How School-Based Health Centers Can Help Save Our Kids

Thanks to my elementary school nurse, I finished school on time. That’s right: In the 5th grade, I strained during a school vision test to read the little letters I saw projected on a screen 10 feet away. Asking in bewilderment if I wanted to try again, the screener asked, “How have you even been seeing the chalkboard?” Off to the nurse I went to get my prescription recorded for her records, and glasses were ordered that day.

In the context of today’s school health services, my experience seems paradisal. That’s because today, public school health services are conspicuously absent. As a youngster, I never gave much thought to how the presence of that nurse or vision screener and her assessment impacted my uninterrupted performance in school. Given that we know academic success and wellbeing are inextricably linked, the low number of school-based health centers and staff is particularly troubling. Increasing the number of centers with fully staffed health professionals—nurses and school psychologists in particular—can greatly improve child health as well as academic performance.

The Affordable Care Act appropriated $200 million for the explicit purpose of building and expanding school health centers, a number that still seems low considering that only 45 percent of public schools have a full-time nurse, and 30 percent can only count on a nurse part time. A quarter of public schools have no nurse at all. A mere 12 states have met the Department of Health and Human Service’s desired ratio of one nurse for every 750 students.

The cost of a school nurse—the average salary hovers around $43,000 a year—and of equipping a center with supplies varies from state to state, and even county to county. If the ACA money were used solely on nurses, it would only allow 4,651 nurses to enter the field. After covering the staffing of public schools in New York City, Los Angeles, and Chicago we would be left with funding for a little over 1,000 full salaries—without even beginning to consider the cost of dedicating and maintaining a physical space in a school and procuring supplies.

Historically, school-based health centers have done everything from dispensing Band-Aids and cleaning cuts to providing immunizations, dispensing medications, and coming to the aid of children suffering from seizures. These centers have also offered preventive care and treatment for children who may not otherwise have access to health insurance. They can have a significant impact on what is known as the “achievement gap,” the major race and socioeconomic disparities in academic success that begin to emerge as early as elementary school, by working to address the health issues that have the greatest impact on a child’s performance in school.

An emerging body of research points to the ways in which these disparities could be drastically reduced, and preventive care restored, with the return of robust care being offered in house at our public schools.

The Journal of School Health devoted an entire issue to research by Charles Basch, Ph.D., of Teachers College, Columbia University, that highlights health issues with historically high socioeconomic, racial, and urban health disparities, how they contribute to poorer academic outcomes for minority youth, and how school-based health care can mitigate them. Children of color currently make up 85 percent of New York City’s public school system, one of the most racially segregated in the nation, and Basch’s research outlines seven health problems that can be easily addressed by a school nurse within these segregated environments and help reduce the disparities.

The least contentious health issues addressed are asthma, vision and nutrition. The prevalence of asthma among black children in the United States is 12.8 percent versus 8.8 percent for white children, and the annual estimate of asthma attacks among black children is 8.4 percent compared to 5.8 percent among white youth. Poorly controlled asthma can impact cognition and plays a significant role in absenteeism; the overuse of emergency departments and underuse of effective medications among minority youth are a good measure of how the affliction is having greater negative consequences for children of color.

As someone who needed glasses fairly young, it’s unsurprising that more than a fifth of youth have vision problems. A national sample of nearly 50,000 children showed those from low-income families were less likely to have vision diagnoses than high-income children. Once diagnosed, black children have less intensive and sparser care than whites. And everyone knows that breakfast is the most important meal of the day, but one study showed that among 9-year-old girls over a three-day period, 77 percent of white children had breakfast every day while only 57 percent of black children did. Of children qualifying for reduced or free lunch in their public schools, less than half participated in schools’ free breakfast programs for which they were eligible. Nutrition influences brain activity, which results in significant impacts on children’s learning and cognition.

There are uncomplicated solutions to these problems. Asthma screenings are quick, and medicines are immediately effective. Dealing with symptoms and management of asthma at school can decrease both absences and severe attacks. Vision screening is widespread in schools, but the coordination of follow-up care by a school health professional is essential for children in need of eye-care interventions and is the biggest culprit behind current disparities. Participation in universal school-breakfast programs has shown reductions in absences, and allowing children to eat breakfast in their classrooms as opposed to the cafeteria has resulted in increases in the programs. School-based health centers can oversee the distribution of healthy meals for children in need of these programs, with the added perk of highlighting which students may benefit from other school-health services.

Attention deficit and attention deficit hyperactivity disorders (ADD and ADHD) have received much attention in recent years. ADD/HD affects sensory perception, absenteeism, cognition, and even organizational and planning skills. Urban youth of color are more likely to be affected by and less likely to receive a correct diagnosis and effective medication. Screenings by school psychologists and learning specialists can aid in the diagnosis of ADD and ADHD and the accessing of medications, as well as help students with effective behavioral modifications. School nurses are in a position to manage the medications by dispensing them to students at school if necessary, and ensuring that the timing and dosage are accurate.

Most contentious of the issues tackled by Basch in his call to arms is teen pregnancy. Among 15- to 17-year old girls, the pregnancy rate among blacks is more than three times higher than whites, and the rate among Hispanic teens is more than four times as high. Teen mothers on average have two fewer years of schooling. They are 10-12 percent less likely to finish high school, and have 14-29 percent lower odds of attending college. The implementation of evidence-based, comprehensive sex education is the best way to reduce the teen pregnancy disparity. This requires the overhaul of the popular abstinence-only education programs, which have been shown to leave students ill-equipped to make the healthiest decisions. Given the fraught political environment, comprehensive sex education is not widespread, and school nurses can be an essential resource for students beginning to engage in sexual activity. From dispensing condoms to connecting students to community resources for treatment who may disclose concerns about both pregnancy and sexually transmitted infections, and being the person on campus who can answer questions privately about reproductive health, nurses can address issues that are not part of classroom learning.

There are signs of hope, as Basch was asked by Secretary of Education Arne Duncan to outline national health strategies in schools, but the now well-known public funding cuts to both healthcare and education continue to threaten the health status and educational attainment of youth in America’s public schools.

The disparities can be shocking. But these specific health issues are fairly straightforward, do not require specialists, and can be tackled easily within a school environment by nurses, resulting in the improvement of both kids’ public health and academic achievement—as long as they are given the finances and support to do so. As a front line of defense against immediate health emergencies and the prevention and maintenance of chronic diseases that develop in elementary school years, ensuring the presence of fully staffed, funded, and stable school-based health centers is essential—most especially for our children already victim to a shameful lack of resources.

 

Originally published at The 2×2 Project

The Declining Mental Health of Millennials: Is Depression the New Normal?

It is a familiar sight to see a group of teens bent over phones or gaming devices, checking in, tagging each other, posting pictures and commenting, and waiting impatiently for all their cyber friends to ‘like’ their work, or re-tweet their location, or post an accompanying video.

Teenagers today are some of the most enthusiastic users of social media sites like Facebook, and as an age group their Internet use is near universal—a full 95 percent of teens are now online.

This trend has provoked anxiety, raising a range of concerns, from sex predators to promoting a sedentary lifestyle. Less noticed has been the effects of heavy media use on mental health.

But just as teen internet use has risen in recent years, teen depression and psychopathology has risen five-fold since the early part of the 20th century.

This relationship has recently been of concern to psychologists and psychiatric epidemiologists. Dr. Jean Twenge, a professor of psychology at San Diego State University, has been one of the most outspoken in her field on linking these two trends.

As she says in her recent book, The Narcissism Epidemic: Living in the Age of Entitlement, rising rates of depression are partly the result of a culture that promotes the narcissism pulsing through social media usage.

Americans—especially teenagers—now rely so much on external and immediate gratification, social status and image, and the superficial gain they get from social media that they are forgoing values that contribute to a sound internal life—like strong communities built more on shared goals than on individual success, and the pursuit of activities that provide internal satisfaction, Dr. Twenge says.

Eight percent of 12-17 year-olds in the United States experienced at least one major depressive disorder in the past year. While some have argued that this is simply the result of greater recognition and diagnosis of the illness than in the past, Dr. Twenge and others say it owes to the rise in materialism and narcissism in what she has termed “Generation Me.”

Teens who have grown up in today’s social media environment know no other reality than the one in which anyone in their ‘network’ has a lens into their life and the chance to judge every act of it. 80 percent of teens active online participate in social networking sites, according to a Pew Research Center study from 2011. For this reason, they get the message that “extrinsic” values like how people perceive—virtually or in reality—is of greater importance than “intrinsic” values like their personal goals and the development of a unique self.

Dr. Twenge has elaborated on this in her blog at Psychology Today, saying that culturally, we have lost rites of passage that demarcate adulthood, emphasize individual fame for fame’s sake as opposed to real accomplishment, over-indulge our children from early developmental stages, and support and even laud self-promotion at the expense of others.

Additionally, Dr. Twenge and colleagues have indicated in their research that this generation of teens and young adults are less civic-minded, care less about social and political issues, are less interested in working towards solutions to environmental concerns, and have less empathy or interest in social justice.

Dr. Twenge’s theory is backed up by parallel psychological research, which has suggested that feeling one’s fate is shaped by external forces rather than one’s own efforts—what is known as ‘locus of control’—is more likely to cause depression and anxiety than feeling an internal drive and control over one’s future.

“Externality,” a measure of one’s perception of the influence of external forces over one’s life versus the influence of internal motivation and action, can be used to determine to what extent someone takes responsibility for their own actions and how accurately one identifies how their own behavior leads to certain outcomes.

High externality also indicates little conviction in one’s ability to behave in a specific way, something known as self-efficacy.

This could mean that those who focus on more materialistic and superficial lavishing of attention are in part doing so because they lack the self-esteem and efficacy to think that they can achieve something more significant and tangible.

This is in line with Dr. Twenge’s hypotheses. She argues that narcissism and the rising but inaccurate levels of self-evaluation can ultimately lead to deeper disappointment in one’s self and depression from alienation caused by increased self-involvement.

There has been a marked increase since 1960 in the number of people who feel this way—that external elements control their lives and future, according to a 2004 epidemiological study that Dr. Twenge and her colleagues conducted.

These feelings are associated not only with depression but also ineffective stress management, feelings of helplessness, and decreased self-control. They are also associated with higher levels of cynicism and self-serving bias.

Two studies of Dr. Twenge’s are illustrative of the fact that this rise in teen depression is indeed both significant and new.

One is a recent meta-analysis she and other researchers conducted, which explored self-reported feelings of depression and sadness in college and high school students from the 1930s to the present.

Even though self-reporting is often questioned, studies have shown that self-reported feelings of depression and compromised mental health tend to be accurate in children and adolescents—perhaps even more so than in adults— and even complement diagnostic criterion for mental illness.

Five times as many teens and young adults now score above cutoffs meeting psychopathology criteria as they did in the earlier through mid 20th century, according to Dr. Twenge’s analysis.

Population level results indicate the underlying shift has societal causes and is not merely the result of genetic predisposition to mental illness or an individual’s circumstances.

The second study took a closer look at teen depression in the past twenty years. Dr. Twenge noted that while major depressive disorder and suicide appear to have slightly receded since the early 1990s—likely a result of an increase in anti-depressant medications—current prevalence remains higher today than before the 1990s and psychosomatic complaints have continued to increase, such as feelings of being overwhelmed and anxious.

Other research has found a relationship between external motivators and neurological patterns.

One study revealed that teens suffering from depression had diminished responses to rewarding stimuli, such as genuine assurance of a job well done, a friendly affirmation from a friend, or small monetary compensations for the actual completion of tasks. Follow-up research showed that 20 year-olds who experienced depression as teens still have muted reward responses, indicating that help needs to be offered as early as possible.

Teen depression of course can have significant consequences, such as the increased likelihood of substance use and abuse, social withdrawal, strained relationships with family and friends, and in the worst cases, suicide.

To be sure, Twenge’s findings are controversial, and some continue to insist that there is no increase in depression or psychopathology in teens. But, in the opinion of Dr. Twenge, to prevent further increases in these depression statistics, teens need to move from constant self-promotion to feeling gratification from real achievement, and to reward feelings deriving from accomplishment as opposed to blindly seeking praise and compliment.

In today’s ubiquitous social media environment, that may be difficult to do, and the results slow to come.

Originally Published at The 2×2 Project November 7, 2012

Juvenile Detention Centers Miss Key Health Indicators for Girls

I listened to a great NPR report this afternoon by Jenny Gold about juvenile detention centers and how they’re missing some key indicators of the health status of girls that enter into the system. As someone specializing in adolescent girls’ health, I was pretty fascinated – it detailed the personal experiences of a few girls being seen in a New Mexico facility and also tried to address ways it could be rectified. Detention centers can actually be helpful entry points for girls and young women to be connected to healthcare resources (we’re talking mental and physical health, so everything from counseling to substance abuse help to medical attention if they are victims of assault or violence or have seen physicians only irregularly).

One of the biggest issues facing these girls was confidential disclosure of their health status and any social, emotional, and physical issues they were facing. Developing rapport with a provider at a detention facility can be difficult in and of itself, but the girls reported having to answer personal questions in an open-door location, often with men and boys – staff or other teens – present; unsurprisingly, this made it difficult for many girls to feel that they could answer questions of a personal nature (sexual behavior, drug and alcohol use, history of assault, abuse or violence) honestly and openly. What we do know about these girls – 41% have vaginal injury consistent with sexual assault, 8% have positive skin tests for tuberculosis, and 30% need glasses but don’t have them – shows that getting all of this information early on is essential for appropriate and timely care.

One proposed solution to this – getting as much information as possible from these girls about their health status and the best ways to then help them, treat them, and connect them with resources – was to have them fill out a survey themselves. Currently, girls are asked 35 questions by an intake nurse when they arrive, that cover things like current medications, alcohol or drug use in the last 24 hours, and whether they have a history of self-destructive behavior. The proposed survey in the New Mexico facility is 132 questions, and according to one facility employee the time that would take is just not feasible given the traffic and business of the facility. Researchers and providers implemented a pilot study of the survey for 30 girls at the detention facility.

Of course, I can’t comment on the actual level of frantic activity in the specific facility at hand, but I can say that having a questionnaire that catches health issues which can be immediately and effectively addressed can prevent a host of issues from getting worse as time goes on without treatment – potential injuries from abuse or assault, needing STI screenings for victims of rape or girls who are sexually active without access to contraceptives or regular gynecological care, and of course mental health resources and immediate connection with social workers or therapists for those girls in need. Either having the girls fill out the survey via computer themselves or having a nurse help them would also be enormously helpful in the long run. This can also be a great way to track the care progress of these girls over the years, as many go in and out of detention centers. For girls who have experienced assault or abuse or multiple infections and injuries, this can be an easy way to follow-up with them without having to go through essentially baseline assessments of their well-being every time they enter a facility.

Some of the sobering stats about the girls from this particular New Mexico facility from this report: Of the 30 girls who participated in the piloting of implementing this survey, 12 needed immediate medical care, and 23 were coded as needing medical care within 24 hours, based on the survey’s questions. Intakes without this survey missed essential things, like burns on one girl’s torso and chest.

Check out the whole report here. I have no doubt that detention centers are in dire need of additional resources and likely way more staff than they have, for more than just this particular issue of adolescent girls’ health, but if the issue is there being one nurse for multiple intakes, having the girls fill out the survey on a computer themselves – when they’re more likely to be honest than in discussion with a nurse anyway, seems like the best solution to these kind of initial entry screenings. Especially since poor physical health is an indicator of recidivism, increasing the likelihood of girls ending up back in a facility.

American Graduate, American Dropout

I don’t know how many of you educators were able to catch parts of PBS’ ‘American Graduate‘ series this year. It’s a great series that’s focused on the major issues of (mostly public) education in America, including urban versus rural education struggles, mentoring and counseling, adolescent health issues like substance use and sexual activity, ensuring that we’re serving the needs of immigrant students, social and economic class issues and how they impact opportunity and subsequently achievement (measured most commonly as high school graduation) and what’s behind some of the alarming and rising rates of dropping out across the country.

The latter three issues were behind a documentary that I was featured in and that aired in September. It was pioneered by a group of teen filmmakers at an organization based in Brooklyn called Reel Works, a group with a great mission that I encourage you to check out. If you want more background on the piece, check out the PBS brief before the video, which also includes a great interview with some of the teen filmmakers. Hope you find it interesting!

Is Media Use Slowing Kids Down Intellectually?

A couple interesting studies recently came out that I thought were clearly linked with implications for the development of our younger generations. I recently wrote a post for The 2×2 Project that discusses the impact of media use on the mental health of teens, so I thought this was fairly pertinent.

The first study showed how much the U.S. economy loses to social media use every year. Take a guess at what that amount is.

10 billion bucks? Nope.

100 billion? Not even close.

500 billion? Still no.

According to Mashable’s summary via LearnStuff, social media costs the U.S. economy $650 billion. Check out the infographic they put together:

I’m someone who is generally really torn about social media. I have a blog and am active on Twitter, though along with my Facebook profile I use these all primarily for semi-professional purposes. ‘Semi’ in the sense that they aren’t part of my job, but I use them to promote interesting finds or essays related to my field of public health; I’ve found the sites to be remarkably helpful in communicating important points and connecting with wider audiences compared to different – usually more traditional – media channels. I use social media heavily to promote work being done in my fellowship – my own and other fellows’ – and it unquestionably has helped us reach researchers and organizations it would have been otherwise very difficult to do.

That being said, I am also fairly hesitant about social media given that I don’t particularly like my personal life broadcast across channels, so I have to be pretty meticulous about what and how I use the mediums. I think it can be enormously helpful for children who have difficulty communicating and making connections; I also find that it can feel almost more isolating than no communication at all since it emphasizes and underscores that real interpersonal interaction isn’t exactly happening. So, I’m clearly torn.

The second study, by the great group Common Sense Media, addresses the concerns of teachers and educators that the various kinds and amount of time kids are using media at home is impacting the quality of their classroom work and engagement. 71% of teachers said that they think media use is hurting kids’ attention spans in school, 59% said that it’s impacting the students’ ability to communicate face to face, and 58% have said that the media use is impacting kids’ writing skills – and not in a good way.

Given that the LearnStuff infographic shows that 97% of college students are daily Facebook users, it seems that these symptoms have the potential to get worse at increasingly younger ages, and that by the time kids who grew up in this media-rich environment are in college…well, who knows. And 60% of people visit social media sites at work (something I found most interesting? that more people are on LinkedIn than Twitter), which are obviously impacting work in the sense that they are taking away from productivity or activities related to the job – unless the job is one that incorporates social media, as many jobs increasingly are. Not to be a doomsday reporter, but I do think the implications for these studies are very real.

Thoughts? Come chat on Twitter.

Lots of Rest Can Prevent STD Transmission! At Least, That’s What Fresno is Telling Kids

In case you wanted to read something today that will make make you fume, check out ThinkProgress’ report about an abstinence-only education program in Fresno (for shame, California). It is massively, massively irresponsible.

Did you know that getting a lot of rest can prevent you from getting STDs? And that HIV can be spread by kissing? Let that marinate for a bit, because that’s what kids in Clovis, CA, are going to come out of school thinking.

Condoms? Not addressed. Contraception? Not covered.

This curriculum is actually against California law, which requires medically accurate sexual health education to be delivered to students. The ACLU is suing.

Maternal Health and the Status of Women

Both globally and domestically, maternal health and the standing of women are inextricably linked. If women do not have the means and access to give birth safely, with trained and educated midwives, physicians and nurses, with appropriate prenatal education and care, it is often indicative of the standing of women in their communities and countries overall. Women’s inequality is also linked to the soaring population growth in developing countries, which will pose a range of new challenges for the next few generations.

Some may point to the United States as an anomaly, citing women’s increasing economic and financial independence, education, and leadership roles in America, while in terms of maternal health rankings, we remain pathetically far down the line for our resources (49 other countries are safer places to give birth than the U.S. – despite us spending more money on healthcare than anywhere else). Of course, the recent and incessant attacks on allowing women to access credible, accurate, up-to-date and comprehensive sexual and reproductive health education and services makes this statistic not entirely…surprising, shall we say.

So, I found the incredibly detailed and visually impressive infographic by the National Post, pulled from spectacular data and research done by Save the Children to be particularly fascinating. What they did was combine information on the health, economic, and education status of women to create overall rankings of the best and worst countries for women, splitting the countries into categories of more developed, less developed, and least developed, and the countries were ranked in relation to the other countries in their category (the divisions were based on the 2008 United Nations Population Division’s World Population Prospects, which most recently no longer classified based on development standing). While these divisions and the rankings can certainly be contentious and may incite some disagreement (nothing unusual there, these kind of rankings usually are), I thought the results were interesting. Some highlights – Norway is first, Somalia is last. The United States was 19th, and Canada was 17th (Estonia fell in between us and the Great White North) in the most developed. Israel is first in the less developed category, and Bhutan is first in the least developed category. The full report with data from Save the Children is also available, if you want to learn more about the information combined to make this image. Take a look:

A Woman’s Place – Courtesy of the National Post

One thing that I thought was particularly great was that the researchers combined women’s health and children’s heath data to create rankings specific to being a mother, when that category is sometimes only assessed based on access to reproductive care.The specific rankings of maternal health highlights largely mimics the overall standing of women, as seen here – Norway is number one, again, and Niger falls into last place:

Mother’s Index, Courtesy of Save the Children

I think these images and graphs are particularly moving given one of the top health stories coming out of the New York Times today, which showed that a recent Johns Hopkins study indicated meeting the contraception needs of women in developing countries could reduce maternal mortality (and thereby increase the standing of women in many of the nations doing poorly in the above ranking) globally by a third. When looking at the countries in the infographic that have low rates of using modern contraception and the correlation between that and their ranking in terms of status of women, it’s not surprising what the JH researchers found. Many of the countries farther down in the rankings have rates below 50%, and for those countries filling the bottom 25 slots, none of them even reach a rate that is a third of the population in terms of contraceptive use – which of course in most cases has to do with availability, not choice. Wonderfully, the Gates Foundation yesterday announced that they would be donating $1 billion to increase the access to contraceptives in developing countries.

Also of note, and in relation to maternal and newborn health, is a new study recently published by Mailman researchers that showed PEPFAR funded programs in sub-Saharan Africa increased access to healthcare facilities for women (particularly important for this region, as 50% of maternal deaths occur there), thereby increasing the number of births occurring in these facilities – reducing the avoidable (and sometimes inevitable) complications from labor and delivery, decreasing the chance of infection and increasing treatment if contracted. This has clear implications for children as well (and why I think this study relates to the National Post infographic and the NY Times article), since newborns are also able to be assessed by trained healthcare workers and potentially life-threatening conditions averted – including HIV, if the newborns have HIV+ mothers and need early anti-retroviral treatment and a relationship with a healthcare worker and system. And it goes without saying that if a new mother is struggling with post-delivery healthcare issues, including abscesses and fistulas, or was dealing with a high-risk pre-labor condition like preeclampsia, the child will have an increasingly difficult early life, perhaps even a motherless one.