Health and Health Care in Schools
Vol 2, No 4 – June 2001


AAP Takes Position on School Condom Programs

By far the most common, most effective, best studied, and most controversial efforts at increasing condom use by adolescents have taken place in school settings, either as part of sex education and HIV/AIDS prevention programs or in the form of direct distribution of condoms, the American Academy of Pediatrics acknowledges in a position statement on adolescent condom use published in the June issue of the journal Pediatrics.

The AAP points out that school-based sex education during the past few years has fallen into three general types: abstinence-only programs in which condoms and other contraceptive methods are rarely mentioned, except to cite their failures; pregnancy-prevention programs that focus on use of contraceptives, including condoms, by those who are sexually active; and HIV-prevention programs that focus on condom use as a safer-sex strategy.

“Despite the controversy that surrounds them, it is becoming clear that sexuality education programs can have some effect on delaying the onset of intercourse, reducing sexual activity, and increasing the use of contraception, including condom use. Unfortunately, the magnitude of these effects is relatively small, in keeping with the known limitations of the effects education can have on complex social and sexual behaviors.”

Because of those limitations, the report notes, more than 400 high schools in the United States have supplemented their sex education efforts with condom availability. Some schools assign the job of distribution to the school nurse or a faculty member; and some make condoms available through vending machines, baskets, drawers, or school-based health centers..

A number of recent studies have evaluated the effects of condom availability in schools. One study showed that 93 percent of students were aware of their school’s condom distribution program, 26 percent had received condoms, and 67 percent of those who received them had used them. A Seattle study found that although students took large numbers of condoms, neither sexual activity nor condom use was reported to have increased.

In Santa Monica, California, 34 percent of students who had used a condom at last intercourse reported obtaining the condom from the school-based availability program, which was strongly accepted by students; and they indicated overall sexual activity had not increased as the result of condom availability. A study that compared New York City schools with condom availability with Chicago schools that don’t have such programs found that students in the two cities reported equal rates of sexual activity, but condom use was slightly more frequent in New York.

The word “modest” seems to describe the results when condoms are made available in school settings, the AAP report notes, which is similar to the results achieved by education programs.

The AAP recommends that:

  • Abstaining from intercourse should be encouraged for adolescents, because it is the surest way to prevent STDs, including HIV infection, and pregnancy.
  • Pediatricians should actively support and encourage correct and consistent use of reliable contraception and condoms by adolescents who are sexually active or contemplating sexual activity.
  • Schools should be considered appropriate sites for the availability of condoms, because they contain large adolescent populations and may potentially provide a comprehensive array of related educational and health care resources.
  • To be most effective, condom availability programs should be developed through a collaborative community process and accompanied by comprehensive sequential sexuality education, which is ideally part of a K-12 health education program, with parental involvement, counseling, and positive peer support.

The position statement, “Condom Use by Adolescents,” by the Committee on Adolescence of the American Academy of Pediatrics, appears in the June issue of the journal Pediatrics.

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‘Pediatric Exclusivity’-Better Information about Drugs for Children?

Concerned that medicines developed and tested only for adults are being prescribed for children, with doctors guessing about proper use or dosage, Congress in 1997 amended the Food and Drug Administration law to give pharmaceutical companies an incentive to conduct pediatric tests.

In return for agreeing to do pediatric testing of a specific drug, a manufacturer is given a six-month extension of the patent on that drug –meaning the pharmaceutical company can continue to set the market price and generic forms of the drug can’t enter the market.

That 1997 “pediatric exclusivity” provision is scheduled to expire in January 2002, and members of Congress who sponsored the original legislation are holding hearings to find out how well pediatric exclusivity is working.

Lined up in favor of extending the incentive are the American Academy of Pediatrics, which is enthusiastic about getting better information about drugs prescribed for children, and the Pharmaceutical Research and Manufacturers of America, trade association for the pharmaceutical companies. Less enthusiastic is the Generic Pharmaceutical Association, which charges that the investment in pediatric testing and the information gleaned from it “pale in comparison to the financial windfall given to brand pharmaceutical companies and the enormous financial burden inflicted on the consumer.”

At a May 8 Senate hearing, the federal General Accounting Office summarized the results of the pediatric exclusivity law so far. Janet Heinrich, director of health care and public health issues for the GAO, noted that availability of the patent extension has led to “substantial increases” in studies of drugs for children. As of April 1 this year, 28 drugs had been granted marketing exclusivity extensions, and “Research results have provided new and useful information about how drugs work in children, which have been incorporated into labels for 18 drugs.”

Among the diseases that may be treated by drugs already granted marketing extensions, according to the GAO, are:

Generalized anxiety disorder (Busiprone)

Epilepsy (Gabapentin)

Obsessive-compulsive disorder (Fluoxetine and Fluvoxamine)

Insulin-dependent diabetes (Type 1) (Insulin glargine and Metformin)

Juvenile rheumatoid arthritis (Etodolac and Oxaprozin)

Hypertension (Bisoprolol and Enalapril)

HIV infection and AIDS (Abacavir and Lamivudine)

In some cases, tests have resulted in better dosage labels, and in others the drug’s use has been expanded to younger or older populations, with special emphasis on making drugs available for treating neonates or older adolescents. As examples, the GAO notes that Ibuprofen, the commonly used drug to treat fever, previously had no dosing information for children younger than 2 years of age. “Studies in thousands of infants established a safe and effective dose in infants and children from 6 months to 2 years.” Fluvoxamine is used to treat children with obsessive-compulsive disorder; studies showed that adolescents may need doses as high as adults’ but the doses may need to be lower for girls ages 8 to 11 years.

The GAO confirmed that pediatric exclusivity has a cost for both private and public health. Prolonging the period of patent protection for a drug results in higher prescription prices, which can be a special problem for people who must pay for their drugs out-of-pocket.

And the GAO report points to two problems with the current law. For one, there is no deadline for when a pharmaceutical company must incorporate test findings into drug labels. The FDA cites five drugs that have gone for more than a year without label changes, after the sponsor was granted patent extension. Other companies are reluctant to add negative test results to their labels.

Another remaining challenge, the GAO said, is that the pediatric exclusivity provision was not designed for off-patent drugs –drugs for which patents have already expired– and provides no incentive for companies to test those products. That’s a big problem, since six of the ten drugs most commonly prescribed for children, including Ritalin, are off-patent. So far, the FDA has requested studies of only nine of 180 off-patent drugs on its priority list for pediatric research.

The GAO report, “Pediatric Drug Research: Substantial Increase in Studies of Drugs for Children, but Some Challenges Remain,” GAO-01-443T, is available online at www.gao.gov.

A list of currently active pediatric drug tests is posted on the Food and Drug Administration’s website at www.fda.gov/cder/pediatric/wrlist.htm.

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Lice, Nits, and School Policy

School policies that require exclusion from school for children with nits alone are likely excessive, according to researchers who examined the degree to which nits (the egg casings that may or may not contain a developing lice embryo) actually develop into infectious lice.

Though it’s known that not all nits are infective, the likelihood that nits will develop into lice is not known, and faced with this uncertainty, some schools have developed “no nits” policies in which students must be treated with a pediculicidal agent and all visible nits removed. In the view of the researchers, this is resulting in missed school days, loss of work for parents, and, most seriously, unnecessary pesticide exposure.

To investigate the probability that children with nits alone will become infested with lice, investigators from the Epidemic Intelligence Service of the Centers for Disease Control and Prevention screened 1,729 children in two Atlanta elementary schools that do not have no-nits policies. Twenty-eight of the children (1.6 percent) had head lice; 63 (3.6 percent) had nits without lice. Of the 63 nits-only children, 50 stayed with the study to completion.

Looking at the popular theory that nits closest to the scalp contain developing louse embryos (based on the assumption that the female louse attaches her eggs at the base of a human hair), the researchers gave special attention to children who had nits within one-fourth inch of the scalp.
Conclusions

The presence of nits did not imply an ongoing active infestation with head lice. On initial screening, only 31 percent of children with nits had lice, and over the next 14 days, only 14 percent of the children with nits alone developed lice.

Consistent with the hypothesis that lice lay their eggs near the base of the hair, children with five or more nits within one-quarter inch of the scalp were significantly more likely to develop an infestation. However, even in those higher-risk children, only 32 percent became infested.

The researchers acknowledge that “Because some nits contain developing lice, it seems intuitive that removing nits would reduce the risk of infestation.” But they point out that in practice, nit removal is often difficult, even for conscientious parents, and painful for children. And the frequent use of a chemical in addition to manual removal has problems of its own, they say.

In the United Kingdom, the use of a pediculicide is recommended only if live lice are found. And since no pediculicide in use in this country is completely ovicidal (i.e., capable of killing all developing all developing embryos within nits), it’s probable that children with nits only would have had similar conversion rates (meaning nits became lice) regardless of whether or not they were treated. Though the researchers believe most currently available pediculicidal agents are safe if used properly, they caution that central nervous system toxicity and anemia have been reported after exposure to lindane, and carbaryl, a pesticide, was restricted to prescription use in the United Kingdom after it was found to be carcinogenic.
Policy Recommendations

“Most children with nits alone will not become infested; therefore, excluding these children from school and requiring them to be treated with a pediculicide is probably excessive.”

Rather than missing an entire day of school, the researchers suggest, children with nits could undergo a thorough five- to ten-minute examination to exclude the presence of live lice. If they have no lice, children with nits could then have regular follow-up examinations for the next 14 days. Children with nits close to the scalp might need more frequent follow-up.

Such a shift from exclusion to examination would require that persons who do the screening be well trained in lice detection and given adequate time for the examinations. In any case, the researchers say, “Effective control of head lice will require rational scientific approaches in an area that has long been dominated by fear and anecdote.”

The article ” Lice, Nits, and School Policy,” by L. Williams, Amanda Reichert, William McKenzie, Allen Hightower, and Paul Blake, was published in the May issue of the journal Pediatrics.

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SAMHSA Identifies Model Prevention Programs

The Substance Abuse and Mental Health Services Administration on May 17 gave its seal of approval to 20 exemplary substance abuse programs, including several school-based programs.

The exemplary 20 were selected from 200 prevention programs submitted in the past year after rigorous scientific review, SAMHSA said. They join 19 other programs already in a National Registry of Effective Programs maintained by the Center for Substance Abuse Prevention.

School-related program identified as effective by SAMHSA include:

  • All Stars (Greensboro, NC): A character development and problem behavior prevention program for youth ages 11 to 15.
  • Bullying Prevention (Bergen, Norway): Designed to reduce bullying by students in elementary, middle, and junior high schools.
  • Coping Power (Tuscaloosa, AL): Substance abuse prevention for 9-year-olds.
  • Early Risers “Skills for Success” (Minneapolis, MN): Substance abuse program designed for high-risk children between 6 and 8 years old.
  • Fairfax Leadership and Resiliency (Fairfax, VA): Intensive substance abuse and violence prevention program for adolescents in mainstream or alternative high schools.
  • Positive Action (Twin Falls, ID): Kindergarten through 12; geared to decreasing negative behaviors, including substance abuse.
  • Project SUCCESS (Tarrytown, NY): A substance abuse prevention program for high-risk youth ages 15 to 19.
  • Project Towards No Drug Use (Los Angeles, CA): Drug abuse prevention program for youth in alternative high schools who are at higher-than-average risk for drug abuse.
  • Skills, Opportunity, and Recognition (SOAR) (Seattle, WA): Prevention program tested in elementary schools serving children from high-crime urban areas.
  • Social Competence Program for Young Adolescents (Chicago, IL): A highly structured training program for 6th and 7th grade students to improve problem-solving ability and social skills.
  • STARS for Families (Jacksonville, FL): A health promotion program for preventing alcohol use by middle and junior high school students.

Fact sheets about the model programs are available at www.samhsa.gov/csap/modelprograms.

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Worth Noting

Emerging Answers: An Overview of Teen Pregnancy Prevention Programs

Teen pregnancy rates in the United States decreased slightly in the 1990s, but the U.S. still has the highest rates of teen pregnancy and birth –by far– of any comparable developed country, according to the National Campaign to Prevent Teen Pregnancy, which released a report May 30 on scientifically evaluated pregnancy prevention programs. Douglas Kirby of ETR Associates more than 200 surveyed programs conducted in the United States or Canada since 1980 targeted at middle or high school students that used experimental designs with control groups and measured their impact on contraceptive behavior, pregnancy, or childbearing. Kirby grouped programs by their focus on sexual or nonsexual antecedents of teen pregnancy, including curricula-based programs (abstinence education or sex/HIV education) and youth development programs. He also evaluated programs that combine the two elements. Print copies of “Emerging Answers: Research Findings on Programs to Reduce Teen Pregnancy,” can be purchased from the National Campaign to Prevent Teen Pregnancy, 1776 Massachusetts Ave. NW, Washington, DC 20036, telephone (202) 478-8500. For further information, see the Alliance website, www.teenpregnancy.org.

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CDC Releases First National Report on Environmental Chemicals

A first national report on human exposure to environmental chemicals lists levels of exposure to 27 chemicals in the U.S. population, based on blood and urine samples from people participating in the 1999 National Health and Nutrition Examination Survey (NHANES 1999). The report, by the Centers for Disease Control and Prevention, will be updated with new data every year and will expand studies of special population groups who may have unique exposures to environmental chemicals. The report is expected to provide physicians and other health care providers with “ranges” that determine whether a person has an unusually high level of one chemical or another. The report emphasizes that just because an environmental chemical is present in the body does not mean it is causing disease; further research will determine which chemicals, and at what levels, are toxic to human beings. Included in the first report are data on blood lead levels in children, which have decreased slightly; exposure to environmental tobacco smoke as measured by levels of cotinine in the body; new data on mercury levels in young children and women of childbearing age, and levels of phthalates, compounds commonly used in consumer products such as soap, shampoo, hair spray, and nail polish, and in flexible plastics such as blood bags and tubing. “First National Report on Human Exposure to Environmental Chemicals” is available on the CDC website at www.cdc.gov/nceh/dls/report.

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What Do Boys Do When They Find a Gun?

A research project discovered that three-fourths of the 8- to 12-year-old boys (all recruited from families that completed a survey on gun ownership, storage practices, and parental perceptions of their children’s gun knowledge) found a handgun within 15 minutes of being placed in a room with a gun, and more than three-fourths of the groups that found a gun handled it. Approximately half of those who handled the gun pulled the trigger with enough force to discharge the weapon. Half of the boys weren’t sure if the gun was real or a toy, but they played with it anyway. Parents’ perceptions of their sons’ interest in real guns didn’t predict a child’s behavior, and 90 percent of the boys who handled the gun or pulled the trigger reported having previously received some sort of gun safety instruction, ranging from informal talks with their parents to formal instruction from a teacher or police officer at school. Researchers, from emergency medical departments of pediatrics at several universities, noted that 80 percent of unintentional firearms injuries to children involve males, and many occur when a child discovers a gun in the home while playing with a friend or sibling. They also note that approximately 40 percent of American households contain at least one gun, and as many as 13 percent of gun-owning families keep a gun loaded and unlocked. For more on the research, see the June 2001 issue of the journal Pediatrics.

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High-Stakes Tests and Mental Health

High-stakes tests such as those used in a number of states to assess student readiness to more to the next grade and the annual assessments called for in education bills now moving through Congress may be bad for children’s mental health –and that of their teachers, school administrators, and parents, as well –according to a group of concerned health care leaders. “Test-related stress is literally making many children sick,” said the Alliance for Childhood, which charges that the emphasis on standardized testing for students in grades 3 through 8 “ignores the true paths that children take to learning.” Stress and test-related anxiety presents itself in such diverse forms as headaches, stomachaches, sleep or attendance problems, acting out, and depression, the Alliance points out. “I’m not sure we teach kids how to handle stress,” said Thomas Young, associate professor of pediatrics at the University of Kentucky School of Medicine and a member of the Committee on School Health of the American Academy of Pediatrics. “We leave them hanging out there.”

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Leaving Welfare May Not Mean Leaving Poverty

Welfare reform has put many more families into the workforce, but that doesn’t necessarily mean they are better off financially, according to a Child Trends Research Brief. The report suggests that “working poor” families with children are families whose incomes are below the federal poverty threshold and in which either two parents work a total of at least 35 hours a week or a single parent works at least 20 hours a week. That’s the “work standard” set in the 1996 welfare reform law. In 1995, 34 percent of all children living in poverty had parents who were making a substantial work effort. By 1998, after the reforms went into effect, that percentage had risen to 42 percent. “Because of this increase,” Child Trends points out, “even though there was an overall decline in child poverty during this period, the number of children in working families with incomes below the poverty level grew by more than 650.000.” Child Trends research briefs are available online at www.childtrends.org.

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Surgeon General Sets Effort to Reduce Suicide

Noting that suicide is the eighth-leading cause of death in this country, U.S. Surgeon General David Satcher has launched a national campaign to prevent suicide, calling it a “preventable problem.” Among the initiatives, Satcher said he will seek to improve suicide prevention education and training for health care professionals, teachers, and others to help them better recognize at-risk behavior. “Suicide has stolen lives and contributed to the disability and suffering of hundreds of thousands of Americans each year,” Satcher said. “Only recently have the knowledge and tools become available to approach suicide as a preventable problem with realistic opportunities to save many lives.” The full text of the Surgeon General’s suicide prevention initiative is online at www.surgeongeneral.gov.

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