In considering children’s health, the need to consider the child’s age, stage of development and social circumstances is of prime importance. The child’s developmental stage will influence the way he or she perceives their world, the way that he or she interacts with others and his or her ability to adjust and adapt to changing health and social situations. Knowledge of child development therefore, provides vital clues for those working with children about the biological, psychological and social influences on a child’s life, and the threats and dangers to children’s health associated with everyday living. The better we understand the particular needs of children at varying developmental stages, the better we can provide care that will be acceptable and less frightening to the child.

The National Service Framework (NSF) for Children (Department of Health (DoH) 2003) contains standards for all groups working with children in health and social care settings and will be central in steering the way that services develop. This document enshrines the basic principle of making services suit the needs of children and states that the care we deliver to children must be genuinely ‘child centred’, wherever that care is delivered. For this to happen, those working with children across health, education and social care settings must ensure that children’s wishes and experiences are taken into account (Smith 2003) and understand that children need very different support and facilities at different developmental stages. These principles are carried forward in an educational context in ‘The Children’s Plan’ (Department for Children, Schools & Families 2007).

Initially, the major influence on infants and very young children comes through the family members with whom the child most frequently comes into contact (Bukatko and Daehler, 1998 and Mountain, 2002). As the child matures and starts attending nursery and school, the social circle of the child extends, providing new contacts and new challenges to the ‘established order’ within the child’s life. For the middle-school-aged child, this extended social network widens to include school friends and others outside of the family.

Many of these contacts will present new intellectual, cultural and physical interests and challenges for the school child; they may be involved in planning activities to help children perform and acquire new skills. Children will also find that as they mature, they have very different expectations placed on them, which will be formal and informal in nature (Bukatko & Daehler 1998).

The early primary school years see young children develop social skills such as sharing, turn taking and participation in group activities. It is the age where rules and rituals are learnt through play and structured activities; the need for conformity in middle school years being a central characteristic within the games that are so important to children (Bukatko and Daehler, 1998 and Piaget, 1968). The later primary/middle school years are a time of gang membership and club membership with secret passwords and rituals that initiate and regulate the order of membership.

Schaffer (2004) proposes that children’s groups usually adopt:

It is easy to see how a peer culture develops and how individual youngsters take on an individuality ascribed by their peers. Shaffer (2004) suggests this may conflict with and differ from the culture shared with adults and questions the assumption that young people acquire knowledge solely from adult family members, as ‘peer collaboration’ is clearly a central feature of maturity and knowledge acquisition. Ladd et al (2008) studied 5–12-year-olds and found that whereas during periods of rejection, children exhibited negative or negligible growth in school participation, when non-rejected, they manifested confidence and positive growth.

Rules are an important part of everyday life. They make it possible for us to get along with one another. If children do not learn how to behave, they will find it difficult to get on, both with grown-ups and with other children. They will find it hard to learn at school, will misbehave and will probably become unhappy and frustrated (Royal College of Psychiatrists 2008). Discipline is also acquired through group and team play and, increasingly, self-discipline must develop if children are to be included in group activities. Leaders are appointed who direct others and roles and rules are established which the school child will be expected to respect. The child is exposed to umpires, referees, school prefects and monitors and other figures of authority who will control and direct activity with authority.

However, not all school children adapt well to their changing world. Spender et al (2001) warn that many children will experience difficulty with these expectations and that not all school children are able to adapt to the challenges placed on them, often resulting in the child refusing to attend school. School refusal is a common phenomenon, which often presents with physical symptoms such as:

Interestingly, such symptoms often subside following the decision to allow a child not to attend school (Rutter 1999, Spender et al 2001). The ‘peak times’ for school refusal are at transition periods and are most commonly seen in 5 and 11 year olds, when children start or change schools.

Spender et al (2001) also noted that up to 5% of school children will present with other disruptive or behaviour problems serious enough to cause dysfunction and referral. Conduct disorder is a well-reported problem for many school children and is diagnosed when the young person can be assessed as displaying different types of misbehaviour, typically three from a prescribed list (Spender et al 2001) and may result, if untreated, in the child being excluded from school. This is an extremely undesirable situation as there are proven links between conduct disorder and childhood truancy which may result in future criminal activity (Mental Health Foundation 1999).

Between 5 and 12 years of age, children rapidly develop strength and balance. Exercise and physical activity is essential for the child’s growing sense of coordination and for muscle and bone development. Much of the school child’s exercise and physical activity will be experienced through school activities and physical education remains a key component of middle school curriculum. There is, however, much concern that school children in the 21st century engage in less physical activity than children of previous decades.

It is suggested that school children are increasingly assessed on cognitive abilities such as numeracy and literacy skills, leaving less time in the curriculum for physical activity (Napier et al 2000). Also, social activity out of school appears to be restricted as school children become more technologically proficient and TV, video and computer games become all consuming. Although these technological games may keep young people occupied for great lengths of time, they certainly result in long periods of inactivity. In fact, obesity and other conditions associated with inactivity such as lethargy and constipation are increasingly prevalent within the middle school population.

The older school child enjoys being creative, enjoying puzzles and quizzes and is able to engage in complex games of fantasy. Stories are enjoyed and reading and numerical skills enable the child to understand more of the world about them. School children also have a developing interest in their bodies and their bodily functions, a factor that has been incorporated into health-enhancing activities. For example, this awareness of the natural interests of children has been successfully applied to teaching about health matters in school as well as leading to the creation of ‘clubs’ and summer schools for children learning how to cope with conditions such as diabetes and asthma.

Between 5 and 12 years, children have the ability to develop a strong sense of citizenship. This is a natural extension of them becoming able ‘navigators’ in the world outside of the home; they develop a strong sense of independence and justice and a developing sense of morality. Schaffer (2004) suggests that children develop morally through social and intellectual means and friendships often act as ‘peer sociometrics’, providing a measure as to how well children are developing moral awareness. However, it should be noted that although some children are naturally shy, prolonged reluctance to go to particular places or to meet particular people may be a sign of bullying or abuse (DoH 2008a). Moral development differs according to how well accepted children are by their peers and how well they engage with those around them. Schaffer (2004) lists characteristics demonstrated by popular children with a strong sense of moral awareness compared with rejected children and children who have suffered neglect and discusses the difficulties children experience internalising and externalising their individual experiences through interaction with their peers. Williams et al (2007) study the developmental course of interpersonal aggression up to and during adolescence. Such interactions are fundamental to the way that children start to formulate ideas about future intentions and career aspirations, largely based on the roles, opinions and expectations of those around them (Schaffer, 2004, Piaget, 1968 and Flatman, 2002).

Napier et al (2000) recognise the ways in which education and play are essential prerequisites to the school child in developing confidence and self-esteem. They adopt a constructivist stance in suggesting that school children play a very active role in their development and oppose views that child development is a passive process, shaped by adults. They assert that children are involved in constantly assessing themselves through their relationships and interactions with others as well as through their own social achievements. There is much evidence that personal attainments and mastery over the environment are important factors in developing confidence and self-reliance in childhood (Bukatko & Daehler 1998 p 255–265, LaMontagne, 1984 and Napier et al., 2000 p 60–65) and that the establishment of self-concept is interrelated with the development of self-esteem in childhood.

Napier et al (2000 p 65) suggest that self-concept and self-esteem are also essential elements in the central task of developing a sense of self-identity. They highlight studies that demonstrate a shift in perspective from the preschool child’s (egocentric) emphasis on self-description towards the older school child’s descriptions of self as compared with others, which happens at about 7 years of age. The fundamental links between physical, emotional and social development of the school-aged child and how this relates to and influences childhood health will underpin much that follows in this chapter.

The application of theories of child development to the health needs of school-aged children is vitally important to ensure successful implementation of health-promotion strategies (Downie et al 1991).

Those involved in promoting health for the middle-school-aged child range from health advisors at government level and Strategic Health Authorities charged with improving the health of local populations and health economies, to individuals working directly with children such as school nurses, teachers, scout and guide leaders and health promotion specialists who might visit schools and organisations as part of the planned curriculum.

The government health strategy as outlined in ‘Our healthier nation’ (DoH 1999) outlined the need to consider child health in the context of healthy families, healthy schools and healthy communities; realising the complex interdependence between children’s health and the society in which they live. Schools are often seen to be ideally placed to improve children’s health and all schools are expected to have policies for promoting health (World Health Organization (WHO) 2002). A new UK-based Child Health Promotion Programme (CHPP) ‘Pregnancy and the first five years of life’ sets out the government’s intentions to provide greater emphasis on promoting the health and well-being of children in the early stages and support a core programme for all children, with additional services for children and families with particular needs and risks. It is recognised that partnership working between different agencies on local service development will be essential along with a re-focus on changing public health priorities such as obesity, social and emotional development (DoH 2008a).

Healthy living and personal and social education (PSE) are key components of the national curriculum, implemented in all schools. In fact, the concept of the health promoting school is now a key indicator against which schools are monitored.

As they progress through school, children are increasingly able to take on board health promotion messages and to begin to take an active role in looking after themselves. The cognitive development of school children enables them to relate increasingly complex events and mental representations (Bukatko and Daehler, 1998 and Piaget, 1968). They begin to understand cause and effect, which is classed as moving through the stage of ‘concrete operations’ between 7 and 11 years, towards the formal operational stage of the older school child who is able to reason hypothetically. The cognitive developmental theorist Piaget (1968) further suggests that school children now become less egocentric and better understand how they relate to others. Although Piagetian theories have received criticism over the years (see Shaffer 2004 p 190), many subsequent studies have confirmed his general claims about the sequence of children’s developmental acquisitions and have refined and built on Piaget’s early work to address weaknesses. According to Piaget, the older school child also has increased ability to classify, sequence, group and sort complex information and understand related concepts. This understanding will help application of health promotion messages for the older school child, as long as the individual abilities of each child are acknowledged within the process.

In agreement with Piaget, the constructivist child theorist Vygotsky proposes that children are active contributors to their own learning and development. Vygotsky stresses the importance of adults needing to understand the motivation behind each individual child’s learning and accurately pick up the cues children send out to other individuals as a ‘cooperative enterprise’ (Shaffer 2004 p 201). Vygotsky places particular emphasis on:

Vygotsky’s theories complement those of Piaget when considering how children might learn about their health and keeping healthy and how adults might more effectively deliver health-promotion messages to children.

The concept of empowering children through health-promotion activities has been prevalent in much of the UK health-promotion literature for the past decade. Many school-aged children take responsibility for managing conditions such as asthma and diabetes, and are fully able to self-manage their conditions, which is especially important in situations where parents are not always around, for example when the child is at school or during leisure activities.

Child health should not be seen as a privilege, afforded to certain groups of children. It is now well recognised, through the UN Convention (United Nations General Assembly 1989), that children have the right to live healthy lives and much work is directed towards addressing ongoing health inequalities in our society.

The links between socioeconomic disadvantage and poor child health are well recognised (Acheson 1999), as is the link between children who live in disadvantaged households and their increased exposure to domestic violence and to childhood accidents. The Children’s National Service Framework (NSF) (DoH 2003), which sets out standards for the health and social care for all children in England, states that:

Successful health promotion strategies are multidimensional and must acknowledge the complex interplay of cultural, sociopolitical, economic and biological factors (Downie et al 1991). To improve the health of school children, the individual child’s ability to take on board health messages and the relevance of those messages to the child’s everyday ‘reality’ must be central to any health promotion activity.

The DoH (2003) has recognised the need to understand the nature of children’s contact with health services and states that children and young people are frequent users of all types of health care, compared with adults. Children will be seen for routine health checks and immunisations during childhood, and are frequent visitors to A&E departments, but the NSF acknowledges the central caring role of families when it states that ‘80% of all episodes of illness in childhood are managed by parents’. The pattern of attendance of children to health services is becoming better understood. The NSF states that ‘a school child will present at the GPs up to two to three times per year and one-quarter of all older children will attend an Accident and Emergency department’. What is less well understood, is how to optimise health-promoting opportunities for children, to reduce the incidence of childhood accidents and promote healthy growth and development.

The middle-school-aged child has constantly developing and improving capabilities. School children become more adventurous in play, have increased mobility, and are generally allowed more freedom to travel alone (Bukatko & Daehler 1999). As children develop major developmental accomplishments, they come closer to danger and are extremely prone to accidents. In fact, the child’s increasing sense of independence can be directly related to many of the major causes of accidents in childhood. Accidents remain the most common cause of death among children over 5 and road traffic accidents account for two-thirds of all fatal accidents among school-aged children (Department of Transport, 1992 and Department of Transport, 2000). The major causes of accidents to school children are:

Minor soft tissue injuries, bruising and abrasions due to accidental injury are extremely common in middle childhood but the most common cause of severe injury and death is due to motor vehicle accidents, usually involving the child as a pedestrian. The DoT (2000) figures show that more than 5000 child pedestrians were killed or seriously injured on British roads that year, with many of these accidents being preventable. There is a national road safety target to reduce child deaths by 2010 (Dept for Transport) underpinned with an educational programme ‘On the safe side – Local responsibilities for road safety education in schools’ strategy which commenced in 2003.

Wilson (1995) states that accident rates in childhood show distinct social class differences. She records that ‘the chances of a child of unskilled manual parents being killed in a traffic accident are four times greater than those of a child of professional parents, and for a child of an unemployed head of household, they are seven times greater’. She suggests that lack of supervision, lack of suitable play areas and lack of private transport are contributing factors, all of which are key indicators of social and economic disadvantage. Additional factors are linked to motivational factors, and particularly adherence to responsible social values appear to be important in placing certain children at greater risk of traffic accident than others (DoT 2008).

The major reasons for non-medical admissions to hospital for school children are either associated with trauma, often following an accident, or for planned surgery. Admissions to general surgical units might typically be due to: