Health and Health Care in Schools
Vol 3, No 11 - January 2003

2003 Immunization Schedule Recommends Catch-ups to Age 18 For the first time this year, the annual Recommended Childhood and Adolescent Immunization Schedule for 2003 includes catch-up schedules for children up to the age of 6, and for children ages 7 through 18, who have fallen behind on their shots or started their immunizations late. There are no major changes from last year for infant immunization, including a recommendation that infants be vaccinated for hepatitis B soon after birth or before hospital discharge. The annual immunization recommendations are approved by the Advisory Committee on Immunization Practices, the American Academy of Pediatrics, and the American Academy of Family Physicians. In a policy statement, the American Academy of Pediatrics notes that new recommendations about any of the immunizations may be made in the course of this year, or new vaccines may be approved by the Food and Drug Administration. Information on new vaccine release, vaccine supply, and statements on specific vaccines can be found at www.aap.org and www.cdc.gov/nip. For additional information about vaccines, including precautions and contraindications for immunization and vaccine shortages, please visit the National Immunization Program Website at www.cdc.gov/nip or call the National Immunization Information Hotline at 800-232-2522 (English) or 800-232-0233 (Spanish). Approved by the Advisory Committee on Immunization Practices (www.cdc.gov/nip/acip), the American Academy of Pediatrics (www.aap.org), and the American Academy of Family Physicians (www.aafp.org). For additional information about vaccines, including precautions and contraindications for immunization and vaccine shortages, please visit the National Immunization Program Website at www.cdc.gov/nip or call the National Immunization Information Hotline at 800-232-2522 (English) or 800-232-0233 (Spanish). Immunization charts are reproduced with permission from the January 2003 issue of the journal Pediatrics. ---------------------------------------------------- Trying to Pin Down the Incidence of Autism There is a general perception that autism in children is increasing, but there have been few population-based studies in the United States to support or contradict that belief. A study reported in the January 1, 2003, issue of the Journal of the American Medical Association (JAMA) found the prevalence of autism among children 3 to 10 years of age in a five-county metropolitan area in 1996 higher than the rates found in studies conducted during the 1980s and early 1990s, but the researchers pointed out that it's impossible to know if the increased prevalence results from changes in diagnostic criteria; heightened public awareness; better training of physicians, psychologists, and other providers in recognizing the condition; or an actual increase in autism itself. In the study, researchers found a rate of 34 cases per 10,000 children for autism spectrum disorders (ASDs) among 3- to 10-year-old children in the Atlanta, Georgia, metropolitan area. The incidence was comparable for African-American and white children; there was an over-representation of boys; more than three-quarters of the cases had cognitive impairments; and there was an unexpected decrease in prevalence among 9- and 10-year-olds. Public schools were a primary source for case identification, partly because many autistic children receive services under the Individuals with Disabilities Education Act. Non-school case identification sources included state departments of human resources, pediatric hospitals and associated clinics, diagnostic and evaluation centers, and private physicians and clinicians. Because the survey was considered public health surveillance under privacy laws, parental consent was not required, and permission to access records was obtained from each data source. Although diagnostic criteria for autism include onset of symptoms before age 3, the mean age of first diagnosis for the Atlanta children was 3.9 years, and many were not identified until they entered school. Citing the importance of population-based data in monitoring this "important and complex condition," the researchers noted that only screening of all children in well-child visits, as is done in Great Britain, would allow children with autism to be consistently identified earlier. They conceded that autism screening instruments have only recently become available, and their usefulness in terms of sensitivity and specificity is still being debated; and they noted that diagnostic tools for clinicians have only recently become available and are not widely used in the United States. In an editorial accompanying the research report, Dr. Eric Fombonne of McGill University believes the 34-per-10,000 ASD rate is probably an underestimate; he suggests a rate of 60 per 10,000 is more in line with other recent surveys. "From the available evidence, it can be concluded that recent rates for both autism and autism disorder are three to four times higher than 30 years ago," he says. Fombonne cited recent efforts to improve surveillance for ASDs, including a network being funded by the Centers for Disease Control and Prevention in several states. Meanwhile, he notes, "The current social context seems to exert a stronger influence on the debate than the scientific arguments." Advocates for autistic children have seen recent increases in funding for research, but so far "no strong candidate environmental exposures have been identified. Claims of an association with measles-mumps-rubella immunization have not been borne out by recent studies, and evidence for causal association with other exposures, such as mercury-containing vaccine, is weak." The research report, "Prevalence of Autism in a US Metropolitan Area," and the editorial "Prevalence of Autism," appeared in the January 1, 2003, issue of the Journal of the American Medical Association. Reprints of the research report are available from mxy@cdc.gov ---------------------------------------------------- Identifying and Treating Eating Disorders It would be ironic, researchers say, if the current emphasis on preventing and correcting obesity and overweight in children and adolescents were to cause another kind of problem—an increase in eating disorders in young persons convinced that they are too fat. In a policy statement published in January, the American Academy of Pediatrics (AAP) cites studies that show the incidence of anorexia and bulimia nervosa in children and adolescents has increased steadily since 1950. The statement also expresses concern that the attention being given to obesity and overweight is often "accompanied by an unhealthy emphasis on dieting and weight loss among children and adolescents, especially in suburban settings." Children are becoming concerned with weight-related issues at progressively younger ages, there is growing awareness of eating disorders in males, and eating disorders are increasing in prevalence in minority populations. Aimed at educating primary care providers for children, including pediatricians who have had little training in how to recognize or treat eating disorders, the policy statement says screening questions about eating patterns and satisfaction with body appearance should be asked of all preteens and adolescents as part of routine pediatric care. Weight and height need to be determined regularly, "preferably in a hospital gown because objects may be hidden in clothing to falsely elevate weight." Children who do not make appropriate weight gains, or lose weight rapidly, may be eating inappropriately and may need as much care and attention as those with full disorders. And there is no point in just asking a patient if he or she has an eating problem, the statement cautions, because most young people—and many parents--will deny it Instead, the policy statement offers some questions to be asked of a young person in a primary care situation, beginning with: What was the most you ever weighed? How tall were you then? When was that? What is the least you ever weighed in the past year? How tall were you then? When was that? What do you think you ought to weigh? How much do you exercise, how often, with what intensity? Are you stressed if you miss a workout? Do you have any food restrictions? Do you count calories? Are some foods taboo? Ever binge-eat or purge? Do you take diuretics, laxatives, diet pills, ipecac? Ever have constipation, diarrhea, vomiting? At what age did you first menstruate? When was your last period? Do you use cigarettes or alcohol? Have you had dizziness, weakness, fatigue? Pallor, easy bruising or bleeding? Cold intolerance? Hair loss, dry skin? Muscle cramps, joint pains, chest pain? Tests to confirm an eating disorder may include blood cell count, electrolyte measurement, liver function tests, urinalysis, and a thyroid-simulating hormone test, sometimes an electrocardiogram or magnetic resonance imaging of the brain or upper or lower gastrointestinal system, and sometimes a bone density measurement. But, the AAP statement concludes, "It should be noted that most test results will be normal in most patients with eating disorders, and normal laboratory test results do not exclude serious illness or medical instability in these patients." There is also the possibility of a psychosocial assessment, which should include an evaluation of the degree of obsession with food and weight and the patient's willingness to receive help, and assessment of how the child or adolescent is functioning at home, in school, and with friends. Except for the most seriously affected patients, most children and adolescents with eating disorders will be managed in an outpatient setting by a multidisciplinary team qualified to deal with issues such as the dietary stabilization required in bulimia nervosa and the weight gain regimens that are a hallmark of treatment for anorexia, the AAP says. Similarly, mental health experts may be called in to provide the necessary psychologic, social, and psychiatric care, including psychotropic medications, though the statement points out that "correction of malnutrition is necessary for the mental health aspects of treatment to be effective." Among the policy statement's recommendations, the first is that pediatricians and other primary care providers need to be knowledgeable about the early signs and symptoms of disordered eating and related behaviors, and, second, "When counseling children on risk of obesity and healthy eating, care should be taken not to foster overaggressive dieting and to help children and adolescents build self-esteem while still addressing weight concerns." The AAP policy statement, "Identifying and Treating Eating Disorders" is published in the January 2003 issue of the journal Pediatrics. Anorexia and Bulimia Nervosa The following characteristics of anorexia and bulimia nervosa are taken from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DMS-IV): Anorexia Nervosa Intense fear of becoming fat or gaining weight, even though underweight. Refusal to maintain body weight at or above a normal weight for age and height (i.e., weight loss leading to maintenance of body weight less than 85 percent of that expected, or failure to make expected weight gain during a period of growth, leading to body weight less than 85 percent of that expected). Disturbed body image, undue influence of shape or weight on self-evaluation, or denial of the seriousness of current low body weight. Amenorrhea or absence of at least three consecutive menstrual cycles (those with periods only inducible after estrogen therapy are considered amenorrheic). Types: There may be no regular bingeing or purging (by self-induced vomiting or use of laxatives or diuretics), or a patient meeting the above criteria for nervosa may regularly binge and purge. Bulimia Nervosa Recurrent episodes of bingeing, characterized by eating a substantially larger amount of food in a discrete period of time (i.e., in two hours) than would be eaten by most people in similar circumstances during that same time period, and by a sense of lack of control over eating during the binge. Recurrent inappropriate compensatory behavior to prevent weight gain, such as self-induced vomiting, use of laxatives and diuretics. Binges or inappropriate compensatory behavior occurring, on average, at least twice weekly for at least three months. Self-evaluation unduly influenced by body shape or weight. The disturbance does not occur exclusively during episodes of anorexia nervosa. Types: Purging or non-purging. (Instead of purging, patient may fast or over-exercise.) ---------------------------------------------------- Getting Hurt by a Backpack—It May Not Be What You Think Backpacks--the way most students transport books and other belongings to, from, and in school-- have come under criticism from health professionals, educators, and parents who claim the heavy packs are causing children to have back problems. Much of the criticism stems from a recent report by the U.S. Consumer Product Safety Commission (CPSC), which noted that backpacks were associated with an estimated 12,688 injuries between 1999 and 2000. Although it seems logical to assume that backpack injuries are to backs, orthopedists working in a children's hospital were skeptical, since that assumption didn't seem to square with the backpack-caused injuries they were seeing in the emergency room. To try to find out what is going on, Dr. Brent Wiersema and colleagues reviewed data on backpack-related injuries to children from 6 to 18 years of age that were reported in 1999-2000 by emergency departments in 100 hospitals across the United States that participate in the National Injury Information Clearinghouse. The search turned up 247 backpack-associated injuries to children, mean age 11.8 years and 50 percent male. In the emergency room data, the most common location of injury from a backpack was the head/ face, followed by the hand, wrist/elbow, shoulder, and foot/ankle. The back ranked sixth--89 percent of the reported injuries did not involve the back. The most common way to get hurt was by tripping over your own or someone else's backpack, or being hit by a pack worn by another student. The authors concede they were dealing only with accidents that came to hospital emergency rooms, and not with any less traumatic back problems that children may be having. But it seems significant, they say, that only 11 percent of the reported backpack injuries were to the back. And of injuries sustained by wearing, lifting, or taking off a backpack, there were more shoulder than back problems, leading the authors to suggest that the shoulder, not the back, is the musculoskeletal "weakest link" that limits load-carrying with backpacks—meaning it would be more productive to teach children correct shoulder-lifting techniques than back-lifting techniques. "Current recommendations to reduce potential backpack injury, such as reducing backpack weight, rolling backpacks, and adjusting weight distribution within backpacks would, at best, eliminate only 23 percent of the injuries in this study," the authors said. "Recommending that children put their backpacks in a safe place so they do not trip over them, and not to use them as a weapon to hit another person, could eliminate 40 percent of backpack injuries presenting to the emergency department." The research report, "Acute Backpack Injuries to Children," by orthopedists at Bi-County Community Hospital, Warren, Michigan, and Children's Hospital, Cincinnati, Ohio, appeared in the January 2003 issue of the journal Pediatrics. Address correspondence to eric-wall@chmcc.org. ---------------------------------------------------- WORTH NOTING Mental Health Parity Law Extended One Year Following the death of United States Senator Paul Wellstone in November, Congress passed a one-year reauthorization through December 2003 of the current mental health parity law, which requires insurers and health plans to provide the same annual and lifetime benefits for physical and mental illness. Wellstone was a major advocate of mental health parity and had pushed for an extension of the law that would have prevented insurance companies from charging higher deductibles and copayments for mental health care and would have barred different limits on numbers of visits, total days of coverage, or scope of treatment. Senator Pete Domenici (R-NM), who co-sponsored Wellstone's proposed expansion of the law, has said he will introduce the revised version in the coming session of Congress. Public Health Report Urges Massive Change In a report released in December, the Institute of Medicine charged that the U.S. public health system is taken for granted and continues to be in disarray and called on the Department of Health and Human Services to "rise above rivalries between different agencies and really pull it all together." The report stops short of offering specific solutions to problems, calling instead for massive shifts in public attitudes. Public health is handicapped, the report said, by uneven laws and regulations, unprepared workers, and inadequate political support. As an example, as many as one-third of local public health departments do not have e-mail. The report, "The Future of the Public's Health in the 21st Century," is available online at www.iom.edu. HHS Reports on Child Insurance Coverage Almost 10 percent of children 17 years of age and under were without health insurance in the first half of 2002, but that was an improvement from 13.9 percent who had no coverage in 1997, the Department of Health and Human Services reported December 31. HHS credited the gain to the fact that more and more children are relying on public coverage for their health care, including the State Children's Health Insurance Program (SCHIP) created in 1997. Children's coverage is part of a statistical report, "Early Release of Selected Estimates Based on Data from the January-June 2002 National Health Interview Study," which can be viewed at www.cdc.gov/nchs. Psychiatric Disorders Common in Detained Youth Nearly two-thirds of boys and three-quarters of girls in juvenile detention have at least one psychiatric disorder, compared with 15 percent of youths in the general population, according to a federal report released in December. As welfare reform, managed care, and a shrinking public health system limit access to services, many poor and minority youth with psychiatric disorders may increasingly fall through the cracks into the juvenile justice system, which is poorly equipped to help them, researchers said. More than half the detained teens in the study were addicted to drugs and more than 40 percent had disruptive behavior disorders such as oppositional defiant disorder. "We are especially concerned about the high rates of depression and dysthymia among detained youth—17 percent of males and 26 percent of females," said study director Linda Teplin. The report appeared in the December 2002 issue of Archives of General Psychiatry. December News Alerts The following information appeared during the month of December in the News Alerts section of this website. Child Health USA Is Available Online The Bureau of Maternal and Child Health has released its annual child health update. Child Health USA 2002 is available online at www.mchb.hrsa.gov/chusa02/index.htm. OCR Issues New HIPAA Guidelines The Office for Civil Rights in the Department of Health and Human Services issued guidance December 4 for complying with privacy requirements of the Health Insurance Portability and Accountability Act (HIPAA). The guidance, which includes answers to frequently asked questions about HIPAA, can be accessed at www.hhs.gov/ocr/hipaa/privacy.html. School-Based Centers Get Grants in Program to Expand Health Centers In the latest round of funding to create new health center sites and expand capacity at existing centers, the Department of Health and Human Services December 9 announced 42 grants totaling more than $13 million to health centers, including two awards that will support school-based health centers. The Community Health Center of Central Coast, in Nipomo, California, and the Peninsula Institute for Community Health in Newport News, Virginia, are among the recipients of grants under the Consolidated Health Center Program. The list of grant recipients is available at www.hhs.gov/news/press/2002pres/20021209.html. Survey Show Some Drug Use by Students Down in 2002 from 2001 The annual "Monitoring the Future" survey of 8th, 10th, and 12th grade students in U.S. schools shows that use of marijuana, some club drugs, cigarettes, and alcohol decreased from 2001 to 2002, according to the U.S. Department of Health and Human Services, though use of crack cocaine and sedatives increased in some grades. The survey, conducted by the University of Michigan's Institute for Social Research and funded by the National Institute on Drug Abuse (NIDA) at the National Institutes of Health, has tracked 12th graders' illicit drug use and attitudes toward drugs since 1975, with 8th and 10th graders added to the study in 1991. The 2002 study surveyed a representative sample of more than 43,000 students in 394 schools about lifetime use, past year use, past month use, and daily use of drugs, alcohol, cigarettes, and smokeless tobacco. Some survey findings: Marijuana use in the past year declined significantly among 10th graders, reaching its lowest rate since 1995. Marijuana use by 8th graders is at its lowest rate since 1994. LSD use declined at all grade levels in 2002. Use of MDMA (Ecstasy) showed statistically significant declines for the first time, after rising sharply in recent years. Steroid use remained stable from 2001 to 2002 in each grade and reporting period. The only significant increases in drug use were crack use by 10th graders in the past year and use of sedatives by 12th graders. New questions were added to the survey this year on nonmedical use of Oxycontin and Vicodin, prescription drugs used to control pain, and "the findings give some reason for concern," the survey report notes. Oxycontin use in the past year without a doctor's orders was reported by 1.3 percent of 8th graders, 3 percent of 10th graders, and 4 percent of 12th graders; and Vicodin use in the same time period was reported by 9.6 percent of 12th graders. Cigarette smoking decreased significantly in each grade, among all subgroups—males and females, college-bound and not, in all major Census regions of the country, cities and rural areas, all socio-economic levels, and in the three major racial groups (whites, African-Americans, and Hispanics). There were significant reductions in alcohol use by 8th and 10th graders, for record lows in the survey for those grades. Findings from the survey will be posted at www.nida.nih.gov. SAMHSA Reports on Mental Health ‘Co-Occurring Disorders' In a December 2 report to Congress, the Substance Abuse and Mental Health Services Administration (SAMHSA) notes that many or most patients with mental health disorders have co-occurring conditions such as substance abuse, and the report urges primary treatment of both illnesses. The report notes that many barriers to such comprehensive treatment exist, including separate administrative structures, eligibility criteria, and funding streams, as well as limited resources for both mental health services and substance abuse treatment. Among other recommendations, the report suggests creating a new SAMHSA-funded State Incentive Grant for Co-Occurring Disorders to help enhance state infrastructure and treatment systems. The report, available at , includes sections on prevention and interventions for children and adolescents. HHS Sets Website for Smallpox Information To try to clear up confusion about the federal government's plans to offer smallpox vaccination to health care workers and others who might be "first responders" in the event of a terrorist attack, the U.S. Department of Health and Human Services has set up a website, www.smallpox.gov, that is supposed to provide "comprehensive and up-to-the-minute information." Noting that the issue of who will get smallpox immunization is "complicated," HHS Secretary Tommy Thompson said December 13 that "those who will be recommended for vaccination will want to study the issue and other Americans with questions about the disease and the vaccine will also need the best information possible." Thompson promised that the new website will include full information, "from basic facts to fine detail." Most Women Now Get Timely Prenatal Care, HHS Reports The National Center on Health Statistics in the U.S. Department of Health and Human Services reported that in the year 2001, 83 percent of women in the United States received prenatal care in the first trimester, up from 76 percent in 1990, and only 1 percent of women received no prenatal care at all. The increase in prenatal care was in all age and ethnic groups but was particularly evident among Hispanic and black women. The report, based on final birth and death vital statistics for the year 2001, also confirmed earlier findings that the teen birth rate declined for the 10th consecutive year in 2001, particularly among young teens aged 15 to 17. According to the data, 4,025,933 babies were born in 2001, 1 percent fewer than the year before, and 33.5 percent of those births were to unmarried women. One in five births was induced, and the number of Cesarean deliveries increased for the fifth consecutive year. The report, "Births: Final Data for 2001" can be read at www.cdc.gov/nchs. U.S. Delegates to U.N. Conference Object to Abortion and Condom Use Saying their government cannot support any program that seems to promote abortion or the use of condoms rather than abstinence to prevent adolescent pregnancy, the U.S. delegation to a United Nations population conference voted against a plan of action on population policies December 17. The U.S. ended up agreeing to the plan but asked that its concerns be expressed in a separate document. The plan adopted by the U.N.-sponsored Asian and Pacific Population Conference calls for action on population policies in a bid to reduce poverty in the Asian-Pacific region, where 67 percent of the world's 1.2 billion persons in extreme poverty live. The plan includes wording including "reproductive health services" and "reproductive rights," which the American delegation said could be read as advocating abortion and underage sex. It also includes a recommendation for "consistent condom use" to reduce the risk of HIV infection, a phrase the U.S. representatives wanted struck out. The 22-page plan adopted by the conference includes a series of recommended steps to implement an international family planning agreement reached in Cairo in 1994. It suggests fighting poverty by concentrating on family planning, gender equality, and combating HIV/AIDS. Information is available at www.unescap.org. FDA to Provide Information on Health Value of Foods, Dietary Supplements The federal Food and Drug Administration has announced a new initiative to encourage makers of conventional foods and dietary supplements to make accurate, science-based claims about the health benefits of their products. The FDA also hopes to eliminate "bogus labeling claims" by taking on dietary supplement makers who make false or misleading claims. As part of the new Consumer Health Information for Better Nutrition initiative, the FDA will: Issue guidance on health claims for conventional foods and dietary supplements. All such claims must be pre-approved by the FDA and meet the "weight of scientific evidence" standard. Strengthen enforcement of dietary supplement rules by actions such as seizing a dietary supplement that makes unapproved drug claims. Establish a task force to help consumers obtain accurate, up-to-date, and science-based information about conventional foods and dietary supplements. This will include issuing regulations that "have the force of law." The FDA also released a list of its enforcement actions over the past year against dietary supplements that made false or misleading claims. As an example of stepped-up enforcement, the agency noted that federal marshals December 16 seized 3,000 bottles valued at more than $100,000 of a dietary supplement, EverCLR, marketed by Halo Supply Company of San Diego, California, as a "natural" treatment for viruses, including herpes, and for cold and flu protection. Information about dietary supplements is available on the FDA's website at www.cfsan.fda.gov/~dms/supplmnt.html. A brief description of the new enforcement initiative is at www.fda.gov. SAMHSA Wants Comments on Changing Mental Health Services Block Grant to ‘Performance Partnerships' with States The Substance Abuse and Mental Health Services Administration (SAMHSA) is calling for comments on a proposal to replace a block grant to states for mental health services that has been in place since 1981 with "performance partnerships" that would give states more flexibility in use of funds in return for accountability for results. Currently, the block grant funds must be spent on community-based mental health services for adults with serious mental illness and children with a serious emotional disturbance, and the new plan would continue to focus on those populations. Current restrictions on the use of funds, including that they may not be used to provide inpatient care or to make cash payments to patients, would remain in place. For details of SAMHSA's request for comments, see the Federal Register for December 24. January 31 Deadline for NIH Education Loan Repayment Programs The deadline for applications for five loan repayment programs sponsored by the National Institutes of Health is January 31, 2003. Up to $35,000 a year of qualified educational debt is available for health professionals pursuing careers in clinical, pediatric, contraception/fertility, and health disparities research, or clinical research having to do with individuals from disadvantaged backgrounds. Applicants must hold doctoral degrees and be prepared to spend at least half their time in research funded by either a nonprofit organization or a government entity, and they must have educational loan debt equal to or exceeding 20 percent of their institutional base salary. U.S. citizens and permanent residents may apply. Additional information is available at www.lrp.nih.gov.