Health and Safety

Chapter 4: Health and Safety

FACTORS AFFECTING CHILDREN'S HEALTH
DISEASES OF CHILDHOOD
MENTAL HEALTH ISSUES IN YOUNG PEOPLE
CHILDHOOD DEATHS

FACTORS AFFECTING CHILDREN'S HEALTH

A variety of factors affect children's health. These range from prenatal influences; access to and quality of health care; poverty, homelessness, and hunger; childhood diseases; and diet and exercise. This chapter discusses these factors and looks at the leading causes of death among infants, children, and adolescents.

Birth Defects

In “Birth Defects: Frequently Asked Questions” (December 12, 2006, http://www.cdc.gov/ncbddd/bd/faq1.htm), the Centers for Disease Control and Prevention (CDC) indicates that birth defects affect one out of every 33 babies born. Birth defects are the leading cause of infant deaths. In addition, these babies have a greater chance of illness and disability than do babies without birth defects. Two major birth defects, neural tube defects and fetal alcohol syndrome, are in large part preventable.

NEURAL TUBE DEFECTS. Major defects of the brain and spine are called neural tube defects. Each year, as many as 3,000 infants are born in the United States with neural tube defects caused by the incomplete closing of the spine and skull. Another estimated 1,500 pregnancies are either stillborn or terminated because of these defects. The occurrence of these defects can be greatly reduced by adequate folic acid consumption before and during early pregnancy.

FETAL ALCOHOL SYNDROME. Alcohol consumption by pregnant women can cause fetal alcohol syndrome (FAS), a birth defect characterized by a low birth weight, facial abnormalities such as small eye openings, growth retardation, and central nervous system deficits, including learning and developmental disabilities. The condition is a lifelong, disabling condition that puts these affected children at risk for secondary conditions, such as mental health problems, criminal behavior, alcohol and drug abuse, and inappropriate sexual behavior. Not all children affected by prenatal alcohol use are born with the full syndrome, but they may have selected abnormalities.

According to the CDC, in “Tracking Fetal Alcohol Syndrome” (December 5, 2006, http://www.cdc.gov/ncbddd/fas/fassurv.htm), estimates of the prevalence of FAS vary from 0.2 to 1.5 per 1,000 births in different areas of the United States. Other alcohol-related birth defects are thought to occur three times as often as FAS. In “Alcohol Consumption among Women Who Are Pregnant or Who Might Become Pregnant—United States, 2002” (Morbidity and Mortality Weekly Report, vol. 53, no. 50, December 2004), the CDC finds that in 2002, 10.1% of pregnant women drank alcohol, putting their babies at risk for FAS. As many as one out of 50 (1.9%) pregnant women frequently drank alcohol. According to James Tsai et al., in “Patterns and Average Volume of Alcohol Use among Women of Child-bearing Age” (Maternal and Child Health Journal, vol. 11, no. 5, September 2007), 2% of pregnant women and 13% of nonpregnant women of childbearing age are estimated to engage in binge drinking, and 21.5% reported drinking at least 45 drinks per month.

Health Care

IMMUNIZATIONS. In America's Children in Brief: Key National Indicators of Well-Being, 2008 (2008, http://www.childstats.gov/americaschildren/index.asp), the Federal Interagency Forum on Child and Family Statistics explains that the proportion of preschool-age children immunized against communicable and potentially dangerous childhood diseases—including diphtheria, tetanus, and pertussis (whooping cough), known collectively as DTP, polio, and measles—dropped during the 1980s but rose significantly during the 1990s. By 2006, 85.2% of all children had received four doses of DTP, 92.8% had received three doses of poliovirus vaccine, 93.4% had received haemophilus influenzae type b vaccine, 93.3% had received three doses of hepatitis B vaccine, 92.3% had received measles

TABLE 4.1 Percentage of children vaccinated for selected diseases, by poverty statusa, raceb, and Hispanic originc, 1996 and 2006
Characteristic	Total		Below poverty		At or above
	1996	2006	1996	2006	1996	2006
Total
Combined series (4:3:1:3:3:1)d	—	76.9	—	73.4	—	78.3
Combined series (4:3:1:3:3)e	67.7	80.5	61.4	76.3	69.9	82.2
Combined series (4:3:1:3)f	76.4	82.1	68.9	77.8	79.2	83.9
Combined series (4:3:1)g	78.4	83.1	71.6	79.0	80.8	84.8
DTP (4 doses or more)h	81.1	85.2	73.9	80.8	83.6	86.9
Polio (3 doses or more)i	91.0	92.8	87.7	91.9	92.0	93.1
MMR (1 dose or more)j	90.6	92.3	87.2	90.9	91.9	93.0
Hib (3 doses or more)k	91.4	93.4	86.9	91.1	93.1	94.2
Hepatitis B (3 doses or more)l	81.8	93.3	78.0	92.7	83.2	93.5
Varicella (1 dose or more)m	12.2	89.2	5.4	88.3	15.3	90.0
PCV (3 doses or more)n	—	86.9	—	84.1	—	88.0
White, non-Hispanic
Combined series (4:3:1:3:3:1)d	—	77.8	—	69.0	—	78.9
Combined series (4:3:1:3:3)e	68.9	82.2	59.3	74.1	70.5	83.1
Combined series (4:3:1:3)f	78.5	83.9	68.0	75.2	80.4	84.9
Combined series (4:3:1)g	80.1	84.7	70.3	76.7	81.9	85.7
DTP (4 doses or more)h	82.7	86.6	72.4	78.0	84.7	87.6
Polio (3 doses or more)i	91.9	93.3	88.2	90.1	92.5	93.6
MMR (1 dose or more)j	91.4	92.8	85.1	87.7	92.5	93.5
Hib (3 doses or more)k	92.8	94.1	87.4	87.9	93.7	94.8
Hepatitis B (3 doses or more)l	82.1	93.8	76.4	91.7	83.3	94.0
Varicella (1 dose or more)m	14.5	88.7	6.4	83.2	16.3	89.4
PCV (3 doses or more)n	—	87.2	—	79.5	—	88.4
Black, non-Hispanic
Combined series (4:3:1:3:3:1)d	—	73.8	—	71.7	—	76.8
Combined series (4:3:1:3:3)e	66.8	76.7	61.3	74.0	71.9	80.4
Combined series (4:3:1:3)f	74.2	78.4	69.3	75.8	79.1	81.9
Combined series (4:3:1)g	76.6	78.9	72.5	76.5	80.9	82.4
DTP (4 doses or more)h	79.0	81.2	74.3	78.8	83.3	84.8
Polio (3 doses or more)i	90.1	90.4	86.8	90.4	92.6	91.4
MMR (1 dose or more)j	89.7	90.9	88.3	90.8	90.8	91.6
Hib (3 doses or more)k	89.4	91.0	85.9	89.9	92.8	93.4
Hepatitis B (3 doses or more)l	81.9	91.5	77.8	91.6	85.0	92.5
Varicella (1 dose or more)m	8.6	89.1	—	89.2	12.9	89.8
PCV (3 doses or more)n	—	82.9	—	82.2	—	84.5

vaccines, and 89.2% had received varicella (chickenpox) vaccine. (See Table 4.1.) More than four out of five of these children received the vaccinations in combined series. Children living below the poverty line and African-American children were slightly less likely than the general child population to be immunized.

In 1994 the U.S. Department of Health and Human Services (HHS) implemented the Vaccines for Children (VFC) program, which provides free or low-cost vaccines to children at participating private and public health care provider sites. Eligible children, including children on Medicaid, children without insurance or whose insurance does not cover vaccinations, and Native American or Alaskan Native children can receive the vaccinations through their primary care physician. Children not covered under the program but whose parents cannot afford vaccinations can receive free vaccines at public clinics under local programs. The HHS states in Budget in Brief, Fiscal Year 2009 (2008, http://www.hhs.gov/budget/09budget/2009BudgetInBrief.pdf) that the VFC program and Section 317 (the supporting vaccine infrastructure) had a budget of $3.2 billion for fiscal year 2009. Vaccines provided through the program represented about 40% of all childhood vaccines purchased in the country.

The World Health Organization (WHO) and the United Nations Children's Fund report in Global Immunization Vision and Strategy, 2006–2015 (October 2005, http://www.who.int/vaccines-documents/DocsPDF05/GIVS_Final_EN.pdf) that developed nations, including the United States, generally have among the highest immunization rates in the world. The global immunization rate for DTP in 2003 was 78%, up from only 20% in 1980. Immunization rates for the developed world for the same time period were 10 to 20 percentage points higher than the global average, reflecting the low immunization rates in many developing nations. The WHO notes in “Global Immunization Data” (January 2008, http://www.who.int/immunization/newsroom/Global_Immunization_Data.pdf) that in 2006 immunization coverage exceeded 90% in Europe and the Americas, 92% in the western Pacific, and 86% in the eastern Mediterranean.

PHYSICIAN VISITS. Children's health depends on access to and usage of medical care. Based on household interviews of a sample of the civilian noninstitutionalized population, the National Center for Health Statistics (NCHS) finds that in 2006, 57.2% of children under the age of 18 visited the doctor between one and three times, 24.6% saw the doctor between four and nine times, and 7.3% saw the

 

TABLE 4.1 Percentage of children vaccinated for selected diseases, by poverty statusa, raceb, and Hispanic originc, 1996 and 2006 [CONTINUED]
Characteristic	Total		Below poverty		At or above
	1996	2006	1996	2006	1996	2006
—Not available.
aBased on family income and household size using US Bureau of Census poverty thresholds for the year of data collection.
bFrom 1996 to 2000, the 1977 OMB Standards for Data on Race and Ethnicity were used. Beginning in 2002, the 1997 OMB Standards for Data on Race and Ethnicity were used.
cPersons of Hispanic origin may be of any race.
dThe 4:3:1:3:3:1 series consists of 4 doses (or more) of diphtheria, tetanus toxoids and pertussis (DTP) vaccines, diphtheria and tetanus toxoids (DT), or diphtheria, tetanus toxoids and any acellular pertussis (DTaP) vaccines; 3 doses (or more) of poliovirus vaccines; 1 dose (or more) of any measles-containing vaccine; 3 doses (or more) of Haemophilus influenzae type b (Hib) vaccines; 3 doses (or more) of hepatitis B vaccines; and 1 dose (or more) of varicella vaccine. The collection of coverage rate estimates for this series began in 2002.
eThe 4:3:1:3:3 series consists of 4 doses (or more) of diphtheria, tetanus toxoids and pertussis (DTP) vaccines, diphtheria and tetanus toxoids (DT), or diphtheria, tetanus toxoids and any acellular pertussis (DTaP) vaccines; 3 doses (or more) of poliovirus vaccines; 1 dose (or more) of any measles-containing vaccine; 3 doses (or more) of Haemophilus influenzae type b (Hib) vaccines; and 3 doses (or more) of hepatitis B vaccines.
fThe 4:3:1:3 series consists of 4 doses (or more) of diphtheria, tetanus toxoids and pertussis (DTP) vaccines, diphtheria and tetanus toxoids (DT), or diphtheria, tetanus toxoids and any acellular pertussis (DTaP) vaccines; 3 doses (or more) of poliovirus vaccines; 1 dose (or more) of any measles-containing vaccine; and 3 doses (or more) of Haemophilus influenzae type b (Hib) vaccines.
gThe 4:3:1 series consists of 4 doses (or more) of diphtheria, tetanus toxoids and pertussis (DTP) vaccines, diphtheria and tetanus toxoids (DT), or diphtheria, tetanus toxoids and any acellular pertussis (DTaP) vaccines, 3 doses (or more) of poliovirus vaccines; and 1 dose (or more) of any measles-containing vaccine.
hDiphtheria, tetanus toxoids, and pertussis vaccine (4 doses or more of any diphtheria, tetanus toxoids, and pertussis vaccines, including diphtheria and tetanus toxoids and any acellular pertussis vaccine).
iPoliovirus vaccine (3 doses or more).
jMeasles-mumps-rubella (MMR) vaccine (1 dose or more) was used beginning in 2005. The previous coverage years reported measles-containing vaccines.
kHaemophilus influenzae type b (Hib) vaccine (3 doses or more).
lHepatitis B vaccine (3 doses or more).
mVaricella vaccine (1 dose or more) is recommended at any visit at or after age 12 months for susceptible children (i.e., those who lack a reliable history of chickenpox).
nThe heptavalent pneumococcal conjugate vaccine (PCV) is recommended for all children ages 2–23 months and for certain children ages 24–59 months. The series consists of doses at ages 2, 4 and 6 months, and a booster dose at ages 12–15 months.
SOURCE: Adapted from “Table HC3. Childhood Immunization: Percentage of Children Ages 19–35 Months Vaccinated for Selected Diseases by Poverty Status, and Race and Hispanic Origin, 1996–2006,” in America's Children in Brief: Key National Indicators of Well-Being, 2008, Federal Interagency Forum on Child and Family Statistics, 2008, http://www.childstats.gov/americaschildren/tables.asp (accessed November 2, 2008)
Hispanicc
Combined series (4:3:1:3:3:1)d	—	77.0	—	76.4	—	78.3
Combined series (4:3:1:3:3)e	63.7	79.7	62.4	78.3	64.1	81.6
Combined series (4:3:1:3)f	71.1	81.3	68.2	80.1	72.7	83.2
Combined series (4:3:1)g	74.1	82.0	70.9	80.9	74.6	83.9
DTP (4 doses or more)h	77.2	84.5	74.0	82.7	77.5	86.3
Polio (3 doses or more)i	89.4	93.3	88.0	93.0	89.8	93.4
MMR (1 dose or more)j	88.2	92.0	87.4	92.8	89.0	91.9
Hib (3 doses or more)k	88.5	93.9	87.1	93.5	90.3	93.9
Hepatitis B (3 doses or more)l	80.8	93.6	79.9	93.2	81.1	93.9
Varicella (1 dose or more)m	7.6	89.6	6.3	90.5	11.2	90.5
PCV (3 doses or more)n	—	88.9	—	87.7	—	89.8

doctor 10 or more times. (See Table 4.2.) However, 10.9% of children did not see a doctor at all. Poor children have less access to health care than nonpoor children.

HEALTH INSURANCE. One reason some children do not have access to medical care is their lack of health insurance. According to the U.S. Census Bureau, 11% (8.1 million) of American children had no health insurance coverage in 2007. (See Figure 4.1.) Factors affecting children's access to coverage included their age, race, and ethnicity, and their family's economic status. Children between the ages of 12 and 17 were more likely to be uninsured (12%) than six- to 11-year-olds (10.3%) and children under the age of six (10.5%). Poor children were proportionately more likely to be uninsured than all children (17.6% versus 11%), and those of Hispanic origin were the least likely racial or ethnic group to receive health insurance coverage—one out of five (20%) Hispanic children were uninsured, compared to 12.2% of African-American children, 11.7% of Asian-American children, and 7.3% of non-Hispanic white children.

Child health insurance coverage increased slightly among all age groups, races, and ethnicities from 2000 to 2004, but then declined from 2004 to 2006. Overall, the percent of children covered by private health insurance declined from 70.2% in 2000 to 64.7% in 2006. (See Table 4.3.) In the press release “HHS Issues New Report Showing More American Children Received Health Insurance in Early 2002” (December 31, 2002, http://www.hhs.gov/news/press/2002pres/20021231.html), the NCHS states that Tommy G. Thompson, the HHS secretary, attributed ongoing increases to a push to provide more government coverage, particularly under the State Children's Health Insurance Program. This trend, however, leveled off in 2005 and 2006.

According to Carmen DeNavas-Walt, Bernadette D. Proctor, and Cheryl Hill Lee of the Census Bureau, in Income, Poverty, and Health Insurance Coverage in the United States: 2005 (August 2006, http://www.census.gov/prod/2006pubs/p60-231.pdf), in 2005 government programs, such as Medicare, Medicaid, and military insurance, covered a greater proportion of African-American and Hispanic children than other children. Almost half (44.9%) of African-American children and 39.3% of Hispanic

 

TABLE 4.2 Health care visits to doctor's offices, emergency departments, and home visits over a 12-month period, by selected characteristics, 1997, 2005, and 2006
[Data are based on household interviews of a sample of the civilian noninstitutionalized population]
Characteristic	Number of health care visitsa
	None			1–3 visits			4–9 visits			10 or more visits
	1997	2005	2006	1997	2005	2006	1997	2005	2006	1997	2005	2006
	Percent distribution
18 years and over, age-adjustedb, c	16.5	15.6	17.2	46.2	46.2	46.9	23.6	24.6	23.1	13.7	13.7	12.8
18 years and over, crudeb	16.5	15.5	17.2	46.5	46.2	46.8	23.5	24.6	23.1	13.5	13.7	12.9
Age
Under 18 years	11.8	10.2	10.9	54.1	56.3	57.2	25.2	26.1	24.6	8.9	7.4	7.3
Under 6 years	5.0	5.1	4.9	44.9	47.9	50.6	37.0	37.5	34.8	13.0	9.5	9.7
6–17 years	15.3	12.7	13.8	58.7	60.4	60.5	19.3	20.6	19.6	6.8	6.4	6.1
18–44 years	21.7	23.1	25.3	46.7	46.0	45.8	19.0	18.8	17.8	12.6	12.1	11.0
18–24 years	22.0	24.3	25.3	46.8	44.7	47.2	20.0	19.2	17.4	11.2	11.8	10.2
25–44 years	21.6	22.6	25.4	46.7	46.5	45.3	18.7	18.7	17.9	13.0	12.2	11.4
45–64 years	16.9	14.1	16.4	42.9	43.1	44.3	24.7	26.4	23.6	15.5	16.4	15.7
45–54 years	17.9	15.9	18.5	43.9	45.1	46.1	23.4	23.9	21.8	14.8	15.1	13.6
55–64 years	15.3	11.5	13.5	41.3	40.5	41.9	26.7	29.8	26.1	16.7	18.2	18.5
65 years and over	8.9	5.7	6.0	34.7	31.1	33.2	32.5	36.7	36.2	23.8	26.5	24.6
65–74 years	9.8	6.0	6.7	36.9	34.8	34.6	31.6	35.1	36.6	21.6	24.1	22.1
75 years and over	7.7	5.3	5.3	31.8	26.9	31.5	33.8	38.5	35.7	26.6	29.2	27.6
Sexc
Male	21.3	20.4	22.8	47.1	46.9	46.8	20.6	21.9	20.0	11.0	10.8	10.4
Female	11.8	10.8	11.8	45.4	45.5	46.8	26.5	27.3	26.2	16.3	16.4	15.2
Racec, d
White only	16.0	15.2	17.2	46.1	46.0	46.2	23.9	24.9	23.4	14.0	14.0	13.2
Black or African American only	16.8	16.0	16.0	46.1	47.5	49.2	23.2	23.6	23.3	13.9	12.9	11.5
American Indian or Alaska Native only	17.1	20.5	13.5	38.0	36.6	44.2	24.2	29.4	27.6	20.7	13.4	14.7
Asian only	22.8	21.6	21.9	49.1	49.5	51.3	19.7	20.5	18.1	8.3	8.5	8.7
Native Hawaiian or other Pacific Islander only	—	*	*	—	*	*	—	*	*	—	*	*
2 or more races	—	15.6	16.3	—	37.9	44.8	—	26.7	21.3	—	19.9	17.6
Hispanic origin and racec, d
Hispanic or Latino	24.9	24.0	27.1	42.3	42.4	43.0	20.3	21.7	19.6	12.5	11.9	10.3
Mexican	28.9	26.7	31.1	40.8	41.7	40.8	18.5	20.5	18.3	11.8	11.1	9.8
Not Hispanic or Latino	15.4	13.9	15.4	46.7	46.8	47.6	24.0	25.2	23.7	13.9	14.0	13.2
White only	14.7	13.1	15.0	46.6	46.7	46.9	24.4	25.7	24.2	14.3	14.6	13.9
Black or African American only	16.9	16.0	15.7	46.1	47.5	49.5	23.1	23.6	23.4	13.8	12.9	11.4
Respondent-assessed health statusc
Fair or poor	7.8	9.2	12.2	23.3	21.9	21.2	29.0	27.1	28.1	39.9	41.9	38.6
Good to excellent	17.2	16.2	17.8	48.4	48.5	49.3	23.3	24.4	22.8	11.1	10.9	10.1
Percent of poverty levelc, e
Below 100%	20.6	20.8	21.0	37.8	37.5	39.5	22.7	24.3	22.3	18.9	17.4	17.2
100%–less than 200%	20.1	20.4	21.6	43.3	42.3	43.5	21.7	22.8	21.5	14.9	14.5	13.3
200% or more	14.5	13.3	15.2	48.7	48.7	49.3	24.2	25.2	23.7	12.6	12.8	11.9
Hispanic origin and race and percent of poverty levelc, d, e
Hispanic or Latino
Below 100%	30.2	28.1	32.8	34.8	37.4	35.3	19.9	19.8	19.2	15.0	14.7	12.7
100%–less than 200%	28.7	27.8	29.9	39.7	39.0	42.0	20.4	22.2	19.3	11.2	11.1	8.8
200% or more	18.9	19.4	22.2	48.8	47.1	47.4	20.4	22.7	20.4	11.9	10.8	10.1
Not Hispanic or Latino
White only
Below 100%	17.0	16.6	16.3	38.3	36.4	38.7	23.9	27.4	24.2	20.9	19.7	20.8
100%–less than 200%	17.3	17.6	18.8	44.1	42.2	43.7	22.2	23.2	22.2	16.3	17.0	15.4
200% or more	13.8	11.8	14.0	48.2	48.7	48.6	24.9	26.0	24.6	13.1	13.6	12.7
Black or African American only
Below 100%	17.4	17.9	18.1	38.5	40.2	45.0	23.4	24.5	21.9	20.7	17.4	15.0
100%–less than 200%	18.8	16.2	17.9	43.7	47.1	45.5	22.9	24.0	24.2	14.5	12.7	12.5
200% or more	15.6	15.2	13.5	51.7	50.4	53.6	22.7	23.4	23.5	10.0	11.0	9.3

children had government insurance, compared to only 18% of non-Hispanic white children and 15.9% of Asian-American children.

To remain in the Medicaid program, families must have their eligibility reassessed at least every six months. If the family income or other circumstances change even

TABLE 4.2 Health care visits to doctor's offices, emergency departments, and home visits over a 12-month period, by selected characteristics, 1997, 2005, and 2006 [CONTINUED]
[Data are based on household interviews of a sample of the civilian noninstitutionalized population]
Characteristic	Number of health care visitsa
	None			1–3 visits			4–9 visits			10 or more visits
	1997	2005	2006	1997	2005	2006	1997	2005	2006	1997	2005	2006
	Percent distribution
Health insurance status at the time of interviewf, g
Under 65 years
Insured	14.3	12.5	14.3	49.0	49.9	50.4	23.6	24.5	23.1	13.1	13.1	12.3
Private	14.7	12.9	14.7	50.6	51.8	52.6	23.1	24.1	22.4	11.6	11.3	10.3
Medicaid	9.8	10.0	11.3	35.5	38.3	37.4	26.5	25.8	25.5	28.2	25.9	25.8
Uninsured	33.7	37.6	39.2	42.8	42.1	42.2	15.3	14.4	12.5	8.2	5.9	6.1
Health insurance status prior to interviewf, g
Under 65 years
Insured continuously all 12 months	14.1	12.4	14.3	49.2	50.1	50.8	23.6	24.5	23.1	13.0	12.9	11.9
Uninsured for any period up to 12 months.	18.9	18.9	19.1	46.0	45.1	46.3	20.8	22.1	20.9	14.4	13.8	13.7
Uninsured more than 12 months	39.0	43.6	45.6	41.4	40.1	40.2	13.2	12.1	9.6	6.4	4.2	4.5
Percent of poverty level and health insurance status prior to interviewe, f, g
Under 65 years
Below 100%
Insured continuously all 12 months	13.8	12.7	12.6	39.7	40.7	43.1	25.2	25.7	24.2	21.4	21.0	20.1
Uninsured for any period up to 12 months	19.7	19.0	17.8	37.6	37.6	39.3	21.9	23.2	23.4	20.9	20.2	19.5
Uninsured more than 12 months	41.2	46.2	50.1	39.9	35.3	35.3	12.2	14.2	9.9	6.6	4.4	4.8
100–less than 200%
Insured continuously all 12 months	16.0	14.9	16.3	46.4	46.1	45.9	21.9	23.6	23.0	15.8	15.4	14.8
Uninsured for any period up to 12 months	18.8	19.3	20.6	45.1	44.9	49.8	21.0	21.7	18.7	15.0	14.1	10.9
Uninsured more than 12 months	38.7	43.6	44.3	41.0	39.4	42.1	14.0	12.5	10.2	6.3	4.5	3.4
200% or more
Insured continuously all 12 months	13.7	11.8	14.1	51.0	51.8	52.6	23.6	24.6	22.9	11.7	11.7	10.4
Uninsured for any period up to 12 months	17.8	18.6	18.6	50.3	48.1	48.0	20.4	22.1	20.7	11.5	11.2	12.7
Uninsured more than 12 months	36.6	41.1	42.8	43.8	44.8	42.4	13.2	10.2	9.3	6.4	3.9	*5.5
Geographic regionc
Northeast	13.2	11.4	12.1	45.9	47.1	47.6	26.0	26.5	25.1	14.9	15.0	15.2
Midwest	15.9	13.8	15.2	47.7	47.4	48.4	22.8	24.7	23.6	13.6	14.0	12.7
South	17.2	16.1	18.3	46.1	46.0	45.6	23.3	24.6	23.5	13.5	13.3	12.6
West	19.1	20.1	21.7	44.8	44.4	46.7	22.8	22.8	20.2	13.3	12.6	11.3

slightly, the family can lose its eligibility for the Medic-aid program, disrupting health care coverage.

From the late 1980s through the mid-1990s the numbers of uninsured American children rose as coverage rates for employer-sponsored health insurance declined, even though the proportion of children covered by Medicaid also rose. In 1997, as part of the Balanced Budget Act, Congress created the State Children's Health Insurance Program (SCHIP) to expand health insurance to children whose families earned too much money to be eligible for Medicaid but not enough money to pay for private insurance. SCHIP provides funding to states to insure children, offering three alternatives: states may use SCHIP funds to establish separate coverage programs, expand their Medicaid coverage, or use a combination of both. By September 1999 all 50 states had SCHIP plans in place. By September 4, 2003, the program had been expanded to enroll even more children at higher income levels. According to the Centers for Medicare and Medicaid Services, in “FY 2008 Number of Children Ever Enrolled Year—SCHIP by Program Type” (January 20, 2009, http://www.cms.hhs.gov/NationalSCHIPPolicy/downloads/FY2008StateTotalTable012309FINAL.pdf), in fiscal year 2008, 7.4 million children were enrolled in SCHIP, up from 7.1 million the year before.

Homelessness

Under the McKinney-Vento Homeless Assistance Act, the U.S. Department of Education is required to file a report on homeless children served by the act. The Department of Education obtains the data from school districts, which use

TABLE 4.2 Health care visits to doctor's offices, emergency departments, and home visits over a 12-month period, by selected characteristics, 1997, 2005, and 2006 [CONTINUED]
[Data are based on household interviews of a sample of the civilian noninstitutionalized population]
Characteristic	Number of health care visitsa
	None			1–3 visits			4–9 visits			10 or more visits
	1997	2005	2006	1997	2005	2006	1997	2005	2006	1997	2005	2006
*Estimates are considered unreliable. Data preceded by an asterisk have a relative standard error (RSE) of 20%–30%. Data not shown have an RSE greater than 30%.
—Data not available.
aThis table presents a summary measure of health care visits to doctor offices, emergency departments, and home visits during a 12-month period.
bIncludes all other races not shown separately and unknown health insurance status.
cEstimates are age-adjusted to the year 2000 standard population using six age groups: Under 18 years, 18–44 years, 45–54 years, 55–64 years, 65–74 years, and 75 years and over.
dThe race groups, white, black, American Indian or Alaska Native, Asian, Native Hawaiian or other Pacific Islander, and 2 or more races, include persons of Hispanic and non-Hispanic origin. Persons of Hispanic origin may be of any race. Starting with 1999 data, race-specific estimates are tabulated according to the 1997 Revisions to the Standards for the Classification of Federal Data on Race and Ethnicity and are not strictly comparable with estimates for earlier years. The five single-race categories plus multiple-race categories shown in the table conform to the 1997 Standards. Starting with 1999 data, race-specific estimates are for persons who reported only one racial group; the category 2 or more races includes persons who reported more than one racial group. Prior to 1999, data were tabulated according to the 1977 Standards with four racial groups and the Asian only category included Native Hawaiian or other Pacific Islander. Estimates for single-race categories prior to 1999 included persons who reported one race or, if they reported more than one race, identified one race as best representing their race. Starting with 2003 data, race responses of other race and unspecified multiple race were treated as missing, and then race was imputed if these were the only race responses. Almost all persons with a race response of other race were of Hispanic origin.
ePercent of poverty level is based on family income and family size and composition using U.S. Census Bureau poverty thresholds. Missing family income data were imputed for 25%–29% of persons in 1997–1998 and 32%–35% in 1999–2006.
fEstimates for persons under 65 years of age are age-adjusted to the year 2000 standard population using four age groups: Under 18 years, 18–44 years, 45–54 years, and 55–64 years of age.
gHealth insurance categories are mutually exclusive. Persons who reported both Medicaid and private coverage are classified as having private coverage. Starting in 1997, Medicaid includes state-sponsored health plans and State Children's Health Insurance Program (SCHIP). In addition to private and Medicaid, the insured category also includes military plans, other government-sponsored health plans, and Medicare, not shown separately. Persons not covered by private insurance, Medicaid, SCHIP, public assistance (through 1996), state-sponsored or other government-sponsored health plans (starting in 1997), Medicare, or military plans are considered to have no health insurance coverage. Persons with only Indian Health Service coverage are considered to have no health insurance coverage.
hMSA is metropolitan statistical area. Starting with 2006 data, MSA status is determined using 2000 census data and the 2000 standards for defining MSAs.
Notes: In 1997, the National Health Interview Survey questionnaire was redesigned.
SOURCE: “Table 82. Health Care Visits to Doctor Offices, Emergency Departments, and Home Visits within the Past 12 Months, by Selected Characteristics: United States, 1997, 2005, and 2006,” in Health, United States, 2007. With Chartbook on Trends in the Health of Americans, Centers for Disease Control and Prevention, National Center for Health Statistics, 2007, http://www.cdc.gov/nchs/data/hus/hus07.pdf (accessed September 15, 2008)
	Percent distribution
Location of residencec
Within MSAh	16.2	15.6	16.8	46.4	46.5	47.5	23.7	24.5	23.1	13.7	13.4	12.6
Outside MSAh	17.3	15.4	19.2	45.4	44.7	43.7	23.3	25.2	23.3	13.9	14.7	13.8

different methods of estimation. In Report to the President and Congress on the Implementation of the Education for Homeless Children and Youth Program under the McKinney-Vento Homeless Assistance Act (2006, http://www.ed.gov/programs/homeless/rpt2006.doc), the Department of Education states that 602,568 children who experienced homeless-ness at some point during the year were enrolled in school during the 2003–04 school year. Of these children, half (50.3%) lived doubled-up with relatives or friends, a quarter (25.3%) lived in shelters, 9.9% lived in hotels or motels, and 2.6% were unsheltered—in other words, sleeping outside, in vehicles, or in abandoned buildings. This number is almost certainly much lower than the number of children who actually experienced homelessness during this period, as the homeless status of children does not always come to the attention of school officials and many homeless children are not enrolled in school.

The U.S. Conference of Mayors find in Hunger and Homelessness Survey: A Status Report on Hunger and Homelessness in America's Cities, a 23-City Survey (December 2007, http://www.usmayors.org/HHSurvey2007/hhsurvey07.pdf) that 23% of homeless people were in families with children, 76% were single men or women, and 1% were unaccompanied youth—usually runaways. According to the Conference of Mayors, between 1994 and 2007 the proportion of families among the homeless generally declined, as did the proportion of unaccompanied youth among the homeless population. Data from this survey show city-by-city estimates of children as a percent of homeless family members. In Mayors Examine Causes of Hunger, Homelessness: The U.S. Conference of Mayors Release 2008 Hunger and Homelessness Survey Results (December 12, 2008, http://www.usmayors.org/pressreleases/documents/hungerhomelessness_121208.pdf), the Conference of Mayors announces that the homeless rate among cities, in general, grew about 12% from 2007 to 2008, and 16 cities cited an increase in homeless families.

Nearly nine out of 10 (87%) mayors surveyed in the 2007 report said the lack of affordable housing was a principal cause of homelessness among families with children, and 57% cited poverty. Another major cause of family homelessness was domestic violence: 39% of mayors cited such violence as a principal cause of homelessness among families with children. In contrast, 65% of mayors said mental illness and 61% said substance abuse were the principal causes of homelessness among single people and

 

unaccompanied youth. In Mayors Examine Causes of Hunger, Homelessness: The U.S. Conference of Mayors Release 2008 Hunger and Homelessness Survey Results “twelve cities (63 percent) reported an increase in homelessness because of the foreclosure crisis.”

The poverty and lack of stability that homelessness brings have a very negative impact on children. An example of the poor educational achievement of homeless youths is shown in Homeless Census and Homeless Youth/Foster Teen Study (2002, http://www.appliedsurveyresearch.org/www/products/MC_Homeless02_report.pdf), a study of unaccompanied homeless youths conducted in Monterey County, California. According to the survey's findings, 21% of 16-year-olds, 22% of 17-year-olds, 33% of 18-year-olds, 51% of 19-year-olds, 59% of 20-year-olds, and 70% of 21-year-olds were below grade level. Only 13% of the homeless youths in the study had a high school diploma or general equivalency diploma. The remaining 87% were performing below grade level.

Homelessness also has a negative impact on children's health. Catherine Karr of the National Health Care for the Homeless Council argues in Homeless Children: What Every Health Care Provider Should Know (December 29, 2003, http://www.nhchc.org/Children/index.htm) that these children suffer from frequent health problems. They are seen in emergency rooms and are hospitalized more often than other poor children. The often crowded and unsanitary conditions they live in lead to a higher rate of infectious diseases, such as upper respiratory infections, diarrhea, and scabies. Homeless children live in less structured and often unsafe environments, leaving them more vulnerable to accidents and injury. They tend not to have access to nutritious food, and are often malnourished or obese. Homeless children tend to lag behind their housed peers developmentally, and school-age homeless children often have academic problems. The greater likelihood that homeless children come from families plagued by mental illness, drug use, and domestic violence negatively affects their own mental health. Homelessness results in serious negative consequences for the children's health.

Hunger

Food insecurity is defined as the lack of access to enough food to meet basic needs. Mark Nord, Margaret Andrews, and Steven Carlson of the U.S. Department of Agriculture report in Household Food Security in the United States, 2006 (November 2007, http://www.ers.usda.gov/Publications/ERR49/ERR49.pdf) that in 2006, 89.1% of U.S. households were food secure, which remained essentially unchanged from the year before. However, the remaining 10.9% (12.6 million) of U.S. households experienced food insecurity at some time during the year. Most of these households used a variety of coping strategies to obtain adequate food, such as eating less varied diets, participating in food assistance programs, or getting food from community food pantries or soup kitchens. Regardless, 4% (4.6 million) of all households experienced very low food security—in other words, some household members reduced or otherwise altered their normal food intake because of a lack of money.

Nord, Andrews, and Carlson find that a higher percentage of children than adults were food insecure—17.2% of children were food insecure, and 15.6% of households with children were insecure. Households experiencing food insecurity tend to go through a sequence of steps as food insecurity increases: first, families begin to worry about having enough food, then they begin to decrease other necessities, then they reduce the quality and quantity of all household members” diets, then they decrease the frequency of meals and quantity of adult members” food, and finally they decrease the frequency of meals and the quantity of children's food. Even though children are usually protected from being hungry, an estimated one out of every 200 children (0.6%) experienced very low food security on one or more days during the year. Households with incomes below the poverty line,

 

TABLE 4.3 Percentage of children under age 18 covered by health insurance, by type of insurance, age, race, and Hispanic origin, 1987–2006
Characteristic	1987	1988	1989	1990	1991	1992	1993	1994	1995	1996	1997	1998	1999	2000	2001	2002	2003	2004	2005	2006
—Not available.
Notes: Children are considered to be covered by health insurance if they had public or private coverage at any time during the year. Some children are covered by both types of insurance; hence, the sum of public and private is greater than the total. The data from 1996 to 2004 have been revised since initially published.
aFor race and Hispanic-origin data in this table: From 1987 to 2002, following the 1977 OMB standards for collecting and presenting data on race, the Current Population Survey (CPS) asked respondents to choose one race from the following: white, black, American Indian or Alaskan Native, or Asian or Pacific Islander. The Census Bureau also offered an “other” category. Beginning in 2003, following the 1997 OMB standards for collecting and presenting data on race, the CPS asked respondents to choose one or more races from the following: white, black, Asian, American Indian or Alaska Native, and Native Hawaiian or other Pacific Islander. All race groups discussed in this table from 2002 onward refer to people who indicated only one racial identity within the racial categories presented. People who responded to the question on race by indicating only one race are referred to as the race-alone population. The use of the race-alone population in this table does not imply that it is the preferred method of presenting or analyzing data. Data from 2002 onward are not directly comparable with data from earlier years. Data on race and Hispanic origin are collected separately. Persons of Hispanic origin may be of any race.
bPersons of Hispanic origin may be of any race.
cPublic health insurance for children consists mostly of Medicaid, but also includes Medicare, the State Children's Health Insurance Programs (SCHIP), and the Civilian Health and Medical Care Program of the Uniformed Services (CHAMPUS/Tricare).
SOURCE: Adapted from “Table HC1. Health Insurance Coverage: Percentage of Children Ages 0–17 Covered by Health Insurance by Selected Characteristics, 1987–2006,” in America's Children in Brief: Key National Indicators of Well-Being, 2008, Federal Interagency Forum on Child and Family Statistics, 2008, http://www.childstats.gov/americaschildren/tables.asp (accessed November 2, 2008)
Any health insurance
Total	87.1	86.9	86.7	87.0	87.3	87.3	86.3	85.8	86.2	85.3	85.3	85.0	87.5	88.4	88.7	88.8	89.0	89.5	89.1	88.3
Age
Ages 0–5	87.6	87.4	87.2	88.5	88.7	89.3	88.5	86.2	86.7	86.4	86.0	84.9	87.6	88.8	89.6	89.5	89.9	90.7	89.6	88.7
Ages 6–11	87.3	87.1	87.1	87.0	87.7	87.6	87.0	86.5	86.5	85.6	86.3	85.6	87.9	88.7	89.1	89.4	89.3	89.8	90.1	88.9
Ages 12–17	86.4	86.3	85.8	85.2	85.4	84.8	83.1	84.8	85.5	84.1	83.6	84.4	87.0	87.7	87.4	87.5	87.8	88.2	87.8	87.4
Race and Hispanic origina
White, non-Hispanic	90.3	90.3	90.3	90.0	90.4	90.2	89.4	89.4	89.5	89.6	89.5	89.6	92.5	92.8	93.0	—	—	—	—	—
White-alone, non-Hispanic	—	—	—	—	—	—	—	—	—	—	—	—	—	—	—	92.6	92.9	93.0	93.0	92.7
Black	83.1	84.0	83.5	85.4	84.7	86.3	84.4	83.4	84.7	81.4	81.5	81.0	84.2	86.3	86.8	—	—	—	—	—
Black-alone	—	—	—	—	—	—	—	—	—	—	—	—	—	—	—	86.5	86.1	88.2	88.2	85.9
Hispanicb	71.5	70.9	69.8	71.6	73.4	74.5	74.3	71.5	73.2	71.4	71.6	70.5	74.1	75.1	76.2	77.8	79.3	79.7	78.5	77.9
Private health insurance
Total	73.6	73.5	73.6	71.1	69.7	68.7	67.4	65.6	66.1	66.5	67.3	67.9	70.0	70.2	68.8	67.9	66.3	66.4	65.8	64.7
Age
Ages 0–5	71.7	71.0	70.6	68.2	66.1	64.6	63.4	59.7	60.4	62.4	63.6	64.3	66.4	66.5	64.9	63.9	62.3	62.3	61.4	60.5
Ages 6–11	74.3	74.1	74.9	72.5	71.2	70.8	70.0	67.3	67.2	67.1	68.4	68.5	70.2	70.4	69.0	68.5	66.6	67.3	66.6	65.4
Ages 12–17	75.1	75.5	75.7	73.0	72.1	70.9	69.0	70.3	71.0	70.2	69.8	70.9	73.2	73.5	72.4	71.2	69.7	69.5	69.2	67.9
Race and Hispanic origina
White, non-Hispanic	83.2	83.2	83.1	80.8	79.9	79.5	77.8	77.1	78.0	77.9	78.0	79.3	81.6	81.4	80.2	—	—	—	—	—
White-alone, non-Hispanic	—	—	—	—	—	—	—	—	—	—	—	—	—	—	—	79.6	78.6	77.9	78.1	76.9
Black	49.2	49.9	51.5	48.5	45.4	46.1	45.5	43.0	43.9	45.4	48.2	47.6	52.2	53.9	53.1	—	—	—	—	—
Black-alone	—	—	—	—	—	—	—	—	—	—	—	—	—	—	—	50.8	48.0	49.3	48.7	49.0
Hispanicb	47.9	48.3	48.2	44.9	42.8	41.9	41.8	37.7	38.3	39.9	41.8	43.2	46.3	45.2	43.9	43.5	42.4	43.8	42.0	40.9
Public health insurancec
Total	19.0	19.2	19.2	21.9	23.9	25.2	26.8	26.3	26.4	24.9	23.4	22.8	23.2	24.4	25.9	26.8	29.1	29.9	29.7	29.8
Age
Ages–5	22.1	22.9	23.7	27.6	30.0	32.8	35.1	33.3	32.6	30.8	28.6	26.8	27.3	29.2	31.3	32.1	34.4	35.5	34.7	34.7
Ages 6–11	18.6	18.2	18.0	20.0	22.3	22.9	24.8	25.2	25.6	24.7	23.1	23.0	23.4	24.5	26.4	26.8	28.8	29.5	29.8	29.5
Ages 12–17	16.1	16.2	15.3	17.5	18.6	19.1	19.8	19.9	20.5	19.2	18.6	18.6	19.2	19.8	20.3	21.9	24.4	25.0	24.7	25.5
Race and Hispanic origina
White, non-Hispanic	12.1	12.5	12.7	14.7	16.1	16.7	18.5	18.1	17.5	17.6	17.0	15.8	16.3	17.2	18.7	—	—	—	—	—
White-alone, non-Hispanic	—	—	—	—	—	—	—	—	—	—	—	—	—	—	—	18.5	20.5	21.2	21.2	22.0
Black	42.1	41.9	41.0	45.5	47.5	49.3	49.5	48.5	48.8	44.8	39.6	41.6	39.8	41.9	41.6	—	—	—	—	—
Black-alone	—	—	—	—	—	—	—	—	—	—	—	—	—	—	—	44.2	46.5	48.4	48.0	44.0
Hispanicb	28.2	27.4	27.0	31.9	36.5	38.3	40.8	38.4	39.0	35.3	33.9	31.5	32.9	34.6	37.0	39.6	42.0	42.2	41.4	42.3

households with children headed by a single woman, and African-American and Hispanic households were the most likely to experience food insecurity.

EMERGENCY FOOD ASSISTANCE . Feeding America (formerly America's Second Harvest), the nation's largest charitable hunger-relief organization, reports in Hunger Study, 2006 (2006, http://www.hungerinamerica.org/key_findings/) that in 2005, 25.3 million Americans sought emergency food assistance. In Hunger and Homelessness Survey, the Conference of Mayors states that 80% of mayors reported that requests for emergency food assistance had increased in 2007, and that the total number of emergency food assistance requests increased by 12% during that year. The Conference of Mayors note, “Overall, it appears that the need for emergency food assistance programs is continuing to increase and that cities are facing many challenges in responding to the demand for assistance.” The most frequent reasons for hunger cited by city officials were poverty (90% of mayors), high housing costs (57% of mayors), and unemployment (52% of mayors). Other causes included high medical, utility, and transportation costs, substance abuse, and a lack of education. In the 2008 report Mayors Examine Causes of Hunger, Homelessness, the Conference of Mayors observes that requests for emergency food assistance had continued to increase in most cities. The organization states that “an estimated 59 percent of requests for food assistance were coming from families—many for the first-time.”

Exposure to Toxins

Another threat to children's health is exposure to environmental toxins. Two toxins that children are most frequently exposed to are lead and second-hand smoke.

LEAD POISONING. Because they have smaller bodies and are growing, children suffer the effects of lead exposure more acutely than adults do. Lead poisoning causes nervous system disorders, reduction in intelligence, fatigue, inhibited infant growth, and hearing loss. Toxic levels of lead in a parent can also affect unborn children.

In “Toys and Childhood Lead Exposure” (August 31, 2007, http://www.cdc.gov/nceh/lead/faq/toys.htm), the CDC indicates that children are primarily exposed to lead in paint and plastics. Leaded paint was banned in the United States in 1978, although children may be exposed to leaded paint in older homes. Even though leaded paint is not used on toys manufactured in the United States, it is still widely used on toys manufactured in other countries. Therefore, children may be exposed to lead when playing with imported toys. In addition, the use of lead in plastic, which makes it more flexible and able to return to its original shape, has not been banned. The CDC explains that “when the plastic is exposed to substances such as sunlight, air, and detergents the chemical bond between the lead and plastics breaks down and forms a dust.”

David Barboza reports in “Why Lead in Toy Paint? It's Cheaper” (New York Times, September 11, 2007) that in 2007 nearly two dozen toys were recalled because they contained toxic levels of lead paint. Dozens of children's jewelry products, most of them made in China, had also been recalled in 2006 and 2007. In September 2007 Mattel, the world's largest toy maker, announced its third recall in six weeks, asking people to return certain toys made in China that contained high levels of lead paint. Lead paint is sometimes used in manufacturing products for children because it is less expensive than nonleaded paint. Ashland University randomly tested plastic toys and children's jewelry and found high lead levels in many of them, most of which had not been recalled. According to the article “China Bans Lead Paint in Toys Exported to U.S.” (Associated Press, September 11, 2007), China signed an agreement on September 11, 2007, to prohibit the use of lead paint on toys for export to the United States. However, Barboza states that “enforcement of the regulations in China is lax.”

In “CDC Surveillance Data, 1997–2006” (November 29, 2007, http://www.cdc.gov/nceh/lead/surv/stats.htm), the CDC states that in 2006, 39,526 children in the United States aged five and under had confirmed blood lead levels greater than the CDC's recommended level of 10 micrograms per deciliter of blood. This was 1.2% of all children tested. According to the Commission for Environmental Cooperation, in Children's Health and the Environment in North America: A First Report on Available Indicators and Measures (January 2006, http://www.cec.org/files/PDF/POLLUTANTS/CEH-Indicators-fin_en.pdf), this number had dropped substantially since the early 1970s, due largely to the phasing out of lead in gasoline between 1973 and 1995. Even though children from all social and economic levels can be affected by lead poisoning, children in families with low incomes who live in older, deteriorated housing are at higher risk. Paint produced before 1978 frequently contained lead, so federal legislation now requires owners to disclose any information they may have about lead-based paint before renting or selling a home built earlier than 1978. Lead is also found in lead plumbing and is emitted by factory smokestacks.

SECONDHAND SMOKE AND CHILDREN. Environmental tobacco smoke is a major hazard for children, whose respiratory, immune, and other systems are not as well developed as those of adults. According to the CDC, in “Disparities in Secondhand Smoke Exposure—United States, 1988–1994 and 1999–2004” (Morbidity and Mortality Weekly Report, vol. 57, no. 27, July 11, 2008), secondhand or passive smoke (smoke produced by other people's cigarettes) increases the number of attacks and severity of symptoms in children with asthma and can even cause asthma in preschool-age children. It also causes lower respiratory tract infections, middle-ear disease, and a reduction in lung function in children, and it increases the risk of sudden infant death syndrome. The CDC

finds the percentage of children aged four to 11 who were regularly exposed to secondhand smoke in their homes decreased from 38.2% in the 1988–94 period to 23.8% in the 1999–2004 period, a reduction of 37.7%. The percentage of children aged 12 to 19 exposed to secondhand smoke decreased from 35.4% in the 1988–94 period to 19.5% in the 1999–2004 period, for an even larger decline of 44.9%.

DISEASES OF CHILDHOOD

Overweight and Obese Children

The number of overweight and obese Americans has reached epidemic proportions and has become a national concern. The percentage of overweight children and adolescents has grown significantly since the 1970s. Between 1976 and 1980, 6.7% of boys and 6.4% of girls aged six to 11 years were overweight. (See Table 4.4.) For boys, this percentage hit a high of 19.9%, or one in five boys, in the 2003–04 period, before dropping to a still high of 16.2% in 2005–06. Girls also hit a high of 17.6% in 2003–04, before it dropped to 14.1% in 2005–06.

An upward trend was also seen in the rates of overweight adolescents; 4.5% of boys and 5.4% of girls aged 12 to 17 were overweight in the period from 1976 to 1980, but 18.1% of adolescent boys and 17.5% of adolescent girls were overweight in the 2005–06 period—and these figures had not dropped from the previous two-year period. (See Table 4.4.) The proportion of overweight children overall between the ages of six and 17 tripled (from 5.7% to 16.5%) between 1976 and 2006.

The percentages of overweight children (in the 85th percentile or above for body mass index) and obese children (in the 95th percentile or above for body mass index) vary by race and ethnicity. In 2007 African-American adolescents were more likely to be overweight (19%) or obese (18.3%) than non-Hispanic white adolescents (14.3% were overweight and 10.8% were obese) or Hispanic adolescents (18.1% were overweight and 16.6% were obese). (See Table 4.5.) Younger students were more likely than older students to be either overweight or obese.

Medical professionals are concerned about this trend, because overweight children have an increased risk for premature death in adulthood as well as for many chronic diseases, including coronary heart disease, hypertension, diabetes mellitus (type 2), gallbladder disease, respiratory disease, some cancers, and arthritis. Type 2 diabetes, previously considered an adult disease, has increased dramatically in children and adolescents. Being overweight or obese can also lead to poor self-esteem and depression in children.

Weight problems in children are thought to be caused by a lack of physical activity, unhealthy eating habits, or a combination of these factors, with genetics and lifestyle playing important roles in determining a child's weight. Watching television and playing computer and video games contribute to the inactive lifestyles of some children. According to Danice K. Eaton et al. of the CDC, in “Youth Risk Behavior Surveillance—United States, 2007” (Morbidity and Mortality Weekly Report, vol. 57, no. SS-4, June 6, 2008), a quarter (24.9%) of high school students spent three or more hours per school day on the computer and more than a third (35.4%) spent three or more hours per school day watching television, often not getting a sufficient amount of physical exercise as a consequence.

Physical activity patterns established during youth may extend into adulthood and may affect the risk of illnesses such as coronary heart disease, diabetes, and cancer. Mental health experts correlate increased physical activity with improved mental health and overall improvement in life satisfaction. Eaton et al. report that only 43.7% of high school boys and 25.6% of high school girls met recommended levels of physical activity. (See Table 4.6.) White students were somewhat more likely to meet recommended levels of physical activity (37%) than African-American (31.1%) or Hispanic (30.2%) students. Only about half (53.6%) of high school students attended physical education classes, 56.3% played on a sports team, and only

 

TABLE 4.4 Percentage of children 6–17 who are overweight, by gender and age group, selected years 1976–2006
Age group	Total						Male						Female
	1976–1980	1988–1994	1999–2000	2001–2002	2003–2004	2005–2006	1976–1980	1988–1994	1999–2000	2001–2002	2003–2004	2005–2006	1976–1980	1988–1994	1999–2000	2001–2002	2003–2004	2005–2006
Note: Overweight is defined as body mass index (BMI) at or above the 95th percentile of the 2000 Centers for Disease Control and Prevention sex specific BMI-for-age growth charts.
SOURCE: “Table HEALTH5. Overweight: Percentage of Children Ages 6–17 Who Are Overweight by Gender and Age Group, 1976–1980, 1988–1994, and 1999–2000, 2001–2002, 2003–2004, and 2005–2006,” in America's Children in Brief: Key National Indicators of Well-Being, 2008, Federal Interagency Forum on Child and Family Statistics, 2008, http://www.childstats.gov/americaschildren/tables.asp (accessed November 2, 2008)
Ages 6–17
Total	5.7	11.2	15.0	16.5	18.0	16.5	5.5	11.8	15.7	18.0	19.1	17.2	5.8	10.6	14.3	15.1	16.8	15.9
Ages 6–11
Total	6.5	11.3	15.1	16.3	18.8	15.1	6.7	11.6	15.7	17.5	19.9	16.2	6.4	11.0	14.3	14.9	17.6	14.1
Ages 12–17
Total	5.0	11.1	14.9	16.8	17.2	17.8	4.5	12.0	15.6	18.4	18.3	18.1	5.4	10.2	14.2	15.2	16.0	17.5

 

TABLE 4.5 Percentage of high school students who were obese and who were overweight, by sex, race/ethnicity, and grade, 2007
Category	Obese			Overweight
	Female	Male	Total	Female	Male	Total
	%	%	%	%	%	%	%
*Non-Hispanic.
Notes: Students who were ≥95th percentile for body mass index (BMI), by age and sex, based on reference data. Previous Youth Risk Behavior Survey reports used the term “overweight” to describe youth with a BMI ≥95th percentile for age and sex and “at risk for overweight” for those with a BMI ≥85th percentile and <95th percentile. However, this report uses the terms “obese” and “overweight” in accordance with the 2007 recommendations from the Expert Committee on the Assessment, Prevention, and Treatment of Child and Adolescent Overweight and Obesity convened by the American Medical Association (AMA) and cofunded by AMA in collaboration with the Health Resources and Services Administration and CDC. Students who were ≥85th percentile but <95th percentile for body mass index, by age and sex, based on reference data.
SOURCE: Danice K. Eaton, “Table 82. Percentage of High School Students Who Were Obese and Who Were Overweight, by Sex, Race/Ethnicity, and Grade—United States, Youth Risk Behavior Survey, 2007,” in “Youth Risk Behavior Surveillance—United States, 2007,” Morbidity and Mortality Weekly Report, vol. 57, no. SS-4, June 6, 2008, http://www.cdc.gov/HealthyYouth/yrbs/pdf/yrbss07_mmwr.pdf (accessed November 5, 2008)
Race/ethnicity
White*	6.8	14.6	10.3	12.8	15.7	14.3
Black*	17.8	18.9	18.8	21.4	16.6	19.0
Hispanic	12.7	20.3	16.6	17.9	18.3	18.1
Grade
9	8.1	17.3	12.7	14.2	17.7	15.1
10	10.7	16.6	13.8	18.3	17.0	17.6
11	9.8	16.4	13.2	14.2	15.9	16.0
12	9.3	14.7	12.0	13.1	14.9	14.0
Total	9.6

 

TABLE 4.6 High school participation in physical activity, by demographic characteristics, 2007
Category	Met recommended levels of physical activity			Did not participate in 60 or more minutes of physical activity on any day
	Female	Male	Total	Female	Male	Total
	%	%	%	%	%	%
Notes: Were physically active doing any kind of physical activity that increased their heart rate and made them breathe hard some of the time for a total of at least 60 minutes/day on 5 or more days during the 7 days before the survey. Did not participate in 60 or more minutes of any kind of physical activity that increased their heart rate and made them breathe hard some of the time on at least 1 day during the 7 days before the survey.
*Non-Hispanic.
SOURCE: Danice K. Eaton, “Table 52. Percentage of High School Students Who Met Recommended Levels of Physical Activity and Who Did Not Participate in 60 or More Minutes of Physical Activity on Any Day, by Sex, Race/Ethnicity, and Grade—United States, Youth Risk Behavior Survey, 2007,” in “Youth Risk Behavior Surveillance—United States, 2007,” Morbidity and Mortality Weekly Report, vol. 57, no. SS-4, June 6, 2008, http://www.cdc.gov/HealthyYouth/yrbs/pdf/yrbss07_mmwr.pdf (accessed November 5, 2008)
Race/ethnicity
White*	27.9	46.1	37.0	28.2	16.7	22.4
Black*	21.0	41.3	31.1	42.1	21.8	32.0
Hispanic	21.9	38.6	30.2	35.2	18.8	27.1
Grade
9	31.5	44.4	38.1	26.1	17.1	21.5
10	24.4	45.1	34.8	31.7	16.3	24.0
11	24.6	45.2	34.8	34.3	18.0	26.2
12	20.6	38.7	29.5	36.2	21.5	28.9
Total	25.6	43.7	34.7	31.8	18.0	24.9

30.3% attended physical education classes daily. (See Table 4.7.) Rigorous activity among high school students also generally declined with age.

Asthma

Another serious disease affecting children is asthma, a chronic respiratory disease that causes attacks of difficulty breathing. In The State of Childhood Asthma, United States, 1980–2005 (December 12, 2006, http://www.cdc.gov/nchs/data/ad/ad381.pdf), Lara J. Akinbami of the CDC indicates that millions of children in the United States have asthma. In 2005, 8.9% (6.5 million) of children were currently suffering from asthma, and 12.7% (9 million) of children had suffered with it at some point in their lifetime. Childhood asthma

 

TABLE 4.7 Percentage of high school students who attended physical education classes and who played on at least one sports team, 2007
Category	Attended PE classesa			Attended PE classes dailyb			Played on at least one sports team
	Female	Male	Total	Female	Male	Total	Female	Male	Total
	%	%	%	%	%	%	%	%	%
aOn 1 or more days in an average week when they were in school.
b5 days in an average week when they were in school.
cNon-Hispanic.
Notes: Run by their school or community groups during the 12 months before the survey. PE is physical education. During the 30 days before the survey, among the 79.6% of students nationwide who exercised or played sports.
SOURCE: Adapted from Danice K. Eaton, “Table 78. Percentage of High School Students Who Attended Physical Education (PE) Classes, by Sex, Race/ Ethnicity, and Grade—United States, Youth Risk Behavior Survey, 2007,” and “Table 80. Percentage of High School Students Who Played on at Least One Sports Team and Who Saw a Doctor or Nurse for an Injury That Happened While Exercising or Playing Sports, by Sex, Race/Ethnicity, and Grade—United States, Youth Risk Behavior Survey, 2007,” in “Youth Risk Behavior Surveillance—United States, 2007,” Morbidity and Mortality Weekly Report, vol. 57, no. SS-4, June 6, 2008, http://www.cdc.gov/HealthyYouth/yrbs/pdf/yrbss07_mmwr.pdf (accessed November 5, 2008)
Race/ethnicity
Whitec	46.8	54.0	50.4	25.6	32.2	28.9	54.8	63.0	58.9
Blackc	50.6	61.0	55.9	27.8	35.8	31.9	44.7	65.1	54.9
Hispanic	57.3	64.7	61.0	35.5	36.4	36.0	41.8	58.1	50.0
Grade
9	65.1	68.3	66.8	40.4	39.7	40.1	54.7	63.4	59.2
10	51.2	62.3	56.8	26.1	35.7	30.9	50.8	64.7	57.8
11	38.8	51.4	45.1	19.8	27.9	23.9	52.5	63.0	57.7
12	38.5	44.6	41.5	20.2	27.5	23.8	41.9	56.2	49.0
Total	49.4	57.7	53.6	27.3	33.2	30.3	50.4	62.1	56.3

caused 27 hospitalizations per 10,000 children in 2004, and caused 12.8 million missed days of school in 2003. The American Lung Association estimates that up to a million asthmatic children are exposed to secondhand smoke, worsening their condition.

According to Akinbami, African-American children suffer from asthma at a rate 60% higher than that of non-Hispanic white children, and Puerto Rican children suffer from asthma at a rate 140% higher than non-Hispanic white children. In addition, she finds that African-American children's asthma is apparently much less well controlled than that of non-Hispanic white children. African-American children have a 250% higher hospitalization rate, a 260% higher emergency department visit rate, and a 500% higher death rate from asthma. Akinbami speculates that this is due to the lower level and quality of health care received by African-American children.

HIV/AIDS

Acquired immune deficiency syndrome (AIDS) was identified as a new disease in 1981, and, according to the CDC, in HIV/AIDS SurveillanceReport: Cases of HIV Infection and AIDS in the United States and Dependent Areas, 2006 (2008, http://www.cdc.gov/hiv/topics/surveillance/resources/reports/2006report/pdf/2006SurveillanceReport.pdf), an estimated one million cases had been diagnosed in the United States through 2006. AIDS is caused by the human immunodeficiency virus (HIV), which weakens the victim's immune system, making it vulnerable to other opportunistic infections. Young children with AIDS usually have the virus transmitted to them either by an infected parent or through contaminated transfusions of blood or blood products. Adolescents who are sexually active or experimenting with drugs are also vulnerable to HIV infection, which can be spread through sexual intercourse without the use of a condom or through shared hypodermic needles.

In adults the most common opportunistic infections of AIDS are Kaposi's sarcoma (a rare skin cancer) and pneumocystis carinii pneumonia. In infants and children, a failure to thrive and unusually severe bacterial infections characterize the disease. Except for pneumocystis carinii pneumonia, children with symptomatic HIV infection seldom develop opportunistic infections as adults do. More often, they are plagued by recurrent bacterial infections, persistent oral thrush (a common fungal infection of the mouth or throat), and chronic and recurrent diarrhea. They may also suffer from enlarged lymph nodes, chronic pneumonia, developmental delays, and neurological abnormalities.

HOW MANY ARE INFECTED? According to the CDC, in HIV/AIDS Surveillance Report, by the end of 2006 there were a cumulative total of 9,144 AIDS cases in children under the age of 13 since record-keeping began in 1981. (See Table 4.8.) African-American children made up the overwhelming majority of these cases (5,654 cases), followed by Hispanic children (1,748 cases), non-Hispanic white children (1,599 cases), Asians or Pacific Islanders (54 cases), and Native Americans or Alaskan Natives (31 cases). By the end of 2006, 5,165 children aged 14 and under had died from the disease.

 

TABLE 4.8 Diagnoses of AIDS in children younger than 13, by year of diagnosis, race and Hispanic origin, and transmission category, 2002–06
	Year of diagnosis					Cumulativea
	2002	2003	2004	2005	2006
Notes: These numbers do not represent reported case counts. Rather, these numbers are point estimates, which result from adjustments of reported case counts. The reported case counts have been adjusted for reporting delays and for redistribution of cases in persons initially reported without an identified risk factor, but not for incomplete reporting.
aFrom the beginning of the epidemic through 2006.
bIncludes children of unknown race or multiple races. Cumulative total includes 58 children of unknown race or multiple races. Because column totals were calculated independently of the values for the subpopulations, the values in each column may not sum to the column total.
SOURCE: “Table 4. Estimated Numbers of AIDS Cases in Children <13 Years of Age, by Year of Diagnosis and Selected Characteristics, 2002–2006 and Cumulative—50 States and the District of Columbia,” in HIV/AIDS Surveillance Report: Cases of HIV Infection and AIDS in the United States and Dependent Areas, 2006, vol. 18, Centers for Disease Control and Prevention, 2008, http://www.cdc.gov/hiv/topics/surveillance/resources/reports/2006report/pdf/2006SurveillanceReport.pdf (accessed November 5, 2008)
Race/ethnicity
White, not Hispanic	14	12	7	4	4	1,599
Black, not Hispanic	70	46	33	38	30	5,654
Hispanic	18	10	9	8	3	1,748
Asian/Pacific Islander	1	0	1	1	1	54
American Indian/Alaska Native	1	0	1	0	0	31
Transmission category
Hemophilia/coagulation disorder	0	0	0	0	0	226
Mother with documented HIV infection or 1 of the following risk factors	104	70	53	52	37	8,508
Injection drug use	12	8	5	3	4	3,220
Sex with injection drug user	4	6	3	2	1	1,397
Sex with bisexual male	2	0	3	1	1	209
Sex with person with hemophilia	0	0	0	0	0	35
Sex with HIV-infected transfusion recipient	0	0	0	0	0	22
Sex with HIV-infected person, risk factor not specified	36	20	20	25	13	1,530
Receipt of blood transfusion, blood components, or tissue	2	1	0	0	0	144
Has HIV infection, risk factor not specified	47	34	21	21	17	1,951
Receipt of blood transfusion, blood components, or tissue	2	0	0	0	0	374
Other/risk factor not reported or identified	0	0	0	0	0	36
Totalb	106	70	53	53	38	9,144

MEANS OF TRANSMITTAL. Most babies of HIV-infected mothers do not develop HIV. HIV-positive mothers can reduce the risk of transmission by taking antiretroviral drugs during the last two trimesters of pregnancy and during labor; giving birth by caesarean section; giving the infant a short course of antiretroviral drugs after birth; and not breast feeding. With these interventions, the transmission rate can be reduced to as low as 2%.

Even though interventions are effective in preventing HIV transmission from pregnant mothers to babies, the overwhelming majority of children with AIDS contracted it from mothers either infected with HIV or at risk for AIDS (8,508 of 9,144 cases, or 93%). (See Table 4.8.) Another way HIV/AIDS has been transmitted to children was through blood transfusions contaminated with the virus, although this means of transmission has been all but eliminated in the twenty-first century.

ADOLESCENTS WITH AIDS . The number of AIDS cases among adolescents is comparatively low. In HIV/AIDS Surveillance Report, the CDC states that by the end of 2006, 6,704 adolescents aged 13 to 19 had been diagnosed with AIDS since the beginning of the epidemic in the early 1980s. However, because of the long incubation period between the time of infection and the onset of symptoms, it is highly probable that many people who develop AIDS in their early twenties became infected with HIV during their adolescence; 36,225 young adults, 20- to 24-year-olds, had been diagnosed since the beginning of the epidemic by the end of 2006.

MENTAL HEALTH ISSUES IN YOUNG PEOPLE

Marital Conflict and Divorce

Marital conflict hurts children whether it results in the breakup of marriages or not. Nearly all the studies on children of divorce have focused on the period after the parents separated. However, recent studies suggest that the negative effects children experience may not come so much from divorce itself as from marital discord between parents before divorce. In fact, some research suggests that many problems reported with troubled teens not only began during the marriage but may have contributed to the breakup of the marriage. According to the article “Children of Divorce” (Journal of the American Board of Family Practice, vol. 14, no. 3, 2001), children raised in discord and marital instability often experience a variety of social, emotional, and psychological problems. Amy L. Baker reports in “The Long-Term Effects of Parental Alienation on Adult Children: A Qualitative Research Study” (American Journal of Family Therapy, vol. 33, no. 4, July–September 2005) that negative effects, such as low self-esteem, depression, drug and/or alcohol abuse, lack of trust, alienation from

own children, and an elevated risk of divorce, persist among these children into adulthood.

Divorce can cause stressful situations for children in several ways. One or both parents may have to move to a new home, removing the children from family and friends who could have given them support. Custody issues can generate hostility between parents. If one or both parents remarry, children are faced with yet another adjustment in their living arrangements.

Eating Disorders

Even though young people who are overweight increase their risk for certain diseases in adulthood, an overemphasis on thinness during childhood may contribute to eating disorders such as anorexia nervosa (a disorder characterized by voluntary starvation) and bulimia nervosa (a disorder in which a person eats large amounts of food then forces vomiting or uses laxatives to prevent weight gain). Girls are both more likely to have a distorted view of their weight and more likely to have eating disorders than boys.

Eaton et al. report that in 2007 students as a whole had a fairly accurate view of their weight: 15.8% of students were overweight (having a body mass index between the 85th and 95th percentile for their age and sex) and 13% were obese (having a body mass index equal to or greater than the 95th percentile for their age and sex). (See Table 4.5.) Approximately 29.3% said they were slightly or very overweight. (See Table 4.9.) However, girls were much more likely than boys to have a skewed perception of their body size. Even though 32.7% of male students were obese or overweight, 24.2% perceived themselves as overweight and 30.4% were trying to lose weight. Among female students, 24.7% of students were obese or overweight, 34.5% described themselves as overweight, and fully 60.3% were trying to lose weight.

Most students used healthy ways to lose weight, such as diet and exercise. However, a significant proportion used unhealthy methods such as extended periods of not eating, taking diet pills or laxatives, or inducing vomiting. Over half (53.2%) of female students and a quarter (28.3%) of male students ate less food, fewer calories, or low-fat foods to control their weight. (See Table 4.10.) Another two-thirds (67%) of female students and over half (55%) of male students exercised to control their weight. However, 16.3% of female students and 7.3% of male students had not eaten for 24 hours or more to lose weight; 7.5% of female students and 4.2% of male students had taken diet pills, powders, or liquids to control their weight; and 6.4% of female students and 2.2% of male students had vomited or taken laxatives to control their weight. (See Table 4.11.) A greater proportion of female students than male students used both healthy and unhealthy behaviors for weight control. In addition, Hispanic and non-Hispanic white students were in general more likely than African-American students to use unhealthy methods of weight control and the use of these methods increased somewhat with age.

Hyperactivity

Attention deficit hyperactivity disorder (ADHD) is one of the most common psychiatric disorders to appear in childhood. No one knows what causes ADHD, although research has focused on biological causes and the role of genetics. Symptoms include restlessness, inability to concentrate, aggressiveness, and impulsivity; and the lack of treatment can lead to problems in school, at work, and in making friends. Methylphenidate, a stimulant, is frequently

 

TABLE 4.9 Percentage of high school students who thought they had a problem with weight and were trying to lose weight, by sex, race/ethnicity, and grade, 2007
Category	Described themselves as overweight			Were trying to lose weight
	Female	Male	Total	Female	Male	Total
	%	%	%	%	%	%
*Non-Hispanic.
SOURCE: Danice K. Eaton, “Table 84. Percentage of High School Students Who Described Themselves As Slightly or Very Overweight and Who Were Trying to Lose Weight, by Sex, Race/Ethnicity, and Grade—United States, Youth Risk Behavior Survey, 2007,” in “Youth Risk Behavior Surveillance—United States, 2007,” Morbidity and Mortality Weekly Report, vol. 57, no. SS-4, June 6, 2008, http://www.cdc.gov/HealthyYouth/yrbs/pdf/yrbss07_mmwr.pdf (accessed November 5, 2008)
Race/ethnicity
White*	34.0	23.6	28.8	62.3	29.0	45.6
Black*	30.1	19.1	24.6	49.5	24.9	37.1
Hispanic	39.3	28.3	33.8	62.1	38.5	50.2
Grade
9	33.6	24.3	28.8	58.6	31.0	44.4
10	33.8	24.8	29.2	60.2	31.6	45.8
11	36.2	25.8	31.0	61.3	30.1	45.8
12	34.9	21.6	28.3	61.6	28.7	45.3
Total	34.5	24.2	29.3	60.3	30.4	45.2

 

TABLE 4.10 Percentage of high school students who ate less food, fewer calories, or low-fat foods and who exercised, by sex, race, ethnicity, and grade, 2007
Category	Ate less food, fewer calories, or low-fat foods to lose weight or to keep from gaining weight			Exercised to lose weight or to keep from gaining weight
	Female	Male	Total	Female	Male	Total
	%	%	%	%	%	%
Note: To lose weight or to keep from gaining weight during the 30 days before the survey.
*Non-Hispanic.
SOURCE: Danice K. Eaton, “Table 86. Percentage of High School Students Who Ate Less Food, Fewer Calories, or Low-Fat Foods and Who Exercised, by Sex, Race/Ethnicity, and Grade—United States, Youth Risk Behavior Survey, 2007,” in “Youth Risk Behavior Surveillance—United States, 2007,” Morbidity and Mortality Weekly Report, vol. 57, no. SS-4, June 6, 2008, http://www.cdc.gov/HealthyYouth/yrbs/pdf/yrbss07_mmwr.pdf (accessed November 5, 2008)
Race/ethnicity
White*	58.4	28.3	43.3	71.5	53.3	62.4
Black*	34.6	21.0	27.8	50.7	53.7	52.2
Hispanic	52.0	32.3	42.1	66.4	60.1	63.2
Grade
9	50.5	27.3	38.6	70.6	58.7	64.5
10	53.0	29.1	40.9	67.7	54.2	60.9
11	54.0	29.8	42.0	65.0	54.9	59.9
12	56.4	27.4	42.0	63.7	51.1	57.5
Total	53.2	28.3	40.6	67.0	55.0	60.9

 

TABLE 4.11 Percentage of high school students who engaged in unhealthy behaviors in an effort to lose weight, by sex, race, Hispanic origin, and grade, 2007
Category	Did not eat for 24 or more hours to lose weight or to keep from gaining weight			Took diet pills, powders or liquids to lose weight or to keep from gaining weighta			Vomited or took laxatives to lose weight or to keep from gaining weight
	Female	Male	Total	Female	Male	Total	Female	Male	Total
	%	%	%	%	%	%	%	%	%
Notes: To lose weight or to keep from gaining weight during the 30 days before the survey.
aWithout a doctor's advice.
bNon-Hispanic.
SOURCE: Adapted from Danice K. Eaton et al., “Table 88. Percentage of High School Students Who Did Not Eat for 24 or More Hours and Who Took Diet Pills, Powders, or Liquids, by Sex, Race/Ethnicity, and Grade—United States, Youth Risk Behavior Survey, 2007,” and “Table 90. Percentage of High School Students Who Vomited or Took Laxatives, by Sex, Race/Ethnicity, and Grade—United States, Youth Risk Behavior Survey, 2007,” in “Youth Risk Behavior Surveillance—United States, 2007,” Morbidity and Mortality Weekly Report, vol. 57, no. SS-4, June 6, 2008, http://www.cdc.gov/HealthyYouth/yrbs/pdf/yrbss07_mmwr.pdf (accessed November 5, 2008)
Race/ethnicity
whiteb	16.7	5.7	11.2	8.3	3.7	6.0	6.9	1.3	4.1
Blackb	13.2	7.4	10.3	3.9	3.6	3.7	3.5	2.5	3.0
Hispanic	17.4	10.7	14.1	7.8	5.1	6.4	7.0	3.7	5.3
Grade
9	16.8	6.5	11.6	6.1	2.9	4.4	5.5	2.1	3.8
10	19.1	6.5	12.7	6.9	3.8	5.3	7.6	1.8	4.7
11	14.8	8.1	11.5	7.4	5.0	6.2	5.7	2.1	4.0
12	13.6	8.0	10.9	10.2	5.7	8.0	6.6	2.6	4.6
Total	16.3	7.3	11.8	7.5	4.2	5.9	6.4	2.2	4.3

used to treat hyperactive children. In Summary Health Statistics for U.S. Children: National Health Interview Survey, 2006 (September 2007, http://www.cdc.gov/nchs/data/series/sr_10/sr10_234.pdf), Barbara Bloom and Robin A. Cohen of the CDC explain that boys are more likely to be diagnosed with ADHD than girls; 10.7% of boys aged three to 17 have been diagnosed at some point, compared to 4% of girls.

Drug and Alcohol Use

Few factors negatively influence the health and well-being of young people more than the use of drugs, alcohol, and tobacco. Monitoring the Future, a long-term study on the use of drugs, alcohol, and tobacco conducted by the University of Michigan's Institute for Social Research, annually surveys eighth, 10th, and 12th graders on their use of these substances. According to Lloyd D.

 

TABLE 4.12 Percentage of high school students who drank alcohol and used marijuana, by sex, race, ethnicity, and grade, 2007
Category	Lifetime alcohol usea			Current alcohol useb			Lifetime marijuana used			Current marijuana usee
	Female	Male	Total	Female	Male	Total	Female	Male	Total	Female	Male	Total
	%	%	%	%	%	%	%	%	%	%	%	%
aHad at least one drink of alcohol on at least 1 day during their life.
bHad at least one drink of alcohol on at least 1 day during the 30 days before the survey.
cNon-Hispanic.
dUsed marijuana one or more times during their life.
eUsed marijuana one or more times during the 30 days before the survey.
SOURCE: Adapted from Danice K. Eaton, “Table 35. Percentage of High School Students Who Drank Alcohol, by Sex, Race/Ethnicity, and Grade—United States, Youth Risk Behavior Survey, 2007,” and “Table 39. Percentage of High School Students Who Used Marijuana, by Sex, Race/Ethnicity, and Grade—United States, Youth Risk Behavior Survey, 2007,” in “Youth Risk Behavior Surveillance—United States, 2007,” Morbidity and Mortality Weekly Report, vol. 57, no. SS-4, June 6, 2008, http://www.cdc.gov/HealthyYouth/yrbs/pdf/yrbss07_mmwr.pdf (accessed November 5, 2008)
Race/ethnicity
Whitec	76.4	75.8	76.1	47.1	47.4	47.3	34.1	41.8	38.0	17.0	22.7	19.9
Blackc	70.0	68.4	69.1	34.9	34.1	34.5	35.0	44.5	39.6	17.1	26.0	21.5
Hispanic	79.3	76.5	77.9	47.5	47.7	47.6	35.9	42.0	38.9	16.4	20.5	18.5
Grade
9	66.1	65.0	65.5	37.2	34.3	35.7	21.7	33.0	27.5	12.5	16.9	14.7
10	74.6	74.9	74.7	42.3	41.4	41.8	34.5	39.2	36.9	16.5	22.0	19.3
11	79.1	79.7	79.4	46.5	51.5	49.0	36.6	48.3	42.4	17.5	25.2	21.4
12	85.2	80.2	82.8	54.2	55.6	54.9	48.3	49.9	49.1	22.6	27.8	25.1
Total	75.7	74.3	75.0	44.6	44.7	44.7	34.5	41.6	38.1	17.0	22.4	19.7

Johnston et al. of the Institute for Social Research, in Monitoring the Future: National Results on Adolescent Drug Use, Overview of Key Findings, 2007 (2008, http://www.monitoringthefuture.org/pubs/monographs/overview 2007.pdf), the percentage of high school students who had used an illicit drug during that past year declined between 1997 and 2007, after sharp increases during the early 1990s. Johnston et al. find that in 2007, 35.9% of seniors (who were more likely than eighth or 10th graders to use an illicit drug) had used an illicit drug in the previous 12 months. Concerning the lifetime prevalence rate, 46.8% of 12th graders had tried an illicit drug. Alcohol (72.7% of seniors) and marijuana (41.8% of seniors) were the most commonly used drugs. Eaton et al. find that in 2007, 75% of all high school students had tried alcohol and 44.7% had used it in the past month. (See Table 4.12.) The researchers also note that 38.1% of high school students reported they had tried marijuana, and 19.7% reported they had used it at least once in the 30 days before the survey.

TOBACCO. Most states prohibit the sale of cigarettes to anyone under the age of 18, but the laws are often ignored and may carry no penalties for youths who buy cigarettes or smoke in public. In fact, 16% of high school students reported in 2007 that they had bought cigarettes in a store or gas station. (See Table 4.13.) The American Lung Association reports in “Smoking and Teens Fact Sheet” (August 2008, http://www.lungusa.org/site/pp.asp?c=dvLUK9O0E&b=39871) that each day 4,000 children smoke their first cigarette—and almost 1,300 of them will become regular smokers. According to Eaton et al., half (50.3%) of all high school students in 2007 said they had tried cigarettes at some point in their lives. (See Table 4.14.) One out of five (20%) high school

 

TABLE 4.13 Percentage of high school students who bought cigarettes in a store or gas station, by sex, race, Hispanic origin, and grade, 2007
Category	Bought cigarettes in a store or gas station
	Female	Male	Total
	%	%	%
—Not available.
*Non-Hispanic.
Note: During the 30 days before the survey, among the 16.1% of students nationwide who were aged <18 years and who currently smoked cigarettes.
SOURCE: Adapted from Danice K. Eaton, “Table 31. Percentage of High School Students Who Usually Obtained Their Own Cigarettes by Buying Them in a Store or Gas Station and Who Currently Used Smokeless Tobacco, by Sex, Race/Ethnicity, and Grade—United States, Youth Risk Behavior Survey, 2007,” in “Youth Risk Behavior Surveillance—United States, 2007,” Morbidity and Mortality Weekly Report, vol. 57, no. SS-4, June 6, 2008, http://www.cdc.gov/HealthyYouth/yrbs/pdf/yrbss07_mmwr.pdf (accessed November 5, 2008)
Race/ethnicity
White*	10.9	20.4	15.9
Black*		22.6	19.3
Hispanic	9 9	17.1	13.8
Grade
9	7.0	11.8	9.7
10	9.4	20.2	15.0
11	13.6	20.9	17.8
12	17.0	34.8	25.6
Total	11.3	20.0	16.0

students had smoked at least one cigarette in the month before the survey and 8.1% had smoked at least 20 days in the past month. (See Table 4.15.) Almost twice as many male students smoked heavily than did female students:

 

TABLE 4.14 Percentage of high school students who ever smoked cigarettes, by sex, race, ethnicity, and grade, 2007
Category	Lifetime cigarette usea			Lifetime daily cigarette useb
	Female	Male	Total	Female	Male	Total
	%	%	%	%	%	%
aEver tried cigarette smoking, even one or two puffs.
bEver smoked at least one cigarette every day for 30 days.
cNon-Hispanic.
SOURCE: Danice K. Eaton, “Table 25. Percentage of High School Students Who Ever Smoked Cigarettes, by Sex, Race/Ethnicity, and Grade—United States, Youth Risk Behavior Survey, 2007,” in “Youth Risk Behavior Surveillance—United States, 2007,” Morbidity and Mortality Weekly Report, vol. 57, no. SS-4, June 6, 2008, http://www.cdc.gov/HealthyYouth/yrbs/pdf/yrbss07_mmwr.pdf (accessed November 5, 2008)
Race/ethnicity
Whitec	48.3	51.7	50.0	14.9	15.8	15.4
Blackc	48.8	52.0	50.3	5.0	7.3	6.2
Hispanic	52.1	54.5	53.3	7.1	8.9	8.0
Grade
9	39.2	46.0	42.7	6.3	10.3	8.3
10	48.7	48.8	48.8	12.4	11.7	12.0
11	51.4	55.4	53.4	14.0	13.4	13.8
12	58.5	60.1	59.3	15.8	18.0	16.8
Total	48.8	51.8	50.3	11.8	13.0	12.4

 

TABLE 4.15 Percentage of high school students who currently smoked cigarettes, frequently smoked cigarettes, or smoked more than ten cigarettes per day, by sex, race, ethnicity, and grade, 2007
Category	Current cigarette usea			Current frequent cigarette useb			Smoked more than 10 cigarettes/day
	Female	Male	Total	Female	Male	Total	Female	Male	Total
	%	%	%	%	%	%	%	%	%
aSmoked cigarettes on at least 1 day during the 30 days before the survey.
bSmoked cigarettes on 20 or more days during the 30 days before the survey.
cNon-Hispanic.
Notes: On the days they smoked during the 30 days before the survey, among the 20.0% of students nationwide who currently smoked cigarettes. During the 12 months before the survey, among the 20.0% of students nationwide who currently smoked cigarettes.
SOURCE: Adapted from Danice K. Eaton, “Table 27. Percentage of High School Students Who Currently Smoked Cigarettes, by Sex, Race/Ethnicity, and Grade—United States, Youth Risk Behavior Survey, 2007,” and “Table 29. Percentage of High School Students Who Currently Smoked More Than 10 Cigarettes and Who Tried to Quit Smoking Cigarettes, by Sex, Race/Ethnicity, and Grade—United States, Youth Risk Behavior Survey, 2007,” in “Youth Risk Behavior Surveillance—United States, 2007,” Morbidity and Mortality Weekly Report, vol. 57, no. SS-4, June 6, 2008, http://www.cdc.gov/HealthyYouth/yrbs/pdf/yrbss07_mmwr.pdf (accessed November 5, 2008)
Race/ethnicity
Whitec	22.5	23.8	23.2	10.2	10.6	10.4	8.0	15.7	11.9
Blacka	8.4	14.9	11.6	2.1	5.8	3.9	1.7	8.6	6.1
Hispanic	14.6	18.7	16.7	3.3	5.1	4.2	4.8	8.4	6.8
Grade
9	12.3	16.2	14.3	3.3	5.4	4.3	6.7	12.6	10.1
10	19.1	20.0	19.6	6.8	7.2	7.0	5.3	12.6	9.0
11	19.6	23.4	21.6	9.7	10.5	10.1	8.1	9.9	9.0
12	25.5	27.4	26.5	11.3	13.1	12.2	7.8	19.2	13.6
Total	18.7	21.3	20.0	7.4	8.7	8.1	7.1	13.8	10.7

13.8% of male adolescents and 7.1% of female adolescents smoked more than 10 cigarettes per day.

Teens say they smoke for a variety of reasons—they “just like it,” “it's a social thing,” and many young women who are worried about their weight report that they smoke because “it burns calories.” Many of them note they have seen their parents smoke. The ALA indicates that youth who have two parents who smoke are more than twice as likely to become smokers than youth whose parents do not smoke. Children in smoking households are at risk not only from secondhand smoke but also from this greater likelihood to take up smoking themselves.

CHILDHOOD DEATHS

Infant Mortality

The NCHS defines the infant mortality rate as the number of deaths of babies younger than one year per 1,000 live births. Neonatal deaths occur within 28 days

 

TABLE 4.16 Infant mortality rate among selected groups by race and Hispanic origin of mother, selected years 1983–2004
[Data are based on linked birth and death certificates for infants]
Race and Hispanic origin of mother	1983–1985a, g	1986–1988a, g	1989–1991a, g	1995–1997b, g	1999–2001b, g	2002–2004b, g
—Data not available.
aRates based on unweighted birth cohort data.
bRates based on a period file using weighted data.
cInfant (under 1 year of age), neonatal (under 28 days), and postneonatal (28 days–11 months).
dStarting with 2003 data, estimates are not shown for Asian or Pacific Islander subgroups during the transition from single race to multiple race reporting.
eePersons of Hispanic origin may be of any race.
fPrior to 1995, data shown only for states with an Hispanic-origin item on their birth certificates.
gAverage annual mortality rate.
Notes: The race groups white, black, American Indian or Alaska Native, and Asian or Pacific Islander include persons of Hispanic and non-Hispanic origin. Starting with 2003 data, some states reported multiple-race data. The multiple-race data for these states were bridged to the single-race categories of the 1977 Office of Management and Budget standards for comparability with other states. National linked files do not exist for 1992–1994. Data for additional years are available.
SOURCE: Adapted from “Table 19. Infant, Neonatal, Postneonatal Mortality Rates, by Detailed Race and Hispanic Origin of Mother: United States, Selected Years 1983–2004,” in Health, United States, 2007. With Chartbook on Trends in the Health of Americans, Centers for Disease Control and Prevention, National Center for Health Statistics, 2007, http://www.cdc.gov/nchs/data/hus/hus07.pdf (accessed September 15, 2008
Infant c deaths per 1,000 live births
All mothers	10.6	9.8	9.0	7.4	6.9	6.9
White	9.0	8.2	7.4	6.1	5.7	5.7
Black or African American	18.7	17.9	17.1	14.1	13.6	13.5
American Indian or Alaska Native	13.9	13.2	12.6	9.2	9.1	8.6
Asian or Pacific Islanderd	8.3	7.3	6.6	5.1	4.8	4.8
Chinese	7.4	5.8	5.1	3.3	3.2	—
Japanese	6.0	6.9	5.3	4.9	4.0	—
Filipino	8.2	6.9	6.4	5.7	5.7	—
Hawaiian	11.3	11.1	9.0	7.0	7.8	—
Other Asian or Pacific Islander	8.6	7.6	7.0	5.4	4.9	—
Hispanic or Latinoe, f	9.2	8.3	7.5	6.1	5.6	5.6
Mexican	8.8	7.9	7.2	5.9	5.4	5.5
Puerto Rican	12.3	11.1	10.4	8.5	8.4	8.1
Cuban	8.0	7.3	6.2	5.3	4.5	4.3
Central and South American	8.2	7.5	6.6	5.3	4.8	4.9
Other and unknown Hispanic or Latino	9.8	9.0	8.2	7.1	6.7	6.8
Not Hispanic or Latino
Whitef	8.8	8.1	7.3	6.1	5.7	5.7
Black or African Americanf	18.5	17.9	17.2	14.2	13.7	13.7
Neonatal c deaths per 1,000 live births
All mothers	6.9	6.3	5.7	4.8	4.6	4.6
White	5.9	5.2	4.7	4.0	3.8	3.8
Black or African American	12.2	11.7	11.1	9.4	9.2	9.2
American Indian or Alaska Native	6.7	5.9	5.9	4.4	4.5	4.5
Asian or Pacific Islanderd	5.2	4.5	3.9	3.3	3.2	3.3
Chinese	4.3	3.3	2.7	2.1	2.1	—
Japanese	3.4	4.4	3.0	2.8	2.6	—
Filipino	5.3	4.5	4.0	3.7	4.0	—
Hawaiian	7.4	7.1	4.8	4.5	4.9	—
Other Asian or Pacific Islander	5.5	4.7	4.2	3.5	3.3	—
Hispanic or Latinoe, f	6.0	5.3	4.8	4.0	3.8	3.9
Mexican	5.7	5.0	4.5	3.8	3.6	3.7
Puerto Rican	8.3	7.2	7.0	5.7	5.9	5.6
Cuban	5.9	5.3	4.6	3.7	3.1	3.1
Central and South American	5.7	4.9	4.4	3.7	3.3	3.5
Other and unknown Hispanic or Latino	6.1	5.8	5.2	4.6	4.4	4.9
Not Hispanic or Latino
Whitef	5.7	5.1	4.6	4.0	3.8	3.8
Black or African Americanf	11.8	11.4	11.1	9.4	9.2	9.2

after birth and postneonatal deaths occur 28 to 365 days after birth. The U.S. infant mortality rate declined from 165 per 1,000 live births in 1900 to a low of 6.9 per 1,000 live births in between 2002 and 2004. (See Table 4.16.) In Health, United States, 2007 (2007, http://www.cdc.gov/nchs/data/hus/hus07.pdf), the CDC notes that several factors—including improved access to health care, advances in neonatal medicine, and educational campaigns—contributed to the overall decline in infant mortality in the twentieth century.

Not all racial and ethnic groups have reached that record-low infant mortality rate. Between 2002 and 2004 the infant mortality rate for non-Hispanic white infants was 5.7 deaths per 1,000 live births, less than half the rate of 13.5 for African-American infants. (See Table 4.16.) Rates for Native American or Alaskan Native, Hispanic, and Asian or Pacific Islander babies were 8.6, 5.6, and 4.8, respectively.

The NCHS lists the 10 leading causes of infant mortality in the United States in 2006. (See Table 4.17.) Birth

 

TABLE 4.17 Ten leading causes of infant death, by race and Hispanic origin, 2006
[Data are based on a continuous file of records received from the states. Rates are per 100,000 live births. Figures are based on weighted data rounded to the nearest individual, so categories may not add to totals or subtotals. Race and Hispanic origin are reported separately on both the birth and death certificate. Rates for Hispanic origin should be interpreted with caution because of inconsistencies between reporting Hispanic origin on birth and death certificates. Race categories are consistent with the 1977 Office of Management and Budget (OMB) standards. Multiple-race data were reported for deaths by 25 states and the District of Columbia and for births by 23 states. The multiple-race data for these states were bridged to the single-race categories of the 1977 OMB standards for comparability with other states. Data for persons of Hispanic origin are included in the data for each race group, according to the decedent's reported race.]
Ranka	Cause of death, race and Hispanic origin	Number	Rate
—Category not applicable.
aRank based on number of deaths.
bIncludes races other than white and black.
cIncludes all persons of Hispanic origin of any race. Because of a misclassification error in New Mexico, statistics for Hispanic decedents of all ages were underestimated by about 3.0 percent, and statistics for Hispanic decedents under 1 year of age were underestimated by about 1.0 percent.
Notes: For certain causes of death such as unintentional injuries, homicides, suicides, and sudden infant death syndrome, preliminary and final data may differ because of the truncated nature of the preliminary file. Data are subject to sampling or random variation.
SOURCE: Adapted from Melonie P. Heron et al., “Table 8. Infant Deaths and Infant Mortality Rates for the 10 Leading Causes of Infant Death, by Race and Hispanic Origin: United States, Preliminary 2006,” in “Deaths: Preliminary Data for 2006,” National Vital Statistics Report, vol. 56, no. 16, June 11, 2008, http://www.cdc.gov/nchs/data/nvsr/nvsr56/nvsr56_16.pdf (accessed November 5, 2008)
	All racesb
—	All causes	28,609	670.6
1	Congenital malformations, deformations and chromosomal abnormalities	5,827	136.6
2	Disorders related to short gestation and low birth weight, not elsewhere classified	4,841	113.5
3	Sudden infant death syndrome	2,145	50.3
4	Newborn affected by maternal complications of pregnancy	1,694	39.7
5	Newborn affected by complications of placenta, cord and membranes	1,123	26.3
6	Accidents (unintentional injuries)	1,119	26.2
7	Respiratory distress of newborn	801	18.8
8	Bacterial sepsis of newborn	786	18.4
9	Neonatal hemorrhage	598	14.0
10	Diseases of the circulatory system	539	12.6
—	All other causes	9,136	214.2
	Non-Hispanic white
—	All causes	13,019	563.6
1	Congenital malformations, deformations and chromosomal abnormalities	2,989	129.4
2	Disorders related to short gestation and low birth weight, not elsewhere classified	1,805	78.1
3	Sudden infant death syndrome	1,171	50.7
4	Newborn affected by maternal complications of pregnancy	751	32.5
5	Accidents (unintentional injuries)	547	23.7
6	Newborn affected by complications of placenta, cord and membranes	472	20.4
7	Respiratory distress of newborn	353	15.3
8	Bacterial sepsis of newborn	331	14.3
9	Neonatal hemorrhage	299	12.9
10	Diseases of the circulatory system	239	10.3
—	All other causes	4,062	175.9
	Total black
—	All causes	8,842	1,335.2
1	Disorders related to short gestation and low birth weight, not elsewhere classified	1,978	298.7
2	Congenital malformations, deformations and chromosomal abnormalities	1,157	174.7
3	Sudden infant death syndrome	656	99.1
4	Newborn affected by maternal complications of pregnancy	595	89.9
5	Newborn affected by complications of placenta, cord and membranes	378	57.1
6	Accidents (unintentional injuries)	351	53.0
7	Bacterial sepsis of newborn	272	41.1
8	Respiratory distress of newborn	267	40.3
9	Necrotizing enterocolitis of newborn	204	30.8
10	Diseases of the circulatory system	175	26.4
—	All other causes	2,809	424.2
	Hispanicc
—	All causes	5,706	549.2
1	Congenital malformations, deformations and chromosomal abnormalities	1,442	138.8
2	Disorders related to short gestation and low birth weight, not elsewhere classified	919	88.4
3	Newborn affected by maternal complications of pregnancy	299	28.8
4	Sudden infant death syndrome	244	23.5
5	Newborn affected by complications of placenta, cord and membranes	227	21.8
6	Accidents (unintentional injuries)	178	17.1
7	Respiratory distress of newborn	159	15.3
8	Bacterial sepsis of newborn	152	14.6
9	Neonatal hemorrhage	113	10.9
10	Diseases of the circulatory system	99	9.5
—	All other causes	1,874	180.4

defects (congenital malformations) were the primary cause of infant mortality (136.6 deaths per 100,000 live births). Premature delivery or low birth weight was the second-leading cause of infant mortality (113.5 per 100,000 live births). Sudden infant death syndrome (50.3), complications of pregnancy (39.7), complications in the placenta or umbilical cord (26.3), accidents (26.2), respiratory distress (18.8), bacterial sepsis (18.4), neonatal hemorrhage (14), and diseases of the circulatory system (12.6) complete the list.

SUDDEN INFANT DEATH SYNDROME. Sudden infant death syndrome (SIDS; sometimes called crib death), the unexplained death of a previously healthy infant, was the third-leading cause of infant mortality in the United States in 2006. Moreover, according to the CDC, in “Safe Sleep for Your Baby: Ten Ways to Reduce the Risk of Sudden Infant Death Syndrome” (August 2003, http://www.nichd.nih.gov/publications/pubs/safe_sleep_gen.cfm), SIDS is the leading cause of death among infants aged one to 12 months. In 1992 the American Academy of Pediatrics recommended that babies sleep on their back to reduce the risk of SIDS and launched its “Back to Sleep” campaign to educate parents. It had been a long-held belief that the best position for babies to sleep was on their stomach. Other risk factors for SIDS include maternal use of drugs or tobacco during pregnancy, low birth weight, and poor prenatal care. For reasons not yet understood, even though the overall rate of SIDS has declined since the beginning of the Back to Sleep campaign, it has declined less among African-Americans and Native Americans than among other groups. The CDC indicates that African-American babies are more than twice as likely to die of SIDS and Native American babies are nearly three times as likely to die of SIDS than white babies.

A number of studies have considered the possible causes of and risk factors for SIDS. For example, the article “SIDS Risk Prevention Research Begins to Define Physical Abnormalities in Brainstem, Points to Possible Diagnostic/Screening Tools” (PR Newswire, October 18, 1999) reports that one study, ongoing since 1985, conducted by Hannah Kinney of Harvard Medical School in Boston, Massachusetts, found a brain defect believed to affect breathing in babies who died of SIDS. Researchers suggest that as carbon dioxide levels rise and oxygen levels fall during sleep, the brains of some babies do not get the signal to regulate breathing or blood pressure accordingly to make up for the change. This condition is particularly dangerous for infants sleeping on their stomachs or on soft bedding. According to the National Institutes of Health, in “SIDS Infants Show Brain Abnormalities,” (November 10, 2006, http://www.nih.gov/news/research_matters/november2006/11102006sids.htm), this project found that this type of brain abnormality might be linked to higher levels of serotonin in the brainstem. Duane Alexander stated, “This finding lends credence to the view that SIDS risk may greatly increase when an underlying predisposition combines with an environmental risk—such as sleeping face down—at a developmentally sensitive time in early life.”

Mortality among Older Children

In the second half of the twentieth century, childhood death rates declined dramatically. Most childhood deaths are from injuries and violence. Even though death rates for all ages decreased, the largest declines were among children.

In 2005 three of the leading causes of death of one- to four-year-olds were unintentional injuries, congenital anomalies (birth defects), and malignant neoplasms (cancers). (See Table 4.18.) The remaining deaths were spread across a variety of diseases, including heart disease, pneumonia, influenza, HIV/AIDS, homicide, and suicide.

MOTOR VEHICLE INJURIES. The National Highway Traffic Safety Administration notes in Determine Why There Are Fewer Young Alcohol-Impaired Drivers (September 2001, http://www.nhtsa.dot.gov/people/injury/research/FewerYoungDrivers/) that even though motor vehicle fatalities decreased by 25% between 1982 and 2000 for 15- to 19-year-olds, traffic accidents were still the leading cause of death for this age group. During the 1980s and early 1990s, traffic fatalities linked to teenage drinking fell. This decline was due in large part to stricter enforcement of drinking age laws and driving while intoxicated or driving under the influence laws. Nevertheless, motor vehicle crashes were the leading cause of death among 15- to 20-year-olds in 2003. In the fact sheet “Mortality: Adolescents and Young Adults” (2006, http://nahic.ucsf.edu/downloads/Mortality.pdf), the National Adolescent Health Information Center reports that in 2003, 25.2 of every 100,000 teenagers in this age group were killed in traffic accidents. Many of those killed had been drinking alcohol and were not wearing their seatbelts. Timothy M. Pickrell of the U.S. Department of Transportation reports in “Driver Alcohol Involvement in Fatal Crashes by Age Group and Vehicle Type” (June 2006, http://www-nrd.nhtsa.dot.gov/pdf/nrd-30/NCSA/RNotes/2006/810598.pdf) that 20% of all young drivers aged 15 to 20 who were killed in crashes were intoxicated.

Eaton et al. find that in 2007, in the month before the survey, 18.3% of high school seniors (those most likely to have their driver's licenses) reported they had driven a vehicle after drinking alcohol. (See Table 4.19.) Male seniors (23.6%) were more likely than female seniors (13.1%) to drive after drinking. Another 29.1% of high school students admitted they had ridden with a driver who had been drinking.

SUICIDE. In 2005 suicide was the fifth-leading cause of death among five- to 14-year-olds and the third-leading cause of death in 15- to 24-year-olds. (See Table 4.18.) Debra L. Karch et al. of the CDC report in “Surveillance for Violent

 

TABLE 4.18 Leading causes of death and numbers of deaths, by age, 1980 and 2005
[Data are based on death certificates]
Age andrank order	1980		2005
	Cause of death	Deaths	Cause of death	Deaths
Under 1 year
—Category not applicable.
SOURCE: Adapted from “Table 32. Leading Causes of Death and Numbers of Deaths, by Age: United States, 1980 and 2005,” in Health, United States, 2007. With Chartbook on Trends in the Health of Americans, Centers for Disease Control and Prevention, National Center for Health Statistics, 2007, http://www.cdc.gov/nchs/data/hus/hus07.pdf (accessed September 15, 2008)
	All causes	45,526	All causes	28,440
1	Congenital anomalies	9,220	Congenital malformations, deformations and chromosomal abnormalities	5,552
2	Sudden infant death syndrome	5,510	Disorders related to short gestatiion and low birth weight, not elsewhere classified	4,714
3	Respiratory distress syndrome	4,989	Sudden infant death syndrome	2,230
4	Disorders relating to short gestation and unspecified low birthweight	3,648	Newborn affected by maternal complications of pregnancy	1,776
5	Newborn affected by maternal complications of pregnancy	1,572	Newborn affected by complications of placenta, cord and membranes	1,110
6	Intrauterine hypoxia and birth asphyxia	1,497	Unintentional injuries	1,083
7	Unintentional injuries	1,166	Respiratory distress of newborn	860
8	Birth trauma	1,058	Bacterial sepsis of newborn	834
9	Pneumonia and influenza	1,012	Neonatal hemorrhage	665
10	Newborn affected by complications of placenta, cord, and membranes	985	Necrotizing enterocolitis of newborn	546
1–4 years
	All causes	8,187	All causes	4,756
1	Unintentional injuries	3,313	Unintentional injuries	1,664
2	Congenital anomalies	1,026	Congenital malformations, deformations and chromosomal abnormalities	522
3	Malignant neoplasms	573	Malignant neoplasms	377
4	Diseases of heart	338	Homicide	375
5	Homicide	319	Diseases of heart	151
6	Pneumonia and influenza	267	Influenza and pneumonia	110
7	Meningitis	223	Septicemia	85
8	Meningococcal infection	110	Cerebrovascular dieases	62
9	Certain conditions originating in the perinatal period	84	Certain conditions originating in the perinatal period	58
10	Septicemia	71	Chronic lower respiratory diseases	56
5–14 years
	All causes	10,689	All causes	6,602
1	Unintentional injuries	5,224	Unintentional injuries	2,415
2	Malignant neoplasms	1,497	Malignant neoplasms	1,000
3	Congenital anomalies	561	Congenital malformations, deformations and chromosomal abnormalities	396
4	Homicide	415	Homicide	341
5	Diseases of heart	330	Suicide	272
6	Pneumonia and influenza	194	Diseases of heart	252
7	Suicide	142	Influenza and pneumonia	106
8	Benign neoplasms	104	Chronic lower respiratory diseases	104
9	Cerebrovascular diseases	95	Cerebrovascular dieases	95
10	Chronic obstructive pulmonary diseases	85	Septicemia	81
15–24 years
	All causes	49,027	All causes	34,234
1	Unintentional injuries	26,206	Unintentional injuries	15,753
2	Homicide	6,537	Homicide	5,466
3	Suicide	5,239	Suicide	4,212
4	Malignant neoplasms	2,683	Malignant neoplasms	1,717
5	Diseases of heart	1,223	Diseases of heart	1,119
6	Congenital anomalies	600	Congenital malformations, deformations and chromosomal abnormalities	504
7	Cerebrovascular diseases	418	Diabetes mellitus	202
8	Pneumonia and influenza	348	Cerebrovascular dieases	196
9	Chronic obstructive pulmonary diseases	141	Pregnancy, childbirth and puerperuim	183
10	Anemias	133	Influenza and pneumonia	172

Deaths—National Violent Death Reporting System, 16 States, 2005” (Morbidity and Mortality Weekly Report, vol. 57, no. SS-03, April 11, 2008) that the male suicide rate (18.4 per 100,000) was more than three times higher than the female suicide rate (4.8 per 100,000). According to Melonie Heron of the CDC, in “Deaths: Leading Causes for 2004”

 

TABLE 4.19 Percentage of high school students who rode with a driver who had been drinking alcohol and who drove when they had been drinking alcohol, by sex, race, ethnicity, and grade, 2007
Category	Rode with a driver who had been drinking alcohol			Drove when drinking alcohol
	Female	Male	Total	Female	Male	Total
	%	%	%	%	%	%
Note: One or more times during the 30 days before the survey.
*Non-Hispanic.
SOURCE: Danice K. Eaton, “Table 5. Percentage of High School Students Who Rode in a Car or Other Vehicle Driven by Someone Who Had Been Drinking Alcohol and Who Drove a Car or Other Vehicle When They Had Been Drinking Alcohol, by Sex, Race/Ethnicity, and Grade—United States, Youth Risk Behavior Survey, 2007,” in “Youth Risk Behavior Surveillance—United States, 2007,” Morbidity and Mortality Weekly Report, vol. 57, no. SS-4, June 6, 2008, http://www.cdc.gov/HealthyYouth/yrbs/pdf/yrbss07_mmwr.pdf (accessed November 5, 2008)
Race/ethnicity
White*	28.0	27.8	27.9	9.3	13.9	11.6
Black*	26.9	28.1	27.4	3.9	7.5	5.7
Hispanic	35.1	36.0	35.5	7.7	13.0	10.3
Grade
9	27.6	27.6	27.6	4.1	6.8	5.5
10	30.4	27.1	28.7	7.3	10.0	8.7
11	26.8	31.4	29.2	9.1	13.7	11.5
12	30.5	32.5	31.5	13.1	23.6	18.3
Total	28.8	29.5	29.1	8.1	12.8	10.5

 

TABLE 4.20 Percentage of high school students who felt sad or hopeless, who seriously considered attempting suicide, and who made a suicide plan, by sex, race, ethnicity, and grade, 2007
Category	Felt sad or hopeless			Seriously considered attempting suicide			Made a suicide plan
	Female	Male	Total	Female	Male	Total	Female	Male	Total
	%	%	%	%	%	%	%	%	%
*Non-Hispanic.
Notes: Almost every day for 2 or more weeks in a row so that they stopped doing some usual activities. During the 12 months before the survey.
SOURCE: Adapted from Danice K. Eaton et al., “Table 19. Percentage of High School Students Who Felt Sad or Hopeless, by Sex, Race/Ethnicity, and Grade—United States, Youth Risk Behavior Survey, 2007,” and “Table 21. Percentage of High School Students Who Seriously Considered Attempting Suicide, and Who Made a Plan about How They Would Attempt Suicide, by Sex, Race/Ethnicity, and Grade—United States, Youth Risk Behavior Survey, 2007,” in “Youth Risk Behavior Surveillance—United States, 2007,” Morbidity and Mortality Weekly Report, vol. 57, no. SS-4, June 6, 2008, http://www.cdc.gov/HealthyYouth/yrbs/pdf/yrbss07_mmwr.pdf (accessed November 5, 2008)
Race/ethnicity
White*	34.6	17.8	26.2	17.8	10.2	14.0	12.8	8.8	10.8
Black*	34.5	24.0	29.2	18.0	8.5	13.2	12.0	7.1	9.5
Hispanic	42.3	30.4	36.3	21.1	10.7	15.9	15.2	10.4	12.8
Grade
9	34.8	22.1	28.2	19.0	10.8	14.8	13.4	9.2	11.2
10	37.7	20.3	28.9	22.0	9.3	15.6	16.1	8.9	12.5
11	34.5	19.5	27.1	16.3	10.7	13.5	11.6	9.2	10.4
12	35.9	22.6	29.4	16.7	10.2	13.5	11.7	9.5	10.6
Total	35.8	21.2	28.5	18.7	10.3	14.5	13.4	9.2	11.3

(National Vital Statistics Reports, vol. 56, no. 5, November 20, 2007), in 2004, the latest year for which detailed statistics were available, white males aged 15 to 19 had twice the suicide rate (13.6 per 100,000) of African-American males (7.4 per 100,000) or Hispanic male youth (9.9 per 100,000). Among females aged 15 to 19, the rate for whites (3.7 per 100,000) was considerably higher than that for Hispanics (2.7 per 100,000) or African-Americans (1.9 per 100,000).

Eaton et al. questioned high school students regarding their thoughts about suicide. Almost one out of seven (14.5%) students surveyed in 2007 claimed that they had seriously thought about attempting suicide in the previous 12 months. (See Table 4.20.) Even though the suicide death rate was much higher among males than females, females (18.7%) were more likely to have considered suicide than males (10.3%). Of all students,

 

TABLE 4.21 Percentage of high school students who attempted suicide and whose suicide attempt resulted in an injury that required medical treatment, by sex, race, ethnicity, and grade, 2007
Category	Attempted suicide			Suicide attempt treated by a doctor or nurse
	Female	Male	Total	Female	Male	Total
	%	%	%	%	%	%
*Non-Hispanic.
Notes: During the 12 months before the survey. One or more times.
SOURCE: Danice K. Eaton, “Table 23. Percentage of High School Students Who Attempted Suicide and Whose Suicide Attempt Resulted in an Injury, Poisoning, or Overdose That Had to Be Treated by a Doctor or Nurse, by Sex, Race/Ethnicity, and Grade—United States, Youth Risk Behavior Survey, 2007,” in “Youth Risk Behavior Surveillance—United States, 2007,” Morbidity and Mortality Weekly Report, vol. 57, no. SS-4, June 6, 2008, http://www.cdc.gov/HealthyYouth/yrbs/pdf/yrbss07_mmwr.pdf (accessed November 5, 2008)
Race/ethnicity
White*	7.7	3.4	5.6	2.1	0.9	1.5
Black*	9.9	5.5	7.7	2.1	2.5	2.3
Hispanic	14.0	6.3	10.2	3.9	1.8	2.9
Grade
9	10.5	5.3	7.9	2.6	1.9	2.3
10	11.2	4.9	8.0	3.1	1.0	2.0
11	7.8	3.7	5.8	1.7	1.4	1.6
12	6.5	4.2	5.4	1.8	1.5	1.7
Total	9.3	4.6	6.9	2.4	1.5	2.0

11.3% (13.4% of females and 9.2% of males) had made a specific plan to attempt suicide. Approximately 6.9% of students (9.3% of females and 4.6% of males) said they had attempted suicide in the previous year, and 2% of high school students (2.4% of females and 1.5% of males) said they had suffered injuries from the attempt that required medical attention. (See Table 4.21.) These numbers reflect the fact that females of all ages tend to choose less fatal methods of attempting suicide, such as overdosing and cutting veins, than males, who tend to choose more deadly methods, such as shooting or hanging.

These rates reflect the fact that a large proportion of students, particularly female students, feel sad or hopeless. In 2007, 35.8% of female students and 21.2% of male students reported these feelings. (See Table 4.20.) The likelihood that a child will commit suicide increases with the presence of certain risk factors. According to the CDC, in “Homicides and Suicides—National Violent Death Reporting System, United States, 2003–2004” (Morbidity and Mortality Weekly Report, vol. 55, no. 26, July 7, 2006), among the factors whose presence may indicate heightened risk are depression, mental health problems, relationship conflicts, a history of previous suicide attempts, and alcohol dependence.

In addition, the suicide rate among male homosexual teens is believed to be extremely high. Gary Remafedi of the University of Minnesota notes in “Suicidality in a Venue-Based Sample of Young Men Who Have Sex with Men” (Journal of Adolescent Health, vol. 31, no. 4, 2002) that 20% to 42% of teens and young men who have sex with other males attempt suicide. Suicidal gay adolescents are not only coping with stressors but also have few coping resources. In “Gay Adolescents and Suicide: Understanding the Association” (Adolescence, vol. 40, no. 159, fall 2005), Robert Li Kitts of Oregon Health and Science University states that “the process of realizing that one is gay and having to accept it is not just an immediate stressor and can actually narrow one's options further by taking away coping resources, such as friends and family.… Gay adolescents who ‘come out’ (disclose their sexuality) may experience great family discord, rejection, and even failure from the disappointment they elicit. … It would make sense to conclude that homosexuality is an important risk factor for adolescent suicide.”