Health and Safety

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Health and Safety

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 leading causes of death among infants, children, and adolescents.

Birth Defects

According to the Centers for Disease Control and Prevention (CDC), in "Birth Defects: Frequently Asked Questions" (December 12, 2006, http://www.cdc.gov/ncbddd/bd/faq1.htm), birth defects affect one out of every thirty-three 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. The CDC notes in "Medical Progress in the Prevention of Neural Tube Defects" (June 17, 2005, http://www.cdc.gov/ncbddd/bd/mp.htm) that each year as many as one out of every one thousand pregnancies is affected by a neural tube defect. Infants born with neural tube defects suffer from an incomplete closing of the spine and skull. 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 those children affected 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 "Fetal Alcohol Spectrum Disorders" (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, December 24, 2004, http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5350a4.htm), 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 fifty pregnant women (1.9%) frequently drank alcohol.

Health Care

IMMUNIZATIONS

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 2004, 87% of all children had received four doses of DTP, 92% had received three doses of the poliovirus vaccine, 94% had received the haemophilus influenzae type b vaccine, 94% had received the measles vaccine, 93% had received three doses of the hepatitis B vaccine, and 88% had received the 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.

TABLE 4.1
Percentage of children vaccinated for selected diseases, by poverty status^a, race, and Hispanic origin^b, 1996–2004
Characteristic	Total									Below poverty									At or above poverty
Characteristic	1996	1997	1998	1999	2000	2001	2002	2003	2004	1996	1997	1998	1999	2000	2001	2002	2003	2004	1996	1997	1998	1999	2000	2001	2002	2003	2004
Total
Combined series (4:3:1:3)^c	76	76	79	78	76	77	78	81	83	69	71	74	73	71	72	72	76	78	80	79	82	81	78	79	79	83	85
Combined series (4:3:1)^d	78	78	81	80	78	79	79	82	84	72	72	76	75	72	73	73	77	79	81	80	83	82	79	80	80	84	86
DTP (4 doses or more)^e	81	82	84	83	82	82	82	85	86	74	76	80	79	76	77	75	80	81	84	84	86	85	84	84	84	87	87
Polio (3 doses or more)	91	91	91	90	90	89	90	92	92	88	89	90	87	87	87	88	89	90	92	92	92	91	90	90	91	93	92
Measles-containing (MCV)^f	91	90	92	92	91	91	92	93	93	87	86	90	90	89	89	90	92	91	92	92	93	92	91	92	92	93	94
Hib (3 doses or more)^g	91	93	93	94	93	93	93	94	94	87	90	91	91	90	90	90	91	92	93	94	95	95	95	94	94	95	94
Hepatitis B (3 doses or more)	82	84	87	88	90	89	90	92	92	78	81	85	87	87	87	88	91	91	83	85	88	89	91	90	90	93	93
Varicella^h	12	26	43	58	68	76	81	85	88	5	17	41	55	64	74	79	84	86	15	29	44	58	69	77	81	85	88
PCV (3 doses or more)ⁱ	—	—	—	—	—	—	41	68	73	—	—	—	—	—	—	33	62	69	—	—	—	—	—	—	43	71	75
White, non-Hispanic
Combined series (4:3:1:3)^c	79	79	82	81	79	79	80	84	85	68	72	77	76	73	71	72	79	78	80	80	83	82	80	80	81	85	86
Combined series (4:3:1)^d	80	80	83	82	80	80	81	85	86	70	73	79	77	74	72	73	80	78	82	82	84	83	81	81	82	86	87
DTP (4 doses or more)^e	83	84	87	86	84	84	84	88	88	72	76	82	81	78	75	75	82	81	85	85	88	86	85	85	86	88	89
Polio (3 doses or more)	92	92	92	90	91	90	91	93	92	88	90	91	88	88	87	88	91	88	93	92	93	91	91	91	92	93	93
Measles-containing (MCV)^f	91	91	93	92	92	92	93	94	94	85	84	90	90	88	87	91	90	90	93	93	94	93	92	92	93	94	94
Hib (3 doses or more)^g	93	94	95	95	95	94	94	95	95	87	90	92	93	92	89	88	91	92	94	95	96	95	95	95	95	96	95
Hepatitis B (3 doses or more)	82	85	88	89	91	90	91	93	93	76	80	87	88	88	86	86	91	92	83	85	88	89	92	90	92	94	93
Varicella^h	15	28	42	56	66	75	79	84	87	6	17	38	51	58	67	75	80	84	16	29	43	57	68	76	80	85	87
PCV (3 doses or more)ⁱ	—	—	—	—	—	—	44	71	75	—	—	—	—	—	—	31	56	66	—	—	—	—	—	—	46	73	77
Black, non-Hispanic
Combined series (4:3:1:3)^c	74	73	73	74	71	71	71	75	76	69	71	72	72	69	69	68	70	74	79	77	74	77	72	74	72	79	80
Combined series (4:3:1)^d	77	74	74	75	72	73	72	77	78	73	72	74	74	70	71	69	72	76	81	78	76	78	73	75	73	80	81
DTP (4 doses or more)^e	79	77	77	79	76	76	76	80	80	74	76	77	78	75	74	74	75	78	83	80	79	83	78	78	77	84	83
Polio (3 doses or more)	90	89	88	87	87	85	87	89	90	87	89	88	86	85	84	87	86	90	93	91	87	88	87	86	87	91	91
Measles-containing (MCV)^f	90	89	89	90	88	89	90	92	91	88	87	89	90	88	88	90	91	90	91	91	90	91	87	90	90	93	91
Hib (3 doses or more)^g	89	91	90	92	93	90	92	93	91	86	91	90	91	92	87	88	90	90	93	94	90	94	93	91	94	95	92
Hepatitis B (3 doses or more)	82	82	84	87	89	85	88	92	91	78	82	86	86	89	85	89	92	89	85	84	83	90	90	85	88	92	92
Varicella^h	9	21	42	58	67	75	83	85	86	*	16	40	57	60	71	80	84	85	13	27	44	60	72	77	84	86	87
PCV (3 doses or more)ⁱ	—	—	—	—	—	—	34	62	68	—	—	—	—	—	—	30	61	67	—	—	—	—	—	—	38	64	70
American Indian and Alaska Native
Combined series (4:3:1:3)^c	82	73	78	75	69	76	*	77	75	*	*	*	*	*	*	*	*	*	*	*	87	79	*	84	*	*	*
Combined series (4:3:1)^d	83	78	79	78	70	76	*	79	76	*	*	*	*	*	*	*	*	*	*	*	87	81	*	84	*	*	*
DTP (4 doses or more)^e	85	80	83	80	75	77	*	80	77	*	*	*	*	*	*	*	*	*	*	*	92	83	76	84	*	*	*
Polio (3 doses or more)	90	90	85	88	90	88	*	91	87	92	93	*	*	82	*	87	89	96	*	88	93	94	96	96	*	92	*
Measles-containing (MCV)^f	89	92	91	92	87	94	84	92	89	87	94	*	93	83	96	*	93	*	*	92	96	92	92	93	90	90	89
Hib (3 doses or more)^g	91	86	90	91	90	91	*	89	90	95	93	*	*	82	*	*	92	90	89	*	97	97	97	95	*	*	89
Hepatitis B (3 doses or more)	79	83	82	*	91	86	*	90	91	*	*	*	*	85	*	*	92	95	*	82	87	*	97	91	*	88	89
Varicella^h	*	20	28	*	62	69	70	81	84	*	*	22	*	*	*	*	*	*	*	*	*	*	*	76	*	82	85
PCV (3 doses or more)ⁱ	—	—	—	—	—	—	33	60	75	—	—	—	—	—	—	*	*	*	—	—	—	—	—	—	*	*	*

TABLE 4.1
Percentage of children vaccinated for selected diseases, by poverty status^a, race, and Hispanic origin^b, 1996–2004 [continued]
Characteristic	Total									Below poverty									At or above poverty
Characteristic	1996	1997	1998	1999	2000	2001	2002	2003	2004	1996	1997	1998	1999	2000	2001	2002	2003	2004	1996	1997	1998	1999	2000	2001	2002	2003	2004
—=Not available.
*Estimates are considered unreliable.
^aBased on family income and household size using US Bureau of Census poverty thresholds for the year prior to each year of data collection.
^bFrom 1996 to 2000, the 1977 Office of Management and Budget (OMB) Standards for Data on Race and Ethnicity were used. From 2002 onward, the 1997 OMB Standards for Data on Race and Ethnicity were used. Persons of Hispanic origin may be of any race. Included in the total, but not shown separately, are Native Hawaiian and other Pacific Islanders, and two or more races.
^cThe 4:3:1:3 series consists of ?4 doses of diphtheria, tetanus toxoids and pertussis vaccines, diphtheria and tetanus toxoids, and diphtheria, tetanus toxoids and any acellular pertussis vaccine (DTP/DT/DTaP); ?3 doses of poliovirus vaccine; ?1 doses of any measles-containing vaccine; and ?3 doses of haemophilus influenzae type b (Hib) vaccine.
^dThe 4:3:1 series consists of ?4 doses of diphtheria, tetanus toxoids and pertussis vaccines, diphtheria and tetanus toxoids, and diphtheria, tetanus toxoids and any acellular pertussis vaccine (DTP/DT/DTaP); ?3 doses of poliovirus vaccine; and ?1 doses of any measles-containing vaccine.
^eDiphtheria, tetanus toxoids, and pertussis vaccine (?4 doses of any diphtheria, tetanus toxoids and pertussis vaccines, including diphtheria and tetanus toxoids, and any acellular pertussis vaccine).
^fProviders were asked about measles-containing vaccine, including MMR (measles-mumps-rubella) vaccines.
^gHaemophilus influenzae type b (Hib) vaccine (three or more doses).
^hRecommended in July 1996. Administered on or after the first birthday, unadjusted for history of varicella illness (chicken pox). (One or more doses of varicella at or after child's first birthday, unadjusted for history of varicella illness).
ⁱPneumococcal conjugate vaccine (three or more doses); the percentage of children ages 19-35 months who received 3 (or more) doses of pneumococcal conjugate vaccine was low in 2002, because universal infant vaccination was not recommended until October 2000.
Source: "Table HEALTH5. Childhood Immunization: Percentage of Children Ages 19-35 Months Vaccinated for Selected Diseases by Poverty Status, Race and Hispanic Origin, Selected Years 1996–2004," in America's Children in Brief: Key National Indicators of Well-Being, 2006, Federal Interagency Forum on Child and Family Statistics, 2006, http://childstats.gov/americaschildren/tables/health5.asp (accessed February 25, 2007)
Asian
Combined series (4:3:1:3)^c	78	71	79	77	75	77	83	81	84	*	*	*	*	*	*	*	*	*	77	70	81	80	77	77	84	80	83
Combined series (4:3:1)^d	81	76	83	82	79	80	85	84	87	*	*	80	*	*	*	*	*	*	79	74	84	85	81	79	86	84	87
DTP (4 doses or more)^e	85	80	89	87	85	84	88	89	90	*	*	85	*	*	85	*	*	91	84	79	91	90	87	85	90	90	89
Polio (3 doses or more)	90	89	93	90	93	90	92	91	93	*	90	92	*	*	90	93	92	92	89	88	93	91	93	90	91	90	92
Measles-containing (MCV)^f	93	90	92	93	90	90	95	96	94	94	92	95	86	*	93	98	92	94	93	90	94	94	92	89	95	96	93
Hib (3 doses or more)^g	92	89	92	90	92	92	95	91	92	*	*	*	*	*	95	93	92	96	94	90	94	93	93	92	95	90	90
Hepatitis B (3 doses or more)	85	88	89	88	91	90	94	94	93	*	94	*	84	*	95	95	93	96	86	86	90	88	92	89	94	93	92
Varicella^h	18	36	53	64	77	82	87	91	91	*	*	*	*	*	*	90	93	91	20	41	55	66	80	81	87	90	90
PCV (3 doses or more)ⁱ	—	—	—	—	—	—	55	71	76	—	—	—	—	—	—	*	*	*	—	—	—	—	—	—	55	73	77
Hispanic
Combined series (4:3:1:3)^c	71	73	75	75	73	77	76	79	81	68	70	73	73	70	73	75	78	80	73	77	79	78	74	79	76	81	84
Combined series (4:3:1)^d	74	75	77	77	75	79	77	79	82	71	71	76	76	73	76	76	79	80	75	77	80	80	75	80	77	81	84
DTP (4 doses or more)^e	77	78	81	80	79	83	79	82	84	74	75	79	78	76	79	78	81	83	78	81	83	82	80	83	80	84	86
Polio (3 doses or more)	89	90	89	89	88	91	90	90	91	88	88	90	89	88	90	89	89	90	90	90	90	90	87	91	91	92	92
Measles-containing (MCV)^f	88	88	91	90	90	92	91	93	93	87	85	90	90	90	91	91	93	92	89	90	92	91	90	93	89	93	94
Hib (3 doses or more)^g	89	90	92	92	91	93	92	93	93	87	89	92	91	88	91	93	92	92	90	92	94	95	93	94	92	95	94
Hepatitis B (3 doses or more)	81	81	86	89	88	90	90	91	92	80	79	83	87	87	88	89	91	91	81	84	88	88	90	91	89	93	93
Varicella^h	8	22	47	61	70	80	82	86	89	6	18	44	59	70	81	82	88	88	11	25	49	62	70	82	81	85	89
PCV (3 doses or more)ⁱ	—	—	—	—	—	—	37	66	70	—	—	—	—	—	—	35	65	71	—	—	—	—	—	—	38	67	71

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 reports in FY 2007 Budget in Brief: Centers for Disease Control and Prevention (February 20, 2006, http://www.hhs.gov/budget/07budget/cdc.html#infectious) that the VFC program had a budget of $2.6 billion for fiscal year 2007. Vaccines provided through the program represented about 40% of all childhood vaccines purchased in the country.

The World Health Organization 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 72% in 1999. Immunization rates for the developed world for the same time period were ten to twenty percentage points higher than the global average, reflecting the low immunization rates in many developing nations. In 2003 only 28% of developing countries reported that their immunization rate for DTP was 80% or higher.

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 CDC's National Center for Health Statistics (NCHS) finds that in 2004, 55.3% of children under age eighteen visited the doctor between one and three times, 26.2% saw the doctor between four and nine times, and 8% saw the doctor ten or more times. (See Table 4.2.) However, 10.6% 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 Carmen DeNavas-Walt, Bernadette D. Proctor, and Cheryl Hill Lee of the U.S. 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), 11.2% of American children (or 8.3 million) had no health insurance coverage in 2005. Factors affecting children's access to coverage included their age, race and ethnicity, and their family's economic status. Children between the ages of twelve and seventeen were more likely to be uninsured than those under age twelve (12.6% versus 10.5%). Poor children were proportionately more likely to be uninsured than all children (19% versus 11.2%) because of government programs such as Medicaid, and those of Hispanic origin were the least likely racial or ethnic group to receive health insurance coverage, with 21.9% of them being uninsured. Uninsured rates for other racial and ethnic groups were 7.2% for non-Hispanic white children, 12.2% for Asian-American children, and 12.5% for African-American children. Robin A. Cohen and Michael E. Martinez of the NCHS estimate in Health Insurance Coverage: Early Release Estimates from the National Health Interview Survey, January-June 2006 (December 2006, http://www.cdc.gov/nchs/data/nhis/earlyrelease/insur200612.pdf) that 9.2% of all children were uninsured for at least part of 2006.

Child health insurance coverage increased slightly among all age groups, races, and ethnicities from 2000 to 2004, although the percent of children covered by private health insurance declined from 70% in 2000 to 66% in 2004. (See Table 4.3 and Figure 4.1.) 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 HHS secretary Tommy G. Thompson attributes ongoing increases to a push to provide more government coverage, particularly under the State Children's Health Insurance Program. This trend, however, may be leveling off. Cohen and Martinez find that there was no significant change in the number of uninsured children between 2005 and 2006. (See Figure 4.1.)

DeNavas-Walt, Proctor, and Hill Lee note that in 2005 government programs, such as Medicare, Medicaid, and military insurance, covered a greater proportion of African-American children and Hispanic children than other children. Almost half (44.9%) of African-American children and 39.3% of Hispanic children had government insurance, compared with only 18% of non-Hispanic white children and 15.9% of Asian children.

To remain in the Medicaid program, families must have their eligibility reassessed at least every six months. If family income or other circumstances change even slightly, the family can lose its eligibility for the Medicaid 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 fifty 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 2005 Annual Enrollment Report (July 12, 2006, http://www.cms.hhs.gov/NationalSCHIPPolicy/downloads/FY2005AnnualEnrollmentReport.pdf), in fiscal year 2005, 6.1 million children were enrolled in SCHIP.

TABLE 4.2
Health care visits to doctor's offices, emergency departments, and home visits over a 12-month period, by selected characteristics, selected years 1997–2004
[Data are based on household interviews of a sample of the civilian noninstitutionalized population]
Characteristic	Number of health care visits^a
	None			1-3 visits			4-9 visits			10 or more visits
	1997	2003	2004	1997	2003	2004	1997	2003	2004	1997	2003	2004
	Percent distribution
All persons^{b, c}	16.5	15.8	16.1	46.2	45.8	45.8	23.6	24.8	24.6	13.7	13.6	13.5
Age
Under 18 years	11.8	11.3	10.6	54.1	54.5	55.3	25.2	26.7	26.2	8.9	7.5	8.0
Under 6 years	5.0	5.5	5.3	44.9	46.0	47.5	37.0	39.0	36.9	13.0	9.4	10.3
6-17 years	15.3	14.0	13.1	58.7	58.7	59.0	19.3	20.8	21.1	6.8	6.6	6.8
18-44 years	21.7	22.4	23.8	46.7	46.7	45.6	19.0	19.1	19.2	12.6	11.8	11.5
18-24 years	22.0	23.6	25.7	46.8	47.2	45.0	20.0	18.2	19.2	11.2	11.0	10.1
25-44 years	21.6	22.0	23.1	46.7	46.6	45.8	18.7	19.4	19.2	13.0	12.0	12.0
45-64 years	16.9	14.7	15.0	42.9	42.2	43.3	24.7	26.6	25.3	15.5	16.5	16.3
45-54 years	17.9	16.9	16.9	43.9	44.2	45.0	23.4	24.5	22.9	14.8	14.3	15.2
55-64 years	15.3	11.4	12.3	41.3	39.2	40.9	26.7	29.8	28.9	16.7	19.6	18.0
65 years and over	8.9	6.3	5.6	34.7	31.5	31.6	32.5	35.8	36.8	23.8	26.4	26.1
65-74 years	9.8	7.1	6.8	36.9	34.0	36.0	31.6	35.7	34.5	21.6	23.3	22.6
75 years and over	7.7	5.4	4.1	31.8	28.6	26.4	33.8	36.0	39.5	26.6	30.0	30.0
Sex^c
Male	21.3	20.6	20.9	47.1	46.8	46.6	20.6	21.9	21.6	11.0	10.7	10.9
Female	11.8	11.1	11.5	45.4	44.9	45.0	26.5	27.7	27.5	16.3	16.3	16.0
Race^{c, d}
White only	16.0	15.7	16.0	46.1	45.6	45.4	23.9	25.1	24.8	14.0	13.6	13.8
Black or African American only	16.8	14.7	15.8	46.1	45.8	47.0	23.2	25.2	24.6	13.9	14.3	12.6
American Indian or Alaska Native only	17.1	23.3	17.7	38.0	41.4	41.7	24.2	20.6	25.0	20.7	14.7	15.5
Asian only	22.8	22.6	20.8	49.1	47.8	51.5	19.7	20.7	19.7	8.3	8.9	8.1
Native Hawaiian or other Pacific
Islander only	—			—			—			—
2 or more races	—	11.1	13.6	—	44.9	42.9	—	23.0	26.2	—	21.0	17.3
Hispanic origin and race^{c, d}
Hispanic or Latino	24.9	25.3	26.7	42.3	42.9	41.8	20.3	20.3	20.6	12.5	11.5	10.9
Mexican	28.9	27.8	29.7	40.8	42.5	41.0	18.5	18.8	18.9	11.8	11.0	10.4
Not Hispanic or Latino	15.4	14.1	14.2	46.7	46.3	46.5	24.0	25.6	25.2	13.9	14.0	14.14
White only	14.7	13.5	13.5	46.6	46.2	46.1	24.4	26.1	25.7	14.3	14.2	14.7
Black or African American only	16.9	14.6	15.6	46.1	45.9	47.3	23.1	25.3	24.6	13.8	14.2	12.5
Respondent-assessed health status^c
Fair or poor	7.8	8.7	8.1	23.3	23.2	22.0	29.0	28.8	28.0	39.9	39.3	41.9
Good to excellent	17.2	16.4	16.9	48.4	48.1	48.0	23.3	24.5	24.4	11.1	10.9	10.7
Percent of poverty level^{c, e}
Below 100%	20.6	20.9	21.1	37.8	37.8	37.7	22.7	23.7	23.5	18.9	17.6	17.7
100%-less than 200%	20.1	19.8	20.9	43.3	41.5	42.5	21.7	23.6	22.3	14.9	15.1	14.4
200% or more	14.5	13.7	13.8	48.7	48.4	48.1	24.2	25.4	25.3	12.6	12.6	12.8
Hispanic origin and race and percent of poverty level^{c, d, e}
Hispanic or Latino:
Below 100%	30.2	29.9	31.6	34.8	37.0	35.0	19.9	18.5	19.6	15.0	14.6	13.9
100%-less than 200%	28.7	28.6	30.5	39.7	40.2	39.3	20.4	20.6	19.4	11.2	10.5	10.9
200% or more	18.9	20.7	21.5	48.8	47.7	47.0	20.4	21.2	22.2	11.9	10.3	9.2
Not Hispanic or Latino:
White only:
Below 100%	17.0	17.0	16.2	38.3	37.5	37.5	23.9	25.9	25.4	20.9	19.5	20.9
100%-less than 200%	17.3	16.6	16.7	44.1	41.0	43.2	22.2	24.9	23.4	16.3	17.4	16.7
200% or more	13.8	12.5	12.7	48.2	48.1	47.4	24.9	26.3	26.1	13.1	13.1	13.8
Black or African American only:
Below 100%	17.4	15.7	15.9	38.5	38.1	40.9	23.4	26.5	25.7	20.7	19.6	17.5
100%-less than 200%	18.8	15.4	18.1	43.7	44.2	44.5	22.9	25.9	23.8	14.5	14.5	13.7
200% or more	15.6	13.7	14.3	51.7	50.6	51.3	22.7	24.3	24.4	10.0	11.4	10.0

TABLE 4.2
Health care visits to doctor's offices, emergency departments, and home visits over a 12-month period, by selected characteristics, selected years 1997–2004 [continued]
[Data are based on household interviews of a sample of the civilian noninstitutionalized population]
Characteristic	Number of health care visits^a
	None			1-3 visits			4-9 visits			10 or more visits
	1997	2003	2004	1997	2003	2004	1997	2003	2004	1997	2003	2004
*Estimates are considered unreliable.
—Data not available.
^aThis table presents a summary measure of health care visits to doctor's 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 1999–2004.
^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).
^hMSA is metropolitan statistical area.
Source: "Table 80. Health Care Visits to Doctor's Offices, Emergency Departments, and Home Visits within the Past 12 Months, by Selected Characteristics, United States, Selected Years 1997–2004," in Health, United States, 2006, with Chartbook on Trends in the Health of Americans, Centers for Disease Control and Prevention, National Center for Health Statistics, 2006, http://0-www.cdc.gov.mill1.sjlibrary.org/nchs/data/hus/hus06.pdf (accessed February 6, 2007)
Health insurance status at the time of interview^{f, g}
Under 65 years of age:
Insured	14.3	12.8	13.4	49.0	49.1	49.1	23.6	25.2	24.6	13.1	12.9	12.8
Private	14.7	13.2	13.6	50.6	51.1	51.4	23.1	24.6	23.9	11.6	11.1	11.2
Medicaid	9.8	9.9	11.8	35.5	35.2	35.1	26.5	28.1	28.2	28.2	26.8	24.9
Uninsured	33.7	38.1	37.8	42.8	42.4	42.5	15.3	13.4	13.6	8.2	6.1	6.1
Health insurance status prior to interview^{f, g}
Under 65 years of age:
Insured continuously all 12 months	14.1	12.7	13.4	49.2	49.3	49.4	23.6	25.2	24.6	13.0	12.8	12.7
Uninsured for any period up to 12 months	18.9	20.4	20.0	46.0	46.2	45.7	20.8	21.2	21.9	14.4	12.2	12.3
Uninsured more than 12 months	39.0	44.3	43.9	41.4	39.8	41.3	13.2	11.2	10.0	6.4	4.7	4.8
Percent of poverty level and insurance status prior to interview^{e, f, g}
Under 65 years of age:
Below 100%:
Insured continuously all 12 months	13.8	12.7	14.3	39.7	40.9	39.6	25.2	25.8	25.7	21.4	20.5	20.4
Uninsured for any period up to 12 months	19.7	18.4	17.6	37.6	43.9	42.0	21.9	21.6	24.6	20.9	16.1	15.7
Uninsured more than 12 months	41.2	47.7	47.1	39.9	35.7	38.6	12.2	11.7	9.4	6.6	4.9	5.0
100%-less than 200%:
Insured continuously all 12 months	16.0	13.8	15.7	46.4	45.0	45.4	21.9	24.4	23.5	15.8	16.8	15.5
Uninsured for any period up to 12 months	18.8	20.2	21.7	45.1	42.0	45.1	21.0	24.8	22.1	15.0	12.9	11.1
Uninsured more than 12 months	38.7	43.4	45.0	41.0	39.1	39.4	14.0	12.1	9.9	6.3	5.4	5.7
200% or more:
Insured continuously all 12 months	13.7	12.4	12.6	51.0	51.1	51.3	23.6	25.3	24.7	11.7	11.3	11.5
Uninsured for any period up to 12 months	17.8	20.4	20.3	50.3	49.6	47.5	20.4	19.1	20.4	11.5	10.9	11.9
Uninsured more than 12 months	36.6	41.8	39.7	43.8	44.7	45.4	13.2	9.6	10.9	6.4	4.0	4.1
Geographic region^c
Northeast	13.2	10.4	11.6	45.9	47.6	45.5	26.0	27.0	27.5	14.9	15.0	15.4
Midwest	15.9	14.2	13.9	47.7	47.2	47.5	22.8	25.4	25.1	13.6	13.2	13.5
South	17.2	16.5	16.7	46.1	45.1	46.2	23.3	24.8	23.8	13.5	13.6	13.3
West	19.1	21.0	21.3	44.8	44.2	43.8	22.8	22.2	22.7	13.3	12.6	12.2
Location of residence^c
Within MSA^h	16.2	16.0	16.3	46.4	45.9	45.9	23.7	24.8	24.4	13.7	13.3	13.4
Outside MSA^h	17.3	15.0	15.3	45.4	45.6	45.4	23.3	24.9	25.3	13.9	14.5	14.0

TABLE 4.3
Percentage of children under age 18 covered by health insurance, by type of insurance, age, race, and Hispanic origin, 1987–2004
Characteristic	1987	1988	1989	1990	1991	1992	1993	1994	1995	1996	1997	1998	1999	2000	2001	2002	2003	2004
All health insurance
Total	87	87	87	87	87	87	86	86	86	85	85	85	87	88	88	88	89	89
Gender
Male	87	87	87	87	87	88	87	86	86	85	85	85	87	88	88	88	89	89
Female	87	87	87	87	88	87	86	86	86	85	85	85	87	88	88	89	89	89
Age
Ages 0-5	88	87	87	89	89	89	88	86	87	86	86	84	87	89	89	89	90	90
Ages 6-11	87	87	87	87	88	88	87	87	87	85	86	85	88	88	89	89	89	89
Ages 12-17	86	86	86	85	85	85	83	85	86	84	83	84	87	87	87	87	87	88
Race and Hispanic origin^b
White, non-Hispanic	90	90	90	90	90	90	89	89	90	89	89	89	92	93	93	92	93	92
Black	83	84	84	85	85	86	84	83	85	81	81	80	84	86	86	86	86	87
Hispanic^c	72	71	70	72	73	75	74	72	73	71	71	70	74	75	76	77	79	79
Region
Northeast	92	93	91	92	92	91	90	88	89	88	88	89	92	92	92	91	91	91
Midwest	92	93	92	91	92	91	91	91	91	91	90	89	91	92	92	92	92	92
South	82	81	82	83	83	84	83	83	83	82	82	82	84	86	86	86	86	87
West	85	85	84	84	85	86	84	83	84	83	83	82	84	86	86	87	88	88
Private health insurance
Total	74	74	74	71	70	69	67	66	66	66	67	68	70	70	68	67	66	66
Gender
Male	73	74	74	71	70	69	68	66	66	67	67	68	70	70	69	67	66	65
Female	74	73	74	71	69	68	67	65	66	66	67	67	70	70	68	68	66	66
Age
Ages 0-5	72	71	71	68	66	65	63	60	60	62	63	64	66	66	64	63	62	61
Ages 6-11	74	74	75	73	71	71	70	67	67	67	68	68	70	70	69	68	66	67
Ages 12-17	75	76	76	73	72	71	69	70	71	70	69	70	73	73	72	71	69	69
Race and Hispanic origin^b
White, non-Hispanic	83	83	83	81	80	80	78	77	78	78	78	79	81	81	80	79	78	77
Black	49	50	52	49	45	46	46	43	44	45	48	47	52	53	52	50	47	48
Hispanic^c	48	48	48	45	43	42	42	38	38	40	42	43	46	45	44	43	42	43
Region
Northeast	79	78	78	77	75	73	71	70	71	69	69	70	73	74	72	71	71	71
Midwest	79	80	80	76	75	74	73	74	74	75	76	75	77	78	77	76	74	73
South	68	68	69	66	65	64	63	62	61	61	62	64	66	66	64	63	61	61
West	71	70	70	68	66	67	65	60	61	62	63	63	65	65	64	65	62	63
Government health insurance^d
Total	19	19	19	22	24	25	27	26	26	25	23	23	23	24	26	27	29	30
Gender
Male	19	19	19	22	24	25	27	26	26	25	23	22	24	25	26	27	29	30
Female	19	19	19	22	24	26	27	27	27	25	24	23	23	24	26	27	29	29
Age
Ages 0-5	22	23	24	28	30	33	35	33	33	31	29	27	27	29	31	32	34	35
Ages 6-11	19	18	18	20	22	23	25	25	26	25	23	23	23	25	26	27	29	29
Ages 12-17	16	16	15	18	19	19	20	20	21	19	19	19	19	20	20	22	24	25
Race and Hispanic origin^b
White, non-Hispanic	12	13	13	15	16	17	19	18	18	18	17	16	16	17	19	18	21	21
Black	42	42	41	45	48	49	50	48	49	45	40	42	40	42	42	44	47	48
Hispanic^c	28	27	27	32	37	38	41	38	39	35	34	31	33	35	37	40	42	42

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; school districts use different methods of estimation. In the 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 homelessness at some point during the year were enrolled in school during the 2003–04 school year. Of these children, about half (50.3%) lived doubled-up with relatives or friends; 25.3% lived in shelters, 10% stayed 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 that 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, in the Hunger and Homelessness Survey: A Status Report on Hunger and Homelessness in America's Cities, a 23-City Survey (December 2006, http://www.usmayors.org/uscm/hungersurvey/2006/report06.pdf), finds that 30% of homeless people were in families with children, 51% were single men, 17% were single women, and 2% were unaccompanied youth—usually runaways. Since 1994 the proportion of families among the homeless has generally declined, as has the proportion of unaccompanied youth among the homeless population. Data from the Conference of Mayors survey show city-by-city estimates of children as a percent of homeless family members. Values range from 20% of family members in Charleston, South Carolina, and Los Angeles, California, to 83% in Santa Monica, California, and Trenton, New Jersey.

TABLE 4.3
Percentage of children under age 18 covered by health insurance, by type of insurance, age, race, and Hispanic origin, 1987–2004 [continued]
Characteristic	1987	1988	1989	1990	1991	1992	1993	1994	1995	1996	1997	1998	1999	2000	2001	2002	2003	2004
^aChildren are considered to be covered by health insurance if they had government or private coverage at any time during the year. Some children are covered by both types of insurance; hence, the sum of government and private is greater than the total.
^bFor race and Hispanic-origin data in this table: From 1987 to 2002, following the 1977 Office of Management and Budget (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, or 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; Hispanics may be any race.
^cPersons of Hispanic origin may be of any race.
^dGovernment 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).
Note: Estimates beginning in 1999 include follow-up questions to verify health insurance status and use the Census 2000-based weights. Estimates for 1999 through 2004 are not directly comparable with estimates for earlier years, before the verification questions were added.
Source: "Table ECON5.A. Access to Health Care: Percentage of Children Ages 0-17 Covered by Health Insurance by Selected Characteristics, Selected Years 1987–2004," in America's Children in Brief: Key National Indicators of Well-Being, 2006, Federal Interagency Forum on Child and Family Statistics, 2006, http://childstats.gov/americaschildren/tables/econ5a.asp (accessed February 25, 2007)
Region
Northeast	18	19	18	21	22	22	25	23	23	24	23	24	24	24	25	25	26	26
Midwest	18	17	17	20	22	23	24	24	23	21	19	19	20	19	21	22	25	26
South	20	19	20	23	25	28	29	29	28	27	25	24	24	26	29	30	32	32
West	20	22	22	23	27	27	28	29	30	27	25	24	25	27	27	28	31	32

The poverty and lack of stability that homelessness brings has a negative impact on children. An example of the poor educational achievement of homeless youths is shown in the 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. Twenty-one percent of sixteen-year-olds, 22% of seventeen-year-olds, 33% of eighteen-year-olds, 51% of nineteen-year-olds, 59% of twenty-year-olds, and 70% of twenty-one-year-olds were below grade level, according to its findings. Only 13% of the homeless youths in the study had a high school diploma or general equivalency diploma (GED). 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, in Homeless Children: What Every Health Care Provider Should Know (2006, http://www.nhchc.org/Children/), argues that these children suffer from frequent health problems. They are seen in emergency rooms and 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 impacts their own mental health. Homelessness results in serious negative consequences for 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, 2005 (November 2006, http://www.ers.usda.gov/Publications/ERR29/ERR29.pdf), that in 2005, 89% of U.S. households were food secure. However, the remaining 11% (12.6 million 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. However, 3.9% of all households (4.4 million 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 in 2005 a higher percentage of children than adults were food insecure (16.9% and 11%, respectively). Households that are 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, almost one out of every one hundred children (0.7%) experienced very low food security on one or more days during 2005. Households with incomes below the poverty line, 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

America's Second Harvest, the nation's largest charitable hunger-relief organization, reports in the Hunger Study, 2006 (http://www.hungerinamerica.org/key_findings/) that in 2005, 25.3 million Americans sought emergency food assistance. In the Hunger and Homelessness Survey, the Conference of Mayors finds that requests for emergency food assistance increased by 7% in 2006, and requests for food assistance by families with children increased by an average of 5% in the surveyed cities. Almost half (48%) of those requesting assistance were members of families with children; 18% of requests by families were estimated to have gone unmet because of lack of resources. The most frequent reasons for hunger cited by city officials were unemployment and low-paying jobs. Other causes included high housing and medical costs, substance abuse, high utility and transportation costs, and a lack of education.

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 secondhand smoke.

LEAD POISONING

Lead exposure now comes primarily from leaded paints that have worn off or been scraped from older homes. Lead is also found in lead plumbing and emitted by factory smokestacks. 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 "CDC Surveillance Data, 1997–2005" (February 16, 2007, http://www.cdc.gov/nceh/lead/surv/stats.htm), the CDC indicates that in 2005 approximately 46,770 children from age five and under had confirmed blood lead levels greater than the center's recommended level of ten micrograms per deciliter of blood. This was about 1.6% of all children tested. According to the U.S. Environmental Protection Agency (EPA), in Children's Health and the Environment in North America, United States (December 2005, http://www.cec.org/files/PDF/POLLU TANTS/CountryReport-US-CHE_en.pdf), this number has dropped substantially since the early 1970s, due largely to the phasing out of lead in gasoline between 1973 and 1995. Although 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 contains 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.

SECONDHAND SMOKE AND CHILDREN

In Children's Health and the Environment in North America, United States, the EPA reports that environmental tobacco smoke (ETS) is a major hazard for children, whose respiratory, immune, and other systems are not as well developed as those of adults. 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. As noted in the American Lung Association's Secondhand Smoke and Children Fact Sheet (August 2006), "Exposure to secondhand smoke causes 150,000 and 300,000 acute lower respiratory tract infections (pneumonia and bronchitis) annually in children 18 months and younger; these infections result in 7,500 to 15,000 hospitalizations each year." Passive smoking can also cause middle-ear disease and a reduction in lung function in children, and is considered a risk factor in sudden infant death syndrome. The EPA finds in Children's Health and the Environment in North America, United States that the percentage of children under age six who were regularly exposed to secondhand smoke in their homes decreased substantially from 27% in 1994 to 11% in 2003.

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 eleven years were overweight. (See Table 4.4.) In the 2003–04 period those percentages had almost tripled for boys (19.9%) and more than doubled for girls (17.6%). An even more alarming upward trend was seen in the rates of overweight adolescents; 4.5% of boys and 5.4% of girls aged twelve to seventeen were overweight in the 1976–80 period, but 18.3% of adolescent boys and 16% of adolescent girls were overweight in the 2003–04 period. The proportion of overweight children overall between the ages of six and eighteen more than tripled (from 5.7% to 18%) between 1976 and 2004.

Percentages of overweight children vary by race and ethnicity. In the 2003–04 period African-American adolescents (21.5%) were more likely to be overweight than white, non-Hispanic adolescents (16.9%) or Mexican-American adolescents (16.3%). (See Table 4.4.) Among children aged six to eleven, white, non-Hispanic children were the least likely to be overweight (17.7%), compared with African-American (22%) and Mexican-American (22.5%) children of the same age.

Medical professionals are concerned about this trend, because overweight children are at 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. According to the CDC, in 2005, 15.7% of high school students were at risk for becoming overweight and 13.1% were already overweight. (See Table 4.5.)

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. Television watching and playing computer and video games contribute to the inactive lifestyles of children. According to the CDC, in "Youth Risk Behavior Surveillance—United States, 2005" (Morbidity and Mortality Weekly Report, June 6, 2006), 21.1% of high school students spent three or more hours per school day on the computer, and 37.2% 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 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. The CDC reports that less than half of students in high school participated in vigorous physical activity, exercise, and physical education classes, and this percentage was even lower for females than for males. (See Table 4.6.) Only 43.8% of male high school students engaged in sufficient vigorous physical activity, whereas only 27.8% of female high school students did. White students were somewhat more likely to meet recommended levels of physical activity (38.7%) than Hispanic (32.9%) or African-American (29.5%) students. 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 reports that millions of children in the United States have asthma. In 2005, 8.9% of children (6.5 million) were currently suffering from asthma, and 12.7% of children (9 million) had suffered with it at some point in their lifetime. Childhood asthma caused 27 hospitalizations per 10,000 children in 2004, and caused 12.8 million missed days of school in 2003. The American Lung Association (ALA) estimates that up to a million asthmatic children are exposed to secondhand smoke, worsening their condition.

Akinbami notes that African-American children suffer from asthma at a rate 60% higher than that of non-Hispanic white children, whereas Puerto Rican children

TABLE 4.4
Percentage of children 6-17 who are overweight, by gender, race, and Hispanic origin, selected years 1976–2004
	Total					Male					Female
	1976–1980	1988–1994	1999–2000	2001–2002	2003–2004	1976–1980	1988–1994	1999–2000	2001–2002	2003–2004	1976–1980	1988–1994	1999–2000	2001–2002	2003–2004
—=Not available.
*Estimates are considered unreliable.
^aFrom 1976 to 1994, the 1977 Office of Management and Budget (OMB) Standards for Data on Race and Ethnicity were used to classify persons into one of the following four racial groups: white, black, American Indian or Alaskan Native, or Asian or Pacific Islander. For data from 1999 to 2004, the revised 1997 OMB standards were used. Persons could select one or more of five racial groups: white, black or African American, American Indian or Alaska Native, Asian, and Native Hawaiian or other Pacific Islander. Data on race and Hispanic origin are collected separately but are combined for reporting. Persons of Mexican origin may be of any race. Included in the total but not shown separately are American Indian or Alaska Native, Asian, or Native Hawaiian or other Pacific Islander race due to the small sample size for each of these groups. Data from 1999 onward are not directly comparable with data from earlier years. The National Health and Nutrition Examination Survey (NHANES) sample was designed to provide estimates specifically for persons of Mexican-origin and not for all Hispanic-origin persons.
^bEstimates are unstable because they are based on a small number of persons.
Notes: Overweight is defined as body mass index (BMI) at or above the 95th percentile of the 2000 Centers for Disease Control and Prevention BMI-for-age growth charts (http://www.cdc.gov/growthcharts). BMI is calculated as weight in kilograms divided by the square of height in meters.
Source: "Table HEALTH4. Overweight: Percentage of Children Ages 6-17 Who Are Overweight by Gender, Race, and Hispanic Origin, 1976–1980, 1988–1994, 1999–2000, 2001–2002, and 2003–2004," in America's Children in Brief: Key National Indicators of Well-Being, 2006, Federal Interagency Forum on Child and Family Statistics, 2006, http://childstats.gov/americaschildren/tables/health4.asp (accessed February 25, 2007)
Ages 6-17
Total	5.7	11.2	15.0	16.5	18.0	5.5	11.8	15.7	18.0	19.1	5.8	10.6	14.3	15.1	16.8
Race and Hispanic origin^a
White, non-Hispanic	4.9	10.5	11.2	14.6	17.3	4.7	11.3	11.9	16.0	18.8	5.1	9.6	10.5	13.2	15.7
Black, non-Hispanic	8.2	14.0	21.1	20.4	21.7	5.8^b	11.5	19.2	17.7	18.3	10.7	16.5	23.1	23.3	25.3
Mexican American	—	15.4	24.1	21.5	19.6	—	16.1	28.0	25.2	22.3	—	14.7	20.0	17.6	16.6
Ages 6-11
Total	6.5	11.3	15.1	16.3	18.8	6.7	11.6	15.7	17.5	19.9	6.4	11.0	14.3	14.9	17.6
Race and Hispanic origin^a
White, non-Hispanic	5.7	10.2	11.7	14.8	17.7	6.1	10.7	11.9	15.5	18.5	5.2	9.8	11.6	14.1	16.9
Black, non-Hispanic	9.0	14.6	19.6	19.9	22.0	6.8^b	12.3	17.1	16.9	17.5	11.2	17.0	22.4	23.1	26.5
Mexican American	—	16.4	23.4	20.1	22.5	—	17.5	26.7	26.0	25.3	—	15.3	19.8	13.6	19.4
Ages 12-17
Total	5.0	11.1	14.9	16.8	17.2	4.5	12.0	15.6	18.4	18.3	5.4	10.2	14.2	15.2	16.0
Race and Hispanic origin^a
White, non-Hispanic	4.3	10.8	10.7	14.4	16.9	3.6	12.0	12.0	16.5	19.0	5.0	9.5	9.3	12.4	14.6
Black, non-Hispanic	7.5	13.3	22.7	21.0	21.5	*	10.7	21.6	18.6	19.1	10.3	16.0	23.5	23.4	24.1
Mexican American	—	14.2	24.9	23.1	16.3	—	14.4	29.8	24.2	18.8	—	14.0	20.3	22.0	13.4

TABLE 4.5
Percentage of high school students who had or perceived they had a problem with weight, by sex, race/ethnicity, and grade, 2005
^aStudents who were ?85th percentile but <95th percentile for body mass index, by age and sex, based on reference data.
^bStudents who were ?95th percentile for body mass index, by age and sex, on the basis of reference data.
^cNon-Hispanic.
Source: Adapted from "Table 60. Percentage of High School Students Who Were at Risk for Becoming or Were Overweight, by Sex, Race/Ethnicity, and Grade," and "Table 62. 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," in "Youth Risk Behavior Surveillance—United States, 2005," Morbidity and Mortality Weekly Report, vol. 55, no. SS-5, June 9, 2006, http://www.cdc.gov/mmwr/PDF/SS/SS5505.pdf (accessed February 25, 2007)
Category	At risk for becoming overweight^a			Overweight^b
Category	Female	Male	Total	Female	Male	Total
	%	%	%	%	%	%
Race/ethnicity
White^c	13.8	15.2	14.5	8.2	15.2	11.8
Black^c	22.6	16.7	19.8	16.1	15.9	16.0
Hispanic	16.8	16.5	16.7	12.1	21.3	16.8
Grade
9	15.9	18.3	17.1	10.4	15.0	12.7
10	15.4	14.5	14.9	10.6	16.5	13.6
11	15.2	15.9	15.6	9.4	17.2	13.3
12	15.6	14.1	14.8	9.7	15.5	12.6
Total	15.5	15.8	15.7	10.0	16.0	13.1
	Described themselves as overweight			Were trying to lose weight
	Female	Male	Total	Female	Male	Total
	%	%	%	%	%	%
Race/ethnicity
White^c	37.7	24.7	31.1	63.5	28.8	45.9
Black^c	36.3	17.6	27.2	52.7	24.4	38.9
Hispanic	42.4	32.0	37.1	64.1	38.6	51.2
Grade
9	36.2	24.3	30.2	60.1	31.9	45.8
10	36.2	24.5	30.2	61.5	28.2	44.4
11	39.1	26.0	32.6	61.7	30.5	46.2
12	41.8	25.6	33.7	64.0	28.7	46.4
Total	38.1	25.1	31.5	61.7	29.9	45.6

TABLE 4.6
High school participation in physical activity by sex, race/ethnicity, and grade, 2005
Category	Met currently recommended levels of physical activity^a			Met previously recommended levels of physical activity^b			No vigorous or moderate physical activity^c
Category	Female	Male	Total	Female	Male	Total	Female	Male	Total
^aWere 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 of the 7 days preceding the survey.
^bParticipated in at least 20 minutes of vigorous physical activity (i.e., physical activity that made them sweat and breathe hard) on ?3 of the 7 days preceding the survey and/or at least 30 minutes of moderate physical activity (i.e., physical activity that did not make them sweat and breathe hard) on ?5 of the 7 days preceding the survey.
^cDuring the 7 days preceding the survey.
^dNon-Hispanic.
Source: "Table 52. Percentage of High School Students Who Met Currently Recommended Levels of Physical Activity, Who Met Previously Recommended Levels of Physical Activity, and Who Participated in No Vigorous or Moderate Physical Activity, by Sex, Race/Ethnicity, and Grade," in "Youth Risk Behavior Surveillance—United States, 2005," Morbidity and Mortality Weekly Report, vol. 55, no. SS-5, June 9, 2006, http://www.cdc.gov/mmwr/PDF/SS/SS5505.pdf (accessed February 25, 2007)
	%	%	%	%	%	%	%	%	%
Race/ethnicity
White^d	30.2	46.9	38.7	63.3	77.0	70.2	9.3	6.9	1.1
Black^d	21.3	38.2	29.5	53.1	71.7	62.0	18.2	10.2	1.8
Hispanic	26.5	39.0	32.9	62.6	76.0	69.4	12.3	8.9	2.0
Grade
9	30.8	42.8	36.9	68.4	78.4	73.5	8.2	7.2	1.4
10	30.0	46.8	38.5	63.0	77.8	70.5	10.3	7.5	1.4
11	25.1	43.8	34.4	60.7	74.2	67.4	12.4	8.4	1.7
12	24.0	41.9	32.9	51.7	71.9	61.8	15.2	8.4	2.0
Total	27.8	43.8	35.8	61.5	75.8	68.7	11.3	7.9	0.9

suffer from asthma at a rate 140% higher than non-Hispanic white children. Akinbami finds that besides their higher prevalence rates, African-American children's asthma is apparently much less well controlled than non-Hispanic white children's asthma. African-American children have a 260% higher emergency department visit rate, a 250% higher hospitalization rate, and a 500% higher death rate from asthma. She speculates that this is because of the lower level and quality of health care received by African-American children.

HIV/AIDS

Acquired immunodeficiency syndrome (AIDS) was identified as a new disease in 1981, and, according to the CDC, in the HIV/AIDS Surveillance Report (2006, http://www.cdc.gov/hiv/topics/surveillance/resources/reports/2005report/pdf/2005SurveillanceReport.pdf), an estimated 988,376 cases had been diagnosed in the United States through 2005. 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?

By the end of 2005 the CDC reported a cumulative total of 9,078 AIDS cases in children under the age of thirteen since record keeping began in 1981. (See Table 4.7.) African-American children made up the overwhelming majority of these cases (5,614 cases), followed by Hispanic children (1,732 cases), non-Hispanic white children (1,613 cases), Asians and Pacific Islanders (54 cases), and Native Americans or Alaskan Natives (32 cases). By the end of 2005, 5,136 children aged fourteen and under had died from the disease.

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 breastfeeding. With these interventions, the transmission rate can be reduced to as low as 2%.

Although interventions are effective in preventing HIV transmission from pregnant mothers to babies, the overwhelming majority of children with AIDS contracted it from mothers who were either infected with HIV or at risk for AIDS (8,438 of 9,078 cases, or 93%). (See Table 4.7.) 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. The CDC reports that by the end of 2005, 6,324 adolescents aged thirteen to nineteen 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; by 2005, 34,987 twenty- to twenty-four-year-olds had been diagnosed.

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 focus on the period after the parents separated. However, some recent studies suggest that the negative effects children experience may not come so much from divorce itself as from the 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, 2001), children raised in discord and marital instability often experience a variety of social, emotional, and psychological problems.

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 can give 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 (extreme and often fatal weight loss) and bulimia ("binging and purging"). Girls are both more likely to have a distorted view of their weight and more likely to have eating disorders than boys.

TABLE 4.7
Diagnoses of AIDS in children younger than 13, by year of diagnosis, race/ethnicity, and transmission category, 2001–05
	Year of diagnosis					Cumulative^a
	2001	2002	2003	2004	2005	Cumulative^a
Note: 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 2005.
^bIncludes children of unknown race or multiple races. Cumulative total includes 33 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, 2001–2005 and Cumulative—50 States and the District of Columbia," in HIV/AIDS Surveillance Report, vol. 17, Centers for Disease Control and Prevention, 2006, http://www.cdc.gov/hiv/topics/surveillance/resources/reports/2005report/pdf/2005SurveillanceReport.pdf (accessed February 25, 2007)
Race/ethnicity
White, not Hispanic	12	14	11	7	8	1,613
Black, not Hispanic	83	72	43	29	39	5,614
Hispanic	22	16	10	9	9	1,732
Asian/Pacific Islander	1	1	0	1	1	54
American Indian/Alaska Native	0	1	0	1	0	32
Transmission category
Hemophilia/coagulation disorder	0	0	0	0	0	226
Mother with documented HIV infection or 1 of the following
risk factors	115	102	67	47	57	8,438
Injection drug use	13	11	7	6	4	3,196
Sex with injection drug user	10	4	6	2	1	1,388
Sex with bisexual male	3	2	0	2	1	202
Sex with person with hemophilia	1	0	0	0	0	36
Sex with HIV-infected transfusion recipient	0	0	0	0	0	22
Sex with HIV-infected person, risk factor not specified	39	36	19	19	25	1,501
Receipt of blood transfusion, blood components, or tissue	1	2	1	0	0	143
Has HIV infection, risk factor not specified	47	47	32	18	25	1,949
Receipt of blood transfusion, blood components, or tissue	0	2	0	0	0	372
Other/risk factor not reported or identified	3	0	0	0	0	42
Total^b	118	104	67	47	58	9,078

The CDC reports that although 13.1% of students were overweight in 2005, a much higher proportion thought they were overweight (31.5%). (See Table 4.5.) Girls (38.1%) were much more likely than boys (25.1%) to believe they were overweight. Non-Hispanic white (31.1%) and especially Hispanic (37.1%) youths were more likely than African-American youths (27.2%) to think of themselves as overweight.

In 2005 nearly half (45.6%) of high school students nationwide were trying to lose weight by a variety of methods. (See Table 4.5.) Almost one out of twenty (4.5%) high school students had taken laxatives or induced vomiting to lose weight, 12.3% went without eating for twenty-four hours or more, and 6.3% took diet pills. (See Table 4.8.) Hispanic and non-Hispanic white students were more likely to resort to these unhealthy behaviors than were African-American students. Many more females than males engaged in risky weight-loss methods.

Many more high school students engaged in healthier methods of losing weight. Well over half of high school females dieted or exercised to lose weight (54.8% and 67.4%, respectively); among males, only 26.8% dieted and 52.9% exercised to lose weight. (See Table 4.8.) Once again, among females these behaviors varied by race: Far more white and Hispanic female students engaged in these weight-loss activities than did African-American female students.

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 recent research reported by the National Institute of Mental Health finds a link between a person's ability to pay attention and the body's use of glucose in the brain. Symptoms include restlessness, inability to concentrate, aggressiveness, and impulsivity; lack of treatment can lead to problems in school, at work, and in making friends. In "Attention Deficit Hyperactivity Disorder" (2001, http://www.nimh.nih.gov/publicat/helpchild.cfm), the National Institute of Mental Health estimates that 4.1% of youths aged nine to seventeen are affected in any six-month period by ADHD. Boys are two to three times more likely to be affected by ADHD than girls. Methylphenidate, a stimulant, is frequently used to treat hyperactive children.

TABLE 4.8
Percentage of high school students who engaged in healthy and unhealthy behaviors associated with weight control^a, by sex, race/ethnicity, and grade, 2005
Category	Ate less food, fewer calories, or foods low in fat to lose weight or to keep from gaining weight			Exercised to lose weight or to keep from gaining weight			Went without eating for ?24 hours to lose weight or to keep from gaining weight			Took diet pills, powders, or liquids to lose weight or to keep from gaining weight^c			Vomited or took laxatives to lose weight or to keep from gaining weight
Category	Female	Male	Total	Female	Male	Total	Female	Male	Total	Female	Male	Total	Female	Male	Total
^aDuring the 30 days preceding the survey.
^bNon-Hispanic.
^cWithout a doctor's advice.
Source: Adapted from "Table 64. Percentage of High School Students Who Engaged in Healthy Behaviors to Lose Weight or to Keep from Gaining Weight, by Sex, Race/Ethnicity, and Grade," and "Table 66. Percentage of High School Students Who Engaged in Unhealthy Behaviors to Lose Weight or to Keep from Gaining Weight, by Sex, Race/Ethnicity, and Grade," in "Youth Risk Behavior Surveillance—United States, 2005," Morbidity and Mortality Weekly Report, vol. 55, no. SS-5, June 9, 2006, http://www.cdc.gov/mmwr/PDF/SS/SS5505.pdf (accessed February 25, 2007)
	%	%	%	%	%	%	%	%	%	%	%	%	%	%	%
Race/ethnicity
White^b	58.8	26.4	42.4	69.8	51.2	17.6	7.5	12.5	9.2	4.2	6.6	6.7	2.3	4.4
Black^b	39.6	22.0	31.1	56.5	51.6	54.1	14.0	8.6	11.4	4.9	5.1	5.0	4.0	2.8	3.4
Hispanic	53.2	31.5	42.2	68.9	63.0	65.9	17.7	7.4	12.6	7.5	5.7	6.6	6.8	3.9	5.4
Grade
9	50.8	27.1	38.8	68.3	57.7	62.9	18.4	8.1	13.3	6.0	4.3	5.2	5.5	2.7	4.1
10	55.3	25.7	40.1	69.0	52.1	60.3	16.2	7.4	11.7	7.7	4.4	6.0	7.2	3.0	5.1
11	55.6	26.8	41.4	66.3	49.4	58.0	17.2	6.8	12.1	9.2	4.8	7.0	6.1	2.5	4.3
12	58.4	27.6	43.0	65.5	51.2	58.3	16.0	7.8	11.9	10.2	4.4	7.3	5.9	2.6	4.3
Total	54.8	26.8	40.7	67.4	52.9	60.0	17.0	7.6	12.3	8.1	4.6	6.3	6.2	2.8	4.5

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, tenth, and twelfth graders on their use of these substances. According to the Monitoring the Future: National Results on Adolescent Drug Use, Overview of Key Findings, 2005 (April 2006, http://www.drugabuse.gov/PDF/overview2005.pdf), University of Michigan researchers Lloyd D. Johnston et al. indicate that the percentage of high school students who have ever tried any illicit drug either remained steady or decreased slightly from the mid-1990s to 2005. This plateau followed sharp increases during the early 1990s. Johnston et al. find that by the time they neared high school graduation, half (50%) of American students had tried an illicit drug. Between 1975 and 2005, 83% to 90% of high school seniors reported that they could easily obtain marijuana, more than any other illicit drug. A third of twelfth graders had used marijuana in the previous twelve months. The CDC finds that in 2005, 38.4% of high school students reported they had tried marijuana, and 20.2% reported they had used it at least once in the thirty days before the survey. (See Table 4.9.)

TOBACCO

Most states prohibit the sale of cigarettes to anyone under the age of eighteen, but the laws are often ignored and may carry no penalties for youths who buy cigarettes or smoke in public. The ALA reports in "Smoking and Teens Fact Sheet" (April 2006, http://www.lungusa.org/site/pp.asp?c=dvLUK9O0E&b=39871) that each day six thousand children smoke their first cigarette and that almost two thousand of them will become regular smokers. The CDC indicates that in 2005, 23% of high school students had smoked at least one cigarette in the month prior to being surveyed and 9.4% had smoked at least twenty days in the past month. (See Table 4.10.) Almost twice as many male students smoked heavily than did female students: 7.2% of female adolescents and 14.2% of male adolescents smoked more than ten 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.

ALCOHOL

According to Johnston et al., alcohol remained the drug of choice for teenagers in 2005. (See Table 4.11.) Almost seven out of ten (68.6%) high school seniors had used alcohol in the twelve months prior to the survey, and 47% had used alcohol in the previous thirty days. Although there was some decline in drinking among students in the 1980s, alcohol use remained generally stable among young people between 1995 and 2005. The CDC finds that in 2005, 74.3% of all high school students had had at least one alcoholic drink in their lifetime, 43.3% had taken a drink in the thirty days prior to being surveyed, and 25.5% had had five or more drinks on one occasion at least once in the previous thirty days. (See Table 4.9.) African-American youth were less likely than either non-Hispanic white or Hispanic high schoolers to have ever had a drink, to have had a drink in the previous thirty days, or to engage in episodic heavy drinking.

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 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 6.8 per 1,000 live births in 2003, after increasing in 2002 for the first time in decades. (See Table 4.12.) In Health, United States, 2003 (http://www.cdc.gov/nchs/data/hus/hus03.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. In 2003 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 4.12.) Rates for Native American or Alaskan Native, Hispanic, and Asian and Pacific Islander babies were 8.7, 5.6, and 4.8, respectively.

The NCHS lists the ten leading causes of infant mortality in the United States in 2004. (See Table 4.13.) Birth 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 (113.8 per 100,000 live births). Sudden infant death syndrome (51.2), complications of pregnancy (41.4), complications in the placenta or umbilical cord (24.2), respiratory distress (21.3), bacterial sepsis (19.4), neonatal hemorrhage (14.4), and intrauterine hypoxia/birth asphyxia (12.2) completed 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 2004. Moreover, it was the leading cause of death for infants older than one month. In 1992 the

TABLE 4.9
Percentage of high school students who drank alcohol and used marijuana, by sex, race/ethnicity, and grade, 2005
Category	Lifetime alcohol use^a			Current alcohol use^b			Episodic heavy drinking^c			Lifetime marijuana use^e			Current marijuana use^f
Category	Female	Male	Total	Female	Male	Total	Female	Male	Total	Female	Male	Total	Female	Male	Total
^aHad at least one drink of alcohol on ?1 day during their life.
^bHad at least one drink of alcohol on ?1 of the 30 days preceding the survey.
^cHad ?5 drinks of alcohol in a row (i.e., within a couple of hours) on ?1 of the 30 days preceding the survey.
^dNon-Hispanic.
^eUsed marijuana one or more times during their life.
^fUsed marijuana one or more times during the 30 days preceding the survey.
Source: Adapted from "Table 28. Percentage of High School Students Who Drank Alcohol, by Sex, Race/Ethnicity, and Grade," and "Table 30. Percentage of High School Students Who Used Marijuana, by Sex, Race/Ethnicity, and Grade," in "Youth Risk Behavior Surveillance—United States, 2005," Morbidity and Mortality Weekly Report, vol. 55, no. SS-5, June 9, 2006, http://www.cdc.gov/mmwr/PDF/SS/SS5505.pdf (accessed February 25, 2007)
	%	%	%	%	%	%	%	%	%	%	%	%	%	%	%
Race/ethnicity
White^d	75.7	75.0	75.3	45.9	47.0	46.4	28.1	31.8	29.9	36.0	40.0	38.0	19.2	21.3	20.3
Black^d	71.4	66.5	69.0	32.5	29.6	31.2	10.4	11.9	11.1	37.8	43.8	40.7	18.8	22.1	20.4
Hispanic	79.0	79.9	79.4	44.8	48.9	46.8	21.9	28.7	25.3	37.5	47.7	42.6	18.0	28.1	23.0
Grade
9	66.5	66.6	66.5	36.2	36.3	36.2	17.3	20.7	19.0	27.8	30.9	29.3	16.2	18.6	17.4
10	75.6	73.2	74.4	42.7	41.4	42.0	24.1	25.1	24.6	35.7	39.0	37.4	18.9	21.5	20.2
11	77.1	75.5	76.3	44.2	47.8	46.0	25.0	30.4	27.6	39.4	45.1	42.3	18.5	23.5	21.0
12	81.8	81.5	81.7	49.6	52.0	50.8	29.2	36.2	32.8	42.8	52.4	47.6	19.5	26.1	22.8
Total	74.8	73.8	74.3	42.8	43.8	43.3	23.5	27.5	25.5	35.9	40.9	38.4	18.2	22.1	20.2

TABLE 4.10
Percentage of high school students who used tobacco, by sex, race/ethnicity, and grade, 2005
	Lifetime cigarette use^a			Lifetime daily cigarette use^b			Current cigarette use^d
Category	Female	Male	Total	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.
^dSmoked cigarettes on ?1 of the 30 days preceding the survey.
^eSmoked cigarettes on ?20 of the 30 days preceding the survey.
^fOn the days they smoked during the 30 days preceding the survey, among the 23.0% of students nation wide who reported current cigarette use.
^gDuring the 30 days preceding the survey, among the 19.1% of students nationwide who were aged <18 years and who reported current cigarette use.
Source: Adapted from "Table 20. Percentage of High School Students Who Ever Smoked Cigarettes, by Sex, Race/Ethnicity, and Grade," and "Table 22. Percentage of High School Students Who Currently Smoked Cigarettes, by Sex, Race/Ethnicity, and Grade," and "Table 24. Percentage of High School Students Who Tried to Quit Smoking Cigarettes, Who Usually Got Their Own Cigarettes by Buying Them in a Store or Gas Station, and Who Were Not Asked to Show Proof of Age When They Bought or Tried to Buy Cigarettes in a Store, by Sex, Race/Ethnicity, and Grade," in "Youth Risk Behavior Surveillance—United States, 2005," Morbidity and Mortality Weekly Report, vol. 55, no. SS-5, June 9, 2006, http://www.cdc.gov/mmwr/PDF/SS/SS5505.pdf (accessed February 25, 2007)
	%	%	%	%	%	%	%	%	%
Race/ethnicity
White^c	53.2	54.9	54.0	17.0	15.1	16.1	27.0	24.9	25.9
Black^c	53.2	56.3	54.7	3.2	7.5	5.2	11.9	14.0	12.9
Hispanic	52.0	62.1	57.1	9.2	11.5	10.4	19.2	24.8	22.0
Grade
9	47.7	49.8	48.7	10.2	9.9	10.0	20.5	18.9	19.7
10	50.8	54.1	52.5	11.5	11.6	11.5	21.9	21.1	21.4
11	55.3	59.6	57.5	16.0	14.5	15.3	24.3	24.2	24.3
12	58.3	62.2	60.3	17.4	18.1	17.8	26.0	29.1	27.6
Total	52.7	55.9	54.3	13.5	13.3	13.4	23.0	22.9	23.0
	Current frequent cigarette use^e			Smoked >10 cigarettes/day^f			Bought cigarettes in a store or gas station^g
Category	Female	Male	Total	Female	Male	Total	Female	Male	Total
	%	%	%	%	%	%	%	%	%
Race/ethnicity
White^c	11.7	10.6	11.2	7.5	16.2	11.7	11.1	17.4	14.1
Black^c	2.4	5.1	3.7	2.5	4.4	3.5	18.6	24.6	21.6
Hispanic	4.7	8.1	6.5	6.1	10.4	8.5	12.2	21.3	17.4
Grade
9	7.0	6.7	6.9	4.6	12.8	8.6	5.0	11.6	8.2
10	8.4	7.0	7.7	6.5	6.7	6.6	7.8	13.4	10.6
11	10.0	10.5	10.3	8.6	17.9	13.1	14.8	25.8	20.3
12	12.5	13.9	13.2	9.2	16.9	13.2	27.7	34.0	30.8
Total	9.3	9.3	9.4	7.2	14.2	10.7	11.7	18.8	15.2

American Academy of Pediatrics recommended that babies sleep on their backs 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 stomachs. The American SIDS Institute (2005, http://www.sids.org/) reports that the Back to Sleep campaign has resulted in the reduction of SIDS cases by over 50% since 1983. 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, the CDC notes in "Sudden Infant Death Syndrome" (November 13, 2006, http://www.cdc.gov/SIDS/index.htm) that 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.

A number of recent studies consider the possible causes of and risk factors for SIDS. One study, "SIDS Risk Prevention Research Begins to Define Physical Abnormalities in Brainstem, Points to Possible Diagnostic/Screening Tools" (PRNewswire, October 18, 1999), which has been ongoing since 1985 and is being conducted by Hannah Kinney of Harvard Medical School in Boston, Massachusetts, finds a brain defect believed to affect breathing in babies who die 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 article "SIDS Infants Show Brain Abnormalities" (NIH Research Matters, November 10, 2006), the project finds that this brain abnormality might be linked to higher levels of serotonin in the brainstem. Duane Alexander, the director of the National Institute of Child Health and Human Development, states that "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."

TABLE 4.11
Percent of high school seniors who reported drug and alcohol use during 12-month period and 30-day period, 2005
	Used in past 12 months	Used in past 30 days
Source: Adapted from Lloyd D. Johnston et al., "Table 2. Trends in Annual Prevalence of Use of Various Drugs for Eighth, Tenth, and Twelfth Graders," and "Table 3. Trends in 30-Day Prevalence of Use of Various Drugs for Eighth, Tenth, and Twelfth Graders," in Monitoring the Future: National Results on Adolescent Drug Use, Overview of Key Findings, 2005, U.S. Department of Health and Human Services, National Institutes of Health, National Institute on Drug Abuse, April 2006, http://www.drugabuse.gov/PDF/overview2005.pdf (accessed February 25, 2007)
Marijuana/hashish	33.6	19.8
Inhalants	5.0	2.0
PCP	1.3	0.7
MDMA (ecstasy)	3.0	1.0
Cocaine	5.1	2.3
Crack	1.9	1.0
Heroin	0.8	0.5
Other narcotics	9.0	3.9
Amphetamines	8.6	3.9
Methamphetamine	2.5	0.9
Sedatives (barbiturates)	7.2	3.3
Tranquilizers	6.8	2.9
Alcohol	68.6	47.0
Steroids	1.5	0.9

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 2004 three of the leading causes of childhood death were unintentional injuries, congenital anomalies (birth defects), and malignant neoplasms (cancers). (See Table 4.14.) The remaining deaths were spread across a variety of diseases, including heart disease, pneumonia, influenza, HIV/AIDS, homicide, and suicide.

MOTOR VEHICLE INJURIES

According to the National Highway Traffic Safety Administration (NHTSA), in "Determine Why There Are Fewer Young Alcohol-Impaired Drivers" (September 2001, http://www.nhtsa.dot.gov/people/injury/research/FewerYoungDrivers/), 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 fifteen- to nineteen-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 25.2 of every 100,000 teenagers in that age group were killed in traffic accidents in 2003. 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 fifteen to twenty who were killed in crashes were intoxicated.

The CDC's 2005 "Youth Risk Behavior Surveillance" finds that in the month before the survey 17.1% of high school seniors (those most likely to have their driver's licenses) reported they had driven a vehicle after drinking alcohol. (See Table 4.15.) Male seniors (19.2%) were more likely than female seniors (15%) to drive after drinking. Another 28.5% of high school students admitted they had ridden with a driver who had been drinking. Females were slightly more likely to ride with a driver who had been drinking (29.6%) than were males (27.2%).

SUICIDE

In 2004 suicide was the seventh-leading cause of death among five- to fourteen-year-olds and the third-leading cause of death in fifteen- to twenty-four-year-olds. (See Table 4.14.) The CDC reports in "Homicides and Suicides—National Violent Death Reporting System, United States, 2003–2004" (Morbidity and Mortality Weekly Report, July 7, 2006) that the male suicide rate is more than four times higher than the female suicide rate. Robert N. Anderson and Betty L. Smith of the CDC's Division of Vital Statistics note in "Deaths: Leading Causes for 2001" (National Vital Statistics Reports, November 7, 2003) that in 2001, the most recent year for which detailed statistics are available, white males aged fifteen to nineteen had twice the suicide rate (14 per 100,000) of African-American males (7.3 per 100,000) or Hispanic male youth (7.8 per 100,000). Among females aged fifteen to nineteen, the rate for whites (2.9 per 100,000) was considerably higher than that for Hispanics (2.5 per 100,000) or African-Americans (1.3 per 100,000).

The CDC's "Youth Risk Behavior Surveillance" questioned high school students regarding their thoughts about suicide. In 2005 almost one out of six students (16.9%) surveyed claimed that they had seriously thought about attempting suicide in the previous twelve months. (See Table 4.16.) Although the suicide death rate was much higher among males than among females, females (21.8%) were more likely to have considered suicide than males (12%). Of all students, 13% (16.2% of females and 9.9% of males) had made a specific plan to attempt suicide, 8.4% of students (10.8% of females and 6% of males) said they had attempted suicide in the previous year, and 2.3% of high school students (2.9% of females and 1.8% of males) said they had suffered injuries from the attempt that required medical attention. 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.

TABLE 4.12
Infant mortality rate among selected groups, by race and Hispanic origin of mother, selected years 1983–2003
[Data are based on linked birth and death certificates for infants]
Race and Hispanic origin of mother	1983^a	1985^a	1990^a	1995^b	1999^b	2000^b	2001^b	2002^b	2003^b
*Estimates are considered unreliable. Rates preceded by an asterisk are based on fewer than 50 deaths in the numerator. Rates not shown are based on fewer than 20 deaths in the numerator.
^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.
^ePersons 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.
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, and Postneonatal Mortality Rates, by Detailed Race and Hispanic Origin of Mother: United States, Selected Years 1983–2003," in Health: United States, 2006, with Chartbook on Trends in the Health of Americans, Centers for Disease Control and Prevention, National Center for Health Statistics, 2006, http://www.cdc.gov/nchs/data/hus/hus06.pdf (accessed February 25, 2007)
Infant^c deaths per 1,000 live births
All mothers	10.9	10.4	8.9	7.6	7.0	6.9	6.8	7.0	6.8
White	9.3	8.9	7.3	6.3	5.8	5.7	5.7	5.8	5.7
Black or African American	19.2	18.6	16.9	14.6	14.0	13.5	13.3	13.8	13.5
American Indian or Alaska Native	15.2	13.1	13.1	9.0	9.3	8.3	9.7	8.6	8.7
Asian or Pacific Islander^d	8.3	7.8	6.6	5.3	4.8	4.9	4.7	4.8	4.8
Chinese	9.5	5.8	4.3	3.8	2.9	3.5	3.2	3.0	—
Japanese	5.6*	6.0*	5.5*	5.3*	3.5*	4.5*	4.0*	4.9*	—
Filipino	8.4	7.7	6.0	5.6	5.8	5.7	5.5	5.7	—
Hawaiian	11.2	9.9*	8.0*	6.5*	7.0*	9.0	7.3*	9.6
Other Asian or Pacific Islander	8.1	8.5	7.4	5.5	5.1	4.8	4.8	4.7	—
Hispanic or Latino^{e, f}	9.5	8.8	7.5	6.3	5.7	5.6	5.4	5.6	5.6
Mexican	9.1	8.5	7.2	6.0	5.5	5.4	5.2	5.4	5.5
Puerto Rican	12.9	11.2	9.9	8.9	8.3	8.2	8.5	8.2	8.2
Cuban	7.5	8.5	7.2	5.3	4.6	4.6	4.2	3.7	4.6
Central and South American	8.5	8.0	6.8	5.5	4.7	4.6	5.0	5.1	5.0
Other and unknown Hispanic or Latino	10.6	9.5	8.0	7.4	7.2	6.9	6.0	7.1	6.7
Not Hispanic or Latino:
White^f	9.2	8.6	7.2	6.3	5.8	5.7	5.7	5.8	5.7
Black or African American^f	19.1	18.3	16.9	14.7	14.1	13.6	13.5	13.9	13.6
Neonatalc deaths per 1,000 live births
All mothers	7.1	6.8	5.7	4.9	4.7	4.6	4.5	4.7	4.6
White	6.1	5.8	4.6	4.1	3.9	3.8	3.8	3.9	3.9
Black or African American	12.5	12.3	11.1	9.6	9.5	9.1	8.9	9.3	9.2
American Indian or Alaska Native	7.5	6.1	6.1	4.0	5.0	4.4	4.2	4.6	4.5
Asian or Pacific Islander^d	5.2	4.8	3.9	3.4	3.2	3.4	3.1	3.4	3.4
Chinese	5.5	3.3	2.3	2.3	1.8	2.5	1.9	2.4	—
Japanese	3.7*	3.1*	3.5*	3.3*	2.8*	2.6*	2.5*	3.7*	—
Filipino	5.6	5.1	3.5	3.4	3.9	4.1	4.0	4.1	—
Hawaiian	7.0*	5.7*	4.3*	4.0*	4.9*	6.2*	3.6*	5.6*	—
Other Asian or Pacific Islander	5.0	5.4	4.4	3.7	3.3	3.4	3.2	3.3
Hispanic or Latino^{e, f}	6.2	5.7	4.8	4.1	3.9	3.8	3.6	3.8	3.9
Mexican	5.9	5.4	4.5	3.9	3.7	3.6	3.5	3.6	3.8
Puerto Rican	8.7	7.6	6.9	6.1	5.9	5.8	6.0	5.8	5.7
Cuban	5.0*	6.2	5.3	3.6*	3.5*	3.2*	2.5*	3.2*	3.4
Central and South American	5.8	5.6	4.4	3.7	3.3	3.3	3.4	3.5	3.6
Other and unknown Hispanic or Latino	6.4	5.6	5.0	4.8	4.8	4.6	3.9	5.1	4.7
Not Hispanic or Latino:
White^f	5.9	5.6	4.5	4.0	3.8	3.8	3.8	3.9	3.8
Black or African American^f	12.0	11.9	11.0	9.6	9.6	9.2	9.0	9.3	9.3

In "Homicides and Suicides" the CDC reports that the likelihood that a child will commit suicide increases with the presence of certain risk factors. 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's Youth and AIDS Projects, in "Suicidality in a Venue-Based Sample of Young Men Who Have Sex with Men" (Journal of Adolescent Health, October 2002), corroborates previous estimates that 20% to 42% of teens and young men who have sex with other males attempt suicide.

TABLE 4.13
Ten leading causes of infant death by race and Hispanic origin, 2004
[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 Rates for Hispanic origin should be interpreted with caution because of inconsistencies between reporting Hispanic origin on birth and death certificates]
Rank^a	Cause of death and age	Number	Rate
	All races^b
—	All causes	27,835	676.3
1	Congenital malformations, deformations and chromosomal abnormalities	5,623	136.6
2	Disorders related to short gestation and low birth weight, not elsewhere classified	4,685	113.8
3	Sudden infant death syndrome	2,109	51.2
4	Newborn affected by maternal complications of pregnancy	1,705	41.4
5	Newborn affected by complications of placenta, cord and membranes	998	24.2
6	Accidents (unintentional injuries)	995	24.2
7	Respiratory distress of newborn	877	21.3
8	Bacterial sepsis of new born	798	19.4
9	Neonatal hemorrhage	593	14.4
10	Intrauterine hypoxia and birth asphyxia	502	12.2
—	All other causes	8,950	217.5
	Non-Hispanic white
—	All causes	13,084	567.8
1	Congenital malformations, deformations and chromosomal abnormalities	3,002	130.3
2	Disorders related to short gestation and low birth weight, not elsewhere classified	1,895	82.3
3	Sudden infant death syndrome	1,123	48.8
4	Newborn affected by maternal complications of pregnancy	753	32.7
5	Accidents (unintentional injuries)	534	23.2
6	Newborn affected by complications of placenta, cord and membranes	482	20.9
7	Respiratory distress of newborn	398	17.3
8	Bacterial sepsis of new born	344	14.9
9	Neonatal hemorrhage	277	12.0
10	Intrauterine hypoxia and birth asphyxia	264	11.4
—	All other causes	4,013	174.2
	Total black^c
—	All causes	8,347	1,362.8
1	Disorders related to short gestation and low birth weight, not elsewhere classified	1,766	288.4
2	Congenital malformations, deformations and chromosomal abnormalities	1,049	171.3
3	Sudden infant death syndrome	683	111.5
4	Newborn affected by maternal complications of pregnancy	624	101.9
5	Newborn affected by complications of placenta, cord and membranes	306	49.9
6	Respiratory distress of newborn	302	49.4
7	Accidents (unintentional injuries)	300	49.0
8	Bacterial sepsis of new born	268	43.7
9	Neonatal hemorrhage	157	25.6
10	Necrotizing enterocolitis of newborn	151	24.6
—	All other causes	2,741	447.5

TABLE 4.13
Ten leading causes of infant death by race and Hispanic origin, 2004 [continued]
[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 individuals, so categories may not add to totals or subtotals Rates for Hispanic origin should be interpreted with caution because of inconsistencies between reporting Hispanic origin on birth and death certificates]
Rank^a	Cause of death and age	Number	Rate
—Category not applicable.
^aRank based on number of deaths.
^bIncludes races other than black and white.
^cRace and Hispanic origin are reported separately on both the birth and death certificate. Race categories are consistent with the 1977 Office of Management and Budget (OMB) standards. California, Hawaii, Idaho, Maine, Michigan, Minnesota, Montana, New Hampshire, New Jersey, New York, Oklahoma, South Dakota, Washington, Wisconsin, and Wyoming reported multiple-race data in 2004. 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.
^dIncludes all persons of Hispanic origin of any race.
Notes: For certain causes of death such as unintentional injuries, homicides, suicides, and respiratory diseases, preliminary and final data differ because of the truncated nature of the preliminary file. Data are subject to sampling and/or random variation. Although the infant mortality rate is the preferred indicator of the risk of dying during the first year of life, another measure of infant mortality, the infant death rate, is shown elsewhere in this report. The two measures typically are similar yet they can differ because the denominators used for these measures are different.
Source: Adapted from Arialdi M. Miniño, Melonie P. Heron, and Betty L. Smith, "Table 8. Infant Deaths and Infant Mortality Rates for the 10 Leading Causes of Infant Death, by Race and Hispanic Origin: United States, Preliminary 2004," in "Deaths: Preliminary Data for 2004," National Vital Statistics Reports, vol. 54, no. 19, June 28, 2006, http://www.cdc.gov/nchs/data/nvsr/nvsr54/nvsr54_19.pdf (accessed February 25, 2007)
	Hispanic^d
—	All causes	3,782	400.2
1	Congenital malformations, deformations and chromosomal abnormalities	1,288	136.3
2	Disorders related to short gestation and low birth weight, not elsewhere classified	828	87.7
3	Newborn affected by maternal complications of pregnancy	268	28.3
4	Sudden infant death syndrome	241	25.5
5	Newborn affected by complications of placenta, cord and membranes	174	18.4
6	Bacterial sepsis of new born	163	17.2
7	Respiratory distress of newborn	160	16.9
8	Accidents (unintentional injuries)	132	14.0
9	Neonatal hemorrhage	127	13.5
10	Atelectasis	108	11.4
—	All other causes	294	31.1

TABLE 4.14
Leading causes of death and numbers of deaths, by age, 1980 and 2004
[Data are based on death certificates]
Age and rank order	1980		2004
Age and rank order	Cause of death	Deaths	Cause of death	Deaths
Under 1 year
—	All causes	45,526	All causes	27,936
1	Congenital anomalies	9,220	Congenital malformations, deformations and chromosomal abnormalities	5,622
2	Sudden infant death syndrome	5,510	Disorders related to short gestation and low birth weight, not elsewhere classified	4,642
3	Respiratory distress syndrome	4,989	Sudden infant death syndrome	2,246
4	Disorders relating to short gestation and unspecified low birth weight	3,648	Newborn affected by maternal complications of pregnancy	1,715
5	Newborn affected by maternal complications of pregnancy	1,572	Unintentional injuries	1,052
6	Intrauterine hypoxia and birth asphyxia	1,497	Newborn affected by complications of placenta, cord and membranes	1,042
7	Unintentional injuries	1,166	Respiratory distress of newborn	875
8	Birth trauma	1,058	Bacterial sepsis of newborn	827
9	Pneumonia and influenza	1,012	Neonatal hemorrhage	616
10	Newborn affected by complications of placenta, cord, and membranes	985	Diseases of circulatory system	593
1-4 years
—	All causes	8,187	All causes	4,785
1	Unintentional injuries	3,313	Unintentional injuries	1,641
2	Congenital anomalies	1,026	Congenital malformations, deformations and chromosomal abnormalities	569
3	Malignant neoplasms	573	Malignant neoplasms	399
4	Diseases of heart	338	Homicide	377
5	Homicide	319	Diseases of heart	187
6	Pneumonia and influenza	267	Influenza and pneumonia	119
7	Meningitis	223	Septicemia	84
8	Meningococcal infection	110	Certain conditions originating in the perinatal period	61
9	Certain conditions originating in the perinatal period	84	In situ neoplasms, benign neoplasms and neoplasms of uncertain or unknown behavior	53
10	Septicemia	71	Chronic lower respiratory diseases	48
5-14 years
—	All causes	10,689	All causes	6,834
1	Unintentional injuries	5,224	Unintentional injuries	2,666
2	Malignant neoplasms	1,497	Malignant neoplasms	1,019
3	Congenital anomalies	561	Congenital malformations, deformations and chromosomal abnormalities	389
4	Homicide	415	Homicide	329
5	Diseases of heart	330	Suicide	285
6	Pneumonia and influenza	194	Diseases of heart	245
7	Suicide	142	Chronic lower respiratory diseases	120
8	Benign neoplasms	104	In situ neoplasms, benign neoplasms and neoplasms of uncertain or unknown behavior	84
9	Cerebrovascular diseases	95	Influenza and pneumonia	82
10	Chronic obstructive pulmonary diseases	85	Cerebrovascular diseases	77

TABLE 4.14
Leading causes of death and numbers of deaths, by age, 1980 and 2004 [continued]
[Data are based on death certificates]
Age and rank order	1980		2004
Age and rank order	Cause of death	Deaths	Cause of death	Deaths
—Category not applicable.
Source: Adapted from "Table 32. Leading Causes of Death and Numbers of Deaths, by Age: United States, 1980 and 2004," in Health: United States, 2006, with Chartbook on Trends in the Health of Americans, Centers for Disease Control and Prevention, National Center for Health Statistics, 2006, http://www.cdc.gov/nchs/data/hus/hus06.pdf (accessed February 25, 2007)
15-24 years
—	All causes	49,027	All causes	33,421
1	Unintentional injuries	26,206	Unintentional injuries	15,449
2	Homicide	6,537	Homicide	5,085
3	Suicide	5,239	Suicide	4,316
4	Malignant neoplasms	2,683	Malignant neoplasms	1,709
5	Diseases of heart	1,223	Diseases of heart	1,038
6	Congenital anomalies	600	Congenital malformations, deformations and chromosomal abnormalities	483
7	Cerebrovascular diseases	418	Cerebrovascular diseases	211
8	Pneumonia and influenza	348	Human immunodeficiency virus (HIV) disease	191
9	Chronic obstructive pulmonary diseases	141	Influenza and pneumonia	185
10	Anemias	133	Chronic lower respiratory diseases	179

TABLE 4.15
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, 2005
Category	Rode with a driver who had been drinking alcohol^a			Drove when drinking alcohol^a
Category	Female	Male	Total	Female	Male	Total
^aOne or more times during the 30 days preceding the survey.
^bNon-Hispanic.
Source: "Table 4. 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," in "Youth Risk Behavior Surveillance—United States, 2005," Morbidity and Mortality Weekly Report, vol. 55, no. SS-5, June 9, 2006, http://www.cdc.gov/mmwr/PDF/SS/SS5505.pdf (accessed February 25, 2007)
	%	%	%	%	%	%
Race/ethnicity
White^b	30.4	26.2	28.3	10.1	12.4	11.3
Black^b	24.0	24.3	24.1	3.5	6.5	4.9
Hispanic	34.7	37.4	36.1	6.4	14.6	10.5
Grade
9	30.1	25.8	27.9	4.5	6.5	5.5
10	29.5	26.2	27.8	4.8	8.3	6.6
11	28.1	27.7	28.0	9.5	14.7	12.1
12	30.7	29.5	30.1	15.0	19.2	17.1
Total	29.6	27.2	28.5	8.1	11.7	9.9

TABLE 4.16
Percentage of high school students who felt sad or hopeless, who seriously considered attempting suicide, who made a suicide plan, and who attempted suicide, by sex, race/ethnicity, and grade, 2005
Category	Felt sad or hopeless^{a, b}			Seriously considered attempting suicide^b			Made a suicide plan^b			Attempted suicide^{a, d}			Suicide attempt treated by a doctor or nurse^a
Category	Female	Male	Total	Female	Male	Total	Female	Male	Total	Female	Male	Total	Female	Male	Total
^aAlmost every day for ?2 weeks in a row so that they stopped doing some usual activities.
^bDuring the 12 months preceding the survey.
^cNon-Hispanic.
^dOne or more times.
Source: Adapted from "Table 16. Percentage of High School Students Who Felt Sad or Hopeless, Who Seriously Considered Attempting Suicide, and Who Made a Plan about How They Would Attempt Suicide, by Sex, Race/Ethnicity, and Grade," and "Table 18. Percentage of High School Students Who Actually 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," in "Youth Risk Behavior Surveillance—United States, 2005," Morbidity and Mortality Weekly Report, vol. 55, no. SS-5, June 9, 2006, http://www.cdc.gov/mmwr/PDF/SS/SS5505.pdf (accessed February 25, 2007)
	%	%	%	%	%	%	%	%	%	%	%	%	%	%	%
Race/ethnicity
White^c	33.4	18.4	25.8	21.5	12.4	16.9	15.4	9.7	12.5	9.3	5.2	7.3	2.7	1.5	2.1
Black^c	36.9	19.5	28.4	17.1	7.0	12.2	13.5	5.5	9.6	9.8	5.2	7.6	2.6	1.4	2.0
Hispanic	46.7	26.0	36.2	24.2	11.9	17.9	18.5	10.7	14.5	14.9	7.8	11.3	3.7	2.8	3.2
Grade
9	38.5	19.9	29.0	23.9	12.2	17.9	17.6	10.2	13.9	14.1	6.8	10.4	4.0	2.1	3.0
10	37.0	21.3	28.9	23.0	11.9	17.3	18.1	10.3	14.1	10.8	7.6	9.1	2.4	2.2	2.3
11	38.0	19.4	28.8	21.6	11.9	16.8	16.3	9.5	12.9	11.0	4.5	7.8	2.9	1.4	2.2
12	32.6	20.2	26.4	18.0	11.6	14.8	12.0	9.0	10.5	6.5	4.3	5.4	2.2	1.0	1.6
Total	36.7	20.4	28.5	21.8	12.0	16.9	16.2	9.9	13.0	10.8	6.0	8.4	2.9	1.8	2.3