The Rights of Children for Optimal Development and Nurturing Care Julie Uchitel, BS,a Errol Alden, MD, FAAP,b Zulfiqar A. Bhutta, PhD, MBBS, FRCPCH, FAAP,c,d Jeffrey Goldhagen, MD, MPH,e Aditee Pradhan Narayan, MD, MPH,f Shanti Raman, PhD, FRACP,g,h Nick Spencer, MPhil,i Donald Wertlieb, PhD,j Jane Wettach, JD,k Sue Woolfenden, MBBS, PhD, MPH,l Mohamad A. Mikati, MDa,m

Millions of children are subjected to abuse, neglect, and displacement, and abstract millions more are at risk for not achieving their developmental potential. Although there is a global movement to change this, driven by children’s rights, progress is slow and impeded by political considerations. The United aDivision of Pediatric Neurology and fDepartment of Pediatrics, Duke University Health System, Durham, North Nations Convention on the Rights of the Child, a global comprehensive Carolina; bInternational Pediatric Association and commitment to children’s rights ratified by all countries in the world except Department of Pediatrics, Uniformed Services University of the Health Sciences, Bethesda, Maryland; cDivision of the United States (because of concerns about impingement on sovereignty Women and Child Health, Aga Khan University, Karachi, and parental authority), has a special General Comment on “Implementing Pakistan; dCentre for Global Child Health, The Hospital for ” Sick Children, Toronto, Canada; eDivision of Community and Child Rights in Early Childhood. More recently, the World Health Societal Pediatrics, Department of Pediatrics, College of Organization and United Nations Children’s Fund have launched the Medicine, University of Florida, Jacksonville, Florida; g Nurturing Care Framework for Early Childhood Development (ECD), which International Pediatrics Association Standing Committee, International Society of Social Pediatrics and Child Health, calls for public policies that promote nurturing care interventions and Geneva, Switzerland; mEarly Childhood Development addresses 5 interrelated components that are necessary for optimal ECD. This Standing Advisory Group, International Pediatrics Association, St Louis, Missouri; hDivision of Community move is also complemented by the Human Capital Project of the World Bank, Pediatric, South Western Sydney Local Health District, providing a focus on the need for investments in child health and nutrition Sydney, New South Wales, Australia; iDivision of Mental fi ’ Health and Wellbeing, Warwick Medical School, University of and their long-term bene ts. In this article, we outline children s rights under Warwick, Coventry, United Kingdom; jEliot-Pearson international law, the underlying scientific evidence supporting attention to Department of Child Study and Human Development, School ’ of Arts and Sciences, Tufts University, Medford, ECD, and the philosophy of nurturing care that ensures that children s rights Massachusetts; kDuke Children’s Law Clinic, School of Law, are respected, protected, and fulfilled. We also provide pediatricians Duke University, Durham, North Carolina; and lDiscipline of anywhere with the policy and rights-based frameworks that are essential for Paediatrics, School of Medicine, University of New South Wales, Sydney, New South Wales, Australia them to care for and advocate for children and families to ensure optimal developmental, health, and socioemotional outcomes. These Ms Uchitel served as the major role in drafting the manuscript for intellectual content, creating the recommendations do not necessarily reflect American Academy of Pediatrics figures for the manuscript, revising the manuscript policy. for intellectual content, and preparing the manuscript for submission; Drs Alden, Bhutta, Goldhagen, Narayan, and Raman, Mr Spencer, Dr Wertlieb, Mrs Wettach, and Dr Woolfenden drafted components of the manuscript for intellectual It is imperative that all children receive Rights of the Child (CRC), an content and revised the entire manuscript for the necessary care and support to allow international commitment to ensuring intellectual content; Dr Mikati planned the outline of them to reach their full potential. children’s rights, was adopted in 1989 the article, guided the drafting of the article, and However, an estimated 250 million by the United Nations (UN) General contributed heavily to revision of the manuscript for , intellectual content and preparing the manuscript children 5 years of age, in low-, Assembly and entered into force in for submission; and all authors approved the final middle-, as well as high-income 1990.3 The CRC has been ratified by manuscript as submitted and agree to be countries, are at risk for not achieving 196 countries, making it the most accountable for all aspects of the work. their potential because of risk factors of widely ratified UN human rights treaty DOI: https://doi.org/10.1542/peds.2019-0487 1 extreme poverty and stunting, and to date.4 Subsequently, the Millennium Accepted for publication Sep 19, 2019 nearly 17 million children have been Development Goals, adopted by world forcibly displaced because of violence leaders in 2000 (to be reached by To cite: Uchitel J, Alden E, Bhutta ZA, et al. The and conflict as of the end of 2017.2 2015), concentrated on child survival.5 Rights of Children for Optimal Development and But there is a global movement to These goals have now been replaced by Nurturing Care. Pediatrics. 2019;144(6): e20190487 change this. The Convention on the the Sustainable Development Goals

Downloaded from www.aappublications.org/news by guest on September 26, 2021 PEDIATRICS Volume 144, number 6, December 2019:e20190487 SPECIAL ARTICLE (SDGs). The SDGs, as outlined in the and protection.10 In response to CHILD RIGHTS AND THE CRC: US UN 2030 Agenda for Sustainable increasing calls for a legally binding CONTEXT ’ Development, are a collection of 17 children s rights treaty, in 1989, the Although the United States has signed global goals related to global poverty, UN General Assembly adopted the the CRC, indicating its support for the 11 inequality, peace, and justice as well CRC (Table 1). The CRC enshrines embodied principles, the US Congress as human and child rights protection, promotion, and has not ratified it, meaning that its 6,7 fi standards. More recently, the World participation rights and af rms protections, unless already ’ Health Organization (WHO) and children s right to health, to be guaranteed by existing US laws, are ’ United Nations Children s Fund protected from abuse, and to freedom legally unenforceable in the United 11 (UNICEF) have launched the of expression, among other rights. States. Opponents of ratification have fi Nurturing Care Framework (NCF) in The CRC has been rati ed by 196 concerns about infringements on an effort to support early childhood countries, making it the most widely national sovereignty and parental fi development (ECD) and transform rati ed UN human rights treaty to authority.13 Many believe that 8 4 child rights principles into practice. date. After recognizing the critical ratification would conflict with the US role that early childhood plays in the In this article, we outline children’s system of federalism, which leaves human life course, the Committee on rights under international law, the most issues relating to the rights and the Rights of the Child prepared an underlying scientific evidence protections of children to individual authoritative interpretation of the 14 supporting attention to ECD, and the state governments. Others observe CRC’s articles and their relevance to philosophy of nurturing care that that laws throughout the United early childhood: “General Comment ensures that children’s rights are States are consistent with the (GC) No. 7 (2005) Implementing respected, protected, and fulfilled. It objectives of the CRC, thereby making Child Rights in Early Childhood.”12 fi is important to note that child rights rati cation unnecessary. The GC 7 defines early childhood as extend into adolescence as the period below the age of 8 years to The United States has no comparable exemplified by the 2030 Agenda for include all children from birth universal statement declaring the Sustainable Development, through the preschool years to rights of children nor are there particularly with respect to transition to school. universal rights to survival, early adolescent mental health, early and forced marriage, and access to sexual and reproductive health care TABLE 1 Summary of the Articles of the CRC services.9 However, for this article, CRC Purpose the focus will be on early childhood, Article fi de ned by the CRC as birth to – , 3 1 2 All children 18 years of age have these rights 8 years. 3–5 All adults should do what is best for children. The government has a responsibility to ensure that these rights are protected, and a child’s family has the responsibility to help In this article, we also provide new a child exercise these rights. fi information with respect to speci c 6–8 The right to life, a name, and an identity recommendations for pediatricians 9–10, 18 The right to live with their parents and to be raised by their parents and pediatric societies to promote 11, 19, 39 The rights to be protected from kidnapping, to be protected from being hurt in body or and implement nurturing care and mind, and to help in case of injury, maltreatment, or neglect 12–15, 30 The rights to give their opinion, to choose their own religion and beliefs, to choose their child rights–based practices, both in own peers, and to practice their own culture, language, and religion the United States and globally. 16–17 The rights to privacy and to obtain information in any sources so long as this information Pediatricians are the key to ensuring is not harmful children achieve their rights and are 20–22 The rights to special care if a child cannot live with their parents, to protection in adoption provided. or foster care, to special protection if a child is a refugee 23 The right to special education if a child has a disability 24–25 The rights to the best health care and nutrition possible and to safe living conditions – fi CHILDREN’S RIGHTS AND THE CRC: 26 27 The rights to help from the government if a child is in need nancially and to have their basic needs met through food, clothing, and a place to live GLOBAL CONTEXT 28–29 The right to a quality education The need for special protection for 31–32 The rights to play, rest, protection from harmful work, and fair pay for work – children was recognized in 1924 33 38 The rights to protection from harmful drugs, the drug trade, sexual abuse, cruel punishment, and war when the League of Nations adopted 40, 42 The rights to legal help, fair treatment in the justice system, and to know one’s own rights the Geneva Declaration of the Rights 41 If the laws of a country protect a child better than the above articles, those laws should of the Child, the first international apply commitment to ensure children’s 43–54 Explanation of how governments and international organizations will work to ensure that rights to survival, health, education, children are protected with their rights

Downloaded from www.aappublications.org/news by guest on September 26, 2021 2 UCHITEL et al development, or nurturing care. (Table 2) led to the realization that integrated health and nutrition Nevertheless, many children’s rights there was an international need for interventions for children. This in the United States are established a specific framework that supported concept set the stage for the and protected through a complex web the rights of ECD. An answer to this subsequent creation of the NCF for of federal and state constitutional call came from the ECD Series ECD,28 a framework that supports protections and laws at both the Steering Committee, children in reaching their full federal and/or state level. For a multidisciplinary group that developmental potential. example, the right to education is advocated for the importance of ECD guaranteed by state constitutions,15 and nurturing care. The Committee In 2018, the WHO, UNICEF, the World and the right to be protected from introduced the concept “nurturing Bank Group, the Partnership for abuse and neglect is guaranteed for care” for children ,3 years of age and Maternal, Newborn, and Child Health, children under federal and state espoused multisectorial and and the ECD Action Network jointly laws.16 Although health care is not a universal right in the United States, most poor children are able to obtain TABLE 2 The Evolution of International Standards on Child Rights health coverage through combined Year and Treaty Implications 17 federal and state programs. Many 1924 Geneva Declaration on the Rights of the Child This established children’s rights to means for poor children, although not all, material, moral, and spiritual development; aid qualify for social services programs when hungry, sick, disabled, or orphaned; that provide food18 and housing freedom from economic exploitation; first call assistance.19 Children with from relief when in distress; and an upbringing that instills social responsibility. disabilities have the right, through 1948 Universal Declaration of Human Rights Childhood is “entitled to special care and a federal law, to appropriate early assistance.” intervention and educational 1959 Declaration of the Rights of the Child This recognizes the right to freedom from services20 and are protected from discrimination and the right to a name and ’ discrimination.21 Some get income nationality. It also prioritizes childrens rights to 22 education, health care, and special protection. support as well. Children are 1966 International Covenant on Civil and Political These advocate for protection of children from protected from forced labor through Rights and the International Covenant on exploitation and for the right to education. state and federal laws; children Economic, Social, and Cultural Rights ,14 years of age may not be forced to 1973 Convention No. 138 of the International Labor This sets 18 y as the minimum age for work that ’ work, and certain restrictions on child Organizations: The Minimum Age for Admission may be hazardous to an individuals health, , for Employment safety, or morals. labor exist for children 18 years of 1979 Convention of the Elimination of All Forms of This provides protection for the human rights of 23 age. Children born in the United Discrimination Against Women girls and women and declares 1979 as the States are automatically given US International Year of the Child. citizenship24; as such, they are 1989 CRC This outlines the specific rights owed to children protected by the US Constitution along with respect to health, safety, wellness, and education. with adults, although some rights are 1990 Convention No. 182 of the International Labor This establishes the Prohibition and Immediate 25 applied differently for minors. Organization Action for the Elimination of the Worst Forms of Children have the right to due process, Child Labor. equal protection of the laws, free 2000 UN adopts 2 protocols for the CRC One protocol concerns the involvement of children fl speech, and freedom from cruel and in armed con ict, and the other concerns the sale of children, child prostitution, and child unusual punishment and pornography unreasonable searches and seizure. 2002 UN General Assembly hosts the Special This was the first official meeting to specifically They may not be executed for crimes Session on Children discuss children’s issues. World leaders committed while younger than the age committed to a compact on child rights, “A World ” of 18.26 In addition, executive Fit for Children. 2006 UN CRPD This was ratified by 177 nations and elaborated administrations and some powerful US rights for children (article 7), education (article organizations endorse the principles 24), and health (article 25). of the CRC with various reservations, 2007 UN Declaration on Children This was adopted by .140 governments and understandings, and declarations.27 acknowledges the progress achieved and the challenges that remain; it reaffirms the commitment to the World Fit for Children THE NCF FOR ECD compact, the CRC, and the CRC optional protocols. The passage of the CRC, the GC 7, and Adapted from United Nations Children’s Fund. The State of the World’s Children: Celebrating 20 Years of the Convention on numerous other child rights treaties the Rights of the Child. Available at: https://www.unicef.org/rightsite/sowc/fullreport.php. Accessed January 29, 2019.

Downloaded from www.aappublications.org/news by guest on September 26, 2021 PEDIATRICS Volume 144, number 6, December 2019 3 launched “The Nurturing Care THE NEUROBIOLOGICAL JUSTIFICATION synaptogenesis in the hippocampus Framework for Early Childhood FOR THE IMPORTANCE OF NURTURING and cortex,38 and enhance long-term Development.”28 The NCF CARE IN ECD potentiation not only in rat pups but 39 recognizes that pregnancy to age 3 The importance of nurturing care is also in their future offspring. It is is when children are most strongly supported by evidence that also indicated in recent studies that susceptible to environmental early life experiences shape the the human brain is even more influences; thus, this is the best time course of childhood brain dependent in its development on for multifaceted support. This development. The neurobiological early experience than primates and 40 enriched approach, known as processes of early brain development other animals. nurturing care, supports conditions include neurogenesis, synaptogenesis, The roles of the mother and other that promote health, nutrition, pruning, and long-term caregivers are also extremely security, safety, responsive 29 potentiation. During these important. Positive early contact with caregiving, and opportunities for processes, the child brain is extremely a primary caregiver is essential for early learning for children to sensitive to environmental input, synaptic pruning,41 whereas achieve their full developmental a concept known as neuroplasticity in maltreatment can negatively affect potential. fi which synaptic connections are ne DNA methylation, telomere length, tuned in response to experience.30 The NCF itself provides a roadmap for and the expression of brain-growth 42–44 public policies, medical providers, Studies on childhood brain related genes. Indeed, in a study 45 and caretakers to promote nurturing development have revealed that by McGowan et al, postmortem care interventions and addresses 5 positive experiences, such as analysis of the hippocampi of suicide interrelated components that are responsive caregiving, stimulation victims with a history of child abuse necessary for optimal ECD. and enrichment, opportunities for revealed a reduced glucocorticoid Specifically, the framework outlines early learning, and social interaction receptor expression. Altogether, these (1) the necessity of improving promote learning and growth of the findings support that the effects of health and well-being in the brain. Negative experiences, such as early childhood experiences are earliest years; (2) major threats to environmental insult and abuse, can multiple across the life course and ECD; (3) how nurturing care can cause maladaptive structural changes indicate that supporting ECD is protect young children from adversity that persist into adulthood.31–34 crucial to overall development and promote physical, emotional, and Studies in animal models have (Fig 2). cognitive development; and (4) what demonstrated that environmental caregivers need to do to provide enrichment can increase progenitor CHALLENGES TO PROVIDING 8 35,36 nurturing care for young children cell proliferation rates, promote NURTURING CARE AND ENSURING (Fig 1). neuron maturation,37 promote CHILD RIGHTS IN THE UNITED STATES AND GLOBALLY Given that childhood is so crucial for holistic development, it is critically important that a rights-based approach be used to address the challenges children face with respect to achieving optimal health and well- being. These issues demand the attention of child health professionals because they can assist in mitigating risks and promoting optimal development via a child’s rights–based approach.46–48

Challenges Posed by Poverty, Inequity, and Social Determinants of FIGURE 1 Health Child’s rights as a foundation for the NCF. The NCF naturally builds on children’s rights. Together, the All children have rights to the 2influence a child across their life course, and even influence the next generation through multiple intergenerational effects (see section on Challenges Posed by Poverty, Inequity, and Social Deter- essential requirements for healthy minants of Health). Only through realization of children’s rights can human rights be realized, and growth and development, such as only through nurturing care can a child’s full developmental potential be achieved. clean water, sanitation, nutrition, and

Downloaded from www.aappublications.org/news by guest on September 26, 2021 4 UCHITEL et al UNICEF reports that half of the world’s children are below the poverty line of 2 dollars per day.61 In the United States alone, 13% of all children are living in poverty.62 Poor children in low- to middle-income countries (LMICs) are twice as likely to be stunted as their more advantaged peers.63 For example, in the Middle East, the level of maternal education was found to be independently associated with higher mean developmental score.64 Authors of 2 recent reports highlight wide differences in immunization coverage FIGURE 2 between the poorest and richest Risk and protective factors for healthy developmental trajectory. The top green arrow represents infants in LMICs.65,66 The effects of developmental trajectory shaped by nurturing care, the middle blue arrow represents development unaided by nurturing care interventions, the bottom red arrow represents development negatively poverty on child development, influenced, and the dashed red arrow represents developmental regression. The most sensitive particularly cognitive developmental window for environmental influences on development occurs during the prenatal stage through and educational outcomes, are thus early childhood. significant, with longer durations of exposure to poverty associated with education, for an optimal life under child’s family’s socioeconomic status, worse outcomes.67 articles 24, 27, and 28 of the CRC. including financial wealth, material However, the impact of poverty, wealth, and education level, ethnicity- The presence of child health 54 inequities results in a life with less inequity, and social determinants on based discrimination, and the chance to reach one’s potential and health, growth, and development are extent of societal protection of means that certain groups in the considerable and often overlooked. children and their families. A common population are unable to contribute feature of the social determinants is Child health inequities are differential to society’s productivity and that they follow a social gradient such outcomes in children’s health, revenue.68 By addressing inequities, that the risk of adverse outcome development, and well-being that are societies achieve better health and increases with increasing unjust, unnecessary, systematic, and development outcomes overall, and disadvantage.29,33,41,55 Social preventable.49 This disadvantage the social gradient flattens with gradients indicate that inequities in arises from unequal opportunities, a “spillover” effect on nonhealth child health do not manifest as unhealthy environments, and unfair outcomes such as social, educational, a single event; rather, they are policies.50,51 Children suffering from and workforce inclusion. More dependent on the enduring context of inequities suffer the situational equitable societies, among both a child’s development, including disadvantage of not being able to LMICs and high-income differential, additive, and cumulative access high-quality health, welfare, countries,69,70 have better child exposure to risk and protective and early childhood services health and developmental outcomes factors.56,57 Differential exposure according to their needs.50 Hart52 with universal affordable health starts long before the child’s birth and called this the inverse care law, which coverage, higher levels of education, is influenced by the mother’s states that “the availability of good especially of women, and lower levels exposure to risk and protective medical care tends to vary inversely of income inequality. factors in her own childhood and in with the need for it in the population 52 pregnancy so that their infants are served.” Children in conflict areas, more likely to be born with low birth Challenges Related to Child Abuse, migrant children, and those in the 29 58 Neglect, and Labor poorest families are most at risk to weight, as preterm, or with 32 Rights enshrined in CRC articles 11, suffer from the inverse care law.53 a disability, such as cerebral palsy. These intergenerational effects 19, and 39 and reasserted in the NCF These inequities are rights violations contribute to inequity for the next as reflected in Fig 3 emphasize the that are related to the social generation of children.59,60 right to be free from abuse, the rights determinants of health, which include to be protected from kidnapping, to the safety and social capital of the Access to care is most difficult for be protected from being hurt in body community that the child lives in, the those children living in poverty. and mind, to help in the case of injury,

Downloaded from www.aappublications.org/news by guest on September 26, 2021 PEDIATRICS Volume 144, number 6, December 2019 5 maltreatment or neglect.3 violence) and negative health marriage results in increased Furthermore, studies indicate that outcomes, such as premature death, mortality for young girls who become early childhood adversity and toxic poor school and work performance, pregnant and worsened infant health stress can lead to later impairments repeated interpersonal violence, outcomes.79 Female genital in learning, behavior, and both depression, and engaging in mutilation, which often occurs in physical and mental well-being.71 unhealthy activities.34,77 Authors of early childhood, results in increased the “Global Status Report on Violence risks for infection as well as negative Unfortunately, rates of child Prevention 2014” identified similar psychological well-being.80 maltreatment remain high throughout adverse health outcomes, including 72–74 Child labor is also a major cause of the world. According to the worsened physical health, mental and concern for children in the upper “Global Status Report on Violence behavioral health, sexual and range of early childhood (6–8 years). Prevention 2014,” 23.6% of adults reproductive outcomes, and chronic Of the 250 million children that reported physical abuse, 36.3% diseases.75 reported emotional abuse, and 16.3% participate in the work force reported neglect as children.75 In the Cultural practices that harm young worldwide, 171 million are considered to work in unsafe United States alone, nearly 700 000 children are also associated with 81 children are abused annually.76 There adverse health outcomes. For conditions. The US Fair Labor are significant adverse outcomes for example, son preference, child Standards Act of 1938 provides children experiencing maltreatment marriage, and female genital restrictions on the duration that , during early childhood. The Adverse mutilation are termed by the UN as children 14 years of age can work 78 and the conditions they can work Childhood Experiences study harmful traditional practices. Son 82 identified a graded dose-response preference promotes inequitable in ; however, these regulations do relationship between adverse access to health care and caregivers not apply to agricultural labor, and childhood experiences (which include for girls, as well as increased studies have revealed that children various types of abuse, neglect, and mortality for infant girls. Child working in agriculture in the United States comprise the majority of work- related child fatalities.83

Challenges for Children in Displacement and Armed Conflict Situations As of 2015, .1 in 10 children worldwide were affected by armed conflict.84 In recent years, children have been increasingly exposed to situations of armed conflict, although subjecting children to armed conflict situations is a direct violation of article 38 of the CRC.3 These situations have direct effects on children’s health, including physical, mental, developmental, and behavioral health effects, as well as indirect effects, including deprivation and toxic stress, which may last across the life course.85 Even outside direct participation, an environment of armed conflict may lead to FIGURE 3 psychological effects.85 Authors of 1 Articles of the CRC and CRPD classified by the categories of the NCF. The articles of the CRC are study on the effects of war on represented within the 5 domains of nurturing care: early learning, health, nutrition, responsive children in Kabul found that .80% of caregiving, and safety and security. Each number represents a different article of the CRC as summarized in Table 2. The number 7 in italics indicates Article 7 of the CRPD, which calls for the Afghan children bore some protection and consideration of the best interests for the child. Adapted from the WHO with psychological scars of war.86 permission. Adapted from: World Health Organization. Nurturing Care for Early Childhood De- velopment. Availible at: https://apps.who.int/iris/bitstream/handle/10665/272603/9789241514064- Forced displacement is also a major eng.pdf. Accessed June 20, 2018. area of concern that is in direct

Downloaded from www.aappublications.org/news by guest on September 26, 2021 6 UCHITEL et al violation of the CRC. Worldwide, .31 exclusion from schools (eg, young and interventions for creating million children have been forcibly girls with disabilities are associated enabling environments that allow displaced because of violence and with amplification of risk and poor children to reach their optimal conflict.2 Within the United States, outcomes). These conditions and development potential are set out in these effects are particularly relevant figures are in direct violation of both the NCF (Table 1). Key policies to given the current conditions in the CRC and the CRPD.91,92 promote equity in children’s Central America that drive child development are reduction of migrants to the United States. inequality (SDG goal 10) and the Between 2016 and 2018, nearly SPECIFIC RECOMMENDATIONS FOR social protection and security PEDIATRIC ASSOCIATIONS TO ADDRESS 70 000 migrant children were including elimination of poverty (SDG . CHALLENGES TO THE IMPLEMENTATION 153 detained in Mexico, and 2000 OF NURTURING CARE AND CHILD target 1.2). Relatedly, policies to children were detained and separated RIGHTS counteract intergenerational risk from their families at the US border in exposures are adequate nutrition 2018.87 Many factors underlie this Focus: Training for Child Rights and including maternal nutrition (SDG migration crisis, including poverty, Nurturing Care target 2.2), universal health coverage high rates of domestic violence, All national and regional pediatric including antenatal and child birth sexual abuse, scarce social services, societies need to provide training care (SDG target 3.8), parental leave, limited opportunities to learn, and modules on child rights, child affordable child care, good quality the desire of children to be with their development, and violence against inclusive day care, and preprimary 153 parents who are already working in children, as well as ensure that education (SDG target 4.2). These 88 the United States. pediatricians in training and those policies, along with those of the CRC, who work in child health care settings NCF, and CRPD are grounded in the Challenges for Children With undergo such training and comply principle of inclusion: leave no child Disabilities with it (Tables 3, 4, and 5).93 These behind. The UN’s Convention on the Rights of training requirements can be linked Recently, the National Academy of Persons with Disabilities (CRPD), the to other existing requirements, such Sciences released the report “A current international framework of as the Continuing Medical Education Roadmap to Reducing Child Poverty” human rights for persons with credit system in the United States and fi 94 that provides speci c policy and disabilities, offers standards of elsewhere. Advocacy training program recommendations for protection for civil, cultural, should also be provided to young reducing the number of children economic, political, and social rights pediatricians to prepare them to living in poverty in the United States of persons with disabilities on the shape the future of ensuring by half within 10 years.62 Major ’ basis of inclusion, equality, and children s rights. This is particularly assistance programs and their long- 89 nondiscrimination. Of note, article 7 important for pediatric societies in term effects are also discussed, which calls for state protection of the rights low- or middle-income settings. would be useful for pediatric of children with disabilities, for Of note, the International Pediatric associations to consider supporting. actions to be taken only in the best Association (IPA) and WHO host Other organizations that pediatric interest of a child, and for states to workshops on child rights and on associations may consider partnering 154 ensure that children with disabilities implementing nurturing care with include the Gates Foundation, have the right to express their views strategies at the biennial IPA the Abdul Latif Jameel Poverty Action 155 on an equal basis with other children. Congress.152 UNICEF provides a child Lab, and the Campbell These rights naturally align with Collaboration.156 3 rights toolkit with training materials, articles 4, 12, 13, and 23 of the CRC. and the Human Rights Campus offers However, an estimated 53 million online courses on child rights Child Abuse, Neglect, and Labor 119,126 children globally ,5 years of age are (Table 4). A vital step in ensuring children’s living with developmental disabilities; rights to safety includes recognition this is a figure that has been constant Poverty, Inequity, and the Social and intervention by pediatricians. In since 1990.1 These children are at Determinants of Health 2010, the UN Study on Violence greater risk of suboptimal health, The SDGs and the CRC provide against Children recommended that educational attainment, and well- a global foundation for the reduction States establish confidential and being than are children without of children’s exposure to the above accessible mechanisms for children, disabilities.90 Children with adverse social circumstances and for their representatives, and others to disabilities are at greater risk of the promotion of equity in ECD and report violence against children.157 victimization, violence, poverty, and later childhood. The laws, policies, However, physicians in training often

Downloaded from www.aappublications.org/news by guest on September 26, 2021 PEDIATRICS Volume 144, number 6, December 2019 7 TABLE 3 Obstacles to Ensuring Children’s Rights and Solutions to Overcome Them Obstacle What Pediatricians Should Do What National Pediatric Associations Should Do Child labor: Of the 250 million children that Child health professionals must be involved in the Advocate to ratify the International Labour participate in the work force, 171 million are documentation of, recognition of, reporting of, and Organization convention No. 182 to forbid considered to work in unsafe conditions. These advocacy against child labor. unsafe conditions, ensure time for education, children often suffer from poverty and do not go and support children’s development thought to school.95 health, nutrition, and sanitation95 Establishing a Nurturing Care environment Learn about and implement the Nurturing Care Provide intervention training packages that program and encourage parenting support, integrate nurturing care with provider attachment and bonding support, prevention of practices and with sector specific programs96 child maltreatment, out of home interventions, and Implement the 5 strategic actions of the NCF8 social safety net interventions8,28,96 Consider supporting evidence-based, cost-effective interventions to increase child survival, such as those reviewed by the Lancet97 Support for children with disabilities: There are Provide support advocacy and training to parents and Support legislation that supports children with 170–350 million children in the world with caregivers of young children with disabilities disabilities disabilities, but in developing countries, only 2% Promote awareness of the needs of individuals with Ensure access to quality early childhood care and receive rehabilitative assistance and disabilities through lobbying and activism95 preprimary education for children with education.1,95 disabilities Promote coordination between authorities, the organizations of disabled persons, and other NGO partners98 Violence against children: Violence against children Encourage children to report violence Provide opportunities for children to report is widely prevalent, including at home, in Identify early signs of violence against patients and violence against them, appoint an individual to communities, and even in prisons.95 advocate for measures to combat the violence99 speak on behalf of children, provide education of human rights and children’s rights95 Participation in health care decisions: Researchers Ensure that rights are explained to caretakers and to Promote the following to be employed in child indicate that children are generally excluded children in terms that are clear to them100,101 care settings: the Task Force on Health from health care decisions, violating CRC Promotion for and with Children and articles 17 (right to information) and 12 Adolescents has 12 specific CRC rights that (opportunity to express views and concerns). must be fulfilled to ensure a child’s The evolving capacities of children are often participation ignored and arbitrary age limits for Before administering immunization, a child’s assent The European Association for Children in Hospitals participating in medical decisions are often should be obtained.102 has a charter that delineates the rights of employed.100 children; this should be made available in hospitals.100 If children are truly to participate, they should be Implement similar approaches in other countries informed not only of their rights but also of other information that would be necessary to make an informed descion.100 The CRC is often not incorporated into domestic Support efforts to incorporate the CRC into clinical Advocate for the CRC to be incorporated into legislation. practice, even if it is not in legislation, and domestic legislation advocate for the CRC to be incorporated into If not incorporated, encourage public authorities legislation to consider the CRC when making decisions101 Lack of integration of children’s rights into health Promote principles of child rights, social justice, Promote training programs domestically as well professional training93,101 human capital investment, and equity ethics in as internationally, such as through the medical school and residency93 International Society for the Prevention of Child Abuse and Neglect103 Children in armed conflict situations: Many Be aware that the 2 organizations War Child and Develop and publish policies that prohibit national pediatric associations have no UNICEF create opportunities for recovery and for children’s involvement in armed conflict104 established policy with respect to the impact of reintegration to ameliorate some of the harmful Address armed conflict questions in the context of armed conflict on children. Article 40 calls for effects of war on development. These organizations child rights104 the protection of children as humanitarian also provide physicians with training in advocacy In countries in which armed conflict has recently crises.104 for children affected by armed conflict in clinical occurred or is currently occurring, children care, health systems, and policy.104 must be the prime focus of attention through sustained efforts at improving health, nutrition, and education86 NGO, nongovernmental organization. lack knowledge on how to properly programs in the United States, 25% well” prepared to address child abuse address child abuse with respect to did not require any rotations in child and neglect.159 Nurses in various child rights.158 Authors of 1 study abuse during training, and only 12% countries have reported similar found that of 203 pediatric residency of residents reported feeling “very dissatisfaction with their professional

Downloaded from www.aappublications.org/news by guest on September 26, 2021 8 UCHITEL et al TABLE 4 Educational Tools for Clinicians and Children on Child Rights and ECD particularly timely given the current Organization Toola state of separation of immigrant AAP EBCD Education and Training Modules105 children from their parents at EBCD Resource Library106 national borders. The Early Childhood Learning and Knowledge Center: a national online resource for early childhood health information107 Children With Disabilities 108 Connected Kids: Clinical Guide Initiatives for early child Bright Futures Guidelines, tools, and resource kit109 Press releases on advocacy efforts in child health, child development, and development must be disability 166 child rights110 inclusive. Olusanya et al call for Trauma Toolbox for Primary Care111 intervention at 3 levels: (1) primary Poverty and child health practice tips112 prevention targeting biological and 113 Toxic stress video environmental risk factors to reduce UNICEF Multiple simplified versions of the CRC for children,114,115 a leaflet for children,115 and a children’s book116 about children’s rights and the CRC116 the incidence of developmental and how children can participate in their rights disabilities, (2) secondary prevention Resources for educators, specific to teenagers, protection from violence, the through early detection of disabilities rights of people with disabilities117 during early periods of 117 Other resources available in French, German, Italian, and Ukrainian developmental plasticity, and (3) “Rights with Ruby and Jack”: a video for children about their rights118 Child Rights Toolkit and accompanying e-learning119 tertiary prevention through Cartoons for children’s rights120 community-based programs. Authors Child rights research tools121 of a recent report from the National Plan International Child-friendly poster on the CRC, available in English, French, and Spanish122 Academies of Sciences on ’ 123 Living Democracy Activity plan on childrens rights for children opportunities for enhancing pediatric Children’s Rights This organization offers presentations for physicians to purchase online; Education physicians can also request workshops to come to their institution.124 care for children with disabilities Child Rights Connect Offers training workshops on child rights125 provide compelling guidance to be Human Rights Campus Offers self-directed e-courses and tutored e-learning courses on children’s considered in global contexts as well rights, child development, participation, and protection126 as for care of children without WHO Information on the NCF disabilities.167 In addition, more https://www.who.int/maternal_child_adolescent/child/nurturing-care- framework/en/ research is needed to determine the https://nurturing-care.org prevalence of disability and explore Nurturing Care training materials127 potential risk and protective factors EBCD, Early Brain and Child Development; e-course, electronic course; e-learning, electronic learning. for disability as well as efficacy of the a Web site links to each of these tools can be found in the references. wide range of interventions under consideration for scale-up as training in recognizing and reporting policy with respect to the impact of nurturing care begins to include child maltreatment.160,161 armed conflict on children, many children with disabilities.168,169 other national pediatric organizations Developmental systems frameworks Addressing violence against children do not.104 All national pediatric will guide important research and requires multiple approaches.162,163 associations should have policies on practice.170 Child health care workers must these 2 factors and encourage their receive and have access to high-quality governments to pass laws to protect training to improve their ability to SPECIFIC RECOMMENDATIONS FOR children in these situations. detect abuse and intervene on behalf PEDIATRICIANS TO ADDRESS International programs to support CHALLENGES TO THE IMPLEMENTATION of children. The promotion of training children in these countries include OF NURTURING CARE AND CHILD programs domestically as well as the War Child program and UNICEF, RIGHTS internationally, such as through the which provide recovery and International Society for the reintegration opportunities for All Pediatricians Prevention of Child Abuse and Neglect, children affected by war. These The CRC and the NCF have laid the should be encouraged.103 In addition, organizations also provide physicians groundwork for standards and children should be encouraged to with training in advocacy for children interventions on the international report violence, and avenues should affected by armed conflict in clinical scale; it is now up to pediatricians to be provided for them to report abuse. care, health systems, and policy.104 adopt these standards into daily UNICEF also provides practice. Of note, at the most recent fl Armed Con ict and Displacement recommendations on caring for World Health Assembly’s universal Although the American Academy of children with disabilities in times of health coverage declaration, children Pediatrics (AAP) has established armed conflict.164,165 This issue is and child health are not mentioned at

Downloaded from www.aappublications.org/news by guest on September 26, 2021 PEDIATRICS Volume 144, number 6, December 2019 9 TABLE 5 Organizations and Conferences Concerning Child Development and the Rights of the Child Organization Conferences Children’s AAP Council on Community Pediatrics128 Annual Conferences (including information about 2019 conference) rights AAP Committee on Child Abuse and Neglect129 Association of Maternal and Child Health Programs Annual Conference130 (March 21–24, 2020, Crystal City, VA) AAP Council on Children with Disabilities131 ICFLCR 2019: International Conference on Family Law and Children’s Rights132 (June 27–28, 2019, London, United Kingdom) AAP COCP Immigrant Health Special Interest Group133 International Society for Social Pediatrics and Child Additional conference in 2019 Health134 NOW Working Group on Children’s Rights135 From a Protected to an Empowered Childhood: 30 Years of the Convention on the Rights of the Child136 (November 21–22, 2019, Leuven, Belgium) International Society for the Prevention of Child Abuse and Neglect103 ECD AAP Committee on Development137 Annual Conferences (including information about 2019 conference) AAP Council on Children with Disabilities131 The Division for Early Childhood’s 35th Annual International Conference on Young Children with Special Needs and Their Families138 (October 1–4, 2019, Hilton Anatole, Dallas, TX)a AAP Council on Early Childhood139 Zero to Three Annual Conference140 (October 2–4, 2019, Fort Lauderdale, FL)a AAP Section of Developmental and Behavioral National Association for the Education of Young Children Annual Conference142 Pediatrics141 (November 20–23, 2019, Nashville, TN)a Society for Research in Child Development143 The National Association for Family Child Care Annual Conference144 (June 19–22, 2019, Orlando, FL)a Society for Developmental and Behavioral International Society of Early Intervention Conference146 (25–June 28, 2019, Sydney, Pediatrics145 Australia)a International Developmental Pediatrics Association147 International Congress of Infant Studies148 (July 6–9, 2020, Glasgow, United Kingdom)a IPA Child Rights and Child Protection Sub Committee International Maternal and Child Health Conference149 (November 4–5, 2019 in Porto, (https://ipa-world.org/page.php?id=399) Portugal) IPA Special Advisory Group on Early Child Development Society for Developmental and Behavioral Pediatrics Annual Meeting150 (September (https://ipa-world.org/sag-ecd.php) 13–16, 2019, Washington, DC) International Developmental Pediatrics Association Congress151 (December 9–12, 2019, Manila, Philippines)a COCP, Council on Community Pediatrics; NOW, xxx. a Holds conferences every 2 to 3 years. all.53 Pediatricians globally must other information that is necessary to disabilities and ECD interventions recognize the threat this poses to make an informed descion.100 The that take into account the needs of ensuring child rights and must take responsibility of this task, in part, falls children with or at risk for – action internationally and locally on pediatricians, who must not only developmental disabilities.172 174 (Tables 4 and 5). be aware of the rights of the child but Child health professionals must also also ensure that children they treat be involved in the documentation of Pediatricians should attend are aware of their rights. workshops and conferences that the health effects of child labor, child Clinicians should also adopt early maltreatment, and neglect, as well as provide training in child rights and childhood preventive health and care advocacy against these at national ECD (Table 5). After becoming practices. Although developmental and international levels.175 Not only informed more about child rights and surveillance is helpful in identifying should pediatricians educate the NCF, child health care workers possible developmental delay, the themselves on reporting child should also adopt child rights–based goal is to prevent delay in the first maltreatment, but they should also practices in their clinics, as outlined place by supporting ECD. effectively engage with community in these tools. Ideally, children systems that support the child, such attending clinics should be educated With regard to supporting early as social services. about their rights as per the CRC in childhood education, clinicians child-friendly language, and should be asking families about In working with children affected by individuals must be available to speak educational arrangements for armed conflict or displacement, on the proper implementation of children and encourage 3-way physicians should be aware that War child rights.95 For children to truly communication between families, Child and UNICEF provide physicians participate in their rights, they and educational professionals, and the with training in advocacy for children their caretakers should be informed pediatrician.171 Specific consideration affected by armed conflict, in clinical not only of their rights but also of any should be given to children with care, health systems, and policy.104

Downloaded from www.aappublications.org/news by guest on September 26, 2021 10 UCHITEL et al Physicians should attend these development must also be given a solid foundation that serves them for training programs in addition to those consideration: in 1 survey, the rest of their lives. In the global of national and international pediatric researchers found that 22% of US context of vulnerabilities, children society trainings on ECD and child pediatricians do not offer prenatal exposed to violence or forced to rights. Consideration should also be visits to expecting mothers.179 migrate with their families have major given to children affected by vulnerabilities to their health and In light of the current situation of child migration, orphans, and those who long-term developmental outcomes. migration at the US border, the AAP live in areas of high crime as these The amplification of rights inclusive of recommends a child rights–based children often lack support.53 children with disabilities as enshrined approach to addressing the multiple in both the CRC and the CRPD position In addition to these measures, effects of armed conflict and health professionals as key monitoring child development is displacement on children. Relatedly, implementers and advocates. Now, recommended to ensure the AAP has released a statement on more than ever, is the time to integrate accountability. This includes informed how physicians should handle children nurturing care and children’srightsto watching, enjoying, and supporting the in situations of displacement.180 support ECD; now is the time for child’s development with the family as Recommended practices include pediatricians to ensure children’s well as partnering with caregivers to providing culturally and linguistically achievement of their human potential. enhance strengths, address risk sensitive medical care and eliminating factors, and provide additional exposure to conditions or settings that individualized support and services.8 may retraumatize children. ACKNOWLEDGMENTS We thank Dr Bernadette Daelmans US-Based Pediatricians and Marcus Stahlhofer of the WHO for CONCLUSIONS AND THE WAY FORWARD Although the CRC has not been their assistance in reviewing this ratified by the United States and For children to reach their maximum article. adopted into legislation, US-based developmental potential, ECD must pediatricians should still make the be supported by nurturing care and best efforts to incorporate child rights the principles of children’s rights. ABBREVIATIONS principles into practices. In addition, Nurturing care interventions must AAP: American Academy of advocates for children’s rights in the begin before birth during the prenatal Pediatrics United States are likely to find stage (as per the NCF) and must CRC: Convention on the Rights of success by lobbying at the state level continue throughout childhood to the Child for additional protections and ensure health and well-being CRPD: Convention on the Rights of affirmative rights and to adequate throughout the life course. These Persons with Disabilities education, health care, nutrition, and benefits are not only individual, they ECD: early childhood development housing. are societal; improving child health outcomes will increase global GC: General Comment The AAP provides numerous productivity and sustainability; it is IPA: International Pediatric resources for pediatricians to address also cost-effective.181 Achievement of Association the above described challenges, such these goals requires governments to LMIC: low- to middle-income as guidance on what should take actively implement ECD interventions country place during early childhood visits to through a multifaceted, multisectoral NCF: Nurturing Care Framework promote nurturing care,176 reporting approach. SDG: Sustainable Development and recognition of child abuse and Goal maltreatment,175 providing care for A child rights approach responds to UN: United Nations children that have been the vulnerability of children in UNICEF: United Nations maltreated,177 and supporting society, commits to the protection of Children’s Fund children affected by the social their health and well-being, and WHO: World Health Organization determinants of health.178 Prenatal commits to the establishment of

Address correspondence to Mohamad A. Mikati, MD, Division of Pediatric Neurology and Developmental Medicine, Duke University Health System, 2301 Erwin Rd, Durham, NC 2771. E-mail: [email protected] PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2019 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

Downloaded from www.aappublications.org/news by guest on September 26, 2021 PEDIATRICS Volume 144, number 6, December 2019 11 FUNDING: No external funding. POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

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