Faculty Bibliography

Childhood lead poisoning is a problem that disproportionately affects impoverished children. Many aspects of affected children's lives may be involved in the prevention and treatment of this disease. Changes in child health services are occurring in the context of fundamental changes of virtually all human services. Managed care changes may alter the sites where children get primary care services, the content of that care, and linkages of medical services to public health, nutrition support, housing, mental health, education, and social services. This article discusses the opportunities and the dangers that managed care changes may pose to the prevention and treatment of childhood lead poisoning

OBJECTIVE: To investigate whether students who are old-for-grade have higher rates of reported behavior problems and to investigate whether this association is independent of having been retained a grade in school. METHODS: Cross-sectional analyses of parental reports from the nationally representative sample of 9079 children ages 7 to 17 years who participated in the Child Health Supplement to the 1988 National Health Interview Survey. Students older than the modal age for their grade were considered old-for-grade, either due to delayed school entry (those without grade retention) or to delayed school progress (with history of grade retention). Behavior problems were defined as scores >90th percentile on a well-utilized, standardized Behavior Problem Index (BPI). RESULTS: Twenty-six percent of 7- to 17-year-old children in the United States are old-for-grade. Being old-for-grade is more common in males (31%), blacks (33%), Hispanics (32%), those living in single-parent households (31%) or poverty (43%), and those with mothers with low educational attainment (42%). Most children (84%) who repeated a grade are old-for-grade, but only 54% of old-for-grade students have been retained. For children who were old-for-grade, 19% of those grade-retained and 12% of those nonretained had extreme BPI scores, and for those not old-for-grade, 17% of grade-retained and 7% of nonretained children had extreme BPI scores. Although rates of extreme BPI scores were consistently lower for children who were neither old-for-grade nor grade-retained, and consistently higher for those with both, these rates increased with age for children who were old-for-grade without being retained. Controlling for multiple potential confounders with logistic regression, both old-for-grade status and grade retention are independently associated with increased rates of behavior problems. Separate logistic regression analyses for blacks and whites showed that these findings pertained only to white children. CONCLUSIONS: Whereas grade retention is associated with increased rates of behavior problems in children and adolescents, simply being older than others in one's class, without having experienced grade retention, is also associated with increased rates of behavior problems, most noticeably among adolescents. These data suggest that there may be latent adverse behavioral outcomes that result from delaying children's school entry

OBJECTIVES: This prospective study describes the impact of residential lead-based-paint hazard remediations on children with mildly elevated blood lead levels. METHODS: Changes in blood lead levels were observed following paint hazard remediation alone and in combination with soil abatement. RESULTS: After adjustment for the confounding variables paint hazard remediation alone was associated with a blood lead increase of 6.5 micrograms/dL (P = 0.5), and paint hazard remediation combined with soil abatement was associated with an increase of 0.9 microgram/dL (P = 36). CONCLUSIONS: Lead-based-paint hazard remediation as performed in this study, is not an effective secondary prevention strategy among children with mildly elevated blood lead levels

Children, particularly adolescents, have unique health care needs and experience frequent barriers to receiving needed medical care. The expansion of school-based health services since the early 1970s is one recent development in the area of health services delivery that is a specific response to facilitate meeting the medical needs of youth. Limited resources, shrinking budgets, demographic and behavioral changes among our nation's youth, and recent trends toward managed care all demand innovative strategies by school-based health services if they are to ensure their viability in providing adequate health care to children and adolescents. This article reviews the recently published literature regarding the role of school-based health centers as sites providing primary care services to children and adolescents. In addition, it addresses recent efforts to develop strategies that school-based health centers may need to consider in order to adapt and survive within the environment of health care reform and managed care.

OBJECTIVE: To better understand the epidemiology and behavioral correlates of bed-wetting in a nationally representative sample of children. METHODS: Bivariate and multivariate logistic regression analyses of cross-sectional data regarding 10 960 children aged 5 through 17 years from the 1981 Child Health Supplement to the National Health Interview Survey. Behavior problems were determined by extreme scores on a 32-item Behavior Problem Index (BPI, > 90th percentile). RESULTS: Bed-wetting was reported in 33% of 5-, 18% of 8-, 7% of 11-, and 0.7% of 17-years-olds. At all ages, infrequent bed-wetting (fewer than six episodes per year) accounted for half of all reported bed-wetting. Lower age, male gender, and extreme scores on the BPI all were independently associated with both infrequent and frequent bed-wetting. Extreme scores on the BPI were more common among children with bed-wetting than those who did not wet the bed, and the risk for this was similar among children with infrequent and frequent bed-wetting (adjusted odds ratios, 1.8 and 1.7, respectively). Parents' perceived need for help with emotional and behavioral problems, however, was increased only among children with frequent bed-wetting. CONCLUSIONS: Bed-wetting in children aged 5 years and older, irrespective of its frequency, is associated with increased rates of behavior problems. Thus, although infrequent bed-wetting may not warrant medical intervention, this condition should prompt health care providers to explore behavioral issues in greater depth

OBJECTIVES: To analyze data from a nationally representative sample of high school students to investigate the relationship between substance use and violent behavior among adolescents and to examine this relationship in both male and female adolescents. DESIGN: Cross-sectional analyses of the 1991 Centers for Disease Control and Prevention's Youth Risk Behavior Survey. SETTING: Public and private schools in the 50 states. PARTICIPANTS: The participants were 12,272 high school students. MAIN OUTCOME MEASURE: To determine the prevalence of weapon carrying and physical fighting among male and female adolescents. RESULTS: A significant increase in the number of male and female adolescents carrying weapons and physically fighting was associated with all forms of substance use. Reports of carrying a weapon increased with recent alcohol consumption (34% vs 17%, P < .001) and use of marijuana (48% vs 22%, P < .001), cocaine (71% vs 25%, P < .001), and anabolic steroids (62% vs 25%, P < .001). The prevalence of physical fighting was also significantly higher among adolescents who used illicit substances than among adolescents who denied drug use. The risk of violent behavior increased significantly, and was of equal magnitude, for adolescent females and males who were illicit substance users. CONCLUSIONS: Alcohol and illicit substance use are highly associated with an increased risk of violent behavior. These data also demonstrate that the risk of violence by adolescent females who are substance users is substantial