Our database searches returned 14,658 unique articles, of which 342 met inclusion criteria upon review of titles and abstracts. Full text review yielded 72 relevant articles. Purposive sampling of relevant literature complemented our electronic searches, and was refined in light of the emergent results from data analysis. adding an additional 51 original articles, for a total of 123 articles (eFigure 1).
Our review of the literature exposes few explicit analyses of the normative foundations of child health and social policy. Formal attempts to name, interrogate, or prioritize select values—either generally or in specific policy domains—are rare. Three central themes, each encompassing a few key values, emerge from the literature: potential, rights, and risk. The theme of potential captures discourse on childhood as a developmental state angled toward adulthood, and the evolving capacity implied by this trajectory. Rights relate to ideas, normative and legal, about the human rights held by children, which have gained prominence over recent decades. Risk incorporates ideas about vulnerability and the corollary need for protection that animate scholarship about children and childhood across a range of disciplines. Many of the values within these themes crop up and retain relevance in diverse policy domains. A set of established foundational concepts related to social policy for children—well-being, participation, and best interestsof the child—cuts across and links these central themes. Finally, an overarching theme of embeddingboth familial and societal—emerges from the academic discourse in all policy domains examined; it gives form to the pervasive issue of a child’s place, in the family and in society, at the heart of much social theory and applied analysis on children and childhood (Figure 1).
Potential
The idea of latent or unrealized potential inherent in children dominates in much of the literature. Allusions to childhood as a ‘state of becoming’ cross disciplinary bounds and policy domains, as do justifications for policy agenda setting, development and implementation premised on the realization of childhood potential. A number of distinct, if overlapping, sub-themes surface recurrently. Notions of futurity, and arguments for investment in children, inhere in both theoretical discourse about childhood and applied analyses of a range of child-centred policies [19]. These arguments emphasize and often explicitly value children’s potential to contribute to society as eventual adults—especially as ‘return on investment’ in economic terms—and leverage this idea as guidance for policy formulation [20,21]. Critically, this future orientation often eclipses valuing the present needs, experiences, and perspectives of children [22]. Such constructs closely align with the core values and assumptions of economic liberalism, wherein productive work and economic contribution epitomize social capital. Related to this are frequent equations of childhood with preparation. Childhood is routinely construed as a preparatory stage of life, framed as both an opportunity and a means to socialize the young into prevailing societal norms and expectations [24].
Varied policy domains invoke the idea of the child’s potential in different ways. Both ‘return on investment’ and health promotion have served as key normative frames for child health policy debate. Evidence suggests these tropes have helped disaggregate children from other disadvantaged groups and produce the political consensus necessary to move policy initiatives on health coverage for children forward [25]. Childhood potential has also been invoked in health policy discourse to address national security concerns. Successive child health coverage expansions in the US relied heavily on policy frames such as early vulnerability, human potential, future economic contribution, and, in particular, long-term national economic productivity and military strength [26]. Notions of return on investment also prevail in the scientific and policy literature on early childhood development ECD. Mounting knowledge about the impacts of early childhood environments and experiences on brain development and long-range cognitive outcomes has underwritten the development of policy arguments based on future potential and ultimate economic contribution [27]. By contrast, in the field of child welfare, the available evidence on policy impact at the population level is comparatively thin, so discourse focuses on extrapolating moral arguments from individual cases to broader child welfare policies. Moralistic frames predominate: arguments based on desert, rather than outcomes, have often held sway [28,29].
Rights
Rights-based language figures prominently in the academic literature concerned with the moral dimensions of public policy for children. Rights have the broadest disciplinary reach, mirroring the 20th century ascendance of human rights legislation and jurisprudence in national and international spheres of governance. Much of the literature draws on discourse and tenets from the United Nations Convention on the Rights of the Child (CRC), the signal child rights covenant of modernity [30]. The ratification of the CRC dramatically increased the volume and changed the tenor of academic scholarship on children’s rights. The construct of ‘the competent child’ has emerged, an image focused on the child as a rights-bearing individual: one with legitimate needs and preferences, the right to voice them, and the right to participate in decisions about how to meet them. Notably, while the discourse on ‘potential’ focuses on the effects of policy, rights discourse introduces issues of policy process; the participatory rights of children, and the inclusion of their voice in policy decisions impacting them, are fundamental concerns. This discourse strains traditional notions—common in the child protection movement and couched in the rhetoric of risk—of the child as a passive, incomplete and ultimately incompetent vessel in need of protection and edification [31].
The literature reveals important synergies between child rights and children’s well-being. A parochial definition of well-being conceives it as the absence of abuse, neglect, exploitation; a more expansive definition focuses minimally on need, and optimally on inclusive, holistic definitions of a high quality of life [32,33]. Conceptions of child well-being in academic discourse have evolved from narrowly-conceived ideas related to the protection of the most vulnerable in the 19th and early 20th centuries, to expansive ideas about well-being couched in the universal rights of children [34]. The justification for child well-being has evolved in tandem from one founded in charity to one premised on entitlement. The broad acceptance achieved by the CRC has tied notions of child well-being to achievement of their social, cultural, economic, civil and political rights [35], and has tempered culturally relativistic renderings of children’s purpose and well-being [36].
A parallel narrative centred on participation emerges in the literature, which sets in relief the role of rights in changing ideas about a child’s well-being. Changing mores about children, founded in changing models of the young child, have influenced ideas about the legitimacy and necessity of involving children in policy decisions that affect them. Child rights are one of the principal drivers of changing societal perceptions [37]. Relatedly, recent insights in the field of child development studies have contributed to major changes in conceptual models of the young child, with corresponding implications for, and impacts on, ideas about involving children in policy decision-making [38]. The upshot has been a progressive incorporation of ideas of autonomy and participation into the ideas about children’s well-being: in policy domains as diverse as predictive genetic testing, sexuality and sexual health, child welfare, public health, and research involving children; and in forms as varied as a seat at the policy table, proxy communication through identified advocates, and the incorporation of research evidence on children in policymaking [39].
Risk
Risk is a central theme linking social values to policies for children, its expression varying by discipline and domain of social policy [40]. Innocence is a frequent precursor to notions of risk. Representations of the child as primitive and innocent abound in popular, scholarly, and political cultures, with either positive and utopian or negative (feral, delinquent) connotations [1]. Innocence relates closely to notions of vulnerability and protection, as well as to the conception of childhood as a preparatory period of ‘socialization’ discussed above. Allusions to vulnerability shape a common view of childhood as inherently risky. Vulnerability discourse is marked in the childhood development and welfare literatures. Insights from developmental science identify sensitive periods during which early experiences can have outsized influence on developmental trajectories, especially cognitive, psychological and physiological patterns of behavior [41,42]. The child-as-vulnerable also prefigures but draws inspiration from theories and evidence on maternal-child bonding in developmental psychology [43]. Permanency is a closely related idea that has predominated in child welfare discourse and policymaking. Child welfare scholars and advocates theorize that stability in early childhood environments allows for bonding with a ‘psychological parent’ that diminishes risk in early childhood and fosters improved developmental outcomes [44]. The confluence of these perceived determinants of risk—innocence, vulnerability, and a need for relationship permanency - induce an emphasis on protection and provision as natural domains for social policy touching on children. Protection from abuse and neglect has served as a hegemonic principle in social work and child welfare systems across disparate polities for much of the past century [40].
Themes about protection from risk relate closely to the concept of children’s best interests. This connection emerges most clearly from the child health and welfare fields, in which the concept of ‘best interests of the child’ (BIC) has served as a dominant moral and legal yardstick [45]. The standard assimilates concepts related to protection from harm and promotion of welfare, and centres on an assessment of the balance between the benefits and risks of an intervention or policy [46]. The health care field has long adjudicated clinical or research interventions in children by reference to BIC. BIC is a central standard in the ethics of clinical practice. However, the locus of interests accounted for—those of child, parent, or family—complicates the interpretation of BIC. A prime example relates to genetic testing in children [47]. When genetic disease is not amenable to prevention or mitigation during childhood proper, the BIC standard has often dictated deferral of such testing until such time as the child can make an informed decision about it [48–50]. Questions surrounding the handling of incidental results from whole genome sequencing, and the rights of family members to knowledge of such results, have challenged the traditional understanding of best interests [51]. A tension is evident between notions of family-embeddedness and the evolving autonomy and capacity of children [52,53]. In the realm of research involving children, a different tension emerges between the protection of children, as a uniquely vulnerable population, and the promotion of aggregate child welfare through advancements in scientific knowledge [54]. Lags in child-centred health research—particularly in the realm of drug and technology development—have challenged the definition of BIC as protection of the individual child from research-related harm, widening its scope to encompass the harms suffered by populations of children from constraints on scientific progress [55].
Child welfare scholarship and case law have also routinely employed BIC as a means to measure the need for, and justify interventions to enhance, child protection. The concept itself has roots in English feudal law, and relates to the doctrine of parens patriae: the king as father of his people. Initially employed to legitimate sovereign wardship over ‘natural fools and idiots’, it was gradually expanded to include state duty towards the protection of children [46]. The best interests standard has come to serve, in most liberal democracies, as a bulwark against historically unfettered parental possessory rights. A child’s best interests have become an elemental facet of legal decisions—and popular sensibility—regarding the protection and well-being of children in society. The institutionalization of rights discourse, culminating in the CRC, has underwritten this tendency: the rights of the child imply specific corollary duties—of the parent, of society—that justify the curtailment of certain freedoms [56]. As with potential and rights, risk is relational: it is situated in family and societal contexts, and calibrated against the interests of each.