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OCR for page 28
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
OCR for page 31
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
OCR for page 34
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
OCR for page 36
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
OCR for page 37
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
OCR for page 38
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
OCR for page 39
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
Representative terms from entire chapter:
child care
