Full Journal - The Future of Children

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CENTER FOR THE FUTURE OF CHILDREN • THE DAVID and LUCILE PACKARD FOUNDATION
The Future
of Children
VOLUME 4 • NUMBER 3 – WINTER 1994
CRITICAL HEALTH
ISSUES FOR
CHILDREN AND
YOUTH
Statement of Purpose
T
he primary purpose of The Future of Children is to disseminate timely information
on major issues related to children’s well-being, with special emphasis on
providing objective analysis and evaluation, translating existing knowledge into
effective programs and policies, and promoting constructive institutional change. In
attempting to achieve these objectives, we are targeting a multidisciplinary audience
of national leaders, including policymakers, practitioners, legislators, executives, and
professionals in the public and private sectors. This publication is intended to complement, not duplicate, the kind of technical analysis found in academic journals and the
general coverage of children’s issues by the popular press and special interest groups.
The varied topics selected for this issue of the journal are individually very important to the
future of children. In addition, several themes recur in these articles despite the diversity of subject
matter. In one way or another, the family is central to each of the health problems faced by children and
youth whether the issue is ambulatory illness, care of an infant of a single mother, or the violent
behavior of a teenager from a two-parent household. Further, the need for an effective public health
infrastructure cuts across many of the issues from the untoward consequences of involuntary smoke
exposure to protecting adolescents from the HIV/AIDS epidemic. Finally, an appreciation of ethnic
differences in the United States is increasingly important to helping children and youth overcome the
financial and nonfinancial barriers to obtaining health care, whether the issue is private health
insurance coverage or public education relating to violence, HIV/AIDS, or smoking.
The articles presented here summarize knowledge and experience in selected areas that we
believe are relevant to improving public policies in the United States which have an impact on the wellbeing of children and youth. We hope the information and analyses these articles contain will further
understanding of the important issues and thus contribute to reasonable changes in policies which will
benefit children and youth.
We invite your comments and suggestions regarding this issue of The Future of Children. Our
intention is to encourage informed debate about children’s issues. Toward this end we invite
correspondence to the Editor. We would also appreciate your comments about the approach we have
taken in presenting the featured topics and welcome your suggestions for future topics.
Richard E. Behrman, M.D.
Editor
The Future of Children
Published by the Center for the Future of Children, The David and Lucile Packard Foundation
Volume 4 • Number 3 – Winter 1994
David M. Eddy, M.D., Ph.D.
Professor of Health Policy
and Management
Duke University
Leon Eisenberg, M.D.
Presley Professor of
Social Medicine
Harvard University Medical School
Editor
Richard E. Behrman, M.D.
Managing Editor
Dona M. LeyVa
Senior Staff Editors
Deanna S. Gomby, Ph.D.
Carol S. Larson, J.D.
Eugene M. Lewit, Ph.D.
Patricia H. Shiono, Ph.D.
Research Associate/Editor
Linda Sandham Quinn, Ph.D.
Research Librarians
Michele Butler
Lynette Fannon-Lamkin
Design/Production Editor
Bobbie Sorensen
Production/Photo Editor
Julie Koyano
Publications Assistant
Katherine Reynolds
Copy Editor
Sherri M. Butterfield
Proofreader
Lauren Rusk
Victor R. Fuchs, Ph.D.
Henry J. Kaiser, Jr. Professor
Department of Economics
and Department of Health
Research and Policy
Stanford University
David E. Hayes-Bautista, Ph.D.
Professor of Medicine,
Director, Center for the Study of
Latino Health
University of California, Los Angeles
Shirley M. Hufstedler, LL.B.
Partner, Hufstedler & Kaus
Editorial Advisory Board
Byron Wm. Brown, Jr., Ph.D.
Professor and Chair, Department
of Health Research and Policy
Stanford University School of
Medicine
Peter P. Budetti, M.D., J.D.
Hirsh Professor and Director,
Center for Health Policy Research
The George Washington
University
Eleanor E. Maccoby, Ph.D.
Professor (Emerita) of
Developmental Psychology
Stanford University
Martha Minow, J.D.
Professor of Law
Harvard Law School
David B. Mitchell
Judge
Circuit Court for Baltimore City
Baltimore, Maryland
Paul W. Newacheck, Dr. P.H.
Professor of Health Policy
Institute for Health Policy Studies
University of California,
San Francisco
Alfred E. Osborne, Jr., Ph.D.
Professor and Director,
Entrepreneurial Study Center
Anderson Graduate School of
Management
University of California, Los Angeles
Judith S. Palfrey, M.D.
Chief, Division of General Pediatrics
The Children’s Hospital
Harvard University
Nigel Paneth, M.D., M.P.H.
Director, Program in
Epidemiology
Professor of Pediatrics
College of Human Medicine
Michigan State University
Nancy Scheper-Hughes, Ph.D.
Professor of Medical Anthropology
Director, Medical Anthropology
Ph.D. Program
University of California, Berkeley
Alvin L. Schorr, M.S.W., L.H.D.
Leonard W. Mayo Professor
(Emeritus) of Family and
Child Welfare
Case Western Reserve University
Barbara Starfield, M.D., M.P.H.
Professor and Head,
Health Policy Division
Johns Hopkins University
Heather B. Weiss, Ed.D.
Director, Harvard Family
Research Project
Harvard University
Daniel Wikler, Ph.D.
Professor of Medical Ethics
University of Wisconsin Medical
School
The David and Lucile Packard Foundation
Board of Trustees
David Packard, Chairman
Nancy Packard Burnett
Robin Chandler Duke
Robert J. Glaser, M.D.
Dean O. Morton
Susan Packard Orr
David W. Packard
Julie E. Packard
Frank Roberts
Edwin E. van Bronkhorst
The Future of Children (ISSN 1054-8289) © copyright 1994 by the Center for the Future
of Children, The David and Lucile Packard Foundation, all rights reserved. Printed in
the United States of America. Cover photo © 1994 Nita Winter
paper.
Printed on recycled
The Future of Children is
published tri-annually by
the Center for the Future
of Children, The David
and Lucile Packard
Foundation, 300 Second
Street, Suite 102, Los Altos, California 94022.
Third-class postage paid
at Los Altos, California,
and at additional mailing
offices. The Future of
Children is a controlledcirculation publication
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Opinions expressed in
The Future of Children by
the editors or the writers
are their own and are not
to be considered those of
The Packard Foundation.
Authorization to photocopy articles for personal
use is granted by The Future of Children. Reprinting is encouraged, with
the following attribution:
from The Future of Children, a publication of the
Center for the Future of
Children, The David and
Lucile Packard Foundation. Correspondence
should be addressed to
Dr. Richard E. Behrman,
Editor, The Future of Children, Center for the Future of Children, 300 Second Street, Suite 102, Los
Altos, California 94022.
To be added to the mailing list, write to the Circulation Department at the
same address.
Photographs that appear
in The Future of Children
were acquired independently of articles and have
no relationship to material discussed therein.
Critical Health Issues for
Children and Youth
The Future of Children Vol. 4 • No. 3 – Winter 1994
Contents
Statement of Purpose . . . . . . . . . . . . . . . .
Inside front cover
Violence and Today’s Youth . . . . . . . . . . . . . . . . . . . . . .
4
Felton J. Earls, M.D.
A review of the state of knowledge about the magnitude of this
problem, its causes and consequences, and the effectiveness of interventions.
The Changing American Family: Implications for
Children’s Health Insurance Coverage and the Use of
Ambulatory Care Services . . . . . . . . . . . . . . . . . . . . . . . 2 4
Peter J. Cunningham, Ph.D.
Beth A. Hahn, Ph.D.
An analysis of the utilization of preventive and illness-related health
care services by children in single-parent and two-parent families which
takes into account insurance coverage, income, and a number of other
financial and nonfinancial impediments to children’s access to and use
of health care services.
The Health of Latino Children in the United States . . . . . . . . . 4 3
Fernando S. Mendoza, M.D., M.P.H.
An examination of the demography and of the social and health status
of this diverse population of children focusing on the implications for
the formulation of public policy and the implementation of programs.
Public Policy Implications of HIV/AIDS in Adolescents . . . . . . . 7 3
Jill F. Blair
Karen K. Hein, M.D.
A review of the special risks of this epidemic to adolescents, the role of
youth in the spread of HIV/AIDS, and the importance of effective
school-based educational intervention programs.
Involuntary Smoking and Children’s Health . . . . . . . . . . . . 94
Jonathan M. Samet, M.D.
Kenneth E. Warner, Ph.D.
A review and analysis of findings indicating that exposure to involuntary smoking is detrimental to the health of children, of the measures
taken to decrease their exposure, and of additional interventions that
might be considered.
Beyond Benefits: The Importance of a Pediatric Standard
in Private Insurance Contracts to Ensuring Health Care
Access for Children . . . . . . . . . . . . . . . . . . . . . . . . .
115
Elizabeth Wehr, J.D.
Elizabeth J. Jameson, J.D.
An examination of the risks to children from inappropriate, discretionary coverage decisions by private health care insurance plans which
result in restricted access to needed health care.
CHILD INDICATORS: Race and Ethnicity—Changes for
Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
Linda G. Baker, M.P.H.
An analysis of the ethnic and racial makeup of the childhood population in the United States.
Journal Issues in Print . . . . . . . . . . . . . . . . Inside back cover
The next issue of The Future of Children
will focus on low birth weight.
Violence and Today’s
Youth
Felton J. Earls
Issue Editor’s Note
Felton J. Earls, M.D.,
is professor of human
behavior and development in the Department of Maternal and
Child Health, Harvard School of Public
Health, and professsor
of child psychiatry at
Harvard Medical
School.
The violent behavior of adolescents in our society is a topic of enormous interest and
concern, limited data and knowledge, and, unfortunately, substantial misinformation and distortion. In 1990, some 16.3% (1,749,343) of the total number of arrests
in the United States were of youth 17 years of age or younger, and 5.5% (95,677) of
these arrests were for violent crimes. Of incarcerated youth (fewer than 100,000 of
all prisoners), about one quarter have committed crimes against persons. Although
the overall magnitude of this problem is often distorted by the media, these numbers,
which have increased over the past decade, do mask the substantially higher rates in
extremely poor, populous urban communities. In addition, on a national survey,
about 20% of adolescents reported having engaged in one violent incident by 18
years of age. Other youths are the predominant victims of violent behavior by
adolescents,
Many environmental, psychologic, and biologic risk and protective factors and
population indicators have been related to violent behavior and, in various combinations, increase or decrease the likelihood of its occurrence. However, no one
theory or combination of variables allows prediction of which individuals will
commit violent acts or what interventions will prevent these acts initially or reduce
the incidence of repeated offenses. Few, if any, of the individual therapeutic
techniques, promising state or community-based programs, or traditional law
enforcement and judicial approaches have been adequately evaluated to determine
whether they are effective in reducing violent incidents in schools and neighborhoods. The juvenile courts have become increasingly punitive, more youths are
being transferred to adult criminal courts, and increasing numbers of adolescents
are being incarcerated at a national average cost of about $35,000 per youth per
year. Nevertheless, despite our lack of certainty about what will work to decrease
violence among youth, we do know enough to take a number of practical steps that
are likely to ameliorate the situation. These include a combination of activities
directed toward improving the quality of life in areas of extreme poverty in large
cities, and reforming the juvenile justice system.
— R.E.B.
A
15-year-old boy is back in a Boston public school after being
convicted of fatally stabbing a neighborhood boy in retaliation for
an April Fools’ Day prank. The victim is a member of a gang that
has threatened and assaulted other youths in the neighborhood. While
the 15-year-old awaits sentencing by the juvenile court, a matron trails
1
him to keep him separated from members of the victim’s gang.
CRITICAL HEALTH ISSUES FOR CHILDREN AND YOUTH Vol. 4 • No. 3 – Winter 1994
5
School officials, their attorneys, and
many parents are understandably concerned about the safety of students, and
opinions abound as to how the school, the
district attorney and courts, and society
should respond to this type of incident.
The district attorney believes that the convicted student should not return to school,
but he is stymied by a Massachusetts law
requiring that “no student shall be suspended, expelled, or otherwise disciplined on account of conduct which is not
connected with any school-sponsored activity.”1 The school district appealed the
juvenile court’s order to keep the student
in school while he was awaiting sentencing. The district lost. Friends of the convicted student, anticipating a sentence
that probably would return the youth to
the custody of his parents and permit him
to attend school, staged a protest to prevent the student’s forcible transfer to another school.
This incident happens to be the news
for today, but it will almost certainly be
eclipsed by tomorrow’s news of another
episode of juvenile violence. Nevertheless,
this incident exemplifies the central concern of this article and of a rising public
debate: how best should society respond
to violence by juveniles? Fueling public
debate is a feeling that old solutions to the
problem of juvenile violence have not
worked and that we face today an acceleration and intensification of violence among
youth, in part because today’s youthful
offender is a new “breed”—detached, remorseless, and armed with a gun. Determining how best to respond to today’s
violence requires an understanding of the
prevalence and causes of juvenile violence
and of available preventive and treatment
alternatives. As will be seen, available evidence indicates that today’s juveniles are
not a new breed, yet they are committing
more frequent violent acts, at least in
particular communities. There is much we
do not yet understand regarding the fundamental causes of this violence, but there
is also much that we do know and much
that we can and should be doing.
This article is divided into five sections. The first reviews what is known
about the problem of youth violence: its
frequency, trends over time, the perpetrators, and the settings in which it occurs.
The second section reviews the theories
and causal models that have been proposed to explain why violence occurs. The
third section discusses the effectiveness of
interventions available to criminal justice, school, and mental health authorities,
as well as the potential of new treatment
initiatives. The last two sections include
recommendations for future policymaking and research.
What Do We Know About
Juvenile Violence?
Answering questions about the nature and
extent of juvenile violence depends on reliable sources of data. This section reviews
the sources for and conclusions based on
data that are often used to estimate frequency and prevalence of juvenile violence among various groups and in various
settings.
Sources of Data on Rates of Juvenile
Violence
There are four main sources of data on
juvenile violence: the National Center for
Health Statistics (NCHS), the National
Crime Survey, the Uniform Crime Reports
(UCRs), and the National Youth Survey
(NYS). Some (for example, NCHS) profile
victims of violence. Others (for example,
UCRs and NYS) profile perpetrators of
violent crimes. Most are imperfect, either
because they are limited in scope or because they rely on reporting mechanisms
that may under or overestimate true rates
of violence. Nevertheless, these are the
best data available and, when used in combination with one another, can help draw
a picture of the extent of violence by juveniles in the United States.2
The National Center for Health Statistics
The National Center for Health Statistics
compiles data annually on numbers and
rates of homicide, based on reports of
6
THE FUTURE OF CHILDREN – WINTER 1994
medical examiners. Although homicide
represents only a small fraction of all
violent crimes (slightly more than l%),
these figures are quite accurate; therefore, these data are perhaps the most accurate available to gauge trends in the
prevalence of violence across population
groups, settings, and time. The major
source of error in compiling these statistics is the variation in the judgments of
medical examiners.
The National Crime Survey
The National Crime Survey, organized by
the Bureau of Justice Statistics and conducted by the Census Bureau, gathers interview data on a probability sample of U.S.
households to yield a reliable estimate of
victimization for nonfatal violence on individuals 12 years of age and older. Excluded from these data are counts of the
victimization of children younger than 12
years of age and robberies of businesses
and other organizations.
Uniform Crime Reports
In contrast, Uniform Crime Reports
(UCRs) are used to characterize perpetrators rather than victims of crimes. UCRs,
the most commonly cited source of information on the frequency of crime, are
annually compiled data that are based on
counts of offenders supplied to the FBI by
police agencies throughout the country.
These data are prone to sampling biases,
changes in police practices, and other
sources of measurement error.
Most of those arrested in 1990 were
male (88%), African-American or
Hispanic (60%), and 14 through
17 years of age (80%).
Self-Reported Survey Data
The National Youth Survey also provides
data concerning perpetrators, but it relies
on self-reports of violent behavior rather
than on arrest reports.3 This survey, begun
in 1976 by investigators at the Behavioral
Research Institute in Boulder, Colorado,
has followed a national sample of approximately 1,500 youths from adolescence to
young adulthood (25 to 31 years of age in
1990). While the validity of these selfreport data has been difficult to establish,
the data do provide a useful contrast with
official police reports. More recently, the
Centers for Disease Control and Prevention has begun to collect self-report data
on a wide range of health-compromising
behavior, including fighting, suicidal actions, and use of weapons.4
Rates and Trends in Arrests,
Incarcerations, Self-Reported
Violence, and Homicides
Arrests
According to the Uniform Crime Report
for 1990, 1,749,343 arrests during that
year involved youth 17 years of age or
younger. Of these, 95,677, or 5.5%, were
for violent crimes. This number of juvenile arrests represents 16.3% of arrests for
all age groups, a proportion that has increased by 27% since 1980. Most of those
arrested in 1990 were male (88%), AfricanAmerican or Hispanic (60%), and 14
through 17 years of age (80%).5
Incarcerations
Currently, more than 95,000 youths are
incarcerated in the United States, an increase of more than 20% in less than a
decade. Twenty-five percent of these incarcerated youths are held for crimes
against persons. Although a relatively
small proportion of youths arrested and
convicted are responsible for violent offenses, violent incidents are increasing at
a high rate for all racial/ethnic and socioeconomic groups of youths.6
Self-Reported Violence
According to findings of the National
Youth Survey, a substantial minority of
adolescents (21%) engage in at least one
serious violent incident by age 18, and
about 5% engage in multiple violent incidents.3 Based on these findings, one
would estimate that 21% of the roughly 29
million youth aged 11 through 17 in the
United States, or more than 6 million
youths, will have committed a single serious violent offense, and nearly 1.5 million
will have engaged in multiple violent offenses by the time they reach age 18. Because, as mentioned above, it is estimated
that fewer than 5.5% of all arrests among
juveniles in a single year are for violent
offenses, these self-reported data may imply that only a fraction of all youth committing a violent offense are apprehended.
Homicides
Homicides are the most salient evidence
of the problem of juvenile violence, and
the strong quality of the data available
concerning homicides makes it the best
available candidate to judge trends in vio-
7
Violence and Today’s Youth
Table 1
Use of Guns and Other Weapons to Kill Adolescent Murder
Victims Ages 10 to 18 in 1976 and 1988
Adolescent Murder Victims
1976
1988
Victim’s
Age
Total
Killed by
a Gun
10
29
14
15
27
17
10
11
18
7
11
32
12
20
12
54
27
27
38
20
18
13
47
30
17
51
29
22
14
65
40
25
78
59
19
15
101
55
46
194
102
92
16
204
150
54
237
192
45
17
296
212
84
340
276
64
18
324
222
102
435
330
105
Totals
1,138
757
381
1,432
1,037
395
Killed by
Another
Weapon
Total
Killed by
a Gun
Killed by
Another
Weapon
Source: U.S. Department of Justice, Federal Bureau of Investigation. Unpublished 1976 and 1988 data from Crime in
the United States. Uniform Crime Reports. Washington, DC: U.S. Government Printing Office, 1989.
lence. Table 1 shows that the proportion
of adolescent murder victims killed with
a gun increased from 66.5% to 72.4% between 1976 and 1988. Although not listed
in the table, the proportion of black victims who were killed by guns (80%) is
much higher.7 The overall number of
adolescent murder victims per year (1,432
in 1988) may not seem large, but it is
important to note that homicide represents the leading cause of death for 11through 17-year-olds.
Who Are the Perpetrators?
Information about age, geographic location, minority overrepresentation, secular
change, and community context is of particular importance to this discussion because it can provide clues to understanding the causes and solutions to juvenile
violence. Key findings are presented here,
but greater detail can be obtained from
the 1993 report of the National Research
Council’s Panel on Understanding and
Preventing Violence.8
Crime and Age
Most violent crimes are committed by
offenders who are 17 to 25 years of age,
but these violent acts are usually the culminations of long histories of nonviolent
offenses.9 Once a juvenile has committed
a violent crime, the probability increases
significantly that he will continue criminal activity of some sort into adulthood.10
As indicated in Table 2, the arrest rate
for violent crimes shows a clear relationship with age for each of four forms of
violence: homicide, rape, robbery, and aggravated assault. The arrest rate for robbery is highest in adolescence, while the
other types of violence all have a peak
age of occurrence in young adulthood.
Robbery is the only crime for which there
is an overrepresentation of adolescents
compared with young adults; while adolescents make up approximately 16% of
the population, they account for 24% of
robberies. For all four types of violence,
the rates for children younger than 15
years of age are quite low, and there is a
sharp and progressive decline in rates after age 30. Males represent about 90% of
all persons arrested for all types of violent
crimes. The proportion who are female
ranges from less than 1% for forcible rape
11
to 16% for simple assaults.
8
Table 2
Arrest Rates for Violent Offenders, 1990 (per 1,000 male population)
Age
Murder/
Nonnegligent
Manslaughter
Rape
Robbery
Aggravated
Assault
≤ 14
0.03
0.08
0.36
0.54
15–19
0.45
0.62
4.42
6.33
20–24
0.47
0.81
3.67
7.35
25–29
0.32
0.66
2.45
6.34
1.67
4.91
30–34
0.21
0.51
Source: U.S. Department of Justice, Federal Bureau of Investigation. Crime in the United States. Uniform Crime Reports.
Washington, DC: U.S. Government Printing Office, 1991.
Crime Rates and Population Size
Figure 1 illustrates the variation in total
violent crime rate by the population size
of cities and towns. What is so striking
about the figure is the uniformity with
which increasing population size is associ-
Minority overrepresentation
for all types of crime has
become progressively more
marked over the past two
decades.
ated with increasing levels of violence.
Violent crime increases at each level of
city/town size but is most marked for
cities with more than one million residents. The relationship between population size and crime rate holds true for
homicide, rape, and aggravated assault but
is especially pronounced for robbery (not
depicted in Figure 1). This implies that
rates of robbery may be especially sensitive to the effects of the environment of
youthful offenders.
As mentioned above, data on homicide
are relatively reliable, so an examination
of homicide rates affords a detailed view
of the experience of large metropolitan
areas with youth violence generally over
the past three decades. Homicide has increased, but that increase has typically
been limited to key areas within a given
city. For example, Washington, D.C., had
a homicide rate of 10.6/100,000 in 1960.
By 1991, the homicide rate in the nation’s
capital had reached 79.6/100,000 (the
12
highest in the nation). Washington,
D.C. police department records reveal
that the proportion of all homicide victims
under age 21 rose from 12% in 1986,
when the city counted 194 victims overall,
to 30% in 1991, when the number of victims was 489. During these same years,
among all persons arrested for homicide,
the proportion who were under age 21
12
rose from 21% to 51%.
Despite the heavy concentration of
violence in large urban areas, the variation among neighborhoods within a
given city may be even more marked than
the variation according to city size. Again
for Washington, D.C., a few census tracts
account for a large proportion of homicides.12
Crime Rates Among Different Racial and
Ethnic Groups
Minority overrepresentation for all types
of crime has become progressively more
marked over the past two decades and is
evident at each juncture in the criminal
justice system, beginning with arrest rates
and continuing through sentencing and
incarceration.13 For example, from 1980
to 1990, the arrest rate for white males
aged 15 to 24 has hovered around 12 to
13/100,000, while the rate for black males
in the same age range has been nearly 10
times greater.14 Although black youth
make up 12% of the population, they accounted for 24% of arrests for burglaries
and 67% of arrests for robberies in a 1987
study of 14 states.14 Another study indicated that the proportion of youths held
in detention among 13 states increased by
9
Figure 1
Total Violent Crime Rate by City Size, 1973 through 1992
Year
Sources: U.S. Department of Justice, Federal Bureau of Investigation. Crime in the United States. Uniform Crime Reports. Washington, DC:
U.S. Government Printing Office. (1974 through 1993.)
15% over the decade of the 1980s, but this
increase was only 1% for whites compared
with 30% for blacks.15 Black males aged 10
to 17 make up 4.5% of the general population of California but 34.4% of the juveniles in custody.15 The rates for Hispanics
are usually intermediate between the high
rates represented by blacks and the low
rates represented by whites at each point
in the system. Data comparing Spanishspeaking groups of different national origin, Asians, and Native Americans are
either unavailable or imprecise.
The Settings Where Juvenile Violence Occurs
Most data sources do not record the settings where violent incidents among
youths occur. This information should be
recorded, however, because it can suggest
possible interventions. It is unlikely, for
example, that all violence by youth occurs
in favorite neighborhood gathering places
or in protection of gang-designated “turfs.”
The distribution and selling of illicit drugs
constitutes one likely source of violent
confrontations, although more generally
it may be the recruitment of young people
into illegal economies of various types that
increases their risk for committing violent
acts as well as being victims of violence.
Schools have traditionally been considered safe havens, but the insularity of
school settings from violence is eroding in
many locales. In a recently conducted survey of public schools in Illinois, for example, nearly 8% of students said they had
been physically attacked in or near their
10
school, and sentenced by a judge than
other students, and one-third reported
that they had used the gun to shoot at
someone. The rate of gun ownership
among female students was only 1.5%.
The authors of this study suggest that
these rates of access to and use of handguns are underestimates due to sampling
limitations and the fact that many of the
most deviant children may have already
dropped out of school. Because the homicide rate for Seattle is not one of the highest among the larger cities in the country
and because it has a relatively small minority population, it is likely that rates of gun
possession and use by students are higher
in cities where the homicide rate is higher.
Theories About the
Causes of Juvenile
Violence
school, and another 15% reported only
narrowly escaping an attack.16 One-third
of the students in the state’s public high
schools reported carrying a weapon to
school, and 5% reported carrying a gun.
These figures for Illinois are consistent
with figures reported in a 1991 survey of
public schools in Seattle.17 In the Seattle
survey, 47% of males reported easy access
to a gun, 6.4% said that they owned a
Handgun owners were more likely to
have been members of a gang, charged
with assault and battery, suspended or
expelled from school, and sentenced by
a judge than other students.
handgun, and 6% reported that they had
carried a gun to school. These handgun
owners were more likely to have been
members of a gang, charged with assault
and battery, suspended or expelled from
In 1954, Cyril Burt introduced the fourth
edition of his The Young Delinquent with
the following authoritative statement:
“Thirty years ago, when I first began my
work, the most urgent need appeared to
be a systematic and scientific investigation
into the chief causes of delinquency. Now,
as we have seen, a general measure of
agreement has at length been reached [as
to both] the nature and the relative importance of the various causal factors.”18
Burt thought the cause was the psychological traits or inherent defects of individuals, but other researchers have believed, with equal conviction, that the root
causes of violence were environmental.
Jack Tizard, for example, suggested: “ . . .
we need to develop a theory about the
environmental determination of characteristic ways of behaving in different circumstances . . . and research on the
characteristics that differentiate one natural environment from another, and to explore ways of changing some of them and
of assessing their effects.”19
Still other researchers have posited
that genetic factors, neurochemical mechanisms, temperament, family environment, early experiences, institutional settings, social conditions, or labeling were
important determinants of violent behavior.20 Currently, the most hotly debated
theory regards the potential role of genetic and neurochemical factors such as
the gonadal hormone, testosterone, and
the neurotransmitter, serotonin. While
evidence exists for a correlation between
11
these substances and aggression, the findings are hardly conclusive.21 It may be that
preexisting behavior or other environmental conditions determines the level of
such substances. For some biological systems, biological factors may be the conse22
quences, not causes, of behavior.
Any proposed theory must fit the data.
That is, an adequate theory must explain
why rates of violence differ by age, gender,
and size of community, and whether it is
environmental conditions that cause individuals to behave violently (social causation), or whether persons prone to behave violently create environments characterized by high rates of violence (social
selection).
Theories must fit one other key finding
that has emerged from the literature on
root causes of violence: some children
show signs of disruptive and antisocial behavior from as early as 2 to 3 years of age.23
These children are likely to continue to
show signs of disruptive behavior throughout childhood, and to engage in a higher
frequency and more severe delinquency
during adolescence than others. Theories
should therefore explain the backgrounds
and causal pathways that distinguish this
important group of delinquent youths because it is this group that is likely to be disproportionately involved in offending.24
Developing a theory that fits the data
is a tall order, and no theory presently
comes close to approximating these requirements. As suggested by Tizard, the
difficult task that remains is development
of an integrative theory—one that deals
simultaneously with individual differences
and contextual influences.
Testing Theories: Risk Factors and
Population Indicators
Typically, theories are tested by examining
rates of crime in large groups and seeing
if models can be built to predict which
children will display violent behavior later
in life, or which adolescents or adults may,
as young children, have had particular experiences that predisposed them to later
violence. The key experiences or characteristics of individuals that are used in these
models are called risk factors.
Investigators typically select risk factors
to include in a model based on a favorite
theory. For example, disruption in motherinfant bonding might be the most important risk factor included in a model by a
psychoanalyst, but exposure to violence in
the home and inconsistent disciplinary
practices might be the risk factors included in a model by a social learning
theorist. Eventually, however, most researchers try to include as many variables
as feasible. What may have begun as a
theoretically guided investigation therefore can sometimes turn into an exploratory exercise. This is probably an inevitable
response to the nature of violent behavior. No one theory or limited set of risk
factors can go very far in producing a
powerful explanation, given the multiply
determined nature of violent behavior.
Understanding the different kinds of
risk factors is essential to interpreting how
violent behavior is caused. Variables such
as sex, race, ethnicity, and social class, for
example, are sometimes called risk factors
No one theory or limited set of risk
factors can go very far in producing a
powerful explanation, given the multiply
determined nature of violent behavior.
for violent behavior. Such variables are
most usefully employed to increase precision in identifying and locating vulnerable groups. They may be misused if they
are assumed to be part of a mechanism
that causes delinquency. To be clear, it is
perhaps best to refer to these noncausal
types of risk factors as population indicators. In contrast, other risk factors such as
temperament, family relationships, and
school performance do suggest the operation of potential causal mechanisms.
It is also important to consider the multiple levels on which risk factors typically
operate. Risk factors can exert influence
on individual, family and peer, institutional, community, or societal levels. Psychologists and psychiatrists often build theories
beginning with individual factors and
gradually incorporating environmental influences. Sociologists, on the other hand,
begin with societal and institutional influences and gradually incorporate individuallevel factors. Psychologists and sociologists
have rarely engaged in interdisciplinary
efforts in this field. Yet, it is during such
encounters that the search for understanding may be most powerfully advanced.
Risk factors for juvenile violence may
be organized into the following five do-
12
Magnitude of Relationship Between
Risk Factors and Outcomes
Box 1
Population Indicators and Risk Factors
for Youth Violence
Population Indicators
Sex: male
Age: 15 to 19
Race/Ethnicity: African-American, Hispanic
Residence: large urban areas
Income level: less than average
Risk Factors
Neighborhood
High level of male unemployment
Extreme poverty (40% or more of residents below poverty line)
Social disorganization of formal and informal networks
and institutions
School-Related
High absenteeism and dropout rates
Lack of strong central authority
High proportion of students carry weapons
Peer Network
Association with delinquent peers or membership in a gang
Peer facilitation of access to weapons, alcohol, and drugs
Family
Parental criminality
Lack of supervision and involvement
Parental rejection, neglect, or abuse
Marital discord
Older sibling criminality
Individual—Psychological
Low verbal and reading skills
Poor impulse control
School underachievement
Early age of onset of disruptive behavior
Individual—Health
High lead level
History of head injury
Prenatal exposure to alcohol, drugs, or tobacco
Substance abuse
Attention-deficit hyperactivity disorder
mains: (1) social disorganization of communities, (2) poor school climate, (3) exposure to deviant peers (through gang
membership and delinquent behavior, access to weapons, and substance use), (4)
adverse family relationships, and (5) individual physical or psychological predispositions. Box 1 outlines some of the variables that represent these domains and
that have been demonstrated through a
variety of studies to be the most important
characteristics associated with juvenile
violence.25
Some risk factors are more important
than others, although their relative importance may shift with age and maturation. Relevant studies to address questions
about the magnitude of the relationship
between risk factors and violent behavior
are limited. Nevertheless, based on the
strong assumption that multiple developmental pathways lead to violent behavior—one for those who display chronic
violent behavior, beginning at an early
age, another for those who display violent
behavior only later in life, and others in
which there exists no substantial evidence
of previous problem behavior—it can be
hypothesized that the risk factors and
causal mechanisms will be different for
these groups. Using the list provided in
Box 1, we might hypothesize that family
adversity and individual psychological and
health-related problems are most closely
associated with violence in the early-onset,
high-persistence pathway, while community and peer influences are most important for the more late-onset and transient
pathway.26
Protective Factors
It is common in developmental psychology today to cite protective factors to explain why only some children living in
adverse conditions develop problematic
outcomes. Perhaps the children who escape adverse consequences are exposed
to or possess a set of protective factors.
Research about protective factors is still
at an early stage, but is summarized in the
recent Office of Technology Assessment
(OTA) report on adolescent health as follows: “Overall, a picture emerges of the
resilient child as having an easy temperament and a higher IQ, being more autonomous, having a good relationship with
at least one adult, and being more successful and involved in school.”27
Results of studies of risk and protective
factors should be applicable to the design
of interventions, which is discussed in the
following section. But, as pointed out in
the OTA report, crafting an intervention
is difficult because, “ . . . few, if any, risk
factors for delinquency act independently. Many
of the risk factors for adolescent delinquency are
interrelated in ways that are still not well understood. It is clear that no one factor by
itself is correlated with or predicts delinquency very well, but rather for most adolescents, delinquency is the result of the
13
interaction of multiple risk factors . . . ,
each of which incrementally increases the
risk of delinquent behavior. The importance of each factor also depends on the
age of the individual.”28 [Italics in the
original.]
Interventions
This section is divided into two parts: one
dealing with treatments, or interventions
that reduce the chronicity and negative
consequences of delinquent and violent
behavior once it has occurred; and the
other with prevention, or interventions designed to reduce the likelihood that such
behavior will occur. The assessment of
treatment approaches is presented first
because these are much better established
in most communities than are prevention
efforts. Further, much of the impetus to
launch prevention strategies is born of a
recognition that treatment often comes
too late and is ineffective.
Interventions Following an Offense
After an offense occurs and a suspect is
arrested, the juvenile justice system, a
system that varies widely across states,
assumes responsibility to assist the child or
adolescent in resuming normal development. The next sections describe the judicial process and the interventions offered to those juveniles who are formally
adjudicated.
The Judicial Process
Several key decision points exist between
arrest and a judicial disposition. Decisions
at these points determine the overall effectiveness of the juvenile justice system, particularly with respect to how well serious
offenses are handled. Only about 6% of
the cases referred to juvenile courts are for
serious violent offenses, with aggravated
assault and robbery representing more
than 90% of these cases.15
Figure 2, based on data from National
Juvenile Court Data Archives, indicates the
ways in which juvenile courts typically discharge their work load.29 As depicted in
the figure, approximately 20% of juveniles
are held in detention immediately following an arrest. More than half the cases
(54% in 1987) referred to courts are handled informally, meaning that they are
either dismissed, referred to a mental
health or social service agency, or placed
on probation. These are, with few exceptions, juveniles involved in minor offenses
or first-time offenders. Of the remaining
cases which are formally petitioned to the
court, about one-third do not advance to
a formal hearing but are, instead, likely to
be dismissed. Thus, of all arrested cases,
only about one-third are formally adjudicated, and even a small proportion of these
may be dismissed. Roughly 30% of those
adjudicated receive a placement, but most
are placed on probation. Most, but not all,
serious violent offenders probably encounter one of these dispositions, but
there may be significant variation by jurisdiction.
Dispositions handled in the juvenile
justice system are supposed to balance the
best interest of the child with public safety
concerns. To varying degrees, all juvenile
justice systems operate on a philosophy
that mixes treatment with punishment.
But over the past decade many juvenile
Only about 6% of the cases
referred to juvenile courts are
for serious violent offenses.
justice systems have become increasingly
punitive.30 For example, the proportion
of youths transferred from custody of juvenile courts to adult criminal courts increased from less than 1% in 1970 to 5%
in 1987. During this same period, the rate
of confinement in institutional settings
increased by 43%; and, despite intense
solicitations from the American Bar Association, the Children’s Defense Fund, and
the National Council on Crime and Delinquency, the U.S. Supreme Court refused
to raise the minimum age for executions
from 15 to 18.31 In many instances, this
may be a response to the perception that
there are an increasing number of chronically violent offenders, a different “breed,”
who are tougher and younger than the juveniles encountered in the past.32 This
perception may make it easy to believe
that strong negative sanctions are not
only indicated, but justifiable.
Treatment Facilities and Programs
Treatment facilities and programs can be
classified as either institutional or community based. Many institutional programs
rely on a high degree of supervision and
a punitive environment. Frequently referred to as “lock-ups,” these institutions
are reserved for the most violent and
14
Figure 2
Juvenile Court Processing of Delinquency Cases, 1987
Source of
Referral
Intake
Decision
Intake
Disposition
Petitioneda
531,000
46%
Judicial
Decision
Judicial
Disposition
Waivedb
11,000
2%
Placement
99,000
30%
c
Adjudicated
333,000
63%
Probation
191,000
57%
Other
28,000
9%
Dismissed
15,000
4%
Police
958,000
84%
Other
187,000
16%
Nonpetitioned
614,000
54%
Placement
2,000
<1%
Placement
4,000
2%
Probation
179,000
29%
Probation
44,000
24%
Other
133,000
22%
Dismissed
300,000
49%
Nonadjudicated
187,000
35%
Other
23,000
12%
Dismissed
116,000
62%
a
A petition is filing a document in juvenile court alleging that a juvenile is a delinquent, a status offender, or dependent.
A petition requests that the court assume jurisdiction over the juvenile or that the juvenile be transferred to criminal
court for prosecution as an adult.
b
A waived case is one that is transferred to the criminal court.
c
An adjudicated case is one in which the court has entered a judgment.
Source: U.S. Congress, Office of Technology Assessment. Adolescent health. Vol. 2: Background and the effectiveness of selected
prevention and treatment services. Washington, DC: OTA, 1991, p. 627.
chronic group of offenders. “Boot camps,”
devised for nonviolent offenders, use
strong disciplinary codes to expose youths
to a kind of “shock” incarceration. Many
community-based interventions are either
low-security group homes or diversion
programs, such as restitution programs,
intensive probation, or wilderness camps,
designed to steer youth away from violent
behavior.
The effectiveness of these various types
of programs is routinely measured by the
number of juveniles who are rearrested or
reincarcerated over a specified period of
time. Unfortunately, interpreting the data
is difficult because of measurement error,
sampling biases, and the use of inconsistent definitions and differing lengths of
time over which discharged youth are followed. Most jurisdictions probably exper-
15
ience a 60% to 70% rearrest rate over a
12-month period. Such high rates provoke
widespread reservation, if not resignation,
about the effectiveness of most of these
programs.
An Example of Statewide Reform
The Massachusetts Department of Youth
Services gained national prominence during the early 1970s through its radical
reform.33 In 1972, all of the state’s large
juvenile correctional institutions were
closed, and the more than 500 residents
were transferred to smaller, 15- to 18-bed
secure facilities. This policy change has
resulted in a permanent and, based on the
evidence, positive change in the state. Perhaps most notable is the support coming
from directors and staff who operate the
system. The Massachusetts recidivism rate
(the proportion rearrested within 12
months of discharge) has remained lower
than that for most other states for well over
a decade. For example, California reports
a recidivism rate of 70% compared with a
40% to 50% rate in Massachusetts.33 The
number of violent youthful offenders in
the Massachusetts system who have been
transferred to the adult criminal courts has
plummeted. In 1973, 129 juveniles were
transferred; by 1987, the number had
fallen to 14. Since then, the number has
increased only slightly. Because of the
highly selective use of the most secure
beds, the Massachusetts system is less costly
than the systems in most other states.
While a secure bed costs more in Massachusetts than in other states, the expanded
use of low-cost community-based programs for most offenders produces an
estimated cost of $23,000 per youth in
the Massachusetts juvenile justice system,
compared with a national average of
about $35,000.33 The success of this system has led to replications in some states,
most notably Utah, and to a renewed and
widespread interest in closing large public
juvenile correctional schools.33
Interventions Occurring Prior to an
Offense
There is now broadbased support for the
benefits of early intervention programs
which are aimed at increasing the school
readiness and social competence of preschool children.34 In addition, youngsters
exposed to such programs have lower
rates of socially disapproved behaviors,
such as early pregnancy, substance abuse,
and delinquency as teenagers.35,36 Just as
preventive interventions can be crafted
for young children, so too can preventive
interventions be designed for adolescents.
Such preventive efforts can be grouped
into those that are (1) school based (for
example, changing the school climate and
introducing violence prevention curricula), (2) community based (for example,
neighborhood watch programs and recreation programs), or (3) aimed at influencing the mass media.
Two recent documents review many of
the nation’s violence prevention programs
for adolescents. The first, prepared by the
Education Development Center (EDC),
reviewed 51 programs that responded to a
nationwide survey and selected 11 pro-
A key element in some of the most
promising interventions appears to
be the active participation of youth.
grams with credible evaluation components for a more detailed description.37
The second document, commissioned by
the National Institute of Justice to introduce the concepts and strategies that underpin violence prevention programs to
police and other criminal justice professionals, reviewed a smaller but overlapping
number of programs.38
The reviews reveal the broad range of
violence prevention programs. Some programs aim specifically to reduce recruitment into gangs or to produce alternatives
to gang membership while other, broader
programs, seek to teach children to deal
more effectively with many forms of stress.
Few have undergone extensive evaluation,
but a key element in some of the most
promising interventions appears to be the
active participation of youth. Two programs, the Resolving Conflict Creatively
Program and the Violence Prevention Project, exemplify this approach.
The Resolving Conflict Creatively Program
The Resolving Conflict Creatively Program is based in the New York City public
schools and coordinated with a private organization known as Educators for Social
Change. Begun in 1985, the program consists of curricula for students from grades
K-12. Teachers and students are trained to
address conflict with nonviolent alternatives and negotiation skills. The curricula
also contain strategies to promote mul-
16
ticultural acceptance and global peace. To
encourage acceptance and integration of
the program into the school, administrators and teachers are asked to accept the
principles of the program before students
are engaged. Teachers receive approximately 20 hours of instruction, and then
student mediators are trained. These mediators, who work in pairs during recess
and lunch periods, are believed to be essential to the ultimate goal of moving the
school toward a more cooperative and
peaceful climate. Finally, parents are invited to workshops to help them develop
skills to handle conflict at home. The project has sustained itself over several years
and has now expanded to more than 150
New York schools. More than 2,000 students have been trained as mediators, and
more than 60,000 students have participated in the program.
The Violence Prevention Project
Established in 1986 as a community-based
program of the Boston Department of
Health and Hospitals, the Violence Prevention Project combines outreach
through schools, recreational facilities,
and other youth organizations with education through a high school curriculum.
The goal is to mobilize community resources and activate schools and community organizations around a core con-
Evaluations to determine program effectiveness
in reducing violent incidents in schools and
neighborhoods have not been conducted.
cept: nothing is to be gained by fighting.
The creed of the program, disseminated
through public-awareness educational and
media campaigns, is “Friends For Life,
Don’t Let Friends Fight.” The project has
developed a 10-session violence prevention curriculum which has been adopted
by more than 150 school districts throughout the nation, a series of public service
announcements for television, a peer leadership program, a summer camp program, and a hospital-based, clinical program that augments and monitors the
care of children who are victims of violence. Staff members of youth agencies
have been trained in violence prevention
approaches, and strides have been made
toward creating a community-based view
of violence as a controllable and preventable problem. The program’s founder,
Deborah Prothrow-Stith, has become a
pioneer in the national campaign to make
violence prevention a central component
of modern public health.32
Both of these programs have evaluations that primarily gauge program implementation. The evaluations indicate
that the programs are satisfactorily delivering designed services. However, evaluations to determine program effectiveness
in reducing violent incidents in schools
and neighborhoods have not been conducted.
Policy Considerations
The material presented thus far suggests
some important policy directions. These
are organized into five groups that represent different spheres of societal influence: the quality of community life, public
health strategies, school and educational
influences, the impact of mass media, and
changes in the juvenile justice system.
Quality of Life in Large Cities
As mentioned above, large cities face
higher, and increasing, rates of crime.
These increasing rates reflect changes in
the demographic composition of cities,
which suggest that ways to decrease crime
may include attempts to stabilize urban
populations by improving the quality of
life in cities. The following discussion describes the relevant population shifts and
then reviews some of these approaches.
The population of the largest U.S. cities has been decreasing or holding steady
over the past decade. Middle-class families
have migrated out of the largest cities, but
offsetting numbers of relatively poor and
minority families have migrated into
them. As described by William Julius
Wilson,39 these demographic changes
have left many residential areas in cities
with high concentrations of poor families. The social disadvantage and political
neglect accompanying these demographic
changes have resulted in the progressive
deterioration of these areas. Researchers
more than 50 years ago identified poverty
and social disorganization in urban areas
as two of the major risk factors associated
with delinquency and crime.40 The same
associations still hold 50 years later; the
only difference appears to be that the
physical deterioration and level of social
disorganization have become far worse.
17
Although it is difficult to establish on empirical grounds, the worsening physical
deterioration and social disorganization
may further undermine family support
systems with the result being less supervision and monitoring of children and adolescents. The combination of harsh city
environments and less support and supervision from concerned adults produces a
climate in which more children develop
antisocial attitudes and violent behavior
than in the past.
Approximately 2.4 million people, of
whom 65% are black and 22% Hispanic,
live in extreme poverty in large cities.41 It
is in those areas of extreme poverty that
the rates of violence are highest. As argued by Wilson, the combination of a historically weak attachment to the labor
force (as is true for many black and Hispanic Americans) with the contemporary
restructuring and relocation of jobs outside the central city creates a climate of
hopelessness, lack of discipline, loss of
self-confidence, and fragmentation of the
39
moral structure of neighborhoods. Unless these trends are reversed, it is unlikely
that levels of violence among youth will
decline.
At least two policy options follow.
Either a more systematic approach should
be adopted to help poor families, especially those with young children, relocate
to small cities and towns, or the residential
inner city must undergo a massive revitalization. Indeed, in response to a host of external pressures, such as the relocation of
workplaces or the pursuit of better public
schools, out-migration is already happening. It may be prudent, therefore, to exert
some control over what is happening
spontaneously already. One place to start
would be to encourage residents of public housing complexes to move to betterorganized neighborhoods where schools
and recreational facilities are stronger. A
court-mandated program of this sort has
operated in Chicago for a number of
years.42
The second alternative—rebuilding
cities—is all too easy to dismiss as beyond
the budgetary capacity of our government.
Yet, many expensive projects are being
pursued (for example, farm subsidies and
the space station), and, given sufficient political will, undoubtedly this problem could
be, too. Indeed, recent crime bill deliberations indicate heightened interest in responding to and preventing crime, so a
window of opportunity for renewed public
investment may exist, especially if the clear
relationship between the quality of city life
and crime is made known.
Public Health Strategies
Public health authorities throughout the
country, bolstered by efforts at the Centers
for Disease Control and Prevention, have
placed violence prevention among their
top priorities. 43 Explicit strategies and
goals have been articulated to monitor the
success of this initiative.44 An important
step toward the prevention of violence
among youth is passage and enforcement
An important step toward the prevention of
violence among youth is passage and enforcement of stricter regulations to prohibit the sale
of firearms to persons under the age of 21.
of stricter regulations to prohibit the sale
of firearms to persons under the age of 21.
Such legislation would reduce the lethality and severity of violent incidents. But,
additional strategies are needed to combat
a problem as complex as violence. These
might include interventions to change how
guns are manufactured, stored, and licensed. Public health agencies must also
devise and evaluate preventive interventions of the type reviewed in the previous
section.
School-Based and Educational
Initiatives
Improvements in public education should
be part of efforts to improve the quality of
life in urban neighborhoods. School budgets will probably have to be increased, and
the new monies used both to upgrade urban school facilities, which have often deteriorated in parallel with their neighborhoods, and also to provide incentives to
stimulate the growth of professional competence in teachers.
Some schools have opened their facilities to the neighborhood, thereby converting the schools from isolated institutions to ones which are central to community functions, such as athletic and recreational activities. The climate generated
by such openness should help curb youth
violence.
The personal attention and close supervision required by adolescents, particu-
18
larly those living in socially distressed
neighborhoods, will be difficult to achieve
in large high schools. Policies that encourage the development of smaller and more
personal schools should be examined.
Schools and communities should also
strive to create an alliance with local police.
The concept of community policing should
embrace schools so that police participate
in violence prevention programs and cooperate in providing a climate of safety for
students. To date, there do not appear to
be any systematic efforts to establish community policing programs in schools.45
Mass Media
A fourth area for policy development regards the much disputed role of mass media in sustaining and aggravating a culture
of violence. Although there is some controversy, the vast weight of evidence suggests that young children’s interpretation
of violent episodes is correlated with their
own violent behavior.46 The greater their
exposure to media depictions or coverage
of violent encounters, particularly when
such events are depicted callously, the
more jaded become children’s own perceptions and understandings of interpersonal violence.47
Positive policy steps are being taken.
Recent changes in television rating systems permit easier identification of shows
with violent content. Both Congress and
the Justice Department have given indications that close monitoring of television
programming is desirable. To complement these strategies, script writers and
producers should adopt a code of ethics
that encourages, for example, the depiction of harmful consequences of violence
The greater their exposure to media
depictions or coverage of violent encounters,
. . . the more jaded become children’s own
perceptions and understandings of
interpersonal violence.
and expressions of pathos, outrage, and
remorse in response to violence. Script
writers should develop plots in which conflict is resolved without violence and moral themes are adapted to the interests of
today’s youths.
Reforming the Juvenile Justice
System
The ideal that juvenile courts work in the
“best interests of the child” has been eroding for nearly three decades.30 In recent
years, the increasing number of youths
charged with violent and drug-related offenses has pressured juvenile courts to
treat youths more punitively and to transfer more of the most serious offenders to
adult criminal courts. Advocates of this
shift assert that adolescents should be
treated as adults because they have the
same moral reasoning capacity as do
adults.48 These and other factors have led
to a gradual contraction of the jurisdiction
of juvenile courts in most areas of the
country.
At least three policy issues should be
considered when weighing alternatives
for reform: closing juvenile court hearings, linking juvenile and adult records,
and transferring juveniles to adult courts.
Closed Juvenile Court Hearings
The practice of closed hearings should be
carefully reviewed because it insulates
these courts from societal scrutiny and
may contribute to perfunctory and inefficient handling of cases.
Linkage of Juvenile and Adult Records
A national commission should be established to consider whether juvenile and
adult records should be linked, at least for
serious offenders. Most states, if not all, still
provide for the expunging or sealing of
juvenile records because it is believed that
the reduced culpability of youths might
not be observed in sentencing adults with
previous records as juveniles. But not linking records means that adult courts have
incomplete information when judging the
dangerousness of violent offenders. Some
states are, in effect, reversing this policy of
sealing juvenile records by transferring
cases from juvenile to adult criminal courts.
Transferring Juveniles to Adult Courts
The third policy consideration has implications for international relations. One of
the most successful charters developed by
the international community is the Convention on the Rights of the Child.49 This
charter, being implemented by the United
Nations, is a reaction to the many forms of
exploitation and manipulation of children and specifically bars the transfer of
children (defined as individuals under age
18) to adult authorities. Although more
than 150 countries have signed the Con-
19
vention, the United States has not50 and,
obviously, cannot so long as juvenile cases
continue to be transferred to adult courts.
Future Research Needs
The policy considerations and the literature described above suggest some directions for future research. One need is for
better evaluation research that measures
both process and outcomes.51 Our social
and political climate urges quick responses to interpersonal violence, and therefore well-intended action understandably
takes priority over longitudinal research.
All too often, however, intervention and
prevention programs are not evaluated at
all. For example, despite the juvenile
court’s century of service, little evidence
exists to support its effectiveness. When
evaluation of the court or any program
does occur, it is often inadequate, and we
are frequently left with uncertainties about
how well the program worked, whether it
worked better for some individuals than
for others, how its level of success compares with that of other approaches, and
what modifications are needed.
Several basic research issues also need
to be explored. For example, we still do
not understand the causes of juvenile violence. Which individuals are most likely to
behave violently? What types of situations
are likely to bring about violent behavior
in many persons?52 Does everyone have
the capacity to behave violently, given sufficient provocation, or is violence limited
to particular individuals? Though there is
overwhelming evidence that both gender
and poverty are related to violence, we do
not understand the mechanisms that create the associations. Social science research should begin to conceptualize
violent behavior as a response to (1) conditions and experiences that are part of
the individual’s personal history, (2) the
immediate circumstances with which she
or he is confronted, and (3) the interaction of both individual proclivities and situational determinants.
Researchers should use geographic
mapping techniques to determine the
changing patterns of youth violence in urban neighborhoods. 53 The current picture derived primarily from criminal justice sources indicates that violent events
tend to occur in relatively limited areas in
a few neighborhoods. Is that true for all
violence, or just a few types? Do the patterns exist because more violence actually
happens in those neighborhoods? Or because a greater police presence in those
neighborhoods leads to higher rates of
detection? Or because a biased system
leads to increased reports? What role do
drug sales and, more broadly, illegal economies have on violent behavior among
youths? Technologically enhanced systems
of community surveillance, such as com-
All too often, however, intervention and
prevention programs are not evaluated at
all. For example, despite the juvenile court’s
century of service, little evidence exists to
support its effectiveness.
puter mapping methods when properly
used, can provide useful information to
communities that may allow them to maintain or restore a sense of local social control and effective monitoring of youth
activities.
We also do not yet understand how age
and maturation influence patterns of violent behavior. Undoubtedly, part of the
rise in crime rates during adolescence occurs as adolescents try to secure an identity through trial and error, but what might
account for the finding that age of onset
of aggressive behavior may discriminate
those individuals more likely to persist in
violent behavior beyond adolescence from
those with shorter periods of involvement? Cultural, psychological, and biological explanations are all plausible, but
we do not yet have evidence regarding the
relative importance of these factors.
The National Research Council’s Panel
on Violence has called for studies to understand how community, situational, and
individual factors operate in combination.8 A multidisciplinary, longitudinal
study that examines simultaneously a
broad range of community properties,
family factors, and individual characteristics is needed. One such study is currently
in its early stages of field work.54
Longitudinal research will help us understand how developmental trajectories
that steer children toward or away from
delinquent and violent lifestyles are conditioned by individual propensities and
social circumstances. Such research is essential if we are to know what to expect
of prevention efforts that are aimed at
20
changing communities, but it does not
necessarily address the special needs of
particularly vulnerable subgroups, or preventive efforts that target individuals without attempting to change the settings in
which they live, learn, and work. In other
We have not advanced very far in our
understanding, control, or prevention
of all types of delinquency and crime,
and especially of violent crime.
words, how much effort is needed and
what degree of effectiveness can we expect
of preventive efforts that seek to improve
communities and schools, in contrast to
changing individuals? Which will reduce
the toll of youthful violence the most,
which is most cost effective, and which will
produce the most durable results? These
are questions only research can answer.
Conclusion
This article has not explored with great
depth the causes of youth violence.55
Rather the effort has been to assert that,
despite decades of research and a great
number of well-intended interventions
into the lives of troubled youths, we have
not advanced very far in our understanding, control, or prevention of all
types of delinquency and crime, and especially of violent crime. No evidence exists
to suggest that a fundamental difference
has occurred in the types of youths committing delinquent and violent acts in today’s society, but there is evidence showing that the circumstances and experiences of growing up in American society
have worsened over the past 30 to 40 years
and that violence by juveniles is increasing
in frequency and severity.56 As reflected in
the opening vignette, adults charged with
the responsibility of raising and caring for
children—from parents and teachers to
district attorneys—are feeling more helpless and ineffectual in dealing with the
present generation of youths. Easy access
to handguns, alcohol, and illicit drugs, the
deterioration of neighborhoods, the weakening of family structure, and saturation
of the media with the reporting on violent
incidents are indeed making America’s
youth tougher and more dangerous at
younger ages. Could we really expect them
not to be affected by such strong forces?
Modern society has not succeeded in
creating multiple and useful roles for adolescents, and in no place is this more obvious than in large cities. Besides the role
of successful student or athlete, the adolescent has few opportunities to operate
with positive social or economic purpose.
The absence of guidance from family and
institutions constitutes a kind of late developmental deprivation, which may be just
as insidious and damaging as is early deprivation. Perhaps it is this weakening of
the social structure, as much as anything,
which explains the relationship between
age and crime.57
Despite this bleak picture, public
health authorities, educators, the police,
other criminal justice professionals, and
politicians have renewed their efforts to
control and prevent violence. All acknowledge the very serious conditions that seem
so obviously linked to violence, yet so difficult to transpose into a concerted plan
of action. The types of interventions, policies, and evaluation and basic research
described in this article represent the elements required for a concerted effort. We
must not wait to pursue this effort, for the
longer we wait, the fewer children will be
prepared who can as adults create and
maintain a society in which conflict is controlled and social justice is valued. Violence is not the inevitable result of an
ill-suppressed instinct. It is rightfully perceived as an ugly distortion of human behavior, an indication of something wrong,
something that requires urgent attention
and action.
1. The circumstances of the incidents described here are taken from an article appearing in a
local newspaper. Names and details of events have been deliberately altered, but not to
the extent that the story has been distorted.
2. A full discussion of these sources of data and their limitations is reported in Reiss, Jr., A.J.,
and Roth, J.A., eds. Understanding and preventing violence. Washington DC: National Academy Press, 1993.
3. Elliott, D.S., Huizinga, D., and Morse, B. Self-reported violent offending: A descriptive
analysis of juvenile violent offenders and their offending careers. Journal of Interpersonal
Violence (1986) 1,4:472-514.
4. Kolbe, L.J. An epidemiological surveillance system to monitor the prevalence of youth behaviors that most affect health. Health Education (1990) 21:44-48.
5. U.S. Congress, Office of Technology Assessment. Delinquency: Prevention and services. In
Adolescent health. Vol. 2: Background and the effectiveness of selected prevention and treatment services. Washington, DC: OTA, November 1991, pp. 583-89.
6. Office of Juvenile Justice and Delinquency Prevention. Juveniles taken into custody: Fiscal year
1990 report. Washington, DC: U.S. Department of Justice, 1991, pp. 7-16.
7. U.S. Department of Justice, Federal Bureau of Investigation. Crime in the United States 1988.
Uniform Crime Reports. Washington, DC: U.S. Government Printing Office, 1989.
8. See note no. 2, Reiss and Roth, for further discussion.
9. Weiner, N. Violent criminal careers and violent career criminals: An overview of the literature. In Violent crime, violent criminals. N. Weiner and M.E. Wolfgang, eds. Newbury Park,
CA: Sage, 1989, pp. 35-138.
10. Farrington, D. Childhood aggression and adult violence: Early precursors and later-life outcomes. In The development and treatment of childhood aggression. D.J. Pepler and K.H. Rubin,
eds. Hillsdale, NJ: Lawrence Erlbaum Associates, 1991, pp. 5-29.
11. U.S. Department of Justice, Federal Bureau of Investigation. Crime in the United States 1990.
Uniform Crime Reports. Washington, DC: U.S. Government Printing Office, 1991.
12. Johnson, C.M., and Robinson, M.T. Homicide report. Washington, DC: Office of Criminal Justice Plans and Analysis, April 1992.
13. Fagan, J., Slaughter, E., and Hartstone, E. Blind justice? The impact of race on the juvenile
justice process. Crime and Delinquency (1987) 33:224-58.
14. Bazemore, G., and McKean, J. Minority overrepresentation. In Hard times, helping hands: Developing primary health care services for incarcerated youth. L.S. Thompson and J.A. Farrow,
eds. Arlington, VA: National Center for Education in Maternal and Child Health, 1993,
pp. 99-120.
15. Snyder, H.N., Finnegan, T.A., Nimick, E.H., et al. Juvenile court statistics, 1985. Pittsburgh,
PA: National Center for Juvenile Justice, 1989.
16. Illinois Criminal Justice Information Authority. Trends and issues 91: Education and criminal
justice in Illinois. Chicago: Illinois Criminal Justice Information Authority, 1991.
17. Callahan, C.M., and Rivara, F.P. Urban high school youth and handguns: A school based
survey. Journal of the American Medical Association (June 1992) 267:3038-42.
18. Burt, C. The young delinquent. 4th ed. London: Tavistock Press, 1954, Introduction, pp. 1-14.
19. Tizard, B. The psychology of Jack Tizard. London: University of London, 1978, p. 312.
20. Earls, F. Oppositional and conduct disorder. In Child psychiatry. L. Rutter, E. Taylor, and L.
Hersov, eds. London: Blackwell Publishers, 1994.
21. Constantine, J. Testosterone and aggression in children. Journal of the American Academy of
Children and Adolescent Psychiatry (1993) 32,6:1217-22.
22. Susman, E. Psychosocial, contextual, and psychobiological interactions: A developmental
perspective on conduct disorder. Development and Psychopathology (1993) 5:181-89.
23. White, J., Moffitt, T., Earls, F., et al. How early can we tell?: Predictors of conduct disorder
and adolescent delinquency. Criminology (1991) 28:507-33.
24. Moffitt, T. Juvenile delinquency and attention-deficit disorder: Developmental trajectories
from age 3 to 15. Child Development (1990) 61:893-910.
25. Earls, F. A developmental approach to understanding and controlling violence. Theory and
Methods in Behavioral Pediatrics (1991) 5:61-88.
26. Moffitt T. Life-course-persistent and adolescent-limited antisocial behavior: A developmental taxonomy. Psychological Review (1993) 100:674-701.
27. See note no. 5, U.S. Congress, p. 616.
28. See note no. 5, U.S. Congress, p. 615.
29. See note no. 15, Snyder, Finnegan, Nimick, et al. The 1,133 courts providing information
to this archive constitute roughly half of all jurisdictions in the country.
30. Field, B. Criminalizing the American juvenile court. In Crime and justice: A review of research.
Vol. 17. M. Tonry, ed. Chicago: University of Chicago Press, 1993, pp. 197-280.
31. Wilkins vs. Missouri. U.S. Law Weekly (1989) 57:4973.
21
22
32. Prothrow-Stith, D. Deadly consequences: How violence is destroying our teenage population and a
plan to begin solving the problem. New York: HarperCollins, 1991.
33. National Council on Crime and Delinquency. Unlocking juvenile corrections: Evaluating the
Massachusetts Department of Youth Services. San Francisco: NCCD, 1991.
34. Zigler, E., and Styfco, S.J. Using research and theory to justify and inform Head Start expansion. Social Policy Report (Summer 1993) 7,2:1-22.
35. McGuire, J., and Earls, F. The prevention of psychiatric disorder in early childhood. Journal
of Child Psychiatry and Psychology (1991) 32:129-53.
36. Earls, F., Cairns, R., and Mercy, J. The control of violence and promotion of non-violence.
In Promoting the health of adolescents. S. Millstein, A. Peterson, and E. Nightingale, eds. New
York: Oxford University Press, 1993, pp. 285-304.
37. Wilson-Brewer, R., Cohen, S., O’Donnell, L., and Goodman, I.F. Violence prevention for young
adolescents: A survey of the state of the art. Working paper. Cambridge, MA: Education Development Center, 1991.
38. DeJong, W. Preventing interpersonal violence among youth: An introduction to school,
community, and mass media strategies. Washington, DC: U.S. Government Printing Office. In press.
39. Wilson, W.J. Studying inner-city social dislocations: The challenge of public agenda research. American Sociological Review (1991) 56:1-14.
40. Shaw, C., and McKay, H. Juvenile delinquency and urban areas. Chicago: University of Chicago
Press, 1942.
41. Extreme poverty areas are described by Wilson (1991) as census tracts in which 40% or
more of the residents live below the federally defined poverty line. Wilson indicates why
the 2.4 million designated by this definition seriously underestimates those who are unable to live decently.
42. Begun in 1976, this program is designed to help families in public housing move into
private housing using Section 8 federal housing subsidies. Some 6,000 families have been
involved in the project. For a reference reporting on evidence of the program’s effectiveness, see Rosenbaum, J., and Popkin, S. Employment and earnings of low-income blacks
who move to middle-class suburbs. In The urban underclass. C. Jencks and P. Peterson, eds.
Washington, DC: Brookings Institute, 1991, pp. 342-56.
43. Rosenberg, M., and Fenley, M., eds. Violence in America: A public health approach. New York:
Oxford University Press, 1991.
44. U.S. Department of Health and Human Services. Healthy people 2000. Washington, DC: U.S.
Government Printing Office, 1991.
45. The Los Angeles-based DARE program involves police in a drug education program. Other
local efforts may involve police in peer mediation or in returning truants to school, but
none of these is a systematic effort.
46. Centerwall, B.S. Television and violence: The scale of the problem and where to go from
here. Journal of the American Medical Association (June 1992) 267:3059-63.
47. Slaby, R., ed. Violence and youth: Psychology’s response. Summary report of the American Psychological Association Commission on Violence and Youth. Washington, DC: APA, 1993.
48. Forst, M., and Blomquist, M. Cracking down on juveniles: The changing ideology of youth
corrections. Notre Dame Journal of Law, Ethics and Public Policy (1991) 5:323-75.
49. Madinger, E., Mayridges, J., Namazi, B., et al. Child rights. The Convention: Child rights and
UNICEF experience at the country level. Innocenti Studies. ISSN 1014-8795. Florence, Italy:
UNICEF International Child Development Centre, 1991.
50. Himes, J. Implementing the United Nations Convention on the Rights of the Child: Resource mobilization and obligations of the states parties. Innocenti Occasional Papers. ISSN 1014-7837.
Florence, Italy: UNICEF International Child Development Centre, 1992.
51. Earls, F., McGuire, J., and Shay, S. Evaluating a community intervention to reduce the
risk of child abuse: Findings from a neighborhood survey. Child Abuse & Neglect (1994)
18:473-85.
52. Farrington, D. Have any individual, family or neighborhood influences on offending been
demonstrated conclusively? In Integrating individual and ecological aspects of crime, D. Farrington, R. Sampson, and P. Wikstrom, eds. Stockholm, Sweden: National Council for
Crime Prevention, 1993, pp. 7-37.
53. For an example of computerized mapping technology currently in use, see Block, C. Spatial
and Temporal Analysis of Crime (STAC). Available from the Illinois Criminal Justice Authority, 120 South Riverdale Plaza, Chicago, IL 60606-3997.
54. Some elements of the basic design of this project are reported in Tonry, M., Ohlin, L., and
Farrington, D. Human development and criminal behavior: New ways of advancing knowledge.
New York: Springer-Verlag, 1991. For a list of publications that have been derived from
the preparatory stage of this project, contact the author of this paper.
55. For such a detailed analysis, see note no. 20, Earls, and note no. 36, Earls, Cairns, and
Mercy.
56. Earls, F., and Carlson, M. Towards sustainable development for American children. Daedalus (1993) 122:93-121.
57. Earls, F. The social reconstruction of adolescence. Perspectives in Biology and Medicine (1978)
22:65-82.
23
Peter J. Cunningham,
Ph.D., is senior researcher at the Agency
for Health Care Policy
and Research, Center
for Intramural Research.
Beth A. Hahn, Ph.D.,
was a medical sociologist at the Agency for
Health Care Policy
and Research at the
time this article was
written. She is currently a medical sociologist in the International Department of
Pharmacoeconomic
Research at Glaxo, a
pharmaceuticals company in North Carolina.
The Changing American
Family: Implications for
Children’s Health
Insurance Coverage and
the Use of Ambulatory
Care Services
Peter J. Cunningham
Beth A. Hahn
An increasing number of children are being raised by one parent, a divorced or
never-married woman (see the Spring 1994 issue of The Future of Children). These
families are a heterogeneous group in terms of income, education, employment, and
ethnicity or race. Black and Hispanic children are disproportionately represented.
This article focuses on one of many important consequences for children of this
change in family structure in the United States: the utilization of ambulatory health
services by children.
The views expressed in this
paper are those of the
authors, and no official endorsement by the Department
of Health and Human Services or the Agency for Health
Care Policy and Research is
intended or should be inferred.
The findings indicate that expansion of private or public insurance coverage will
significantly increase the access to and use of preventive and illness-related ambulatory care for uninsured children (see the Summer/Fall 1993 issue of The Future of
Children). However, other differences between single- and two-parent families play
an important role in impeding children’s utilization of health care services and also
need to be addressed. Family income has a significant effect on utilization of
preventive services even for those with health insurance coverage; out-of-pocket costs
and lack of transportation are obstacles. The lower likelihood of illness-related
ambulatory visits for children in mother-headed families compared with children in
two-parent families is not adequately explained by their lower rates of health insurance coverage or lower incomes. Despite a higher burden of illness in low-income
families (see the Winter 1992 issue of The Future of Children) these children are using
fewer services. This appears to be a consequence of many cultural, social, behavioral, and health system variables which constitute nonfinancial barriers to service
utilization.
— R.E.B.
CRITICAL HEALTH ISSUES FOR CHILDREN AND YOUTH Vol. 4 • No. 3 – Winter 1994
25
T
he media, the academic community, and political leaders have
given considerable attention to the dramatic changes that have
transformed the American family over the past 30 years. Among
these changes are the high rates of divorce and births to unmarried
mothers, which are largely responsible for the growing proportion of
families headed by a single, primarily female parent. About one-fourth
of families with children had only one parent present in 1992—compared
1
with about 11% of households in 1970. In fact, one study showed that
nearly half of all children born since 1975 will live in a single-parent family
2
at some point in their childhood.
Along with the possible consequences
of single parenthood for children’s development, health, and economic well-being,
adequate access to health services is also
a concern.3 Numerous studies have examined differences in health care use for
children by demographic, socioeconomic,
and physician supply factors, but few have
examined the implications of different
family structures on children’s health care
use.4 Research has shown that children in
single-parent families use fewer health
care services than children in two-parent
families,5 but it is unknown whether this
is a result of medical need, the dramatically lower economic resources of singleparent families, or other noneconomic
characteristics.
It is unlikely that the need for health
services is substantially higher for children
in two-parent families than it is for children in single-parent families. A recent
study has shown that there is no difference
in physician assessments of children’s
physical health problems by family type,
although single mothers are more likely to
report their children as being in poor
health than are mothers of children in
two-parent families.5 Also, considerable research has shown that children in motheronly families have greater emotional and
behavioral problems, which would suggest that specific types of medical need
are higher for children in mother-only
families than for children in two-parent
families.5,6
Clearly, need is only one motivating
aspect in the use of health care services,
and other factors, particularly economic,
play a substantial role in the lower health
care use by children in single-parent families. Children in single-parent families are
overrepresented among persons who are
not in the labor force, or are poor or low
income, and thus more at risk for being
without continuous health care coverage
and living in medically underserved areas.
Access to health care services for children
who lack adequate health care coverage is
a persistent problem in the United States,
as has been demonstrated in past studies.7
In this article, we use data from the
1987 National Medical Expenditure Survey
(NMES) to examine differences between
children in two-parent and single-parent
families in their health care coverage and
use of ambulatory care services. Our findings support previous research findings
that children in mother-headed families
are less likely to use ambulatory care than
are children in two-parent families. We
explore whether these differences in
health care use are related to health care
coverage. In other words, if all children
had public or private insurance coverage,
would the health care use of children in
mother-headed families be more comparable with the use by children in twoparent families ? Our findings indicate
that, even if all children were covered by
private or public health care coverage,
differences in use between family types
26
would still exist. We conclude by discussing other possible explanations for the
discrepancies in use by family type.
Data Source
Data from the Household component of
the 1987 National Medical Expenditure
Survey were used in the analysis. The NMES
sampled approximately 14,000 households, resulting in data on 36,259 civilian
noninstitutionalized individuals. Because
of policy interest, blacks, Hispanics, the
low income, the elderly, and persons with
functional limitations were oversampled.
The NMES was designed to provide
measures of use and expenditures for
health services, insurance coverage, and
sources of payment for 1987. The survey
was fielded in four rounds with interviews
conducted at approximately four-month
intervals.8 Data on household characteristics, employment, insurance, and medical care utilization and expenditures were
recalled by the respondent (most typically
the mother with respect to children) and
recorded at each of the four interview
rounds.
Our analysis was limited to the 9,200
children who were either living with both
parents or with their mothers in 1987.9
Although father-headed families are an
ever-increasing sector of single-parent
families (they accounted for about 15% of
More than 40% of children in motherheaded families had incomes below the
federal poverty line, compared with only
13% of children in two-parent families.
single-parent families with children in
1992),1 children with single fathers represented only 2% of all children in the
NMES data and were insufficient for the
analyses conducted in this study.
Except for the results in Table 1, estimates of health care coverage and utilization are provided separately for preschool
children (0 to 5 years) and other children
(6 to 17 years). A social and economic
profile of two-parent families, all motherheaded families, divorced mothers, and
never-married mothers is presented in
Table 1 for children of all ages (0 to 17
years). For the remainder of the analyses,
mother-headed families are treated as a
single group when compared with two
parent-families. Although mother-headed
families are diverse, particularly when
comparing divorced mothers with nevermarried mothers, our analysis of health
care coverage and utilization could not
support separate estimates for each of
these groups along with the two age cohorts of children (ages 0 to 5 years; 6 to 17
years). Moreover, despite differences in
race/ethnicity, education, and employment, all mother-headed families have
substantially lower family incomes than do
two-parent families.
In the analysis that follows, we use
NMES data to provide descriptive comparisons of demographic and economic
characteristics for two-parent and motherheaded families and to point out the differences in their use of ambulatory health
care services. Multivariate models are
used to test whether changes in insurance
status would resolve the differences in
health care use by family structure.
Social and Economic
Profile of Children by
Family Type
Economic differences between two-parent
and mother-headed families are striking.
In 1987, the average family income of children with single mothers was less than
half the family income of children in twoparent families (Table 1; $18,079 versus
$39,840). As a result, more than 40% of
children in mother-headed families had
incomes below the federal poverty line,
compared with only 13% of children in
two-parent families. Almost three-fourths
of children in mother-headed families were
poor or low income (defined as having
family incomes less than 200% of the poverty line) compared with fewer than onethird of children in two-parent families.
These dramatic differences in the economic circumstances between children in
two-parent and mother-headed families
reflect the labor force participation as well
as the wages of their parents. In 1987,
more than three-fourths of children in
two-parent families had fathers who were
employed full-time and throughout the
year, and only about 7% of children’s fathers were not employed at all, either because they were unemployed or not in the
labor force. Combined with the labor
Implications for Children’s Health Insurance Coverage and the Use of Ambulatory Care Services
Table 1
Social and Economic Profile of Children by Family Type, United
a
States, 1987
Mother-Headed
Families
Two-Parent
Families
Total population (in thousands)
All
Divorced
Never
Married
47,294
14,697
6,174
4,679
Family income
39,840
18,079
19,861
16,049
Percentage below federal
poverty lineb
13.1
43.6
31.6
54.2
Percentage other low income
(100% to 200% of poverty line)b
18.6
29.2
31.0
27.0
Average income ($)
Father
Mother
Percentage employed full
time, all yearc
76.4
29.0
31.0
46.4
17.6
Percentage not employed
7.4
30.7
37.9
23.1
52.8
Percentage with less than a
high school education
19.0
18.5
36.9
27.6
46.3
3.4
6.7
13.5
3.0
31.3
Parents’ characteristics
Percentage less than age 25
Children’s characteristics
Average age
8.2
8.7
10.2
6.2
Percentage black
7.9
37.8
21.2
60.0
Percentage Hispanic
9.7
14.2
10.4d
7.2
d
Percentage in fair or poor
healthe
4.3
5.5
13.4d
7.1
a
All differences between mother-only families and two-parent families are statistically significant at
the .05 level unless otherwise noted.
b
In 1987, the federal poverty line was defined as $8,319 for a family of three.
c
Includes those who worked at least 35 hours per week and 46 weeks in 1987.
d
Difference with estimate for two-parent families not statistically significant at the .05 level.
e
Fair or poor health is based on mother’s perception of children’s health.
Source: Agency for Health Care Policy and Research, 1987 National Medical Expenditure Survey — Household
Survey.
force participation of their mothers,
more than 80% of children in two-parent
families had at least one parent employed
full-time and all year, and only 3% of children in two-parent families had parents
who were both unemployed. By comparison, more than one-third of the children
in mother-headed families had mothers
who were not employed in 1987, and
fewer than one-third of these women
were employed full time and all year.
Continued wage differentials between
men and women make it difficult for a
single woman to earn a wage comparable
to that of a male counterpart with similar
education and experience, and extremely
unlikely that her earnings could equal that
of a married couple.10 Furthermore, many
single mothers’ lower educational attainment impedes employment in jobs that
pay more than minimum wage; over onethird have less than a high school education compared with 18.5% of mothers in
two-parent families.
Although mother-headed families encompass all racial and ethnic groups, black
children have a substantially higher likelihood of residing in a mother-headed
family than do white children, and 60% of
27
28
Table 2
Health Care Coverage of Children by Family Type, United States,
a
1987
Two-Parent Families
Mother-Headed Families
Percentage Distribution
All ages
Uninsured
All year
Part year
9.7
13.7
12.5
19.6
Insured all year
Private
Publicb
71.0
5.7
32.2
35.7
Uninsured
All year
Part year
9.2
11.7
8.3c
23.4
Insured all year
Private
Publicb
66.7
6.8
22.6
45.7
Uninsured
All year
Part year
9.9
11.7
14.4
17.8
Insured all year
Private
Publicb
73.3
5.1
36.8
30.9
Ages 0 to 5
Ages 6 to 17
a
b
Most public coverage is Medicaid but may also include CHAMPUS/CHAMPVA or other state and
local assistance.
c
Difference with estimate for two-parent familiesnot statistically significant at the .05 level.
Source: Agency for Health Care Policy and Research, 1987 National Medical Expenditure Survey—Household
Survey.
children living with never-married mothers are black. More Hispanic children are
in mother-headed families than in twoparent families.
In regard to health, mothers in singleparent families and never-married mothers were more likely to rate their child’s
health as fair or poor (about 7%) than were
mothers in two-parent families (4.3%).
Health Care Coverage of
Children by Family Type
Family income and parent’s employment
status are perhaps the most important
determinants of whether children have
health care coverage and of the specific
type of coverage they have.11 Children of
middle- and upper-income families who
have a parent employed full time are likely
to obtain private insurance through their
parent’s place of employment. By contrast, poor and low-income children are
less likely to have private insurance because their parents are more likely either
to be unemployed or to work for an employer who does not offer private health
insurance. These children are more likely
to be covered by Medicaid—a federal-state
program that provides health care coverage to poor and low-income persons who
meet the eligibility requirements of the
program—or to lack public or private coverage entirely. These patterns are reflected in an examination of children’s
health care coverage by family type for
1987 (Table 2).12
For all ages, children in two-parent
families—who generally have higher incomes and at least one parent who is employed—are more than twice as likely to
have private insurance all year compared
with children in mother-headed families.
By contrast, 35.7% of children in motherheaded families—whose mothers are
more likely to have lower incomes or to be
unemployed—have public coverage (primarily Medicaid) compared with only
5.7% of children in two-parent families.
Nearly one-third of children in motherheaded families did not have any insurance coverage (either public or private)
for all or part of 1987 compared with
nearly one-fourth of children in twoparent families.
Some differences in children’s health
care coverage exist according to age of
the child. For example, children 6 to 17
years old were more likely to be covered
by private insurance than were children 0
to 5 years of age. The higher percentage of
older children with private coverage (in
both two-parent and single-parent families) may reflect the greater labor force
participation of mothers. In two-parent
families, one-third of children 6 to 17 years
old had mothers employed full time and
all year, compared with 22% of children 0
to 5 years old (estimates not shown). In
mother-headed families, 37% of children
6 to 17 years old had mothers employed
full time and all year, compared with only
19% of children 0 to 5 years old (estimates
not shown). Obviously, the greater the
labor force participation of parents, the
more opportunities there are to obtain
employment-related private insurance.
By contrast, 45.7% of children 0 to 5
years of age in mother-headed families
had public coverage compared with 30.9%
of children 6 to 17 years of age. Younger
children are more likely to have Medicaid
coverage because they have higher poverty rates (and, thus, are more likely to
qualify for Medicaid) and also because of
the expansion of Medicaid benefits to
young children during the 1980s, beginning with the Deficit Reduction Act of 1984
(DEFRA 1984). The majority of Medicaid
expansions took place in the late 1980s
and early 1990s. Consequently, large increases in the number of young children
eligible for Medicaid—who were the target of this legislation—are not reflected in
these estimates.13
An examination of the characteristics
of uninsured children shows that those in
mother-headed families had significantly
higher poverty rates and were much less
likely to have a parent employed full time
and all year than uninsured children in
two-parent families (Table 3). For uninsured children 0 to 5 years of age in
mother-headed families, 57.6% were poor
and another 21.1% were low income, compared with 36.6% and 29.8%, respectively,
of uninsured children 0 to 5 years of age
in two-parent families. Only about one in
five uninsured children 0 to 5 years of age
in mother-headed families had mothers
who were employed full time and all year,
and almost one-third had mothers who
did not work at all in 1987. By contrast,
almost 60% of uninsured children 0 to 5
years of age in two-parent families had at
least one fully employed parent, and only
about 3% of these children had two unemployed parents. Thus, lack of employment per se does not appear to be the
main factor involved with the lack of
health care coverage for children in twoparent families.
Nearly one-third of children in motherheaded families did not have any insurance
coverage (either public or private) for all
or part of 1987 compared with nearly onefourth of children in two-parent families.
These findings suggest that Medicaid
expansions in recent years—including
the 1989 and 1990 Omnibus Budget Reconciliation Act (OBRA) and provisions retained under the 1988 Medicare Catastrophic Coverage Act—are likely to benefit children in mother-only families disproportionately. This is true even though
it has probably become easier for poor
and low-income children in two-parent
families to be on Medicaid because eligibility is no longer restricted to families
receiving assistance through Aid to Families with Dependent Children (AFDC), the
major welfare program that has traditionally served single mothers and their children. The 1989 OBRA mandated coverage to all pregnant women and children
up to age 6 in families with incomes below 133% of the federal poverty line, and
the 1990 OBRA mandated coverage of
children between the ages of 7 and 19
below the poverty line to be phased in by
the year 2002. Assuming continued high
rates of poverty and low rates of employment among single mothers, the findings
29
30
Table 3
Characteristics of Children Uninsured All or Part Year in 1987
a
Two-Parent
Families
Mother-Headed
Families
Percentage below federal poverty lineb
36.6
57.6
Percentage other low income
(100% to 200% of poverty line)b
29.8
21.1
Percentage with parent employed full time,
all yearc
59.5
19.2
3.4
31.8
31.2
56.6
Percentage below federal poverty lineb
31.1
53.0
Percentage other low incomeb
31.6
29.7d
Percentage with parent employed full time,
all yearc
63.4
32.8
6.5
24.7
36.9
61.7
Ages 0 to 5
Percentage with parent not employed in
1987
Percentage nonwhite
Ages 6 to 17
Percentage with parent not employed in
1987
Percentage nonwhite
a
In 1987, the federal poverty line was defined as $8,319 for a family of three.
c
lncludes those who worked at least 35 hours per week and 46 weeks in 1987.
d
Difference with estimate for two-parent families not statistically significant at the .05 level.
b
Source: Agency for Health Care Policy and Research. 1987 National Medical Expenditure Survey — Household
Survey.
indicate that reliance on government assistance for health care coverage for them
and their children will increase substantially in the future.
Children’s Use of
Ambulatory Health Care
Services
Previous research has compared the health
care utilization of persons with different
socioeconomic and demographic characteristics; more specifically, such research
has examined differences in use by income, insurance, race and ethnicity, and
urban and rural locale.14 Lower health
care use by persons in one group (such as
poor and low income, uninsured, racial
and ethnic minority, rural areas) relative
to others has typically been taken as strong
evidence of access problems for persons
with those characteristics. In this tradition,
we examine differences between children
by family structure using four measures of
ambulatory health care utilization: (1) the
likelihood of using preventive ambulatory
health services such as immunizations,
well-child visits, and general exams, (2) the
number of preventive visits for children
having use of this type, (3) the likelihood
of an ambulatory health care visit related
to a specific illness or medical condition,
and (4) the number of illness-related visits
for children having use of this type.15
For each of these measures, we examine overall differences between children
in two-parent and mother-headed families, and separately for young children (0
to 5) and school age children (6 to 17).
Differences in children’s use by family type
are also examined across categories of
health care coverage to determine the extent to which variations in health care
coverage between children in different
family types account for their differences
in utilization.
Table 4
Children's Use of Ambulatory Health Care Services by Age and
Family Type, United States, 1987
Preventive Services
Age and Family
Type
Percentage
with
Any Use
Number of
Visits
for Users
Illness-Related Services
Percentage
with
Any Use
Number of
Visits
for Users
All ages
Two-parent
Mother-headed
41.0
35.3a
1.8
1.7
60.5
53.8a
4.3
4.4
Ages 0 to 5
Two-parent
Mother-headed
61.9
51.9a
2.2
1.8
67.2
57.2a
4.2
3.8
Ages 6 to 17
Two-parent
Mother-headed
29.1
27.4
1.4
1.6
56.7
52.1a
4.3
4.8
a
Difference with estimate for two-parent families statistically significant at the .05 level.
Survey.
Differences by Family Structure
Table 4 shows that children in motherheaded families were less likely to use both
preventive and illness-related ambulatory
care compared with children in two-parent
families. Forty-one percent of children in
two-parent families had at least one preventive health care visit in 1987 compared
with 35.3% of children in mother-headed
families. The differences are greater for
young children; in two-parent families,
62% of children 0 to 5 years of age had a
preventive health care visit compared with
52% in mother-headed families. On the
whole, older children were considerably
less likely to have a preventive visit than
younger children, as one would expect
given that the American Academy of Pediatrics recommends fewer and less frequent visits for older children compared
with the numerous well-child visits and
immunizations recommended for very
young children.16 Nevertheless, in contrast with 0- to 5-year-olds, preventive use
by older children did not differ significandy across family types.
Children in mother-headed families
were also less likely to have an illnessrelated visit compared with children in
two-parent families (53.8% versus 60.5%).
As with preventive care, these differences
were even larger for young children: 67.2%
of children 0 to 5 years old in two-parent
families had an illness-related visit compared with 57.2% of their counterparts in
mother-headed families. For the 6 to 17
age group, children in mother-headed
families were also less likely to have an
illness-related visit, although the difference between children in two-parent and
Children in mother-headed families were
less likely to use both preventive and illnessrelated ambulatory care compared with
children in two-parent families.
mother-headed families was smaller than
for young children (56.7% for children in
two-parent families compared with 52.1%
for children in single-parent families).
Once contact with the health care system had been made, differences in the
frequency of ambulatory use between children in single-parent and two-parent families were less apparent. Children 0 to 5
years of age in two-parent families had a
slightly higher number of both preventive
and illness-related visits than did children
the same age in mother-headed families
(2.2 versus 1.8 preventive visits and 4.2
versus 3.8 illness-related visits), but these
31
32
Table 5
Predicted Use of Preventive Ambulatory Health Services for
Children by Age, Family Type, and Health Insurance Status,
a
United States, 1987
Predicted Probability of Use
Two-Parent
Mother-Headed
Predicted Number of Visits
for Users
Two-Parent
Mother-Headed
Percentage
Ages 0 to 5
Uninsured
Part year
All year
61.5
58.6
53.2
37.1
2.2
2.2
1.9
1.6
Insured
Private
Publicb
61.1
70.5
53.1
52.3
2.1
2.0
2.0
1.9
Uninsured
Part year
All year
32.8
22.9
27.8
15.5
1.4
1.4
1.7
1.5
Insured
Private
Publicb
29.4
31.1
28.4
28.2
1.4
1.6
1.5
1.6
Ages 6 to 17
a
Estimates derived from logistic and least-squares regressions. Separate models were estimated for
each age and family type group. Predicted probabilities and average number of visits for users for
each category of health care coverage were obtained by holding constant all other independent
variables in the model, except for variables pertaining to health care coverage. The predicted
logarithmic values of utilization were then retransformed to the original scale.
b
local assistance.
Survey.
differences were not statistically significant.17 Similarly, children 6 to 17 years
of age in mother-headed families had a
somewhat higher number of illnessrelated visits than did children in twoparent families, but these differences were
also not statistically significant.
Differences by Type of Health Care
Coverage
It is possible that the generally lower rates
of full-year health care coverage among
children in mother-headed families are the
primary explanation for their lower likelihood of ambulatory health care use relative to children in two-parent families. In
Tables 5 and 6, we compare preventive and
illness-related ambulatory health care use
for children in different family types across
categories of health care coverage. Within
each age and family type, the estimates
were adjusted to control for children’s age,
race/ethnicity, perceived health status, the
number of days spent in bed as well as the
number of days with a reduction in normal
activities due to health problems, family
income, family size, and mother’s characteristics (that is, employment status, education, age, use of ambulatory care), and U.S.
Census Region.18 The purpose of these
adjustments was to determine the true effects of insurance coverage on use and to
control for other factors that would potentially confound this relationship.
For young children, the findings in
Table 5 show that differences in the probability of preventive care use between types
of families remain regardless of insurance
coverage and, in some instances, are even
larger than the simple bivariate differences shown in Table 4. For example, the
Table 6
Predicted Use of Illness-Related Ambulatory Health Services for
Children by Age, Family Type, and Health Insurance Status,
United States, 1987a
Predicted Probability of Use
Two-Parent
Mother-Headed
Predicted Number of Visits
for Users
Two-Parent
Mother-Headed
Percentage
Ages 0 to 5
Uninsured
Part year
All year
68.4
59.4
62.7
44.9
3.9
4.1
3.5
3.7
Insured
Private
Publicb
67.7
68.2
52.3
59.0
4.1
4.9
4.1
3.8
Uninsured
Part year
All year
53.8
51.1
48.3
43.5
4.1
4.0
4.2
4.1
Insured
Private
Publicb
57.2
55.1
52.8
56.3
4.5
4.8
4.6
4.7
Ages 6 to 17
a
Estimates derived from logistic and least-squares regressions. Separate models were estimated for
each age and family type group. Predicted probabilities and average number of visits for users for
each category of health care coverage were obtained by holding constant all other independent
variables in the model, except for variables pertaining to health care coverage. The predicted
logarithmic values of utilization were then retransformed to the original scale.
b
local assistance.
Survey.
probability of use for children in twoparent families who were uninsured all
year was 58.6%, compared with 37.1% for
all-year uninsured children in motherheaded families. Similarly, the probability
of use for children in two-parent families
with public coverage was 70.5%, compared
with only 52.3% of children in motherheaded families with public coverage.
There were also differences between family types in the probability of use for children with private coverage, although the
differences were somewhat smaller.
For children 6 to 17 years of age with
public or private coverage, the probability
of use was similar for mother-headed and
two-parent families. Uninsured children
in mother-headed families were somewhat
less likely to use preventive health care
than were the uninsured in two-parent
families. Possibly because there are fewer
guidelines for using preventive and routine health care for older children, there
tends to be less overall use of this type and
less variation across family type and health
care coverage categories—with the exception of the all-year uninsured.
Differences in the probability of preventive
care use between types of families remain
regardless of insurance coverage and, in
some instances, are even larger.
Frequency of preventive health care
use for all children varies less by family
structure and health care coverage. The
average number of preventive visits for
33
34
Table 7
Children Without Health Care Coverage for All of 1987 and the
Effects of Extending Health Care Coverage on the Probability of
a
a Preventive Visit
Predicted Probability of a Visit for
Children Uninsured All Year
Children
Uninsured
All of 1987
Actual
Probability of a
Visit by All-Year
Uninsured
If Covered by
Private Insurance
If Covered by
Public Insurance
Percentage
Ages 0 to 5
Two-parent
Mother-headed
Ages 6 to 17
Two-parent
Mother-headed
a
Estimates derived from logistic regressions. Separate models were estimated for each age and
family type group. Predicted probabilities for each category of health care coverage were
obtained by holding constant all other independent variables in the model except for variables
pertaining to health care coverage. The predicted logarithmic values of utilization were then
retransformed to the original scale.
Survey.
children with at least one visit was between
1.6 and 2.2 visits for children 0 to 5 years
of age, and 1.4 to 1.7 visits for children 6
to 17 years of age. The largest difference
between types of families was for children
Among young children, those in twoparent families had higher probabilities
of use across all categories of health care
coverage than did children in motherheaded families.
0 to 5 years of age who were uninsured all
year in 1987: those in two-parent families
averaged 2.2 visits compared with 1.6 visits
for children in mother-headed families.
The findings were similar for the use of
illness-related services (Table 6). Among
young children, those in two-parent families had higher probabilities of use across
all categories of health care coverage than
did children in mother-headed families.
Differences were particularly large for children who were uninsured all year (59.4%
for children in two-parent families compared with 44.9% for children in motherheaded families) and children with private insurance (67.7% for children in
two-parent families compared with 52.3%
for children in mother-headed families).
For children 6 to 17 years of age, those in
two-parent families also had higher probabilities of use than children in motherheaded families except for those with
public coverage, where probability of use
was similar. As with preventive health care,
there was less variation in the frequency of
illness-related visits, with the exception of
children 0 to 5 years of age with public coverage. For the latter group, children in
two-parent families averaged more than
one additional visit compared with children in mother-headed families (4.9 versus
3.8 visits). Differences between family
types in the number of illness-related visits
were much smaller across the other age
and health care coverage categories.
Although the findings show that differences in health care coverage do not
Table 8
Children Without Health Care Coverage for All of 1987 and the
Effects of Extending Health Care Coverage on the Probability of
a
an Illness-Related Visit
Predicted Probability of a Visit for
Children Uninsured All Year
Children
Uninsured
All of 1987
Actual
Probability of a
Visit by All-Year
Uninsured
If Covered by
Private Insurance
If Covered by
Public Insurance
Percentage
Ages 0 to 5
Two-parent
Mother-headed
49.1
49.3
56.8
54.5
57.4
61.0
39.2
38.8
45.1
46.4
43.0
49.8
Ages 6 to 17
Two-parent
Mother-headed
a
Estimates derived from logistic regressions. Separate models were estimated for each age and
family type group. Predicted probabilities for each category of health care coverage were
obtained by holding constant all other independent variables in the model except for variables
pertaining to health care coverage. The predicted logarithmic values of utilization were then
retransformed to the original scale.
Source: Agency for Health Care Policy and Research, 1987 National Medical Expenditure Survey—Household
Survey.
account for the lower probability of ambulatory health care use for children in
mother-headed families, this is not to suggest that there is no effect of health care
coverage. On the contrary, when examining the actual reported probability of use
for children uninsured the entire year and
comparing it to their predicted use if they
were given private or public coverage, it
appears that the effect of health care coverage on use is actually greater for children in mother-headed families than for
children in two-parent families (see Tables
7 and 8).19 For uninsured children 0 to 5
years of age in mother-headed families,
the predicted probability of having a preventive visit is 54.5% if covered by private
insurance and 53.6% if covered by public,
about 40% higher than their actual reported use of 38% (Table 7). By contrast,
uninsured children 0 to 5 years of age in
two-parent families would experience little
change if covered by private insurance,
although their predicted probability of a
preventive visit is 61% if they were covered
by public, a 26% increase from their reported use of 48.5%. For uninsured children 6 to 17 years of age, the proportion
with a preventive visit would double in
mother-headed families (from 13.4% with
reported use to about 26% with use if
covered by private or public), while the
Although the findings show that differences
in health care coverage do not account for
the lower probability of ambulatory health
care use for children in mother-headed
families, this is not to suggest that there is
no effect of health care coverage.
percent in two-parent families would increase from 15.1% with reported use to
22.2% if covered by private and 23.6% if
covered by public.
The effect of private insurance on the
predicted probability of using illnessrelated care is slightly higher for uninsured children 0 to 5 years of age in
two-parent families compared with
mother-headed families (Table 8). How-
35
36
ever, the probability of an illness-related
visit for uninsured children 0 to 5 years of
age in mother-headed families would increase from 49.3% to 61% if covered by
An expansion of private or public
coverage will significantly increase access to
and use of ambulatory care for uninsured
children, regardless of family type. However,
other systematic differences between family
types exist that impede children’s ability to
use health care.
public insurance, a somewhat larger increase than for children in two-parent
families. The effects of public and private
coverage on expected use for uninsured
children 6 to 17 years of age would also be
larger in mother-headed families.
It is also worthwhile to note that predicted use for uninsured children if given
public coverage was at least as high as
their predicted use if they were covered by
private insurance, and, in some instances,
predicted use for public coverage was substantially higher. While there has been
much concern over access to medical care
for children with Medicaid because of low
physician reimbursement rates in many
states and a lack of providers willing to
accept Medicaid patients, other aspects of
the program—such as the Early and Periodic Screening, Diagnosis, and Treatment
(EPSDT) program, and the generally wide
range of services that are covered (compared with the limited benefits of many
private insurance plans)—enhance access
to health care for children who would
otherwise be uninsured.
In sum, these findings indicate that an
expansion of private or public coverage
will significantly increase access to and use
of ambulatory care for uninsured children, regardless of family type. However,
other systematic differences between family types exist that impede children’s ability
to use health care, since the findings clearly
show that children in mother-headed families—particularly young children—have
consistently lower probabilities of use regardless of their health care coverage. Furthermore, it is not at all clear how or if
these “nonfinancial” differences could be
resolved simply by providing universal
health care coverage to all children and
their families. Possible explanations for
the persistent differences in the use of
health care between children in different
family types are explored further in the
concluding section of this article.
Conclusion
The primary goal of most of the major
health care reform proposals is to extend
health care coverage to all persons who are
currently uninsured. An expansion of pub-
lic or private coverage would greatly increase access to ambulatory health care for
children with single mothers. For many of
these children, private insurance is difficult to obtain because of high rates of
poverty and the lack of employment
among single mothers, who—even if they
work—are less likely to be able to acquire
the types of jobs where private insurance
plans are offered. Even with the recent
expansions in Medicaid eligibility requirements (all children 0 to 10 years of age who
are below the federal poverty level are
required to be covered as of 1994), significant gaps in coverage remain. For example, the phase-in of all poor children age
18 and under will not be completed until
the year 2002. Also, coverage of infants in
families with incomes between 133% and
185% of poverty is optional but not mandatory, and there is no optional coverage
for other children in this income category.
There is also no requirement or option to
cover children age 6 and older with incomes above the poverty line.
Moreover, although the number of
Medicaid beneficiaries grew by 2.6 million
in 1991 as a result of mandated coverage
of pregnant women and children, a recent
study based on data from the Current
Population Survey shows that the percentage of uninsured children increased between 1988 and 1990.20 Most of the increase in the percentage of uninsured
children occurred between ages 7 and 21.
Analyses of the 1991 Current Population
Survey have shown increased rates of coverage for children below poverty but decreased coverage for other low-income
children.21
Lack of health care coverage is a serious problem among low-income persons
and families who do not meet the federal
definition of “poor” or “near poor” because
they are not eligible for the mandatory
coverage requirements under Medicaid,
and less than half of employed persons in
this income category have employmentrelated private coverage.22 The implications for single mothers moving off welfare and into the labor force are even
more profound because movement is
most likely to be into low-wage jobs where
health benefits are less likely to be offered.23 Medicaid coverage ends after 12
months of becoming employed, if earnings exceed previous income limits received under the Aid to Families with
Dependent Children program. Therefore,
fear of losing Medicaid benefits may be a
significant disincentive for these mothers
to enter the labor force.24
Universal health coverage would eliminate most of the current gaps in health care
coverage and would greatly improve access
to care for those currently without coverage. However, even if universal health care
coverage were to be enacted, the findings
in this study show that children in motherheaded families would still be less likely to
use ambulatory care, either for preventive
or illness-related purposes. Furthermore,
the gap in use between children in different family types is even wider for young
children. Additional analysis revealed that
family income has a significant effect on
Family income has a significant effect on the
probability of children’s use of preventive
services even after controlling for health care
coverage. . . . Out-of-pocket costs for health care
could be a significant obstacle even for poor and
low-income persons with coverage.
the probability of children’s use of preventive services even after controlling for
health care coverage. Poor children in
mother-headed families were less likely to
use preventive care than children with
higher incomes, regardless of their health
care coverage. Also, income, not health
care coverage, explains more of the difference between two-parent and motherheaded families in the probability of
having a preventive visit.25 The interpretation of the effects of poverty independent
of health care coverage is not straightforward. Out-of-pocket costs for health
care could be a significant obstacle even
for poor and low-income persons with coverage. Transportation to medical providers may be more problematic for poor and
low-income families, and providers are
often unavailable in poor and low-income
residential areas.26
With regard to illness-related care,
neither health care coverage nor income
are major factors in explaining the lower
probability of illness-related visits for children in mother-headed families. Other
potential explanatory variables in the
models used for this study include children’s health status and disability days,
race/ethnicity, physician supply, and char-
37
38
acteristics of the mother (for example,
age, educational attainment, employment
status, use of health care). While most of
these variables had differing effects, no
single one appeared to account for the
lower use by children in single-parent
families. This suggests that the differences
between family types regarding illnessrelated use are dispersed across a wide
range of factors. Alternatively, it is possible that more direct measures of family
process and functioning (for example,
the amount of supervision children receive from their parents) and the time
involved in utilizing services (not included in NMES) are necessary to clarify the
differences in children’s use between family types.
One should be cautious about generalizing these findings to all children in
single-parent families. As has been noted
by other authors as well as illustrated by
the findings in Table 1 of this paper,
single-parent families can vary substantially by other socioeconomic and demographic characteristics, such as race/
ethnicity, socioeconomic status, and place
of residence. We would not necessarily
expect the experiences of single-parent
children of middle- or upper-income families living in affluent suburban areas to be
similar to that of single-parent children in
poor or low-income families living in underserved inner-city or rural areas. These
differences may be reflected to some extent across the different types of singleparent families. For example, other data
have shown that single fathers are far different from single mothers: they tend to
have higher incomes, higher rates of employment, and higher educational attainment.27 While it is likely that children’s
health care coverage and use differs across
many of these subgroups, separate analy-
While there were many differences between
two-parent and mother-only families in the
effects of financial and nonfinancial factors
on children’s health care use, there were few
differences between children with nevermarried and divorced mothers.
ses for all of these groups were not conducted for this article because of sample
size limitations and analytical complexity.
Using multivariate techniques, however, it is possible to examine differences
between two-parent and mother-headed
families as well as between types of motheronly families in the effects of other demographic and socioeconomic factors on
children’s health care use. Such an analysis is the subject of another research paper
by the authors.28 The findings show that,
while there were many differences between two-parent and mother-only families in the effects of financial and nonfinancial factors on children’s health care
use, there were few differences between
children with never-married and divorced
mothers.
Implications for Policy
To what extent should family structure be
addressed with respect to health care policy for children? Some could argue that,
although family structure is intricately entwined with risk factors that are more directly related to children’s health care use
(for example, poor and low income, lack
of health care coverage, low educational
attainment of the mother, time constraints), these risk factors are not unique
to single mothers, and therefore family
structure is extraneous. In this view, policy
should focus exclusively on factors that are
more directly related to lack of access to
health care.
However, it is difficult to completely
ignore the issue of family structure because it is clear that many of the direct
factors associated with lower health care
use by children appear more frequently in
single-parent families (for example, low
incomes, lack of health insurance, low
educational attainment of the parent).
Moreover, it is likely that these risk factors
have probably increased over the past 25
years along with the increase of singleparent families. Public policy should be
concerned with the increase of children in
single-parent families at least to the extent that their high degree of reliance on
Medicaid coverage has resulted in an
increased burden on federal and state
budgets during an era of fiscal constraints.
Also, other research by the authors
mentioned above indicates that family
structure interacts with other factors to
affect health care use.28 In sum, the results
showed that the effects of being uninsured
on the use of preventive services were
more strongly felt in mother-headed families than in two-parent families. Low edu-
cational attainment of mothers had a
stronger negative effect on illness-related
use in mother-headed families, while
mother’s predisposition to use care (as
reflected by her own use and attitudes
toward health and health care) were more
strongly felt in mother-headed families
than in two-parent families. These latter
findings suggest that family structure is
not merely a proxy for other risk factors,
but that behavior and decision making
regarding the health care of children is
somewhat conditional on family structure.
Changes in the demographic characteristics of families over the past 25 years
as well as any future changes have implications for the focus of health care policy.
Because factors other than health care
coverage or income appear to be important reasons children in single-parent
families are less likely to use ambulatory
care and because the number and percentage of these children has increased
markedly over the past 25 years, it is reasonable to conclude that there should be
an even stronger policy emphasis on these
nonfinancial barriers to health care use in
addition to the more traditional policy
emphasis on economic well-being.
For health care policy, this suggests
that, in addition to expanding the availability of health coverage, it is likely that
service delivery and outreach should also
be a major concern. While the findings in
this study do not point to any specific
method, some examples would include
neighborhood or community health centers that serve the dual purpose of being
convenient sources of primary health care
There should be an even stronger policy emphasis on these nonfinancial barriers to health care
use in addition to the more traditional policy
emphasis on economic well-being. . . . Service
delivery and outreach should also be a major
concern.
as well as centers of health promotion and
education for parents and their children.
In addition, school-based health clinics
have been promoted by many as efficient
and effective centers for health promotion
and education for children, in addition to
being a point of entry into the health care
system.29
The authors would like to thank Nancy
Kieffer, James Maedke, and Edward Hock of
Social Scientific Systems, Inc., for providing
excellent programming assistance. The authors
would also like to thank Dan Walden, Pam
Short, and several anonymous reviewers for their
helpful comments and suggestions.
1. U.S. Bureau of the Census. Statistical Abstract of the United States: 1993. Washington, DC: U.S.
Government Printing Office, October 1993, p. 61.
2. Bumpass, L. Children and marital disruption: A replication and update. Demography (1984)
21:71-82.
3. For a summary of research on the effects of single-parent families on the well-being of children, see McLanahan, S., and Booth, K. Mother-only families: Problems, prospects, and
politics. Journal of Marriage and the Family (1989) 51:557-80.
4. See for example, Newacheck, P. Characteristics of children with high and low usage of physician services. Medical Cure (1992) 30:30-42; Cafferata, G., and Kasper, J. Family structure
and children’s use of ambulatory physician services. Medical Care (1985) 23:350-60; Wolfe,
B. Children’s utilization of medical care. Medical Care (1980) 18:1196-1207; Colle, A., and
Grossman, M. Determinants of pediatric care utilization. Journal of Human Resources
(1978) 13:115-43.
5. Angel, R.J., and Angel, J.L. Painful inheritance. Madison: University of Wisconsin Press, 1993.
6. Dawson, D.A. Family structure and children’s health and well-being: Data from the 1988 National Health Interview Survey on Child Health. Journal of Marriage and the Family (1991)
53:573-84; Peterson, J.L., and Zill, N. Marital disruption, parent-child relationships, and
behavior problems in children. Journal of Marriage and the Family (1986) 48:295-307;
Chase-Lansdale, L., and Hetherington, E.M. The impact of divorce on life-span development: Short and long term effects. In Life-span development and behavior. P.B. Baltes, D.L.
Featherman, and R.M. Lerner, eds. Hillsdale, NJ: Lawrence Erlbaum Associates, 1990,
pp. 105-51; Allison, P.D., and Furstenberg, F.F. How marital dissolution affects children:
Variations by age and sex. Developmental Psychology (1989) 25:540-49.
39
40
7. Monheit, A.C., and Cunningham, P.J. Children without health insurance. The Future of Children (1992) 2,2:154-70; Cunningham, P.J., and Monheit, A.C. Insuring the children: A
decade of change. Health Affairs (Winter 1990) 9:76-90; Spillman, B.C. The impact of being uninsured on utilization of basic health care services. Inquiry (Winter 1992) 29:457-66.
8. For detailed information on the survey instrument and design, see Edwards, W., and Berlin,
M. Questionnaires and data collection methods for the Household Survey and the Survey of American Indians and Alaska Natives. National Medical Expenditure Survey Methods, Vol. 2. National Center for Health Services Research and Health Care Technology Assessment.
DHHS Publication No. PHS-89-3450. Rockville, MD: Public Health Service, September
1989.
9. Children in the same family type throughout all four rounds were assigned to that family
type. Children whose family type changed during the year were assigned to the family
type that they had been in for the majority of the year.
10. According to the 1991 Current Population Survey, the average weekly earnings for female
workers were $368, compared with $497 for male workers. The average weekly earnings
for female workers who maintained families were $362, compared with $448 for male
workers who maintained families. These figures appeared in U.S. Bureau of the Census.
Statistical Abstract of the United States: 1992. Washington, DC: U.S. Government Printing Office, 1992, p. 412, Table 654. Research by Bianchi and Spain indicates that, on average,
women earn 40% less than men. Bianchi, S., and Spain, D. American women in transition.
New York: Russell Sage Foundation, 1986.
11. See note no. 7, Monheit and Cunningham, and Cunningham and Monheit.
12. Children were classified into the following health care coverage categories: Children with
private insurance were covered by individual or group insurance for medical or related expenditures, including prepaid health plans such as health maintenance organizations
(HMOs). Policies that included only extra cash coverage, medical benefits linked to specific diseases, and casualty benefits were excluded. The vast majority of children with public coverage were covered by Medicaid, although a few were covered by other public
programs, including state or local assistance programs, the Civilian Health and Medical
Program of the Uniformed Services (CHAMPUS), and/or Medicare. Children uninsured
all year did not have any type of coverage during 1987. Children uninsured part year had
either public or private coverage for part of the year but were uninsured the rest of the
year.
13. The Deficit Reduction Act of 1984 (DEFRA 1984) mandated Medicaid coverage of pregnant women (single and in two-parent unemployed families) and children born after September 10, 1983, in households with incomes below standards set for the Aid to Families
with Dependent Children (AFDC) program. The Omnibus Budget Reconciliation Act
(OBRA) of 1985 covered all remaining pregnant women and children under age 5 with
AFDC family income levels. OBRA 1986 provided for optional coverage of pregnant
women and children born after September 30, 1983, with family incomes not exceeding
100% of the federal poverty line. OBRA 1987 allowed optional coverage for pregnant
women and infants with family income up to 185% of the federal poverty line. OBRA
1989 mandated coverage of all pregnant women and children under 6 years old in families with incomes up to 133% of the federal poverty line. OBRA 1990 mandated coverage
of all poverty-level children under age 19 born after September 30, 1983, with incomes up
to 100% of the federal poverty line. Under this legislation, the full cohort under age 19
will be covered by the year 2002. For a more detailed discussion of the Medicaid expansions, see The Kaiser Commission on the Future of Medicaid. The Medicaid cost explosion:
Causes and consequences. Menlo Park, CA: The Henry J. Kaiser Family Foundation, 1993.
14. For example, see Aday, L.A., and Andersen, R. Development of indices of access to medical care.
Ann Arbor, MI: Health Administration Press, 1975; Freeman, H.E., Blendon, R.J., Aiken,
L.H., et al. Americans report on their access to health care. Health Affairs (1987) 6:6-18;
Davis, K., and Rowland, D. Uninsured and underserved: Inequities in health care in the
United States. Milbank Memorial Fund Quarterly (1983) 61:149; Rowland, D., and Lyons, B.
Triple jeopardy: Rural, poor, and uninsured. Health Services Research (1989) 23:975.
15. Ambulatory visits were recalled by the respondent and recorded at each of the four interview rounds. Ambulatory visits were defined as any visit to a medical person (physician or
nonphysician) that took place in an emergency room, outpatient clinic, physician’s office,
other clinics, or during inpatient hospital stays of less than one night. Preventive visits included vision exams, immunizations, well-child visits, or general checkups not associated
with a specific medical problem. Illness-related visits included those for which the reason
for the visit was related to a specific mental or physical health problem.
16. American Academy of Pediatrics. Recommendations for preventive pediatric health care.
In American Academy of Pediatrics: Policy reference guide. Elk Grove Village, IL: AAP, 1990,
p. 561.
17. T-tests of differences between means were used to assess statistical significance.
18. The estimates shown in Tables 5–8 were derived from two-part multivariate models consistent with traditional health services research. In the first part, logistic regression models
were used to estimate the probability of having a given medical service (preventive ambulatory visit, illness-related ambulatory visit). In the second part, a weighted least-squares regression model was used to determine the natural log of the number of preventive or
illness-related visits for persons who had some utilization. Predicted probabilities and
number of visits for each category of health care coverage were obtained by holding constant all other independent variables in the model, except for variables pertaining to
health coverage. The predicted values were then retransformed to the original scales. The
predicted logarithmic values of the number of preventive and illness-related visits were retransformed to natural scales by applying the “smearing” methodology developed by
Duan, Manning, and Morris to yield consistent estimates of expected utilization from loglinear equations if the error term is nonnormal. For an explanation of this smearing methodology, see Duan, N., Manning, W., Morris, C.N., and Newhouse, J.P. A comparison of
alternative models for the demand for medical care. Santa Monica, CA: RAND Corporation,
1982. For a description of the two-part model, see Manning, W.G., Morris, C.N., and
Newhouse, J.P. A two-part model of the demand for medical care: Preliminary results
from the Health Insurance Study. In Health, economics, and health economics. J. van der Gaag
and M. Perlman, eds. Amsterdam: North-Holland, 1981, pp. 103-23. The complete regression results are available from the authors upon request.
19. The expected probabilities of use shown in Tables 7 and 8 were derived from the same multivariate results used to compute the findings in Tables 5 and 6. The estimated probabilities of use assuming all children had private and public insurance shown in Tables 5
and 6 were subset to children uninsured all year to derive the expected probabilities
shown in Tables 7 and 8.
20. Cartland, J.D.C., and Yudkowsky, B.K. State estimates of uninsured children. Health Affairs
(Spring 1993) 12,1:144-51.
21. Levit, K.R., Olin, G.L., and Letsch, S.W. Americans’ health insurance coverage, 1980-91.
Health Care Financing Review (1992) 14,1:31-57.
22. Cooper, P., and Johnson, A. Employment-related health insurance in 1987. National Medical Expenditure Survey, Research Findings, Vol. 17. AHCPR Pub. No. 93-0044. Rockville, MD:
Agency for Health Care Policy and Research, Public Health Service, 1993.
23. The effects of welfare reform policies that focus on job training and employment as the way
to reduce dependency on public assistance were discussed at a meeting of the National
Health Policy Forum. Welfare reform in the 1990’s: Coercion or catalyst for change? Issue
Brief #608 presented at a conference of the NHPC at The George Washington University.
Washington, DC, November 9, 1992.
24. Support for this hypothesis can be found in a study by R. Moffit and B. Wolfe. The effect of
the Medicaid program on welfare participation and labor supply. The Review of Economics
and Statistics (November 1992) 4:615-26. The findings showed that an increase in expected Medicaid benefits strongly increased AFDC participation of female household
heads and decreased the probability of their labor force participation.
25. The importance of income in explaining these differences was ascertained by computing
the probability of use for children in mother-only families holding all variables constant
to the sample mean, except for income which used the sample means for children in twoparent families. The result was that the probability of preventive use for children 0 to 5
years old in mother-only families increased significantly. Similar analyses were conducted
for other variables in the model (for example, health status, mother’s characteristics).
However, no significant increase (or decrease) in the probability of use for children in
mother-only families was observed when using the sample means for children in two
parent families for these other variables.
26. Fossett, J.W., Perloff, J.D., Kletke, P.R., and Peterson, J.R. Medicaid and access to child
health in Chicago. Journal of Health Politics, Policy and Law (1992) 17:273-98.
27. Zill, N., and Rogers, C. Recent trends in the well-being of children in the United States
and their implications for public policy. In The changing American family and public policy.
A. Cherlin, ed. Washington, DC: Urban Institute, 1988, p. 31-98.
28. Cunningham, P.J., and Hahn, B.A. The family and children’s health care: Results from the
1987 National Medical Expenditure Survey. Presented at the winter meetings of the
41
42
American Statistical Association, Fort Lauderdale, FL, January 1993. Because children of
all ages (0 to 17 years) were pooled into the same models, it was possible to estimate separate models for never-married mothers as well as divorced mothers.
29. Walker, D.K., Butler, J.A., and Bender, A. Children’s health care in the schools. In Children
in a changing health system. M.J. Schlesinger and L. Eisenberg, eds. Baltimore, MD: Johns
Hopkins University Press, 1990, pp. 265-93.
The Health of Latino
Children in the United
States
Fernando S. Mendoza
The Latino population in the United States is large and fast-growing, with a high
proportion of children relative to other U.S. populations. These demographic trends
make it imperative for policymakers to consider health issues for Latino children
and families. This article provides an overview of the important health issues for
Latino children in the United States. Its aim is not to set out specific policies, but
rather to identify factors that are critical to consider in policy development. Factors
discussed include current and projected demographic trends; the underlying diversity of the Latino population and its implications for health and health care;
significant health issues in each developmental phase of maturation, from infancy
through adolescence; and more global issues including limited access to medical
care and high rates of uninsured children. Finally, policy implications are outlined.
Although comparative data on health status for Latinos and other U.S. populations
are limited, available data indicate that Latino children are particularly at risk for
communicable diseases, including HIV infection and AIDS, and are especially
vulnerable to the environmental risks associated with poverty. Programs aimed at
prevention should receive high priority. An “epidemiological paradox” is found in
some areas, such as pregnancy outcome, where health status indicators are better
than would be expected considering poverty levels. The author concludes that
policymakers should focus on increasing access to medical care and on mitigating
factors associated with poverty. Further, effective policies should build upon existing
social and cultural strengths of the Latino population, such as high labor force
participation and high rates of family formation, to help ensure the health of
children.
— R.E.B.
M
ore than ever before, Latinos form a significant presence in the
United States. Demographically, socially, and politically, Latinos and other minority groups are changing the face of American society. (See the Child Indicators article in this journal issue.)
California is one example. In California, almost 26% of the population is now
Latino.1 Among children entering kindergarten with English as their second language, 100 different dialects are spoken.
Three-quarters of these children are
Spanish-speaking.2
In the United States as a whole, the
Latino population increased about 4%
each year from 1980 to 1991. By 1991,
Latinos were 9.3% of the U.S. population,
up from 6.8% in 1980.3 This rapid growth
occurred as a result of both higher-thanaverage fertility and sustained flow of im-
CRITICAL HEALTH ISSUES FOR CHILDREN AND YOUTH
Vol. 4 • No. 3 – Winter 1994
Fernando S. Mendoza,
M.D., M.P.H., is associate professor of pediatrics and associate
dean of student affairs
at Stanford University
School of Medicine.
44
migrants from Latin America.3 Clearly,
Latinos are a significant part of America’s
future.
What does this population trend mean
for our society and its institutions? How
should those who set public policy respond to these changes to ensure that we
have a united and not a divided nation?
To build upon one of the country’s
fundamental strengths, the diversity of its
people, each individual must have the opportunity to succeed and believe that suc-
Latinos comprise approximately 9% of
the total U.S. population—just over 22
million people. . . . Between 1980 and
1990, the Latino population in the United
States increased by 53%.
cess is a possibility for him or her. One step
toward achieving this match between opportunity and self-empowerment is to ensure that children remain healthy so that
they can achieve their fullest potential.
Not only do children need to learn behaviors that will keep them healthy, but also
the social conditions in which they grow
and mature must foster their health and
well-being.
This article will outline the important
health issues for Latino children in the
United States. The intent is not to delineate specific policies, but to identify critical
factors to consider in policy development.
First, current demographic trends are reviewed to provide a context for the discussion. A brief historical perspective on each
of the major subgroups is given to highlight the underlying diversity of the Latino
population. Next, significant health issues
are discussed by developmental phase,
including infancy, preschool age, school
age, and adolescence. Then, issues that affect Latinos more globally, such as access
to medical care and health insurance, are
discussed. Finally, conclusions about policy implications are drawn.
A Word About
Terminology
“Hispanic” is the term used by the U.S.
Department of Commerce, Bureau of the
Census, for all individuals with ethnic ori-
gins from countries where Spanish is the
primary language. Included are Mexico,
Puerto Rico, Cuba, the Dominican Republic, Central and South America, and Spain.
In the census materials, where detailed
information is presented, data on persons
of Mexican, Puerto Rican, and Cuban origin are provided, while those who are from
Spain or are identified only as Hispanic are
categorized in an “other Hispanic” group.
The term “mainland Puerto Rican” is used
to describe Puerto Ricans living in the
continental United States. In numerous
studies, the terms “Mexican-American”
and “Cuban-American” are used to describe persons of Mexican or Cuban descent who reside in the United States but
whose citizenship is not explicitly defined.
Persons of Hispanic origin are sometimes called Latinos, Spanish Americans
or Hispanos. While most individuals identify themselves by their country of origin,
one of these generic terms usually is used
to describe all subgroups. “Hispanic” is the
most general term, as it encompasses all
Spanish-speaking origins. “Latino” usually
is used to describe persons with ethnic
origins from a Spanish-speaking country
in the Americas. Because this is the term
that best describes the vast majority of people in the United States who originated
from a Spanish-speaking country, here it
will be used interchangeably with “Hispanic.”
Demographic Trends: A
Complex and
Heterogeneous Population
The Latino population in the United
States is large and fast-growing. Within the
Latino population, each subpopulation
historically has been concentrated in specific geographic areas, and each has a distinct social history. We will briefly examine
these demographic and historical trends,
for they are the driving force that will
require policymakers at local, state, and
national levels to consider the needs of the
Latino population.
Composition, Size, and Growth
Latinos comprise approximately 9% of
the total U.S. population—just over 22
4
million people. This figure represents
significant growth over the past decade,
which is the result of both high fertility
rates and ongoing immigration. Between
1980 and 1990, the Latino population in
the United States increased by 53%. By
45
The Health of Latino Children in the United States
Table 1
Number of Births, Fertility Rates, and Total Fertility Rates, by Race and Hispanic
Origin, United States, 1990
Number of
Births
Fertility Ratea
Total Fertility
Rateb
2,626,500
661,701
3,457,417
62.8
89.0
67.1
1,850.5
2,547.5
1,979.5
Hispanicd
Mexican American
Puerto Ricane
Cuban American
Otherf
Total
385,640
58,807
11,311
139,315
595,073
118.9
82.9
52.6
102.7
107.7
3,214.0
2,301.0
1,459.5
2,877.0
2,959.5
Asian/Pacific Islander
Chinese American
Japanese American
Hawaiian
Filipino American
Otherg
Total
22,737
8,674
6,099
25,770
78,355
141,635
49.9
40.8
115.1
63.5
91.8
69.6
1,357.5
1,111.8
3,223.3
1,881.0
2,675.0
2,002.5
39,051
76.2
2,184.5
70.9
2,081.0
Race/Ethnicity
of Mother
Non-Hispanic
White
Black
Totalc
American Indian/Alaskan Native
Total
Allh
4,158,212
a
Per 1,000 women aged 15 to 44 years.
Rates are sums of birthrates for five-year age groups multiplied by 5.
c
Includes races other than white and black.
d
Persons of Hispanic origin may be of any race. Rates are based on births and population in 48 states and the District
of Columbia; New Hampshire and Oklahoma did not report Hispanic origin on the birth certificate.
e
Comprising persons of Puerto Rican origin residing in the 50 states and the District of Columbia.
f
Includes Central and South American infants (83,008) and other and unknown Hispanic infants (56,307).
g
Comprising primarily Southeast Asian and Asian Indian Americans.
h
lncludes persons for whom origin was not stated.
b
Source: Centers for Disease Control and Prevention. Childbearing patterns among selected racial/ethnic minority groups—United States,
1990. Morbidity and Mortality Weekly Report (May 28,1993) 42,20:398-403.
comparison, non-Latino whites increased
by 4.4% and black Americans, by 13.2%.
Asians showed the largest percentage increase at 107.8%, although the absolute
number of persons was smaller.
Table 1 shows U.S. fertility rates for
1990. For the United States as a whole, the
fertility rate was 70.9 per 1,000 women of
childbearing age. Latinos’ fertility rate
(107.7) was about 71% higher than that
for white non-Latinos (62.8). Among Latino subgroups, Mexican Americans had
the highest fertility rate (118.9).
As noted above, the Latino population
in the United States is diverse. Figure 1
depicts the composition of the Latino
population by subgroup, based on country
of origin.4 Data from the Latino National
Political Survey5 indicate that individuals
of Latino heritage prefer to identify themselves by a national-origin-based term
rather than by a more pan-ethnic Latino
or Hispanic label.
Between 1980 and 1990, population
growth varied by subgroup, with the largest increase in absolute numbers in the
Mexican population, which increased by
4.8 million. The high level of growth in the
Latino population is projected to continue into the next century. The Census Bu-
46
of all illegal immigrants were from Mexico.
Unofficial 1993 estimates by the U.S. Bureau of the Census showed that 52.1% of
the undocumented population lived in
California, 13% lived in Texas, and 9.3%
lived in New York.6 It is not known how
many undocumented residents are children. A 1987 study8 reported that 70.5%
of the counted undocumented population
was aged 15 to 44. In the young adult ages,
there was a marked excess of males, particularly of those born in Mexico; for ages
15 to 34, 57.5% of undocumented Mexicans were males. About 20% of those from
Mexico were children under age 15, suggesting that many of those counted in the
census are in families which have established residence in the United States.
Figure 1
Latino Population in the United States by
Country of Origin, 1992
Other
7%
Cuban
5%
Puerto Rican
11%
Central/South American
14%
Mexican
63%
Source: U.S. Bureau of the Census, The Hispanic population in the United States: March
1992. Current Population Reports, Series P-20, No. 465RV. Washington, DC: U.S. Government Printing Office, 1993.
reau indicates that Latinos may be 11% of
the population in the year 2000, 13% in
2010, 17% in 2030, and 21% in 2050.1 (See
Figure 2.)
Undocumented Immigrants
The exact number of Latinos who are undocumented immigrants (“illegal aliens”)
in the United States at any given time is not
known. A number of estimates have been
made; these are necessarily speculative
and preliminary. Unofficial estimates from
the U.S. Bureau of the Census put the total
number of illegal immigrants at about 4
million persons as of April 1993.6 According to the U.S. Immigration and Naturalization Service (INS), the number was
about 3.2 million in October 1992.7 Net
growth in the undocumented population
is estimated at 250,000 to 300,000 per
year.6 The U.S. Bureau of the Census estimates that at least 50% of all undocumented immigrants in the United States
are of Hispanic origin—a total of about 2
million. Undocumented persons of Hispanic origin are primarily from Mexico, El
Salvador, and Guatemala;7 persons from
Puerto Rico do not fall into this category.
In 1992, the INS estimated that slightly
more than 30%, or just over one million,
The Census Bureau is currently working in conjunction with the INS to update
their estimates using data from the Immigration Reform and Control Act (IRCA)
of 1986, which allowed persons who remain in the United States illegally and who
arrived before January 1982 to register
with impunity, and other indirect sources
of information.
It is estimated that, of the 3 million
immigrants provided amnesty through the
Immigration Reform and Control Act of
1986, nearly 1.6 million were in California.
The demographic data on this group of
immigrants as of 1990 show that 4.9% were
less than 14 years, and another 5.5% were
between 14 and 17 years. These are children belonging to families that were in the
United States prior to 1982 or families that
had worked in agriculture for at least 90
days in each of the three years prior to
1986. Therefore, it is likely that the proportion of new undocumented immigrants who are children is probably
around 10%.
It should be noted that research on
health needs of Latinos generally has not
differentiated between those who are U.S.
citizens and those who are undocumented
immigrants; thus, it is unknown how many
undocumented residents are included in
the studies. For example, the Hispanic
Health and Nutrition Examination Survey
(HHANES) did not ask whether or not
participants were legal residents. It may be
assumed that HHANES probably included
many who were undocumented. It is reasonable to assume that the needs of this
population are similar to those of other
Latinos living in poverty. Further, while
the parents may be undocumented, some
47
Box 1
Caring for Undocumented Children:
A Personal Perspective
The use of public services for children of undocumented immigrants is currently a
front-line political issue. Many have difficulty understanding why tax revenues should
be used to provide health and educational services to children who do not belong
in this country. A more humanitarian approach acknowledges that children do not
have control over where they reside and therefore should not be punished by having
services withheld because they are “illegal.” Still others take the public health
perspective that illnesses left untreated will likely become worse and may increase
the risk for illness among others; therefore, provision of health services to children of
undocumented adults is good public health policy.
Yet in the current atmosphere of political debate involving health care reform,
support for health care for undocumented children has not been prominent. Rather,
the undocumented workers and their children have become political untouchables,
viewed as the cause of unemployment, increased government spending, and
increased crime. While none of these views can be well supported, immigrants often
become scapegoats during economically troubled times.
In reality, much of what is legal or illegal in terms of immigration is determined by
the needs of the host country at the time policies are set. In this instance, especially
in the Southwest and specifically in California, the need has been for cheap labor
for agriculture. At the turn of the century, Mexicans immigrated to California to work
in the fields. It was agriculture that made California a leading economic power in
the United States and provided the basis for its subsequent technological development. Many of these Mexican field workers were undocumented, but when they
were working in the fields doing back-breaking labor, many times with their children,
no one asked for their papers. When they were paid less than the minimum wage
but were charged excessive prices for food and shelter, no one asked whether they
were detracting from the state’s economy. And when their children attended
segregated schools and rarely received basic health care, no one asked whether
they were underutilizing the social services they were entitled to.
Today, undocumented Mexican immigrants continue to provide the cheap labor
needed to support the economy of California and other states. However, they are
not only working in the fields, but also tending our gardens, cleaning our homes,
making and serving our food, and taking care of our children. A recent report by
the Amnesty Education Unit of the Chancellor’s Office of California Community
Colleges shows that they are 5% of California’s population but make up 12% of the
work force. Even more remarkable findings were that 89% worked (compared with
53% of all Californians), and of those who worked most held more than one job
(compared with 6% of all Californians). Yet, the average annual income for these
immigrants was $11,400 compared with $24,921 for all Californians.
Even with these hardships, immigrants from Mexico and other countries continued
to come to the United States, documented and undocumented, because they
believed that, by coming to this country, they could invest in the futures of their
children and their children’s children. Although society as a whole denied them, they
believed in themselves and their families. Today, the children of Mexican immigrants
are the teachers, doctors, lawyers, and business people who are on the verge of
leading this country into the twenty-first century. Like many others of Mexican
descent, I am thankful to my grandparents and parents for their sacrifices. So when
I see the faces of children of the new immigrants, whether documented or undocumented, rich or poor, of color or not, I see the future and understand the importance
of their success.
—F.S.M.
* Source: Amnesty Education Unit. The new Californians: Ten facts about immigration amnesty
applicants. Sacramento, CA: Chancellor’s Office, California Community Colleges, June 1,
1992.
48
Figure 2
Hispanic Population Growth, United States, 1970 to 2050
1970
1980
1990
1992
2000
2010
2020
2030
a
2040
2050
Year
a
From 1992 on the figures are based on middle series projections.
Sources: U.S. Bureau of the Census. 1970 census of population: Persons of Spanish origin. PC(2)1C. Washington, DC:
U.S. Government Printing Office, 1973; U.S. Bureau of the Census. 1980 census of population: General social and
economic characteristics. PC80-S1-7. Washington, DC: U.S. Government Printing Office, 1984; U.S. Bureau of the
Census. U.S. Department of Commerce News. CB91-100. Washington, DC: U.S. Government Printing Office, 1991;
U.S. Bureau of the Census. Population projections of the United States, by age, sex, race, and Hispanic origin: 1992
to 2050. Current Population Reports, Series P-25, No. 1092. Washington, DC: U.S. Government Printing Office, 1992.
or all of the children may have been born
in the United States and may, therefore,
be U.S. citizens.
census, 63% of Latino families had children under 18 living with the family, compared with 47% of non-Latino families.
Age Structure
Geographic Distribution
The Latino population is a relatively
youthful one (see Figure 3). According to
the U.S. Census Bureau, about 30% of
Latinos are under age 15, compared with
only 20% of the non-Hispanic white population. In 1992, the median age of Latinos was 26 years, compared with 34 years
among non-Latino persons.4 Among Latino subgroups, persons of Cuban origin
were oldest, with a median age of 40
years, and persons of Mexican origin were
the youngest, with a median age of 24
years. These distinctions suggest differing
health-related needs among subgroups.
While issues relating to children have particular urgency for Mexican and Puerto
Rican families, Cuban Americans—like
non-Latino whites—will soon require attention to their growing group of elderly.
Although Latinos live in every state, almost
90% of all Latinos live in 10 states (Figure
5). In particular, California is home to one
of every three Latinos, and Texas, to nearly
one of every five Latinos. In the Northeast,
much of the Latino population is located
in Massachusetts, New Jersey, and New
York. In the South, Florida is the state with
the most sizable Latino population, as are
Illinois in the Midwest and Arizona, Colorado, and New Mexico in the Southwest.
Latino families are more likely to have
children present than are non-Latino
families (Figure 4). According to the 1990
Of Latino subpopulations, those of
Mexican origin are most likely to live in
California and the southwestern states. A
substantial proportion of the Puerto Rican
population is located in the New York City
metropolitan area, and many of Cuban
origin are living in Florida. In addition,
significant populations of these subgroups
now live in other areas of the country (Figure 6). For example, more than 600,000
persons of Mexican origin live in Illinois,
49
Figure 3
Age of the Population, United States, 1990
Hispanic
Non-Hispanic
Sources: U.S. Bureau of the Census, Data User Services Division. 1990 census of population and housing. Summary
tape file 1C. Washington, DC, 1990; U.S. Bureau of the Census. The Hispanic population of the United States: March
1992. Current Population Reports, Series P-20, No. 465RV. Washington, DC: U.S. Government Printing Office, 1993.
primarily in the Chicago metropolitan
area. Many of Cuban descent live in California, New Jersey, and New York.
Income and Poverty
Latinos of all ages are more apt to live in
poverty than non-Latinos1 (Figure 7). In
1991, more than one in four Latinos
(28.8%) were living below the poverty level, compared with 12.9% of non-Latinos.
As Figure 7 shows, 41% of all Latino children live in poverty, twice the proportion
of non-Latino children living in poverty.
In 1992, while Latino children represented 11.6% of all children in the United
States, they were 21.5% of all children
living in poverty.4 And while Latinos are
now about 9% of the total population, they
are about 18% of all those living below
poverty level in the United States.
Table 2 shows how the Latino population compares with other ethnic groups in
terms of the proportion living in poverty.
Among the ethnic groups reported in the
census, Latinos rank second (black Americans are first) in terms of the proportion
in poverty.
Latino families were also more likely
than non-Latino families to live in poverty
50
Figure 4
Families with Own Children, United States, 1970 to
1990
class, legal status, educational levels, and
cultural norms. This is particularly true for
the first generation of immigrants, based
upon the history of their immigration and
experience as immigrants in this country.
These differences have an important bearing on current health status and will be
briefly described for each subpopulation.
Mexican
There is great variability in the population
of Mexican origin in the United States.
Persons of Mexican descent have lived in
the United States since the formation of
the country and may be U.S. citizens, legal
residents, or illegal immigrants.
1980
1970
1990
Year
Hispanic
Non-Hispanic
Sources: U.S. Bureau of the Census. 1970 census of population: Persons of Spanish origin.
PC(2)1C. Washington, DC: U.S. Government Printing Office, 1973; U.S. Bureau of the
Census. 1980 census of population: General social and economic characteristics. PC801-C1. Washington, DC: U.S. Government Printing Office, 1984; U.S. Bureau of the Census.
1990 census of population and housing. CP-1-1. U.S. Government Printing Office, 1992;
U.S. Bureau of the Census. Fertility of American women: June 1990. Current Population
Reports, Series P-20, No. 454. Washington, DC: U.S. Government Printing Office, 1991.
(Figure 8). Since 1989 the proportion of
Latino families living below the poverty
level has been rising (from 23.4% in 1989
to 26.5% in 1991). Similar increases were
not seen in the non-Latino population.
Among Latino subgroups, poverty rates
for families and children differ dramatically (Table 3). Puerto Rican families are
most likely to be living in poverty (35.6%),
and Cuban families are least likely (13.9%).
A brief look at the immigration history
of each ethnic subgroup will help to put
some of these population trends into perspective.
A Brief Historical Overview of Latino
Subpopulations
While Latinos share a common language
and, to some degree, common cultural
elements, there are differences among
and within subgroups that pertain to social
The recent history of Mexican immigration consists of two broad periods.9 The
first is from the turn of the century
through the mid-1960s. This period was
characterized by extreme fluctuations in
the number immigrating, depending on
the labor demand in the United States.
Most immigrants worked in agriculture,
meat packing, brickyards and canneries,
becoming the backbone of the work force
in these industries. Since the mid-1960s,
growing unemployment in Mexico and the
prospect of employment has led to increased immigration to the United States.
Many of the immigrants are undocumented and are working in low-paying jobs.
Puerto Rican
In contrast, Puerto Ricans have a very different history of immigration. Migration
for this subpopulation reflects the dependent relationship of the island, first as a U.S.
possession in 1898 and then as a commonwealth in 1952. It was after World War II
that the most significant migration to the
United States began. Most migrants moved
to the industrial centers of the eastern
seaboard, especially New York, where they
worked in the textile and garment industries; 50% of all mainland Puerto Ricans
reside in the New York City area. In addition, all Puerto Ricans are U.S. citizens,
which means that they are eligible for state
and federal health care programs. This
universal citizenship has resulted in a backand-forth migration between Puerto Rico
and the United States. Thus, Puerto Ricans
are particularly linked to their country of
origin even though they may reside in the
continental United States.
Cuban
Cuban immigration began after the 1959
Cuban Revolution, with political refugees. The early Cuban immigrants were
well educated and better off economically
51
Figure 5
Hispanic Population Growth for Selected States, 1990
(percentage distribution)
All other states
13.0%
Massachusetts 1.3%
Colorado 1.9%
New Mexico 2.6%
Arizona 3.1%
California
34.4%
New Jersey 3.3%
Illinois 4.0%
Florida
7.0%
New York
9.9%
Texas
19.4%
Source: U.S. Bureau of the Census. U.S. Department of Commerce News. CB91-100. Washington, DC: U.S. Government Printing Office, 1991.
than those who followed in later years.
Moreover, they were eligible for government refugee resettlement assistance,
which aided in the preservation of the
Cuban professional and middle classes.
Through political asylum, Cuban immigrants also qualified for citizenship quickly, further increasing their access to governmental programs. The support for resettlement and the geographic concentration in Florida, where at present
two-thirds of all Cuban Americans reside,
provided Cuban Americans with an economic and political base to develop their
community. Although many of the later
immigrants from Cuba to the United
States have been of lower socioeconomic
status, the Cuban-American community
has been able to maintain a better economic position than other Latino groups.
from the Dominican Republic who seek
to improve their economic condition. Unlike Cubans, Central Americans have not
been able to obtain ready political asylum.
Thus, many are illegal residents who do
not feel that they can return to their home
countries, leaving them as persons without a country.
Summary
Three factors emerge as critical in considering the health of Latino children in the
United States:
n the heterogeneity of the Latino population, including distinctive immigration
histories for each subgroup,
n the geographic concentration of specific Latino subgroups, and
Central/South American and Other
n the high rates of poverty among Latino
families and children.
The most recent arrivals are Latinos from
Central America who are fleeing political and economic turmoil, and those
All of these factors have a significant
bearing on the health status of Latino
children.
52
Figure 6
Percentage Hispanic of Total Population, by State, 1990
Sources: U.S. Bureau of the Census. 1980 census of population: General social and economic characteristics. PC80-S1-7. Washington, DC: U.S.
Government Printing Office, 1984; U.S. Bureau of the Census. U.S. Department of Commerce News. CB91-100. Washington, DC: U.S. Government Printing
Office, 1991.
Critical Health Issues for
Latino Children
To analyze what is known about the health
status of Latino children, we will examine
topics from a developmental point of view.
Significant issues arise in each developmental phase—infancy (0 to 24 months),
preschool age (2 to 4 years), school age (5
to 11 years), and adolescence (12 to 18
years). However, an important concern
for all age groups is access to health care.
This will be discussed first because it is an
issue that should be kept in mind when
considering specific health problems of
Latino children.
Access to Health Care
Latinos’ access to health care is an issue
that affects all age groups. Studies of
health care utilization by Latinos have
found that Latinos, particularly Mexican
Americans, have lower utilization of physician services than other ethnic groups.
For example, Trevino and Moss10 found
that about one-third of Mexican Americans did not visit a physician at all during
the course of a year. Only one-fourth of
non-Latinos, Cuban Americans, and
“other Hispanics” and one-fifth of Puerto
Ricans had no physician visits during the
course of a year.
In 1986, Andersen and colleagues reported that Latinos found it more difficult
than whites to get medical care in 1982,
were more often refused medical care for
financial reasons, and had less insurance
coverage than in previous years.11 More
Latinos than whites said they put off medical care in 1982 because they had less insurance, needed medical care that year but
did not get it, had a serious illness in the
family that caused a financial problem, had
medical emergencies, and were not satisfied with the medical care they received.
In 1986, the National Access Survey1 2
found that the proportion of Latinos who
53
Figure 7
Persons Below the Poverty Level by Age, United States, 1991
Total population
65 years and over
18 to 64 years
Under 18 years
Percentage of Total
Hispanic
Non-Hispanic
Source: U.S. Bureau of the Census. The Hispanic population in the United States. March 1992. Current Population
Reports, Series P-20, No. 465RV. Washington, DC: U.S. Government Printing Office, 1993.
reported fair or poor health increased
from 1982, although it decreased for
whites and blacks. The study found that
21.7% of Latinos were uninsured, a 50%
increase from 1982 and more than double
the rate for blacks and whites. The percentage of Latinos without a regular
source of health care was almost double
that for non-Latino whites.
In 1991, Trevino and colleagues13 analyzed data from two separate surveys: the
March 1989 Current Population Survey
(CPS) and the Hispanic Health and Nutrition Examination Survey (HHANES).
These data showed that, among all ethnic
groups in the United States, Latinos were
least likely to have insurance coverage
against losses due to illness. More than
one-third of the Mexican-American population, one-fifth of the Puerto Rican population, and one-fourth of the CubanAmerican population were uninsured for
medical expenditures. These percentages
compared with one-fifth of the black nonHispanic population and one-tenth of the
white non-Hispanic population. Among
the uninsured, most Mexican Americans
(53%) and Cuban Americans (60%), and
46% of Puerto Ricans were gainfully em-
Among all ethnic groups in the United
States, Latinos were least likely to
have insurance coverage against
losses due to illness.
ployed. Compared with Latinos with private health insurance, uninsured Latinos
were less likely to have a regular source of
health care, less likely to have visited a
physician in the past year, less likely to
have had a routine physical examination,
and less likely to rate their health status as
excellent or very good.
Valdez and colleagues14 note that Latinos, particularly Mexican Americans, are
uninsured because their primary employment is in the lower skilled and paid sec-
54
Figure 8
Families Below the Poverty Level, United States, 1981 to 1991
30
20
10
0
1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991
Year
Hispanic
Non-Hispanic
Source: U.S. Bureau of the Census. Poverty in the United States: 1991. Current Population Reports. Series P-60, No.
181. Washington, DC: U.S. Government Printing Office, 1992.
tors of the economy, which are less likely
to provide insurance coverage as a benefit.
Further, a large percentage of Latinos live
in states such as Texas and Florida, which
severely restrict eligibility for Medicaid
services and thereby increase the number
of uninsured. Even those who are eligible
for Medicaid have “access” difficulties because low reimbursement rates and payment delays limit the number of providers
who are willing to take Medicaid patients.
Valdez and colleagues found that, in 1989,
39% of Latinos under age 65, or 7.2 million persons, were uninsured for the entire year (Table 4). This rate was three
times higher than that for Anglos (nonLatino whites) and almost twice the rate
experienced by blacks. Among Latinos,
there was substantial variability by subgroup. Mexican Americans and Central
and South Americans experienced the
highest rates. The proportion of uninsured also varied by state because of differences in Medicaid coverages and by
geographic region (with highest rates in
the South and Southwest, Table 5). Most
individuals obtain their health insurance
coverage through employment, either di-
rectly or through a parent or spouse. Latinos had a higher concentration than
other ethnic groups in low-coverage industries and smaller firms, reducing their
likelihood of receiving health benefits.
Infant Health
Among the most widely used measures of
infant health in populations are infant
mortality and birth weight. What do we
know about these pregnancy outcome
measures in Latino populations?
Mortality
Only recently have infant mortality data on
Latinos in the United States been published. Before 1991, infant mortality risks
among Latinos had not been evaluated at
the national level. In 1991, Becerra and
colleagues15 analyzed the 1983 and 1984
Linked Birth and Infant Death data sets,
providing the first national assessment of
Latino infant mortality.
As Table 6 shows, Latino neonatal (less
than 27 days) and infant (28 to 364 days)
mortality rates overall are much lower
than those of black Americans and approximate the rates of the non-Hispanic
55
Table 2
Persons Below Poverty Level, 1991
Persons
Percentage Below Poverty Level
Total
14.2
Hispanic
Non-Hispanic white
Asian and Pacific islander
Black
28.7
9.4
13.8
32.7
Source: U.S. Bureau of the Census. Poverty in the United States: 1991. Current Population Reports, Series P-60, No. 181.
Washington, DC: U.S. Government Printing Office, 1992.
white population. These rates are lower
than might be expected given the high
rates of poverty among Latinos, since morbidity and mortality are often associated
with poverty. When Latino subgroups are
examined, rates for Latinos of Mexican
and Cuban origin are the same as or even
lower than those for non-Hispanic whites.
However, Puerto Ricans have rates that are
significantly higher (7.9 and 11.6 for neonatal and infant mortality, respectively)
than those of non-Hispanic whites. Except
for Puerto Ricans, Latinos in all subgroups
who were born outside the continental
United States had slightly lower mortality
rates than those born in the continental
United States.
Low Birth Weight and Preterm Birth
In a 1993 study of final natality statistics for
1991, Ventura and Martin16 found that
rates of low birth weight (LBW)—that is,
less than 2,500 grams—were 6.1% among
all Hispanic infants, 5.7% among nonHispanic white infants, and 13.6% among
non-Hispanic black infants. Rates of low
birth weight, like neonatal and infant
mortality rates, varied within the Hispanic
population. Among infants born in the
continental United States, the low birth
weight rate was highest among infants of
Puerto Rican descent (7.9%) and lowest
among those of Cuban origin (4.8%). The
low birth weight rate among single-delivery
infants born in Puerto Rico was 8.3%.
Mendoza and colleagues17 examined
data from the 1987 National Vital Statistics
System and the Hispanic Health and Nutrition Examination Survey (1982 through
1984), comparing incidence of low birth
weight among Mexican, Puerto Rican, and
Cuban infants by nativity status of the
mother and by the trimester when prenatal
care was begun. Overall, the low birth
weight rate for Latinos (7.0%) was higher than that for non-Hispanic white infants (5.6%) but lower than that for nonHispanic black infants (12.9%). However,
rates among Latino subgroups again
showed differences. Rates were lowest for
infants of Mexican and Cuban origin
(5.7% and 5.9%, respectively) and highest
for Puerto Rican infants (9.3%).
Overall, Latinos had a higher rate of
preterm births (less than 37 weeks gestation) than non-Latino whites for women
over 20 years of age (10.5% and 7.9%, respectively). However, when comparisons
between Latino subgroups were made, differences emerged. Women of Cuban descent had a preterm birth rate of 8.7%,
while those of Mexican descent had a rate
of 10.5%, and those of Puerto Rican origin,
a rate of 12.1%. Black women had a rate of
17.3%. Among all groups, the incidence of
preterm birth was found to be associated
with the timing of prenatal care.
Mendoza and colleagues observed
that prenatal care seemed to have the
least effect on the prevalence of low birth
weight for mothers of Mexican origin.
Latino neonatal and infant mortality rates
overall are much lower than those of black
Americans and approximate the rates of
the non-Hispanic white population.
Even with no prenatal care or care begun in the third trimester, only 7.2% of
mothers had low birth weight infants.
This compares with 9.5% for non-Latino
56
Table 3
Poverty Rates for Latino Families and Children, 1991
Ethnicity
Families Below
Poverty Level
Female-Headed
Families Below
Poverty Level
Children Below
Poverty Level
Percentage
Latino
Mexican
Puerto Rican
Cuban
Central/South
American
Non-Latino white
26.5
27.4
35.6
13.9
23.9
49.7
47.7
66.3
—
42.9
40.4
39.7
57.9
33.3
33.4
7.1
24.6
13.1
Source: U.S. Bureau of the Census. The Hispanic population in the United States: March 1992. Current Population
Reports, Series P-20, No. 465RV. Washington, DC: U.S. Government Printing Office, 1993, pp. 16-17, 20-21.
whites with the same care pattern. This
finding is important because women of
Mexican descent are least likely to utilize
prenatal care; approximately 40% do not
start prenatal care in the first trimester,
and 13% receive late or no prenatal care.18
Reasons for the lower-than-expected
rate of low birth weight among women of
Mexican origin are unknown. Health behaviors during pregnancy have been suggested as a possible explanation, but
further research is needed to identify specific behaviors or other factors that may
contribute to this finding. For example,
while Mexican-American women have a
lower rate of cigarette smoking, Shiono
and colleagues19 found that this fact is not
responsible for their low rate of low birth
weight. It has been suggested that, although low birth weight has been a principal means for assessing pregnancy outcome, it may not adequately indicate infant health status for some populations.20
Other Parameters
Information available on other parameters of infant health among Latinos is
limited. The Hispanic Health and Nutrition Examination Survey (HHANES), conducted by the National Center for Health
Statistics in 1982-1984, was the first comprehensive health survey of Mexican
Americans in the Southwest, Puerto Ricans
living in NewYork City, and Cuban Americans residing in Miami. Before HHANES,
data on Latino children were limited to results of small clinical studies and regional
epidemiologic studies.21
Congenital Anomalies
Among Latinos, congenital anomalies do
not appear to occur at a greater rate than
for non-Latino whites. Approximately 2%
of newborn infants are born with a major
malformation, and another 3% have
anomalies found later in childhood.22
Data from HHANES showed that, among
Mexican-American, Cuban-American, and
Puerto Rican children living in the continental United States, 0.5% or less had a
known or physically visible congenital
anomaly.20 Chavez and colleagues analyzed data from the Birth Defect Monitoring Program of the Center for Disease
Control and Prevention and found that,
overall, Latinos had fewer congenital
anomalies (14.4 per 1,000) than did nonLatino whites (18.9 per 1,000) or blacks
(17.9 per 1,000).23
For Mexican-American children, only
1 per 1,000 live births had Down’s syndrome, a rate slightly lower than that for
the non-Latino white population (1 per
600 to 800 live births).23 Because data on
congenital anomalies causing fetal or
neonatal death are not currently available, conclusions about risks for congenital anomalies among Latinos must be
guarded. In 1989, the U.S. Standard Certificate of Live Births was modified by the
National Center for Health Statistics both
to increase the data base concerning live
births and to improve the data on Latinos
and other minorities.24 Beginning with
the 1989 data year, the information should
be available on almost all births in the
United States each year. More complete
57
Table 4
Proportion of Uninsured Nonelderly (<65-Year-Old) Residents in the United States by
a
Year and Ethnicity
Ethnicity b
1989
1979
Change
Number
(x1000)
Percentage
Number
(x1000)
Percentage
Number
(x1000)
Percentage
All United States
28,703
14.8
37,739
17.5
9,036
31.5
Latino
Mexican
Puerto Rican
Cuban
Otherc
2,860
2,119
291
165
285
25.7
27.8
16.5
22.1
28.9
7,177
5,301
463
192
1,221
39.0
41.6
22.6
22.1
44.3
4,317
3,182
172
27
936
150.9
150.2
59.1
16.4
328.4
Anglo
19,716
12.7
22,281
13.8
2,565
13.0
Black
5,236
22.7
6,584
24.0
1,348
25.7
891
22.1
1,695
21.8
804
90.2
Asian and other
a
Sources of data were March 1980 and 1990 Current Population Surveys.
Latino indicates Hispanics of any race from the Western hemisphere; Anglo, the non-Hispanic white population and Hispanics
of European country of origin; black, the non-Hispanic black population or African Americans; and Asian and other, the
remainder of the non-Hispanic population, which is composed primarily of peoples of Asian heritage.
c
Other Latinos include Central and South Americans.
b
Source: Valdez, R.B., Morgenstern, H., Brown, E.R., et al. Insuring Latinos against the costs of illness. Journal of the American Medical Association
(February 1993) 269,7:891.
data and, thus, more accurate conclusions
about the prevalence of congenital anomalies and other conditions should result.
Growth and Nutrition
The growth patterns of Latino infants (0
to 24 months) are difficult to assess because of the lack of longitudinal data.
Cross-sectional data from HHANES are
available for 12-, 24-, and 36-month-old
children. These data suggest that, through
infancy and early childhood, Latino children—specifically Mexican-American
and Puerto Rican children living in the
continental United States—have growth
patterns similar to those for non-Latino
whites.25 Yet clinical studies report high
rates of failure to thrive among poor Latino children.26 Most of these studies drew
their samples from public facilities that
may be treating a poor population of children, those who are new immigrants with
limited access to health and nutritional
programs, and those whose families may
be in a tenuous socioeconomic situation.
Nutritional data from the HHANES
show that the prevalence of iron deficiency
anemia is less than 2% among MexicanAmerican, mainland Puerto Rican, and
Cuban-American infants 0 to 2 years.27
An evaluation of the dietary intake of infants found that Mexican-American infants 1 to 2 years were most deficient in
intakes of fruits and vegetables and least
deficient in milk intake.28 Last, of note
in the Mexican-American sample from
HHANES, 49% of eligible children less
than 2 years of age had received nutritional supplements from the Women, Infants, and Children (WIC) program.29
Overall, although some growth and nutritional findings indicate that Latino
infants are doing fairly well, others still
suggest that the quality of diets available
to these infants and their access to nutritional supplement programs may be lacking. Moreover, the demographics of this
population of children imply that their
economic resources are not sufficient to
meet adequate housing and food needs.
This alone should be sufficient reason to
give high priority to nutritional programs
for Latino infants.
58
Table 5
Health Insurance Coverage in the Nine States with the Largest
a
Latino Nonelderly Populations in 1989
State
Total (x1000)
Proportion of Nonelderly Latino Population,
Percentage
Uninsured
Medicaid
Other
lnsuredb
All United States
18,422
39.0
11.8
49.2
California
Texas
New York
Florida
Illinois
New Jersey
Connecticut
Washington
Michigan
6,944
3,980
1,727
1,331
828
533
123
106
100
43.7
47.6
31.0
36.5
22.9
28.1
13.5
23.3
12.5
11.0
7.8
26.2
6.7
12.0
10.5
11.5
20.3
25.5
45.3
44.6
42.8
56.8
65.2
61.5
75.0
56.4
62.1
a
Source of data was March 1990 Current Population Survey.
Other insured category includes group and individual coverage, as well as some Medicare
coverage.
b
Source: Valdez, R.B., Morgenstern, H., Brown, E.R., et al. Insuring Latinos against the costs of illness. Journal of the
American Medical Association (February 1993) 269,7:892.
Developmental Issues
Developmental problems during infancy
are always of concern because they may be
the antecedents of significant functional
impairment for preschool and school-age
children. At present, there is very little
documented epidemiologic data on the
prevalence of significant developmental
problems among Latino infants.
Parental reports in the HHANES indicated that approximately 0.2% of MexicanAmerican and mainland Puerto Rican
children, ages 6 months to 4 years, had
mental retardation.25,30 It is not possible
to determine if the mental retardation of
these children is mild, moderate, or severe. Among the general population of
children, 3% have some degree of mental
retardation, and approximately 0.15%
have severe retardation.22
Speech problems were reported by
parents in HHANES for 2.3% of MexicanAmerican and 1.3% of mainland Puerto
Rican children 6 months to 4 years.30 One
could speculate that the parental reports
in the HHANES may underestimate the
developmental problems among Latino
children because such a high proportion
of persons are uninsured and, therefore,
may not have had access to a physician for
diagnosis. Future studies are needed to
both estimate and validate the prevalence
of developmental problems among Latino
children.
Infectious Diseases
Infectious diseases are of particular concern in Latino infants because of adverse
environmental conditions associated with
poverty, lack of immunizations, and limited access to health care. Latinos appear
to be at higher risk of common childhood
illnesses preventable by immunization
than members of other ethnic groups.31
For example, in Los Angeles County, California, in 1988 Latinos’ risk of measles was
3.6 times greater than for black children
and 12.6 times greater than for non-Latino
white children. An overrepresentation of
Latinos was documented in periodic measles outbreaks in the United States during
the 1980s. As a result of a lack of rubella
immunizations among susceptible women
in their childbearing years, increased rates
of rubella and congenital rubella syndrome were reported in New York City in
1986.31
In 1990, low rates of immunization
among Latino children were documented
by the Children and Youth Policy Project.
Among Latino infants, only 34.6% had
59
Table 6
a
U.S. Neonatal and Infant Mortality Risks by Ethnicity, 1983 – 84
Ethnicity
Neonatal Mortality
Infant Mortality
5.2
8.3
10.9
17.2
5.6
5.2
7.9
5.0
5.5
8.7
8.3
11.6
7.0
8.4
Non-Hispanic white
Black
Hispanic
Mexican
Puerto Rican
Cuban
Otherb
a
Risks calculated per 1,000 live births.
lncludes Central American, South American, and other Spanish ethnic origin.
b
Source: Becerra, J.E., Hogue, C.J.R., Atrash, J.K., and Perez, N. Infant mortality among Hispanics: A portrait of
heterogeneity. Journal of the American Medical Association (January 1991) 265,2:217.
adequate immunizations by 2 years of age,
and only 11.8% of immigrant Latino infants were immunized fully by 2 years of
age. Non-Latino whites were immunized
at a rate of 47.3%, and blacks at a rate of
20.0%.
An increase in HIV infection and AIDS
among Latina women has resulted in an
increased incidence of AIDS among their
infants. Latina women account for 20.8%
of the reported AIDS cases among U.S.
women but comprise only 8.6% of the U.S.
female population. 32 Twenty-four percent
of childhood AIDS cases are Latino children, although Latino children comprise
only 13% of U.S. children. Puerto Ricans
seem to be disproportionately affected
compared with other Latino subgroups.
The greatest number of Latino pediatric
AIDS cases are in New York City, followed
by Puerto Rico. Perinatal transmission accounts for 88% of pediatric AIDS cases
among Latino infants.32
These figures make clear the need for
aggressive and effective health education
for Latinos, particularly for women of
childbearing age. Latino women and men,
especially youth and young adults, need
education on how their behavior might
affect themselves and others, including
those who are unborn.
Chronic Illness and Unintentional Injury
Mortality from chronic illnesses and unintentional injury is difficult to estimate
for Latino infants because of the lack of
ethnic-specific mortality data. Recently,
the National Center for Health Statistics
(NCHS) and the Centers for Disease Control and Prevention (CDC) have begun to
obtain ethnic-specific mortality data. 33
This information will greatly improve our
knowledge in this area. At present, the
rates of chronic medical conditions among
Latino infants do not appear to be higher
than those for non-Latino white infants.34
Summary
It is premature to describe with any certainty the health and developmental status
of Latino infants. Clearly, we need to improve our knowledge about health issues
in this population. In the meantime, because infancy is the most critical time with
An increase in HIV infection and
AIDS among Latina women has
resulted in an increased incidence
of AIDS among their infants.
respect to the rapidity of physical and developmental growth, programs such as
WIC and immunization programs seem
appropriate and needed, as is general access to health care.
Preschool-Age Children
The preschool-age period, from two to five
years of age, is a unique and critical time
in a child’s life. Although the rate of physical growth of children slows somewhat,
their rate of cognitive, psychological, and
60
Table 7
Percentage of Children and Adolescents Rated in Poor Health
MexicanAmerican
Mainland
Puerto Rican
CubanAmerican
Intergroup
Differencea
Mothers of children
6 months to 11 years
14.1
19.9
6.7c
p<.01
Mothers of adolescents
12 to 18 years
16.9
20.1b
8.4c
NS
Children
6 to 11 years
11.4
15.2b
16.5c
NS
Adolescents
12 to 18 years
18.7
17.0
7.5c
NS
a
By chi-square adjusted for sample weights and complex sample design.
Population estimate does not meet usual reliability standards and can be used only for an approximation
of true population estimates.
c
Population estimate is unreliable and, therefore, estimate only reflects attributes of examined subjects.
b
Source: Mendoza, F.S., Martorell, R., and Castillo, R.O. lnterim report—Health and nutritional status of Mexican-American
children. Grant No. MCJ-060518. Rockville, MD: Maternal and Child Health Research Program, Bureau of Maternal and Child
Health and Resources Development, 1989, p. 110.
social development continues at a rapid
pace. Preschool children are more interactive with their environment than infants,
and this activity can have both positive and
negative consequences. For example,
problems resulting from exposure to environmental toxins such as lead become
critical at this age. Unintentional injuries
also become more common.
Although the environment holds risks
to children’s health, the environment also
provides the stimulation so necessary for
cognitive development. It is during this
period that children begin to experience
organized learning with other children, in
either formal or informal settings. The
preschool period is when children begin
to develop independence from their parents and begin to develop their own selfawareness and identity.
Health and developmental problems
that manifest themselves during infancy
and receive little or no treatment may
continue into the preschool years. Such
chronic problems may affect a young
child’s health and development during
these years. Moreover, children living in
impoverished environments—first as infants, then as preschoolers—may require
even more health services than the family
and local health agencies are able to provide. Forty-two percent of Latino children
in this age group are living in poverty. 35
Twenty-nine percent live in single-parent
families, and 30% are without health insurance.35 These figures demonstrate the
limited resources available to Latino preschool children and their families.
The growth of children traditionally has
been a measure of children’s overall wellbeing. Although Latino children demonstrate average weight gains during the
preschool years, their linear growth, or
height, is somewhat stunted. It is linear
growth that best measures overall growth
of children and that is best for comparing one population with another. While
linear growth, or stature, of individual
children can be affected by genetic factors,
for most populations of children, poor
nutrition and recurrent illness are the
major factors causing poor linear growth
and leading to populations of shorter
children.36
In contrast, a child’s weight can be
affected by similar factors but is more
likely to show catch-up growth. Indeed, for
Mexican-American children in particular,
weights seem to be less affected by poverty than their heights. Martorell and
colleagues37 found that, for MexicanAmerican children two to five years old in
the HHANES, poverty or socioeconomic
status was a major determinant of children’s stature. Children of Mexican origin
were about 2 centimeters shorter on the
61
Table 8
Projected Percentage Reduction in the Uninsured Rates Under Different
a
Strategies for Covering the Uninsured by Ethnicity
Strategy
Percentage uninsured in 1989
Total
United
States
Latino
Anglo
Black
Asian
and
Other
17.5
39.0
13.8
24.0
21.8
Projected Percentage Reduction
Poor (<1.0 PI)
29
37
23
42
25
All children (<18 years)
34
36
33
37
33
Full-time workers
18
21
19
16
17
Full-time workers and minor dependents
34
39
34
32
30
Full-time/part-time workers
22
23
23
20
20
Full-time/part-time workers and dependents
41
44
41
38
38
Full-time workers and poor
46
54
40
56
40
a
Source of data was March 1990 Current Population Survey. PI indicates Poverty Index.
Source: Valdez, R.B., Morgenstern, H., and Brown, E.R., et al. Insuring Latinos against the costs of illness. Journal of the American Medical
Association (February 1993) 269,7:894.
average than the U.S. norm. Their findings indicate that, if these children were
not living in poverty, their heights and
overall growth would be similar to that of
the average U.S. child.
One reason for slower growth may be
poor nutritional intake. One study of the
Central Valley in California found that
one in eight children was going hungry;
most of these children were poor and
Latino. Nutritional supplement programs
such as WIC usually are not available to
children older than two or three years of
age because of the limited resources of
this program. Food stamp distribution to
families is also dependent upon legal residency status and, therefore, may not be
meeting the needs of all Latino children.
Latino children three to five years old
were found in one study to have poor
intakes of fruits and vegetables, and high
28
intakes of fat and sugar. According to
the HHANES, iron deficiency anemia was
present in only 0.5% of Mexican-American
and 1.3% of mainland Puerto Rican preschoolers assessed. These rates compare
with the national rate of 5%.38
Chronic Medical Conditions
Unlike growth and nutrition, chronic
medical conditions among preschoolers
do not appear to vary with poverty levels. According to the HHANES, 2.3% of
Mexican-American, 7.4% of mainland
Puerto Rican, and less than 1% of
Cuban-American preschoolers had chronic medical conditions.34 Except for the
Mexican-American sample, in which
younger children had a lower prevalence
than older children, the rates of chronic
medical conditions for preschool, school
age, and adolescence were not significantly different. The conditions found included both physical and developmental
health problems. Both the overall rate of
chronic medical conditions and the types
of conditions were similar to those of nonLatino whites, except for a higher prevalence among the mainland Puerto Rican
children. Among mainland Puerto Rican
children sampled in the HHANES who
had a chronic medical condition, 62%
had asthma. A similar high rate of asthma
has been noted in Puerto Rico.39 If the
cases of asthma were eliminated from the
Puerto Rican sample, the prevalence of
62
chronic medical conditions among Puerto
Rican children would be similar to or lower
than that of the non-Latino white population (5%).
Parental Perceptions of Children’s Health
Another way of measuring overall health
is to obtain the assessment of a parent.
When a parent categorizes a child’s health
as excellent, very good, good, fair, or
poor, important insight is obtained about
the parent’s perspective of health. While
this perspective may be influenced by a
variety of factors, such as socioeconomic
status, cultural perspective, or prior experiences with the health care system, it
still may provide the best global assessment of the child’s functional health status, answering the question, “Is the child
doing well or not?”
The physical environment of poverty
can have a direct health and developmental effect on Latino children.
In the 1984 National Health Interview
Survey conducted on a national probability
sample by the National Center for Health
Statistics,40 3% of non-Latino white mothers stated that their children were in fair
to poor health. About 5% of black mothers
reported their children to be in fair or
poor health. Among preschool children
sampled in HHANES, 11.3% of MexicanAmerican mothers, 15.7% of mainland
Puerto Rican mothers, and 2.4% of CubanAmerican mothers reported their children in poor health. These rates doubled
for children who lived in poverty and for
children whose home language was Spanish. Interestingly, the children who came
from bilingual homes had a rate that was
intermediate to the rates of children who
spoke English at home (lowest rate) and
those who spoke Spanish at home (highest
rate). This suggests that a cultural influence, in addition to the socioeconomic,
may be affecting mothers’ perception of
children’s health status.
Latina mothers who perceived their
own health as poor were more likely to perceive their children’s health as poor. Most
important, if Latina mothers perceive
their children to have poor health, then
their children appear to have increased
utilization of health care services.41 How-
ever, questions remain. Does increased maternal concern about a child’s health support or detract from the child’s health and
developmental status? Does increased
health care utilization improve the child’s
health or label him or her as a vulnerable
child? We need to understand the determinants of this perception among the mothers. Because policies and interventions involving preschoolers must involve parents,
a better understanding of the parental perspective of risk for children is needed.
Exposure to Environmental Toxins
Exposure to environmental toxins can
have direct effects on the health and development of Latino preschoolers. Most
commonly, lead is the toxin of concern
because of its ubiquity and its now welldocumented effects on the developing
child, even at low levels of exposure. In
1990, Carter-Pokras and colleagues reported blood lead levels among 4- to 11year-old Mexican-American, Puerto Rican,
and Cuban-American children in
HHANES.42 Preschoolers were most at
risk, with 4.9% of Mexican-American and
10.6% of Puerto Rican preschoolers having
levels greater than 25 micrograms per deciliter (µg/dl). Fifteen percent of MexicanAmerican and 20.1% of Puerto Rican children had lead levels greater than 15 µg/dl.
(The current standard for an elevated lead
level is 15 mg/dl.) It might be expected
that Puerto Rican children would have
higher-than-normal lead levels because
they were principally sampled in the
HHANES from the New York City area.
Yet Mexican-Americans who were sampled in the southwestern United States also
showed significant levels. It is clear from
their data that the physical environment of
poverty can have a direct health and developmental effect on Latino children.
Exposure to pesticides has also been a
source of concern. Unfortunately, data on
this type of exposure are seriously lacking.
It is surmised that, because many of the
farmworkers in the United States are Latino, particularly in the midwestern and
western states, their children are at risk for
exposure to pesticides. The risk may be
compounded by substandard housing,
often located in close proximity to the
fields. Children may be sprayed inadvertently while they play outdoors in the vicinity of fields.43
Children may also be at risk while working in the fields. Wilk43 estimates that 25%
of farm labor is performed by children,
63
and young children frequently are in the
fields with their parents because of a lack
of child care. Pollack44 surveyed 50 children of migrant farmworkers in the state
of New York and found that 36% had been
sprayed in the fields, and 35% had been
sprayed while in their farm dwelling.
Moses45 has raised concerns about the
short- and long-term exposure to pesticides of the children of farmworkers and
the possible links to health and developmental problems, particularly cancers.
This area of research is vitally important
for Latino children who live in rural areas.
Summary
Latino preschoolers are at particular risk
of exposure to environmental toxins and
suffer from lack of access to medical care.
Some health problems are more likely to
occur within certain subgroups. For example, Puerto Rican children in this age
group have a higher rate of asthma.
School-Age Children
The health issues of school-age Latino children, ages 5 to 11 years, are, to some degree, a continuation of those previously
seen in the infancy and preschool periods.
Chronic Medical Conditions
The rate of chronic medical conditions
such as asthma does not change significantly during this period compared with
the preschool years. However, the increased demand on children to undertake
normal activities and become active learners requires that any morbidity or dysfunction arising from a chronic medical condition be minimized to have the least effect
on the child’s development. For example,
asthma can be effectively controlled to
minimize its effect on children. However,
lack of access to health care and insufficient funds to purchase needed medication and equipment can result in even
mild asthma causing significant morbidity
and mortality.46
The HHANES data showed differences
among Latino subgroups in medical treatment obtained for chronic medical conditions. Of Mexican-American children with
chronic conditions, 58% reported visiting
a physician in the past year, while 79% of
Puerto Rican children with chronic conditions visited a physician in the previous
year.34 This difference reflects the fact that
36% of Mexican-American children are
uninsured, while only 13% of mainland
Puerto Rican children are without health
insurance.35 Of all school-age Latino chil-
dren, one-third are uninsured. This compares with 14% of non-Latino white school
children. Thus, while the prevalence of
chronic conditions for Latino school-age
children is probably no greater than for
non-Latino whites, the lack of health care
is likely to have a particularly significant
impact on those who do have chronic
health problems.
Perceptions of Health Status
As noted above, how a person perceives his
or her health can be taken as an assessment
of overall functional health. The HHANES
queried half of all school-age children surveyed about their perception of their own
health. At the same time, the survey’s physicians were asked to make a global assessment of each child’s health.
Although the physicians assessed less
than 1% of school-age children’s health as
fair to poor, 11.4% of Mexican-American
and 15.2% of Puerto Rican school-age children rated themselves in fair to poor
health (Table 7).34 The proportions were
even higher for Spanish-speaking schoolage children, 25% for Mexican Americans
and 27% for mainland Puerto Ricans.30 It
is evident from these findings that schoolage Latino children have significant concerns about their health. Furthermore,
mothers’ ratings of school-age children
also showed high percentages concerned
about their children’s health. Seventeen
percent of Mexican-American and 23.3%
of Puerto Rican mothers believed that
their children were in poor health.
Differences between physicians’ assessments and mothers’ and children’s assessments of health status are difficult to
64
evaluate. Perhaps Latino children have
unmet health care needs. These could be
health problems that would respond to
medical treatment (for example, recurrent infections), or they could be health
concerns that are less amenable to medical
therapy (for example, stress-related disorders). Health problems in the latter group
may have cultural underpinnings and may
be affected by the family’s cultural perspective of health. This is not to say that
the conditions initiating these health concerns are not real. Rather, initiators for
these disorders may be the same as for
For Latino adolescents, several issues
emerge as critical: problems with growth
and nutrition, perceived poor health
status, high rates of infectious disease, and
high-risk behaviors that can have serious
consequences for health and well-being.
other, non-Latino patients (such as poverty, family disruption, or anxiety with a
life situation), but the symptoms may be
expressed differently by Latino patients. If
health care providers are unable to respond to these patient issues, then the
patients’ health care needs will not be met.
To accomplish this task requires that
health care providers, and health care systems, be culturally sensitive. In the final
analysis, it is this psychosocial connection
of health care providers to their patients
that is required to meet the health care
needs of patients. At the program level,
improving the situation for Latinos can be
accomplished by educating health care
providers about Latino culture(s) and increasing the number of persons from Latino backgrounds who enter the health
care professions.
Obesity
Perhaps most problematic to school-age
Latino children, for long-term health, is
the issue of obesity. Mexican-American
and Puerto Rican children are significantly more obese than non-Latino white children.37,47 Both of these Latino subgroups
show increased fat deposition in the
trunk, which has been linked with higher
cardiovascular disease risk in adults.47,48
Interestingly, despite this deposition of fat
in the trunk area, Mexican Americans may
have less heart disease than members of
other ethnic groups. 48 The higher prevalence of obesity among Mexican-American
and Puerto Rican children seems to start
as early as six to seven years of age and is
seen throughout adolescence and adulthood.47,48
The high rate of obesity is of concern
not only because of the potential risk for
cardiovascular disease, but because of its
link to Type II diabetes. Latinos, especially
Mexican Americans, are at high risk of
Type II diabetes, which is associated with
obesity. The prevalence of Type II diabetes
among Latinos is two to three times greater than that found among non-Hispanic
whites.49 At present, more than twice as
many Latino as non-Latino adults are
above the 95th percentile for weight, that
is, are considered obese.50
To avoid the morbidity associated with
obesity in adulthood, aggressive nutritional and physical exercise programs which
are culturally appropriate are needed for
school-age Latino children. That programs
be culturally appropriate is essential because of the importance of helping Latino
children maintain a positive self-image.
This is particularly true with respect to diet
manipulation, where cultural norms need
to be taken into account.
Summary
Among school-age children, obesity emerges as a problem of particular significance
for long-term health, which is added to
those previously described for the younger
age groups.
Adolescents
Adolescence is the transition from childhood into adulthood (ages 12 to 18 years).
For Latino adolescents, several issues
emerge as critical: problems with growth
and nutrition, perceived poor health
status, high rates of infectious disease, and
high-risk behaviors that can have serious
consequences for health and well-being.
In adolescence, it appears that Mexican
Americans and mainland Puerto Ricans
undergo less of a growth spurt than do
non-Latino white adolescents.37 The overall result is that Latino adolescents are
significantly shorter than non-Latino adolescents. Mexican Americans also are
somewhat delayed in their sexual maturation, while mainland Puerto Ricans are
similar to other U.S. adolescents.48
65
This stunting of linear growth for
Mexican Americans and Puerto Ricans
and possible delay in sexual maturation
for Mexican Americans may be the result
of poor nutrition. For example, MexicanAmerican adolescents report very poor
nutrient intake, with only 55% taking in
the recommended daily food group
requirements. In addition, MexicanAmerican and mainland Puerto Rican female adolescents have been found to have
the highest rates of iron deficiency anemia when compared with other age and
sex groups of Latinos.27 These data suggest that the quality of the diets of Latino
adolescents with respect to specific nutrients such as iron may not be adequate.
Like their younger cohort, Latino adolescents have high intakes of fats and
sugar, and these intakes most likely are the
underlying cause of the obesity noted
among Latino adolescents.47,50 The high
sugar content of Latino adolescents’ diets
may also be one reason that Latino adolescents, especially Mexican Americans, appear to have a higher prevalence of dental
caries and gingivitis, or gum inflammation, than the general population and a
greater need for dental care.51
Nutritional programs providing education and supplements are fairly limited for
adolescents in general and for Latino adolescents in particular. This is because the
limited resources available for nutritional
programs have been directed at younger
age groups. But with the high rates of poverty and the possible nutrition-related
health problems that are evident among
Latino adolescents, specific policies are
needed to improve the nutritional status
of this population. Beyond the growth and
dietary deficiencies noted above, inadequate diets and hunger among Latino adolescents may be compromising their ability to learn in school. Nutritional programs
could be one of the keys to improving
school performance, thus easing the transition of this group into the adult world.
Infectious Diseases and High-Risk Behaviors
The period of adolescence is a time when
high-risk health behaviors—including
early sexual activity, other behaviors increasing the risk of HIV infection, substance abuse, and violence—can result in
lifelong consequences. In particular, sexual activity of adolescents can put them at
risk of early pregnancy, as well as of infection with sexually transmitted diseases
(STDs). The most serious of these is infec-
tion with HIV and the development of
AIDS. Although Latinos comprise only
12% of 13- to 19-year-olds, they account for
18% of the cases of AIDS reported for this
age group.52
Throughout the 1980s, rates of gonorrhea decreased for all ethnic groups, including Latinos, although the decline was
slower among teenagers than among
other age groups. In 1991, Latinos were
found to be twice as likely to be infected
with gonorrhea as whites. However, Latinos experienced the largest decrease in
gonorrhea rates when compared with
either blacks or whites. The gonorrhea
rate for Latinos decreased by 60%, from
311.0 per 100,000 population in 1985 to
124.4 per 100,000 in 1990. Among whites,
the decrease was 64% (129.0 per 100,000
in 1985 and 45.8 in 1991). Among blacks,
the rate decreased by only 9% (from
1,972.6 in 1985 to 1,792.1 in 1991).
Latinos and blacks also suffer from
higher rates of primary and secondary
syphilis than whites. Syphilis rates are six
times as high among Latinos as whites
(12.6 per 100,000 population versus 2.0
per 100,000 in 1991). 52 In 1991, syphilis
rates for both whites and Latinos decreased, but for blacks they increased
alarmingly, by 141%.
Inadequate diets and hunger among
Latino adolescents may be compromising
their ability to learn in school.
In the past two to three decades, adolescent sexual activity has been rising, with
age at first intercourse decreasing and the
number of sexual partners increasing over
time.52 Yet high levels of sexual activity
have not been accompanied by consistent
use of condoms, which is one way to reduce the risks for HIV and STDs. A 1992
study analyzing condom use among 1,198
teenage males ages 15 to 19 in 1988 found
that Latinos were less likely to use condoms than either white or black teenagers.52 While Latinos had the fewest
sexual partners, they had intercourse
more often each month than blacks, but
less often than white teenagers.
Clearly, health awareness and prevention programs oriented to Latino adolescents are desperately needed.
66
Substance Abuse
Like other adolescents in the United
States, Latino adolescents are experiencing the problem of substance abuse. Both
legal substances (such as alcohol and tobacco) and illegal drugs (such as marijuana and cocaine) have resulted in serious
health problems for all adolescents, including Latinos. Results of a national survey reported in 1991 showed that alcohol
intake among Latino adolescents was
slightly higher than for non-Latino adolescents.53 Almost 23% of Latinos reported drinking in the past month compared
with approximately 20% of non-Latino
white adolescents, although Latinos reported less heavy drinking than the nonLatinos. According to the survey, about
10% of both Latino and non-Latino white
adolescents had used marijuana in the past
year. Latino adolescents reported less cigarette smoking (16.7% smoked during the
past year) than non-Latino white adolescents, among whom 23.2% smoked in the
past year.
The data available appear to indicate
that, while drug usage among Latinos may
be lower than that among non-Latino
whites during adolescence, it may be
higher during young adulthood.54 Chavez
and Swain55 suggest that the problem of
drug use among Latino adolescents may
Latino adolescents and young adults
have a rate of death from homicide
that is more than three times the rate
for non-Latino whites.
be underestimated because school-based
surveys fail to take dropouts into account.
It is clear that prevention and early intervention programs are needed and that
these must be sensitive to the cultural milieu of the adolescents.
Violence
Violence as a source of injury and death
has become a major public health problem, particularly for adolescents, in the
United States. While all adolescent males
are at risk for violence, poor, urban
young men of color (particularly Latino
and African-American) are at highest
risk.56 Only recently have national statistics on homicide for Latinos been published. During the period from 1979 to 1987,
Latino adult males were more than 3.5
times as likely to die from homicide as
non-Latino whites; Latino females were
twice as likely to be murdered as nonLatino whites.
Data published by the National Center
for Health Statistics 57 from 26 states in
1991 showed that Latino adolescents and
young adults have a rate of death from
homicide that is more than three times the
rate for non-Latino whites (28 per 100,000
population compared with 8 per 100,000
population). These data showed that unintentional injuries were the leading cause
of death for Latino adolescents.
Other data available also suggest the
magnitude of the problem for this segment of the population. For example, in
Los Angeles, California, from 1970 to 1979
the homicide rate of Latino males increased nearly 300%, from 9.1 to 32.6 per
100,000 population. The homicide rate
most likely varies according to the specific
subpopulation and community circumstances.56 Some of the violence is due to
gang activity. According to Prothrow-Stith,
gangs “speak loudly and clearly to the developmental issues of adolescents,” particularly when those needs are not being
met by their environment.56 Gangs provide a sense of community and of belonging. To be successful, violence prevention
strategies must be culturally specific and
age-appropriate; and they must include
the target population in the decisionmaking process.
Perceived Health Status
Perceived health status during adolescence is even worse than it was during the
school-age years (see Table 7). Almost
19% of Mexican-American adolescents report that their health is poor.34 This is
almost matched by the proportion of
mainland Puerto Rican adolescents (17%)
who report poor health. Only 7.5% of Cuban Americans perceive their health to be
poor; this proportion is similar to the percentage of non-Latino white adolescents
(almost 3%) who report that their health
is poor.57
An interesting finding is that almost
33% of Spanish-speaking adolescents believe that their health is poor. These high
rates of poor health perception among
Latino adolescents can be compared with
results of physician surveys of the same
population. Physicians reported that less
than 1% of the adolescents had fair to
poor health. We can only speculate on the
meaning of this discrepancy. Perhaps the
67
combined stresses of adolescence, poverty, and school result in a sense of poor
health. Further investigation of this topic
is needed to understand why Latino adolescents have this perception.
Access to Care
It is estimated that about 34% of Latino
adolescents do not have health insurance,
compared with only 13% of non-Latino
white adolescents.34 Among Latino adolescents, there is significant variability by subgroup. Thirty-seven percent of those of
Mexican descent lack health insurance,
while 11% of Puerto Rican adolescents
lack health insurance. Data from the
HHANES indicate that cost is the most
common barrier to health care for Latino
adolescents, and having a regular source
of health care is the best predictor of gaining access to care.58
Summary
Latino adolescents are particularly at risk
of morbidity and mortality due to high-risk
behaviors and other social causes such as
violence. These adolescents experience a
disproportionately high rate of AIDS and
have a much greater chance of dying from
homicide than do non-Latino white adolescents.
Conclusions and Policy
Implications
To fully evaluate the health risks faced by
Latino children and youth, more research
is needed. The establishment of data
bases, such as the new birth certificates,
will provide standardized information that
will help policymakers and planners determine priorities at national, state, and
local levels. A federal-level initiative
should be developed for obtaining data on
high-risk groups of children and adolescents; and this effort should be coordinated with state and local governments.
Health care reform will require local
health care systems to adjust to the needs
of their patient populations to maximize
efficiency. Clearly, collecting adequate information will be crucial to this process.
We know that adult Latinos have good
life expectancy, low mortality, and restricted intake of alcohol, tobacco, and
drugs among women, especially those who
are not acculturated to U.S. norms. Particular vulnerability exists in the area of
communicable diseases. Some of these infectious diseases can be prevented easily
and inexpensively through immunizations
or other measures. Others, such as HIV
infection and AIDS, are much more difficult to address. Latino families also are
subject to a variety of environmental risks
associated with occupational hazards or
poverty.
We have enough information to know
that in some areas, such as pregnancy outcome, we are faced with what has been
called an epidemiological paradox: Despite the presence of risk factors (late or
no prenatal care, and low-income and education levels), Latinos have relatively low
rates of infant mortality and low birth
weight. These and other health indicators
About 34% of Latino adolescents do
not have health insurance, compared
with only 13% of non-Latino white
adolescents.
have suggested to some researchers that,
despite high levels of poverty and low levels of educational attainment, the Latino
population does not conform to the “urban underclass” model that has formed
the basis of social policies addressing the
needs of poor and minority populations.59
Assumed characteristics of the underclass
include the following:
n
High rates of persistent poverty
n High rates of unemployment and low
labor force participation
n Accelerated family disintegration, with
males largely absent from the economic
and psychological life of the family
n High rates of welfare dependence
n Multiple health problems, including
low birth weight babies, high infant mortality rates, and increased mortality of adolescents from drugs and gang warfare
n Educational failure
n Alienation from major social institutions
Hayes-Bautista and colleagues59 argue
that Latinos do not fit this model because
they exhibit
n High labor force participation and low
labor force desertion
n
High rates of family formation
n Low welfare dependency
n Strong health indicators
68
n Strong educational improvement
n Strong sense of citizenship
Because of these discrepancies, they
conclude that the underclass model is inappropriate for developing social policy
relating to Latinos. Further research is
needed to articulate “protective mechanisms” that may cushion against the effects
of low-income and education levels, and
lack of access to care. Policies should be
developed that maintain and build upon
the strengths that Latinos bring to U.S.
society—in particular, the high cultural
value placed on health, family, and work.
In addition, what needs to be addressed
is lack of opportunity. One such opportunity is access to medical care. In particular,
the lack of health insurance coverage has
reached crisis proportions. Although Latinos have high rates of employment, they
suffer from a number of problems that
have a direct impact on their access to
health insurance. First, they tend to work
for small firms or in other industries that
typically do not offer their employees
health insurance. In addition, Latinos, especially Mexican Americans, have a greater
number of dependents per worker than
do Anglos or blacks, because of high birth
rates.
Valdez and colleagues14 considered
the effects of different strategies for
health care reform on Latino populations
and concluded that, no matter which strategy is employed, Latinos may still face major health care access difficulties (Table
8). Strategies mandating that employers
At greatest risk are children whose families are
undocumented. These children are most likely
to suffer health problems, have little access to
health care, and live in poverty.
provide health insurance coverage to
employees might actually threaten jobs
available to the Latino community. If employers face increased costs of labor, some
may be forced to lay off workers, keep
wages low, or go out of business. This is
especially of concern because of the relatively high concentration of Latinos working for or operating small businesses. In
addition, mandates could leave out large
segments of the Latino population, espe-
cially children. At greatest risk are children whose families are undocumented.
These children are most likely to suffer
health problems, have little access to
health care, and live in poverty. Although
their parents may be supporting local and
regional economies by working for low
wages, the economic infrastructure of
these regions is not always willing to include these children in their future health
care plans. This is a challenge that must be
met by health policymakers and politicians.
Mandates for universal health care coverage could have another deleterious effect: Low-wage jobs could show further
declines in real wages to pay for the mandated benefits. If Medicaid were available
for all of the poor instead of for only categorical groups, many more Latinos would
be insured. However, this solution would
not necessarily improve the problem of
access because of provider dissatisfactions
with the program and reluctance to participate.
As a result of these considerations,
ensuring access to medical care in the
Latino community will require attention
to both the financing mechanisms and
the structure of the medical care system. One suggestion is to further pursue
consumer-sponsored comprehensive prepaid health plans, which can be created
on a large scale and at the local neighborhood level.14 Other alternatives could include the use of school-based clinics or the
development of other community-based
models. (See the Spring 1992 issue of The
Future of Children for discussions about
school-linked services.) The focus should
be on primary care and prevention rather
than on acute care.
Given the positive health attributes of
the Latino population, even with minimal
access to care, the goal of health policies
for Latino children and families should
be to increase levels of wellness and preserve good health behaviors by increasing
the accessibility of health care.60 Preventive measures should be given priority,
especially for communicable diseases that
can fairly easily be controlled. Health promotion and disease prevention programs
are critical for school-age children and
adolescents. In particular, education for
HIV prevention, drug use prevention, and
conflict resolution should be started
during the school-age years to be effective. They must also include parents and
the local community. Latinos need to be
69
involved, not only as health care providers
and educators, but also as consumers with
an influential voice.
The number of Latino health care
providers should be increased. A health
practitioner need not be Latino to practice
in a Latino community; but the needs of
the specific populations being served
should guide the development of local
health policies and programs. Specific local or regional needs may dictate clear
local priorities. For example, MexicanAmerican farmworkers and their families
may be at very high occupational and environmental risk and have extremely limited access to health care.41 Those on the
United States–Mexico border in Texas may
live in settlements that lack septic tanks,
sewers, and running water or that expose
residents to the dumping of hazardous
wastes.61
Perhaps the most difficult group to
make policy recommendations for are the
undocumented Latino children. While
they are most likely to suffer from poverty
and its ensuing health problems, they are
also least likely to receive health care.
These children need to have three categorical issues addressed: funds for health
care, comprehensive health education,
and improved continuity of care.
The first of these recommendations is
the most problematic because of the current political situation. Nonetheless, if the
economy of the United States involves
hemispheric markets with Mexico and
Canada, perhaps in the future with the rest
of Latin America, part of the economic
basis of these markets should go toward
maintaining the health of the people in
these countries, particularly the health of
the children. The initiation of the North
American Free Trade Agreement should
provide the opportunity to examine this
possibility.
The two other issues, comprehensive
health education and improved continuity
of care, are more amenable to quicker
action. First, the medical academies of the
United States and Mexico need to find
better ways to share information on the
health care status of their children. It is
rare that studies focusing on Mexican children who live on the Mexican side of the
border are published in the American literature, and as a result (and noted above),
little is known about the health care needs
of immigrant children. Learning more
about the health of the children living on
both sides of the border would be the first
step toward improving health care for immigrant children. In addition, efforts
should be made to educate Latino children and families about health and illness.
Second, and no less important, would be
Learning more about the health of the children
living on both sides of the border would be the
first step toward improving health care for
immigrant children.
to develop a health care system for these
children and their families that is international, that is usable on both sides of the
border, and that is comprehensive. While
this may seem an expensive endeavor, it is
no more costly than the money spent on
advanced illnesses because of missed diagnoses, unnecessary tests, or increased
number of illnesses resulting from discontinuous care.
In summary, policymakers will need to
anticipate the growth in the Latino population nationwide and to recognize its
heterogeneity. Policies that improve children’s health include those aimed at reducing poverty and its associated risks in
Latino families. Successful policymaking
will require a paradigm shift, from considering Latinos as a social policy problem to
viewing them as an investment opportunity and maximizing their engagement in
society.
The author would like to thank Nora Krantzler for her assistance in editing this article.
1. U.S. Bureau of the Census. Hispanic Americans today. Current Population Reports, Series
P-23, No. 183. Washington, DC: U.S. Government Printing Office, 1993.
2. State of California, Department of Education. Language census report for California public
schools. Sacramento: Educational Demographics Unit, 1989.
3. U.S. Bureau of the Census. U.S. population estimates by age, sex, race, and Hispanic origin: 1980
to 1991. Current Population Reports, Series P-25, No. 1095. Washington, DC: U.S. Government Printing Office, 1993.
70
4. U.S. Bureau of the Census. The Hispanic population in the United States: March 1992. Current
Population Reports, Series P-20, No. 465RV. Washington, DC: U.S. Government Printing
Office, 1993.
5. De La Garza, R.O., DeSipio, L., Garcia, F.C., et al. Latino voices: Mexican, Puerto Rican, and
Cuban perspectives on American politics. Boulder, CO: Westview Press, 1992.
6. Unofficial estimates of the undocumented population in the United States and individual
states, U.S. Bureau of the Census. Estimates are derived from the estimation of the number of undocumented residents counted in the 1980 census, from various national surveys, and from administrative data on undocumented residents who applied for amnesty
under the Immigration Reform and Control Act (IRCA) of 1986.
7. U.S. Immigration and Naturalization Service. Estimates of the resident illegal alien population: October 1992. Unpublished paper.
8. Warren, R., and Passel, J. A count of the uncountable: Estimates of undocumented aliens
counted in the 1980 United States census. Demography (August 1987) 24,3:375-93.
9. Morales, R., and Bonilla, F. Restructuring and the new inequality. In Latinos in a changing
U.S. economy: Comparative perspectives of growing inequality. Series on Race and Ethnic Relations, Vol. 7. Newbury Park, CA: Sage, 1993, pp. l-27.
10. Trevino, F.M., and Moss, A.J. Health indicators for Hispanic, black, and white Americans. Vital
and Health Statistics, Series 10, No. 148. DHHS/PHS 84-1576. Hyattsville, MD: U.S. Department of Health and Human Services, 1984, pp. l-88.
11. Andersen, R.M., Giachello, A.L., and Aday, L.A. Access of Hispanics to health care and cuts
in services: A state of the art overview. Public Health Reports (1986) 101:238-52.
12. Weisfeld, V.D., ed. Access to health care in the United States: Results of a 1986 survey. Special Report No. 2/1987. Princeton, NJ: Robert Wood Johnson Foundation, 1987.
13. Trevino, F., Moyer, M.E., Valdez, R.B., and Stroup-Benham, C. Health insurance coverage
and utilization of health services by Mexican-Americans, mainland Puerto Ricans, and Cuban Americans. Journal of the American Medical Association (January 1991) 265,2:233-37.
14. Valdez, R.B., Morgenstern, H., Brown, E.R., et al. Insuring Latinos against the costs of illness. Journal of the American Medical Association (February 1993) 269,7:889-93.
15. Becerra, J.E., Hogue, C.J.R., Atrash, J.K., and Perez, N. Infant mortality among Hispanics:
A portrait of heterogeneity. Journal of the American Medical Association (January 1991)
265,2:217-21.
16. Ventura, S., and Martin, J. Advance report of final natality statistics, 1991. Monthly Vital Statistics Report, Vol. 42, No. 35. Hyattsville, MD: U.S. Department of Health and Human Services, 1993, p. 37.
17. Mendoza, F.S., Ventura, S.J., Valdez, R.B., et al. Selected measures of health status for
Mexican-American, mainland Puerto Rican, and Cuban American children. Journal of the
American Medical Association (January 1991) 265,2:227-32.
18. National Center for Health Statistics. Advance report of final natality statistics, 1987. Monthly
Vital Statistics Report, Vol. 38, No. 3, Supp. 39. Hyattsville, MD: U.S. Department of
Health and Human Services, 1989.
19. Shiono, P.H., Klebanoff, M.A., Graubard, B.I., et al. Birth weight among women of different
ethnic groups. Journal of the American Medical Association (January 1986) 255,1:48-52.
20. Centers for Disease Control and Prevention. Childbearing patterns among selected racial/ethnic minority groups—United States, 1990. Morbidity and Mortality Weekly Report
(May 28, 1993) 42,20:402.
21. Unfortunately, HHANES has a number of limitations: it lacks non-Latino comparison
groups, it collected only limited types of health data, and it included few children between the ages of 6 and 24 months. Further, it is not based on a national sample, so that
generalization is limited. In particular, rural populations, including migrant farmworkers,
were not well sampled; thus, a group at high risk of exposure to environmental toxins was
missed. Nonetheless, a partial picture of Latino infants’ health status can be obtained
from HHANES and other studies.
22. Behrman, R., ed. Nelson textbook of pediatrics. 14th ed. Philadelphia, PA: W.B. Saunders, 1992.
23. Chavez, C.G., Cordero, J.F., and Becerra, J.E. Leading major congenital malformations
among minority groups in the United States, 1981-1986. Morbidity and Mortality Weekly Report (1988) 37,SS-3:17-24.
24. Taffel, S.M., Ventura, S.J., and Gay, G.A. Revised U.S. certificate of births—New opportunities for research on birth outcomes. Birth (December 1989) 16,4:188-93.
25. Mendoza, F., Takata, G., and Martorell, R. Health status and health care access for mainland Puerto Rican children: Results from the Hispanic Health and Nutrition Examination
Survey. In Puerto Rican women and children: Issues in health, growth, and development. G. Lamberty and C.G. Cole, eds. New York: Plenum, April 1994, pp. 211-28.
26. Malina, R.M., Martorell, R., and Mendoza, R. Growth stature of Mexican-American children and youth: Historical trends and contemporary issues. Yearbook of Physical Anthropology (1986) 29:45-79.
27. Castillo, R.O., Garcia, M., Pawson, I.G., et al. Iron (Fe) status of U.S. Hispanic children.
Western Society for Pediatric Research (February 1990) 38,1:189A.
28. Murphy, S.P., Castillo, R.O., Martorell, R., and Mendoza, F.S. An evaluation of four food
group intakes by Mexican-American children. Journal of the American Dietetic Association
(March 1990) 90,3:388-93.
29. Flannery, B., Martorell, R., and Mendoza, F. Factors affecting participation in the WIC program among Mexican-American children. Unpublished findings. Copies may be obtained
from Fernando Mendoza, Stanford University, Division of General Pediatrics, 750 Welch
Rd., Ste. 325, Palo Alto, CA 94304.
30. Mendoza, F.S., Martorell, R., and Castillo, R.O. Interim report—Health and nutritional status of
Mexican-American children. Grant No. MCJ-060518. Rockville, MD: Maternal and Child
Health Research Program, Bureau of Maternal and Child Health and Resources Development, 1989.
31. Sumaya, C.V. Major infectious diseases causing excess morbidity in the Hispanic population. In Health policy and the Hispanic. A. Furino, ed. Boulder, CO: Westview Press, 1992,
pp. 76-96.
32. Diaz, J. Hispanic children and AIDS: National Council of La Raza Center for Health Promotion Fact
Sheet. Washington, DC: National Council of La Raza, October 1992.
33. Centers for Disease Control and Prevention. Use of race and ethnicity in public health surveillance: Summary of the CDC/ATSDR Workshop. Morbidity and Mortality Weekly Report
(June 25, 1993) 42,10.
34. Mendoza, F.S., Ventura, S.J., Saldivar, L., et al. The health status of U.S. Hispanic children. In Health policy and the Hispanic. A. Furino, ed. Boulder, CO: Westview Press, 1992,
pp. 97-115.
35. Valdez, R. Telephone conversation regarding analysis of Current Population Survey 1991,
August 25, 1993.
36. Martorell, R., Mendoza, F., and Castillo, R. Poverty and stature in children. In Linear growth
retardation in less developed countries. J.C. Waterlow, ed. Nestle Nutrition Workshop Series,
Vol. 14. New York: Vavey/Raven Press, 1988, pp. 57-73.
37. Martorell, R., Mendoza, F., and Castillo, R. Genetic and environmental determinants of
growth of Mexican-Americans. Pediatrics (November 1989) 84,5:864-71.
38. Yip, R., Parvanta, I., Scanlon, K., et al. Pediatric Nutritional Surveillance System—United
States, 1980-1991. Morbidity and Mortality Weekly Report (November 27, 1992) 41,SS-7:18.
39. Mayol, P., Rodriquez Santana, J., Sinfontes, J., et al. Profile of pediatric admissions with diagnosis of asthma at the San Pablo Hospital. Boletin-Asociacion Medica de Puerto Rico (October
1991) 83,10:426-29.
40. National Center for Health Statistics. Current estimates from the National Health Interview
Survey: United States, 1984. Vital and Health Statistics, Series 10, No. 156. DHHS/PHS
86-1584. Washington, DC: U.S. Government Printing Office, 1986.
41. Takata, G. Differential access to health care of Latino children in the Hispanic Health and
Nutrition Examination Survey. Masters Thesis, Stanford University, 1991.
42. Carter-Pokras, O., Pirkle, J., Chavez, G., and Gunter, E. Blood lead levels of 4- to 11-year-old
Mexican-American, Puerto Rican, and Cuban-American children. Public Health Reports
(July/August 1990) 105,4:388-93.
43. Wilk, V.A. Testimony for hearing record on environmental toxins and children: Exploring
the risks. Letter to the House Select Committee on Children, Youth, and Families. Washington, DC, 1990.
44. Pollack, S.H., and Landrigan, P.J. Exposure of children to occupational and environmental
toxins. Address to U.S. House of Representatives Select Committee on Children, Youth,
and Families. Washington, DC, September 13, 1990.
45. Moses, M. Pesticide-related health problems and farm workers. American Association of Occupational Health Nursing Journal (1989) 37,3:115-30.
71
72
46. Stempel, D.A., and Szefler, S.J. Management of chronic asthma. Pediatric Clinics of North
America (December 1992) 39,6:1293-1310. Also see Sullivan, T.J. Is asthma curable? Pediatric Clinics of North America (December 1992) 39,6:1363-82.
47. For a discussion of the problem of obesity among school-age Latino children, see note no.
30, Mendoza, Martorell, and Castillo.
48. Martorell, R., Mendoza, F., Baisden, K., and Pawson, I. Physical growth, sexual maturation,
and obesity in Puerto Rican children. In Puerto Rican women and children: Issues in health,
growth, and development. G. Lamberty and C.G. Cole, eds. New York: Plenum, April 1994,
pp. 119-36.
49. Stern, M.P., and Haffner, S.M. Type II diabetes in Mexican-Americans: A public health
challenge. In Health policy and the Hispanic. A. Furino, ed. Boulder, CO: Westview Press,
pp. 57-76.
50. Kaplowitz, H., Martorell, R., and Mendoza, F.S. Fatness and fat distribution in MexicanAmerican children and youths from the Hispanic Health and Nutrition Examination Survey. American Journal of Human Biology (1989) 1:631-48.
51. Pollick, H.F., Pawson, I.G., Martorell, R., and Mendoza, F.S. The estimated cost of treating
unmet dental restorative needs of Mexican-American children from southwestern U.S.
Hispanic Health and Nutritional Examination Survey, 1982-83. Journal of Public Health Dentistry (Fall 1991) 51,4:195-204.
52. Leyva, M. Adolescents and HIV/STD: National Council of La Raza Center for Health Promotion Fact
Sheet. Washington, DC: National Council of La Raza, June 1993.
53. Substance Abuse and Mental Health Services Administration, Office of Applied Studies. National Household Survey on Drug Abuse: Main findings 1991. Rockville, MD: U.S. Department
of Health and Human Services, Public Health Service, May 1993.
54. Vega, W. Telephone conversation regarding National Household Survey on Drug Abuse,
January 31, 1994.
55. Chavez, E.L., and Swain, R.C. An epidemiological comparison of Mexican-American and
white non-Hispanic 8th and 12th grade students’ substance use. Journal of Public Health
(1992) 82:345-47.
56. Prothrow-Stith, D., with Weissman, M. Deadly consequences: How violence is destroying our teenage population. New York: HarperCollins, 1991.
57. State of Hispanic health. Washington, DC: National Coalition of Hispanic Health and Human
Services Organizations, 1992.
58. U.S. Department of Health and Human Services. Health status of the disadvantaged—
Chartbook 1986. DHHS Pub. No. (HRSA) HRS-P-DU86-2. Washington, DC: Public Health
Service, Health Resources and Services Administration, Bureau of Health Professions, Division of Disadvantage Assistance, 1986.
59. Hayes-Bautista, D.E., Hurtado, A., Valdez, R.B., and Hernandez, A.C.R. No longer a minority:
Latinos and social policy in California. Los Angeles: University of California, Los Angeles,
Chicano Studies Research Center, 1992.
60. Ginzberg, E. Access to health care for Hispanics. Journal of the American Medical Association
(January 1991) 265,2:238-41.
61. Warner, D. Health issues at the U.S.–Mexico border. Journal of the American Medical Association (January 1991) 265,2:242-47.
Public Policy
Implications of
HIV/AIDS in
Adolescents
Jill F. Blair
Karen K. Hein
The relationship between the HIV/AIDS epidemic and the adolescent population
in the United States has not received sufficient attention. Not only are an increasing
number of adolescents of both sexes becoming infected, but a great many adults
acquire the infection, often remaining asymptomatic, during their youth. Thus, the
interface of the education and health systems is of central importance in preventing
HIV/AIDS infection and subsequent death. This problem adds an urgency to making
changes in school-linked health services previously addressed in the Spring 1992
issue of The Future of Children.
For those youth who are in school continuously and for those who are there
intermittently (most school dropouts), the schools represent the most practical and
best locus to deal with what, unfortunately, remains basically a matter of life
(prevention) or death (infection). In this context the community need is to protect
children and others from the epidemic by educating adolescents about high-risk
sexual behaviors and their consequences and about measures to reduce the risk of
infection and death (including programs that involve education about and distribution of condoms). This is in direct conflict with those who do not want matters of
sexuality and reproduction addressed outside family and religious venues because
of concerns about promoting promiscuity, denigrating religious beliefs, or displacing
family responsibilities. The authors of this article attempt to reduce or resolve aspects
of this conflict by analyzing available evidence on some of the important concerns
that are inhibiting the initiation and implementation of life-saving, effective prevention programs. They also suggest changes in existing policies and programs at local,
state, and national levels which might further reduce the risks of infection and death
among this population of children and improve their health care generally.
— R.E.B.
T
he impact of HIV on adolescents is different from its impact on
1
other age groups or communities. Adolescents are neither large
children nor small adults. From an epidemiological standpoint,
the pattern of HIV infection in adolescents differs from that of HIV
2
infection in children or adults. In addition, adolescents are in a stage of
social, physical, and psychological development which requires unique
program and treatment strategies.
Vol. 4 • No. 3 – Winter 1994
Jill F. Blair, M.A., is a
consultant on teen
HIV/AIDS prevention
education. She is currently working with an
international health
organization on the
national replication of
Project ACTION, a
teen AIDS prevention
program that uses social marketing strategies in combination
with a communitybased condom accessibility program.
Karen K. Hein, M.D.,
is director of the Adolescent AIDS Program,
and professor of pediatrics, epidemiology, and
social medicine at Albert Einstein College of
Medicine and Montefiore Medical Center.
74
Characteristics of the HIV
Epidemic Among
Adolescents
Adolescents Are Not Big Children
The route of HIV infection among children is almost always vertical from an
infected mother. HIV-infected young children have a shorter survival time than
adolescents on average.3 HIV prevention
programs designed to address perinatal
infection should be aimed at sexually experienced young men and women, the
pool of potential parents. A small but growing proportion of long-term surviving infants infected with HIV are now reaching
adolescence. Specific educational and
health care services need to be developed
to support these young people as they progress from childhood to adolescence.
Adolescents Are Not Small Adults
HIV-infected adolescents differ also from
their adult counterparts. A greater proportion of infected teenagers acquire HIV
through heterosexual transmission as
compared with adults; a higher percentage
of teenage patients are asymptomatic, becoming symptomatic with HIV-related illnesses during adulthood; and a higher
percentage of infected youth are black or
Half of the 14 million people in
the world who are infected with
HIV were infected between the
ages of 15 and 24.
Hispanic as compared with adults. There
are also unique legal issues that exist for
adolescents regarding consent for HIV
testing and treatment, and limited access
to treatment, including clinical trials.4 Disclosure of HIV serostatus to partners and
parents is particularly difficult for young
people as well.5 Finally, there are cognitive
differences which affect the acquisition
and application of knowledge, information, and skills.6
Health care providers often assume
that HIV testing and related services require parental consent, but laws vary from
state to state. While every state has laws
protecting the confidentiality of medical
information, this protection is not necessarily extended to minors. Depending on
such circumstances as whether the condition presents imminent danger to the
young person or others and the nature of
the treatment or services (for example,
mental health, drug use, hospitalization),
parental involvement may or may not be
required. Some states explicitly require
notification of parents when an HIV test
result is positive for a minor, while others
permit notification under other laws related to medical treatment for minors.7
Unique Needs of Adolescents
The World Health Organization estimates
that half of the 14 million people in the
world who are infected with HIV were infected between the ages of 15 and 24. In
the United States, the three largest national studies of youth in the military,
college health services, and the Job Corps
report overall HIV infection rates of
1/1,000, 2/1,000, and 3/1,000, respectively. The rates vary enormously by region, gender, and ethnic/racial groups.
The fastest growing rates of HIV are no
longer reported from the large coastal
cities known to be hard hit in the early
1980s. Now, mid-Atlantic states are reporting the greatest increase in HIV rates
among young women, according to the
latest study of female Job Corps students.
Studies of youth living in high-risk situations, such as those in a shelter in New
York City, report much higher rates, up to
160/1,000 for older adolescent males. In
several recent studies, young women are
now becoming infected at a faster rate
than either young men or adult women.
For example, in the most recent report
from the Job Corps, female students had
HIV rates twice as high as those of their
male counterparts. In Asia, where HIV is
spreading quickly, teenaged girls ages 15
to 19 are reported to have the highest rates
among women. AIDS cases in adolescents
are not a good indicator of the extent of
HIV infection because most teenagers with
HIV have not been tested and because it
takes, on average, 10 years for people with
HIV to be diagnosed with AIDS.
From a treatment perspective, assessment of individual social, psychological,
and physical development is essential before specific treatment plans can be developed. This requires understanding of
adolescent development and addressing
barriers to care. In addition, the health
assessment—including a social and medical history, physical examination, and
laboratory evaluation—of teenagers dif-
Public Policy Implications of HIV/AIDS in Adolescents
fers from that of young children and
adults. Special attention needs to be paid
to this age group with respect to the presenting signs and symptoms of HIV-related
disease, types of immunization given, the
dosage of medications, and the range of
normal values for laboratory testing of immune function, anemia, and liver function.8 In summary, there are unique epidemiologic features of the HIV epidemic
among youth, in addition to special legal
and programmatic requirements for ageappropriate care of adolescents.
Adolescent Risk Behavior
All adolescents in the United States of
America are affected by the HIV epidemic,
whether infected or not. Virtually all adolescents have heard about AIDS, most now
have heard about someone with HIV or
AIDS, and an increasing number know of
someone with HIV, whether it be a family
member, neighbor, friend, adult, or national celebrity.
According to the 1990 Youth Risk Behavior Survey administered by the Centers
for Disease Control (CDC) and Prevention,9 the median age of reported first
intercourse is 16.1 years for young men
and 16.9 years for young women. Onethird of the young men and 20% of the
young women initiate intercourse before
the age of 15. Among 9th- to 12th-graders,
19% report having had four or more sexual partners during their lifetime. Concomitant with these rates of sexual activity
are the highest rates of sexually transmitted disease, such as gonorrhea, syphilis,
chlamydia, and herpes, of any sexually
active age group.10 Each year between 2.5
and 3 million young people become infected with a sexually transmitted disease.
Therefore, most adolescents are at risk
for acquiring HIV during their teenage
years because HIV has now spread to all
50 states and much of the sexual intercourse in which adolescents are engaging
is unprotected.
Age-appropriate health education programs for adolescents should be built on
the premise that teenagers need to learn
and know about their own bodies.11 At the
same time, they should develop positive
views of sexuality and intimacy in addition
to knowing about the unwanted consequences of sexual intercourse, such as
sexually transmitted disease or unplanned
pregnancy. Practicing new skills and experimenting to learn personal limits are
natural parts of this stage of development.
The risks associated with normal adolescent development can be managed only
through the acquisition of explicit knowledge and the modulation, if not the modification, of one’s behavior. So, it is not only
the consequences of HIV infection among
adolescents that make this topic of particular importance to policymakers, but
also the nature of the debate it inspires
and the strategies it requires.12
Mixed messages about human sexuality generally, and its relationship to adolescent development specifically, make it
difficult for public policymakers to navigate both the complexity and the controversy associated with HIV transmission
and adolescent behavior. Whether this
epidemic is seen from a health or educa-
The threat of HIV to adolescents
requires an acknowledgment of
adolescent sexuality and risk
behavior
tion perspective, the threat of HIV to adolescents requires an acknowledgment of
adolescent sexuality and risk behavior,
and impugns the practice of making concessions and compromises to assuage controversy.
HIV/AIDS Education
Contrasting Styles of Health
Education
In the health care community, education
is provided one on one, usually in a medical office setting. When health education
occurs in schools, presentations are conducted in large groups, and seldom are
they conducted or even influenced by
health care professionals. This is true even
in schools with school-based health clinics. Nurses, nurse practitioners, physician
assistants, and health aides constitute the
vast majority of health care providers who
are visible in school settings. The providers, as a rule, are not involved in health
education curriculum development or
program design.
The HIV/AIDS epidemic and its implications for the adolescent community
justify a reassessment of past practices and
make a compelling argument for ending
the isolationism of both the health and
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76
education sectors. Strategies to prevent the
further spread of the HIV virus among
adolescents are more likely to succeed if
they draw upon the resources, knowledge,
and talent possessed by both health and
education professionals. The recommendations presented in this article reflect a
bias toward collaborative program planning and development, with suggestions of
opportunities and strategies for partnership at the local, state, and federal levels.
nel, and none require the involvement of
HIV experts. Even where school-based or
school board advisory committees exist,
the state model offers little in the way of
guidance or support for extending such
committees to include HIV/AIDS and
adolescent behavior experts. The issue,
then, is not whether states have recognized the need for education but, rather,
the quality of the education that is being
offered.
What States Require
All 50 states either “require or recommend” HIV/AIDS education by legislation or policy, according to a study conducted by the Sex Information Education
Council of the United States (SIECUS).13
What States Provide
Ninety percent of those states . . . have guidelines for the discussion of abstinence, though
few if any have guidelines that . . . require an
explicit discussion of risk behavior and modes
of transmission.
These numbers speak to the prevalence of
HIV/AIDS education programs but not to
the quality of the programs themselves.
All 50 states have also established
HIV/AIDS Advisory Committees, but only
44 include physicians or medical person-
Nationally, and even internationally, AIDS
prevention education materials are being
developed rapidly. The CDC maintains a
resource listing of HIV/AIDS educational
materials, as do several other national organizations concerned with this issue, including the Council of Great City Schools,
SIECUS, and the National School Boards
Association. Some state education departments or health departments maintain a
data base on educational materials. There
is no dearth of educational materials,
though the quality and appropriateness of
materials varies from community to community. New York City established a program that involves adolescents in the
development of peer education materials
for AIDS prevention. This program, called
Be Active in Self Education, provides
groups of young people with small
amounts of money (up to $2,500) to develop educational materials, from newsletters to classroom videos, for use in their
own schools with their own peers. It has
proven effective both in involving young
people in group educational activities and
in producing a myriad of innovative AIDS
prevention educational materials for use
in the New York City public schools.
availability, for example, two issues always
emerge: the effectiveness of condoms in
preventing the sexual transmission of the
AIDS virus and the allegation that condom
availability encourages sexual promiscuity.
A close review of the programs that
currently exist across the country reveals
significant shortcomings. Curricula tend
to concentrate on the scientific and biological aspects of HIV infection—cell biology, DNA, RNA, and the nature of a
retrovirus—avoiding the practical implications and specific details of HIV transmission. There is frequently an overemphasis on abstinence as a prevention strategy without a balanced presentation of
human sexuality and safer sex practices.
Ninety percent of those states that have
HIV/AIDS curricula have guidelines for
the discussion of abstinence, 14 though few
if any have guidelines that specifically address and require an explicit discussion of
risk behavior and modes of transmission.
Programs lack instruction about sexual responsibility and decision-making skills.
They avoid explicit instructions for adolescents on condom usage, and insufficient
staff development is provided to support
program implementation. There is a failure to monitor and assist with program
implementation, and, as a consequence,
school districts develop HIV/AIDS curricula and continue to use materials even
when the information contained within
them is seriously out of date.13
Myths and Facts
The following statements are examples of
arguments employed by people who oppose explicit sex and HIV/AIDS education, as well as school-based condom availability. In each instance, a response is presented that is based on an appreciation
and understanding of adolescent development and scientific studies involving
young people.
In a survey of 4,241 7th- through 12thgrade teachers who were most likely to be
involved in sex education, the majority
were found to believe that education regarding pregnancy, AIDS, and other sexually transmitted diseases should be covered by grades 7 and 8 even though such
education is much more likely to begin in
the 9th or 10th grade.15 This suggests that,
even when sexuality and AIDS education
are being addressed, the grade level at
which schools begin to discuss these issues
is often after the point by which many
adolescents have already begun to engage
in behaviors that place them at risk of
infection.
Too often efforts to implement
HIV/AIDS prevention education become
battles, and they are waged in emotional
terms rather than on the basis of empirical
evidence of medical facts and adolescent
development and behavior.
In the debate that has raged in cities
across the country concerning condom
“Condoms Don’t Work”
Condoms are not 100% effective, but effectiveness is most often determined by
how the condom is used, not by the quality
of the product itself. Succumbing to the
argument that condoms are not 100% effective and should therefore not be promoted as a prevention strategy is tantamount to telling people who ride motorcycles not to use helmets because wearing
a helmet doesn’t protect completely from
head injury in the case of an accident.
Even when sexuality and AIDS education
are being addressed, the grade level at which
schools begin to discuss these issues is often
after the point by which many adolescents have
already begun to engage in behaviors that
place them at risk of infection.
Because condoms are less likely to be
used by people who perceive them to be
ineffective than by those who consider
them to be highly effective, the argument
undermines the goal of preventing the
spread of HIV infection.16
“Condom Availability Encourages Sexual
Intercourse”
The second argument against condom
availability asserts that such a policy promotes sexual intercourse and condones
sexual promiscuity among adolescents. In
1987, Switzerland introduced a public
health campaign targeted to young adults
that promoted condom use as a major
means of HIV/AIDS prevention.17 From
January 1987 until October of 1991, selfreported consistent condom use among
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78
persons aged 17 to 30 years increased from
8% to 52% in association with the campaign. The proportion of adolescents aged
16 to 19 years who had sexual intercourse
did not increase over that period.18
“Talking About Sex Leads to Sex”
Studies from other western industrialized
nations show that, while young people
have the same age of first intercourse elsewhere as in the United States, those nations with comprehensive services and
explicit sex education have lower rates of
unintended pregnancy and abortion than
the United States.19
Divide and Conquer: A
Failed Strategy
Good Kids–Bad Kids Versus All Kids
In practice schools have shied away from
topics that provoke community debate,
and to the extent that they do develop
programs that deal with adolescent sexuality and risk taking, the programs are
targeted to a subset of the school population. We see evidence of this strategy in
programs that deal with so-called highrisk youth: programs for pregnant and
parenting teens, pregnancy prevention
programs, and special substance abuse
prevention counseling services. These
programs isolate segments of young people according to a typology of risk factors.
By their design they are more likely to
work as intervention programs, not prevention strategies.
Those nations with comprehensive services
and explicit sex education have lower
rates of unintended pregnancy and
abortion than the United States.
High school students are referred for
special counseling and educational services if they are deemed to be at risk of
substance abuse. By isolating subsets of
youth, these programs fail, by definition,
as prevention efforts. They reinforce the
myth that risk taking and boundary testing are the exceptions rather than the
rule of adolescent development, and they
give credence to the notion that there are
such things as “good” kids and “bad” kids.
By denying the normalcy of risk taking
among all adolescents and failing to develop strategies that recognize that normalcy, program efforts are compromised
by the conflicted messages of their design.
This tendency to subdivide and isolate
young people as a means of providing
dedicated services is not confined to the
educational community. The CDC provides HIV prevention funding for out-ofschool youth who are considered to be
high risk. This practice is often mirrored
at the state and local level by funding conduits or funding agencies. The underlying
philosophy of these programs implies a
clear-cut distinction between the behavior
of young people who are in school and the
behavior of those who are not, suggesting
that an out-of-school youth is more likely
to engage in high-risk behavior than an
in-school youth. While, in the aggregate,
this hypothesis may be true, from the perspective of protecting individual adolescents, this premise is not only false but
counterproductive.
The tendency to take risks is associated
with a stage of development. Though that
tendency may be exaggerated among certain young people at certain moments, the
greatest benefit will derive to adolescents
when strategies are developed that are responsive to their stage of development. To
the extent that resources are limited and
allocated according to a priority that triages based on need, agencies that claim to
serve high-risk out-of-school youth have a
significant advantage over school-based
programs in garnering public funding for
HIV/AIDS prevention. There are, however, several problems with this approach
to HIV/AIDS prevention for adolescents.
Youth in and out of School
Virtually all out-of-school youth were
once in school, which means that schoolbased programs still provide the best
means to reach the greatest number of
young people. Three principles should
guide HIV prevention strategies:
1. The earlier information about
transmission and prevention is provided,
the better.
2. The term out-of-school youth is a
misnomer because these young people are
more accurately “in and out of school,”
attending school irregularly rather than
not attending at all. This means that
school-based prevention education programs must be offered at every grade level,
on a regular basis. The programs must
include community-based components
that are closely linked with the school,
using outside advisors and presentations,
as well as on-site referral and counseling
services.
3. The competition for resources between school-based and community-based
programs only contributes to the false
notion that adolescent risk taking is an
aberration which occurs among certain
kinds of adolescents. HIV/AIDS prevention education should occur both inside
and outside schools.
A strong argument can and should be
made for providing a base funding level
for school-based HIV/AIDS prevention
education and using these programs as the
foundation upon which supplementary
and community-based programs and services can be built.
The Responsibility for
HIV/AIDS Education:
Public Health System
Versus Education System
The Cost of Concessions
Historically, professional health providers
and educators have made concessions,
succumbed to public pressure, on issues
related to adolescent health. These compromises have been made to mitigate controversy and appease those who either for
religious or personal reasons are more
comfortable with a romanticized version
of adolescence than with a realistic one.
In dealing with sex education, many
people in education were able to tolerate
a watered-down curriculum and a parent’s
right to remove their child from certain
classroom discussions. Such concessions
were justified by the conclusion that potential gains outweighed losses.20 Schools
would teach human sexuality, and that
was progress in addressing adolescent
pregnancy. With school-based health clinics, many people in the health profession
accepted parental consent requirements
that confined health services to those
young people whose parents agreed. The
result was the confining of school-based
health services to a subset of students in
a small proportion of schools where politics and resources permitted. The tendency of adolescents to experiment coupled
with the prevalence of the HIV virus
makes it harder to take comfort in such
compromise.
In considering the need for expanded
and explicit HIV/AIDS education in
schools, there are some who take the position that the controversy provoked by
this subject jeopardizes the consensus required to provide effective public education. They argue that the greater good
School-based prevention education
programs must be offered at every grade
level, on a regular basis.
is served by maintaining the balance of
support for education from a cross section of the community, including those
opposed to HIV/AIDS education, even if
it means watering down the HIV/AIDS
program or compromising on program
components. These people describe
HIV/AIDS as strictly a public health issue
that should be managed by the public
health community. They further argue
that, given the enormity of the task of
educating the nation’s young, it is neither
necessary nor wise to expand the reach of
schools into this realm.
In reality, there is a long history in this
country of providing noneducational services to students in public schools.21 Moreover, there is a history of using public
schools as a vehicle for public health messages and public health services. The incorporation of HIV/AIDS education into
a school’s comprehensive school health
agenda is no different, in this way, from
turn-of-the-century efforts to assimilate
new immigrant children to the proper use
of a toothbrush. What makes this issue
different, however, is its relationship to
adolescent development, adolescent risk
behavior, and adolescent sexuality. If HIV
infection were transmitted through water
fountains, it is hard to imagine a world in
which battles would be fought over curriculum content dealing with modes of
transmission and prevention.
For public policymakers, it is critical
to understand that compromises on
HIV/AIDS prevention have a price and
that the opposition one seeks to assuage
by concession is rooted in beliefs deeper
and with greater implications than HIV
prevention education alone. This is not to
say that compromise has no place in
HIV/AIDS prevention education, but
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80
rather to caution those in positions of
power that the cost of some compromises
may be measured in program effectiveness. The effectiveness of prevention education strategies will be measured in lives
that are saved or lost.
In New York State, education department regulations require that local boards
of education establish HIV/AIDS Advisory
Councils to advise on the content and design of HIV/AIDS prevention education
programs. To allay the potential for controversy associated with the development
of such programs, the state mandated that
Adolescent health issues
and HIV/AIDS prevention
education raise challenging and
complicated social and political
questions about the balance of
church and state interests.
the advisory councils include representatives from the religious sector. The reserved role for religion is in stark contrast
to the lack of a mandate concerning the
participation of HIV/AIDS experts. While
the requirement may pacify some religious interests, it does not necessarily
contribute to the quality of HIV/AIDS
education, whereas a requirement that
HIV/AIDS experts be involved would indeed contribute to the quality of the program developed.
Efforts to address adolescent health
and sexuality by adolescent health advocates and public servants inevitably collide
with some religious precepts of certain
groups, as well as with some parents who
deny the risks their children face. Adolescent health issues and HIV/AIDS prevention education raise challenging and
complicated social and political questions
about the balance of church and state interests, their constitutionally established
separation, parents’ roles, and children’s
rights.
Compromise is not necessarily anathema to high-quality HIV/AIDS prevention, but concessions should be made
carefully to protect against a tradeoff
that lacks substantive merit. HIV/AIDS
prevention programs should stay true to
the medical realities and the realities of
the adolescent experience. Controversy
avoidance alone is not a goal of effective
HIV/AIDS prevention.
Condom Availability as
an HIV/AIDS Prevention
Strategy
Who Wants Condoms in Schools?
In May and June of 1992, Louis Harris and
Associates conducted a survey of 300 public school districts and found that 8% of all
public middle and high school students
now attend schools in districts where condom availability programs have been approved.22 More significant was the finding that 34% of the nation’s middle and
senior high school students attend schools
where substantial discussion has occurred
about HIV/AIDS education and the merits
of expanding HIV/AIDS education programs. Public debate about the quality of
existing HIV/AIDS prevention education
and the potential for new or expanded
program efforts provide communities with
an opportunity to review the health status
of young people and incorporate adolescent risk behavior into the discussion
of appropriate educational and healthrelated programs and services.
As of the fall of 1992, at least 15 and as
many as 50 school-based health centers
were making condoms available to sexually active students as a strategy for preventing pregnancy and the spread of
sexually transmitted diseases and HIV.23
Eleven school-based condom availability
programs were being implemented at that
time, and another 10 programs were being
developed.
Where Are Condoms Available in
Schools?
While such school districts as Los Angeles,
San Francisco, Philadelphia, and Washington, D.C., have all approved condom
availability policies, condom availability is
not a strategy confined to large city school
districts (see Table 1). Commerce City,
Colorado, has adopted a policy, as have
Falmouth and Martha’s Vineyard, Massachusetts. The appropriateness of condom
availability as a prevention strategy for
adolescents can be determined only on a
community-by-community basis. Communities must discuss their own HIV/AIDS
prevention strategies in the context of local health statistics and an assessment of
risk behavior among local youth.
81
Table 1
Cities with Schools Offering Condom Availability Programs
Identified as of June 1, 1994
School-Based Health Center Programs Implemented
Nationally, Advocates for Youtha estimates that more than 70 school-based
health clinics make condoms available to sexually active students, including
those in
Baltimore (MD)
Boston (MA)
Cambridge (MA)
Chicago (IL)
Culver City (CA)
Dallas (TX)
Little Rock (AR)
Los Angeles (CA)
Miami (FL)
Minneapolis (MN)
New York City (NY)
Philadelphia (PA)
Portland (OR)
Portsmouth (NH)
Quincy (FL)
Readfield (ME)
Schoolwide or Districtwide Programs Approved
Alexandria (VA)
Amherst (MA)
Bedford (MA)
Brookline (MA)
Cape Cod
Vocational (MA)
Chapel Hill (NC)
Chelsea (MA)
Commerce City (CO)
Falmouth (MA)
Franklin County
Vocational (MA)
Harvard (MA)
Holden (MA)
Lexington (MA)
Lincoln/Sudbury (MA)
Los Angeles (CA)
Martha’s Vineyard (MA)
Mohawk Trail
Regional (MA)
Moretown (VT)
Mt. Desert (ME)
Mt. Greylock
Regional (MA)
New Haven (CT)
New York City (NY)
Newton (MA)
North Shore
Regional (MA)
Northhampton (MA)
Philadelphia (PA)
Provincetown (MA)
Ralph C. Mahar
Regional (MA)
San Francisco (CA)
Santa Fe (NM)
Santa Monica (CA)
Seattle (WA)
Sharon (MA)
Somerville (MA)
Stockton (CA)
Wachusett (MA)
Washington (DC)
Proposals Defeatedb
Albuquerque (NM)
Chester (VT)
East Lyme (CT)
Kennebunkport (ME)
Lake Washington (WA)
Millville (NJ)
Nashua (NH)
San Lorenzo Valley (CA)
Talbot County (MD)
Tamalpais HS (CA)
Teaneck (NJ)
a
Formerly Center for Population Options.
The Massachusetts Department of Education recommends that all schools in the state consider
school condom availability as part of comprehensive HIV education. As of June 1, 1994, some 42
school committees had voted against condom availability.
b
Source: Advocates for Youth, 1025 Vermont Ave., N.W., Ste. 200, Washington, DC 20005, (202) 347-5700
HIV/AIDS prevention education generally, and condom availability specifically, were the focus of considerable attention when, in February of 1991, the New
York City Board of Education, the largest
school district in the nation, adopted a
policy of condom availability in high
schools. The program design resulted
from a collaborative effort between the
school system and the public health department and other private and public
experts on adolescent development and
HIV transmission. The program relied
substantially on the involvement of the
health and adolescent advocacy community, as well as parents, faculty members,
and students. See Box 1.
The New York City program, which was
implemented in November 1991, affects
the lives of more than 275,000 high school
students in the New York City schools. By
involving parents and students as partners with school faculty members in the
process, the program has nurtured trust
among all members of the school commu-
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Box 1
New York City HIV/AIDS Curriculum with Condom Availability
A Case Study
The New York City condom availability program includes the following provisions, many of which are unique to the New York program
design and have not been adopted by other school districts around the country:
Input
Copies of the draft program design were circulated to more than 1,000 organizations and individuals, including
parent groups, concerned about education issues generally and HIV/AIDS education specifically.
Involvement
The program design involves parents, students, and faculty members, as well as outside experts on HIV/AIDS,
as members of school-based HIV/AIDS education teams.
Confidentiality
The program establishes school-based condom availability for all high school students without parental consent
or the right of parents to opt children out of the program. This provision protects the anonymity of the young
people who wish to participate. The program is strictly voluntary; no student is required to take a condom.
Training
HIV/AIDS education teams—including students, parents, and school faculty members—enroll in a three-andone-half day training program designed and delivered by experts from a range of local and national public and
private health and HIV/AIDS organizations.
School Plan
HIV/AIDS education teams are given latitude in the design of school-specific strategies, within guidelines
established by the central school district.
Quality
Schools whose program design fails to meet the minimum standards promulgated by the chancellor’s office are
given technical assistance by a team of HIV/AIDS and adolescent behavior experts.
Volunteers
Only teachers who volunteer hand out condoms to high school students. They are team members and are fully
trained prior to making condoms available.
Readiness
Schools are not permitted to make condoms available until the school-based HIV/AIDS education team leader
and the school principal agree that the school is ready, they have completed their training, and they have had
their classroom instruction observed and approved by an independent educational administrator.
Partnership
The program is a model of public-private partnership, with the private sector contributing condoms as well as
staff to assist with school-based implementation and the public sector reallocating health education resources to
maximize support for HIV/AIDS prevention efforts.
Evaluation of the Plan
By the time the Board of Education approved the plan to expand HIV/AIDS education with condom availability in 1992, the New York
City school system’s Office of Research, Evaluation and Assessment (OREA) was organizing a process evaluation. Shortly after the plan
was approved, several meetings were held with outside organizations, mostly from academic research institutions, who were interested
in evaluating the plan from different perspectives. Four research organizations combined forces to study the high school HIV/AIDS
prevention education program, in particular, the impact of condom availability on adolescent knowledge and behavior.
This consortium, including the Academy for Educational Development (a nonprofit organization with more than 10 years of
experience helping schools implement and evaluate educational reform), the Hunter College Center on AIDS, Drugs and Community
Health, the Health Studies Department of New York University, and the National Center for Health Education, will use the Chicago
school system, which has not adopted condom availability, as a comparative city. In this way, the evaluators hope to isolate the effect
of specific program components used in New York City high schools. While the evaluation is under way, as of this writing, they have
not published their findings.* They are focusing on the following issues and questions:
n
Does a school-based HIV/AIDS education program which includes a voluntary condom availability component lead
to sexual and drug behavior change among students?
n Does the program lead to changes in communication about sexuality, drugs, AIDS, and condoms among students,
sexual partners, teachers, parents, and other adults?
n
Does the program contribute to changes in the school’s social environment and normative attitudes regarding AIDS,
drugs, sexuality, and condoms?
n Do different levels of program intensity lead to different outcomes in risk behavior, communications, or school
environment?
n Does the program have different impacts on different groups?
n Does the program have different impacts in different settings (types of school)?
n How does political, administrative, parental, community or faculty opinion influence program implementation?
n Does the program serve as a “wedge” for students to raise other concerns about health and sexuality in the school?
The internal evaluation, conducted by OREA, has been ongoing since the program’s inception in February of 1991. The first report,
titled OREA Report: Evaluation of the HIV/AIDS Education Program/Including Condom Availability 1990-92, was issued in the fall of 1993.
Overall, the program was found to have “substantial accomplishments” with respect to improving the quality of school-based HIV/AIDS
education in New York City’s high schools.
83
The goals of OREA’s evaluation were to
n document and assess the program’s training and resource development process;
n
provide feedback to program planners and schools on implementation and program barriers;
n determine the program’s impact on students, teachers, and school staff;
n
identify strategies associated with positive program outcomes; and,
n
recommend changes for strengthening the program.
OREA evaluators examined the goals of the chancellor’s expanded HIV/AIDS program and the progress made by schools in meeting
those goals. The program required the formation of HIV/AIDS education teams in all high schools. Each team, including, at a minimum,
parents, students, and faculty members, was required to participate in a training program and was responsible for ensuring the provision
of a minimum of six classroom lessons per grade on HIV/AIDS prevention. In addition, the teams were responsible for designing a
school-specific strategy for making condoms available.
The teams were to recruit faculty volunteers as health resource room staff to make condoms available. The chancellor’s program
encouraged the involvement of community-based organizations in the development and implementation of HIV/AIDS prevention
education efforts. Finally, the program included a peer education component, funded entirely with private dollars. OREA’s evaluation
examined each of these components, the degree to which they were implemented as they were designed, and the impact on student and
staff awareness and behavior.
Using a 10-high-school sample, the OREA evaluators found that all of the schools had established HIV/AIDS education teams which
were broadly representative of the school community. The teams ranged in size from 10 to 40 members. All of the school principals rated
the overall functioning of the team as “excellent.” And, in general, team members expressed enthusiasm about their involvement in the
program as well.
The training program was equally well received, according to the evaluators. Seventy-seven percent of those people interviewed about
the training described their experience as either “very useful” or “somewhat useful.”
On the curriculum issue, the findings were more uneven. Evaluators found that school staff relied on a variety of sources for the
HIV/AIDS education because the Board of Education had not adopted a high school level curriculum on HIV/AIDS prevention education. At the time of this writing, the Board of Education’s HIV/AIDS Advisory Council is still reviewing a curriculum for grades 7 through
9. This curriculum has been under review for more than two years. The delays associated with the development and release of curricula
for use in schools are due in large part to the Board of Education’s internal conflicts over the explicitness of the language used and the
emphasis on protection against transmission versus abstinence education.
Condom availability was found to have been implemented without incident in each of the sample schools, with four principals reporting
having been “pleasantly surprised” by the maturity and seriousness with which the students accepted condom availability. Principals
reported minimal parent opposition and stated that one obstacle they faced in program implementation was lack of space for health
resource rooms in overcrowded schools. OREA evaluators found that most students thought the HIV/AIDS education program was
having a positive impact in three areas: increasing the likelihood that students would get HIV counseling or testing; opening up
communication between students and staff with respect to student health concerns; and increasing the use of condoms among sexually
active students. Students who were members of the HIV/AIDS education teams thought that the program had a more positive impact
than did students who were not team members.
Two-thirds of the health resource staff were women. The number of volunteers for each school ranged from three to 30. Of the 10
schools visited, only two had a single health resource room dedicated exclusively for the dissemination of health information and condoms.
Staff and students reported that a single site meant that people knew it as a “condom room,” making some students less likely to use it.
The evaluators indicated that their own impression, over the course of their site visits, was that, on the topics of HIV/AIDS and
sexuality, the “lines of communication had opened significantly between student and program staff.” One team leader stated that the
program provided an opportunity for students to talk about sexuality and drug abuse issues. Another said the program gave students
coming from homes with HIV-positive family members someone with whom to talk about their concerns and feelings. One staff member
described the condoms as a “carrot” used to engage students in broader discussions.
Nine of the 10 schools relied on the involvement of community-based organizations in the implementation of their programs. Most
were either HIV/AIDS specific agencies or public health and social service organizations.
A more complete assessment of the effectiveness of the peer education program is under way, though the evaluators found general
support for this component as well, with positive responses from both students and faculty involved.
OREA’s evaluation demonstrates that the New York City public high schools have made progress in implementing key provisions of the
program. Each of the 10 sample schools met the minimum requirements for forming HIV/AIDS education teams, staffing and stocking
health resource rooms, teaching six lessons at each grade level, and conducting parent information sessions. Implementation of condom
availability was found to have gone very smoothly with reports that both student and staff displayed mutual respect in the process. Team
leaders were asked their opinions about the impact of the chancellor’s expanded HIV/AIDS education program including condom
availability. Their answers addressed the impact of the entire program, rather than specific components. Overall, they indicated that the
program had a positive impact in the areas of heightened awareness, increased openness, and better communication and mutual respect.
*Academy for Educational Development. Executive Summary. Evaluation of expanded HIV/AIDS education program including condom
availability. New York: AED, 1992.
84
nity and has given parents and students a
genuine role in the implementation of a
critical program effort. In addition, with
parents and young people working side by
side, each has the opportunity to better
understand the other’s perspective and
experience. The training program for the
school-based HIV/AIDS education teams
emphasizes the importance of opening
lines of communication, encouraging discussions of issues that have traditionally
been too controversial and taboo for the
average classroom.
In the summer of 1991, New York City
Schools Chancellor Joseph Fernandez extended an invitation to more than 35 research institutions from across the nation,
inviting them to evaluate the program’s
The basic challenge is to enable health
care professionals and educators to work
together to provide comprehensive services
with categorical funding streams.
effectiveness. Eight different institutions
came forward with evaluation plans. Four
institutions formed a consortium to focus
specifically on the high school HIV/AIDS
prevention program, with a special emphasis on the impact of condom availability on adolescent attitudes and behavior.
These organizations raised their own financial support to undertake their studies.
They participate in a study group designed
to keep lines of communication open between and among all researchers. This
group is convened by staff from the Board
of Education’s Office of Research, Evaluation and Assessment (OREA). The willingness of the school system to cooperate
with this level of external assessment activity was unprecedented and again reflected the school system’s effort to collaborate
across disciplines and institutional lines to
ensure high-quality HIV/AIDS prevention
strategies. In addition to the external evaluations, the school system implemented a
process evaluation, documenting the program’s progress in meeting its goals.
Two types of evaluations have been
conducted of the New York City Board of
Education experiment: an internal evaluation by the school system’s OREA and an
external evaluation by teams in surrounding institutions and academic research
centers. Often school systems are reluctant
to have outside evaluators working within
the schools. In this instance, the Chancellor welcomed the scrutiny of the independent research community as an important means of learning from this bold
social experiment. In fact, meetings were
held to permit researchers to exchange
ideas and approaches to facilitate a series
of studies using different perspectives and
study designs, rather than a single outcome study. Details of both the internal
and external evaluations are presented
with the description of the New York City
program in Box 1.
The New York City program caught the
interest of the media and the public nationally and internationally. By braving the
controversy of condom availability as a
proposed strategy to prevent the further
spread of HIV/AIDS among adolescents,
the New York City school system enabled
other educational leaders to consider the
issue and explore program options. By the
time the New York City Board of Education approved condom availability, journalists everywhere were asking local school
boards about the state of HIV/AIDS prevention and their views on condom availability. These inquiries placed considerable pressure on school boards large and
small to assess their own HIV/AIDS prevention efforts and improve or refine their
program strategies.
Resources Available for
Educational Programs
While some states and localities make
small contributions to HIV/AIDS education, the bulk of the funding comes from
the CDC. According to the National Association of State Boards of Education, in
1994 Congress appropriated a total of $48
million for HIV/AIDS prevention for
school and college-aged youth combined.
The Associate Director of the Office of
HIV/AIDS Prevention at the CDC reports
that most of these funds are used for
school-based HIV/AIDS prevention programs. The allotment, on its own, is wholly
insufficient to provide adequate schoolbased HIV/AIDS prevention education.
Even if the entire allocation were dedicated to the New York City Public School
system, it would represent slightly more
than $48 per student, or $1,680 per class.
In fact, in 1991-92, the New York City
public schools, with nearly one million
children enrolled, received approximately
$500,000 from the CDC for school-based
HIV/AIDS prevention education.
Conclusion
The policy recommendations that follow
underscore the need for collaboration
across disciplines and institutions, and coordination of resources to develop effective adolescent HIV/AIDS prevention
programs. The basic challenge is to enable
health care professionals and educators
to work together to provide comprehensive services with categorical funding
streams. As a result of the disaggregation
of resources, programs have compartmentalized young people and their needs.
The unintended outcome of categorical
funding has been to separate those young
people who most need integration into
the larger system and isolate services that
would be best delivered comprehensively.
The result of this categorical approach is
the proliferation of disease-specific programs working in isolation and often total ignorance of each other’s activities.
Hence, there are school systems developing AIDS curricula separate from the
health care community, community-based
dropout prevention programs functioning in total isolation from school systems,
and even school-based substance abuse
prevention programs developed in isolation from AIDS prevention programs. In
these instances, service systems are defined
narrowly, and opportunities to share resources and improve the quality of services are lost.
The integrated approach to comprehensive service systems that we propose
specifically for adolescent AIDS prevention will challenge our traditional isolationist approach to both health care and
education. Where health professionals
come into schools to provide medical services, they should be involved in curriculum development, staff training, and
community education projects. Where
educators have been working by themselves developing health education curriculum and training teachers, health care
professionals should be assisting them in
the future.
Until we develop strong systems at the
federal and state levels to support the coordination of resources for the purpose of
promoting and providing accurate information about this epidemic and means to
prevent its spread, the handful of fledgling programs that have been launched in
communities around the nation are fighting an uphill battle against a collective
denial of the reality of adolescent sexuality
and risk behavior. As professionals and
policymakers, we must set our sights on
dispelling the myths and clarifying the
truths about HIV transmission and the
best means of prevention, and on tackling
the taboos that, in the age of AIDS,
threaten our young peoples’ lives.
Specific Policy
Recommendations
The recommendations that follow focus
on specific steps to be taken at all three
levels of government—federal, state, and
local—to help the nation’s youth successfully acquire the knowledge, skills, and
services needed to grow up in the midst of
a world pandemic. In some instances, the
We must set our sights on dispelling the
myths and clarifying the truths about
HIV transmission.
proposals are meant to initiate and, in
other instances, further cultivate partnerships between health and education to
strengthen the respective efforts of each.
The recommendations should be implemented simultaneously and quickly in
view of the rapid spread of the epidemic.
Recommendation 1
The Department of Health and Human
Services (DHHS) should be authorized,
through its new Office of Adolescent
Health, to coordinate personnel and resources for HIV prevention and services
for youth within DHHS, as well as between
DHHS and the federal Departments of
Education (DOE), Defense (DOD), and
Labor (DOL). See Figure 1.
Rationale
The Preventive Health Amendments of
1992 provide specific guidance to establish
a new Office of Adolescent Health under
Title XVII of the Public Health Services
Act.24 The duties of this office would include
n coordinating within DHHS all activities
related to disease prevention, health promotion, preventive health services, health
information and education;
85
86
Figure 1
Proposed Federal Organization (Recommendation 1)
Federal Government
Department
of
Labor
Department
of
Health and Human
Services
Department
of
Defense
Department
of
Education
Office of
Assistant Secretary
for
Health
Office
of
Adolescent
Health
Public Health
Services
Clearinghouse
National plan
to improve
adolescent
health
Demonstration
projects
n coordinating similar activities in the private sector;
n giving grants for demonstration projects to improve adolescent health (including training of health care workers and
educators);
n establishing and maintaining a National
Information Clearinghouse on Adolescent Health; and,
n developing a national plan for improving adolescent health care and health
education.
Responsibilities
The following are examples of HIVspecific responsibilities for this office:
n collation and review of recommendations of the six key reports on adolescent
health and HIV; 25-30
n interdepartment and program communication within DHHS about existing and
proposed programs, including key Public
Health Service agencies such as, CDC’s
Division of Adolescent and School Health,
Division of HIV/AIDS, Health Promo-
tion/Disease Prevention, STD Prevention,
the National Institutes of Health (particularly NICHD, National Cancer Institute,
National Institute of Allergy and Infectious Diseases), the Agency for Health
Care Policy and Research, the Food and
Drug Administration, Health Resources
and Services Administration, Substance
Abuse and Mental Health Services Administration, Office of Assistant Secretary
of Health, National AIDS Program Office,
National Vaccine Program Office, Office
of Disease Prevention and Health Promotion, Office of Population Affairs, Office of
the Surgeon General, Office of Women’s
Health, and the President’s Council on
Physical Fitness;
n analysis of funded HIV prevention and
research programs to determine both the
actual number of adolescents served or participating in programs, and the amount of
money and resources dedicated to adolescents
exclusively; 31
n review of current policies regarding HIV
prevention counseling and HIV testing
and services in other federal departments,
87
Figure 2
Proposed State Organization (Recommendations 2, 3, and 4)
State Government
Department
of
Health
Department
of
Education
Office
of
Adolescent
Health
State Health/Education
Advisory Committee
composed of health
education experts plus
representatives of relevant
state agencies
AIDS/HIV ACTIVITIES
Estimate HIV cases
Advise officials of
adolescent health
Conduct seroprevalence
studies
Inventory resources
Form state network
Convene consensus
conferences
Publish a newsletter
Develop guidelines
(health services,
education curricula)
Consider workforce Issues
Provide technical
assistance
Develop funding
strategies (public/private)
including current policies of mandatory
HIV testing as an admission criterion for
programs within DOL (Job Corps, Peace
Corps programs, and others geared to
young people),32 and DOD (programs
affecting adolescents under the age of 24
in all branches of the military), and also
a review of existing programs within
33
DOE that address adolescent health,
HIV/AIDS prevention, and substance
abuse prevention (Office of Comprehensive School Health, Middle School Education, Drug Free Schools); and,
n review of funded research and service
projects within NIH, HRSA, and CDC to
ascertain the number of adolescents included, not just the age bracket for inclusion, and the amount of and percentage of
research funds specifically aimed at HIV
prevention, evaluation, and care of HIVinfected adolescents.
Recommendation 2
A network of State Offices of Adolescent
HIV/AIDS Prevention should be established to maximize coordination of resources across health and education, and
support the development of high-quality
interdisciplinary approaches for both
school- and community-based adolescent HIV/AIDS prevention programs. See
Figure 2.
Rationale
The federal government should make
funding available to the executive branch
of state governments to support the establishment of an Office of Adolescent
HIV/AIDS Prevention. In addition to facilitating adolescent HIV/AIDS prevention efforts within the state, these offices
would serve as a national network for the
federal government to disseminate infor-
88
mation, research, and model program
strategies. This would allow for easy coordination of programs and services and
would maximize the quality of prevention
efforts nationally.
To qualify for funding, on a competitive basis, States would be required to contribute base level support, either financial
or in-kind, toward the establishment of
the office. The office should be housed
within the executive branch of the state
government, with dual reporting lines to
the state governor and the secretary of
the federal DHHS. The federal govern-
It is of particular importance that
guidelines be based on empirical
data, studies of adolescent and child
development, and health status data.
ment should provide an overview of the
offices’ role and responsibility to ensure
consistency from state to state, but flexibility would be allowed in each state in
the development of program goals and
objectives for each Office of Adolescent
HIV/AIDS Prevention.
States receiving allocations should be
required to participate in a national evaluation that would include a process evaluation to document the process by which
each state develops its program priorities
and an outcome evaluation to determine
the impact of program strategies on adolescent behavior as well as adolescent
health status.
Responsibilities
The following are examples of HIVspecific responsibilities for a state Office of
Adolescent HIV/AIDS Prevention:
n be aware of and, to the extent possible,
coordinate all activities related to adolescent HIV prevention conducted by either
state health or education departments;
n collect and organize statewide data on
adolescent HIV seroprevalence rates,
AIDS cases, and adolescent HIV risk and
health-related behaviors;
n convene regional conferences of health
and education representatives to review
health data and discuss program strategies, from both a clinical and a pedagogic
perspective;
n coordinate the development of statewide guidelines for HIV/AIDS education,
calling on the expertise of health, education, and youth service professionals;
n develop a statewide plan for expanding
HIV/AIDS education for grades K-12, and
considering condom availability for adolescents in secondary and postsecondary
institutions;
n work with the health department to develop a training model to ensure that
health care workers involved in HIV prevention and treatment services are appropriately trained and knowledgeable about
adolescent-specific regulations and laws
governing health care, and are prepared
to deal with the social, psychological, and
medical aspects of adolescent development and HIV infection;
n prepare current and future projections
of the number of youth, 12 to 21 years of
age, who are at risk for HIV infection based
on behavior and other health risk indicators; and,
n provide technical assistance to communities seeking to improve coordination between local health and education authorities for the purpose of expanding and
improving adolescent HIV/AIDS prevention efforts.
It is of particular importance that
guidelines and learner outcomes be based
on empirical data, studies of adolescent
and child development, and health status
data. HIV/AIDS prevention education
materials must be based on the need for
knowledge according to what is known
about the behavior and health of children
and adolescents. By issuing learner outcomes, guidelines for HIV/AIDS education, and instruments for program evaluation, states are in a better position to
compare program strategies across communities.
The state Office of Adolescent
HIV/AIDS Prevention could serve as the
fund manager for all other federal and
state adolescent HIV/AIDS prevention
programs. This approach to adolescent
HIV/AIDS prevention is applicable to
other adolescent health and education
issues. The strategies and skills developed
during this process are easily transferable
to other adolescent health priorities.
Recommendation 3
States should establish a per-capita funding system for HIV/AIDS prevention
education to ensure the provision of high-
quality HIV/AIDS education at all grade
levels and should establish and enforce
minimum program quality standards in its
delivery. See Figure 2.
Rationale
To qualify for this funding allocation,
schools should be required to provide
HIV/AIDS education at all grade levels,
K-12, to provide staff development on
HIV/AIDS, and to involve parents, as well
as health and HIV/AIDS experts, in the
development and regular review of curriculum and educational materials.
While currently every state either requires or recommends HIV/AIDS education, little is done to ensure that this
education is provided, and even less is
done to ensure program quality.
Responsibilities
The following are examples of responsibilities recommended to be fulfilled by
school districts receiving per-capita funding allocations specifically for HIV/AIDS
prevention education:
n meet minimum learner outcome standards for HIV/AIDS education by grade
level;
n document annual review process for
educational materials designed to keep
the curriculum and supplementary educational materials up to date and consistent with current medical knowledge;
n demonstrate ongoing staff and parent
education programs, with evaluations to
ensure high quality and effective delivery;
n establish formal mechanisms to link
prevention efforts with services, such as
adolescent counseling and HIV testing
services, care for HIV infected youth; and
n implement an evaluation, monitoring,
and technical assistance system to facilitate
school-based implementation of program
efforts.
While curriculum and program guidelines should be promulgated at the state
level, school districts should be given latitude in determining specific program
strategies, and they should be encouraged
to provide HIV/AIDS education as a part
of a comprehensive school health education program. In this way, the per-capita
funding allocation should not be restricted to a specific set of program activities,
but rather, it should be linked to the accomplishment of broad-based goals, providing districts with the flexibility they
need to allocate or redistribute resources
to achieve those goals. For example, one
goal of the per-capita funding allocation
should be to foster stronger linkages with
community-based health organizations. If
a district has a plan for achieving this goal
and would like to spend the resources on
another aspect of the HIV/AIDS prevention effort, such as a peer education program, this should be permitted within the
guidelines established by the state.
Recommendation 4
State education departments should establish a Health/Education Collaborative, a committee including health and
education experts, to coordinate across
disciplines and to advise on the development of adolescent HIV/AIDS prevention education program development.
See Figure 2.
Rationale
A Health/Education Collaborative would
establish a formal linkage between the
health and education sectors at the state
level and would be dedicated to ensuring
high-quality HIV/AIDS prevention education through communication and the coordination of resources.
Unlike the proposed state Office of
Adolescent HIV/AIDS Prevention, the collaborative would be comprised of health
and education professionals who volunteer to participate and who are dedicated
to coordinating existing resources within
their own professional sector to ensure
high-quality program efforts. Members of
the collaborative would work closely with
the Office of Adolescent HIV/AIDS Prevention, serving as advisors to that office
and links to institutional resources.
While currently every state either
requires or recommends HIV/AIDS
education, little is done to ensure that
this education is provided, and even
less is done to ensure program quality.
Membership on the collaborative
should be solicited from the professional
health and education communities, as well
as from the public departments of health
and education. The collaborative would
require minimal staff support and would
report to the Commissioners of Health
and Education.
89
90
Responsibilities
The following are examples of specific responsibilities for the collaborative:
n inventory resources—including data collection capability, service delivery systems,
and financial support—within the institutions represented on the collaborative;
n propose resource sharing opportunities
to support program development for adolescents;
n participate in the review of HIV/AIDS
educational materials, including endorsements of materials considered to be of
high quality;
n publish a newsletter featuring model
collaborations between health and education;
n foster maximum cooperation across the
disciplines of health and education; and,
n cultivate regional capability for health
care workers to collaborate with education
experts in addressing adolescent-specific
HIV referral, counseling, testing, and
treatment issues.
Recommendation 5
School systems should establish a health
and education HIV/AIDS advisory committee that includes educational administrators as well as representatives from the
public and private health care community.
See Figure 3.
Rationale
School boards and school administrators
should tackle complicated and controversial issues as they review and improve their
HIV/AIDS prevention education programs. The public and private health care
professionals should assist the school district to develop curriculum, program, and
services strategies by reviewing health
data, undertaking risk-behavior studies,
and conducting a local health needs assessment. This assistance would ensure that
the programs and strategies proposed for
classroom instruction and school-based
services are appropriate to meet the needs
of the students.
Reporting to the school district superintendent, this advisory committee should
consist of educational administrators and
public and private health professionals
who have volunteered to participate.
In addition to the benefits derived to
the school district, the health community
will gain from the experience as well by
learning how schools address health-
related issues, the range of services and
resources available through the schools,
and the process by which faculty are
trained to teach health-related issues.
Finally the health care community will
gain insight into how best to use the education system to advance the public’s understanding of critical public health issues
and concerns.
Responsibilities
The following are examples of specific responsibilities of the proposed health/education HIV/AIDS advisory committee:
review adolescent health data, in particular data related to HIV risk behaviors;
n
convene community education programs on HIV/AIDS issues and concerns
for parents and other interested citizens
to discuss health statistics, adolescent risk
behavior, and model program strategies;
n
review health education and, where
available, HIV/AIDS education materials
to assess the accuracy and appropriateness of the ways in which methods for
HIV/AIDS prevention are presented and
discussed;
n
collect and disseminate information
about model programs;
n
n develop a resource list of health care
providers, including medical schools,
counseling, HIV testing, and treatment
services for adolescents, to be used by
schools in the development of schoolbased plans for expanding HIV/AIDS prevention education;
n advise on the development of evaluation instruments to assess program effectiveness; and
propose guidelines for content and
age-appropriateness of topics to enable
school-based review of supplementary
educational materials, such as brochures,
posters, videos, and the like.
n
Recommendation 6
High schools should establish HIV/AIDS
education teams that include parents,
students, faculty members, and community experts in health, HIV/AIDS, and adolescent development. See Figure 3.
Rationale
To ensure high-quality program strategies, high schools should be required to
establish HIV/AIDS education teams
with mandated participation from the
school principal, along with parents, students, school staff, and outside health
91
Figure 3
Proposed Local Organization (Recommendation 5)
Local Government
Adolescent Advisory
Committee
School System
Review health data
Health
Staff
Education
Staff
Social
Service
Staff
Convene interdisciplinary
meetings, workshops
Review educational
strategies, curricula
Individual
School
Committee
Develop local resource
list (materials and
referrals)
Parents
Teachers
Administrators
Health care providers
Community-based
organizations
experts. Program quality benefits from
the involvement of parents, faculty members, and students in the design and development of school-based strategies for
HIV/AIDS prevention. Programs are
more likely to be well received and understood by the community as a whole
when the whole community has been
involved in their development.
While central school districts are in an
ideal position to collect and disseminate
information about HIV/AIDS issues and
to assist schools in identifying model programs, the school community itself is best
suited to select specific strategies to effect
a particular goal or objective. Schoolbased HIV/AIDS education teams give
parents, students, and faculty members a
sense of program ownership, which helps
sustain the school’s commitment to a program over time.
Responsibilities
The following are examples of responsibilities of high school-based HIV/AIDS
education teams:
n review existing HIV/AIDS educational
program within the school;
n develop a plan for expanding school
community awareness of HIV prevention
and improving school-based HIV/AIDS
prevention education;
n review resource materials proposed for
use in the school as part of the HIV/AIDS
educational program;
n create a calendar of HIV/AIDS educational activities for the school year, including assemblies with outside HIV/AIDS
experts, presentations by People Living
With AIDS (PLWAs), and so on;
n develop a school-based assessment process by which the team can measure the
effectiveness of its strategies;
n identify and publicize on-site counseling resources for students; and,
n establish a referral process to outside
agencies that provide adolescent counseling services, as well as HIV testing, bereavement counseling, and HIV treatment
programs.
92
1. Kunins, H., Hein, K., Futterman, D., et al. Guide to adolescent HIV/AIDS program development. Journal of Adolescent Health (July 1993; supplement) 14,5:1s-140s.
2. Vermund, S., Hein, K., Gayle, H., et al. AIDS among adolescents in New York City. American
Journal of Diseases of Children (1989) 143: 1220-25.
3. Hein, K. Adolescents at risk for HIV infection. In Adolescents and AIDS: A generation in jeopardy. R.J. DiClemente, ed. Newbury Park, CA: Sage, 1992, pp. 3-16.
4. Hein, K. Fighting AIDS in adolescents. Issues in Science and Technology (1991) 7:67-72.
5. U.S. Department of Health and Human Services, Public Health Service, Agency for Health
Care Policy and Research. Evaluation and management of early HIV infection. Rockville, MD:
AHCPR, 1994.
6. Futterman, D., Hein, K., and Reuben, N. HIV-infected adolescents: The first 50 patients in
a NYC program. Pediatrics (1993) 91:730-35.
7. English, A. Expanding access to HIV services for adolescents: Legal and ethical issues. In
Adolescents and AIDS: A generation in jeopardy. R.J. DiClemente, ed. Newbury Park, CA: Sage,
1992, pp. 262-83.
8. Futterman, D., and Hein, K. Medical care of HIV-infected adolescents. AIDS Clinical Care
(1992) 4:95-98.
9. Centers for Disease Control. Selected behaviors that increase risk for HIV infection among
high school students—U.S., 1990. Morbidity and Mortality Weekly Report (1992) 41:33-35.
10. Cates, W. The epidemiology and control of sexually transmitted diseases in adolescents. In
Adolescent medicine: State of the art reviews. M. Schydlower and M. Shafer, eds. Philadelphia,
PA: Hanley & Belfus, 1990, pp. 409-28.
11. Hein, K. Risky business: Adolescents and human immunodeficiency virus. Pediatrics (1991)
88:1052-54.
12. Hein, K. Getting real about HIV in adolescence. American Journal of Public Health (1993)
83:492-94.
13. Sex Information Education Council of the United States, Inc. Future directions: HIV/AIDS
education in the nation’s schools. New York: SIECUS, 1992, pp. 3-7. Available from SIECUS,
130 West 42nd St., Ste. 2500, New York, NY 10036.
14. Kenney, A.M., Guardado, S., and Brown, L. Sex education and AIDS education in
schools: What states and large school districts are doing. Family Planning Perspectives
(1989) 21:56-64.
15. Forrest, J.D., and Silverman, J. What public school teachers teach about preventing pregnancy, AIDS, and sexually transmitted disease. Family Planning Perspectives (1989) 21:65-72.
16. Ehrhardt, A. Trends in sexual behavior and the HIV pandemic. American Journal of Public
Health (1992) 82:1459-61.
17. Roper, W., Peterson, H., and Curran, J. Commentary: Condoms and HIV/AIDS prevention—clarifying the message. American Journal of Public Health (1993) 83:501-3.
18. Hausser, D., and Michaud, P.A. Condom promotion does not increase sexual intercourse
among adolescents. Presented at the Eighth International Conference on AIDS. Amsterdam, the Netherlands. July 19-24, 1992. Abstract TuD0575.
19. Jones, E., Forrest, J.D., Goldman, N., et al. Teenage pregnancy in developing countries.
Family Planning Perspectives (1985) 17:32-35.
20. Blair, J. Condom availability in schools. Journal of Adolescent Health (1993) 14,7:565-68.
21. Larson, C.S., and Behrman, R.E., eds. The Future of Children: School-Linked Services (Spring
1992) 2,1:1-144.
22. Samuels, S.E., and Smith, M.D., eds. Condom availability in the schools. Menlo Park, CA: The
Henry J. Kaiser Family Foundation, 1993.
23. Center for Population Options. Manual on condom availability. Washington, DC: CPO,
1993.
24. U.S. Congress, House. Preventive Health Amendments of 1992. Report No. 102-1019.
102nd Congress, 2d session, 1992.
25. U.S. Congress, Office of Technology Assessment. Adolescent health—Volume 1. Summary and
policy options. OTA-H-468. Washington, DC: U.S. Government Printing Office, 1991,
pp. 1-188.
26. Novello, A. Report of the Secretary’s Work Group on pediatric HIV infection and disease. Washington, DC: DHHS, 1988.
27. Novello, A.C. Adolescents in the age of AIDS: A report for policy makers from the U.S. Public Health Service panel on women, adolescents, and children with HIV infection and
AIDS. Unpublished report.
28. U.S. Congress, House Select Committee on Children, Youth and Families. A decade of denial:
Teens and AIDS in America. Washington, DC: U.S. Government Printing Office, May 1992.
29. AIDS and adolescents: Report to the 1989 Invitational Conference. Journal of Adolescent
Health (1989; special supplement) 10: 1-57.
30. Illusions of immortality: The confrontation of adolescence and AIDS. A report to the New York
State AIDS Advisory Council from the Ad Hoc Committee on Adolescents and HIV. Albany: New York State Department of Health, January 1991.
31. U.S. Department of Health and Human Services, National Institute of Child Health and
Human Development. Recommendations for research on adolescent HIV/AIDS. NICHD Technical Advisory Group Report. Washington, DC: DHHS, January 12, 1989.
32. Hein, K. Mandatory HIV testing of youth: A lose-lose proposition. Journal of the American
Medical Association (1991) 266:2430-31.
33. Takanishi, R. The opportunities of adolescence—research, interventions, and policy: Introduction to the special issue. Adolescence. American Psychologist (February 1993)
48,2:85-88.
93
Jonathan M. Samet,
M.D., is professor and
chair in the Department of Epidemiology,
School of Hygiene and
Public Health, the
Johns Hopkins University.
Eugene M. Lewit,
Ph.D., is director of research and grants for
economics at the Center
for the Future of Children.
Kenneth E. Warner,
Ph.D., is professor and
chair in the Department of Public Health
Policy and Administration, School of Public Health, University
of Michigan.
Involuntary Smoking
and Children’s Health
Jonathan M. Samet
Eugene M. Lewit
Kenneth E. Warner
Involuntary, passive, or secondhand smoking exposure has significant adverse effects
on the health of children. However, its importance in causing and promoting disease
in childhood and the availability, practicality, and effectiveness of various prevention
measures are not fully appreciated by the public or professionals. This article
summarizes the substantial evidence indicating that environmental tobacco smoke
(ETS) exposure plays a major role in childhood illness: respiratory tract disorders,
ear infections, general morbidity, adverse effects on physical and mental development, and increased perinatal mortality and morbidity. Progress is being made in
prohibiting smoking in some public places frequented by children and in the
dissemination of information about the hazards of ETS. However, there is still a need
to initiate and implement such policies in child care centers, public libraries,
restaurants, and sports arenas. There is also a special challenge to develop effective
noncoercive, educational programs directed at parents and their relatives and
friends in home settings and those involved in family child care. In addition, cultural
and language diversity requires the development of new and varied educational
efforts.
— R.E.B.
E
xtensive toxicologic, experimental, and epidemiologic research,
largely carried out since the 1950s, has established that active
cigarette smoking is the major preventable cause of morbidity and
1,2
mortality among adults in the United States. The evidence also indicates that the deleterious effects of active smoking extend to the unborn
child of the smoking mother; maternal smoking during pregnancy
reduces birth weight and increases risk for miscarriage, premature labor
and delivery, perinatal morbidity and death. Exposure to environmental
tobacco smoke (ETS) has also been found to be a cause of preventable
morbidity and mortality in nonsmokers, both children and adults (Box
3
1). The 1986 reports of the Surgeon General on smoking and health
4
and of the National Research Council comprehensively reviewed the
data on ETS exposure to tobacco smoke and reached comparable conclusions with significant public health implications; both reports conThe Future of Children
Vol. 4 • No. 3 – Winter 1994
95
cluded that exposure to ETS causes respiratory disease, including lung
cancer, in nonsmokers. In 1992, the U.S. Environmental Protection
Agency (EPA) published its assessment of the respiratory effects of ETS
5
exposure and provided population estimates of the burden of malignant
and nonmalignant lung disease associated with such exposure. The
agency’s report reaffirmed the conclusions of the earlier reports, and its
estimates indicated that ETS exposure posed a significant and substantial
public health problem for children and adults. The EPA’s classification
of “environmental tobacco smoke” as a Class A carcinogen is likely to
prompt further efforts to control tobacco smoking in the workplace and
in public and commercial environments.
This review considers the effects of involuntary exposures to tobacco smoke on
the health of children. These exposures
occur to the unborn child as components
of tobacco smoke cross the placenta to the
fetal circulation and after birth as the child
breathes tobacco-smoke-contaminated air
at home, in vehicles, and in public places.
Estimates of the number of exposed children and the associated morbidity indicate a significant and largely avoidable
public health problem for which broad
policy initiatives are needed. In formulating policies for ameliorating the health
consequences of tobacco smoking, however, involuntary exposure of children to
tobacco smoke has received limited attention, perhaps because the home, the dominant locus of exposure, is an environment
not typically subject to regulation. In considering approaches for minimizing the
exposure of children to tobacco smoke, we
emphasize the lessons that have been
learned in reducing active smoking and
controlling tobacco smoking in public
places, and make suggestions for areas
where more aggressive actions may be indicated.
adverse effects of smoking on health have
attempted to dismiss epidemiologic research as observational and, therefore, unable to establish cause-effect relationships.
On the other hand, the potential limitations of epidemiologic data have long
been recognized and taken into account
by the many expert panels that have examined the research findings on smoking
and health (see, for example, the 1964 and
1986 reports of the Surgeon General3,6).
As the data on involuntary smoking and
child health have accumulated during the
past 20 years, adverse effects have been
found consistently with different investigational approaches and in different
countries. This consistency along with
demonstration of dose-response relationships between measures of exposure and
health effects strengthen arguments that
the observed associations are causal.
Moreover, the epidemiological studies
may underestimate the actual effects of
involuntary exposure to tobacco smoke
because of the inherent inaccuracy of the
exposure measures used in research and
the nearly universal exposure to tobacco
smoke.4
The central evidence on smoking and
children comes largely from epidemiologic research, scientific investigation conducted in human populations. The epidemiologic evidence is primarily nonexperimental (observational) and subject to
biases which may limit interpretation.
Consequently, critics of the findings of
Of necessity, this article is selective in
its review of a large body of scientific evidence on child health and involuntary exposure to tobacco smoke. Several recent
reports provide comprehensive coverage
of the topic of smoking and children. The
subject has been addressed in the series of
reports on smoking and health of the
96
Royal College of Physicians7 and of the
U.S. Surgeon General8 and in a conference report.9
Involuntary Exposure to
Environmental Tobacco
Smoke (ETS)
Characteristics
Nonsmokers inhale environmental tobacco smoke (ETS), a term widely used to
refer to the combination of side-stream
smoke released from the cigarette’s burning end with mainstream smoke exhaled
by the active smoker.10 The inhalation of
ETS is generally referred to as passive
smoking or involuntary smoking. The exposures of involuntary and active smoking
differ quantitatively and, to some extent,
qualitatively.3,4,11 Because the temperature of the burning cone is lower as the
cigarette smolders than during active puffing, combustion is less complete in sidestream than in mainstream smoke.
Consequently, side-stream smoke has
Involuntary smoking is accompanied by
exposure to and absorption of toxic agents
generated by tobacco combustion and is a
biologically plausible cause of disease.
higher concentrations of some toxic and
carcinogenic substances than mainstream
smoke; however, dilution by room air
markedly reduces the concentrations inhaled by the involuntary smoker in comparison with those inhaled by the active
smoker. Nevertheless, involuntary smoking is accompanied by exposure to and
absorption of toxic agents generated by
tobacco combustion and is a biologically
plausible cause of disease.3,4,10,11
Concentrations
Tobacco smoke is a complex mixture of
gases and particles that contains a myriad
of chemicals.1,10,11 Not surprisingly, the
smoking of tobacco increases indoor levels of respirable particles, nicotine, polycyclic aromatic hydrocarbons, carbon monoxide (CO), acrolein, nitrogen dioxide
(NO2), and many other substances.10 The
impact of smoking on indoor air quality
depends on the number of smokers, the
intensity of smoking, the size of the indoor
space, the rate of exchange of the air of
the indoor space with the outdoor air, and
the use of air cleaning devices.
Several components of cigarette
smoke, including particles and gas-phase
compounds, have been measured in indoor environments as markers of the contribution of tobacco combustion to indoor
air pollution.10 For example, the contribution of smoking in the home and other
places to personal exposure to indoor air
pollution has been assessed by placing samplers for particles of the size breathed into
the lung (respirable particles) directly on
subjects and also in their homes. These
studies have shown that cigarette smoking
can be a dominant source of exposure to
these particles.12 When homes in six U.S.
cities were monitored for respirable particle concentrations over several years, it
was found that the presence of a pack-a-day
smoker almost doubled the usual indoor
level of particles. In homes with two or
more heavy smokers, this study showed that
standards set for outdoor air quality could
be exceeded by smoking-related particle
concentrations indoors. Peak concentrations, particularly in proximity to the
smoker, are undoubtedly higher than the
time-averaged values reported in the study.
Small numbers of homes have been
monitored also for nicotine, another constituent of ETS. In a study of ETS exposure
of day-care children, average nicotine concentration during the time that the ETSexposed children were at home was more
than 10 times greater than the exposure
of children in homes without smoking.13
Levels in homes tend to be highly variable even though the smoking intensity of
adult smokers is typically stable.14 Indoor
monitoring for 20 volatile organic compounds in homes in several communities
showed increased concentrations of benzene, xylenes, ethylbenzene, and styrene
in homes with smokers compared to
homes without smokers.15 The 20 compounds were selected as representative
of toxins and carcinogens that are released outdoors from industry and motor
vehicles.
Biological Markers of Exposure
Biological markers of exposure are substances indicative of exposure that can be
measured in body tissues or fluids. The
presence of ETS components or their
metabolites in body fluids of exposed
nonsmokers strengthens the plausibility
of links between ETS exposure and disease. Biological markers of exposure to
97
Involuntary Smoking and Children’s Health
ETS have been used to describe the
prevalence of exposure to ETS, to investigate the doses of potentially toxic
agents inhaled during involuntary smoking, and to validate questionnaire-based
measures of exposure.
At present, the most valid markers for
tobacco smoke exposure are nicotine and
one of its metabolites, cotinine.4,16 Nicotine and cotinine are almost never present
in body fluids in the absence of exposure
to tobacco smoke. Nicotine remains in the
body for only a short time, and its detection is indicative of very recent exposure.
Cotinine remains in the body longer and
is, therefore, a better indicator of exposure over several days. Cotinine levels
measured in children have shown that
smoking by parents is the predominant
determinant of the level of children’s exposure to ETS.3-5 Urinary cotinine levels
in infants and young children tend to increase with the level of parental smoking,
particularly that of the mother.
The findings of studies of biological
markers have several potential uses in
policy development. First, the demonstration of detectable levels of cotinine or
other markers provides incontestable evidence of exposure to tobacco, and biomarkers are consequently an informative
tool for establishing the prevalence of exposure and for monitoring temporal
trends of exposure or evaluating programs to reduce exposures. Second, biomarkers may have utility for health education. Measurement of biological markers offers a potentially effective approach
for convincing parents that their smoking
may adversely affect their children. Cotinine assays are now widely available, and
cotinine can be measured in either saliva
or urine, fluids that can be readily obtained from a child without drawing
blood. The finding of cotinine in children’s urine or saliva could be used to
personalize health education for parents
about the impact of their smoking and as
an evaluation measure.
Prevalence of Childhood Exposure
Patterns of smoking in the United States
have shifted rapidly in recent decades with
overall declines among adults and the
emergence of strong gradients of smoking
by level of education.2 However, the gains
in reducing smoking have been least
among young females, particularly those
with less education. In 1991, 22% of
women aged 18 to 24 years were current
Box 1
Adverse Effects of Involuntary Smoking
on Children and Adults
Established
Increased lower respiratory infections in children
Increased respiratory symptoms in children
Reduced lung growth in children
Increased lung cancer risk in nonsmokers
Exacerbation of asthma
Irritation of the eyes, nose, throat, and lower respiratory tract
Potential
Increased respiratory symptoms in adults
Reduced lung function in adults
Increased risk of developing asthma
Increased risk for nonrespiratory cancers
Increased risk for sudden infant death
Reduced birth weight
Heart disease in adults
smokers as were 28% of women 25 through
44 years.17 Slightly higher percentages of
men in these same age groups were smokers. These prevalence data indicate that a
substantial percentage of children are
likely to have smoking parents. In fact, data
Smoking by parents is the predominant
determinant of the level of children’s
exposure to ETS.
from a 1988 nationwide survey show that
about one-half of U.S. children under age
five years are exposed to tobacco smoke
(Figure 1).18 For more than a quarter of
children, exposure begins before birth.18
Based on the survey data, 42% of children
in this age range were estimated to live in
a household with a smoker. The probability of children’s exposure to tobacco smoke
doubled from the highest income and maternal education groups to the lowest.
A study of North Carolina children
showed that nonhousehold sources of exposure may become important as the child
98
Figure 1
Percentage Distribution of Children Five Years of Age and Under
by Exposure to Smoke Before and After Birth: United States, 1988
Never exposed
49.9%
Prenatal only
1.2%
Postnatal only
21.2%
Both prenatal
and postnatal
27.6%
Source: Overpeck, M.D., and Moss, A.J. Children’s exposure to environmental cigarette smoke before and after birth.
Hyattsville, MD: U.S. Department of Health and Human Services, 1991, p. 12.
ages.19 Between three weeks and one year
of age, the proportion of study children
reported to be exposed to ETS increased
from 39% to 63%. This increase was accounted for by greater exposure to smoke
from both household smokers and nonhousehold smokers, whether at home or
in other locations. These findings imply
that any control strategy for limiting ETS
exposure of children needs to address
both the home and other locations.
Adverse Effects of
Involuntary Smoking in
Children
Exposure to ETS, involuntary smoking, has now been determined to be a risk
factor for lung cancer in adults and for
nonmalignant lung diseases in adults and
children (Box 1).3-5,20 It has also been
linked to respiratory symptoms, reduced
lung growth, irritation of the mucous
membranes of the eyes and upper airways,
and annoyance. This section reviews the
status of the evidence on involuntary
smoking and children’s health.
Lower Respiratory Tract Illnesses
Epidemiological investigations conducted throughout the world have linked in-
voluntary smoking by infants and young
children to increased occurrence of lower
respiratory tract illnesses, such as bronchitis, bronchiolitis, and pneumonia. ETS
exposure is thought to increase risk for
infection by respiratory pathogens, primarily viruses, rather than to cause illness
by a direct toxic effect of the lung. Investigations conducted throughout the
world have demonstrated an increased
risk of lower respiratory tract illness in
infants with smoking parents. These studies indicate a significantly increased frequency of bronchitis and pneumonia
during the first year of life in children with
smoking parents; the risk has been generally found to increase with the extent of
5
parental smoking. An Australian study,
which used urinary cotinine levels on admission to the hospital as an exposure
indicator, confirmed the increased risk
for lower respiratory illness associated
with tobacco smoke exposure; children
admitted with bronchiolitis had significantly higher urinary cotinine than con21
trol children. While most of the studies
have shown that maternal smoking rather
than paternal smoking is associated with
increased risk, studies in China show that
paternal smoking alone can increase the
incidence of lower respiratory illness.22,23
In the studies of household smoking and
99
lower respiratory illness, however, an effect of exposure has not been readily identified after the first year of life. The
strength of the effect of passive smoking
during the first year of life may reflect
higher exposures consequent to the timeactivity patterns of young infants, which
place them in close proximity to cigarettes
smoked by their mothers, or heightened
susceptibility because of immature defense systems. For school-age children,
parental smoking also increases the occurrence of respiratory illness episodes,
presumably infectious in etiology.24-26 In
the Environmental Protection Agency’s
risk assessment,5 an estimated 150,000 to
300,000 cases annually of lower respiratory tract infection were attributed to ETS
exposure in children up to age 18 months.
The Agency attributed 7,500 to 15,000
hospitalizations annually to ETS exposure. As discussed below, the increased
health care costs associated with children’s exposure to ETS should create incentives for interventions by third-party
payers to reduce that exposure.
Respiratory Symptoms and Illnesses
Data from many surveys of schoolchildren demonstrate a greater frequency of
the most common respiratory symptoms—
cough, phlegm, and wheeze—in the children of smokers.3 The less prominent
effects of passive smoking, in comparison
with the studies of lower respiratory illness
in infants, may reflect the lower exposures
to tobacco smoke of older children who
spend less time with their parents.
Asthma
Asthma, a condition characterized by increased responsiveness of the lung to environmental stimuli with episodic and
sometimes sustained loss of lung function,
is one of the most common chronic diseases of children. Although involuntary
exposure to tobacco smoke is associated
with the symptom of wheeze, evidence for
association of involuntary smoking with
onset of childhood asthma has not been
consistent in the literature. Exposure to
ETS might cause asthma as a long-term
consequence of the increased occurrence
of lower respiratory infection in early
childhood or through other pathophysiological mechanisms, including inflammation of the epithelial surface that lines
the lung’s airway.27 Increased responsiveness of the lung to pharmacologic or cold
air challenge, the hallmark of asthma, is
more often present in children exposed to
ETS.28 Such increased responsiveness can
be demonstrated during the first months
of life, suggesting that in utero exposure to
tobacco smoke components may influence the level of airway responsiveness.29
Tobacco smoke exposure at home, documented by salivary cotinine concentration, has been found to be positively associated with a first emergency room visit
for wheezing in children less than two
years of age.30 On the other hand, the
evidence from older children is conflicting.5,20 The inconsistencies in the literature cannot be readily explained, and the
EPA risk assessment concluded that ETS
is a risk factor for asthma but stopped
short of characterizing the relationship as
causal.
While involuntary exposure to tobacco
smoke has not been established as a cause
of asthma, there is strong evidence that
involuntary smoking worsens the condition of those with asthma. The possibility
that ETS adversely affects children with
asthma was described as early as 1950 in a
case report.31 A more recent evaluation of
asthmatic children demonstrated that indicators of clinical status, including responsiveness on pharmacologic challenge,
were adversely affected by maternal smoking.32,33 Exposure to smoking in the home
has also been shown to increase the num-
An estimated 150,000 to
300,000 cases annually of lower
respiratory tract infection were
attributed to ETS exposure in
children up to age 18 months.
ber of emergency room visits made by
asthmatic children.34 Asthmatic children
with smoking mothers are more likely to
use asthma medications,35 a finding that
confirms the clinically significant effects
of ETS on children with asthma.
The EPA5 concluded that involuntary
smoking is causally associated with additional episodes and increased severity of
the disease in asthmatic children. The
agency estimated that the status of at least
200,000 and possibly as many as l,000,000
asthmatic children is adversely affected
by ETS.
100
Middle-Ear Disease
Recent studies have also shown that children exposed to cigarette smoke in their
homes are at increased risk for middle-ear
disease. Both acute otitis media and persistent middle-ear effusions have been associated with involuntary smoking in a
number of studies.5,20 For example, in a
study of children attending a research day
care center, serum cotinine concentration
predicted the occurrence of episodes of
otitis media with effusion.36
General Morbidity
Analysis of data from the National Health
Interview Survey for children under six
years of age showed that maternal smoking
was associated with an increased number
of days in bed because of illness, whereas
there was no association with paternal
smoking.37 A survey of schoolchildren in
England showed that maternal smoking
was associated with an increased risk of
absenteeism of about 40%.38
Lung Growth and Development
The lung develops and completes its maturation during early childhood and continues to increase in size as the child grows.
Early childhood may represent a period of
particular vulnerability to environmental
pollutants, such as ETS, and respiratory
illnesses during this time may have lasting
consequences. 27 On the basis of the primarily cross-sectional data available at the
time, the 1984 report of the Surgeon General11 concluded that the children of parents who smoked had small reductions of
lung function in comparison with children
The EPA risk assessment reviewed eight
studies of maternal smoking and sudden
infant death syndrome (SIDS) and found
strong evidence for increased risk for
infants whose mothers smoke.
of nonsmokers, but the long-term consequences of these changes were regarded
as unknown. In the two years between the
1984 and the 1986 reports, sufficient longitudinal evidence accumulated to support the conclusion in the 1986 report3
that involuntary smoking reduces the rate
of lung function growth during childhood.
Subsequent data from a number of longi-
tudinal studies have strengthened the basis for this conclusion. In one study in East
Boston, Massachusetts, lifelong exposure
of a child to a mother who smoked was
estimated to reduce growth of one measure of lung function by about 10%.39
The reduced lung growth associated
with involuntary smoking represents an
apparently permanent effect; its permanency and associated reduction of the
lung’s reserve as the child enters adulthood could offer a strong deterrent to
parents’ smoking, if convincingly shown to
parents.
Cancer
The data on childhood cancers and passive smoking are extremely limited, although a larger literature addresses smoking during pregnancy.40 Separating effects of in utero exposure from those of
subsequent inhalation of ETS is problematic. Several studies have suggested links
between ETS exposure in childhood and
risk for a number of cancers, especially
lung cancer among adults.20,41 Because
cancers are usually seen only after long
latency periods, the effects of childhood
exposure would probably not be observed
until adulthood.
Other Adverse Effects
A recent study suggests that even the cardiovascular systems of children may be
adversely affected by passive smoking.42
Laboratory analyses of blood from 216
11-year-old twin pairs suggested unfavorable lipid levels and impaired oxygen
transportation in the twins with smoking
parents. The EPA risk assessment reviewed eight studies of maternal smoking and
sudden infant death syndrome (SIDS) and
found strong evidence for increased risk
for infants whose mothers smoke.5 Because we still lack an understanding of the
underlying mechanisms leading to SIDS,
the agency did not assess the causality of
this association. A lower birth weight for
infants of nonsmoking women passively
exposed to tobacco smoke during pregnancy has also been reported.43,44 A recent study of children with cystic fibrosis
suggested that exposure to ETS at home
adversely affects growth.45 Parental smoking may also increase risk for allergic sensitization.46
Milk production by breast-feeding
mothers is also adversely affected by maternal cigarette smoking.47,48 Although
this adverse effect of cigarette smoking is
101
not mediated by inhalation of ETS, it represents another avoidable consequence of
maternal smoking. In a study of mothers
of preterm infants, 24-hour milk volumes
were approximately 20% less for smoking
compared with nonsmoking mothers, and
milk volume did not increase from two to
four weeks postpartum in the mothers who
smoked.48
Adverse Effects of
Smoking Before and
During Pregnancy
Cigarette smoking has been associated
with reduced fertility, increased risk for
spontaneous abortion, and reduced birth
weight. There are multiple postulated
mechanisms, both direct and indirect, for
these adverse effects of smoking.49 Tobacco smoke components, including carbon monoxide and nicotine, cross the
placenta and enter the fetal blood circulation. Carbon monoxide, by binding to the
oxygen-carrying hemoglobin in the blood,
reduces the amount of oxygen available to
fetal tissues. Maternal smoking has also
been linked to adverse effects on child
development, although the biological
bases for such effects remain unclear.50
Reduced Fertility
There is consistent evidence indicating
that women who smoke at the time of
attempting to conceive have lower fertility.49 Smoking may also increase risk for
ectopic pregnancies (that is, implantation
of the ovum at a site other than the
51
uterus). Smoking cessation returns fertility to that of never smokers.49
Spontaneous Abortion and Perinatal
Mortality
Maternal smoking is associated with increased risk of spontaneous abortion (miscarriage up to 28 weeks of gestation) and
perinatal mortality (from 28 weeks gestation up to 7 days of life).2,7 Whether smoking cessation during pregnancy reduces
the risk is uncertain.49
Reduced Infant Birth Weight
Maternal smoking reduces infant birth
weight, perhaps because of reduced oxygen delivery to the fetus.49 The average
reduction is approximately 200 grams,
and the proportion of low birth weight
infants (birth weight less than 2,500
grams) is approximately doubled by maternal smoking; the adverse effect of
smoking on birth weight increases with
the number of cigarettes smoked by the
mother. Lower birth weight is associated
with higher risk of death in the neonatal
and perinatal periods. The 1990 report of
the Surgeon General concluded that
smoking cessation up to 30 weeks of gestation leads to increased birth weight compared to continuing to smoke.49
Stunted Growth and Development
The results of a number of studies suggest
that maternal smoking could have lasting
adverse effects on physical and mental development during childhood.2,50 The children of smoking mothers tend to be
shorter by 1 to 2 centimeters and to perform less well on achievement and intelli-
Maternal smoking is associated with
increased risk of spontaneous abortion
(miscarriage up to 28 weeks of gestation)
and perinatal mortality.
gence tests.50 Other studies indicate that
maternal smoking may increase risk for
hyperactivity.50,52 Such effects might arise
from smoking-induced changes in germ
cells of the parents or through transplacental exposure rather than as a direct
effect of smoke inhalation.53,54
Policy Options
Eliminating or significantly reducing the
adverse effects of involuntary smoking on
children requires a multifaceted strategy
that addresses exposure in utero and after
birth, in the home and outside the home.
Three types of strategies can be identified, each with favorable impact on child
health: broad programs for smoking prevention and cessation; initiatives to reduce
exposures to ETS generally, and policies
to specifically limit children’s exposure to
tobacco smoke. We focus on the last set of
strategies, acknowledging that substantial
effort is currently directed at reducing active smoking and at controlling ETS exposure in public, commercial, and workplace
environments.
Some elements of a strategy to control
children’s exposure to tobacco smoke are
straightforward and may be accomplished
through a regulatory solution; for example, governments have the authority to
prohibit smoking in public places fre-
102
quented by children, such as schools and
child care facilities. It will be quite difficult
to accomplish other desirable elements of
an ETS control strategy directed at children through regulatory approaches. A
notable example is reduction of children’s
exposure to ETS in their own homes from
cigarettes smoked by parents or others,
the most common form of exposure of
children to ETS. Accordingly, it will be
necessary to develop other less coercive,
but effective approaches to reduce exposure in the home.
Beyond official reports and brochures,
the mass media may be a particularly
appropriate channel to use to educate
the public on the dangers tobacco smoke
poses to young children and fetuses.
Interventions to control children’s exposure to tobacco smoke may arise from
activities in the public sector at federal,
state, and local levels of government, and
in the private sector through the actions
of health care providers, educators, voluntary organizations, and parents or other
caretakers. The potential for substantial
synergy and reinforcement among activities in these various spheres is great and
holds the promise of substantially reducing the exposure of children to tobacco
smoke with a concomitant improvement
in their health.
Public Policies
Governments can take a range of actions
that may reduce the exposure of children
to tobacco smoke. Current approaches include information dissemination, mandatory warning labels, and restrictions on
smoking in various places where children
congregate. These policy options are discussed in this section. All these interventions could be intensified from current
levels. Recent federal legislation to ban
smoking in schools and some other facilities which receive federal funding is a sign
of increased attention to the problem of
children’s exposure to ETS.
Dissemination of Information
Dissemination of the findings of scientific
evaluations of the health consequences of
children’s exposure to tobacco smoke is a
legitimate and perhaps even necessary role
of governments. It is the least coercive of
government interventions but is basic to
the formulation of all other policy in a
democratic society. Without appropriate
information, it will be difficult to form the
popular consensus necessary to develop
and enforce more restrictive policies. In
addition, information dissemination facilitates voluntary action on the part of
parents, caretakers, educators, health care
providers, and children themselves to protect children from the hazards of tobacco
smoke.
Important initial efforts to inform the
public of the dangers of ETS were the two
major reports on the health consequences
of involuntary smoking issued by the U.S.
Surgeon General and the National Research Council in 1986.3,4 A more recent
report by the U.S. Environmental Protection Agency5 has reinforced public concern about the dangers of ETS and served
as a springboard for regulatory initiatives,
discussed below, designed to restrict exposure of children and nonsmokers generally to ETS.
In addition to issuing rigorous scientific reports, government and/or voluntary agencies can disseminate information
on the dangers of ETS through more publicly accessible media. For example, in conjunction with its major 1992 report, the
EPA released a colorful pamphlet on what
parents and others can do about secondhand smoke. Recommendations from this
pamphlet on protecting children in and
outside the home are summarized in Box
2. In addition, the booklet contains a special message for smokers which states in
part: “If you have to smoke, here are some
things you can do to help protect the people close to you: Don’t smoke around children. Their lungs are very susceptible to
smoke. If you are expecting a child, quit
smoking.” 55
Beyond official reports and brochures,
the mass media may be a particularly appropriate channel to use to educate the
public on the dangers tobacco smoke
poses to young children and fetuses. Since
the 1964 Surgeon General’s report on
smoking and health, the public has received many antismoking messages in one
form or another. Few messages, however,
have specifically addressed the relationship between exposure to ETS and children’s health, and overall efforts to use
103
the media to convey anti-tobacco messages
of all kinds have been meager compared
with the well-funded marketing efforts of
tobacco manufacturers. Research on the
potential uses of the media to control tobacco use have likewise been limited and
inconclusive. In general, many observers
credit the decline in tobacco use over the
past several decades to a growing public
awareness of the many hazards of tobacco
use. It is likely that targeted media campaigns have played some role in enhancing public awareness of the dangers of
tobacco, but it has been difficult to quantify the media’s contribution, and no assessments have been made of the effect of
the media campaign on protecting children and fetuses from involuntary exposure to tobacco smoke.56
Warning Labels on Tobacco Products
Warning labels are frequently used with
products associated with a potential risk
for users, and requiring that tobacco products provide health-related information
on packages and in advertising is another
vehicle through which governments can
further the dissemination of this important information. Package warning labels
can include either brief statements printed directly on tobacco packages or more
detailed information on package inserts.
Beginning in 1965, federal law required
that all cigarette packages carry the following health warning: “CAUTION: Cigarette Smoking May Be Hazardous to Your
Health.”56
Warnings of the dangers of cigarette
smoke to children and fetuses were not
mandated until the Comprehensive Cigarette Education Act became effective in
1984. This law required that four warnings
be rotated periodically on all cigarette
packages and in all cigarette advertising.
Two of these warnings (see Figure 2) specifically refer to the dangers posed to the
fetus by smoking during pregnancy; however, these warnings do not call attention
to the hazards ETS poses to children after
birth.56
Research on consumers’ response to
warning labels generally has yielded mixed results. There have been no controlled
studies that look definitively at the independent effects of cigarette warning labels
on knowledge, attitudes, beliefs, or smoking behavior. Some studies suggest that
little attention is paid to the warnings. In
fact, warning labels may not be readable
in some advertising media. Clearly, the
Box 2
Advice from the EPA to Parents on What They
Can Do About Secondhand Smoke
In the Home
n
n
n
n
Don’t smoke in your house or permit others to do so.
If a family member insists on smoking indoors, increase
ventilation in the area where smoking takes place. Open
windows or use exhaust fans.
Don’t smoke if children—particularly infants and toddlers—are present. They are especially susceptible to the
effects of passive smoking.
Don’t allow baby-sitters or others who work in your home
to smoke in the house or near your children.
In Other Places Where Children Spend Time
EPA recommends that every organization dealing with children have a smoking policy that effectively protects children from exposure to environmental tobacco smoke.
n Find out about the smoking policies of the day-care
providers, preschools, schools, and other caregivers for
your children.
n Help other parents understand the serious health risks to
children from secondhand smoke. Work with parentteacher associations, your school board and school
administrators, community leaders, and other concerned citizens to make your child’s environment smoke
free.
In Automobiles
n
Don’t smoke in an automobile with the windows closed
if passengers are present. The high concentration of
smoke in a small, closed compartment substantially increases the exposure of other passengers.
Source: U.S. Environmental Protection Agency. Secondhand
smoke: What you can do about secondhand smoke as parents,
decisionmakers, and building occupants. 402-F-93-004. Washington, DC: EPA, July 1993.
current warnings are of little value in
reaching those who cannot read or understand English.2
There have been numerous suggestions for improving cigarette labeling in
the United States. Up to 16 different warnings have been proposed by the Federal
Trade Commission (FTC), and it has been
suggested that the visibility and effectiveness of the labels be improved by adding
pictures, using different languages, and
increasing the size of the warnings.2
Labeling requirements from other
countries provide some guidance for
modification of current U.S. practice. As
also illustrated in Figure 2, Iceland combines several aspects of these suggestions
in a rotational warning requirement which
104
Figure 2
Examples of Child-Related Health Warnings on Cigarette and
Tobacco Packages
United States (since 1985)
a
Surgeon General’s Warning:
n
SMOKING BY PREGNANT WOMEN MAY RESULT IN FETAL INJURY, PREMATURE BIRTH, AND
LOW BIRTH WEIGHT.
Canada (since 1994, printed in English and in French)
b
Canadian Ministry of Health and Welfare Warnings:
n
n
TOBACCO SMOKE CAN HARM YOUR CHILDREN.
SMOKING DURING PREGNANCY CAN HARM YOUR BABY.
Iceland (since 1985)
c
Director General of Public Health’s Warning:
Smoking during
pregnancy endangers the
health of mother and child.
Protect children from
tobacco smoke.
Sources: a U.S. Department of Health and Human Services. Reducing the health consequences of smoking: 25 years
of progress. A report of the Surgeon General. DHHS Publication No. (CDC) 89-8411. Washington, DC: U.S. Government
Printing Office, 1989. bNo-nonsense warnings will appear on Canadian smokes. Tobacco-Free Youth Reporter
(Summer 1993) 5,2:15. cBlondal, T., and Magnusson, G. Innovation in Iceland: Graphic health warnings on tobacco
products. New York State Journal of Medicine (July 1985) 85,7:405-6.
specifically addresses concerns about the
effects of smoking on children.2 Canada
has also recently modified its cigarette labeling requirements to highlight the risks
of tobacco smoke to children.57
Restrictions on Smoking in Public
Recognition of the dangers of ETS is leading to a ground swell of public support for
nonsmokers’ rights to clean air. Organizations that monitor smoking laws and policies have documented increasing numbers of laws and policies restricting or
banning smoking in public places and
workplaces. In 1990, for example, 45
states had laws restricting smoking in
public places. In addition, the average
restrictiveness of these laws has risen significantly over time.58
During the 1980s, the locus of smoking
control shifted from the state and federal
level to the local level. In 1990, 468 local
communities restricted smoking, compared with 89 only four years earlier.58
The rapidity with which smoking control
has spread in the workplace has verged on
the breathtaking: in 1985, only 27% of
workplaces prohibited or severely restricted smoking: in 1992, the figure had grown
to 59%.
Children also would benefit from regulations to protect them from ETS exposure when they are outside their homes in
105
licensed child day-care centers, family daycare homes, schools, and other public
places where they spend a substantial
amount of time.
A 1990 national survey of licensed
child day-care centers found that, although strong smoking policies were in
effect at the majority of centers, hundreds
of thousands of children in the United
States are at risk for exposure to ETS in
these settings.59 The survey found that
99% of the centers had employee smoking
policies that were in compliance with appropriate regulations; however, only 40
states regulated employee smoking in licensed centers, and only 3 states required
that centers be smoke free indoors. Overall, 55% of centers reported being smoke
free indoors and outdoors, and 26% were
smoke free indoors only.
Children appear to be at greater risk
for exposure to environmental tobacco
smoke in informal family child care arrangements involving relatives, friends, or
others who may care for children in their
homes. Such arrangements may involve
before- and/or after-school programs for
older children, as well as preschool-age
children. There is little information on
smoking in these facilities. A report from
Australia found that only 35% of organizations which provided such care for
children had formal no-smoking policies.60 Overall, 10% of caregivers were
reported to smoke actively while caring
for children; in some centers, 60% of caregivers smoked while caring for children.
Data from the United States suggest that,
among children from birth to three years
old, more than 25% of nonparental
caregivers in the child’s home or in another home setting smoke.61 These same
data suggest that significantly more caregivers smoke than mothers who are at
home with their own children. Even in
family day-care situations where caregivers
do not smoke, children may be exposed
to ETS if other household members smoke
when children are present.
Governments’ ability to take action to
protect children from exposure to ETS in
family day care may be quite limited as
many of these facilities are unlicensed and
unregulated. The most effective activity
may be to educate parents about the hazards of ETS exposure and recommend
that parents take appropriate action to
determine the smoking environment in
the centers they use and either remove
children from a smoke-filled environment
or request that the caregiver protect the
child.
Smoking in Schools
Schools are another venue where children spend a substantial part of their time
and where they may be exposed to ETS.
Smoking restrictions in schools should not
only protect students from exposure to
ETS, but also discourage smoking by children and adolescents.56
A 1988 survey of school smoking policies in a random sample of public school
districts found that 95% of respondents
had a written policy or regulation on tobacco smoking in schools.56 Most districts
restricted smoking by students, faculty,
staff and administration, and other adults;
however, only 17% totally banned smoking at all times on school premises, and
only 24% prohibited smoking by school
personnel in school buildings. In general,
policies which restrict smoking in schools
to designated areas may not protect children from ETS. Unless smoking areas are
adequately ventilated, ETS may circulate
throughout a building, especially via a
common heating or ventilation system,
and expose children to ETS even in nonsmoking areas.
Data from the United States suggest that,
among children from birth to three years
old, more than 25% of nonparental
caregivers in the child’s home or in
another home setting smoke.
Recent Legislation
In March 1994, Congress took the unprecedented step of outlawing smoking in
most of the nation’s schools, except in
areas that are closed off to children and
have outside ventilation.62 This provision
is part of the Goals 2000: Educate America
Act, which sets national education goals. It
would ban smoking not only in schools
which receive federal funding (all public
and some private schools), but also in
other programs for children with federal
funding including Head Start centers,
day-care centers, and most community
health centers. The law could go a long way
in protecting children from exposure to
ETS in those places outside the home
106
where they spend most of their time. What
is unknown at this time is how vigorously
the law will be enforced and what the level
of compliance with the law will be in
practice. Very limited research concerning
The sanctity of the family unit and
the home considerably restricts the ability
of government action to diminish exposure.
. . . [C]oercive legal and regulatory measures appear to be of limited practical usefulness in this area.
legal restrictions on smoking in public
places indicates that compliance can be
spotty and enforcement limited,63 but it is
encouraging that the compliance of public school personnel with restrictions on
smoking in schools has been reported as
generally quite good.57
Other Public Smoking Restrictions
In addition to schools and child care centers, children frequent other specific locations outside the home and may need
protection from ETS in these locales, specifically, restaurants, sports facilities, and
shopping malls.
Restrictions on smoking in restaurants
have long been controversial.62 A majority
of states and localities with populations of
at least 25,000 have enacted some restric-
tions in restaurants.2 Until recently, however, many restaurants, even those that
make specific marketing appeals to children, have not been smoke free.62 The
publication of the EPA’s findings on the
effects of ETS on children resulted in calls
from a variety of groups to eliminate
smoking sections in fast-food restaurants.64 In February 1994, the McDonald’s
Corporation announced that it was banning smoking in all company-owned restaurants and actively encouraging franchisees to make their restaurants smoke
free as well.65 Other restaurant chains
have followed suit, and a national trade
association of restaurant chains is backing
a national bill to end smoking in all restaurants. Clearly, parents and others who
make decisions about where children eat
out can reinforce the importance of a nonsmoking environments for children’s
health by frequenting smoke-free establishments.
Sports arenas and private enclosed
shopping malls are also gradually adopting restrictions on smoking.56 Many of
these facilities should be subject to state
and local restrictions on smoking in public places, but the level and effect of enforcement of these laws for these facilities
is unknown.
Smoking in the Home
The sentiment favoring protection of children can conflict with long-established
tenets when the locus of protection is also
the principal source of children’s exposure to ETS: parents who smoke. The sanctity of the family unit and the home
considerably restricts the ability of government action to diminish exposure. Any
legal attempts to compel nonsmoking in
the home are and will be highly controversial. While such attempts have been few in
number to date, those few have attracted
considerable attention. For example, in
recent divorce cases, judges have awarded
the custody of children to the nonsmoking
parent and have prohibited smoking by
the other parent during visitations.66
These extreme examples aside, coercive legal and regulatory measures appear
to be of limited practical usefulness in this
area of ETS control, and less coercive approaches to diminishing ETS exposure in
utero and in the home warrant special consideration. Health care providers would
appear to have a central and critical role
to play as they interact with parents at key
107
times: during pregnancy, at birth, at wellchild visits, and at visits for illnesses which
may be ETS related.
Counseling During Pregnancy
Prevention of smoking during pregnancy
is of great value because the fetal outcome
is improved when the mother does not
smoke. Yet one in five women continue to
smoke during pregnancy. Because prenatal smoking cessation could substantially
improve maternal and infant health and
save millions of health care dollars, a rate
of 90% smoking abstinence during pregnancy has been established as a national
goal for the year 2000.67 Yet, it appears
very unlikely that this objective will be
achieved.
During the past 10 years, a number of
smoking cessation interventions for pregnant women have been developed and
tested among patients and prenatal care
professionals in a variety of settings. The
behavioral impact of these interventions,
their contribution to improved pregnancy
outcomes, and their cost-effectiveness
have been reported in a number of published reports. Based on these reports, it
appears that available methods can produce smoking cessation rates of 14% to
27% in pregnant women.67
A recent review of smoking in pregnancy found that many factors seem to
account for the variability in success rates
reported in the literature.68 In general, it
appears that information about the risk
of smoking during pregnancy may increase cessation rates above those found
in patients receiving “usual” prenatal
care. Higher quit rates can be obtained
with the addition of specific components
to teach cessation skills and materials specifically targeting the pregnant smoker.
Low-intensity cessation programs which use
a standardized health education counseling session and provide patients with inexpensive self-help manuals have proved
effective. Training time and the costs of
personnel and materials in these lowintensity interventions appear modest, and
studies suggest that the interventions are
cost saving, returning at least three dollars
on the cost of neonatal care for every one
dollar spent on prenatal smoking cessation activities. This return should be particularly attractive to HMOs, Medicaid
programs, and even indemnity insurers,
who will be able to recoup their investment
in intervention costs with savings on neonatal care in a very short period of time.
An added benefit of prenatal smoking
cessation may be that the mother will be
able to remain abstinent after the birth.
This outcome will have a positive effect
not only on her health, but also on the
health of the infant and other children in
the household, who will be less likely to
be exposed to ETS if the mother does
not smoke. A study of English-speaking
women in a large HMO in California
found that 37% of women who had quit
smoking before the 26th week of pregnancy and continued abstinent through
delivery maintained their nonsmoking
status at six months postpartum.69 Other
studies have found somewhat lower rates
of maintenance postpartum.68 All work in
this area suggests that concentration on
smoking cessation during the prenatal period is not enough. Attention should also
be directed toward developing successful
intervention strategies for late pregnancy
and the early postpartum period. Further
work also needs to be done in refining
strategies for application early in preg-
Interventions are cost saving, returning at
least three dollars on the cost of neonatal
care for every one dollar spent on prenatal
smoking cessation activities.
nancy and in customizing interventions
for particular populations. For example, it
appears that, while minimal contact programs with serial mailings of materials
and telephone follow-ups work with
higher socioeconomic groups, programs
for lower socioeconomic women may require more individualized counseling and
follow-up and frequent cessation cues
from multiple sources.69 Successful programs will also have to adapt to different
languages and cultures. Dealing with
women who live in households and communities where smoking is very prevalent
will be a real challenge not only because
of the many personal interactions that
support and provide cues to smoking, but
also because recent studies report that
constituents of ETS can cross the placental
barrier and pose a danger to fetuses of
nonsmoking mothers.70
One problem that has come to light in
studies of smoking cessation programs
during pregnancy is that emphasis on
108
smoking cessation during prenatal care
can lead to increasing rates of nondisclosure.68 Nondisclosure of smoking status
poses a problem for researchers and practitioners alike. For research studies, some
The goal should be a nonsmoking mother not only during
pregnancy, but also after birth.
form of biochemical validation is recommended for measuring outcomes. This
can be expensive and raise issues of consent. An alternative approach, which can
also be applied in clinical settings, is to
use questions that allow respondents to
choose partly favorable responses, such as
“I smoke now, but I have cut down since I
found out that I was pregnant.”68
Unfortunately, it appears that, given
the success rate of tested prenatal smoking cessation programs, the vast majority
of women smokers will continue to smoke
throughout pregnancy even if these techniques are widely disseminated and applied. Therefore, prenatal smoking cessation will require more research; however,
dissemination and implementation of existing knowledge and practice are also
called for. Clinicians need to be persistent
in applying proven techniques, and financing mechanisms need to be established to support the effort.
Nicotine Replacement Therapy
Two forms of nicotine replacement therapy (NRT) have been approved for nonexperimental use to help smokers achieve
abstinence from cigarettes: nicotine gum
and the transdermal nicotine patch. Considerable evidence has accumulated that
these products can substantially increase
the likelihood that a smoker will be able to
quit and remain abstinent for at least six
months.71 The more recently developed
patch is generally regarded as the method
of choice because it is easier to use than
the gum.72
Until recently, NRT has been considered to be contraindicated in pregnant
women despite the evidence of its effectiveness in improving smoking cessation
rates in nonpregnant subjects. 73 Because
nicotine is a potentially toxic drug, perhaps even a teratogen, it was felt that providing pregnant women with NRT raised
important ethical, medical, and medicolegal questions.74,75 Although there have
been no published studies of the efficiency
or safety of NRT in pregnant women, some
experts believe it is less harmful to expose
the fetus to nicotine alone than to the
thousands of potentially noxious chemicals in cigarette smoke. 72,73
It appears likely that some physicians
are prescribing NRT for their pregnant
patients. Even an expert panel convened
by the American Medical Association advises that “physicians must consider the
risk-benefit issues in the individual patient
situation.”72 Accordingly, it would appear
appropriate to consider a clinical trial of
NRT in smoking pregnant women to judge
both its efficacy and safety and potential
contribution, if any, to improved outcomes
for infants exposed to maternal smoking
during pregnancy.
Even if NRT is judged too risky to be
used routinely during pregnancy, it might
be effective and appropriate during the
preconception period. In 1989, the Public
Health Service Expert Panel on the Content of Prenatal Care recommended that
a preconception visit be part of the prenatal process.76 Such a visit permits the
identification of medical and behavioral
problems before conception and offers
mothers-to-be and clinicians a wider choice
of responses to potential problems than
would be available after conception. For a
smoker, the preconception visit affords an
opportunity to counsel the mother on the
dangers of smoking to the fetus and on the
techniques available to facilitate cessation.
It would appear that NRT could be considered and offered during the preconception period. If smoking cessation is
achieved after 6 to 10 weeks of therapy, it
would likely be necessary to offer some
supportive nonpharmacologic therapy
during pregnancy to sustain abstinence.
The goal should be a nonsmoking mother
not only during pregnancy, but also after
birth. Again, although this strategy seems
reasonable, this intervention has yet to be
developed explicitly or investigated scientifically. It appears, however, that such investigations would be worthwhile.
Other Opportunities for Health Care
Providers
Even after the prenatal period, health care
providers have the responsibility and opportunity to counsel patients on the dangers posed to children by exposure to ETS.
The recommended series of 12 well-child
109
visits during the first six years of life can
provide the occasion for pediatricians,
nurse practitioners, and others not only to
warn of the dangers of ETS, but also to
inquire into the smoking habits of parents
and other adults who come in contact with
young children and to suggest strategies to
77
reduce exposure. Similar opportunities
exist for dentists who see children regularly for preventative care.78
many common pediatric illnesses and of
also reducing the costs associated with
those illnesses. Accordingly, such interventions may be of particular interest to
managed care plans which may be able to
offset the added costs of counseling with
the savings from reduced levels of illnessrelated health care.
Physician visits with sick children, particularly for those with respiratory ailments associated with smoking, may
provide a particularly opportune time to
counsel parents on the dangers of ETS.
There has been little research into how to
counsel parents effectively and into the
consequences of counseling. A recent
study from Canada suggested that asthmatic children were exposed to fewer
cigarettes and their asthma was less severe
when doctors advised their parents not to
expose the children to tobacco smoke.79
Parents reported that they attempted to
avoid exposing children to smoke by
smoking outdoors or in another room or
by smoking by an open window or blowing their smoke through exhaust vents.
Another study found that counseling of
parents of asthmatic children in San Diego was associated with substantial reduction in the children’s exposure to ETS.80
The study looked at only five children,
however, and the intervention consisted
of an intensive series of five biweekly, 30minute, counseling/instructional sessions
for parents. These sessions focused on
practical ways that parents could reduce
children’s exposure to ETS. This appears
to have been a costly and time-intensive
intervention. In fact, 4 of the 11 families
eligible to participate in the study refused
because of time constraints or lack of interest. Whether such elaborate interventions are sufficiently more effective than
simple physician advice to warrant their
general implementation is unknown. Also
unknown is what works with parents of
children who are adversely affected by ETS
but who do not have chronic and severe
disease such as asthma.
As this article goes to press, the news on
protecting children from the hazards of
other people’s tobacco smoke is good. The
dangers have been identified in the scientific literature, and validated and quantified in well-publicized government reports. Policies to protect children from
exposure to ETS outside the home have a
strong base of public support, have been
enacted into law, and are being adopted
by private businesses that market to families with children. Even the major tobacco
companies recognize that opposition to
Health care providers have the
responsibility and opportunity
to counsel patients on the
dangers posed to children by
exposure to ETS.
It appears that much remains to be
done to develop, test, and implement procedures that assure frequent and effective
counseling of parents on reducing their
children’s exposure to ETS not only in the
home but in out-of-home settings such as
child care facilities. Such interventions
hold the promise, however, of reducing
substantially the incidence and severity of
Other educational interventions—in
the media, in health care settings, and
elsewhere—may constitute the most feasible method of attacking the problem.
One obvious model is the cooperative effort of pediatricians, hospitals, and car
safety seat manufacturers to encourage
new parents to use safety seats for their
babies and young children. Although
Conclusion
policies designed principally to protect
children is a bad strategy.62 Yet much remains to be done, especially to address the
issue of exposure of children during pregnancy and in their own family units.
One conceptually easy but politically
difficult action would be to include a
warning on the danger to children of ETS
exposure on cigarette packages as is
done in other countries (see Figure 2).
Even if such a requirement were not enacted, the publicity attendant to the debate over its implementation, might raise
public awareness of the issue.81
110
cooperative educational interventions
might be desirable, widespread application may not develop easily. Particularly
discouraging is the limited evidence that
many physicians do not routinely and
effectively counsel parents and pregnant
women on the dangers of tobacco smoke
to children. It is difficult to know the
reasons for this oversight. It may be that
some physicians and other health professionals are too busy to engage in an activity for which they are not financially rewarded.82 They may also not be aware of
the evidence on ETS exposure and child
Media campaigns have succeeded in raising
awareness levels and contributed to behavior
change. . . . California’s unprecedented antitobacco mass media campaign may have
contributed to an increase in the number of
smoke-free homes in the state.
health, although a number of professional societies have prepared statements
on ETS and health. More likely they are
unaware of effective interventions. It
would probably be helpful to place greater emphasis on environmental causes of
disease and their control during the
training of physicians and other health
care providers. A recent study showed
that a brief course on pediatric environmental health assessment increased
awareness of pediatric residents of environmental health problems; identification of smoking in the home of asthmatic
children was one of the indicators favor83
ably affected.
Any educational interventions need to
appropriately take account of the changing demographics of smoking. With smok-
ing increasingly concentrated among
less-educated, lower-income Americans,
educational appeals, particularly those
designed by and for a highly literate
population, will need to be redesigned
and targeted to today’s smokers. Lowerincome individuals are also less likely to
have a regular source of primary care, further complicating the problem of delivering and following up on educational
interventions.
Outside health care delivery, media
interventions deserve attention as well.
Whether sponsored by medical and voluntary health organizations or paid for by
government, media campaigns have succeeded in raising awareness levels and
contributed to behavior change.84 A recently released evaluation of California’s
excise-tax-financed tobacco control program suggests that the state’s unprecedented anti-tobacco mass media campaign
may have contributed to an increase in the
number of smoke-free homes in the
state.85 Households with preschool-aged
children were more likely to be smoke free
than households without children. It is too
early to tell whether this initial response
to the mass media campaign will be sustained, particularly if the campaign is substantially scaled back.
The true “frontier” of smoking control, and perhaps one of the most important determinants of the health damage
wrought by ETS, is how society will deal
in the future with parents’ smoking in the
presence of their children. Given the
sanctity of the home, this most important
locus of ETS exposure remains the one
least likely to be drawn significantly into
the battle. Recent court actions indicate
that the home front will not remain ex66
empt from attention. The practical challenge, however, is to develop educational
interventions that are at once effective
and noncoercive.
1. U.S. Department of Health, Education, and Welfare. The health consequences of smoking, 19771978. DHEW Publication No. (PHS) 79-50065. Washington, DC: U.S. Government Printing Office, 1979.
2. U.S. Department of Health and Human Services. Reducing the health consequences of smoking:
25 years of progress. A report of the Surgeon General. DHHS Publication No. (CDC)
89-8411. Washington, DC: U.S. Government Printing Office, 1989.
3. U.S. Department of Health and Human Services. The health consequences of involuntary smoking. A report of the Surgeon General. Rockville, MD: U.S. Government Printing Office,
1986.
4. National Research Council, Committee on Passive Smoking. Environmental tobacco smoke:
Measuring exposures and assessing health effects. Washington, DC: National Academy Press,
1986.
5. U.S. Environmental Protection Agency. Respiratory health effects of passive smoking: Lung cancer
and other disorders. EPA/600/6-90/006F. Washington, DC: EPA, 1992.
6. Surgeon General’s Advisory Committee on Smoking and Health. Smoking and health: Report
of the Advisory Committee to the Surgeon General of the Public Health Service. Washington, DC:
U.S. Government Printing Office, 1964.
7. Royal College of Physicians. Smoking and the young: A report of a working party of the Royal College of Physicians. London: Royal College of Physicians of London, 1992.
8. U.S. Department of Health and Human Services. Preventing tobacco use among young people. A
report of the Surgeon General. Washington, DC: U.S. Government Printing Office, 1994.
9. Poswillo, D., and Alberman, E. Effects of smoking on the fetus, neonate, and child. New York: Oxford University Press, 1992, p. 230.
10. Guerin, M.R., Jenkins, R.A., and Tomkins, B.A. The chemistry of environmental tobacco smoke:
Composition and measurement. Chelsea, MI: Lewis Publishers, 1992.
11. U.S. Department of Health and Human Services. The health consequences of smoking: Chronic
obstructive pulmonary disease. A report of the Surgeon General. Washington, DC: U.S. Government Printing Office, 1984.
12. Spengler, J.D., Dockery, D.W., Turner, W.A., et al. Long-term measurements of respirable
sulfates and particles inside and outside homes. Atmospheric Environment (1981) 140:23-30.
13. Henderson, F.W., Reid, H.F., Morris, R., et al. Home air nicotine levels and urinary cotinine
excretion in preschool children. American Review of Respiratory Diseases (1989) 140:197-201.
14. Coultas, D.B., Samet, J.M., McCarthy, J.F., and Spengler, J.D. Variability of measures of exposure to environmental tobacco smoke in the home. American Review of Respiratory Diseases
(1990) 142:602-6.
15. Wallace, L.A. The total exposure assessment methodology (TEAM) study: Summary and analysis.
Vol. 1. Washington, DC: U.S. Environmental Protection Agency, Office of Research and
Development, 1987.
16. U.S. Department of Health and Human Services. The health consequences of smoking: Nicotine
addiction. A report of the Surgeon General. Washington, DC: U.S. Government Printing
Office, 1988.
17. U.S. Department of Commerce. Statistical Abstract of the United States, 1993. Lanham, MD:
Bernan Press, 1993, p. 138.
18. Overpeck, M.D., and Moss, A.J. Children’s exposure to environmental cigarette smoke before and
after birth. Hyattsville, MD: U.S. Department of Health and Human Services, 1991, p. 12.
19. Greenberg, R.A., Bauman, K.E., Strecher, V.J., et al. Passive smoking during the first year of
life. American Journal of Public Health (1991) 81:850-53.
20. Samet, J.M. Environmental tobacco smoke. In Environmental toxicants: Human exposures and
their health effects. M. Lippmann, ed. New York: Van Nostrand Reinhold, 1992.
21. Reese, A.C., James, I.R., Landau, L.I., and Le Souef, P.N. Relationship between urinary
cotinine level and diagnosis in children admitted to hospital. American Review of Respiratory
Diseases (1992) 146:66-70.
22. Chen, Y., Li, W., and Yu, S. Influence of passive smoking on admissions for respiratory illness in early childhood. British Medical Journal (1986) 293:303-6.
23. Jin, C., and Rossignol, A.M. Effects of passive smoking on respiratory illness from birth to
age eighteen months, in Shanghai, People’s Republic of China. Journal of Pediatrics (1993)
123:553-58.
24. Schenker, M.B., Samet, J.M., and Speizer, F.E. Risk factors for childhood respiratory disease:
The effect of host factors and home environmental exposures. American Review of Respiratory Diseases (1983) 128:1038-43.
25. Ware, J.H., Dockery, D.W., and Spiro, A., III, et al. Passive smoking, gas cooking, and respiratory health of children living in six cities. American Review of Respiratory Diseases (1984)
129:366-74.
26. Somerville, S.M., Rona, R.J., and Chinn, S. Passive smoking and respiratory conditions in
primary school children. Journal of Epidemiology and Community (1988) 42:105-10.
27. Samet, J.M., Tager, I.B., and Speizer, F.E. The relationship between respiratory illness in
childhood and chronic air-flow obstruction in adulthood. American Review of Respiratory Diseases (1983) 127:508-23.
28. Martinez, F.D., Antognoni, G., Macri, F., et al. Parental smoking enhances bronchial responsiveness in nine-year-old children. American Review of Respiratory Diseases (1988) 138:518-23.
111
112
29. Young, S., Le Souef, P.N., Geelhoed, G.C., et al. The influence of a family history of asthma
and parental smoking on airway responsiveness in early infancy. New England Journal of
Medicine (1991) 324,17:1168-73.
30. Duff, A.L., Pomeranz, E.S., Gelber, L.E., et al. Risk factors for acute wheezing in infants and
children: Viruses, passive smoke, and IgE antibodies to inhalant allergens. Pediatrics
(1993) 92:535-40.
31. Rosen, F.L., and Levy, A. Bronchial asthma due to allergy to tobacco smoke in an infant: A
case report. Journal of the American Medical Association (1950) 144,8:620-21.
32. Murray, A.B., and Morrison, B.J. The effect of cigarette smoke from the mother on bronchial responsiveness and severity of symptoms in children with asthma. Journal of Allergy
and Clinical Immunology (1986) 138:575-81.
33. Murray, A.B., and Morrison, B.J. Passive smoking by asthmatics: Its greater effect on boys
than on girls and on older than on younger children. Pediatrics (1989) 84:451.
34. Evans, D., Levison, M.J., Feldman, C.H., et al. The impact of passive smoking on emergency
room visits of urban children with asthma. American Review of Respiratory Diseases (1987)
135:567-72.
35. Weitzman, M., Gortmaker, S., and Sobol, A. Racial, social, and environmental risks for childhood asthma. American Journal of Diseases of Children (1990) 144,11:1189-94.
36. Etzel, R.A., Pattishall, E.N., Haley, N.J., et al. Passive smoking and middle ear effusion
among children in day care. Pediatrics (1992) 90:228-32.
37. Ostro, B.D. Estimating the risks of smoking, air pollution, and passive smoke on acute respiratory conditions. Risk Analysis (1989) 9:189-96.
38. Charlton, A., and Blair, V. Absence from school related to children’s and parental smoking
habits. British Medical Journal (1989) 298:90-92.
39. Tager, I., Munoz, A., Rosner, B., et al. Effect of cigarette smoking on the pulmonary function of children and adolescents. American Review of Respiratory Diseases (1985) 131:752-59.
40. Pershagen, G. Childhood cancer and malignancies other than lung cancer related to passive smoking. Mutation Research (1989) 222:129-35.
41. Janerich, D.T., Thompson, W.D., Varela, L.R., et al. Lung cancer and exposure to tobacco
smoke in the household. New England Journal of Medicine (1990) 323:632-36.
42. Moskowitz, W.B., Mosteller, M., Schieken, R.M., et al. Lipoprotein and oxygen transport alterations in passive smoking preadolescent children: The MCV Twin Study. Circulation
(1990) 81:586-92.
43. Martin, T.R., and Bracken, M.B. Association of low birthweight with passive smoking exposure in pregnancy. American Journal of Epidemiology (1986) 124:633-42.
44. Rubin, D.H., Levanthal, J.M., Krasilnikoff, P.A., et al. Effect of passive smoking on birth
weight. Lancet (1986) 2:415-17.
45. Rubin, B.K. Exposure of children with cystic fibrosis to environmental tobacco smoke. New
England Journal of Medicine (1990) 323:782-88.
46. Ronchetti, R., Bonci, E., Cutrera, R., et al. Enhanced allergic sensitization related to parental smoking. Archives of Disease in Childhood (1992) 67:496-500.
47. National Academy of Sciences, Committee on Nutritional Status During Pregnancy and Lactation, Subcommittee on Nutrition During Lactation. Nutrition during lactation. Washington, DC: National Academy Press, 1991.
48. Hopkinson, J.M., Schanler, R.J., Fraley, J.K., and Garsza, C. Milk production by mothers of
premature infants: Influence of cigarette smoking. Pediatrics (1992) 90:934-38.
49. U.S. Department of Health and Human Services. The health benefits of smoking cessation. A report of the Surgeon General. DHHS Publication No. (CDC) 90-8416. Rockville, MD:
DHHS, 1990.
50. Rush, D. Exposure to passive cigarette smoking and child development: An updated critical
review. In Effects of smoking on the fetus, neonate, and child. D. Poswillo and E. Alberman, eds.
New York: Oxford University Press, 1992, pp. 150-70.
51. Campbell, O. Ectopic pregnancy and smoking: Confounding or causality? In Effects of smoking on the fetus, neonate, and child. D. Poswillo and E. Alberman, eds. New York: Oxford University Press, 1992, pp. 23-44.
52. Weitzman, M., Gortmaker, S., and Sobul, A. Maternal smoking and behavior problems of
children. Pediatrics (1991) 90:342-49.
53. Everson, R.B. Individuals transplacentally exposed to maternal smoking may be at increased cancer risk in adult life. Lancet (1980) 2:123-27.
54. Grufferman, S., Delzell, E.S., Maile, M.C., and Michalopoulos, G. Parents’ cigarette smoking and childhood cancer. Medical Hypotheses (1983) 12:17-20.
55. U.S. Environmental Protection Agency. Secondhand smoke: What you can do about secondhand
smoke as parents, decisionmakers, and building occupants. 402-F-93-004. Washington, DC: EPA,
July 1993.
56. For more information about the use of tobacco among young people, see note no. 8, U.S.
Department of Health and Human Services.
57. No-nonsense warnings will appear on Canadian smokes. Tobacco-Free Youth Reporter (Summer
1993) 5,2:15.
58. U.S. Department of Health and Human Services. Strategies to control tobacco use in the United
States: A blueprint for public health action in the 1990’s. NIH Publication No. 92-3316. Washington, DC: U.S. Government Printing Office, 1991.
59. Nelson, D.E., Sacks, J.J., and Addiss, D.G. Smoking policies in licensed child day-care centers in the United States. Pediatrics (1993) 91:460-63.
60. Jorm, L., Blyth, F., Chapman, S., and Reynolds, C. Smoking in child family day care homes:
Policies and practice in New South Wales. Medical Journal of Australia (1993) 159:518-22.
61. Holberg, C.J., Wright, A.L., Martinez, F.D., et al. Child day care, smoking by caregivers, and
lower respiratory tract illness in the first 3 years of life. Pediatrics (1993) 91,5:885-92.
62. Seelye, K. Congress considers smoking ban in schools. New York Times, March 23, 1994, at
A14; Rosenbaum, D.E., and Hilts, P.J. New laws on smoking unlikely this year. New York
Times, April 18, 1994, at A7.
63. Rigotti, N.A., Stoto, M.A., Bierrer, M.F., et al. Retail stores’ compliance with a city no-smoking
law. American Journal of Public Health (1993) 83,2:227-32; Lewit, E.M., Botsko, M., and
Meinert, L. The response of restaurants to New Jersey’s smoking control law. New Jersey
Medicine (1992) 89:531-35.
64. Fast food, growing children and passive smoke: A dangerous menu. Washington, DC: National Association of Attorneys General, 1993, pp. 1-18.
65. Hilts, P.J. McDonald’s bans smoking at all company-owned restaurants. New York Times. February 24, 1994, at A13.
66. ETS had role in California child custody case. Tobacco-Free Youth Reporter (Autumn 1993)
5,3:6. Courts’ ruling protect children from ETS. Tobacco-Free Youth Reporter (Summer 1993)
5,2:13.
67. Windsor, R.A., Li, C.Q., Lowe, B., et al. The dissemination of smoking cessation methods
for pregnant women: Achieving the Year 2000 objectives. American Journal of Public Health
(February 1993) 83,2:173-78.
68. Floyd, R.L., Rimer, B.K., Giovino, G.A., et al. A review of smoking in pregnancy: Effects
on pregnancy outcomes and cessation efforts. Annual Review of Public Health (1993)
14:379-411.
69. Mullen, P.D., Quinn, V.P., and Ershoff, D.H. Maintenance of nonsmoking postpartum by
women who stopped smoking during pregnancy. American Journal of Public Health (August
1990) 80,8:992-94; Brenner, H., and Mielck, A. The role of childbirth in smoking cessation. Preventive Medicine (1993) 22:225-36.
70. Eliopoulos, C., Klein, J., Phan, M.K., et al. Hair concentrations of nicotine and cotinine in
women and their newborn infants. Journal of the American Medical Association (February 28,
1994) 271,8:621-23.
71. Silagy, C., Mant, D., Fowler, G., et al. Meta-analysis of efficacy of nicotine replacement therapies in smoking cessation. Lancet (1994) 343:139-42.
72. American Medical Association. How to help patients stop smoking: Guidelines for diagnosis and
treatment of nicotine dependence. Chicago: AMA, 1994. Other forms of NRT include nicotine
sprays and inhalers which have not yet been licensed for general clinical use. Experimental work is also under way using a combination of NRT modalictic. See note no. 71, Silagy,
Mant, Fowler, et al.
73. Benowitz, N.L. Nicotine replacement therapy during pregnancy. Journal of the American Medical Association (December 1991) 266,22:3174-77.
74. Seidman, D.S., and Stevenson, D.K. Letter to the editor: Nicotine replacement therapy during pregnancy. Journal of the American Medical Association (April 1992) 267,14:1922.
113
114
75. Benowitz, N.L. In reply to letter to the editor: Nicotine replacement therapy during pregnancy. Journal of the American Medical Association (April 1992) 267,14:1922.
76. U.S. Department of Health and Human Services. Caring for our future: The content of prenatal
care. Washington, DC: DHHS, 1989.
77. Green, M., ed. Bright futures: Guidelines for health supervision of infants, children, and adolescents. Arlington, VA: National Center for Education in Maternal and Child Health, 1994.
Also see, Landrigan, P.J., DiLiberti, J.H., Graef, J.W., et al. Involuntary smoking: A hazard
to children. Pediatrics (1986) 77,5:755-57.
78. Waldman, H.B. Do the parent(s) of your pediatric patients smoke? Journal of Dentistry for
Children (March/April 1992) 59,2:126-28.
79. Murray, A.B., and Morrison, B.J. The decrease in severity of asthma in children of parents
who smoke since the parents have been exposing them to less cigarette smoke. Journal of
Allergy and Clinical Immunology (January 1993) 91:102.
80. Meltzer, S.B., Hovell, M.F., Meltzer, E.O., et al. Reduction of secondary smoke exposure in
asthmatic children: Parent counseling. Journal of Asthma (1993) 30,5:394-400.
81. Leu, R.E. Anti-smoking publicity, taxation, and the demand for cigarettes. Journal of Health
Economics (1984) 3:101-16.
82. Kligman, E.W., and Narce-Valente, S. Reducing the exposure of children to environmental tobacco smoke: An office-based intervention program. Journal of Family Practice
(1990) 3:263-69; Frankowski, B.L., Weaver, S.O., and Secker-Walker, R.H. Advising parents to stop smoking: Pediatricians’ and parents’ attitudes. Pediatrics (February 1993)
91,2:296-300. See also note no. 68, Floyd, Rimer, Giovino, et al.
83. Bearer, C.F., and Phillips, R. Pediatric environmental health training: Impact on pediatric
residents. American Journal of Diseases of Children (1993) 147:682-84.
84. Flay, B.R. Selling the smokeless society: 56 evaluated mass media programs and campaigns worldwide.
Washington, DC: American Public Health Association, 1987.
85. Pierce, J.P., Evans, N., Farkas, A.J., et al. Tobacco use in California: An evaluation of the Tobacco
Control Program, 1989-1993. La Jolla: University of California, San Diego, 1994.
Beyond Benefits:
The Importance of a
Pediatric Standard in
Private Insurance
Contracts to Ensuring
Health Care Access for
Children
Elizabeth Wehr
Elizabeth J. Jameson
Editor’s Note
This article examines restrictions on children’s access to necessary health care that
result from denials of service pursuant to standard exclusions in indemnity insurance
and managed care plan policies. Plans deny or limit coverage of a service they
determine to be not “medically necessary,” or “experimental,” or “investigative.” The
authors contend that, in making such decisions for children, insurers and providers
do not give proper weight to children’s developmental vulnerabilities and other
characteristics which distinguish their health care from that of adults. The authors
also discuss the difficulties of addressing this problem through current insurance
laws. They urge that health care reform legislation establish a pediatric standard
which would require decisions about appropriate coverage for children to be
consistent with developmental concerns and other important factors in their care.
— C.L.
A
s this country strives to define and implement health care reform,
there is an opportunity to focus on the health care needs of
children and the system reforms that can help ensure that those
needs are met. Much of the attention on children in the health care
reform debate has been on defining a benefit package for them. There
has been a growing understanding of the importance of preventive
services such as immunizations and well-child checkups, and these benefits were specifically included in several leading reform proposals before
Congress this year.
Vol. 4 • No. 3 – Winter 1994
Elizabeth Wehr, J.D., is
a research associate at
The George Washington University Center
for Health Policy Research.
Elizabeth J. Jameson,
J.D., is a staff attorney
at the Youth Law Center and director of the
Project on Children
with Special Medical
Needs, San Francisco.
This article is an adaptation
of the article by Jameson and
Wehr which appeared in
Stanford Law & Policy Review, (Fall 1993) 5,1:15276. Printed with permission.
116
In part, the emphasis on preventive
services for children reflects a recognition
that children’s health care differs from
that of adults in ways which are clinically
important. The defining difference is that
children must be diagnosed and treated
in the context of their rapid and continuous growth and development, a context
that has no counterpart in the health care
of adults. Children are also unique in their
dependence on others for an environ-
Even when benefits are enumerated in
insurance policies, access to them may be
restricted by standard exclusionary clauses
that appear in both indemnity insurance
and managed care contracts.
ment that permits their genetic potential
to unfold. In addition, children are subject
to more types of rare and/or complex
disorders than adults, but relatively few
children have any one condition. And disorders like cancer and human immunodeficiency virus (HIV) which occur in
both age groups can differ markedly in
the ways that they present and play out
in each and the therapies available for
their treatment.1
The Need for a Pediatric
Standard
The special characteristics of children
have implications for their health care coverage which go beyond the types of benefits specified in a reform package. Even
when benefits are enumerated in insurance policies, access to them may be restricted by standard exclusionary clauses
that appear in both indemnity insurance
and managed care contracts. One clause
limits covered services to those that are
“medically necessary” for an individual. A
second bars coverage for any clinical intervention that is “experimental” or “investigative.” The major health reform bills
before Congress this year allowed continued use of these contractual exclusions.
These exclusions give a health plan
considerable discretion to legally withhold covered services from an individual
plan member. The reason is that, in the
context of private health insurance, nei-
ther “medically necessary” nor “experimental” or “investigative” have precise
meanings that may be invoked on behalf
of a patient. Thus, whether and for how
long a child receives speech therapy, for
example, or is referred to a pediatric cardiologist may depend on whether the entity financing the child’s health care
decides that the therapy or the referral is
“medically necessary.” Whether a child receives a new combination of anticancer
drugs may depend on whether the entity
considers the treatment not to be experimental. As will be discussed, current law
does not ensure that these decisions will
take into account the unique needs and
circumstances of children.
At the time of this writing, it is not
certain which reform measure, if any, will
become law. The purpose of this article is
to set forth the rationale for a separate
standard of health care coverage for children. This pediatric standard would not
only specify a comprehensive benefit
package for children, but also establish
parameters for the discretionary decision
making by providers and insurers. The
pediatric standard would be written into
the federal health reform statute; applied
in subsequent regulatory, administrative,
and judicial interpretations of the statute;
and included in the practice guidelines of
health plans, their standards for reviewing
the medical necessity or experimental
status of a procedure, and other plan decision making.
The arguments for a pediatric standard and its implications for a benefit
package for children are set forth in our
recent article in the Stanford Law & Policy
Review which also discusses the legal tools
needed to make the standard enforceable.2 This article focuses on the need
for a pediatric standard to constrain the
discretionary decision making of plans.
Under this standard, the burden would be
on the provider and/or insurer who decides whether a child receives a particular
health service to demonstrate that this decision takes into account and is consistent
with the child’s healthy growth and development and is responsive to disorders of
childhood which require specialized clinical knowledge and skills. This general rule
for discretionary decision making, taken
together with the pediatric benefit package, would comprise a legally binding
standard for measuring the adequacy of
children’s health care at every level in the
health care system.
The Importance of a Pediatric Standard in Private Insurance Contracts to Ensuring Health Care Access for Children
A pediatric standard embodied in
health reform law is necessary in light of
reported failures of health plans to give
proper weight to children’s developmental vulnerabilities and unique needs. We
believe that these failures are a result in
part of aggressive efforts to control costs.
We also recognize that effective controls
on health care expenditures are essential
to systemic reform, to discourage wasteful
and unnecessary consumption of health
care resources. However, recent accounts
discussed below of children’s difficulties
in access to certain types of health care
strongly suggest that, when managed care
methods of cost control3 are applied without taking into account children’s characteristics as patients, nonwasteful, necessary
care for children may be inappropriately
withheld.
Concerns about controlling health
care costs continue to dominate the business and political climate, making an explicit and legally enforceable pediatric
standard of coverage particularly important. The pediatric standard would require
that, as the costs of health care for children
are weighed against benefits, the focus is
on benefits specifically to children, with full
consideration of children’s developmental and health needs. Organizations with
expertise in the clinical care of children,
such as the American Academy of Pediatrics and the National Institutes of Health,
should be designated specifically, or by a
general reference, in a health reform statute, for purposes of establishing and updating the pediatric standard of coverage.
Clinical practice guidelines or consensus
statements about appropriate care of children from such organizations may be expected to reflect developmental considerations and other factors in the appropriate
care of children. A statute might require
a federal agency to establish the standard
in consultation with such organizations;
the agency, in turn, might promulgate its
clinical practice guidelines as part of its
regulation explaining the standard.
The first section of this article reviews
the state and federal laws that regulate
private health insurance and explains why
systemic reform is needed to protect the
health interests of children. The second
section describes the special needs of children. The third section discusses administrative procedures that can operate as
barriers to care, and the fourth section
examines contractual provisions that provide the basis for restricting access to care.
Finally, the fifth section reports on the
status of congressional consideration of
children’s coverage issues in health care
reform legislation (as of July 1994).
Private Health Insurance
Regulation
An estimated 43 million children under
age 18 have some form of private health
insurance or health maintenance organization (HMO) coverage, either as dependents of individuals covered by employer
4,5
plans or otherwise. To understand the
need for a federal standard of health care
coverage for children, it is important to
understand existing laws that regulate indemnity insurance and other types of
health plans, and their limitations as a
means of improving health care coverage
for children.
There are a half dozen bodies of state
and federal law that apply directly to privately financed health coverage. At the
state level, there are specialized common
law doctrines that apply in insurance disputes, and also statutory and administrative
rules that regulate the business of insurance. At the national level, there are three
A pediatric standard embodied in
health reform law is necessary in light of
reported failures of health plans to give
proper weight to children’s developmental
vulnerabilities and unique needs.
federal statutes, and bodies of regulation
interpreting these statutes, that override
state laws in part or completely. The most
far-reaching of the federal statutes is the
Employees’ Retirement Income Security
Act (ERISA),6 which applies to employerfinanced employee benefit plans, notably
those that are “self-insured” (that is, an
employer assumes the financial risk of
benefit payments, rather than a third-party
carrier). Federal statutes set standards for
HMOs choosing to become “federally
qualified,”7 and for insurance coverage of
federal employees under the Federal Employee Health Benefit Act (FEHBA).8
State courts have historically regulated
certain aspects of insurance through spe-
117
118
cialized doctrines of contract and tort law.
Neither generally allows a court to review
the content of insurance benefits directly
and to decide whether they are adequate
for a plan member’s needs. Contract law,
which governs individual and group
health plans that are not subject to ERISA,
concerns the enforcement of private agreements between contracting parties. Thus,
the focus of the court is on the validity of
the agreement between the parties and its
implementation; the focus is not on the
needs of a child. The rationale underlying
contract doctrine is that each party to a
contract has freely negotiated and accepted its terms. In the context of health
insurance, this means that, because members of a health plan have voluntarily accepted the stated limitations and other
Mandatory benefit laws have resulted
in private financing for a wide array of
services important to children, including
blood lead level screening, well-baby care
for newborns, and preventive care for
children through adolescence.
conditions as part of the policy (contract),
they may not later challenge the coverage
spelled out in the policy as inadequate in
itself. The assumption that each party has
accepted the terms of the contract means
that courts are exceptionally reluctant to
alter the integrity of properly made contractual agreements (such as those embodied in private group plan policies) and will
not overturn benefit restrictions or denials
that are unambiguously stated in a health
plan policy, do not violate minimum state
standards, and are actuarially sound.9
A court will reach the issue of adequacy of coverage only if a policy term may be
construed to have more than one meaning. Under basic contract doctrine, ambiguous policy terms, particularly exclusions from coverage, are interpreted in
favor of the insured, who may receive
those benefits that could reasonably be
expected from the policy.10 When a court
finds a term in a health care policy to be
ambiguous, it can waive policy limitations
that would otherwise bar the services (or
financing for the services) sought by the
plan member. This doctrine allows challenges to denials of health care services
under medical necessity or experimental
care exclusions. If a court finds the meaning of such an exclusion to be ambiguous,
it can review a denial of benefits based on
the exclusion. But a court will not review
the reasonableness of a plan’s refusal to
cover important children’s services if such
refusal is based on clearly stated contract
provisions and does not violate state insurance law.
Tort law also rarely focuses on whether
the health care coverage in a plan is appropriate to the needs of a plan member.
Under tort doctrine, individuals may sue
a plan as an insurer, or as an insurer and
provider of health care, for negligence in
the administration of the policy (tortious
breach of contract) or medical malpractice. These types of actions address the way
a plan has carried out its provisions, rather than the substance of the provisions
themselves.11 For example, successful malpractice suits have been brought against
HMOs based on theories of respondeat
superior 12 and ostensible agency,13 both
theories that hold the plan responsible
for the errors of physicians employed by
or closely associated with it. However, because a tort action is based on the conduct
of a specific actor, it cannot bring about
systemwide change, except to the extent
that other plans change their practices to
protect themselves from similar suits. In
this respect, tort doctrine shares the limitations of contract law in that neither is a
means to changing children’s health care
coverage systematically to make it consistent with developmental issues and other
pediatric concerns.
In addition, non-self-insured group
plans are governed by state insurance laws,
which generally override contract law.
State legislatures have universally established minimum standards for group
health insurance plans, including mandatory minimum coverage at least for some
categories or specified types of health
benefits. Health insurance policies must
include any health-related benefits required by the law of the state in which
the policy was written. These mandatory
benefit laws have resulted in private financing for a wide array of services important to children, including blood lead
level screening, well-baby care for newborns, and preventive care for children
14
through adolescence. State laws have
also established minimum standards for
regulating health plans15 and prohibited
discrimination by health plans against
chronically ill or disabled individuals.16
Although such laws can effectively regulate the content of private health insurance benefits, they typically do not address discretionary decision making about
medically necessary or experimental care,
and they do not apply to the large and
growing number of health plans currently
governed by ERISA.
The Special Needs of
Children
The potential harm to children of inappropriate, discretionary exclusions from
coverage may be better understood with a
brief review of the clinically important
factors in their care. Children differ from
adults in that their health care needs—
whether for preventive, acute, or chronic
care services—occur in the context of
overall growth and developmental processes. The maturation of a child’s cognitive, physical, and emotional capacities is
uniquely vulnerable to the impacts of
illness and its treatments, and also to a
wide range of environmental factors.17
The latter include poor nutrition (including that of the child’s mother during pregnancy), insufficient emotional and cognitive stimuli, inadequate opportunities
for motor development or socialization,
and failure to treat promptly those anomalies that may be corrected.
The challenge when a child has an
illness or disability is not merely to treat at
the acute stage, but rather to intervene at
an early enough point, and to continue
the intervention as needed, to prevent or
minimize any effect on overall growth and
development. For example, if an infant’s
strabismus (muscle weakness of the eyes)
is not corrected in the period after birth
when neural pathways between the eye
and the cortex of the brain are being completed, the result will be substantial and
permanent loss of vision. Later correction
cannot restore the lost visual function. In
general, a child must go through each
developmental step in sequence and cannot “catch up.”
The nature of childhood development
means that health care for children is not
merely restorative, but also has the affirmative purpose of promoting healthy
growth and development. Prevention
means not only averting acute illnesses,
such as vaccine-preventable diseases, but
also monitoring a child’s growth and development, counseling parents and older
children, and seeking to minimize potential developmental harms.
Most children are healthy most of the
time, but an estimated 10% to 20% have
some form of chronic illness.18 For approximately 5% of children under 18,
long-term illness may be severe enough to
put a child’s normal functioning and development at risk and to interfere with
schooling, play, and other ordinary childhood activities.19 The number of such children who survived has doubled in the past
two decades, reflecting in part increased
success in their care.20 Of children with
such severe chronic illnesses, an estimated
80% on average now survive to adulthood.21 These children undertake the
same developmental tasks, in the same
sequence, as their peers.20
Because of children’s ongoing development, illness can affect them with
119
120
greater consequence than adults. Inadequately treated, childhood illness can
preclude for an individual’s life the possibility of normal functions or adequate
adjustment to a chronic or disabling condition. Thus, children have a strong claim
to access to specialized providers (that is,
children’s hospitals, clinics, and practitioners) who have the training and experience to recognize, diagnose, and manage
the physical, developmental, and emo-
Inadequately treated, childhood illness
can preclude for an individual’s life the
possibility of normal functions or adequate
adjustment to a chronic or disabling
condition.
tional conditions characteristic of childhood disorders.22 The same reasons argue
for children’s access to a full range of ancillary services such as physical and other
therapies, individual and family counseling, and case management that coordinates complex regimens of medical and
ancillary care.23
Although the distinctive characteristics
and needs of childhood disorders have
long been recognized in medicine, they
do not necessarily influence the discretionary decision making through which
plans restrict beneficiary access to services
and otherwise seek to “manage” their expenditures. Discretionary plan decisions
are accomplished through administrative
processes and supported by contractual
language.
Administrative Barriers to
Care
Utilization review and utilization management 24 are examples of administrative processes that determine what care a child
and other plan member actually receives.
The former traditionally has dealt with
“level of care” questions (for example, provision of care in the least costly setting),
while the latter may also address the question of whether care was needed at all.25
How a plan is constituted and organized
also affects access to care. For example, the
numbers and type of specialists available
to plan members affect what care they
will receive, as does a plan’s use of primary care physicians, “advice” nurses, and
other gatekeepers to determine the services that an individual may receive within
the plan. When some form of gatekeeping is in place, patients may not refer
themselves to specialists or opt for extra
sessions of physical therapy at the expense of the plan without gatekeeper approval. Such administrative and structural
mechanisms originated in HMOs but have
now evolved, diversified, and been adopted in some form by at least 19 forms of
managed care, ranging from traditional,
“closed panel” HMOs with salaried physicians and their own facilities, to organized
networks of providers.24
There is anecdotal and some systematically gathered evidence that utilization
management and gatekeeping efforts
have resulted in restricted access to appropriate care for many children. Insurers
commonly and “arbitrarily” deny coverage
for a variety of services for children with
significant health care needs, according to
congressional testimony of Eva Skubel,
who counsels families at the Newington
Children’s Hospital, Connecticut.26 The
denials occur even when children’s physicians document the clinical necessity of
the care for which coverage is refused.
Skubel estimates that, in her case load of
400 families with chronically ill and/or
disabled children, a majority have been
denied coverage for services under medical necessity clauses.27 The full extent of
the problems that Skubel described is unclear because there are few quantitative
studies in this area. It is clear, however,
that challenging discretionary decisions
directly, on the grounds of inappropriateness for children, is rendered virtually impossible by the contractual barriers discussed in the next section.
Four recent studies document the
types of difficulties that parents encounter
in trying to secure coverage for their children and suggest the scope of the problem. A study of policies in 59 HMOs which
affected children with special needs
showed that most plans offered a liberal
range of the types of ancillary services
needed by children at developmental risk
(that is, home health and mental health
care, and physical, speech, and occupational therapies), but that access to the
services was limited by discretionary decisions of plan administrators.28 These decisions often limited the services to children with acute conditions, children ex-
pected to improve significantly in a short
period of time, or children needing care
to restore a lost function.29 Decisions on
these bases generally exclude children
who require more time to improve and
those needing continuing care to maintain a functional capacity short of complete recovery.
Children’s access to pediatric subspecialists can be similarly problematic in
managed care plans. The HMOs surveyed
in the above study often lacked a full range
of specialists in childhood disorders,
either on staff or on contract.30 Even if a
nonplan specialist were recognized as the
most knowledgeable provider for a specific condition, a child could be referred
to him or her only if the plan considered
it “medically necessary,” a standard that
the HMOs applied restrictively.31 The
study was based on a survey of the HMOs,
supplemented by a literature review.
In a second study, based on a survey
of a sample of Fellows of the American
Academy of Pediatrics, respondents reported both difficulties in referring their
young patients in managed care plans to
specialized sources of care, and negative
health consequences. One-fifth of the
pediatricians reported that HMOs and
preferred provider organizations (PPOs)32
denied some of their referrals to pediatric
subspecialists. One-tenth reported denials
for specialized inpatient care. For a twelvemonth period, the mean proportion of
denials was 10.1% for subspecialist referrals and 8.5% for inpatient referrals.
Thirty-five percent of the referring physicians believed that denials (and delays)
compromised health outcomes, with the
consequences ranging from continued ear
infections to delayed cancer diagnoses
and denials of mental health care for anorexia, bulimia, and child abuse. Physicians
referring PPO patients encountered a lack
of specialized care within a plan, as well as
denial of payment for out-of-plan treatment. Physicians referring children in an
HMO encountered a somewhat different
problem, in that they were often pressured
to refer children in their care to adult
specialists within the plan.
One suggested explanation for these
findings is that economies of scale may
prompt the plans to avoid contracting with
specialized sources of pediatric care because (with the exception of plans dominated by Medicaid populations) children
are unlikely to constitute a majority of plan
participants and relatively few children
will have any one disorder.33
A third study examined the role of case
managers in overseeing the care of children with complex conditions who were
covered either by indemnity insurers or
HMOs. Children with chronic disorders
typically experience acute flare-ups, alternating with periods of remission.19 Such
children may need several types of therapies to minimize the frequency and gravity
of acute episodes, as well as daily medication, frequent hospitalizations and visits
with subspecialists, and individual and
family counseling to help them manage
their emotional reactions to illness.23 To
be most effective, these services must be
carefully coordinated.19 While HMOs and
insurers commonly assign managers to
these cases, the primary function of these
managers, as indicated in one survey, was
to identify potentially costly cases and less
expensive sources of care, rather than to
ensure the continuity and comprehensiveness of care that these children typically
need. Also, financial disincentives may
have discouraged out-of-plan referrals,
and there were few rewards for time spent
Most plans offered a liberal range of
the types of ancillary services needed by
children at developmental risk . . . but
that access to the services was limited
by discretionary decisions of plan
administrators.
overseeing patient care.23 Investigators
also found that the plans anticipated
further restrictions on medically complex cases (as well as those requiring expensive technology), through greater use
of case management or lower ceilings on
coverage for costly services.23 These findings were based on semistructured interviews with the five largest insurers and six
largest HMOs in a state that heavily regulates these entities to protect consumer
interest.
A fourth study, based on a survey of
employers, indicated that, in addition to
selecting expensive illness for case management, their health plans may also have
begun screening somewhat less severe,
chronic conditions of childhood, includ-
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122
ing asthma and middle-ear infections, for
referral to case management.34
Contractual Barriers to
Care
The Medical Necessity Exclusion
Restrictions to access through administrative procedures like those described above
can put ailing children at risk for harsher and more frequent acute episodes of
chronic illness, deteriorating command
of language and motor skills, or a lifetime of preventable physical or intellectual deficits or emotional problems. But
the principles of contract doctrine generally support a plan’s authority to make
such restrictive, discretionary decisions on
the basis of contract provisions in their
policies with the insured. Most significant
is the standard clause that excludes coverage for any care determined not to be
“medically necessary.”
The reason that health plans have such
discretion in medical necessity determinations is that there is no precise, legal definition for the term that would strictly limit
their interpretations.35 Several commen-
The legal function of the
term [medical necessity] is to
entitle a plan to limit what it
will provide or finance for its
members.
tators characterize the term expansively,
as “everyone’s entitlement under both federal and state laws.” 36 However, as it is
currently interpreted, the legal function
of the term is to entitle a plan to limit what
it will provide or finance for its members.
The resulting limitations, like those described above, can be severe and are difficult to appeal. The difficulty is twofold: the
absence of a fixed meaning in law for
“medical necessity”37 and the fact that
plans generally do not disclose either their
criteria or procedures for determining
medical necessity.38
As a legal matter, the meaning of “necessity” varies from “useful” to “indispensable” and “must be determined in relation to the object sought.”39 Given the
competing objectives of the families and
institutions that seek, finance, and/or provide health care, defining medical necessity has proved difficult. Thus, parents’
expectations that their children, notably
those with chronic or unusually expensive
disorders, will receive all useful care that
is not specifically excluded in their policy
may conflict with the economic function
of the plans, which is to spread the risk of
medical expenditures while remaining
financially viable.
Contract doctrine generally upholds
plans’ exercise of their discretionary authority in determining medical necessity
on the theory that a plan member has
accepted, as part of the basic insurance
contract, that the plan will decide what
amount, scope, or duration of a covered
service is medically necessary for an individual member. Contract law permits a
court to order a plan to provide disputed
coverage and/or other remedies in circumstances only where something is defective in the drafting of a contract or the
performance by the health plan. As discussed above, a standard rule of contract
construction authorizes a court to make its
own interpretation, favoring the insured,
only if the policy is unclear or ambiguous.
The term “medical necessity” has been
found ambiguous per se,40 ambiguous as
to who may determine necessity,41 and
ambiguous in that it could refer either to
the professional judgment of a physician
or the good-faith opinion of the insured
(relying on the advice of the insured’s
physician).42 Depending on variations in
contract language and judicial inclinations to characterize contested language
as ambiguous,43 this rule could open the
way to judicial award of disputed benefits
to an individual child. However, decisions
based on interpreting ambiguous contract
language are neither common nor a basis
for systematically reforming children’s
health coverage.
A second basis for judicial award of
benefits is a defect in a plan’s performance
of the legal duty implied in every contract.
The duty is for each party to act in good
faith on the agreement to achieve its purposes and the “justified expectations” of
the other party. 44 Courts have found that
a plan has breached this duty (that is, acted
in bad faith) if it denies a claim without a
proper cause,45 if it uses a standard for
reviewing the necessity of care that is “significantly at variance” with the medical
standards of the community,46 or if a plan
(HMO) physician fails to make a timely
referral of a patient to a specialist in the
47
patient’s disorder. A finding of bad faith
in specific circumstances indicates a standard of conduct that other plans will adopt
in similar situations to avoid legal liability.48 Thus, courts have considerable latitude in indirectly regulating plan conduct
because the definition of good faith is still
evolving and there is no single, accepted
standard.48 But, as with the ambiguity rule,
awarding benefits to individual children
on the basis of bad faith does not establish
the legal relevance of such benefits for the
scope of coverage for all children.
As noted above, many of the legal challenges to denial of access to care have
centered on the plan’s interpretation of
medical necessity. In reviewing determinations of medical necessity, courts historically deferred to a plan member’s physician, holding that a policy obligates a plan
to finance the care that the physician prescribes.49 Implicitly, the plans accepted
physicians’ judgments that the benefit of
prescribed care was worth its cost.
However, it is now standard practice
for plans to reserve to themselves the discretion to override physician judgments
and for the courts to uphold these reservations as agreed-upon contract terms.50
In addition, courts are beginning to condone the integration of cost saving and
clinical judgments embodied in the concept of managed care. In Sarchett v. Blue
Shield of California,51 a California court upheld the authority of a plan to review and
disagree with a physician’s opinion of
medical necessity even though the policy
did not explicitly reserve this authority to
the plan. In reasoning that review of
claims by health plan is indispensable to
the “orderly establishment, administration and dispensation of insurance benefits,”52 the court seemed implicitly to accept consideration of plan resources as
well as clinical values in determining necessity.
Challenging denials of care that are
insensitive to children’s health needs may
become even more difficult after enactment of health reform legislation that—as
in congressional action this year—was
driven almost exclusively by legislators’
concerns with controlling health care expenditures. When legislated policy expressly supports conservation of health
care resources through cost control mechanisms, as in plans subject to the federal
HMO act, FEHBA and ERIUSA, courts may
accept some cost-conscious restrictions
on clinical judgments or even tolerate
troubling medical outcomes as an unavoidable side effect of cost control. For
example, in Pulvers v. Kaiser Foundation
Plan,53 the court found that the fact that
a managed care plan rewarded physicians
Challenging denials of care
that are insensitive to children’s
health needs may become even
more difficult after enactment of
health reform legislation.
financially for “rendering less expensive
forms of care” did not in itself mean that
the physicians fell below a community
standard of medical practice. Presumably
the standard referred to by the court was
that established by physicians without
such incentives (that is, those paid by the
fee-for-service method).
The Pulvers court noted approvingly
that the use of incentives to encourage a
sparing style of medical practice was not
only recommended by professional organizations but also required by the federal HMO act “as a means of reducing
unnecessarily high medical costs.”54 The
plaintiffs, the widow and children of a deceased HMO beneficiary, claimed that, by
delaying a biopsy in diagnosing his fatal
illness, the HMO failed to meet the “high
standards” of medical service it had promised members and, further, that the incentives were fraudulently at variance with
that promise. The court dismissed the
complaint, reasoning that the disputed
language was merely “generalized puffing.”55 The court found no indication that
the incentives caused HMO physicians to
be negligent. A state statute whose purpose is to promote cost control in health
care also may shield a health service plan
from liability grounded in malpractice.56
Medical Necessity Under a Pediatric
Standard
The function of a pediatric standard in a
cost-conscious health care system is to assure that coverage decisions are consistent
with the clinical judgments of physicians
and other professionals who are trained
and experienced in the care of children.
The standard would put plans under an
123
124
affirmative obligation to adjust their coverage decisions to developmental considerations and other factors which differentiate
the care of children from that of adults.
Such coverage decisions may go both
to the specific types of benefits that are
offered by a plan (which are not the focus
of this article),57 and to discretionary decisions about whether an individual child
should receive the covered service, how
much of it she should receive, who would
provide it, and in what setting.
Several examples may illustrate how a
pediatric standard would function. For example, the development of a child’s capacity to speak is relatively time-limited and is
essential not only to an individual’s capacity to communicate with other people
throughout life, but also to his or her social
and cognitive development. Thus, a plan
that covered surgical repair of an infant’s
For some children with very serious
illness or disability, access to innovative
procedures and technologies and to newly
developed drugs or uses of drugs becomes
very important.
cleft palate but did not include postoperative speech therapy in its covered benefits
would violate a pediatric standard of coverage. Furthermore, the pediatric standard would require that, in deciding upon
the amount, scope, or duration of speech
therapy for the child, the plan must determine that limiting therapy would not put
the child’s normal development at risk.
A second example concerns the wellestablished and very substantial risk to
normal development of institutionalizing a child.58 Thus, a decision to institutionalize a technology-dependent infant or
toddler who could reasonably be expected
to live at home with appropriate services
and equipment would violate a pediatric
standard.
A third example concerns the reported
resistance of plans to refer children with
complex disorders or rare or chronic conditions to specialized sources of pediatric
care. In limiting the care of these children
to a primary care physician or to an adult
specialist within the plan, there would
have to be a determination that the treat-
ing physician is, for example, capable of
recognizing and treating conditions that
are rare in children or that are never seen
in adults. The pediatric standard would
create a presumption for the referral, unless a plan could show that its physicians
were competent to care for the specific
condition of the child. The pediatric
standard would also shape regulations to
which a health plan is subject and would
be the standard for judicial review of children’s benefits restrictions and denials.
The Experimental Treatment
Exclusion
For some children with very serious illness
or disability, access to innovative procedures and technologies and to newly developed drugs or uses of drugs becomes
very important. Recent advances in science and technology have enabled American medicine to cure or manage a number of previously untreatable fatal or debilitating disorders of childhood. During
the past four decades, for example, clinical
cancer research has led to curative therapy
for childhood leukemia and many solid
tumors in children.59
However, these new treatments are
often expensive, and both private indemnity and managed care plans limit a patient’s access to state-of-the-art medical
treatments as a means of “rationing” expensive medical care.60 They typically do
so under the authority of a contract clause
excluding coverage for treatments determined to be experimental or investigative.
Like the term “medically necessary,”
these terms have no universally accepted
definitions and insurance contracts commonly fail to define them or articulate the
type of evidence needed to establish that
a given treatment has passed from “experimental” status into nonexcluded, “accepted practice.” No legal or administrative mechanism exists for the introduction
of innovative medical technologies that is
comparable to the procedures governing
the introduction of new drugs into the
marketplace. While the National Institutes
of Health issues infrequent “consensus”
opinions on selected clinical issues, and
the federal Agency for Health Care Policy
and Research 61 is charged with developing
clinical practice guidelines, neither is yet
equivalent to the authority and scope of
the Food and Drug Administration in its
ability to establish a unitary standard on
which plans can base their coverage of
innovative medical procedures.
Over the past decade, private insurance and managed care plans have struggled to formulate criteria for identifying
useful new medical procedures while limiting their financial liability for unproven,
ineffective, and/or potentially harmful
procedures. Although this effort has not
yet produced any single, generally accepted criterion used by all health plans
in determining the medical efficacy of
new treatments, private plans commonly
base their coverage decisions on the status
of clinical research in the treatment
sought. Thus, the plans generally require
the individual seeking the treatment to
establish the existence of a body of peerreviewed literature on the treatment or
that it has met the most rigorous statistical
standard (“statistical significance”) of
probable success in ameliorating or curing a disorder.
The use of these criteria in assessing
the clinical appropriateness for a child of
a new procedure disadvantages children
because the development of research results and peer-reviewed literature for them
takes longer and is less certain than for
adults. The reason is that, because of several factors unique to children, they have
proportionately less access to appropriate
clinical trials than adults. Their access is
restricted both because fewer children
than adults suffer from disorders requiring major clinical interventions and because legal and ethical rules severely limit
the participation of children in clinical
trials. These factors make it more difficult
to assemble an adequate sample of subjects for clinical research in children so
that research involving children may take
substantially longer or yield less conclusive
answers than comparable investigations
with adult subjects.
Because the status of research generally determines whether a health plan will
finance such care, the difficulties inherent
in clinical research with children directly
affect their access to the most promising
new medical treatments. Plan administrators’ exclusive reliance on a data-based
standard designed for adults, without
proper consideration of the limitations on
clinical trials in children and clinical judgments in the pediatric community, has a
troubling effect for children. It puts them
at greater risk of being forced by lack of
financing to forgo therapies that may currently be considered by the scientific community to be both efficacious and not
unreasonably risky for them, and neces-
sary in light of existing alternatives (including no treatment).
Because of numbers alone, clinical trials involving treatments for diseases seen
in adults are likely to reach the state of
evaluation in peer-reviewed literature in
less time than similar clinical trials involving children. Children manifest a significantly broader range of disabling diseases
and conditions than do adults, but comparatively few disorders are common to
children in general. Adults, on the other
hand, experience a relatively larger number of more common illnesses with only a
few rare diseases.62 For example, brain
The status of research with children
is similar to the status of research on
adults with exceedingly rare diseases or
conditions.
tumors are the second leading cause of
cancer deaths among children, but proportionately fewer children than adults
63
suffer this disorder. While medical researchers are currently demonstrating the
efficacy of high-dose chemotherapy with
bone marrow support for the treatment
of recurrent brain tumors in both children and adults, they estimate that, for at
least one type of brain tumor, it may take
up to a decade longer to develop a body
of peer-reviewed literature on the use of
this treatment in children than to develop
a similar body of literature on its use in
adult patients.64
The status of research with children is
similar to the status of research on adults
with exceedingly rare diseases or conditions, with one exception. The development of peer-reviewed literature may be
impeded further by legal and ethical restrictions arising from children’s very limited legal capacity to consent to participate
in research. These restrictions have two
necessary but troubling effects. First, they
add to the epidemiology-related difficulties in assembling a sample of children
large enough to yield meaningful research
results and thereby slow progress toward
such results. Second, they lessen the access
of individual children to therapies with
enough potential benefit to warrant clinical trials involving human subjects.65
125
126
The governmental response to the
growing incidence of human immunodeficiency virus (HIV) in foster children illustrates how legal and ethical constraints
can, by restricting the number of potential
subjects in clinical trials, both slow the
completion of a clinical trial of an experimental treatment and deprive children of
what may be the most promising care for
their condition.
State and federal courts are limited
in their capacity to improve children’s
access to innovative treatments.
Despite the growing incidence of HIV
infection, there is no standard treatment
for HIV-infected children at this time, due
to unique problems faced by their treating
physicians. Participating in ongoing clinical trials of new treatments often represents a child’s best opportunity for care.
However, many HIV-infected children are
in foster care, and concerns for their legal
rights and safety have led some state social
service agencies to withhold approval for
the participation of these children in clinical trials.65 Thus, the state’s necessary concerns with foster care children’s capacity
to consent to medical care means that
these children lose the possible benefit of
therapies for HIV, and progress toward the
development of standard therapies for the
condition is slowed. Also, federal regulations66 intended to protect the rights of
children in medical research have had a
chilling effect on the willingness of researchers to include at least one category
of children (adolescents with HIV) in clinical trials.
The procedures used by insurance
companies and managed care plans to determine whether a given treatment is “experimental” and, therefore, excluded from
coverage have come under increasing judicial scrutiny. Courts have ruled, for example, that coverage of innovative treatments under standard contract language
may not be denied under an experimental
care exclusion solely because the treatment is part of a research protocol,67 because the treatment lacked a significant
body of published, peer-reviewed literature,68 or because the treatment lacked
statistical evidence of its overall efficacy.69
These rulings have important preceden-
tial value, in that the criteria they invalidate are those with a particularly adverse
impact on children.
Even with these precedents, however,
state and federal courts are limited in their
capacity to improve children’s access to
innovative treatments. As a matter of law,
a court may not order a group health plan
to cover specific treatments for children
or adults if the disputed care is specifically
identified in the terms of the plan policy.
Also as a matter of law, courts generally
may not reverse specific coverage decisions made by plan administrators.70 In
practice, courts do intervene if, as with
medical necessity, they can be persuaded
that a specific contract term (for example,
“experimental”) is ambiguous or if a plan
followed questionable procedures in making a coverage decision.70 Such limited
judicial interventions are not a satisfactory answer to the problems presented by
children’s difficulties in gaining access to
innovative medical care. Litigation is expensive, and its results are unpredictable71 and generally restricted to the party
bringing suit.
Rollo v. Blue Cross illustrates the limited
role of the judiciary in contract disputes
over access to potentially life-saving new
treatments.72 The plaintiff challenged
Blue Cross/Blue Shield of New Jersey’s
decision to deny payment for high-dose
chemotherapy and bone marrow support,
an innovative cancer treatment, for an
eight-year-old girl suffering from a recurrent malignant kidney tumor found almost exclusively in children. At the time
the case was filed, the girl’s tumor had
failed to respond to conventional therapy.
Without the bone marrow transplant, she
had a less than 2% chance of surviving the
recurring tumor. Blue Cross/Blue Shield
denied coverage for the procedure on the
grounds that it was “experimental” and
therefore excluded from policy coverage.
The court found, however, that the procedure was generally accepted in the pediatric oncology community and represented the child’s only viable treatment for
the recurrent tumor.72 On that basis, it
ruled that the Blues’ denial of coverage,
because of insufficient peer-reviewed literature, was illegal. The Rollo court was
able to intervene in this contract dispute,
however, only because the policy did not
explicitly exclude the treatment in question from coverage and because Blue
Cross/Blue Shield had not followed its
own procedures for determining whether
a clinical intervention was considered
“experimental” under the terms of the
contract. The court lacked authority to determine itself, on the basis of views of pediatric oncologists, whether the procedure
was a reasonable and necessary treatment
for this particular child. Instead, its authority was limited to ensuring that the
insurer complied with the terms of the
contract between it and the insured child.
Experimental Treatment and the
Pediatric Standard
The extent to which new technologies
and procedures should be financed in a
national health reform law raises difficult
and controversial questions about fairness, medical and financial risk, and ra73
tioning of expensive health services.
Neither private insurers nor the courts
have successfully resolved the tension between access to medical technology and
the need to control health care costs. No
generally accepted legal standard currently exists for assessing a given technology’s efficacy for purposes of coverage
determinations.
The first issue that reform law must
resolve, for both children and adults, is
procedural. By what process will it be determined that a diagnostic method or a
treatment is investigative or experimental
for purposes of excluding it from coverage? There are a number of procedural
options which might be used singly or in
combination. A law might leave the determination completely to the discretion of
health plans themselves, as was true at the
time of this writing. A reform statute might
instead require that specified criteria be
used in the determination. This approach
appeared in two prominent health reform
bills this year, sponsored by Sen. John H.
Chafee (R-RI) and Rep. William M.
Thomas (R-CA), and by Rep. Jim Cooper
(D-TN) and Sen. John B. Breaux (DLA).74 Or a reform law might limit plan
discretion by both defining “investigative”
in statute and charging a new national
health board with a duty to “refine” the
definition, as did President Clinton’s original bill.75
A second reform issue that is critically
important to children is whether the determination process included in a national
health reform law must or may be modified so as to permit specialized rules for
children’s access to experimental or investigative procedures. While these rules
must certainly protect children from un-
due risk and plans from unwarranted expenditures, it is essential that they make
allowances for the inherent difficulties of
clinical research with children. For example, if the experimental status of a treatment for adults continued to depend on
a showing of statistically significant benefit
associated with it, or the existence and
nature of peer-reviewed literature, the
status of a child’s treatment might instead
depend on establishing that a clinically
meaningful benefit is associated with it. A
clinically meaningful benefit is one that is
somewhat less probable to occur than one
with statistical significance. But even with
this lesser level of probability, clinicians
with appropriate expertise and experience
would see the treatment as potentially
beneficial for a patient. This is the type of
adjustment in an adult-oriented rule that
could let children receive new treatments
which otherwise might never become
available or might become available only
after long delays.
Another alternative that would satisfy
a children’s standard would be to limit
coverage to innovative treatments that a
child receives at a children’s hospital, an
academic medical center, or other designated institutions with recognized expertise in the treatment of specified childhood disorders.
In the current climate of cost control, the
disparity between children’s severely limited
access to the benefits of research and that of
adults seems certain to continue unless there
is a child-specific and legally enforceable
provision with regard to children.
When Congress adjourned for its July
4 recess, none of the major reform proposals had made any explicit, special provision for children’s access to innovative
procedures, although several could have
allowed for special consideration of them
in determinations of experimental or investigative status.74,75 However, in the current climate of cost control, the disparity
between children’s severely limited access
to the benefits of research and that of
adults seems certain to continue unless
there is a child-specific and legally enforceable provision with regard to children.
127
128
For several reasons, the likelihood that
a final statute would not include such a
child-specific rule is a matter of concern.
First, without a pediatric standard, individual children will continue to be denied
care that they seek, and difficulties in securing adequate research samples for in-
The difficulties of securing adequate
“medical necessity” and “experimental” care
determinations for children . . . reflect ongoing
efforts by private health plans and courts to
find the appropriate balance between clinical
and economic considerations.
novative care will continue. In addition,
severe constraints on coverage of new procedures for children mean substantially
less financial support to bring those procedures along to the point where they are
no longer investigational. The authors believe that, if a reform statute does not
resolve the disparity between childrens’
and adults’ access to new types of health
care, the problem must be addressed in
future regulations, in statutory amendments, in informal “consensus” statements
of clinical experts, and by other means.
Reform Proposals and a
Pediatric Standard
health reform measure. A fifth committee
was so deadlocked that its chairman, Rep.
John D. Dingell (D-MI), abandoned attempts to complete a reform proposal. As
House and Senate leaders of both parties
prepared for voting in each chamber, unresolved questions about the scope of reform legislation, its financing and reliance
on market forces, and coverage of abortion dominated the debate and were so
divisive that whether any reform bill could
be enacted, and what its substance might
be, remained in doubt.78
Both Senate committees of jurisdiction had, however, given serious consideration to the general issue of medical
necessity determinations, and both had
acted to make such determinations responsive to the developmental vulnerabilities of children and their other distinctive characteristics as patients. A Senate
Finance Committee version of health reform legislation required a national health
board to determine the “medical necessity
and appropriateness” of basic benefits that
all health plans would be required to offer
and specified child-specific criteria for
these determinations. (The board was to
“refine” a statutory list of categories of
mandatory benefits.)79
The Senate Labor and Human Resources Committee did not specify medical necessity criteria in its health reform
bill, but instead delegated responsibility
for such determinations to a new national
board, as in the Clinton bill. However, the
committee report on the legislation directed the board to develop appropriate
determinations for children. A committee
staff draft of the report language read as
follows: “The Committee intends that any
determinations of the medical necessity or
appropriateness of a covered service or
item for an individual under age 21 shall
be consistent with the factors that enter
into clinical judgments on behalf of individuals in that age group. These factors
include but are not limited to healthy
growth and development of an individual
patient. By development, the Committee
means the maturing of an individual’s
physical, emotional and intellectual ca80
pacities from birth to adulthood.”
In an article for the Fall 1993 issue of
Stanford Law & Policy Review, we observed
that both the Supreme Court76 and Congress77 have determined that significant
differences exist between children and
adults, that the developmental processes
that are unique to childhood are legally
relevant to children’s access to health and
other forms of public assistance, and that
comparable—that is, equitable—treatment of children and adults requires special accommodation for children. While
these precedents concern publicly funded programs, the principle is equally germane to any health reform effort that seeks
to improve access to health care for all
Americans, including children, through
private health plans.
Conclusion
As Congress adjourned for its July 4
recess, four of five House and Senate
committees of jurisdiction had finished
amending President Clinton’s original
The difficulties of securing adequate
“medical necessity” and “experimental”
care determinations for children that we
discuss in this article reflect ongoing ef-
The Importance of a Pediatric Standard in Private insurance Contracts to Ensuring Health Care Access for Children
forts by private health plans and courts to
find the appropriate balance between
clinical and economic considerations in
the provision of health care. Where the
balance will rest is not clear. However, if
health reform legislation establishes a
strong, legislated policy to control health
care costs, without an equally authoritative
endorsement of health values, the balance
will be tipped away from adequate access
of children and, indeed, of any individual
beneficiary to health care. That outcome
is perverse if cost control is the means to
the end of improving allocation of health
care resources rather than an end in itself.
It is a somewhat hopeful sign for children that their developmental vulnera-
bilities and other characteristics as patients received some congressional recognition this year in health reform debate. It
is also important to recognize that the creation of a new law as massive as national
health reform does not end with enactment
of a single measure but continues in rulemaking and adjudicative processes, and in
subsequent statutory amendments. Regardless of how Congress concludes its
reform actions this year, society’s interest
in healthy childhood growth and development, and in the adequate financing of
health care to promote that interest, requires that a reformed national health
system recognize the unique nature of
childhood in a legally meaningful way.
1. Jameson, E.J., and Wehr, E. Drafting national health care reform legislation to protect the
health interests of children. Stanford Law & Policy Review (Fall 1993) 51:152,155.
2. See note no. 1, Jameson and Wehr, pp. 152-76.
3. In this article, the term managed care is used broadly to refer both to organizations that combine the functions of insurance and health care delivery, notably health maintenance organizations (HMOs), and to administrative procedures, such as utilization review and case
management, that are intended to integrate clinical and economic evaluations of a given
medical intervention.
4. Employee Benefit Research Institute (EBRI). Sources of health insurance and characteristics of
the uninsured. Analysis of the March 1993 Current Population Survey. Special Report and Issue
Brief No. 145. Washington, DC: EBRI, January 1994, p. 66, Table 38. The numbers cited
are for 1992, the latest year for which these data are available.
5. A health maintenance organization (HMO) is an organization that both finances and provides health services as needed by an individual plan member and receives an annual,
fixed “capitation” fee from each member. Unlike indemnity insurance, which finances
but does not itself provide health care services, an HMO assumes the financial risks of
care for its members. There are several types of HMOs. These include a staff model, in
which plan physicians receive a salary from the organization and see only those individuals who are members of the plan, and an independent practice association, in which independent physicians see HMO members for a discounted fee.
6. The Employee Retirement Income Security Act of 1974, 29 U.S.C.A. §§1001-1461 (West
1993).
7. 42 U.S.C.A. §§300e-300e-17 (West 1993). This statute governs HMOs that elect to be federally qualified, a status that gives them competitive advantages in marketing themselves to
employers and enrolling beneficiaries of certain publicly funded health programs.
8. 5 U.S.C.A. §§8901-8914 (West 1993).
9. See Couch, G. Cyclopedia of insurance law. 2d ed. Rochester, NY: Lawyers Cooperative, 1984,
§41A:4 (“parties to a contract of insurance are free to determine its coverage, subject to
statutory limitation . . . (a) health and accident insurer may limit its liability in any reasonable manner”).
10. See note no. 9, Couch, at §15:74.
11. Hall, M.A., and Anderson, G.F. Health insurer’s assessment of medical necessity. University
of Pennsylvania Law Review (1992) 140:1637-61.
12. Sloan v. Metropolitan Health Council of Indianapolis, Inc., 516 N.E.2d 1104 (1987) (holding
that a corporation may be vicariously liable for an employee-physician’s malpractice if
employer-employee or agency relationship is shown).
13. Boyd v. Albert Einstein Medical Center, 547 A.2d 1229 (1988) (holding that an issue of material
fact exists as to whether physicians participating in an HMO were the ostensible agents of
the organization); Schleier v. Kaiser Foundation Health Plan, 76F.2d 174 (D.C. Cir. 1989)
129
130
(holding that an HMO may be vicariously liable for its consulting physician’s failure to diagnose).
14. For example, 15 states mandate coverage for well-child care. Other benefits include blood
lead level screening for children under six (California, Massachusetts, and Rhode Island),
newborn nursery care (Kentucky), early intervention services up to age three (Massachusetts), newborn metabolic and sickle cell testing (Rhode Island), payment for school psychologists (Tennessee), and nutrition for PKU children (Washington). In addition, 24
states require coverage for adopted children. Blue Cross/Blue Shield Association. Update
on state mandated benefits. Rev. ed. 1992.
15. Wisconsin law, for example, mandates conversion benefits, Wis. Stat. Ann. §632.897 (West
1991), and the establishment of risk-sharing plans for residents unable to secure ordinary
health coverage. Wis. Stat. Ann. §619.10-619.18 (West 1991). California requires that nonprofit hospital service plans and health care service plans provide for adequate financing
and reserve funds. Cal. Ins. Code §11507-11511 (West 1990), Cal. Health and Safety Code
§1375.1 (West 1990).
16. California, for example, prohibits discrimination against physically handicapped persons,
Cal. Ins. Code §10123.1 (West Supp. 1992), victims of Alzheimer’s or other diseases that
cause dementia, Cal. Ins. Code §§10123.16, 10123.17, 11512.177 (West Supp. 1992), and
individuals who are blind, Cal. Ins. Code §10145 (West 1992).
17. Stanton, W.R., McGee, R., and Silva, P. Indices of prenatal complications, family background, child rearing, and health as predictors of early cognitive and motor development. Pediatrics (1991) 88,5:954.
18. The percentages reflect differing definitions of chronic illness. Horwitz, S.M., and Stein,
R.E.K. Health maintenance organizations vs. indemnity insurance for children with
chronic illness. American Journal of Diseases of Children (1990) 144:581.
19. Fox, H.B., and Newacheck, P.W. Private health insurance of chronically ill children. Pediatrics (1990) 85:50
20. Anastasiow, N.J. Development and disability. Baltimore, MD: Brooks, 1986, pp. 23, 52-61.
21. Gortmaker, S.L., and Sappenfield, W. Demography of chronic childhood diseases. In Issues
in the care of children with chronic illness. N. Hobbs and J.M. Perrin, eds. San Francisco:
Jossey-Bass, 1985, p. 827.
22. “Specialty physicians and other health care professionals are almost always needed to participate in the diagnosis, treatment, and monitoring of children’s physical, emotional,
and developmental problems.” Fox, H., Wicks, L., Kelly, R., and Greary, A. An examination of HMO policies affecting children with special needs. Unpublished report, September 1990, p. 35. Available from Fox Health Policy Consultants, Inc., 1140 Connecticut
Ave., N.W., Ste. 1205, Washington, DC 20036.
23. See note no. 18, Horwitz and Stein, pp. 581-86.
24. Utilization review is the analysis of medical services provided by a health plan with the
purpose of discouraging overuse. A negative review may result in the plan reducing or
refusing payment for the reviewed care. The common types of review are (1) requiring a
physician to secure prior approval (“precertification”) for specified procedures, (2) monitoring treatment plans of hospitalized patients (“concurrent review”), and (3) assessing
the necessity and appropriateness of hospitalization or treatment after it is completed
(“retrospective review”). Utilization management (“case management”) combines elements
of review with proposing alternate forms of care. U.S. Congressional Budget Office.
Effects of managed care on use and costs of health services. Memorandum to the House
Ways and Means Committee and the Senate Finance Committee. June 1992, p. 22.
25. McManus, M., Newacheck, P., Kelly, R., and Macklin, M. High-cost children: The unknown
liability. Business & Health (May 1992) 10,6:28-33.
26. U.S. Congress, Senate. Meeting maternal and child health needs under the Health Security Act of
1993. Hearing before the Senate Committee on Labor Human Resources. 103d Congress, 1st Session. November 16, 1994.
27. Personal communication with Eva Skubel, April 4, 1994.
28. See note no. 22, Fox, Wicks, Kelly, and Greary.
29. See note no. 22, Fox, Wicks, Kelly, and Greary, p. 17.
32. A preferred provider organization (PPO) is a network of providers (for example, physicians, hospitals, and clinics) which contracts with an insurer or an employer to provide
services at predetermined or discounted rates and subject to utilization review. Plan members may choose their own providers but pay a larger share of the cost if they do so. See
note no. 25, McManus, Newacheck, Kelly, and Macklin.
33. Cartland, J.D.C., and Yudkowsky, B.K. Barriers to pediatric referral in managed care systems. Pediatrics (1992) 89:183.
34. See note no. 25, McManus, Newacheck, Kelly, and Macklin, p. 28.
35. Cline, S., and Rosten, K. The effect of policy language on the containment of health care
costs. Tort Insurance Law Journal (1985) 21:120. The absence of a precise, uniform meaning of “medical necessity” is shown by, inter alia, substantial variation among plans in their
interpretation of the term. For example, each of the 34 private insurance carriers that
process benefit claims for the federal Medicare program “used differing working definitions of what is medically necessary” when screening the same type of clinical intervention. For one service, one carrier required additional documentation of necessity after
12 physician visits, a second did not require additional documentation until the 30th visit,
and a third based the number of additional visits allowed on the area of the spine being
treated for injury. U.S. Congress, House. Hearings before the Subcommittee on Regulation,
Business Opportunities, and Technology, Committee on Small Business. 103d Congress, 2nd
session 2, 3, 16. Statement of Eleanor Chelimsky, assistant comptroller general, U.S. General Accounting Office.
36. Graetz, M.J., and Mashaw, J.L. Praise reform and start the litigation? New England Journal of
Medicine (1993) 329,23:1735.
37. According to Cline and Rosten, “Numerous definitions have been offered for this term, but
none provides satisfactory guidance in a particular case.” Among the standard limiting
terms of insurance contracts (“reasonable,” “usual,” “customary,” and “necessary”), the
term most subject to litigation has been “necessary.” See note no. 35, Cline and Rosten.
38. Hershey, N. Fourth-party audit organizations: Practical and legal considerations. Law, Medicine & Health Care (1987) 14:54.
39. Black’s Law Dictionary. 6th ed. St. Paul, MN: West, 1990.
40. Dallis v. Aetna Life Ins. Co., 574 F. Supp. 547, 551 (1983).
41. Schroeder by Swanson v. Blue Cross, 450 N.W. 2d 470 (Wis. App. 1989). (Medical necessity determined by physician when ambiguous medical necessity clause, construed to favor the
insured, does not reserve to the insurer the right independently to review home care services certified by the physician.)
42. Van Vactor v. Blue Cross Assn., 365 N.E. 2d 368 (1977). (Medical necessity of hospitalization
for oral surgery determined by insured’s physician, on basis of policy language “vest[ing]”
determinations of necessity in the physician and the absence of language conditioning
benefits or insurer review.)
43. Hall and Anderson contend that courts “extend . . . coverage to patients in desperate circumstances at all costs”; however their discussion illustrates the uncertainty of judicial outcomes. They note that in 17 recent cases, courts overruled insurers’ refusals to finance a
new and expensive treatment for advanced cancer (with variable rates of short-term success and unknown long-term success) on the basis of ambiguities in the policy exclusions
of experimental or investigative procedures. But in about a dozen similar cases, judges upheld these exclusions. See note no. 11, Hall and Anderson, pp. 1638-40.
44. Restatement (Second) of Contracts §205, comment. a (1981).
45. Hanson v. Prudential Ins. Co. of America, 783 F. 2d 762, 766 (9th Cir. 1985). (Insurer did not
act in bad faith when it denied payment for treatment of plaintiff's son at a residential psychiatric facility that did not qualify as a “hospital” for purposes of coverage under the
plan; the court found persuasive the insurer’s attempt to pay part of the claim under its
administrative practice of paying social workers at qualified mental health clinics.)
46. Hughes v. Blue Cross of Northern California, 263 Cal. Rptr. 850 (Cal. App. 1 Dist. 1989).
47. Williams v. Healthamerica, 535 N.E. 2d 717 (Ohio App. 1987).
48.
Jerry, R.H. Understanding insurance law. New York: Matthew Bender, Times Mirror, 1987, pp.
115-16.
49. Scalia v. American Progressive Health Ins. Co., 146 N.Y.S. 2d 537 (1955) (speech therapy
medically necessary for a child whose speech, swallowing, and breathing were impaired by
polio because therapy was a “necessary extension and indivisible continuation” of physician care); Fassio v. Montana Physician's Service, 553 P. 2d 993 (1976) (implicit meaning of
131
132
necessary with regard to medical services is that services are necessary . . . when . . . prescribed or performed; physician opinion that the care “may do nothing more than assure
. . . parents that everything is being done that can be done” [for a Down’s syndrome
child] establishes necessity.); Group Hospitalization, Inc. v. Levin, 305 A. 2d 248 (1973) (necessity of postoperative nursing determined by attending physician’s opinion that the exceptional pain of the patient required such care.); Zuckerberg v. Blue Cross & Blue Shield,
464 N.Y.S. 2d 678 (Sup. 1983) (necessity of care for cancer patient determined by physician opinion that the care did not “adversely” affect the patient and may have “stabilized”
his condition).
50. For an account of insurer attempts to use contract language to limit liability, arguing that
these attempts do not dissuade courts from “rewriting” policies, see note no. 11, Hall and
Anderson.
51. Sarchett v. Blue Shield of California, 233 Cal. Rptr. 76 (1987).
52. See note no. 51, Sarchett, p. 82.
53. Pulvers v. Kaiser Foundation Plan, 160 Cal. Rptr. 392 (1979).
54. See note no. 53, Pulvers, p. 394.
55. See note no. 53, Pulvers, p. 393.
56. Harrel v. Total Health Care, Inc., 781 S.W. 2d 58 (Mo. Banc 1989). (Statute in effect at time of
injury to patient, from alleged failure of a health services corporation to select a competent surgeon to treat the patient, exempted the corporation from liability for, inter alia, patient injuries resulting from malpractice.)
57. Budetti, P., and Feinson, C. Ensuring adequate health care benefits for children and adolescents. The Future of Children (Summer/Fall 1993) 3,2:37.
58. Stein, R.E.K. Pediatric home care: An ambulatory “special care unit.” Journal of Pediatrics
(March 1978) 92,3:495,498.
59. Antman, K., Schnipper, L.E., and Frei, E. The crisis in clinical cancer research: Third-party
insurance and investigational therapy. New England Journal of Medicine (1988) 319,1:46-48.
60. James, F.P. The experimental treatment exclusion clause: A tool for silent rationing of
health care. Journal of Legal Medicine (1991) 12:359-418.
61. The Federal Agency for Health Care Policy and Research, first authorized in 1989, is under
a statutory duty to “conduct and support research, demonstration projects, evaluations,
training, guideline development, and the dissemination of information, on health care
services and on systems for the delivery of such services,” with regard to, inter alia, the “effectiveness, efficiency and quality of health care services.” The purpose of Agency activities is to “enhance the quality, appropriateness and effectiveness of health care services,
and access to such services.” P.L. 101-239, §§901. et seq. Agency findings with regard to appropriate medical care are advisory.
62. Pless, I.B., and Perrin, J.M. Issues common to a variety of illnesses. In Issues in the care of children with chronic illness. N. Hobbs and J.M. Perrin, eds. San Francisco: Jossey-Bass, 1985,
pp. 41, 43.
63. Heideman, R.L. Tumors of the central nervous system. In Principles and practice of pediatric oncology. P. Pizzo and D. Poplack, eds. Philadelphia: J.B. Lippincott, 1993, pp. 505-68.
64. Finlay, J., Department of Pediatrics, Memorial Sloan Kettering Cancer Center. Interview
with author, August 12, 1992.
65. Martin, J., and Sacks, H. Do HIV infected children in foster care have access to clinical trials of new treatments? AIDS and Public Policy Journal (1989) 5:3,6.
66. 42 U.S.C.A. 289 (West 1991); 45 C.F.R. §§46.101-46.409.
67. Adams v. Blue Cross/Blue Shield of Maryland, 757 F. Supp. 661, 663-664 (D. Md. 1991).
68. Pirozzi v. Blue Cross/Blue Shield of Virginia, 741 F. Supp. 586,591. E.D. Va. 1990; Rollo v.
Blue Cross/Blue Shield of New Jersey, U.S. Dist. Lexis 5376 No. 90-597, 1990 WL312647,
at *7 (D.N.J. March 22, 1990); Dozsa v. Crum & Forster Insurance Company, 716 F. Supp.
131, 138-139 (D.N.J. 1989).
69. Bucci v. Blue Cross/Blue Shield of Connecticut, 764 F. Supp. 728,732 (D. Connecticut 1991).
70. See, for example, Clark v. K-Mart Corporation, No. 91-3723. 3d Cir., May 22, 1992 (holding
that trial court’s grant of preliminary injunctive relief to a metastatic breast cancer patient
who sought to have her employer’s self-funded plan pay for a bone marrow transplant was
abuse of discretion, since trial court had only limited authority to review plans’ decisionmaking process).
71. For example, many courts have ruled that autologous bone marrow transplantation is not
experimental and have ordered insurers to pay for it. Adams v. Blue Cross/Blue Shield of
Md., 757 F. Supp. 661 (D. Md. 1991); Bucci v. Blue Cross/Blue Shields of Conn., 764 F. Supp.
728 (D. Conn. 1991); Bradley v. Empire Blue Cross & Blue Shield, 562 N.Y.S.2d 908 (1990).
Other courts, however, have ruled that the procedure is still experimental and have upheld insurance companies’ refusal to pay for such treatment. Harris v. Blue Cross & Blue
Shield, 729 F. Supp. 49 (N.D. Tex. 1991); Thomas v. Gulf Health Plan, 688 F. Supp. 590 (S.D.
Ala. 1988); Sweeney v. Gerber Prod. Co. Medical Benefits Plan, 728 F. Supp. 594 (D. Neb. 1989).
72. See note no. 68, Rollo.
73. See, for example, Newcomer, L. Defining experimental therapy—A third-party payor’s
dilemma. New England Journal of Medicine (1990) 323,24:1702; McQuillen, M.P., and Khatri, B.O. Experimental therapy—Who shall pay? New England Journal of Medicine (1991)
324:1291.
74. The “investigational” procedures exclusion in each of these bills is part of their broader exclusions of procedures that are “not medically necessary or appropriate”
(Chafee/Thomas, §1302, S. 117/H.R. 3774) or “not medically appropriate” (Cooper/Breaux, §1302, H.R. 3222/S 1579). In Chafee/Thomas, the general exclusion comes
into play only for purposes of resolving disputes about the scope of coverage. In the Cooper/Breaux bill, the general exclusion applies at plan level in that it would modify the basic benefit package prescribed by a national health board.
In both bills, as introduced, “not investigational” is defined in a way that could be interpreted
to permit more liberal access for children to innovative procedures. Each bill stipulates
that a procedure is not investigational if there is “sufficient evidence on which to base conclusions about the existence and magnitude of the change in health outcome resulting
from the treatment or diagnostic procedure, compared with the best available alternative
(or with no treatment or diagnostic procedure).” The “evidence” could be “opinions of
medical specialty groups and other medical experts” (both bills), and/or recommendations by a national commission (Cooper/Breaux). However, neither bill would require
coverage for innovative pharmacotherapies that have not been approved for general use
by the Food and Drug Administration, a process requiring rigorous clinical proof of efficacy and safety for a specified use.
75. President Clinton’s original proposal expressly made coverage of “qualifying investigational” treatments discretionary for a plan. To be a “qualifying investigational treatment,”
a treatment must meet two conditions stipulated in the bill. First, its “effectiveness . . . has
not been determined.” And second, it is “under clinical investigation” as part of a research trial approved by one of several types of federal agencies or other authoritative organizations specified in the statute (§1128, Gephardt/Mitchell, H.R. 3600/S 1757).
76. For discussion of Plyler v. Doe, 457 U.S. 202 (1982) and Sullivan v. Zebley, 493 U.S. 521
(1990), see note no. 1, Jameson and Wehr, pp. 157, 158.
77. For discussion of the Medicaid law, see note no. 1, Jameson and Wehr.
78. Rubin, A. Big decisions now on shoulders of House, Senate leaders. Congressional Quarterly
Weekly Report (July 9, 1994) 52,27:1866.
79. Remarks of Karen Hein, Senate Finance Committee Democratic Staff, July 7, 1994, at Workshop on Maternal and Child Health under Health Care Reform, a conference at the Institute of Medicine, Washington, DC, July 7-8, 1994.
80. Senate Labor and Human Resources Committee staff draft of health reform committee report language, on file with one author, Elizabeth Wehr, at The George Washington University Center for Health Policy Research, Washington, DC.
133
CHILD
INDICATORS
Race and Ethnicity—
Changes for Children
Eugene M. Lewit
Linda G. Baker
Eugene M. Lewit,
Ph.D., is director of
research and grants
for economics at the
Center for the Future
of Children
Linda G. Baker,
M.P.H., is a research
analyst at the Center
for the Future of Children.
T
he idea of America as a melting pot appears to date from the early days
1
of the republic. The concept of the melting pot married the fact that
America was settled by waves of immigrants from different parts of the
world with the hope that, in America, traditional distinctions and prejudices
would be put aside and a new homogenous “race” formed. With the passage of
time, the country gradually raised barriers against immigration and turned its
attention more toward resolving the problems of its domestic and, by then,
largely native-born population. Today, fueled in part by recent new waves of
immigration and increased awareness of ethnic identities, the issue of the racial,
cultural, and/or ethnic makeup of American society is again very much a topic
of discussion and concern.
Perhaps more than other
population groups, children
have an important stake in
how effectively the nation responds to what appears to be
an increasingly heterogeneous
population. Accordingly, this
Child Indicators article explores some of the data underlying the observation that the
U.S. population of children is
becoming more heterogeneous. First, we review the concepts of race, ethnicity, and
national origin—factors that
can be used to characterize
and measure the heterogeneity of the population. Then, we
examine historical trends in
the ethnic mix of the U.S.
population, including projections for the next century and
differences between the ethnic
makeup of the child and adult
populations. The relative roles
of immigration and varying
birthrates in shaping the U.S.
ethnic mix are also reviewed.
Finally, we look at the geographic distribution of children who are likely to face
significant challenges as a result of not speaking English at
home.
planation of the historical usage of these terms, skirts the
definition issue by saying that
“the classification of the population by race reflects common
usage rather than an attempt
to define biological stock.”3
The official federal document
What Is Meant
that sets the standards for data
collection on race, called Staby Race and
tistical Directive No. 15, also
Ethnicity?
comments that the classifications of race and ethnicity
Despite their common usage, “should not be interpreted as
or perhaps because of it, the being scientific or anthro4
terms race and ethnicity are pological in nature.” After
hard to define precisely and making that statement, the Staexplicitly. Typically, the term tistical Directive proceeds to derace has a biological or physi- fine several categories of race
ological undertone (but is cer- and ethnicity, using the term
tainly not so strictly limited), “origins” under the race catewhile ethnicity refers broadly to gories and “culture or origin”
culture and custom.2 Both for ethnicity categories, but
terms are used to group peo- leaving the bulk of the definple who have some similar ex- ing to the reader.
periences and backgrounds
Because of the difficulties
together into one category.
The Census Bureau, in its ex- in defining exactly what these
The Future of Children CRITICAL HEALTH ISSUES FOR CHILDREN AND YOUTH
Vol. 4 • No. 3 – Winter 1994
135
(with revision) by the Office of
Management and Budget
(OMB) in May of 1977. Statistical Directive No. 15, as the
standards are called, establishes classifications for federal statistics and administrative
reporting, and requires that
data on race and ethnicity be
collected separately where
possible. Ethnicity is designated as “Hispanic origin” or
“not Hispanic origin” with the
remaining categories falling
into the race groups: American Indian or Alaskan Native,
The official subgroups used in Asian or Pacific Islander, Black,
the census to define race and and White. In addition, data
ethnicity have changed repeat- may be collected in a comedly over time. The original bined format, where whites
census, in 1790, broke the and blacks are designated as
population into racial groups non-Hispanic. The basic cateof free whites, other persons gories in use today are:
(including free blacks and
n American Indian or Alaskan
“taxable Indians”), and slaves.5
Native: A person having oriFrom the early 1900s through
gins in any of the original peo1950, the census subgroups
ples of North America, and
included white, Negro, and
who maintains cultural idenother (which included Ameritification through tribal affilican Indians, Japanese, and
ations or community recogniChinese), and a person’s race
was determined by the census tion.
taker. Mexican was considered n Asian or Pacific Islander: A
a race group in the 1930 cen- person having origins in any of
sus; but in 1940 it was dropped, the original peoples of the Far
and Mexicans were included East, Southeast Asia, the Inin the white category as in dian subcontinent, or the Paciprior censuses.6 People of fic Islands. This area includes,
mixed race were usually classi- for example, China, India, Jafied by the race of the father, pan, Korea, the Philippine Iswith a few exceptions that lands, and Samoa.
changed from census to census. In 1960, the census intro- n Black: A person having oriduced some self-classification, gins in any of the black racial
and by 1970, classifications groups of Africa.
were primarily made by the
n Hispanic: A person of Mexihead of household.7
can, Puerto Rican, Cuban,
The categories were fur- Central or South American, or
ther refined when, in June other Spanish culture or ori1974, a federal committee was gin, regardless of race.
formed to develop terms and
definitions for the collection n White: A person having oriof data on race and ethnicity. gins in any of the original peoAfrica,
The committee drafted a set of ples of Europe, North
4
standards which, after review or the Middle East.
It is noteworthy that there
by various federal agencies
and the public, was adopted is considerable variation withterms mean, in most current
data collection efforts, an individual’s race and ethnicity are
generally self-reported, and no
definitions of the terms race
and ethnicity are provided to
the respondent. In the decennial census, the race and ethnicity of children are defined
and chosen by the head of the
household.
Race and Ethnic
Groupings
in each larger group. Hispanics, for example, come from
many different countries, and
the various subgroups have
had disparate experiences in
this country. (See the article by
Mendoza in this journal issue
for a more detailed discussion
of differences among subgroups of the Hispanic, or Latino, population.)
The continual changes in
the categories reflect actual
population changes, the unfolding views of Americans
about race and ethnicity, and
political considerations. For
example, the Asian population
in this country has exploded in
recent years, from 1.5 million
in 1970 to 7.5 million in 1990,8
and thus the interest in data
on this group has grown. Creation of the Asian/Pacific Islander category in 1980 led to
a reclassification of individuals
from the Indian subcontinent
(previously classified as white).
In addition, the Asian/Pacific
Islander category includes native Hawaiians who are not
classified with other indigenous people (American Indians or Alaskan Natives) because they are not eligible for
the special government benefits to which so-called federal
5
Indians are entitled.
Sources of Data
The standard source for basic
data on the racial and ethnic
makeup of the U.S. population
is the decennial census. All of
the data in this article come
from the census and from
projections of population
changes modeled by the Census Bureau based on census
data. Since the first census in
1790, the Census Bureau has
collected data every 10 years
on all residents of the United
States, including their race
3
and ethnicity.
136
Comparing data from
sources other than the census
can be problematic. Individual surveys often differ in their
methods of data collection,
the content and format of
questions, and the definitions
of categories. For example,
U.S. vital statistics (birth and
death records) and the census
1910 to 1950
Between the early 1900s and
1950, some relatively small
changes in the makeup of the
population of children echoed
larger changes in the adult
population. In 1910, 4% of
children (under the age of 20)
were born in countries other
In 1990, only 69% of children were
classified as white, non-Hispanic, down
from 86% of children classified as white
in 1950.
collect information on race
and ethnicity in different
ways. The census currently determines race and ethnicity
using self-identification, while
for birth and death records,
vital statistics surveys often rely
on classification by a health
care provider or next of kin.
One study of infant birth and
death records found that, in
many instances, the race of an
infant recorded at birth was
different from the race of the
same infant recorded at death.
These discrepancies occurred
because different people reported the race of the infant at
birth and at death.9
Changes in the
U.S. Population
over Time
than the United States, along
with more than 20% of adults.
Many children, although born
in this country, had parents
who were recent immigrants.10
In general, these individuals
were disadvantaged by barriers
of language and culture and
discrimination. Even though
they were largely white, the
Central, Eastern, and Southern European immigrants in
the early 1900s were commonly “defined as racially inferior and incapable of being
assimilated.”11
By 1950, the proportion of
children who were foreignborn dropped to only 1%, and
only 10% of adults were born
outside the United States. The
proportion of the population
that was black (“Negro” in the
terms of the day) for both
adults and children remained
about the same as it was in
1910, while the native-born
white population grew in relative size. Thus, the 1950 populations of adults and children,
as measured by the census,
were more homogenous in
terms of language and culture
than they had been in 1910.
The apparent increase in homogeneity not only stemmed
from the decline in immigration between 1910 and 1950,
but also reflected the bluntness
of the classification scheme
used at the time.
Figure 1 presents data on the
racial and ethnic makeup of
the U.S. population of children (under the age of 20)
and adults for several key time
periods in this century: 1910,
1950, and 1990. Information
for these years is from the official census reports and incorporates the definitions and
reporting procedures in place
at the time of each census.
Also shown are recent projections for 2025. The projections incorporate ethnic categories presently in use and
current demographic trends.
With regard to the latter, at 1950 to 1990
least, the projections are sub- In 1990, only 69% of children
ject to error.
were classified as white, non-
Hispanic, down from 86% of
children classified as white in
1950. A substantial part of the
decline in the proportion of
the child population classified
as white is attributable to the
creation of the Hispanic category in 1980. Since 1940,
Hispanics had been classified
as white, black, or other, although most were included in
the white population.6 The
changes in census race and
ethnicity classifications between 1950 and 1980 make
comparisons over time difficult; however, the growth of
the proportion of the child
population classified as black
to 15% in 1990 from 12% in
1950 (despite the reclassification of some blacks as Hispanic) and the increase in the
Asian/Pacific Islander and Indian groups to 4% of children
in 1990 from 1% in 1950
(these groups were largely
classified as “other” in 1950)
both suggest that the population of children was more ethnically heterogeneous in 1990
than in 1950. The population
of children also appears to be
more ethnically heterogeneous in 1990 than the population of adults. This is a change
from earlier years when the
adult population appeared,
within the limits of the available classification schemes,
more diverse than the child
population.
The foreign-born population expanded between 1950
and 1990 to become 4% of
children (under age 19) and
10% of adults (not shown on
the chart).12 In other words,
the same proportion of children were foreign-born in
1990 as in 1910, while the proportion of foreign-born adults
was the same in 1990 as it had
been in 1950.
1990 and Beyond
As shown in Figure 1, predictions have been made that,
from 1990 onward, the Hispanic, Asian/Pacific Islander,
American Indian, and nonHispanic black populations
will increase, and the nonHispanic white population will
decrease proportionately. By
2025, some 65% of adults are
predicted to be non-Hispanic
137
CHILD INDICATORS: Race and Ethnicity—Changes for Children
white, and only a little more
than half of children (52%)
will be in the same group.13
The fastest-growing group
is predicted to be Asians/Pacific Islanders, who are expected to triple in number by 2025.
Hispanic children are projected to increase to 22% of the
child population by 2025, making them the largest group
after non-Hispanic whites.
Children will be the driving
force for the general increase
in the Hispanic population,
which is expected to be the
second largest racial/ethnic
group in the country from
2010 through 2050.13
Sources of
Change
Two key factors, immigration
and natural increase (births
minus deaths), determine
both the growth of the U.S.
population and its ethnic
composition. Immigration of
different ethnic groups is
necessary to introduce these
groups into the national population, and differential rates of
immigration among groups
are also reflected in the relative share of the population
each represents. Among ethnic groups already settled in
the United States, differential
rates of natural increase will,
over time, change the relative
representation of the groups
in the population. Groups with
relatively high birthrates will
gradually account for a larger
share of the population.
Figure 2 illustrates ethnicgroup-specific differences in
the two factors which determine population growth.
Overall, in recent years, the
annual rate of growth attributable to natural increase has
been more than double the
rate for immigration. For
Asians/Pacific Islanders and
Hispanics, however, immigration has been and is projected
to continue to be an important
factor in population growth.
Although immigrants in the
big wave of immigration that
occurred around the turn of
the century were predominantly young adults, it appears
that current immigrant families contain many children. In
1910, only 12% of immigrants
were under 14 years old, while
between 1987 and 1990, 22%
of immigrants were age 14 or
under. 14
In addition to differences
in rates of immigration, Figure 2 also gives some insight
into how different rates of
natural increase are changing
the face of U.S. society. Rates
of increase among all nonwhite groups are two to three
times greater than the rate for
non-Hispanic whites. This
difference is largely the result
of higher birthrates for nonwhite groups, although the
white population also has the
highest death rate because it
is the oldest of all the groups.
Hence, even in the absence
of any additional immigration, the proportion of nonHispanic whites in the current
population is likely to continue to decline over time,
although somewhat more
slowly than has been projected in models which account
for immigration such as the
projection for 2025 found in
Figure 1.
are reduced when adult policy
and decision makers are from
ethnic groups other than those
represented by a large segment of the child population.
Barriers to
Services
Although a large number of
children who are impoverished, doing poorly in school,
or are in poor health are nonHispanic whites, these problems occur more frequently
among children in most other
broadly defined racial and
15
ethnic groups. The low incomes and education levels of
many nonwhite heads of
families are likely important
factors in the differential status of nonwhite children; however, cultural isolation and
limited language skills may
also present particular obstacles to children in certain ethnic groups.
One group of particular
notice is the more than 2 million U.S. children who are
foreign-born and the millions
more who are the children of
16
recent immigrants. Many of
these children are part of the
Another consequence of more than 6.3 million schooldifferential rates of natural in- age children (14% of the U.S.
crease is that the distribution population ages 5 to 17) who
of children among ethnic speak a non-English language
17
groups will be different than at home. Approximately
the distribution of adults (see two-thirds of these children
data for 1990 and 2025 in Fig- come from Spanish-speaking
Overall, in recent years, the annual rate
of growth attributable to natural increase
has been more than double the rate for
immigration.
ure 1). The implications of this
development for the wellbeing of children cannot be
determined at present. However, it has been observed that
ethnic groups frequently function like extended families,
bound by common links of culture, language, customs, and
interests.1 Accordingly, it may
be that concern for and attention to the needs of children
homes, and an important proportion of the remainder
speak a variety of Asian languages. Children who speak a
non-English language at home
may be particularly challenged
in relating to mainstream U.S.
society. They may require special programs in preschool
and school and may find that
they are less able to rely on
their families for help with
138
Figure 1
The Ethnic and Racial Distribution of the U.S. Population of
Adults and Children, 1910 to 2025
Adults
(20 and over)
Children
(19 and under)
1910
1950
Data in this figure are from the official U.S. decennial census. In general, the population
was divided into three categories of race: white, black, and other. The “other” category
included American Indians, Japanese, and Chinese. The census also collected data on the
place of birth of white residents, allowing the division into native- and foreign-born shown
above.
n In general, the population of both children and adults became more homogenous
between 1910 and 1950. This change is caused by the small number of categories,
and by the decline in immigration. Between 1910 and 1950, the proportion of white
children (those under age 20) who were born outside the country decreased from
4% to l%, following the larger trend within the adult population. The proportion
who were black was unchanged.
n The heterogeneity of the child population may be understated because children of
recent immigrants were classified as native-born.
Source: U.S. Bureau of the Census. Historical statistics of the United States: Colonial times to 1970. Bicentennial ed.
Part 1. Series 119-134. Washington, DC: U.S. Government Printing Office, 1975, pp. 16-18.
139
Figure 1 (continued)
Adults
(20 and over)
Children
(19 and under)
1990
2025
The 1990 census collected data on four categories of race (white, black, Asian/Pacific
Islander, and American Indian/Eskimo/Aleut) and one of ethnicity (Hispanic or nonHispanic). The change in the designation of the race options was made in the 1980 census,
after Statistical Directive No. 15 was adopted in 1977. Data for 2025 are projections from the
1990 census based on demographic trends and predictions for future growth.
n Between 1950 and 1990, the diversity of the populations of adults and children
appears to increase. Part of the difference is due to the major changes in definitions
that occurred in the 1980 census, where the race category “Asian/Pacific Islander”
and the ethnicity category “Hispanic” were added. In 1950, most Hispanics were
classified as white, most Asians and American Indians as other.
n In 1910 and 1950, the adult population appeared more diverse than the child
population. Recently, and as projected for the future, it appears that the child
population is more heterogeneous.
n Between 1990 and 2025, the diversity of the populations of both children and adults
is expected to increase rapidly.
Sources: Hollmann, F.W. U.S. population estimates by age, sex, race, and Hispanic origin: 1980 to 1991. Current
Population Reports, Series P-25, No. 1095. Washington, DC: U.S. Government Printing Office, February 1993, p. 5, Table
1; Day, J.C. Population projections of the United States by age, sex, race, and Hispanic origin: 1993 to 2050. Current
Population Reports, Series P-25, No. 1104. Washington, DC: U.S. Government Printing Office, November 1993, p. xxi.
140
Figure 2
Average Annual Rate of Natural Increase and Net Immigration, 1981 to 1991
50
45
40
35
30
25
20
15
10
5
0
White
Black
American Asian/Pacific
Islander
Indian
Hispanic
Total
Race/Ethnicity
Both natural increase and immigration contribute to the growth and the changing ethnic mix of the population.
Natural increase is the difference between the birth and death rates for each group. Net immigration includes both
legal and estimated illegal immigration. All groups shown (except Hispanics) exclude Hispanic origin populations,
and American Indian includes Eskimos and Aleuts.
n Rates of natural increase are two to three times lower for non-Hispanic whites than for other groups.
n Even if immigration were to cease completely, the proportion of the U.S. population that is non-Hispanic white
would continue to decrease.
n The different rates of natural increase are important factors in the increasing diversity of the child population.
Source: Hollmann, F.W. U.S. population estimates by age, sex, race, and Hispanic origin: 1980 to 1991. Current Populution Reports, Series P-25, No.
1095. Washington, DC: U.S. Government Printing Office, February 1993, pp. 30-31, Table 2.
children ages 5 to 17 live in
such households.16
ico, Arizona, New Jersey, and
Florida.
Immigrants and their children tend to cluster in certain
parts of the country. California, Texas, and New York are
homes for almost two-thirds of
Even more constrained all foreign-born children. As
are those children who live in illustrated in Figure 3, chil“linguistically isolated” house- dren who do not speak English
holds. These are households at home, immigrant children,
in which no member age 14 or and the children of recent imolder speaks English at least migrants, are concentrated in
“very well.” Nationwide, 4% of these states and in New Mex-
The concentration of
immigrant children and the
native-born children of recent
immigrants in certain geographic areas can have both
desirable and undesirable consequences.
homework and with accessing
necessary services, such as
health care. As they grow
older, some may also be at a
disadvantage in finding employment and making the
transition to adulthood.
Concentration may facilitate the delivery of specialized
culturally and linguistically appropriate services. Such serv-
141
Figure 3
Percentage of Children Ages 5 to 17 in Households Where a Language Other
than English is Spoken, 1990
Children who speak a non-English language at home may be particularly challenged when relating to mainstream
U.S. society. The data on these children come from a 1990 census question which asked whether or not individuals
in households spoke English at home. These data represent households with one member between the ages of 5 and
17 where all members age 14 and older spoke a language other than English (although one or more members may
speak English to some degree).
n Eleven percent of children ages 5 to 17 in the United States live in households where all members speak a
language other than English. These children, primarily immigrant children and the children of recent
immigrants, are concentrated in several states.
n Four percent of children nationwide are linguistically isolated, meaning that all members of their household
speak a language other than English, and no one over age 14 was reported to speak English “very well.”
Source: U.S. Bureau of the Census, Population Division, Education and Social Stratification Branch. Language use and English ability, persons 5 to 17
years, by state: 1990 census. Unpublished data from the 1990 census of population. Table ED90-4.
ices may be difficult or expensive to deliver to small population groups or in areas where
providers with appropriate
training or backgrounds are
rare. On the other hand, the
demand for a full complement
of specialized services may be
perceived as particularly burdensome by state and local
governments and by their taxpayers. Recent attempts by the
states of California and Florida
to receive additional financial
assistance and other relief
from the federal government
to help cope with the demands
placed on state service delivery
systems by legal and illegal immigrants are evidence of the
perceived burdens placed on
state and local governments by
immigrant populations and
their children.18
Conclusion
The growing ethnic diversity of
the U.S. population presents
the nation with a variety of
challenges. The challenge of
delivering appropriate health
care, child care, and educational and social services to
immigrant children and the
native-born children of recent
immigrants may be especially
142
pressing. Children, particularly young children, are very
dependent on their parents,
and when parents or other
adult family members are unfamiliar with the social system,
children are at risk of being
underserved. In the current
environment, this risk is compounded by the fact that, for
some children of immigrants,
their parents and older siblings or the children themselves may be here illegally. For
many undocumented immigrants, frequent or vigorous
contact with public institutions
may place them or their continued residence in this country in jeopardy.
Generalizations about specific groups of children and
about the consequences of
ethnic diversity can sometimes be divisive rather than
helpful. As the article by Mendoza in this journal issue on
the health needs of Latino
children makes clear, there is
great variety within any large
ethnic group with regard to
language and culture, proximity of immigration and
degree of assimilation, geographic location, and special
needs. Even the so-called majority group, non-Hispanic
whites, includes a large number of subgroups with origins
groups are disproportionately
poor, in poor health, or otherwise deprived is also of limited usefulness. Although analyses of ethnic differences may
be important in identifying
special barriers to services
faced by certain racial or ethnic groups, they should not
divert attention from the fact
that, by and large, such problems as poverty, lack of health
insurance, school failure, and
teenage pregnancy are found
in all ethnic groups and that,
in most instances, the majority
of children who are actually at
risk are non-Hispanic whites.
For example, in 1990, there
were 4.6 million non-Hispanic
white children who lived in
families with incomes below
the poverty level, compared
with 3.6 million non-Hispanic
black children and 2.4 million
19
Hispanic children. Accordingly, policies that address
generic problems directly,
wherever they are found, may
prove to be more effective and
popular than approaches
which emphasize ethnic differences.
The classification of the
population into different ethnic groups has a long and
checkered history in this country. Racial and ethnic labels
have had many uses other than
negative stereotype can be
harmful to children.20
With regard to the data on
ethnicity and race, continued
controversy surrounding the
usefulness of the census categories has caused OMB to review the official groups once
again. Nationwide criticism
suggests that the current categories have become “less useful in reflecting the diversity of
our nation’s population.”4
The most obvious problem
with the current categorization is that it does not provide
for multiracial individuals.
Several multiracial groups
have proposed that a multiracial category be added—to
the great dismay of those who
advocate for the groups that
would lose members to the new
category. Many other changes
have also been proposed.
Some have argued that the collection of data on race and
ethnicity be stopped altogether, because the very act of
collecting the data emphasizes
stereotypes.4 In part, the debate appears to be focused on
recognizing, protecting, and
enhancing the status and entitlements of certain subgroups
of the population.
With the passage of the
civil rights legislation in the
mid-1960s, ethnic labeling in
the United States, as embodied in Statistical Directive No. 15,
took on a special importance.
Nationwide criticism suggests that the
Highly detailed information
about minority participation
current categories have become “less
in various activities became
useful in reflecting the diversity of our
fundamental to monitoring
and enforcing desegregation,
nation’s population.”
and as a result, the official procedures that followed to classify individuals by race and
ethnicity took on an increasin the different countries of to describe the population. ed political importance. The
Europe and the Middle East. For individuals, ethnic labels authority of these classificaRecent immigrants within this may serve the positive function tions extends to programs for
group and their children face of identification with a partic- children. For example, in one
many of the same linguistic ular group, its history, accom- selective San Francisco high
and cultural barriers as so- plishments, and tribulations. school, the test score required
called minority immigrants. In Positive identification with a for admission is lower for black
addition, children who are larger population group may and Hispanic students than it
members of subcultures with- be particularly important to is for Asian students. The
in ethnic groups may have dif- the development of self- school is only permitted to adferent experiences from those esteem in children. But ethnic mit up to 45% of its students
in the mainstream because of labels can be destructive when from any one racial or ethnic
customs, traditions, or dis- they are used pejoratively or to group, and the differential adcrimination. The observation limit full participation in soci- mission criteria are needed to
that children in certain ethnic ety, and identification with a satisfy that quota.21
143
Because of preferential
policies, the five broad ethnic
and racial categories of classification, themselves quite ad
hoc and arbitrary, have developed their own constituencies, lobbies, and vested interests.22 The risk associated
with making political decisions and creating social welfare programs based on race
or ethnic classification is that
they may be ineffective if the
categorization process is
flawed and may set groups
against one another because
of perceived and sanctioned
differences.
at present a daunting combination of tasks.
The data strongly suggest
that, regardless of any changes
in immigration, the U.S.
population will become increasingly heterogeneous over
time because of differences in
ethnicity/race-specific rates
of natural increase. In this
fluid environment, the challenge to public policy will be
to deliver appropriate services, monitor performance,
and foster a cohesive society—
The helpful comments of
David Hayes-Bautista, Dana
Hughes, and Alan Watahara are
gratefully acknowledged, as are the
comments of Richard Behrman,
Deanna Gomby, Carol Larson,
and Pat Shiono. Rebecca Sutterlin,
David Fleck, and Edward Fernandez of the U.S. Bureau of the Census provided helpful information.
Karen Andrews assisted with
manuscript preparation. The
usual caveats apply.
1. Glazer, N., and Moynihan, D.P. Beyond the melting pot: The Negroes, Puerto Ricans, Jews,
Italians, and Irish of New York City. Cambridge: Massachusetts Institute of Technology
Press, 1963.
2. According to Webster’s Ninth New Collegiate Dictionary, race is “a family, tribe, people, or
nation belonging to the same stock” or “a class or kind of people unified by community of interests, habits, or characteristics.” The first definition suggests a biological
basis for race, while the second sounds very similar to the definition of ethnic. The
definitions of the term ethnic are: “a member of an ethnic group: esp. a member of a
minority group who retains the customs, language, or social views of his group” or “of
or relating to large groups of people classed according to common racial, national,
tribal, religious, linguistic, or cultural origin or background.” Springfield, MA: A.
Merriam-Webster, 1991.
3. U.S. Bureau of the Census. Historical statistics of the United States: Colonial times to 1970.
Bicentennial ed. Part 1. Series 119-134. Washington, DC: U.S. Government Printing
Office, 1975, p. 3.
4. Standards for the classification of federal data on race and ethnicity. Federal Register
(June 9, 1994) 59,110:29831.
5. Wright, L. One drop of blood. The New Yorker (July 25, 1994) 70,22:46-55.
6. Hayes-Bautista, D.E., and Chapa, J. Latino terminology: Conceptual bases for standardized terminology. American Journal of Public Health (January 1987) 77,1:61-68.
7. McKenney, N.R., and Bennett, C.E. Issues regarding data on race and ethnicity: The
Census Bureau experience. Public Health Reports (January/February 1994) 109,1:16-25.
8. Personal communication with the Division of Race Statistics, U.S. Bureau of the Census,
August 25, 1994; Hollmann, F.W. U.S. population estimates by age, sex, race, and Hispanic
origin: 1980 to 1991. Current Population Reports, Series P-25, No. 1095. Washington,
DC: U.S. Government Printing Office, February 1993.
9. Hahn, R.A. Inconsistencies in coding of race and ethnicity between birth and death in
U.S. infants: A new look at infant mortality (1983 through 1985). Journal of the American Medical Association (January 8, 1992) 267:259-63.
10. See note no. 3, U.S. Bureau of the Census, Series C 195-227, p. 116.
11. Pavalko, R.M. Racism and the new immigration: A reinterpretation of the assimilation
of white ethnics in American society. Sociology and Social Research (October 1980)
65,1:56-77.
12. U.S. Bureau of the Census. The foreign-born population in the United States, 1990. CP-3-1.
Washington, DC: U.S. Government Printing Office, July 1993, p. 1, Table 1.
13. Day, J.C. Population projections of the United States, by age, sex, race, and Hispanic origin:
1993 to 2050. Current Population Reports, Series P-25, No. 1104. Washington, DC:
U.S. Government Printing Office, November 1993, p. xxi.
14. See note no. 3, U.S. Bureau of the Census, Series C 138-142, p. 112; also, see note no. 7,
McKenney and Bennett, p. 1, Table 1.
15. Rosenbaum, S., Layton, C., and Liu, J. The health of America’s children. Washington, DC:
The Children’s Defense Fund, 1991; Starfield, B., Shapiro, S., Weiss, J., et al. Race,
144
family income, and low birth weight. American Journal of Epidemiology (1991)
134,10:1167-74; see also note no. 13, Day, p. 69.
16. U.S. Bureau of the Census, Population Division, Education and Social Stratification
Branch. Language use and English ability, persons 5 to 17 years, by state: 1990 Census.
Unpublished data from the 1990 census of population. Table ED90-4.
17. The census asks, “Does this person speak a language other than English at home?” If
the answer is yes, the language is determined, and then the respondent is asked, “How
well does this person speak English?” This series of questions is not asked about children under five years old. (Rebecca Sutterlin, U.S. Bureau of the Census, Education
Branch. Telephone conversation with author, September 2, 1994.)
18. Farragher, T. Wilson tour focuses on immigration. San Jose Mercury News. April 21, 1994,
at 3B; Kleindienst, L., and Hirth, D. Florida delegation joins forces. Sun Sentinel (FL).
February 22, 1994, at 10A.
19. U.S. Bureau of the Census, Housing Division, Poverty and Wealth Statistics Branch. Unpublished data from the 1990 census of population.
20. Spencer, M.B., and Markstrom-Adams, C. Identity processes among racial and ethnic minority children in America. Child Development (1990) 61:290-310; Porter, J.R., and
Washington, R.E. Minority identity and self-esteem. Annual Review of Sociology (1993)
19:139-61.
21. Telephone conversation with Archie Fokin, San Francisco Board of Education, Educational Placement Center, August 26, 1994.
22. The new discrimination. Editorial. San Jose Mercury News. August 17, 1994, at 11B; see
also note no. 5, Wright; Johnson, S. Census ruling could affect city budgets: Minority
influence likely to be bolstered. San Jose Mercury News. August 10, 1994, at 1B.
JOURNAL ISSUES IN PRINT
The following back issues are available free of charge from the Center for the Future of Children:
Sexual Abuse of Children
Volume 4, Number 2 (Summer/Fall 1994) 248 pp.
Edited by Carol S. Larson, J.D. and Donna L. Terman, J.D.
This issue focuses on the difficult and emotionally charged problem of the sexual abuse of children. In addressing this important topic,
articles summarize current knowledge and experience relevant to improving public policies in the United States and highlight the need for
better coordination between the judicial and child welfare systems in working with abused children, their families, and the perpetrators.
Articles examine specifically immediate and long-term impacts of child sexual abuse, reporting and investigating of child sexual abuse,
adjudication of child sexual abuse cases, prevention of child sexual abuse, and characteristics and treatment of offenders.
Children and Divorce
Volume 4, Number 1 (Spring 1994) 256 pp.
Edited by Linda Sandham Quinn, Ph.D.
This issue examines the process of divorce and its consequences upon the lives of children and their families. Articles focus on the history of
divorce, its financial impact on families, child custody, child support, and children’s adjustment to divorce. Articles also review high-conflict
divorce, a feminist perspective on divorce, and the role of the father after divorce.
Home Visiting
Volume 3, Number 3 (Winter 1993) 216 pp.
Edited by Deanna S. Gomby, Ph.D. and Carol S. Larson, J.D.
This issue examines the use of home visiting programs to serve pregnant women and families with young children. Articles focus on the
diversity of home visiting programs and their goals, the use of home health visiting in Europe, the research literature evaluating the effectiveness of home visiting approaches, the economic evaluation of home visiting programs, staffing issues for home visiting programs, the
importance of societal and cultural context, and the ways in which home visiting programs must be designed and delivered to best address
the health and developmental needs of young children.
Health Care Reform
Volume 3, Number 2 (Summer/Fall 1993) 216 pp.
Edited by Eugene M. Lewit, Ph.D.
This issue focuses on making health care reform work for children. It brings together updated papers for congressional staff on health
insurance for children with additional articles about selected issues of importance to the current debate on health care reform. Articles focus
on an appropriate benefits package for women and children, innovative ways of paying for health care services, how to guarantee coverage
with multiple insurers, state initiatives to cover uninsured children, the distribution of costs and benefits of universal coverage, public opinion
and health care reform, and managed care for children and pregnant women.
Adoption
Edited by Irving Schulman, M.D.
This issue examines adoption as the primary means of providing a stable, nurturing, loving home to some children who, for a variety of
reasons, have been deprived of such an environment. From the perspective of what is in the best interests of the child, the authors explore
the major barriers to adoption and an overview of adoption today, including articles about adoption law, statistics on adoption in the United
States, benefits and risks of open adoption, adoption of children with special needs, international adoption, agency versus independent
adoption, outcomes of transracial adoption, and adoption of drug-exposed children.
U.S. Health Care for Children
Volume 2, Number 2 (Winter 1992) 192 pp.
Edited by Eugene M. Lewit, Ph.D.
This issue assesses the strengths and weaknesses of the U.S. health care system for children and pregnant women. Written by research and
medical experts, articles examine the measurement of health status, the effectiveness of health care, health care services, and resources and
expenditures. Also examined are public and private financing of health care, children without health insurance, and nonfinancial barriers to
access. This issue highlights components of the system needing reform and proposes a number of policy changes to improve the health care
system.
School-Linked Services
Edited by Carol S. Larson, J.D.
This issue focuses on the current trend toward having schools coordinate and/or provide health and other social services for children and their
families. Contributing authors, including school and government officials, program administrators, and researchers, offer a variety of
viewpoints about financing, planning, implementing, and evaluating school-linked services. The issue identifies emerging criteria for
developing school-linked programs and highlights critical policy concerns. (Related Working Paper #1932 also available.)
To order back issues, please submit requests to: Circulation Department,
The David and Lucile Packard Foundation, Center for the Future of Children,
300 Second Street, Suite 102, Los Altos, CA 94022.
Call (415) 948-3696 or fax (415) 948-6498.

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