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The Center forHealth and Health 2121 K Street, NW, Suite 250Washington, DC 20037 Health and Health Care in Schools
202-466-3396 fax 202-466-3467 A report from the Center for Health and Health Care in Schools on the policies and financing of health programming in schools Volume 9, Number 2 In this issue:
Prescription for Danger--Trends in Teen Drug Abuse
Prescription for Danger--Trends
signs and symptoms of drug abuse, includ- in Teen Drug Abuse
Using the catch-phrase "There's a new They are seen by teens as safe and dealer in town," the White House Office easily available, but increasing abuse of National Drug Control Policy (OND- Constricted pupils, nausea and vomit- of prescription and over-the-counter CP) reported in January on "the troubling ing, respiratory depression (pain reliever drugs by young people is a serious trend of prescription and over-the-counter matter, says the White House Office of drug abuse among the nation's teens." Anxiety and delusions, flushed skin, Drug Control Policy.
chest pain with heart palpitations (stimu- The report notes that: Slurred speech, dizziness, respiratory Preventing Influenza--The Case
More teens abuse prescription drugs depression (depressant abuse).
for Immunizing Children at
than any illicit drug except mari- Children are the first to come down Most of the abusing teens get their Schools are advised to properly dispose of with the flu and they spread it to fam- prescription drugs easily and for old or unused medicines, and to set clear ily and friends. Would immunizing free, primarily from friends and rela- rules about not sharing medicines with children at school be a good way to friends. Health professionals are urged to The prescription drugs most often make sure their patients, especially teens 12 abused are painkillers that were years of age and older, understand the risks CDC Reviews School Laws, Poli-
prescribed to treat pain; depressants cies on Child/Adolescent Health
such as sleeping pills or anti-anxi- A report on federal laws and the many ety drugs; and stimulants that were To keep professionals informed, here are and diverse state and local statutes and prescribed to treat attention-hyperac- some of the definitions used in the report: regulations that affect health programs tivity disorder (ADHD); Painkillers (opioids) are prescribed and services in schools.
The over-the-counter drugs most to alleviate pain and include drugs often abused are cough and cold prescribed after surgery. Examples of remedies that contain dextrametho- narcotics/painkillers are oxycodone (OxyContin), propoxyphrene (Darvon), WORTH NOTING
rphan, a cough suppressant; • Research Cites Reduced Risk Many teens believe prescription and hydrocodone (Vicodin), hydromorphone from Mercury in Vaccines OTC drugs provide a safe "high." (Dilaudid), and meperidine (Demerol); • CMS Details Ways to Avoid Depressants slow normal brain func- ‘Crowd Out' in SCHIP That last point has been belied, the tion and are used to treat anxiety and • FDA Warns on Seizure Drugs ONDCP said, by a dramatic increase in sleep disorders. In higher doses, some • January News Alerts recent years in the number of poisonings depressants can become general anes- and deaths associated with abuse of pre- thetics. Tranquilizers (benzodiazepines scription and over-the-counter drugs. The such as Valium and Xanax) and seda- report notes that serious medical conse- tives are examples of depressants, as are quences can follow, especially when the barbiturates such as Amytal, Nembutal, teenagers mix OTC or prescription drugs Seconal, and Phenobarbital.
with alcohol or other drugs in what the Stimulants increase alertness, concentra- Health & Health Care in Schools is a monthly ONDCP calls "a risky combination." tion, and energy, which are accompanied journal published in html and PDF versions by by increases in blood pressure, heart The Center for Health and Health Care in Parents and caregivers whose medicine rate, and respiration. Stimulants are Schools. The Center is located at: School of Public Health chests may be raided by teens looking prescribed to treat narcolepsy (a rare and Health Services for drugs are a first-line defense against form of sleep disorder), attention deficit The George Washington University Medical Center abuse, the report says, but the ONDCP hyperactivity disorder (ADHD), and de- Support for Health & Health Care in Schools has advice for school and health profes- pression that has not responded to other is provided by The Robert Wood Johnson sionals, as well, including how to spot treatments. Examples of prescription Volume 9, Number 2 stimulants include Biphetamine, Dexedrine, and methylphe- ranted, the researchers said. nidates such as Ritalin and Adderall.
Some of the factors in the trial: If you need to know what constitutes "abuse," it is defined as In the intervention schools, 47 percent of children received "use of prescription medications without medical supervision for the intranasal influenza vaccine and 56 percent of those got a the intentional purpose of getting high, or for a reason other than what the medication was intended, regardless of prescription sta- The average vaccination cost per household in the interven- tus." That's different from "misuse," which is defined as missing tion schools was $41.66, much more than the average $5.56 doses or not taking medication with food as recommended on the families spent for flu shots in non-participating schools. But when expenditures by families for over-the-counter medica- tions, herbal supplements, and emergency care and hospital- The ONDCP report, "Prescription for Danger: A Report on the izations were included, costs somewhat evened out between Troubling Trend of Prescription and Over-the Counter Drug intervention and control schools and were higher for families Abuse Among the Nation's Teens," is available online at http:// in the non-immunizing schools.
While admitting that there were flaws in the research model, including that all the medical data was self-reported, the research- ers concluded that school-based influenza immunization with the Preventing Influenza--The Case for
nasal vaccine used in the trial "is cost-effective over the season," Immunizing Children at School
meaning the several weeks of the year in which influenza inci- dence is at its peak.
Faced with the fact that current recommendations for vaccinating And as to effects other than money, the researchers admitted they high-risk people such as the elderly against the flu don't seem did not attempt to value the long-term educational and achieve- to be reducing the incidence of seasonal influenza in the United ment consequences when student are absent from school with States, U.S. policymakers are considering whether flu shots influenza. They did note, however, that in school districts where should be recommended for school-age children 5 to18 years old. funding is based on average daily attendance, there are real finan- cial benefits for schools from higher attendance. They estimate There is logic in such an idea, the journal Health Affairs said Jan- that during the peak week of influenza incidence, schools that uary 23, since school-age children are more likely than adults to offer vaccine may lose an average of $784 as the result of student contract influenza and spread it to high-risk populations, includ- absences, while schools without vaccine are likely to lose an ing the adults in their own households. But in the most recent flu average of $1,395. season for which data are available—the 2004-05 season—only 10 percent of healthy children were immunized against flu.
The study also looked at the time it takes to immunize a student at school as compared with providers' offices. What the research- That brings up the possibility that school-based immunizations ers refer to as "mass vaccination" can run to as high as 30 per might offer "an efficient and feasible approach to increase the hour, they note, once staff are trained, while the average time for coverage of school-age children, which would be expected to re- office-based vaccine administration is about 10 to 15 minutes of duce the spread of influenza and decrease the burden of seasonal professional time per dose.
flu on households and communities." But whether school-based immunizations would be economically warranted is not clear, "Our findings suggest that school-based immunization programs with some analyses indicating that immunizing healthy school- are cost-neutral after the peak week alone and cost-saving over age children isn't cost-effective.
an influenza season." And if economic benefits of immunization to the household are included, the researchers concluded, "The To try to find out more about this relatively untested idea, clinical and economic benefits of expanding immunization to researchers who acknowledge they were funded by the vaccine school-age children deserve further consideration." maker Medimmune looked at the effects when more than 15,000 schoolchildren were offered nasal live attenuated influenza im- The article "Benefits and Costs of Immunization Children Against munizations at school. Influenza at School" appears in the January 23, 2008, issue of Health Affairs, a publication of project HOPE. They found, first, that there was a statistically significant reduc- tion of flu-like symptoms in the vaccine-offering schools, less health care resource use, and fewer absences from school and work. Those advantages are important, but that still leaves the question of whether the immunizations were economically war- Center for Health and Health Care in Schools Volume 9, Number 2 CDC Reviews School Laws, Policies on
staff and families. Federal law does not require such services, and regulation of health services is left largely to state and local governments and individual school districts, except for students In a comprehensive report by the Division of Adolescent and with disabilities who must receive services under the federal Indi- School Health (DASH), the Centers for Disease Control and viduals with Disabilities Education Act (IDEA). Federal and state Prevention (CDC) outlined in February the laws and policies laws generally require parental consent before health services are schools need to follow as they implement a coordinated school provided to students. Use of identifiable health information about health program (CSHP). Divided into the components defined students is covered under the federal Family Educational Rights by the CDC as making up a comprehensive school health pro- and Privacy Act (FERPA). Schools are required in some instances gram, the report discusses possible legal implications for schools to report to families if a child is ill or if disabilities are uncovered in areas including physical education; health services, nutrition in school screenings or by observation. Schools are most often services, mental health and social services, creating healthy and not required to report student illnesses to state health authorities.
safe school environments, and promoting staff wellness.
The report mentions the two main federal meals programs avail- The report notes that a 2006 assessment found that more than 85 able to public schools, the National School Lunch Program and percent of states have policies stating that elementary, middle, the School Breakfast Program, which provide subsidies and and high schools will teach at least one of 14 health topics donated commodities to schools for meals that meet federal chosen to reflect the leading causes of mortality and morbidity nutritional requirements. The report also notes that "competi- among both youth and adults. Of the many potential subjects, tive foods" are sold in competition with the federally subsidized the topic of human sexuality is unique in its degree of regula- programs in many schools, with federal law currently limiting tion. Federal restrictions on sex education prohibit recipients of their sale only in certain locations at certain times and prohibit- federal funding from encouraging sexual activity, distributing ing sale of "foods of minimal nutritional value" such as chewing obscene materials to students on school grounds, providing sex gum. State and school districts may impose further limitations education or HIV prevention education unless the instruction on school sale of competitive foods, and industries such as the is age-appropriate and includes the benefits of abstinence, or soft drink industry have recently taken measures to limit sale of providing contraceptives. Courts have held that parents do not their products in schools. Commercial activities such as pouring have a federal constitutional right to exempt their children from contracts and corporate-sponsored contests and incentives aimed required physical education classes but state or local laws may at students have been noted in recent reports by the Government give parents more rights. Accountability Office (GPO) and the Institute of Medicine.
Physical Education and Activity
Mental Health and Social Services
Most states and districts have policies requiring elementary, The report notes that federal laws require schools to provide middle, and high schools to teach physical education, includ- psychological and social services to students whose health condi- ing such possible activities as calisthenics and gymnastics. The tions adversely affect their educational performance (under the report covers related topics in this area, including what is legally IDEA) and to students whose health conditions substantially limit required of schools, the role of national physical education stan- their ability to learn (under section 504 of the Rehabilitation Act.) dards, teacher qualifications and preparation, and the provision State laws differ on whether such services are available to all of protective gear. Most states and districts require schools to students, but schools may be authorized by their school districts provide adapted physical education to children with permanent to conduct screening or to develop policies for mental health physical or cognitive disabilities.
conditions such as depression, suicide, substance abuse, eating disorders, ADHD, and mental or physical abuse. A federal law requires prior parental consent before a student may participate in any questionnaire that asks about mental or psychological prob- The report defines school heath services as including health lems, and several states have laws that limit the ability of school screening and assessment; care plan development and imple- officials to subject a student to psychological evaluation without mentation; health education; health counseling; acute, chronic, prior parental consent. State laws broadly authorize schools to episodic, or emergency care; nursing interventions and case provide counseling services, most commonly in high schools, and management; medication and administration; assistance with treatment services or referrals are "widely available," according access to an ongoing source of health care in the community; to the report. Counseling, psychological, and social services may medical case management and referral; outreach to students and be provided by counselors, psychologists, social workers, nurses, families, and provision of professional development for school and other professionals in the school setting. State laws often Center for Health and Health Care in Schools Volume 9, Number 2 authorize schools to employ such professionals but do not require of School Laws and Policies Concerning Child and Adolescent every school to have them. School records containing sensitive Health," is published in the February issue of the Journal of personal psychological information are subject to the same pri- School Health. vacy protection under FERPA as other student records.
Healthy and Safe School Environment
According to the report, factors that influence school environment are addressed in state and federal laws and regulatory man- dates. In addition to state requirements concerning the location, Research Cites Reduced Risk from Mercury in Vaccines
lighting, heating, and sanitation of school facilities, schools are subject in many states to regulations about asbestos-containing Coincident with the airing on ABC television January 31 of a pro- materials, indoor radon, use of pesticides, and lead in drinking gram in which a fictional jury compensated a fictional mother for water. In addition to concerns about the physical conditions of autism allegedly caused by mercury in a vaccine given to her son, school buildings, many states and districts have developed poli- the American Academy of Pediatrics (AAP) released a research cies to prevent unintentional injuries, and federal law sets safety report January 30 showing that mercury-containing preserva- standards for school buses. States and localities have laws or tives once used in childhood vaccines "have always been safe." regulations calling for speed reduction in school zones or requir- Researchers reporting in the February 2008 issue of the journal ing schools to conduct fire drills. Federal law makes it a felony to Pediatrics said new studies show that infants' bodies expel the possess or knowingly discharge a firearm in a school zone, and form of mercury present in the preservative thimerosal "much nearly all states have similar laws. Personal and property searches faster than originally thought," thereby leaving little chance for a of students in an effort to prevent violence are subject to Fourth progressive build-up of the metal. "This debunks the great myth, Amendment protections against unreasonable search and seizure, believed by both parents and many pediatricians, that the gauntlet with the Supreme Court setting parameters in recent cases for of thimerosal-containing shots many infants received in the 1990s what constitutes a reasonable search. Use of metal detectors and has put them at risk for developmental disorders," researchers school dress codes to prevent violence are also subject to state said. Thimerosal, a bacteria-killing substance used as a preserva- laws and constitutional challenges. In the area of substance abuse, tive in vaccines since the 1930s, is now banned in the United a federal law prohibits smoking within any indoor facility that States but is widely used in other countries. In their studies, provides routine or regular K-12 education or library services to researchers compared ethyl mercury used in vaccines to its better- children if that facility receives any federal funding. Nearly all understood chemical cousin, methyl mercury, which is associated states, school districts, and schools have policies prohibiting use with eating fish, and found that the body rids itself of the kind of of alcohol and illegal drugs by students. The Supreme Court has mercury found in thimerosal more than 10 times faster than it re- found random testing of students for drugs to be constitutional moves "the kind one might encounter in a Friday night fish fry." as "a reasonably effective means" of preventing and deterring At the end of the TV program that featured the autism charges, student drug use. In addition to policies addressing drug use in ABC ran a notice that the episode of "Eli Stone" was fictional general, some states have enacted laws to limit use of anabolic and involved no real persons or companies, and referred listen- steroids by students. ers to the Centers for Disease Control and Prevention (CDC) for information about autism. CMS Details Ways to Avoid ‘Crowd Out' in SCHIP
State laws often set prerequisites for hiring school employees, re- quiring prospective employees to undergo physical examinations Noting requests by states to extend eligibility under the State or screening for tuberculosis or illegal drug use. Many states also Children's Health Insurance Program (SCHIP) to children in fam- require school staff to submit to ongoing health-related screen- ilies with income levels above 250 percent of the federal poverty ing at periodic intervals. Many states have enacted employee level, the Centers for Medicare and Medicaid Services (CMS) wellness initiatives that promote fitness and health in schools and last month outlined steps states should take to prevent "crowd other workplaces, with employers commonly encouraged but not out"--the situation that happens when parents drop private health required to have such programs. Factors that influence school insurance in order to enroll their children in SCHIP. The CMS wellness may include the availability of health insurance and said the potential for crowd-out is greater for higher income availability of routine screening for health conditions, as well as beneficiaries, and it said states should have in place at least five state occupational safety laws and regulations.
general crowd-out strategies, including: Imposing waiting periods between dropping private coverage The report from which this article is excerpted, "A CDC Review and enrollment in SCHIP; Imposing cost-sharing in approximation to the cost of private Center for Health and Health Care in Schools Volume 9, Number 2 Monitoring health insurance status at the time of application; January 24, 2008
Verifying family insurance status through insurance data- House Fails to Override Veto of SCHIP
Preventing employers from changing dependent coverage Trying again to get a reauthorization of the State Children's policies that would favor a shift to public coverage.
Health Insurance Program (SCHIP) through Congress, the House The CMS said reducing the potential for crowd-out is essential of Representatives yesterday failed by 15 votes to override in order to focus SCHIP on "the core population of uninsured President Bush's veto of a bill that would have added $35 billion targeted low-income children." to the popular state/federal program over the next five years. The 260 to 152 vote, in which all House Democrats and all but 42 of FDA Warns on Seizure Drugs
Republicans voted to override, left the House 15 votes short of the two-thirds majority needed to overcome a veto. Democratic Patients across age groups who take antiepileptic drugs to prevent leaders cited a current "sour turn" in the economy as an added seizures in conditions such as epilepsy and bipolar disorder reason to support the SCHIP expansion, and they vowed to bring may be at increased risk of suicidal thoughts and behavior, the the SCHIP reauthorization up again in this session of Congress. federal Food and Drug Administration (FDA) announced January SCHIP is currently funded through March 2009 under emergency 31. The FDA said patients should not stop taking the drugs but legislation passed by Congress last year. should be monitored for signs of suicidal thinking. The agency said it is working with manufacturers of antiepileptic drugs to in- January 29, 2008
clude warnings on their labels of the newly identified risks. Drugs AAP Calls for Cancellation of Fictional TV Episode With
analyzed by the FDA include widely used medications such as Vaccine/Autism Link
Topamax, Carbatrol, Neurontin, and Trileptal. Further informa- tion for health care professionals is available at fda.gov/cder/ The American Academy of Pediatrics (AAP) has called on the ABC network to cancel an episode of the program "Eli Stone"scheduled to air Thursday this week, because the episode features a lawsuit in which attorneys for parents argue success- fully that vaccines caused their child's autism. Airing the program January News Alerts could result in a "tragic decline in immunization rates" with pos- sible serious consequences to the health of America's children, The following information appeared during the month of January the AAP said. In a January 25 letter to the president of the Dis- 2008 in the News Alerts section of the website of the Center for ney-ABC Television Group and the creators and executives of the Health and Health Care in Schools, at www.healthinschools.org "Eli Stone" program, the AAP noted that parents often trust the health information presented on fictional television shows. If the program airs, the ABC "will bear responsibility for the needless January 17, 2008
suffering and potential death of children from parental decisions FDA Cautions on OTC Cough, Cold Medications for
not to immunize based on the content of the episode," the letter said. The AAP urged that if a decision is made to go ahead with The federal Food and Drug Administration (FDA) yesterday airing the episode, the network should include a disclaimer that issued a Public Health Advisory warning that over-the-counter no mercury is used as a preservative in routinely offered child- cough and cold medicines should not be used to treat infants and hood vaccines and no scientific link exists between vaccines and children under the age of 2 years because "serious and potentially autism.
life-threatening side effects can occur from such use." In the same announcement, the FDA said it is reviewing whether such January 30, 2008
OTC medicines can safely be used for children 2 to 11 years old. Emergency Department Visits Linked to Cough and Cold
Pending completion of that review, the FDA recommends that parents and caregivers of older children should carefully follow dosing directions on any OTC cough or cold medicine and should An estimated 7,000 children ages 11 and younger are treated in understand that the products will not cure or shorten the duration hospital emergency rooms each year because they have ingested of the common cold. Further information on the FDA's recom- cough and cold medications, sometimes without their parents' mendations on use of OTC cough and cold medicines for children knowledge, according to an article published in the February is- is available at www.fda.gov/cder/drug/advisory/cough_cold¬_ sue of the journal Pediatrics. Two-thirds of those visits involved children between the ages of 2 and 5 years, and 80 percent of the events for this age group were from unsupervised ingestions. Most of the children did not require hospital admission, but one- Center for Health and Health Care in Schools Volume 9, Number 2 fourth needed additional treatment to eliminate the medicine from their bodies. The federal Centers for Disease Control and Preven- tion (CDC) noted today that cold and cough medications market- ed to infants and toddlers under the age of 2 have recently been withdrawn from sale, and the CDC is currently reviewing the safety of such medications for children between 2 and 11 years old. The cough and cold medications examined in the Pediatrics study included decongestants (for unclogging a stuffy nose), expectorants (for lessening mucus so that it can be coughed up), antitussives (for quieting coughs), and histamines (for sneezing and runny nose).
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