KEYWORDS: social medicine, children’ fundamental rights, global health, wellbeing, prevention, community grounded.

ABSTRACT: Community social pediatrics is an innovative and integrated approach centered on meeting the needs of children and youth. It ensures that children’s fundamental rights are respected, and that they are helped to develop to their full potential. This approach enables a more accurate diagnosis because it assesses physical, psychological, cognitive, and social health together. Relying on the children’s strengths, their families, and the community, social pediatrics combines medicine, lawandsocialwork to identify, reduce, and eliminate stressors affecting the development and well-being of the child.

The heart of a child is a precious thing that deserves love and respect.
A responsible society places children at the very heart of life
with everyone looking out for them.

The community–based social pediatrics’ approach is an innovative model of integrated social medicine dedicated to meeting the global needs of children and ensuring that their fundamental rights are respected. It has originally developed from two key concepts:

• The desire to make sure that no child “falls through the cracks” in the system – bereft of resources and care, with no one who can really “be there” for the child;
• The importance of applying the principle that it takes a village to raise a child.     

It implies the interconnection of medicine, law, and social services for empowering the child and the family as essential partners for the success of the child overtime.

It is clearly a new paradigm of medicine in proximity completely integrative in its actions and outputs.

Community social pediatrics is properly applied not only to the medical specialty of pediatrics, but also to a way of caring for children that sets in motion an entire support process involving the local milieu. It promotes a true dynamic of change within the community based on children's fundamental needs. That is why this practice, first and foremost, aims to mobilize the children themselves, their families, and friends to create environments that are conducive to their growth. The movement, which forms a circle around the child, is gaining ground, just as a single snowflake falling from the sky piles up with many other snowflakes and forms bigger and bigger snowballs. It is an ongoing process of developing innovative tools, fuelled by the desire of the entire community to meet children's multifaceted needs.

The goal is to make sure that children’s rights, needs, and interests are respected. Community social pediatrics targets not only at children's psychomotor and physiological development but also at their growth and “blossoming” in every area of life. Therefore, it promotes the formation of different teams to set up appropriate and tailored treatment and prevention programs that will help children grow up in good health, both in mind and body.

Community social pediatrics makes every effort to respect and satisfy the global needs of children in the community (neighborhood or a village) by considering major determinants of health (e.g., income and social status, social support networks, level of education and literacy, employment and working conditions, social and physical environments, etc.) and rights of children in the most integral sense [1]. It makes use of recognized tools, specifically tools used in the network approach, the global approach, and the complementary interdisciplinary approach, but also tools that promote empowerment – holding people responsible – attachment, and respect for individuals based on their culture and potential.

The concrete tools used may be just as varied as the specific needs of children in the community in question. The point is that they are developed within the community and interrelated with the community, with the greatest respect for everyone involved –children, their families, relatives and friends, and mentors. The Community social pediatrics approach is essentially based on:

• taking the above individuals out of their shell;
• sharing common values and objectives designed to foster the child's well-being;
• arriving at a mutual understanding of these individuals in terms of knowing what to do and how to be;
• a call to action based on identified needs and recognized priorities for a joint mobilization that follows a predetermined schedule.

The practice of community social pediatrics is meant for everyone who has an interest in the wellbeing of the children around them.

More specifically, it targets the child who has manifested symptoms and problems, frequently due to multiple causes. These problems may take the form of distress, prejudice, injuries, diseases, exclusion, rejection, and the like. They may also present in the form of major disorders, barriers in access to services, or poor living conditions due to social inequities. Under such circumstances, as experience has shown, it is much more productive for the child, his/her family, and the society to promote a comprehensive network approach rather than trying to find a solution in a piecemeal way [2-3].

To achieve these ambitious objectives, social pediatrics emerged in our communities as a service designed to complement existing services.  The goal was to compensate, at least partially, for the gaps in the systems that frequently act alone and inconsistently, and are physically located too far from the children and families that are in a state of such great vulnerability. During the 1990s, a more global bio-psycho-social approach emerged based on confidence, proximity, and interdisciplinarity, drawing upon the concepts of mobilization and empowerment [4]. First and foremost, there was a need to spell out the steps that should be taken to support and accompany families from this milieu in a therapeutic and healing manner. Far too many children were struggling with social problems, poor living conditions, and a lack of access to services that would provide a sufficiently high level of health and wellbeing.

Over the years, three social pediatrics centers were set up in two disadvantaged neighborhoods in Montreal: Hochelaga-Maisonneuve and Côte-des-Neiges. They sprang from a community movement to achieve the ultimate objective of good health for children. The target group was children on a difficult trajectory, and everything was based on using and pooling resources in the family and social networks.

The social pediatrics approach applies to various types of intervention – clinical measures designed to offer a full range of integrated services for children, as well as other measures involving the determinants of health, including factors that target the social inequities that play a role in the failure to respect children's fundamental rights.

Today, the three Montreal social pediatrics centers offer both – frontline and secondary services, addressing the problems that children from these neighborhoods may encounter and anything else that may be harmful to their health, development, and wellbeing. The centers are local models of know-how in terms of getting things done and organizing effective ways to help.

To date, the Foundation of Dr. Julien has inspired, trained, and certified more than twenty community social pediatrics centers in the province of Quebec and a few more in Canada on the whole.

A four-dimensional approach

To understand the specific way social pediatrics works, we suggest examining four major measures that are essential for the ongoing development of services for children:

1. First of all, we must make sure that quality services are accessible [5]. These services must be present in an integrated form for those who need them. This involves training a small core group of competent people in the community who are ready to help children who are in trouble. They are there to support the children and act on their behalf, helping to prevent or eliminate factors that are deep-rooted in the problem, or at least reduce the impact of these factors on the child's health and development.
   
   
2. The next step is to find ways to make the child's environment conducive to physical wellbeing. There are so many factors that can be potentially harmful to health. Constantly living in a precarious state, the way many people barely survive, dealing with difficult everyday circumstances, with no access to appropriate and timely health care, feeling no sense of hope, dreading birthdays and holidays – all of these create a negative climate. In such vulnerable situations, the extended activation of stress response can have harmful impacts on brain development and architecture, and consequently increase the risk of developing diseases and cognitive disorder [6].

Moreover, not having appropriate seasonal clothing, healthy food that provides the energy to complete daily tasks, or school supplies to support learning are a few minor but all too common examples of inadequate living conditions. Apartments that are cramped, poorly heated, infested with rats, cockroaches, or bugs, affect the morale of the whole family, create stress, and put children's health at risk. It should come as no surprise that we find so many respiratory diseases, undiagnosed or untreated hearing problems, gum infections, concentration problems, and developmental delays in impoverished areas. Nor is it surprising that under such conditions, more than one-third of children are not ready to start school successfully, which in its turn leads to rejection, reports to youth protection, and juvenile delinquency [7]. There is nothing normal about the fact that children can no longer play safely in lanes or parks, which have become dangerous and toxic places. Under such conditions, is it any wonder that we see so many children who have forgotten how to dream? That's why the practice of community social pediatrics involves taking action every single day to reduce the impact of social injustices on children’s health.

3. Since the wellbeing of children is an issue that affects the whole community, the third major characteristic of community social pediatrics practice involves mobilizing the community. It all starts with a significant initiative for the child built around a small core group of motivated people, with other people, projects, and measures added gradually and spontaneously as needed. All this forms a true “protective circle” around each child in the community, helping children to develop fully, discover their talents, and put them to use for the good of humanity [8]. Only a community that stays close to its children can hope to earn the title of a “healthy community,” a title every community should aspire to achieve.
   
   
4. The final measure targets the full and complete recognition of children's fundamental rights by society. The practice of community social pediatrics presupposes that those who are mobilized via this approach will speak out long and loud on behalf of and with the children, with the goal of training the community to come together to eradicate the known inequities that run counter to any social justice [9].

Advocacy, the defense of their interests in action, one of the moving forces of community social pediatrics, illustrates that commitment. The aim is to have children's obvious value to society recognized, denounce the injustices, large and small, that children struggle with every day, and most of all, take action to reduce or eliminate the impact of injustice on children's health. The Convention on the Rights of the Child [10] serves as a backdrop for this movement, which must be understood, disseminated, and integrated into any action or policy that involves children. As we know, inequities, prejudices, and disparities are harmful to their full development; talk is cheap, and it is not enough to make things change. It is equally important to implement measures that promote equity – locally and globally.

A prevention-based approach

Built into the community social pediatrics approach is the need to proceed with confidence and empathy to better understand, win over, and really help children who come from fragile backgrounds. People who are engaged in this practice do not behave like judges or accusers; instead, they take a comprehensive and constructive attitude to reassure and guide the children and their circle onto more harmonious pathways while helping to empower them. The goal of this approach is to offer accompaniment and support so that children can develop fully.

In this type of helping relationship, we must always consider the deepest nature of the individual, which remains sensitive and fragile despite the defense mechanisms that are frequently erected to hide it. A child – or even an adult – who is in a stressful situation or feels helpless will be reassured by such an approach. The child will drop his or her defenses, revealing the true personality, the personality with a deep desire for peace, happiness, and love. This is the personality the community social pediatrics team wants to work with, not the personality that resorts to subterfuge, hides behind a mask, and can only act in the face of constraints, rules, and authority. To fully respect individuals and defend their rights, the sole authority is unconditional love.

Preventive action is thus an essential basis for establishing a true social project for the children of a given community. A successful preventive model is a model in which no children from the community are left behind, in which everyone receives the services they need, fairly, without distinction as to race or social status, and in accordance with their overall needs and fundamental rights.

Taking preventive action is a serviceable concept for informing, warning, and influencing individuals or groups when it comes to finding a solution to a harmful and predictable problem. It lets us to rely on the strengths and abilities of the individuals and their circle, calling on individuals, parents, and communities to get involved and watch out for our children [11]. The initial step is to get to know, respect, and understand the people and provide information and support for the active steps they take in a positive environment. Taking preventive action means, first and foremost, setting up support tools that can serve as reinforcements and safety nets so that all children get the attention they need for their full and ongoing development.

The concept of empowermen

The social project advanced by community social pediatrics is based on empowerment, the power of the child, parents, and community to take action. Significant participation by the family in studying the problem, seeking appropriate treatment, evaluating all the help received, and deciding whether to continue receiving assistance is crucial [12-13]. The child and parents have the right to be directly involved in all decisions regarding support plans for health care, social services, or legal assistance. The form of treatment is designed with the direct participation of the child and those in the child’s circle. Nothing is ever imposed, except in uncontrollable critical situations. Those with the greatest interest in the child’s wellbeing consent to the treatment, which makes it acceptable to all because a consensus has been reached [14].

Community social pediatrics and protecting children

Protecting children should be the top priority for every society. With the major social upheavals we have experienced over the past few decades, changing values, and the growing tendency for communities to disengage from watching out for our children, we find ourselves in a complex situation today.  We have reached the point where responsibility for protecting and educating our children has been largely handed over to government systems. In practice, however, we can see that the system is often overwhelmed. So the time has come to react and reclaim responsibility for our children, with support from the systems set up to protect and educate them. We have certainly gained some ground as a society, and of course there is no question of jettisoning it all.  But we need to remodel the ways we intervene to make life settings more conducive to children’s development.  Enhancing children’s harmonious development requires a clear consensus from the communities involved and finding appropriate ways of doing things locally. First and foremost, the government must agree to share power with the family and the community, especially when it comes to preventing neglect and responding to children’s needs and best interests [15].

To facilitate this change of paradigm, we have implemented jointly with community social pediatric centers, the “Alliance droit santé” model – a powerful  alliance between the law and health care.  As its name suggests, this is an association of practitioners of community social pediatrics and members of the legal profession, the type of partnership, which has become a necessity in the field.

The political changes that should happen

To make sure that children’s development in their milieu is protected, the community social pediatrics approach focuses on major changes that are needed in the administrative, legislative, and political spheres:

• Funding for child protection should be redistributed to local authorities so that communities can take back the responsibility that is rightly theirs.
• Human and material resources (including the capacity to diagnose in medicine) should also be transferred to communities, in close proximity to the target groups.
• Respite programs, local foster families, interdisciplinary assistance centers, and support mechanisms for children and families should be set up based on the community social pediatrics model.
• Authorities that provide services for children should ideally be local players, recognized by families and children, and chosen to serve as their representatives.

The input from the local community on issues of children’s health and development is essential and fundamental. It is extremely important to preserve the integrity of children and the milieu as much as possible. Any form of detachment or disengagement by the community in favor of an outside policy or group means that the community is renouncing its responsibility to children.  In fact, as we have seen, once an outside force takes power, there is a serious risk that the child’s rights are not being considered, such as the right to personal identity, the right to preserve family relationships, and the right to speak for oneself.

References

[1] What Determines Health? Public Health Agency of Canada. Retrieved July 26th 2017 from http://www.phac-aspc.gc.ca/ph-sp/determinants/index-eng.php#key_determinants

[2] Epp, J. (1986). Achieving Health for All: A Framework for Health Promotion. Ottawa, Ontario: Health and Welfare Canada. .Evans, R.G., Barer, M.L., Marmor, T.R. (Editors).

[3] Garner A.S., Shonkoff, J.P.(2012). Committee on Psychosocial Aspects of Child and Family Health, Committee on Early Childhood, Adoption, and Dependent Care, Section on Developmental and Behavioral Pediatrics. Early childhood adversity, toxic stress, and the role of the pediatrician: translating developmental science into lifelong health. Pediatrics. 129 (1). Available at: www.pediatrics.org/cgi/content/full/129/1/e224pmid:22201148

[4] Julien, G. (2004). A Different Kind of Care: The Social Pediatrics Approach, Montreal: McGill-Queen’s University Press.

[5] Andersen, R.M. & Dadvison, P.L. (2001). Improving access to care in America: individual and contextual indicators. In : Andersen R.M., Rice T.H., Kominsiki E.F. (Eds.). Changing the US health care system: Key issues in health services, policy and management. San Francisco, CA.

[6] Shonkoff, J.P, & Garner, A.S. (2012). The lifelong effects of early childhood adversity and toxic stress. American Journal of Pediatrics.129, e232-e246.

[7] Chaudry, A., & Wimer, C. (2016). Poverty is Not Just an Indicator: The Relationship Between Income, Poverty, and Child Well-Being. Academic Pediatrics, 16, 23-29.

[8] Maguire-Jack, K. & Showalter, K. (2016). The protective effect of neighborhood social cohesion in child abuse and neglect. Child Abuse & Neglect, 52, 29-37.

[9] Zuckerman, B. (2012). Medicine and Law: New Opportunities to Close the Disparity Gap, Pediatrics, 130, 943-944.

[10] Convention Relative aux Droits de l’enfant. Unicef. Retrieved July 26th 2017 from  https://www.unicef.org/french/crc/

[11] Shonkoff, J.P. (2010). Neuroscience and the Future of Early Childhood Policy: Moving from Why to What and How. Neuron, 67, 689-691.

[12] Harrison, C. (2004). Treatment decisions regarding infants, children and adolescents: position statement. Paediatric Child Health, 9, 99–103.

[13] Lemay, L. (2007). L’intervention en soutien à l’empowerment: du discours à la réalité. La question occultée du pouvoir entre acteurs au sein des pratiques sociales. Nouvelles pratiques sociales,20, 165-180.

[14]  Luc, E. (2010). Le leadership partagé : modèle d’apprentissage et d’actualisation, Montréal : Les presses de l’université de Montréal..

[15] Plough, A., Chandra, A., Bolla, P., Leviton, L., Miller, C., Orleans, C.T., Shah, T., Tait, M., Trujillo, M., Acosta, A., Carman, K., Dubowitz, T., Martin, L., Nelson, C., Ryan, G., Smith, B., Towe, V., Williams, M., & Yeung, D. (2015). From Vision to Action: A Framework and Measures to Mobilize a Culture of Health, Princeton, N.J.: Robert Wood Johnson Foundation.