In This Issue

Prescription for Danger--Trends in Teen Drug Abuse
Using the catch-phrase "There's a new dealer in town," the White House Office of National Drug Control Policy (ONDCP) reported in January on "the troubling trend of prescription and over-the-counter drug abuse among the nation's teens." The report notes that: • More teens abuse prescription drugs than any illicit drug except marijuana; • Most of the abusing teens get their prescription drugs easily and for free, primarily from friends and relatives; • The prescription drugs most often abused are painkillers that were prescribed to treat pain; depressants such as sleeping pills or anti-anxiety drugs; and stimulants that were prescribed to treat attention-hyperactivity disorder (ADHD); • The over-the-counter drugs most often abused are cough and cold remedies that contain dextramethorphan, a cough suppressant; • Many teens believe prescription and OTC drugs provide a safe "high." That last point has been belied, the ONDCP said, by a dramatic increase in recent years in the number of poisonings and deaths associated with abuse of prescription and over-the-counter drugs. The report notes that serious medical consequences can follow, especially when the teenagers mix OTC or prescription drugs with alcohol or other drugs in what the ONDCP calls "a risky combination." Parents and caregivers whose medicine chests may be raided by teens looking for drugs are a first-line defense against abuse, the report says, but the ONDCP has advice for school and health professionals, as well, including how to spot signs and symptoms of drug abuse, including: • Constricted pupils, nausea and vomiting, respiratory depression (pain reliever abuse); • Anxiety and delusions, flushed skin, chest pain with heart palpitations (stimulant abuse); and • Slurred speech, dizziness, respiratory depression (depressant abuse). Schools are advised to properly dispose of old or unused medicines, and to set clear rules about not sharing medicines with friends. Health professionals are urged to make sure their patients, especially teens 12 years of age and older, understand the risks of drug abuse. To keep professionals informed, here are some of the definitions used in the report: • Painkillers (opioids) are prescribed to alleviate pain and include drugs prescribed after surgery. Examples of narcotics/painkillers are oxycodone (OxyContin), propoxyphrene (Darvon), hydrocodone (Vicodin), hydromorphone (Dilaudid), and meperidine (Demerol); • Depressants slow normal brain function and are used to treat anxiety and sleep disorders. In higher doses, some depressants can become general anesthetics. Tranquilizers (benzodiazepines such as Valium and Xanax) and sedatives are examples of depressants, as are barbiturates such as Amytal, Nembutal, Seconal, and Phenobarbital. • Stimulants increase alertness, concentration, and energy, which are accompanied by increases in blood pressure, heart rate, and respiration. Stimulants are prescribed to treat narcolepsy (a rare form of sleep disorder), attention deficit hyperactivity disorder (ADHD), and depression that has not responded to other treatments. Examples of prescription stimulants include Biphetamine, Dexedrine, and methylphenidates such as Ritalin and Adderall. If you need to know what constitutes "abuse," it is defined as "use of prescription medications without medical supervision for the intentional purpose of getting high, or for a reason other than what the medication was intended, regardless of prescription status." That's different from "misuse," which is defined as missing doses or not taking medication with food as recommended on the actual prescription. The ONDCP report, “Prescription for Danger: A Report on the Troubling Trend of Prescription and Over-the Counter Drug Abuse Among the Nation's Teens," is available online at
Preventing Influenza--The Case for Immunizing Children at School
Faced with the fact that current recommendations for vaccinating high-risk people such as the elderly against the flu don't seem to be reducing the incidence of seasonal influenza in the United States, U.S. policymakers are considering whether flu shots should be recommended for school-age children 5 to18 years old. There is logic in such an idea, the journal Health Affairs said January 23, since school-age children are more likely than adults to contract influenza and spread it to high-risk populations, including the adults in their own households. But in the most recent flu season for which data are available—the 2004-05 season—only 10 percent of healthy children were immunized against flu. That brings up the possibility that school-based immunizations might offer "an efficient and feasible approach to increase the coverage of school-age children, which would be expected to reduce the spread of influenza and decrease the burden of seasonal flu on households and communities." But whether school-based immunizations would be economically warranted is not clear, with some analyses indicating that immunizing healthy school-age children isn’t cost-effective. To try to find out more about this relatively untested idea, researchers who acknowledge they were funded by the vaccine maker Medimmune looked at the effects when more than 15,000 schoolchildren were offered nasal live attenuated influenza immunizations at school. They found, first, that there was a statistically significant reduction 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 warranted, the researchers said. Some of the factors in the trial: • In the intervention schools, 47 percent of children received the intranasal influenza vaccine and 56 percent of those got a second dose; • The average vaccination cost per household in the intervention schools was $41.66, much more than the average $5.56 families spent for flu shots in non-participating schools. But when expenditures by families for over-the-counter medications, herbal supplements, and emergency care and hospitalizations were included, costs somewhat evened out between intervention and control schools and were higher for families 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 researchers concluded that school-based influenza immunization with the nasal vaccine used in the trial "is cost-effective over the season," meaning the several weeks of the year in which influenza incidence is at its peak. And as to effects other than money, the researchers admitted they did not attempt to value the long-term educational and achievement consequences when student are absent from school with influenza. They did note, however, that in school districts where funding is based on average daily attendance, there are real financial benefits for schools from higher attendance. They estimate that during the peak week of influenza incidence, schools that offer vaccine may lose an average of $784 as the result of student absences, while schools without vaccine are likely to lose an average of $1,395. The study also looked at the time it takes to immunize a student at school as compared with providers' offices. What the researchers refer to as "mass vaccination" can run to as high as 30 per hour, they note, once staff are trained, while the average time for office-based vaccine administration is about 10 to 15 minutes of professional time per dose. "Our findings suggest that school-based immunization programs are cost-neutral after the peak week alone and cost-saving over an influenza season." And if economic benefits of immunization to the household are included, the researchers concluded, "The clinical and economic benefits of expanding immunization to school-age children deserve further consideration." The article "Benefits and Costs of Immunization Children Against Influenza at School" appears in the January 23, 2008, issue of Health Affairs, a publication of project HOPE.
CDC Reviews School Laws, Policies on Child/Adolescent Health
In a comprehensive report by the Division of Adolescent and School Health (DASH), the Centers for Disease Control and Prevention (CDC) outlined in February the laws and policies schools need to follow as they implement a coordinated school health program (CSHP). Divided into the components defined by the CDC as making up a comprehensive school health program, the report discusses possible legal implications for schools in areas including physical education; health services, nutrition services, mental health and social services, creating healthy and safe school environments, and promoting staff wellness. Health Education This report notes a 2006 assessment found that more than 85 percent of states have policies stating that elementary, middle, and high schools will teach at least one of 14 health topics chosen to reflect the leading causes of mortality and morbidity among both youth and adults. Of the many potential subjects, the topic of human sexuality is unique in its degree of regulation. Federal restrictions on sex education prohibit recipients of federal funding from encouraging sexual activity, distributing obscene materials to students on school grounds, providing sex education or HIV prevention education unless the instruction is age-appropriate and includes the benefits of abstinence, or providing contraceptives. Courts have held that parents do not have a federal constitutional right to exempt their children from required physical education classes but state or local laws may give parents more rights. Physical Education and Activity Most states and districts have policies requiring elementary, middle, and high schools to teach physical education, including such possible activities as calisthenics and gymnastics. The report covers related topics in this area, including what is legally required of schools, the role of national physical education standards, teacher qualifications and preparation, and the provision of protective gear. Most states and districts require schools to provide adapted physical education to children with permanent physical or cognitive disabilities. Health Services The report defines school heath services as including health screening and assessment; care plan development and implementation; health education; health counseling; acute, chronic, episodic, or emergency care; nursing interventions and case management; medication and administration; assistance with access to an ongoing source of health care in the community; medical case management and referral; outreach to students and families, and provision of professional development for school 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 with disabilities who must receive services under the federal Individuals with Disabilities Education Act (IDEA). Federal and state laws generally require parental consent before health services are provided to students. Use of identifiable health information about students is covered under the federal Family Educational Rights and Privacy Act (FERPA). Schools are required in some instances to report to families if a child is ill or if disabilities are uncovered in school screenings or by observation. Schools are most often not required to report student illnesses to state health authorities. Nutrition Services The report mentions the two main federal meals programs available to public schools, the National School Lunch Program and the School Breakfast Program, which provide subsidies and donated commodities to schools for meals that meet federal nutritional requirements. The report also notes that "competitive foods" are sold in competition with the federally subsidized programs in many schools, with federal law currently limiting their sale only in certain locations at certain times and prohibiting sale of "foods of minimal nutritional value" such as chewing gum. State and school districts may impose further limitations on school sale of competitive foods, and industries such as the soft drink industry have recently taken measures to limit sale of their products in schools. Commercial activities such as pouring contracts and corporate-sponsored contests and incentives aimed at students have been noted in recent reports by the Government Accountability Office (GPO) and the Institute of Medicine. Mental Health and Social Services This report notes federal laws require schools to provide psychological and social services to students whose health conditions adversely affect their educational performance (under the IDEA) and to students whose health conditions substantially limit their ability to learn (under section 504 of the Rehabilitation Act.) State laws differ on whether such services are available to all students, but schools may be authorized by their school districts to conduct screening or to develop policies for mental health 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 problems, and several states have laws that limit the ability of school officials to subject a student to psychological evaluation without prior parental consent. State laws broadly authorize schools to provide counseling services, most commonly in high schools, and treatment services or referrals are "widely available," according to the report. Counseling, psychological, and social services may be provided by counselors, psychologists, social workers, nurses, and other professionals in the school setting. State laws often authorize schools to employ such professionals but do not require every school to have them. School records containing sensitive personal psychological information are subject to the same privacy 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 mandates. In addition to state requirements concerning the location, lighting, heating, and sanitation of school facilities, schools are subject in many states to regulations about asbestos-containing materials, indoor radon, use of pesticides, and lead in drinking water. In addition to concerns about the physical conditions of school buildings, many states and districts have developed policies to prevent unintentional injuries, and federal law sets safety standards for school buses. States and localities have laws or regulations calling for speed reduction in school zones or requiring schools to conduct fire drills. Federal law makes it a felony to possess or knowingly discharge a firearm in a school zone, and nearly all states have similar laws. Personal and property searches of students in an effort to prevent violence are subject to Fourth Amendment protections against unreasonable search and seizure, with the Supreme Court setting parameters in recent cases for what constitutes a reasonable search. Use of metal detectors and school dress codes to prevent violence are also subject to state laws and constitutional challenges. In the area of substance abuse, a federal law prohibits smoking within any indoor facility that provides routine or regular K-12 education or library services to children if that facility receives any federal funding. Nearly all states, school districts, and schools have policies prohibiting use of alcohol and illegal drugs by students. The Supreme Court has found random testing of students for drugs to be constitutional as "a reasonably effective means" of preventing and deterring student drug use. In addition to policies addressing drug use in general, some states have enacted laws to limit use of anabolic steroids by students. Staff Wellness State laws often set prerequisites for hiring school employees, requiring prospective employees to undergo physical examinations or screening for tuberculosis or illegal drug use. Many states also require school staff to submit to ongoing health-related screening at periodic intervals. Many states have enacted employee wellness initiatives that promote fitness and health in schools and other workplaces, with employers commonly encouraged but not required to have such programs. Factors that influence school wellness may include the availability of health insurance and availability of routine screening for health conditions, as well as state occupational safety laws and regulations. The report from which this article is excerpted, "A CDC Review of School Laws and Policies Concerning Child and Adolescent Health," is published in the February issue of the Journal of School Health.
Credits: Virginia Robinson, Editor,
Health & Health Care in Schools is a monthly journal published in html and PDF versions by The Center for Health and Health Care in Schools. Support for Health & Health Care in Schools is provided by The Robert Wood Johnson Foundation.