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An A+ for adolescent health.

Who would have dreamed that schools would have to have formal violence prevention programs? And yet most of them do, along with many reforms that recognize the connection between good health and good school performance.

Would you like to live through adolescence again? Pose this question to a group of adults, and it's likely they will agree that, although at times being a teenager was fun, the good times were often overshadowed by the difficulties of becoming an adult. No one yearns for the pressure we felt to smoke, have sex or conform to the ideal body image. No one misses the stress of family break-ups, threats of violence at school or the struggle for academic success amidst personal turmoil.

Today's adults shouldn't forget those battles of adolescence. The stakes are too high. In their December 1998 Spotlight News, the Educational Development Center Inc. (EDC) reported that 25 percent of children suffer social, emotional and health problems that could affect their school performance. Numbers like these put us face-to-face with the relationship between a child's health and his or her educational success. This realization has led to school reforms that address adolescent health issues as well as academics.


Nora Howley, acting project director of the Council of Chief State School Officers' School Health Project, says, "One of the things we stress is that healthy kids make better learners. Continuing that logic, better students make for better communities. So health issues can't be separated from a school's academic mission."

In many ways, adolescence serves as a testing ground for adulthood. And that's a test that many educators, health care professionals and policymakers would like to see more young people pass. The new approach is to address health issues - ranging from sex education to nutrition to drug use prevention - in a comprehensive manner. At the center of this movement lies the school site, which is used as the link between the student and the many health agencies involved in adolescent care.

Government has used schools to address children's health concerns for decades. School lunch programs began during World War I. Policymakers added school breakfast programs in the '60s and '70s. When the public became aware of the wide-ranging effects of teen pregnancy, school-based health clinics were added to the mix. And when the clinics did not reduce the incidence of teen pregnancy, as developers had hoped, professionals saw the need to address more than the physical aspects of the problem.

"The clinics did good things," says Diane Allensworth, chief of program development at the Division of Adolescent and School Health, Centers for Disease Control (CDC), "but they didn't reduce the pregnancy rate. That's when folks realized that it's not enough to have health care, but that we needed social services and juvenile justice and vocational education. That was the advent of full-service schools."

Add to this the Institute for Educational Leadership's 21st Century Schools project, which focuses on parental involvement, youth development and academic success. "That initiative," explains Aliensworth, "allows for so many things: a comprehensive approach for using the school site with an end focus of improving academics."

To advance the development of such an approach, the CDC has identified eight main components of coordinated, comprehensive school health programs. These include health services, psychological services, health education and more. Creating the ideal structure within any educational system requires an extraordinary effort by state government and the many agencies involved. To this end, the CDC has given grants to 15 states to assist the development of an infrastructure that would support such a task. Some of the largest and the smallest states - from California to Rhode Island - are using the federal seed money to take this approach to teen health care.


Bad habits identified by the CDC as preventable are very often established in childhood. They include tobacco use; poor eating patterns; abuse of alcohol or other drugs; violence; physical inactivity; and sexual activities that result in HIV infection, other sexually transmitted diseases (STDs) or unintended pregnancy.

Although most people agree that these affect teen success in and out of school, many disagree on which health issues schools should tackle and the appropriate methods. Most of the controversy centers around sexual issues: birth control, STDs, homosexuality. South Carolina Senator Warren Giese has seen this firsthand: "Issues such as obesity, alcohol abuse and the like are known to be harmful. There is consensus there. But a lot of people feel that parents have the responsibility to deal with sex education."

Professionals have experienced comparable conflicts in other states. Maria Hilbring, project coordinator for the American Medical Association's (AMA) school-based health centers, ran into similar controversy when she attempted to implement the AMA Guidelines for Adolescent Preventive Services (GAPS) in Louisiana schools. "A lot of communities can't come to grips with the early sexual involvement that is going on today," says Hilbring. "Many schools in one Louisiana district were in Catholic communities. The health center is not permitted to even ask students if they are sexually active."

The AMA brought another effort to a halt when it tried to implement a substance abuse prevention program in a community where most people worked at the local brewery. "They wouldn't allow alcohol to be Fisted as an abused substance," Hilbring explains.


What grew from experiences like these was a respect for local decision making and the need to bring families and the entire community into the planning process for comprehensive school health programs. The National Education Association's Health Information Network (HIN) has developed several programs for just this purpose. Their Kids ACT program, developed to educate kids about tobacco use, involves teachers, students and parents, with an emphasis on parents. "One thing that is very effective is to bring parents back into the educational process," says Paul Sathrum, project coordinator for the HIN. "In the '60s and '70s, there was a migration of parents out of the school system. We are trying to bring them back as partners in the system."

This and other HIN programs teach parents how they can effectively talk with and teach their children in coordination with what educators are doing in the classroom.

This is especially important in certain health areas. The HIN program, "Can We Talk?" is a parent education program, designed to give morns and dads the confidence and skills to talk with their children about sexuality, peer pressure and relationships. "We are looking at parents as the primary educators on these issues with support from the school," says Sathrum. "It is important to have a consistent message from the classroom, the home and the community."

State governments and agencies also find it beneficial to respect local control. Rhode Island and West Virginia are two states receiving CDC infrastructure grants. They are using the money to create bridges to link teen health services in the state departments of education and health and other appropriate agencies. But when it comes to setting standards, marking goals or implementing programs, the talk is about partnership.

"We develop partnerships with schools, community agencies and families," says Linda Nightingale Greenwood, manager of Rhode Island's comprehensive school health programs. "We encourage schools not to work in a vacuum, and that's how we function on the state level. Sometimes it takes longer to create those partnerships, but they work better in the long run."


In 1993, for instance, lawmakers passed legislation enabling the creation of Rhode Island's Child Opportunity Zone Family Work Centers (COZs). These centers provide a good example of community, school and family partnerships with the goal of improving the academic success of children. They serve as a link between schools, families and health and social services agencies. For instance, COZ centers distribute health information, sponsor family-centered activities, provide adult education and sponsor school-readiness programs.

"In our school reform policy," says Rhode Island Senator Mary Parella, "we talk about kids meeting high standards and about holding schools accountable. With the COZs, we're trying to release some of the pressure from the schools by providing resources and helping schools communicate with parents." Most COZ centers are located either in a school building or beside it. "We're making efforts," says Senator Parella, "to address all the issues that kids face so that we can improve educational outcomes."

In West Virginia, community involvement also has been crucial to the success of adolescent health education. Lenore Zedosky, executive director of West Virginia's Office of Healthy Schools, says community involvement in program development has softened initial resistance. "We had some concern from the conservative right. But since locals have had the ability to design and implement their own programs, we've been able to overcome some of that."

On the state level, West Virginia focuses on preventing controversial behaviors with noncontroversial approaches. For instance, research shows that teens who have goals for the future are less likely to engage in risky behavior. So the West Virginia program builds on goal setting. "We look at many aspects of health," says Zedosky. "We help students learn to manage stress, communicate effectively, engage in conflict resolution - things that businesses want." Through such course work, students build skills and stay healthy. This combination of education for prevention and goal setting is working. West Virginia has implemented 85 percent of the original recommendations from its CDC grant program.

For states not receiving federal funds for teen health, it is important to note that efforts in both West Virginia and Rhode Island started before the federal grants came in. In West Virginia, for instance, a local businessman started things rolling when he became concerned about children's health. He saw the results of ill health and its effects on learning as he hired new workers for his business. He voiced his concern to policymakers, spurring Governor Gaston Caperton to appoint a task force in 1990 to identify the health issues and needs of West Virginia's youth.

"We crafted that work around the CDC's eight-component model for comprehensive school health programs," says Zedosky. "Their recommendations were very specific: more school nurses, more school-based health centers. That work positioned us for the CDC money."

Partnerships had already been formed between the Department of Education, the Bureau of Public Health, the PTA and members of the legislature. Once the CDC money came in, West Virginia was ready to consider a broad, school-based approach to adolescent health.


One component of comprehensive school health that many states are tackling on their own is the creation of a healthy school environment through the prevention of violence and disruptive behavior. The National Center for Education Stastistics (NCES) reported in 1998 that 10 percent of all public schools experienced one or more serious violent crimes (murder, rape, suicide or robbery) in the 1996-97 school year.

The numbers skyrocket when less serious offenses are included. According to NCES, 74 percent of middle schools and 77 percent of high schools reported one or more violent incidents during that year.

State and local governments show firm support for safe schools. As Ohio Senate President Richard H. Finan puts it, "If students are going to learn, they have to come to a safe environment." To that end, Ohio legislators are considering a bill that would increase penalties for crimes committed near schools and require schools to develop plans for responding to crime-related emergencies.

Lawmakers from Maine are debating other facets of school safety. Representative Elaine Fuller has introduced three bills this year related to school violence. "We are debating several ideas regarding what to do with children who are suspended from school. For example, we are considering the development of community service programs and alternative school settings."

In this case, state policy has translated into local practice. According to the NCES study, 78 percent of schools have some type of formal violence prevention or violence reduction program in place.


Where do things move from here? Early on, all work in the area of teen health was reactive: feeding hungry children, caring for babies of teen mothers, providing medication for adolescents with STDs. Now, organizations and government agencies are becoming proactive and focusing on prevention. Lawmakers can help by developing policies that enable agencies and school districts to start programs aimed at teaching adolescents about health and how to take care of themselves. But policies that are restrictive could have negative effects if they take away local decision-making ability.

In Rhode Island, for instance, legislation allows parents to opt out of sex or HIV education for their children. "It becomes a community discussion and not a state level discussion, and that's where those decisions belong," suggests Greenwood.

Zedosky of West Virginia agrees: "State policy will serve best if it says 'you need to do this, but how you do it is up to you.'"

Maine's Representative Fuller sees the importance of both state and local involvement: "Our school systems traditionally have a lot of local control. But my position is that you need certain standards, and all kids should be entitled to a quality education, including health education. And at the state level, we have extended Medicaid so they can have health care."

Funding is also an issue. Federal funds going to the CDC infrastructure states decrease each year as activities increase. Any program that starts with grant money, from this or other sources, will eventually need some state backing in order to continue once the grant fades.

As a first step though, legislators can take time to educate themselves on the issues faced by today's adolescents and the programs that currently are in progress. "There is a tendency to see teens as angels or devils," says Torrey Wilson, project director for the AMA's GAPS program. "The reality is that violence, for instance, is down, but we still see adolescents as predators. State legislators, like everyone else involved in this discussion, have to educate themselves about the facts in all areas of teen health."

Evidence strongly suggests that the more support states give to prevention programs for adolescents, the more likely it is for these kids to move into adulthood with healthy bodies, healthy attitudes and healthy minds. If that happens, everyone comes out on top.

"Education is key to how people live," says Representative Fuller. "And health is the key to education."


States receiving funds from the Centers for Disease Control for the development of statewide support systems for comprehensive coordinated school health programs are:

Arkansas California Florida Maine Michigan Minnesota New Mexico New York North Carolina Ohio Rhode Island South Carolina South Dakota West Virginia Wisconsin


Young people of the 1990s face different health challenges than past generations. Advances in medications and vaccines have largely eradicated the deadly infectious diseases that killed people in the past. Today's major killers, such as heart disease, lung cancer and HIV infection, are often the result of risky behaviors started in the teen years.

* Every day, more than 3,000 young people take up smoking.

* Over 48 percent of all high school students have had sexual intercourse. And every year, more than 1 million adolescent girls become pregnant, and more than 3 million adolescents become infected with a sexually transmitted disease.

* Daily participation in high school physical education classes dropped from 42 percent in 1991 to 27 percent in 1995.

* Seventy percent of young people do not eat the recommended number of servings of fruits and vegetables.

* Every year, more than 30,000 young people die in automobile crashes.

Can we change these bad habits and help youngsters develop into healthy adults? State and local governments are trying to through school health programs. Schools are in a unique position to educate America's youth about health - 48 million children sit in classrooms approximately 180 days per year. Health programs can encourage healthy lifestyles and help reduce the risks of many medical problems.

The funding and resources for school health programs vary from state to state. Generally, states and local school districts use federal money, grants awarded by private foundations and state appropriations.

Over the last two years, 28 states and American Samoa reported using money from the Maternal and Child Health block grant. For example:

* School health services are mandated in Florida, and the state uses both state appropriations and federal funds to pay for them.

* Five regional health districts in Georgia that provide education, health services, nutrition services, psychological and social services counseling, and parent and community involvement are partly funded with the block grant money.

* In Hawaii, the grant helps pay for two occupational and physical therapists and a health educator who provide services for public school children with special needs. Grant money also is used for school health services, a health education curriculum and adolescent health surveillance.

* In FY 1998, three county health departments in Kansas used more than $113,000 in federal block grants for clinic services at or near schools. The state also provides an additional $160,000. These school-linked services consist of preventive and primary care for children and youth with limited or no access to health care.

In addition to federal block grants, some states appropriate money specifically for school health programs. During 1998 at least 23 states appropriated funds for school health programs.

* California appropriates $500,000 for after school enrichment programs for kindergarten through ninth graders at participating schools.

* Colorado's General Assembly allots $17.7 million for public school health services.

* The Connecticut legislature authorizes nearly $4.5 million for school-based health centers (which includes a 1998 increase of $800,000.)

* Florida designated $70 million from its tobacco settlement revenues to continue implementation of the Florida Kids Campaign Against Tobacco pilot program. The money must be used for a media campaign urging youth to live tobacco-free; a comprehensive tobacco education and training initiative for preschoolers through high school; community-based tobacco prevention programs that include activities for minority youngsters; law enforcement; evaluations; and administration.

* Iowa provides $83,000 for a school-based educational program aimed at reducing methamphetamine abuse.

* The Michigan Legislature kicks in $142.7 million for school-based health services.

* Nebraska provides $200,000 for school nursing services.

Louise Bauer, NCSL


1. Complete health education 2. Family and community involvement 3. Healthy environment 4. Physical education 5. Counseling, psychological and social services 6. Health services 7. Nutrition services 8. Healthy staff

Source: Centers for Disease Control

Connie Koprowicz writes about children's policy issues for NCSL.
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Title Annotation:includes related article on risky behavior among adolescents
Author:Koprowicz, Connie
Publication:State Legislatures
Date:May 1, 1999
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