculum highlighted widespread concern that they are not provided with the information they need.

In summary then, when working with children and young people, you need to take account of their changing needs – for information, for advice, and for recognition of their emerging capacity to be involved in decisions affecting them, including their health care. These needs are equally important for boys and girls. They are also as important to children with disabilities as they are to all other children: while other children are developing greater capacity for independence, the need to be able to ‘grow up’ can be particularly difficult for an adolescent with disabilities, for example, who is necessarily reliant on others.

3.4 Understanding children’s rights

The relationship between needs and rights

You have learned that children’s needs are universal. They apply to children in all socio-economic and cultural environments. It does not matter whether a child lives in sub-Saharan Africa, Brazil or Sweden, he or she has needs for a stable family life, adequate food, education, and respect for his or her abilities. You have also learned that the fulfilment of all needs is essential for children’s optimal health and development, and that they are mutually inter-dependent: none take precedence over another.

However, children’s needs cannot be met without adult support. Their youth, vulnerability and lack of power mean they are dependent on the adults who have responsibility for them. This places obligations on adults to create the necessary conditions that will ensure this happens.

Acceptance of the idea that adults have responsibilities or obligations to meet children’s needs has led the international community – all the governments of the world – to accept that children are entitled to have their needs met. In other words, children have rights.

You will study the detail of children’s rights in Module 2

The difference between a need and a right is that a need describes the conditions required for children to thrive. A right is a recognition of the child’s entitlement, by virtue of being a child, to have that need fulfilled. This, in turn, places a specific obligation on adults at all levels of society to take the necessary action to ensure that those rights are implemented for every child. For example, action to protect the rights of the individual child, such as family life, access to health care or education, but also the consideration of public policies that potentially impact on children’s health and development – housing, transport and poverty. Figure 3.2 shows how children's rights are recognised and fulfilled.

Figure 3.2 How children's rights are recognised and fulfilled

Rights are based on the shared recognition of the conditions that are fundamental to children’s dignity, identity, health, development, and well-being. They are universal and applicable to every child in all contexts and cultures. All rights have equal importance. Everyone is equally entitled to human rights without any discrimination. Some rights can only be fulfilled if governments and other responsible people provide certain conditions – for example, health and education services. Other human rights are described as freedoms – for example freedom to choose your own religion. Everyone is entitled to enjoy their rights without undue interference.

Adults’ and children’s rights

In the same way that adults and children’s needs have similarities and differences, children have rights, which are both similar and different to adult rights.

In summary then, it is important that you, as a health worker, understand the relationship between needs and rights. Needs and rights are not the same, but they are closely related. Many needs are enshrined in rights and, children in particular, have a right to have their needs met. There are international agreements about children’s rights that you will look at in detail in Module 2. Rights are important in promoting optimal health and development of all children. The following table provides an overview of the differences between needs and rights:

3.5 The relationship between rights and responsibilities

3.6 Summary

1. All children have needs, which are physical, psychological, social, economic, cultural and spiritual in nature. Failure to meet the needs of children will affect their development and their ability to participate and contribute to society, both in their childhood and later in life. Meeting children’s basic needs is essential for their optimal health and development. Although all children have the same needs, the way in which they will be met will differ according to their age and understanding.
2. Recognition of the universal needs of children has led to a commitment across the governments of the world to introduce measures to meet the needs of children. It has been accepted that children are entitled to have their needs fulfilled: in other words, they have rights. Rights are based on deep-rooted understandings of how individuals should live together in a society, so that everyone is treated fairly and with human dignity and respect. Adults and children have rights. Many of these rights are the same or similar, but because children are more vulnerable and dependent, they do have additional protection rights. These rights are recognised in specific international agreements.

3.7 Self-assessment questions

4 Answers to self-assessment questions

Study Session 1

Study Session 2

Study Session 3

Bibliography

ACPF (2001) Violence Against Children in Africa, The African Child Policy Forum. Available at www.africanchildforum.org/site/images/stories/ACPF_violence_against_children.pdf (Accessed 26 January 2014).

Boyden, J. and Mann, G. (2005) ‘Children’s risk, resilience, and coping in extreme situations’, pp. 3–26 in Ungar, M. (ed.) Handbook for Working with Children and Youth: Pathways to Resilience Across Cultures and Contexts, Thousand Oaks, CA, Sage.

Lake, L., Proudlock, P., Nhenga-Chakarisa, T., Mahery, P. and Lansdown, G. (2011) ‘Module 1: Child health and children’s rights’ in Lake, L. and Proudlock, P. (eds) Child Rights and Child Law for Health Professionals: A Short Course, Children’s Institute, University of Cape Town and International Institute for Child Rights and Development, University of Victoria.

Lansdown, G. (2005) The Evolving Capacities of the Child, UNICEF, Innocenti Research Centre, Florence.

Lansdown, G. and Wernham, M. (2012) Are Protection and Autonomy Opposing Concepts?, International Planned Parenthood Federation. Available at www.ippf.org/system/files/ippf_right_to_decide_03.pdf (Accessed 3 March 2014).

Save the Children (2008) The Child Development Index: Holding Governments to Account for Children’s Well-being, Save the Children. Available at www.savethechildren.org.uk/sites/default/files/docs/Child_Development_Index%281%29_1.pdf (Accessed 26 January 2014).

United Nations (n.d.) What are Human Rights?, Office of the High Commissioner of Human Rights. Available at www.ohchr.org/EN/Issues/Pages/WhatareHumanRights.aspx (Accessed 26 January 2014).

Acknowledgements

This is one of five modules in the CREATE curriculum on children’s rights education for health care workers in Ethiopia, Kenya, Tanzania and Uganda. It has been developed through a partnership between the MS Training Centre for Development Cooperation based in Arusha in Tanzania, The Open University in the UK and Child Rights Education for Professionals (CRED-PRO), an international programme committed to strengthening the understanding and application of children’s rights in professional practice.

We would like to thank the Oak Foundation in Geneva for its generous funding for the development of this programme and OPITO for additional funding to support advocacy and engagement activities.

CREATE was produced by a team of experts from the four participating countries, including representatives from government, academia, professional practice and the NGO sector. They were led in Child Rights Advocacy by Gerison Lansdown from CRED-PRO and trained and supported by experts in blended learning pedagogy from the CREATE team at The Open University. Many thanks to the governments and agencies who enabled them to participate. The authors are:

• Humphrey Onyango Wandeo, Children Services, Government of Kenya
• Kellen Karanu, Deputy Director of Children’s Services, Government of Kenya
• Kabanda Obed, MD, Executive Director, Action for Community Development (ACODEV), Uganda
• James Kaboggoza Ssembatya, Assistant Commissioner/Children’s Affairs, Ministry of Gender, Labour and Social Development, Uganda
• Hajat Safinah Kisu Museene, Principal, Jinja School of Nursing and Midwifery, Uganda
• Sarah Bunoti, PhD, Lecturer Department of Psychology, Faculty of Education, Kyambogo University, Uganda
• Stella Ayo-Odongo, Executive Director, Uganda Child Rights NGO Network (UCRNN), Uganda
• Yodit Tesfaye, Child Protection and Promotion Officer, Ministry of Health, Ethiopia
• Samrawit Tassew Mekuria, MD, Medical Education Team Coordinator, Ministry of Health, Ethiopia
• Stephen Ataro Ayella, MD, Save the Children, Tanzania.

The contributors of original material are:

• Gerison Lansdown, Co-Director, Child Rights Education for Professionals
• Andy Rixon, Lecturer in Faculty of Health and Social Care, The Open University, UK
• Tony O’Shea-Poon, Head of Equality and Information Rights, The Open University, UK
• Anna Peachey, Deputy Director (Academic) for International Development, The Open University, UK.

We would like to particularly acknowledge the additional material for this curriculum that was produced by TAMASHA in collaboration with District Youth Networks in Temeke (Dar es Salaam), Arusha and Magu. This was research conducted with young people by young people in Tanzania on their experiences of health care.

We would also like to thank those who acted as critical readers for the CREATE curriculum:

• Kate McAlpine, Freelance Consultant, Caucus for Children’s Rights, Tanzania.
• Els Heijnen-Maathuis, Technical Adviser Education, Save the Children International (Uganda)
• Richard Mabala, Director, Tamasha
• Dr Terry DiPaolo, Freelance Consultant
• Dr Helen Yanacopulos, Senior Lecturer in International Development, The Open University, UK.

The CREATE Team are:

• Gerison Lansdown, Co-Director, Child Rights Education for Professionals
• Andy Rixon, Lecturer in Faculty of Health and Social Care, The Open University, UK
• Tony O’Shea-Poon, Head of Equality and Information Rights, The Open University, UK
• Lindsay O’Dell, Senior Lecturer in Faculty of Health and Social Care, The Open University, UK
• Lesley-Anne Long, Deputy Director (Academic) for International Development (until April 2013), The Open University, UK
• Anna Peachey, Deputy Director (Academic) for International Development (after April 2013), The Open University, UK
• Ellen Scott, Senior Project Manager for International Development, The Open University, UK
• Alison Robinson, Senior Operations Manager for International Development, The Open University, UK
• Gail Vardy, Projects Coordinator for International Development, The Open University, UK
• Delphine Mugisha, Training Coordinator, MS-TCDC, Tanzania
• Steven Ndosi, Manager for Cross Cultural Department, MS-TCDC, Tanzania
• Anna Mbwambo, Programme Assistant, MS-TCDC, Tanzania.

Photographs and illustrations:

• Courtesy of Action for Community Development (ACODEV)
• Child-to-Child in collaboration with Unicef Ethiopia, March 2010.

All editing by Learning and Teaching Solutions at The Open University.

The opinions expressed in the CREATE materials are those of the authors and do not necessarily reflect the views of the donor organisations whose generous support made the production of this material possible.

Grateful acknowledgement is made to the following sources:

Cover image: Children at a vaccinations clinic, Yasmin Abubeker/DFID. This file is licensed under the Creative Commons Attribution-ShareAlike Licence http://creativecommons.org/licenses/by-sa/3.0/

Illustrations

Page 12: (a) Child bride in Ethiopia, ©Sean Sprague/Alamy; (b) Going to school Kasese, ©cowyeow/Daniel Rosenberg; (c) Fishing in Zanzibar, ©iStockphoto.com/Gary Tognoni; Page 14: Child working in community. This file is licensed under the Creative Commons Attribution-NonCommercial-No Derivatives Licence http://creativecommons.org/licenses/by-nc-nd/3.0; Page 19: (top) Child looking after brother, ©iStockphoto.com/Britta Kasholm-Tengve; (bottom) Children ploughing farm field, ©iStockphoto.com/nwbob.

Every effort has been made to contact copyright holders. If any have been inadvertently overlooked the publishers will be pleased to make the necessary arrangements at the first opportunity.