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Supreme Court Strikes Down Ban on Tobacco Ads Near Schools The United States Supreme Court ruled June 28 that Massachusetts regulations banning advertisements for cigarettes and other tobacco products within 1,000 feet of a school or playground were an unconstitutional violation of advertisers' free speech rights under the First Amendment. The Court also indicated that a federal law, the Federal Cigarette Labeling and Advertising Act, which requires health warnings on cigarette packages and bans cigarette advertising on radio and television, preempts state laws that try to control tobacco advertising. In an opinion written by Justice Sandra Day O'Connor, the Court acknowledged that "tobacco use, particularly among children and adolescents, poses perhaps the single most significant threat to public health in the United States." "It is understandable for the states to attempt to prevent minors from using tobacco products before they reach an age where they are capable of weighing for themselves the risks and potential benefits of tobacco use, and other adult activities," O'Connor noted. But the Court decided that the First Amendment constrains state efforts to limit advertising of tobacco products because, "so long as the sale and use of tobacco is lawful for adults, the tobacco industry has a protected interest in communicating information about its products and adult customers have an interest in receiving that information." The Supreme Court ruled in a case brought by the Lorillard Tobacco Company against the attorney general of Massachusetts challenging the advertising ban. Kids and Risk Perception A study of thousands of young smokers released June 11 by the Annenberg Public Policy Center of the University of Pennsylvania concluded that exposure to cigarette advertising leads young people to associate smoking with popularity and relaxation, and those associations are stronger than any perceived risks from smoking. For adolescents, "feelings about smoking are more important than perceptions of risk" at the time they start to smoke; and while teens may begin to pay attention to risk warnings later, they have by that time become addicted and are unable to give up smoking. The effectiveness of anti-tobacco advertising is limited when it focuses more on risk perception than on feelings, the study found, and has little effect on first trials of smoking and subsequent progression to a smoking habit. "Tobacco marketing encourages adolescents to avoid facing risks when considering smoking and places a heavy burden on counteradvertising to counter favorable images of smoking." The Annenberg study, Smoking Risk Perception and Policy, published by Sage Publications, is available in book stores and at Amazon.com. ----------------------------------------------------------- Surgeon General Calls for Action on Sexual Health In a report released June 28, U.S. Surgeon General David Satcher called on Americans to recognize and discuss significant public health challenges regarding the sexual health of citizens, including alarmingly high levels of sexually transmitted disease and HIV/AIDS infection, unintended pregnancy, abortion, sexual dysfunction, and sexual violence. The Surgeon General urged parents to overcome any discomfort they may feel about talking to their children and adolescents about sexual matters. He noted that although media programming rarely depicts sexual behavior in terms of long-term relationships, more than half of high school boys and girls in a recent survey said most of what they knew about birth control and contraception came from television or magazines. A majority of Americans favor some form of sexuality education in schools, the report notes, though curriculum content remains a source of controversy. Abstinence-only programs have not as yet been well evaluated, and their value for adolescents who have already initiated sexual activity is not well known. Programs that emphasize abstinence but also cover condoms and other methods of contraception have a larger body of evaluation that indicates either no effect on initiation of sexual activity or, in some cases, a delay in the initiation of sexual activity. "This evidence gives strong support to the conclusion that providing information about contraception does not increase adolescent sexual activity, either by hastening the onset of sexual intercourse or increasing the number of sexual partners." Given that one-half of adolescents in the United States are already sexually active, it seems clear that adolescents need accurate information about contraceptive methods, the report concludes. Not only parents have trouble discussing sex, the report notes. "Physicians, nurses, pharmacists, and other health care professionals, often the first point of contact for individuals with sexual health concerns or problems, can have great influence on the sexual health and behavior of their patients. Yet, both adolescents and adults frequently perceive that health care providers are uncomfortable when discussing sexuality and often lack adequate communication skills on this topic." The report suggests that may be because health care providers typically don't receive training in sexual aspects of health and disease and in taking sexual histories. Prevention programs in health clinics that have an impact on sexual health and behavior are of three types: counseling and education, condom or contraceptive distribution, and STD/HIV screening. In this category, the report points out that most school-based condom and contraceptive availability programs include some form of abstinence or risk-reduction counseling to address the concern that increased condom availability could lead to increased sexual behavior. "The evidence suggests that these programs, while still controversial in some communities, do not increase sexual behavior and that they are generally accepted by parents, adolescents, and school staff." In the conclusion to his report, the Surgeon General said: "Based on the scientific evidence, we face a serious public health challenge regarding the sexual health of our nation. Doing nothing is unacceptable. More than anyone, it is our children who will suffer the consequences of our failure to meet these responsibilities. "Solutions are complex, but we do have evidence that we can promote sexual health and responsible sexual behavior. Given the diversity of attitudes, beliefs, values, and opinions, finding common ground might not be easy, but it is attainable. We are more likely to find this common ground through a national dialogue with honest and respectful communication." The report, "The Surgeon General's Call to Action to Promote Sexual Health and Responsible Sexual Behavior," is available online at www.surgeongeneral.gov/library/sexualhealth/call.htm. ----------------------------------------------------------- Barriers to Care Bring Children with Dental Problems to ERs When doctors in an urban hospital pediatric emergency department noted that numbers of children were coming to the ER with non-traumatic dental problems, they decided to try to find out why that was happening. Why, they wondered, were the children not going to a dentist or a dental care clinic, rather than bringing their toothaches to the emergency room? To explore the question, the doctors created a questionnaire and administered it to two hundred patients, ranging in age from one to 22 years, with a median age of 17. Half were African-American, 49 percent had Medicaid. Though 50 percent said they had a dentist, and 71 percent had a primary care physician, 34 percent of the children four years of age and older had not seen a dentist in the past year. Most of the visits (73 percent) were for problems related to caries. Asked why they hadn't gone to a dentist instead of the emergency room, respondents commonly said the dentist's office was closed, or the family had no dental insurance and couldn't afford to pay, or the family simply didn't have a dentist. Patients whose symptoms had lasted more than 72 hours were the most likely (72 percent) to say they had no regular dentist. "Access to preventive and emergency dental care has become an issue of increasing concern," the researchers noted. "Dental insurance coverage in the United States is relatively low. Forty-four percent of people have private dental insurance, 9 percent have public dental insurance, and another 2 percent have some other form of coverage. Forty-five percent have no dental insurance." Among parents who reported in 1998 that their children had unmet health needs, 57 percent reported unmet dental needs. A 1997 study of dental caries-related emergencies treated in a children's hospital found that the emergency room visit was the first contact with a dentist for 27 percent of patients and for 50 percent of children younger than three and a-half years, though the American Academy of Pediatric Dentistry and the American Dental Association recommend a first evaluation at 12 months and an initial visit not later than 36 months. There are some significant financial barriers to dental care, the researchers note. The cost of seeing a dentist can be a big problem for a low-income family, and patients on Medicaid may have trouble finding a dentist willing to accept Medicaid's low reimbursement rates, delays in payment, prior authorization procedures, and contradictory benefits packages that may pay to extract a tooth but not to repair it. In 1993, only 20 percent of children covered by Medicaid received preventive dental treatment. "There was a significant amount of confusion among our patients regarding their dental insurance. Many patients who were covered by Medicaid and in theory had dental insurance said that they were without dental coverage. Patients and families may have been uninformed about the full extent of their coverage, or perhaps they were simply acknowledging the shortcomings of Medicaid." Medicaid expenditures for dental care are extremely low, the researchers note. Only 2.3 percent of Medicaid's child health expenditure are for dental care, though nationally, dental care accounts for about 30 percent of total health care expenditures. The emergency room doctors are quick to point out that the care they can give is not what their dental patients need. "The dental care that patients receive in the PED is limited to medications and, when necessary, incision and drainage of abscesses. Many of these patients would have received more appropriate care in a dentist's office." The report, "Dental Concerns Unrelated to Trauma in the Pediatric Emergency Department," by David Dorfman MD, Beth Kastner MPH, and Robert Vinci, MD, appeared in the June 2001 issue of Archives of Pediatrics and Adolescent Medicine. ----------------------------------------------------------- A legal controversy is being added to the medical controversies that have gone on for many years about use of the stimulant Ritalin to make children more attentive and quiet in school classrooms. Charging that Ritalin is “a drug in search of a disease,” an attorney who was one of the leading negotiators in the 1997 tobacco settlement has filed class action lawsuits in several states against the makers of Ritalin and the American Psychiatric Association, alleging that the two conspired to hype the benefits of Ritalin for schoolchildren in order to create a market for the drug. In a panel discussion convened by a major Washington, D.C., think tank June 18, physicians and lawyers squared off to examine whether there is or is not a widespread childhood condition called attention deficit hyperactivity disorder that requires medication, or whether most children diagnosed by teachers and parents as ADHD are simply manifesting in exaggerated form the problems all children have in accommodating to school structures and family rules. Doctors on the panel conceded that misdiagnoses of ADHD are common, often too hasty, and often not supported by thorough examination of the child by a psychologist or psychiatrist. They also agreed that the symptoms described in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders are "nonspecific" and can be misinterpreted. Attorney John Coale placed responsibility for the large numbers of children diagnosed as ADHD on “misleading marketing” by Ritalin’s manufacturer and the willingness of the APA to come up with a diagnosis that can be used to support medication. In his class action lawsuits, Coale is representing parents whose children were diagnosed with ADHD and who were pressured by schools or others to place their children on Ritalin. The lawsuits are expected to be heard over the next year. ----------------------------------------------------------- Diagnosing STDs in Adolescent Girls Using Vaginal Swabs Three readily treatable sexually transmitted diseases (Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis) can be diagnosed effectively through the use of patient-obtained vaginal swabs, and young adolescent women much prefer the swabs to traditional pelvic examinations, according to a study of 1,130 teenage girls in adolescent and school-based primary care centers and in health education classes in high schools. The development of ligase chain reaction testing makes it possible to detect STDs in nonclinical settings with the use of self-obtained vaginal swabs, and that offers new opportunities for controlling STDs, researchers say. Self-obtained vaginal specimens have been used successfully in research settings, but until now there have been few published data on the possibility of employing the technique for STD diagnosis in teenage girls. In the current study, reported in Archives of Pediatrics and Adolescent Medicine, adolescent girls living in neighborhoods with high rates of unemployment, substance abuse, violence, and STDs, were told of their eligibility to participate in a young women's health study, and their eligibility was assessed by a brief questionnaire. All participants were African-American girls between the ages of 14 and 18 who had been sexually active in the past six months and provided written consent. Four intervention workshops and data collection sessions were held in a local health clinic on Saturdays; each participant received a $20 cash incentive. Of 609 eligible adolescents who had been referred to the intervention workshops, 522 attended and agreed to participate in the study. Eighty-seven recruited teens didn't participate for a variety of reasons. Ten others were not asked to provide vaginal swabs because they were in the third trimester of pregnancy. That left 512 participants who were asked to provide vaginal swabs. They were instructed in the use of the swabs and offered the option of a pelvic examination if that was preferred, with no loss of the $20 incentive payment. None declined the swabs option. Two specimens were collected in three or four minutes in a private clinic examination room, using sterile Dacron-tipped swabs inserted as far as comfortable into the vagina and rotated for 15 to 30 seconds before removal. One swab was placed in a specimen transport tube for ligase chain reaction testing by Abbott Laboratories, and the second was used to inoculate culture medium for T. vaginalis at a second laboratory. All specimens were transported to the laboratories in insulated containers within 48 hours. Nearly all participants were asymptomatic at the time of enrollment in the study, but unsuspected gonorrhea, Chlamydia and Trichomonas infections were found in 27.8 percent of the samples. Whether any infections were missed by the swab technique as compared with traditional clinical examinations was not examined in this particular study, the researchers acknowledge, but they say their own previous work and that of others lead them to believe "the diminution of sensitivity was slight, if any." "These data add to the growing literature that suggests that, for women,
patient-obtained vaginal swabs are adequate and appropriate specimens
for STD screening at sites or in situations where pelvic examinations
are not otherwise required." The report, "Self-Obtained Vaginal Swabs for Diagnosis of Treatable Sexually Transmitted Diseases in Adolescent Girls," by researchers from the departments of medicine and pediatrics at the University of Alabama, Birmingham, and Rollins School of Public Health and Center for AIDS Research at Emory University, appeared in the June 2001 issue of Archives of Pediatrics and Adolescent Medicine. ----------------------------------------------------------- IN CONGRESS ESEA Reauthorization The United States Senate June 14 passed its version of H.R. 1, a bill to reauthorize and extend federal programs for elementary and secondary education. The House had passed its version of H.R.1 in May. Differences between the two measures will now be worked out in a House/Senate conference. Provisions that appear in both bills are likely to be retained in conference, but where the bills differ, conferees may keep or drop the disputed items. Here are provisions of the two bills having to do with school health: Sex Education None of the funds authorized under this Act shall be used
21st Century Schools The Senate bill authorizes funding for 21st Century Community Learning Centers to be operated by local education agencies and community groups, that would offer education enrichment and drug prevention programs, after school and when schools are not in session. Discipline The House bill authorizes schools to discipline or suspend a child with a disability in the same manner that a child without a disability would be disciplined, if the child with a disability carries or possesses a weapon on school premises; knowingly possesses, sells, or uses illegal drugs at school; or commits an aggravated assault on school premises. The Senate bill specifies that if the behavior of a child with disabilities that led to the child's removal from a regular education placement is determined to be a manifestation of his disability, the child must be placed in an alternative education setting. If the behavior was not a manifestation of the child's disability, school personnel may apply the same disciplinary procedures that would apply to children without a disability. Parental Rights/Student Privacy The House bill, but not the Senate, also requires written, informed parental consent before a school may use funds under any program authorized by the law to "undergo health or mental examination, testing, treatment, or immunization" except in the case of a medical emergency. That provision doesn't apply if a state expressly permits such examinations or treatment without parental consent. The Senate bill requires LEAs to develop policies to protect students from commercial entities that seek to obtain information about the students for commercial purposes. School Nursing Pest Management Suicide Prevention Mental Health Environmental Tobacco Smoke Alcohol Abuse Healthy and High Performance Schools ----------------------------------------------------------- WORTH NOTING Treating Children and Adolescents after Possible Exposure to HIV There is confusion among practitioners about how to treat children
and adolescents who may have been exposed to HIV in sexual assaults,
or by accidentally pricking themselves with discarded drug needles picked
up on school playgrounds or in the street. There are no national guidelines,
but doctors who mailed a questionnaire to pediatric infectious disease
(PID) and pediatric emergency medicine (PEM) departments in the United
States and Canada found many PIDs and PEMs would do a baseline assessment
of HIV status immediately after the incident and start antiretroviral
drugs within 24 to 72 hours, for lengths of therapy ranging from 2 to
12 weeks. The most frequently recommended drugs were zidovudine and
lamivudine. Reprints of an article on this subject in the June issue
of Archives of Pediatrics and Adolescent Medicine are available
from Dr. Franz Babi at franz.babi@bmc.org.
Initiative to Expand Access to Prescription Drugs Community health centers and other safety-net providers who participate in the 340B discount program for prescription drugs will be able to reduce their administrative costs under an experimental program announced June 18 by Health and Human Services Secretary Tommy Thompson. Demonstration projects will be allowed to participate in single purchasing and distribution systems that serve covered entity networks, to contract with multiple pharmacy service providers, and to use contracted pharmacy services to supplement in-house pharmacy services. Currently, participants in the 340B program can't take any of those steps. The drug discount program established under Section 340B of the Public Health Service Act requires manufacturers to sell drugs to specified safety-net providers at a discount rate that averages 25 percent to 40 percent on most drugs. ------------------------------------- The incoming president of the American College of Obstetricians and Gynecologists has told his colleagues that every woman should have emergency contraception, or a prescription for it, in her medicine cabinet. That would help cut the rate of unintended pregnancies in the United States by half, said Dr. Thomas Purdon. Currently, only half of obstetricians and gynecologists include emergency contraception as part of their routine contraception counseling; 34 percent of women have never heard of the method, which involves accelerated doses of regular contraception pills taken immediately after unprotected sex; and only 1 percent of U.S. women have ever used it. ------------------------------------- The Canadian Association for School Health has launched a website containing more than 400 lesson plans and on-line learning activities in sex education, organized by grade level and learning outcome. Sponsored by the Sexuality and Reproductive Health Promotion Unit at Health Canada, the site says its lesson plans were drawn from credible sources from several countries. The website can be accessed at www.safehealthyschools.org/sexualityeducation/gateway.htm. ------------------------------------- Noting that 20 years ago, on June 5, 1981, the Morbidity and Mortality Weekly Report published the first report of five cases of a virulent form of pneumonia among young men, the Centers for Disease Control and Prevention notes that MMWR has since published more than 400 reports about human immunodeficiency virus (HIV) and AIDS and remains the primary source of information about the epidemiology, surveillance, prevention, care, and treatment of HIV and AIDS. The June 1 issue and other issues of MMWR are available on website www.cdc.gov/mmwr. As part of the 20th anniversary of the first AIDS recognition, the National Institutes of Health has launched an oral history website that records the voices of researchers as they encountered the new epidemic. Described as "a window into the world of biomedical science" for the public, the website can be accessed at http://aidshistory.nih.gov. ------------------------------------- The National Academy of Sciences, the science advisory body to the
federal government, is urging the government to back early routine screenings
of children for autism and related disorders. In a report, "Educating
Children with Autism," the Academy says early diagnosis is important
because prompt educational intervention is the key to greater progress
in children's mastery of fundamental communication, social, and cognitive
skills. The Academy report is available online at www.nap.edu/catalog/10017.html. What Works, What Doesn't: Reports from the Office of Juvenile Justice A report from the U.S. Justice Department's Office of Juvenile Justice and Delinquency Prevention summarizes what is known about the origins of juvenile crime and what can be done to prevent and reduce juvenile violence. The report urges schools and communities to take seriously delinquent acts by young persons under the age of 13, but says there is no evidence that a new breed of superpredators is emerging. It appears that putting young offenders in correctional institutions has little impact on preventing future offenses, and the best bet, the report concludes, is to develop programs that enhance youngsters' problemsolving and interaction skills. The report, "What Works and What Doesn't: Research 2000," is available online at www.ncjrs.org/txtfiles/fs-9420.txt. In a report on bullying and its effect in both the perpetrator and the victim,. The Office of Juvenile Justice notes that adults are beginning to take bullying seriously and cites some programs that seem to work in reducing its incidence and effects. That report, "Addressing the Problem of Juvenile Bullying," is also posted online at www.ncjrs.org/txtfiles1/ojjdp/fs200127.txt.
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