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4. Children and Adolescents Children, as a group, constitute one of the most vulnerable segments of our society. They are subject to a wide range of health problems and are dependent on families and communities for sustenance and protection from health hazards. At the same time, childhood offers an important opportunity to set lifelong healthy behavioral patterns. Thus, the health promotion and disease prevention needs of children and adolescents need to be examined. Almost 50 witnesses focused their testimony on issues related to the health promotion and disease prevention needs of children and adolescents. Some addressed crosscutting topics, most notably problems that children face with access to health care, but also the special needs and opportunities presented by day- care facilities, the role that the media can play in promoting child health, the necessity for coordinated services for adolescents, the special needs of children with a chronic illness or disability, and special data and information requirements for children and adoles- cents. Other testifiers addressed specific health prob- lems and opportunities for health promotion, but with a special focus on children and adolescents. In health promotion, for example, testifiers addressed nutrition, substance abuse, physical fitness, and mental health with a special focus on adolescent suicide. In health protection, they addressed primarily the prevention of unintentional accidents, as well as child abuse and other forms of violence. Finally, with regard to pre- ventive services, testifiers addressed the prevention of infectious diseases, improving oral health, and screen- ing for chronic diseases. Other issues of interest to children and adolescents are discussed throughout this report. Chapter 22 on maternal and infant health, for instance, deals at length with the problems of infants, so these are not discussed here. The section on the school as a setting for health promotion and disease prevention programs in Chapter 9 is clearly relevant to children and adolescents. One problem with school-based Pro- grams, however, is that not all adolescents stay in school long enough to benefit from them. Richard Eberst of the American School Health Association points out, "A large percentage of school age children are disenfranchised from the nat~on's schools. They are in jail, on the street, working, or on the run." Thus, health objectives regarding school children are 28 Healthy People 2000: Citizens Chart the Course not enough to cover the full needs of children and, especially, adolescents. (#055) CROSSCUTTING TOPICS Some witnesses addressed issues that cut across established priority areas for the national objectives but are necessary for designing interventions to improve the health of children and adolescents. The most central issue is access to health care, which is seen as a serious impediment to improving child health. Child-care centers are seen as both a problem to be addressed and an opportunity for implementing some of the national goals. The media, too, present problems that must be addressed yet can be a power- ful force in educating children about improving their health. According to a number of testifiers, many of the problems that adolescents face-substance abuse, mental health, teen pregnant y, violence, and so on are interrelated; thus, coordinated services, not individual approaches, are required to address the complex of issues. Other testifiers addressed the problem of the growing number of children with chronic diseases and suggested programs designed to meet their needs. Access to Care A recurring theme in the testimony is the effect of economic and financial concerns on health, resulting in lack of both access to and availability of health care. Such concerns are of particular relevance to children because they are more likely than other age groups to be living in poverty and, thus, to be subject to the attending health problems. In 1981, 19.5 percent of children under 18 were below the poverty level, compared to 14 percent of persons of all ages.t The American Academy of Pediatrics (AAP) gives access to care for all children its highest priority. "The American Academy of Pediatrics feels that the ultimate child health goal is to assure access to health care for all of America's children." The academy suggests objectives to reduce the proportion of children who are uninsured, to ensure that all Medicaid jurisdictions adopt maximum eligibility options, to reduce the proportion of uninsured chronically ill children, and to reduce the number of

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U.S. counties that are underserved by child health physicians. The AAP recommends that these goals be accomplished by providing universal access to care through entitlement programs or by expanding Medicaid and private insurance coverage, encouraging states to take advantage of Medicaid services, and legislation. The academy suggests that the supply of physicians for underserved areas could be improved by making practice opportunities more attractive and available in rural areas and inner cities through such programs as the National Health SeIvice Corps scholarship program. (#115) Child-care Centers and Health An important focus for child health mentioned by a number of testifiers is the child-care or day-care center. An increasing number of U.S. families are in need of child care, according to Thomas Hyslop and his colleagues at the Harris County Health Depart- ment in Texas. Of working mothers with children younger than three years of age, 53 percent are in the workforce.2 (#104J When parents work full time and adequate child care is unavailable, older children are often left unsupervised, according to Hyslop. He also contends that unsupervised children are at higher risk for a number of problems, including accidents leading to injury, earlier sexual involvement (potentially leading to unintended pregnancy or sexually transmitted diseases), being the victims of crimes such as sexual assault, and becoming involved in undesirable be- haviors such as drug abuse or petty crime. Undue stress is another health problem experienced by children who fear being home alone and by the parents who must leave them. (#104) Michael Jarrett, Commissioner of the South Carolina Department of Health and Environmental Control, says that day care should be addressed in the Year 2000 Health Objectives, especially because of the continual growth of single-parent families and employ- ment of both parents in two-parent families. Further, he feels that day care should reflect not only the narrow perspective of care for the healthy child, but also the needs of the acutely ill child or of children with special health care problems. He recommends that the objectives address such issues as licensing, standards, staffing, availability, and accessibility of day- care facilities. (~108) Improvements are needed to offer greater access to quality child care, to ensure the optimal development of children of working parents, and to ease the stress associated with working families and worries about quality child care, according to the American Academy of Pediatrics. The specific improvements suggested include making child care more affordable for low and moderate income families, increasing the number of child-care programs and qualified child- care staff, improving the quality of child care, assisting parents in locating child care that meets their needs, and coordinating child-care funding with state and local early childhood development programs-Head Start, general preschool programs, and preschool programs for handicapped children. (~115) The American Academy of Pediatrics and the American Public Health Association are developing joint performance standards in health, nutrition, safety, and sanitation for out-of-home child care, and Debra Hawks, the project's director, recommends that these standards be used as the basis of new national objectives addressing child care, intervention strategies, and data collection systems. (~089) Hyslop and Holly Wieland of Silver Spring, Maryland, advocate federal initiatives for child care at the national level. (#104; #331 J Mary Grimord of Texas Woman's University wants an objective to promote affordable day care that meets minimum standards. She says that this will reduce childhood injuries and provide a more healthful environment. (#303) David Lurie, Commissioner of the Minneapo- lis Health Department, asks that all child-care facilities be required to follow proper procedures for food storage and preparation, environmental sanita- tion, and health and safety codes, and that health advice be available to all facilities. (#535) The Media and Children's Health According to the American Academy of Pediatrics, television has a strong, but as yet unrealized, potential for improving the health of children. The AAP mentions the adverse effects that television advertising and programming can have on the learning and behavior of children and adolescents: promoting violence; decreasing physical activity and fitness, and possibly increasing the likelihood of obesity; detracting from time spent reading; and presenting unrealistic or inappropriate messages about drugs, alcohol, tobacco, nutrition, sex roles, and sexuality. The AAP supports legislative efforts to improve the content of children's programming and promote more constructive viewing. The AAP hopes that, through improvement of the quality of children's television programming, the health of children and adolescents can be influenced Children and Adolescents 29

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positively in such areas as teenage pregnancy, alcohol or substance abuse, tobacco use, accidental injury and death, nutrition, physical fitness, suicide or homicide, and the school dropout rate. (~115J The Oregon Department of Human Resources, in its own draft of objectives for the year 2000 (submitted as testimony), calls for the impact on children of violence in television and movies to be reduced through measures such as revision of the motion picture code to rate violent content separate from language and sex. The age requirement for attending "xn- and Urn- rated movies, the objectives say, should be enforced, and children should be taught to be Violence-literate" in viewing television and movies. (~321) Lou Large, a school nurse from La Porte, Texas, also favors regulating violence in children's television programs and educating parents and children about appropriate viewing. (#304) Coordination of Adolescent Health Services Programs for adolescents usually concentrate on a particular problem, such as drug abuse, and use a medical model of intervention, according to Claire Brindis and Phillip Lee of the University of Cali- fornia, San Francisco. These witnesses and many others advocate a more comprehensive, integrated approach to adolescent health, including outreach, education and counseling, and removal of financial barriers, as well as actual treatment. Coordination of services at various levels is important, as is consistent and adequate funding. (#027) Jarrett concurs and advocates a greater emphasis on comprehensive care centers that meet "not only health needs, but develop- mental needs of the adolescent" as well. After-school programs should be developed, he says, to occupy these adolescents who are often Left to fend for themselves." (#108) Brindis and Lee recommend the following strate- gies to improve access to health care for adolescents: Develop comprehensive-care centers easily accessible to adolescents near the school or in the community, or expand existing facilities to meet the needs of this age group. Allow participation by school dropouts and the homeless as well as those who may have access to other health care services in school-based programs. Establish weekend and evening hours to enable a continual source of health care. Provide education as well as health care, and establish a networking system for referral of specific problems such as crisis counseling, family planning, 30 Healthy People 2000: Citizens Chart the Course and drug abuse. Ensure that staff are sympathetic and qualified to deal with adolescent problems by requiring specific training in this area. Provide the privacy and confidentiality that is vital to participation by adolescents. Improve the integration of health care with social, vocational, and educational services for youth with chronic illnesses and disabilities. (#027) Brindis and Lee also recommend that those who work with adolescents be proficient in adolescent health care and that this be a component of licensing and accreditation for professionals who will be treat- ing this population. Hey believe that adolescent- care issues should be integrated into continuing education programs and that upgraded skills should be required of those who serge children and youth. (~027) Chronic Illness and Disability in Children According to Margaret West of the University of Washington, coping with chronic disease and disability is a way of life for an increasing number of children. Various estimates she cites suggest that 6 to 12 percent of children have chronic or disabling health conditions. In addition, one in ten chronically ill children lack any health insurance.3 Thus, West says, objectives and programs should be developed to prepare children with chronic disease and disability for adult life. Measures of health outcomes for this population should relate to quality of, and satisfaction with, life and meaningful participation in adult roles. According to West, care for these children should focus on helping them manage their conditions and grow to their maximum potential. Programs for this group should include preparation for adult life skills; a health promotion, family-focused component; and issues of separation from families and maintaining maximum independence. Children with chronic di- sease or disability also need better-coordinated systems of care, says West. For example, specialW- care health clinics should expand their personnel to include nutritionists, social workers, and psychologists, and should provide continuity in the transfer from pediatric- to adult-care services; health insurance should be provided without clauses related to income or "spending down" of assets; and health care profes- sionals who care for this population should receive training in preparing the youth for adult roles in society. (~333) The use of community-based, comprehensive, coor

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dinated care; the use of family members as care givers; and strong partnerships between families and health professionals~ll are important elements in the care of chronically ill and disabled children, according to several witnesses. (#108; #372) Linda Henry of Children's Hospital in Denver was critical of the nation's past efforts in aiding these children. What is America's policy toward its chronically ill children? In displacing human dignity, it resembles abandonment, neglect, and ignorance. These children deserve the same rights, protec- tion, respect, and choices that we all would like for ourselves. They deserve choices and oppor- tunities to see what they can become and a chance to live as independent and autonomously as possible. (~3 72) The National Association of State Boards of Education also wants "comprehensive programs aimed at modifying behaviors that involve the broader community." Society cannot afford to address health problems piecemeal through discrete programs aimed at reducing substance abuse, teenage pregnancy, AIDS, and other issues. Rather, they must see these problems as part of a more general at- risk syndrome that requires a comprehensive approach including school and community. (#573J HEALTH PROMOTION A number of witnesses addressed their comments to health promotion needs of children, primarily be- havioral risk factors. Testimony on nutrition focused on the early formation of eating habits, as well as the special nutritional problems of children. Testimony on physical fitness stressed health-related fitness and programs to help children achieve it. Substance abuse, including the use of tobacco and alcohol, is identified as a major public health problem, and programs are proposed for dealing with it. Others testified about mental health issues, especially preven- ting adolescent suicide. Although the specifics differ, one underlying theme in this body of testimony is the attempt to help children and adolescents form pat- terns of healthy behavior that can last throughout their lives. Many of the issues mentioned in this section are discussed more fully in the context of school-based programs in Chapter 9. Nutrition . Those who testified on issues of childhood nutrition addressed a wide range of topics, including nutrition education and the composition of children's diets, nutritional problems such as anemia and growth retardation, and breast-feeding. Evan Kligman, representing the Society of Teachers of Family Medicine, feels that successful educational interventions with the family can improve children's nutrition by decreasing the fat content of meals prepared at home; increasing average daily dietary fiber; increasing dietary calcium intake; decreasing salt intake; and including trace minerals, fresh fruit, and cruciferous vegetables known to have a role in the primary prevention of cancer and cardiovascular disease. (#118J Improving the general nutrition of children through such programs as the Special Supplemental Food Program for Women, Infants and Children (WIC) and school lunches also received support from Jarrett. (#108) The American Academy of Pediatrics suggests that deaths from nutritional anemia can be prevented through education about good nutrition and, most important, through access to health care that includes correct identification of the problem and early treat- ment. Early recognition is needed, the AAP explains, because some anemias are recessive traits and carriers can be helped through genetic screening and counsel- ing. (#115) c~ The AAP also believes that the number of cases of growth retardation can be reduced through better nutrition. It reports that in 1984, 7-13 percent of children had "stunted" growth, and in most cases, the cause was nutritional.4 The AAP recommends that the situation be eased by increased use of such programs as WIC, subsidized school lunches, and Head Start, and by early recognition and treatment of the condition. (#115) Breast-feeding, dealt with more fully in Chapter 22, was frequently mentioned as important to the nutri- tion and subsequent health of infants and children. Physical Fitness The Oregon health objectives sum up the primary concerns of those who testified about physical fitness in the suggested goal of increasing the proportion of children who meet health-related fitness standards and the proportion who participate regularly in a physical Children and Adolescents 31

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education and fitness program that can be earned into adulthood. (#321) The American Academy of Pediatrics also believes that programs should emphasize aerobic and lifetime activities such as bicycling, swimming, tennis, and running, and decrease time spent on football, basket- ball, and baseball-traditional school sports that do not particularly enhance fitness. The AAP says that ef- forts should be made to ensure equal emphasis on sports programs for both males and females. (#115) Substance Abuse Jule Sugarman, Secretary of the Washington State Department of Social and Health Services, sees the misuse and abuse of substances as "one of the major public health menaces today. Such misuse, he feels, plays a causal or contributing role in child abuse, juvenile delinquency, adolescent pregnancy, adolescent suicide, and intentional or unintentional injury. (#337) Others joined Sugarman in his concern, and discussed specific problems and potential interven- tions. The most common substance mentioned was tobacco, including smokeless tobacco, but the prob- lems of alcohol and addictive drugs were addressed as well. The American Academy of Pediatrics cites a report that found that 40 percent of high school seniors did not believe there was a great health risk associated with smoking.S This same report says that 57 percent of high school seniors who ever smoked had their first cigarette by eighth grade or earlier.6 Furthermore, cigarette use by high school seniors has not dropped over the last few years. The AAP attributes this to the effectiveness of advertising by the tobacco industry, which counterbalances health messages on the hazards of cigarette smoking. The AAP advocates continued education of school students and the public, as well as enhancement of legislative efforts to restrict advertisement of cigarettes. (#115) The Oregon Department of Human Resources also recommends using legislation to restrict print advertis- ing of tobacco products, especially when it is aimed at young people. Educational programs about tobacco should be targeted to children and adolescents including the provision of smoking and health infor- mation in school and the development of incentive programs to encourage young people not to smoke. Oregon also calls for better enforcement of existing laws that prohibit the sale of tobacco to minors. (~321) Kligman sees an "intergenerational" impact of 32 Healthy People 2000: Citizens Chart the Course smoking. He advocates programs to reduce smoking among parents of infants and young children in order to reduce the prevalence of otitis media, upper respiratory disease, and other infections associated with passive exposure to smoke. (~118) According to Gabrielle Acampora of the Greater New York Association of Occupational Health Nurses, Black and low-income adolescents are more likely to begin smoking and resist quitting. She suggests that those who drop out of school and then work in small enterprises without health programs might be reached by peer group teens trained as health educators, accompanying occupational health nurses in outreach vans that travel to worksites or in community agencies. (#002) Marge Reveal, testifying on behalf of the American Dental Hygienists' Association (ADHA), and others are concerned about an increase in the use of smoke- less tobacco. The ADHA cites evidence that as many as 22 million people may use these products.7 Even now, despite various health warnings, many users do not consider smokeless tobacco dangerous. The association recommends that smokeless tobacco be included in any objectives or initiatives that address the prevention and control of tobacco use. (#575) According to the American Public Health Association, programs to discourage the use of smokeless tobacco among youth should also be targeted toward athletes and other role models for young people. ~198) Many witnesses are concerned about the use of alcohol by adolescents. Studies indicate that children and adolescents are drinking at earlier ages, and programs in the schools and the media are recom- mended to deal with this problem. (~008; #675) Jarrett sees the need for objectives to address the abuse or misuse of commonly available substances such as cough medicine, glue, and correction fluid, and the misuse of prescribed substances such as steroids in young athletes. (~108) Kenneth Kaminsly of the Wayne County Intermediate School District in Michigan recommends objectives about the use of cocaine (including crack) among adolescents. (#426) Sugarman wants objectives to focus on all addictive and mind-altering drugs. (#337) The American Academy of Pediatrics spells out specific goals for reducing drug use among adolescents, including marijuana, cocaine, hallucinogens, stimu- lants, inhalants, sedatives, and tranquilizers, as well as tobacco and alcohol. (#llSJ These and other topics are discussed more fully in the chapters on tobacco (Chapter 10) and on alcohol and duly abuse (Chapter 11~.

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Mental Health and Suicide Testimony on mental health in children focused on three issues: the promotion of mental health as a factor in general health and well-being, the prevention of severe mental illness, and the prevention of adoles- cent suicide. The three issues are related, of course, but the first is concerned with mental health as a contributor to other diseases, and the latter two are concerned with specific outcomes to be avoided. Kevin Dwyer, a representative of the National Association of School Psychologists, advocates preven- tion of mental health problems of children through a cascade of programs composed of proven communiW- based preventive and treatment interventions that are interdisciplinary and dependent on interagency cooperation. Such programs would use the schools to identifier risk factors in children to treat them, and to educate and involve the parents and family. A national health agenda must focus on primary and secondary prevention of mental illness in the schools, according to the association. To ensure that today's and tomorrow's diverse population of children benefit from schooling, schools must help address personal, emotional, and social development, as well as the concerns of students. (#802) Stress is an important problem that children face. Donna Gaffney of the Columbia University School of Nursing recommends that children between 10 and 14 years of age participate in stress identification and stress reduction programs in the public schools, and that professional educational programs for mental health workers include formal course work in mental health promotion and stress reduction. (~731) Marcia Leventhal of New York University and Nancy BrooksSchmitz of Columbia University suggest that dance can increase self-esteem and self-awareness, relieve tension, heal and strengthen the body, and provide a means of social communication. Therefore, dance should be included as a "core discipliner within the educational framework, and it should also be included in therapeutic regimens and as a common recreational activity in community organizations. (#595) Ellen Speert of Los Angeles suggests that art therapy can be used in the schools to help children deal with stresses caused by the fear of nuclear war. (#477) Gaffney believes that too broad an age group is addressed in the current mental health objectives (15-24 year olds), which obscures the seriousness of the problem in each group and the uniqueness of cognitive, emotional, and social development during three developmental stages. She advocates looking separately at 10-14 year olds, 15-19 year olds, and 20-24 year olds. She also reports an increase in self- destructive behavior in the group age 4 to 15 years, and a concern that children under the age of 10 do not understand the finality of death. (#731) Tom Barrett, a psychotherapist from Denver, says that there is increasing evidence that American youth are finding it difficult to cope with the stresses of growing up in a rapidly changing society. Suicide is the second leading cause of death for youth between ages 15 and 25.8 A contributing factor, Barrett believes, is the failure to recognize suicidal behavior. Barrett cites surveys indicating that many youth agencies, including those directed at drug and alcohol use, do not fund suicide-related programs, although substance abuse accounts for many diagnoses of suicide. He recommends that the new objectives set as a goal an increase in the number of school systems with programs to identify youngsters at risk of suicide, an increase In schools with crisis intervention teams, and an increase in suicide prevention programs in colleges and universities. (#702) Martha Medrano of the University of Texas Health Science Center at San Antonio indicates that adoles- cent suicide has nearly tripled over the last several decades.9 Because of this, she proposes an objective to reduce the U.S. teen suicide rate by educating the media about what factors lead to the "contagious" effect of suicide and encouraging the media to volun- tarily adopt reporting guidelines. Education about risks and warning signs for suicide in adolescents should be given to medical students, Primary care . . ~ physicians, emergency room attendants, teachers, parents, and students. Medrano also recommends testing professionals to assess their knowledge, as well as surveys of community-based referral sources after a suicide has occurred "to see if there has been an increase of referrals of adolescents (suicidal or not) from the victim's school." (~500) Damien Martin of New York City reports that homosexual and bisexual young people attempt suicide at substantially higher rates than other adolescents. He recommends that questions of sexual orientation and sexual problems always be considered by those who treat or counsel adolescents who have attempted suicide. He suggests that programs about sexuality in general, including homosexuality, be offered in schools and other adolescent settings, and that such programs also be offered to adult groups such as parent-teacher associations. Research, clinical, and educational pro- grams about teenage suicide should include sexual ori Children and Adolescents 33

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entation as a possibly important factor. (~466) The American Association of Child and Adolescent Psychiatry (AACAP) says that the number of children and adolescents at risk for psychiatric illness, though undocumented, is overwhelming and growing at the same time that federal resources for training in this area are shrinking. The AACAP argues that preven- tive programs are highly fragmented and that a systems approach is required. It cites examples of good approaches such as a new project to upgrade the visibility and services of the mental health component of Head Start, and the Child and Adolescent Service System Program, a coordinated network of children's mental health sentences, funded by the National Institute of Mental Health and being developed in 28 states and 11 communities. (#009) Carl Hager of Seattle is concerned about the overuse of psychoactive drugs in children. He says that many children who are diagnosed as having an attention deficit disorder are put on drugs that have dangerous side effects. (#347) HEALTH PROTECTION Witnesses who addressed health protection issues focused primarily on the prevention of injuries-both accidents and intentional violence, particularly child abuse. There also was some testimony on environ- mental hazards for children, especially lead. Unintentional Injury Unintentional injury is the leading cause of death in the first decade of lifer and many testifiers suggested ways to prevent it in the home and especially in automobiles, where many of these injuries occur. The Oregon health objectives suggest that special emphasis be placed on fatal injuries in children under 15 years of age, because this is the only age group in which the rate of fatal unintentional injuries is increasing. They mention specific steps that should be encouraged in the home, including installing cabinet locks, lowering water heater temperature, blocking electrical outlets, and using safety containers for potentially harmful substances. Oregon also recommends improvement of home safety through adoption and enforcement of building codes and regulations pertaining to fire alarms and smoke detectors. (#321) Jarrett would also like to see emphasis placed on injury prevention for children. Parents and care givers must be educated to recognize risks and 34 Healthy People 2000: Citizens Chart the Course hazards that emerge as children develop, and to know what preventive measures should be taken, for example, eliminating access to guns in homes. (#108) Claude Earl Fox, the Alabama State Health Officer, reports that motor vehicle accidents are the leading cause of death from birth to age 34, and that increased and correct use of child safety seats can reduce loss of life and prevent serious injuries. He refers to recent studies showing that correctly used child safety seats in passenger cars are 71 percent effective in preventing fatalities, 67 percent effective in reducing the need for hospitalization, and 50 percent effective in preventing minor injury. Only 44 percent of Alabama children under five, however, are fully protected by the correct use of safety seats, he reports.~3 (~0663 Joseph Hill of the Detroit Department of Health also recommends that the objectives seek to increase correct child safety seat use. To help promote this goal, public education should teach correct use, manufacturers should update construction of proper seats to match changes in automobile design, law enforcement agencies should clarify requirements of safety seats for children under four, and financial provisions should be made for those who cannot afford to buy seats. (~404J The American Public Health Association suggests that there be a separate objective for reducing alcohol-related vehicular accidents for those under age 25, because this remains a leading cause of death in this age group. (~198) The American Academy of Pediatrics focuses on several particular preventable injuries: 1. Bicycle-related head injuries could be reduced through increased use of bicycle helmets and educa- tion in proper bicycle safety procedures. 2. Drowning deaths of younger children could be reduced through increased use of secure fencing around swimming pools. Drowning accidents of older children, particularly teens, could be averted through swimming lessons, education in boat safety, proper maintenance and use of flotation devices, and enforce- ment of laws prohibiting consumption of alcohol with boat use. 3. Reduction in the number of deaths from accidental poisoning could be achieved through labeling poisonous products, establishing and main- taining poison control centers, maintaining and improving child-proof packaging, and increasing education and public awareness campaigns. 4. A substantial number of accidents and deaths could be avoided by banning the use of all-terrain

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vehicles (ATVs) by children under the age of 16. The public should be educated about the hazards ATVs pose for children, and these vehicles should be eliminated by the year 2000. (#115J Child Abuse and Family Violence Child abuse and family violence were seen by many of the witnesses as serious problems that should be addressed in the Year 2000 Health Objectives. The American Academy of Pediatrics says that in 1987, 2.3 million cases of child abuse were reported.~4 (#115) According to Sugarman, intentional injuries can result in death or significant and lasting health damage to children, and such injuries should be regarded as largely preventable. Owe must give up the idea that violence is something we can do nothing about except call the police after the damage has been done.n (#33 7J A representative of the Detroit Department of Health suggests a range of strategies for lowering the rate of child abuse and neglect, including support programs for new and prospective parents, parenting education, affordable and accessible child care, home visiting by health professionals, and life-skills training for children and young adults. Further recommenda- tions are to increase public awareness of child abuse prevention; to increase the knowledge of health professionals and other service providers; to coor- dinate and improve the availability, accessibility, and quality of health services for families; to develop data systems for monitoring trends in incidence and prevalence; and to expand research efforts on predi- sposing factors and the effects of intervention and prevention activities. (#207) Both chronic neglect and pathological violence against children must be targeted. (~108) Blanche Russ, Executive Director of Parent-Child in San Antonio, also suggests mass media awareness campaigns and more manpower in agencies that deal with child abuse and family violence. (#748) A reduction in the number of cases of child abuse could be achieved through early recognition of poten- tial abusers by social service agencies and health personnel, early intervention and treatment of abusive parents, and increased public awareness of the prob- lem, according to the AAP. (#115) Oregon reports that risk factors for perpetrators of child abuse have been studied extensively. Structural factors include poverty and unemployment, too many or unplanned- for children, lack of education about childrearing, prolonged marital stress, and social isolation of the family. Cultural factors include belief in physical punishment as a socializing agent, belief that parents have a right to do what they want with a child, and parents' unrealistic expectations of children. Psycho- logical factors include parents having been abused as children or parents having had a violent role model. Children who are victims of violence have delayed physical, emotional, and social development; even children who witness violence may become victims, with many experiencing post-traumatic stress disorders. The Oregon objectives urge that prevention programs be developed to help parents increase their skills in raising and responding to their children; required parenting curricula should be developed for the public schools. (#321) Lead Poisoning John Strauther of the Detroit Department of Health reports that lead poisoning has been called the most common preventable pediatric disorder in the United States. It should be of concern not only in children with overt symptoms, but also in those with only moderately elevated levels. (#412) Ellen Mangione of the Colorado Department of Health says that since the 1990 Objectives were written, the definition of lead toxicity has changed, and lower threshold values have been established. The Year 2000 Health Objec- lives should strive to set a lower, scientifically feasible toxicity level or else set a population target of zero. (#362) Strauther recommends a broad-based, intensive effort to reduce lead in the environment, especially in gasoline, water, street and house dust or dirt, and food. He also recommends that children ages one through five should be screened annually for lead poisoning and that the medical community should be better informed about lead hazards. (~412) Environ- mental regulations, such as establishing sanitary landfills and separating potentially contaminating materials from household garbage, also can help eliminate lead hazards. (#108) PREVENTIVE SERVICES Several testifiers addressed interventions to prevent specific diseases and health problems in children and adolescents. They focused primarily on reducing the spread of infectious diseases, preventing oral disease, and screening for chronic diseases. A large body of testimony dealt with the prevention of AIDS, sexual- ly transmitted diseases, and teen pregnancy, all of Children and Adolescents 35

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which have an important bearing on adolescents and are discussed in Chapters 19, 20, and 23. Infectious Diseases The Oregon objectives point to the high levels of childhood immunization that have been achieved in many areas for most vaccine-preventable diseases and the consequent reduction in the incidence of measles, rubella, diphtheria, tetanus, whooping cough, and poliomyelitis. They recommend further improvement in the proportion of children in schools and day-care centers who are up-to-date on all their immunizations. (#321) One representative of the Detroit Depart- ment of Health, however feels that it is unrealistic to expect that 95 percent of children will have up-to- date official immunization records by 1990 (the current goal), or possibly even by 2000. (#393J Since the 1990 Objectives were written, new vaccines have become available, and certain popula- tions have special needs for both new and existing vaccines, says the Oregon Department of Human Resources, which projects that immunization of all infants against Hemophilus influenzue during infant y could lead to at least a 90 percent reduction of H. inpuenzae invasive disease and its sequelae, including meningitis. Most such cases of meningitis are in children under five years of age; 5 percent of these children die, and 25-35 percent of those who survive sustain damage to the central nervous system. Immunization of 18-month-old children would prevent about 40 percent of the cases. A newly developed vaccine, if approved for younger infants as expected, could prevent another 50 percent of cases.~5 (#321) Sugarman points out that the increased use of day- care centers suggests the need to address infectious diseases in those centers. (~337) George Smith of the Tennessee Department of Health and Environ- ment says that such centers, along with schools, should educate and supervise students in proper hygiene practices (such as hand-washing techniques). (#201) Oral Health Many witnesses felt that many more opportunities exist for the prevention of oral health problems in children and adolescents than were addressed In the 1990 Objectives. Thus, they suggested interventions such as systemic fluoride, fluoride dentifrice, and pit and fissure sealants. Focusing on these three proven measures, says Stephen Moss, representing the 36 Healthy People 2000: Citizens Chart the Course American Academy of Pediatric Dentistry, is the most effective way to reduce caries in children. (#154) Diners focused on special problems such as nursing bottle tooth decay, oral cancer, and the cariogenicity of foods. Jane Weintraub of the University of Michigan and others point out that the 1990 Objec- tives included only one objective related to the prevalence of dental caries. which focused on nine- year-old children. The new objectives, they feel, should specify additional age groups, the different types of dental caries that may develop, and the proportions of each group with decayed, unfilled teeth, indicators of unmet need. In children, much of the caries prevalence occurs among a small segment of the population; therefore, mean values for a broader group may not be informative. (~391) The American Dental Hygienists' Association and others raise a concern about nursing bottle tooth decay, which results from prolonged use of a nursing bottle containing milk or sugared liquid as a pacifier. The association calls for ~ large-scale national program directed toward educating the public about nursing bottle caries, a major contributor to decay in the primary teeth of infants that often leads to unsatisfactory oral health conditions in the permanent teeth. (#575) "Oral cancers claim the lives of thousands of individuals each year, yet young persons, especially teenage females, continue their smoking habit, reports Jarrett. It is well recognized that the use of chewing tobacco and snuff, smoking, excess alcohol, and prolonged exposure to ionizing radiation signi- ficantly increase one's risk of developing oral cancer. Jarrett and other witnesses suggest development of an objective to reduce oral cancer mortality. (#108) _ . ~. . . . Screening for Chronic Health Problems in Children A number of witnesses recommend more screening of children for chronic health problems, especially vision and hearing. Lurie, for instance, recommends routine screening of young children for vision, hearing, and other health problems, with further assessment of those who do not pass a screening test and follow-up until age five of all those screened. (#535) More specifically, Robert Reinecke, representing the American Academy of Ophthalmology, maintains that the screening of preschool children for visual problems is inadequate. He recommends the initi- ation of rigorous programs to detect visual abnor

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malities within six weeks of birth, with repeated testing at regular intervals as the child develops. Furthermore, whenever a child is seen by a health care worker (e.g., for immunization or routine visits), Reinecke suggests that the eyes be examined and the child referred to a pediatric ophthalmologist if neces- sa~y. He believes that testing of vision in school should be universal and carried out by properly trained individuals, and that children should be tested at least every other year throughout elementary and high school. (#455) DATA NEEDS A number of testifiers called for better data on children and adolescents, both in general and with regard to particular issues. Ronald Feinstein of the University of Alabama at Birmingham, for instance, suggests that data be consistently reported for the age group from 8 to 22 years old to avoid grouping adolescents with children. A breakdown into several narrower ranges would be even more beneficial, he says. He also suggests that objectives be established and reported specifically for age, gender, ethnic, and racial segments of the adoles- cent population. Data should be collected on adoles- cents who have left the "system" (e.g., by dropping out REFERENCES of school). (#250) Brindis and Lee add to this recommendation and suggest that federal data bases on adolescent health be improved to allow for easier access, age-specific analyses, and greater comparability among data sets. They also suggest that information systems on special populations of adolescents be improved, including those for school dropouts, institutionalized youth, and chronically ill or physically disabled adolescents. (#027) On more specific issues, Reveal advocates prevalence studies of nursing bottle caries because existing baseline data are limited. f#5 75) The AAP reports that data on child abuse are difficult to collect and analyze due to the lack of a uniform surveillance and reporting system. The AAP feels that develop- ment of an improved reporting procedure would yield more accurate figures on the active number of child abuse cases. (#115) Patrick O'Malley and Lloyd Johnston report on the National High School Senior Survey, which is carried out each year by the Institute for Social Research of the University of Michigan. This survey of about 17,000 high school seniors, they say, is a major source of the country's reliable population data on substance abuse. It scores as a valuable source of trends in drug and alcohol abuse, the potential for accidents, and physical fitness and nutrition; it should be used to set and track objectives and teen behavior. (~419) 1. U.S. Bureau of the Census: Statistical Abstract of the United States, 1989 (109th Edition). Washington, D.C.: U.S. Government Printing Office, 1989 2. U.S. Department of Labor: "Labor Participation Unchanged Among Mom's with Yollng Children. News Release. April 10, 1988 3. Hobbs N. Perrin JM, Ireys HT: Chronically Ill Children and Their Families. San Francisco: Jossey Bass Publishers, 1985 4. U.S. Department of Health and Human Services: Nutrition Monitoring in the U.S.: A Progress Report from the Joint Nutrition Monitoring Evaluation Committee (DHHS Publication No. [PHS] 86-1255), July 1986 5. Bachman JO, Johnston LD, O'Malley PM: Monitoring the Future: Questionnaire Responses from the Nation's High School Seniors, 1986. Ann Arbor: Institute for Social Research, University of Michigan, 1987 6. Ibid. 7. U.S. Department of Health and Human Services: The Health Consequences of Using Smokeless Tobacco: A Report of the Advisory Committee to the Surgeon General (DHHS Publication No. [NIH] 86-2874), 1986 Children and Adolescents 37

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8. National Center for Health Statistics: Health United States, 1987 (DHHS Publication No. [PHS] 88-1232), 1988 9. Ibid. 10. Ibid. 11. National Center for Health Statistics: Health United States, 1989 (DHHS Publication No. [PHS] 90-1232), 1990 12. U.S. Department of Transportation, National Highway Traffic Safety Administration: National Child Passenger Safety Awareness Week Idea Sampler. Washington, D.C.: U.S. Government Printing Office, 1989 13. Alabama Department of Public Health: Child and Occupant Restraint Programs: Survey Results 1988. A Report on the Child Occupant Restraint Survey Program in Alabama. Birmingham: December 1988 14. Straus MA, Gelles R. Steinmetz SK: Behind Closed Doors: Violence in the American Family. Garden City, N.Y.: Anchor Press, 1980 15. Centers for Disease Control: ACIP update: Prevention of Haemophilus Influenzae Type b disease. Morbid Mortal Wkly Rep 37~2~:13 - 16, 1988 16. Klein SP, Bohannan HM, Bell RM, et al. The cost and effectiveness of school-based preventive dental care. Am J Pub Health 75~4~:382-91, 1985 TESTIFIERS CITED IN CHAPTER 4 002 Acampora, Gabrielle; Greater New York Association of Occupational Health Nurses 008 Anderson, Dave; American Automobile Association 009 Anthony, Virginia; American Association of Child and Adolescent Psychiatry 027 Brindis, Claire and Lee, Phillip; University of California, San Francisco 055 Eberst, Richard; Adelphi University (Long Island) 066 089 104 108 Fox, Claude Earl; Alabama Department of Public Health Hawks, Debra; American Academy of Pediatrics and American Public Health Association Hyslop, Thomas; Harris County Health Department (Texas) Jarrett, Michael; South Carolina Department of Health and Environmental Control 115 King, Caroler American Academy of Pediatrics 118 Kligman, Evan; Society of Teachers of Family Medicine 154 Moss, Stephen; American Academy of Pediatric Dentistry 198 Sheps, Cecil; American Public Health Association 201 Smith, George; Tennessee Department of Health and Environment 207 Gaines, George; Detroit Department of Health 250 Feinstein, Ronald; University of Alabama at Birmingham 303 Grimord, Mary; Texas Woman's University 304 Large, Lou; La Porte Independent School District (Texas) 321 Skeets, Michael; Oregon Department of Human Resources 331 Wieland, Holly; Silver Spring, Maryland 333 West, Margaret; University of Washington 337 Sugarman, Jule; Washington State Department of Social and Health Services 347 Hager, Carl; Citizens Commission on Human Rights, Seattle Chapter 362 Mangione, Ellen; Colorado Department of Health 372 Henry, Linda; Children's Hospital (Denver) 38 Healthy People 2000: Citizens Chart the Course

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391 Weintraub, Jane; University of Michigan 393 Gaines, George; Detroit Department of Health 404 Hill, Joseph; Detroit Department of Health 412 Strauther, John; Detroit Department of Health 419 O'Malley, Patrick and Johnston, Lloyd; University of Michigan 426 Kaminsky, Kenneth; Wayne County Intermediate School District (Michigan) 455 Reinecke, Robert; Wills Eye Hospital (Philadelphia) 466 Martin, ~ Damien; Hetrick-Martin Institute (New York) 467 Aguirre-Molina, Marilyn and Lubinski, Christine; National Council on Alcoholism 477 Speert, Ellen; American Art Therapy Association 500 Medrano, Martha; University of Texas Health Science Center at San Antonio 535 Lurie, David; Minneapolis Health Department 573 Wilhoit, Gene; National Association of State Boards of Education 575 Reveal, Marge; American Dental Hygienists' Association 595 Leventhal, Marcia; New York University and BrookSchmitz, Nancy; Columbia University 675 Teague, Wayne; Alabama Department of Education 702 Barrett, Tom; Center for Psychological Growth (Denver) 731 Gaffney, Donna; Columbia University 748 Russ, Blanche; Parent-Child, Inc. (San Antonio) 802 Dwyer, Kevin; National Association of School Psychologists Children and Adolescents 39