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

Fostering Social Entrepreneurship in Rwanda

This post also appears on the Spark blog. It serves as a profile of one of Spark’s most recent grantees, an organization I happily support, The Komera Project.

It’s not every day that you get to see the foundations of graduate school flourish into a burgeoning non-profit organization halfway across the globe. So, when one of my close friends from graduate school told me in 2008 that she was starting an organization in Rwanda where she had been living, I was of course eager to support her. And the more I learned about Rwanda and the work her organization was undertaking, I became invested in seeing its success grow.

Named The Komera Project (in Rwanda the word “Komera” means “be strong, have courage”), Margaret Butler developed the idea to start the group over the course of her many runs through the Rwandan countryside. She noticed that sometimes girls from the local villages would jump in and join her on these runs until she realized that her behavior wasn’t going to be considered socially acceptable. Combined with the fact that Margaret was seeing first hand how most girls did not make it to secondary school, she decided to host a girls-only ‘fun run’ one day to promote the education and rights of these girls. As they started off, supporters shouted “Komera!” to the girls, and the group was born.

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Working with the local government, schools, and some on the ground staff from Partners in Health based in Rwanda, Margaret steered the first of Komera’s 10 girls onto their fully funded secondary education path. Komera has since grown to over 60 scholars, and has expanded their reach beyond just funding the girls’ schooling. They now also provide mentorship, a leadership program, and now a social entrepreneurship program.

Some context and understanding of Rwanda is essential to underscore how significant this is. Only 17% of girls in Rwanda go to upper secondary school (high school). 87% of the country lives in rural areas. All Komera scholars are from these rural areas and live on about $1 a day from families working as subsistence farmers or tin miners – so these girls would be farming, mining, and/or working in their households if not in school. Komera focuses on supporting the girls in grades 10-12, since the majority of girls begin dropping from school in grade 10. Komera never takes on a scholar unless they have the cash to fully fund them for those three years – this cost is $500 a year for tuition, uniforms, boarding, all school supplies, and personal supplies like hygiene products.

By 2010, the focus at the Komera Project had shifted from primarily scholarship to figuring out how to keep the girls in school and create a real Komera community, and that’s when the themes of mentorship and leadership came into play.

The transition into boarding at school can be really difficult for the girls, especially since they are spread between 13 different schools. In Rwanda, once you have the funds to pay, the local government decides what school you will go to, so while Komera would prefer all the girls to be in the same 4-5 schools, that isn’t possible. However, they are all in the same district (there are 30 districts in the country total).

To help combat some of the difficulties around these transitions, Komera provides school-based volunteer mentors for all the girls – female staff or teachers who meet one-on-one with the scholars every week. They actually use curriculum to cover topics like health education, financial literacy, what their rights are as women in Rwanda, to any personal concerns they may be having. The girls also meet with the Komera social worker (one of only two paid Komera staff members!) regularly when she visits each school throughout the year. Their next goal is to launch a university mentoring program, and they have started to do some outreach to universities in Kigali (the Rwandan capital) to see if there is interest among Rwandan university women to mentor these girls.

Leadership is another key component of the Komera Project. The Komera scholars attend Leadership Empowerment camp during their month-long summer break, where they take part in the now-annual Girls Fun Run and participate in workshops focused on topics like English-speaking skills, how to use computers, and sex education. These have been essential for the girls, because these month-long breaks can be vulnerable times for the girls who go back home. Most stay with extended family, get pulled back into working with the family and can potentially be convinced that they need to leave school – especially true for the nearly 20% of girls who come from families who don’t fully support their education efforts.

In regards to the new Social Entrepreneurship Program that Spark is helping to support, most recently the idea of sustainability has come up – how does Spark keep the momentum of being a Komera Scholar going once the girls graduate from secondary school? This was particularly pressing since 15 girls will be graduating in 2013.

The girls had been requesting a social entrepreneurship type training for some time – wanting to learn the skills necessary to starting and maintaining a business, a non-profit or grassroots venture. When asked about social entrepreneurship training, all the girls said that they had never even considered how they might be able to give back to their community or considered themselves leaders, and they were really excited about the idea of learning how to create something to benefit and incorporate their community.

The winter break, in November-December hasn’t been able to be filled by Komera because they haven’t been able to fund camps both in May-June when they have the leadership and empowerment camps as well as during the winter months. Finding funding for this new social entrepreneurship training became essential, as well as a way to get a tested and evaluated curriculum in their hands.

A local Rwandan group, Global Grassroots, has been offering entrepreneurship, business training, and skills-based workshops for women in Rwanda since immediately after the genocide – and they’ve been doing so pretty successfully. They have agreed to modify their program for a weeklong intensive program for teen girls, as well as moderate the weekly follow-ups. This will be called the “Girls Academy for Global Conscious Change.”

The girls will work in groups of ten, separated by interests – they’ll select a topic they want to focus on, like health, education, water, and they will learn how to craft a mission statement, develop a program goal and implementation plan, and how to write and follow a budget. They will be given small grants of $50, which will be managed by the social worker and through each phase can retrieve part of the money for supplies, then implementation or advertising. The goal is to have them create these mini-organizations and incubate them throughout the school year, with the hope of maintaining it beyond that year, turning it into a profitable business, and growing it beyond their immediate school community.

When I heard that this was their well thought out plan, I thought Spark would be the perfect place for Komera to seek funding help to cover the costs of the girls supplies, food, transportation, and personal supplies throughout the training. The perfect way to blend two of the organizations that are most dear to me.

The Komera Project embodies the exact kind of values and practices that Spark looks for in grantees, and I look forward to what these budding entrepreneurs are up to in just a few years.

Check out their Facebook and Twitter pages, and visit their site to learn more about Komera and meet some of their scholars.

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.

Social Media Continues to Make People Feel Bad About Themselves

A study out of the UK has found (as have others more than once), that use of social media sometimes doesn’t make you feel like…really socializing. Rather, it can make you feel anxious and depressed.

The study found that participants noted a drop in their own self-esteem after viewing the accomplishments of their Facebook friends. Combine this with the fact that 25% of them claimed to have had relationship issues due to online ‘confrontations’ (which could, of course, mean many things), that more than half were rendered uncomfortable when they couldn’t easily access their social media accounts, that other studies have claimed more socially aggressive (subtly termed ‘hateful’) folks use Facebook more often, that people often deliberately post bad pictures of their friends to make themselves look better and subsequently compare their weight, body size, and physical appearance to these friends, and that Facebook is cited in divorce proceedings as being problematic for couples, and you may be liable to think that this phenomenon offer little in the way of improving our lives.

A good thing to remember here, aside from the pretty remarkable things being done with social media in terms of education, research, medicine, and public health (this USC study is great news, and touches upon the influence of social networks in ways I’ve been exploring as it relates to substance use, sexual behavior, and disordered eating behaviors, and that other studies have shown the exact opposite in terms of emotional response, is that social media does allow users to tailor the perception and identity they project. Another recent study (I’ll try to find the URL for it!) showed, unsurprisingly, that what users often admire about their friends’ virtual lives is the positive sliver that their friends elect to promote about themselves.

Also encouragingly, those children and adolescents who will have known no life without social media, recently were surveyed about their use of technology and reported that they still preferred face-to-face communication. I put limits on myself in terms of use (though I’m sure to some of you it may not seem like it!) since I feel as though I miss a lot in terms of nuance when communication online, but it remains true that both my research and personal communication projects require a fairly consistent social media presence – I admit that I’m torn. As with most everything, balance is key, but how can we monitor our behavior in ways that allow us to strike that balance without teetering into territory that destroys our positive sense of self?

Thoughts? How about you ironically follow me on Twitter to discuss?