Child health in the United States: prospects for the 1990s.

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CHILD HEALTH IN THE UNITED Annu. Rev. Public Health 1990.11:185-205. Downloaded from www.annualreviews.org Access provided by Michigan State University Library on 02/04/15. For personal use only.

STATES: PROSPECTS FOR THE 1990s Nathalie Akin Vanderpool and Julius

B.

Richmond

Division of Health Policy Research and Education, Harvard University, Boston, Massachusetts 02115

INTRODUCTION

It seems appropriate to introduce a discussion of child health prospects for the 1990s by reviewing trends of the past decade. The Surgeon General's report, Healthy People, in 1979 for the first time set out health objectives for the nation for the next decade (66). According to a review of progress in 1985, 14% of the more detailed National Health Objectives had been achieved and 35% seemed likely to be reached. Childhood mortality was reduced 23% and adolescent mortality by 13% (70). These results were attributed to the signifi cant efforts undertaken by parents' groups, state and local governments, the health professions, and many organizations serving children and youth. In the latter part of the 1980s a renewed national consciousness concerning the problems of children emerged. This was reflected in the many national commission reports on various issues concerning children and in the establish ment in 1987 by the National Academy of Sciences of a National Forum on the Future of Children and Families, which took cognizance of this growing concern in summarizing 22 national reports of the previous five years (37). We can properly speculate on the reasons for the current level of interest. In no small measure, it may be due to certain deteriorating health, educational, and welfare circumstances for many children and their families over the past decade. A few examples illustrate this trend: 1. Poverty has become more prevalent among children (from 14.4% in 1974 to approximately 21% in 1985) (37, 76). Children are more likely to be poor than any other group. Indeed, the elderly population has been emerg ing from poverty at about the same rate that children have been slipping into it. 185

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2. More children are uninsured for health services than in prior years (76): In

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Annu. Rev. Public Health 1990.11:185-205. Downloaded from www.annualreviews.org Access provided by Michigan State University Library on 02/04/15. For personal use only.

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1986, over 12 million children had neither public nor private health insurance, an increase of 25% since 1982 (56, 62). One consequence is that fewer children have a source for regular primary health care. There has been a serious erosion of the public health system on which poor families depend heavily for health care and related services, as documented in a comprehensive report by the Institute of Medicine (25). Single-parent families are increasing in number (37, 62). Approximately one quarter of America's children live in female-headed, single-parent families, and the poverty rate for these families exceeds 50% (12, 16). An increasing percentage of children are living in families of minority group background in which poverty often complicates issues related to ethnic differences in child rearing (53). An erosion of the immunization rates achieved earlier in the decade has developed (53, 61, 62). The decline in the infant mortality rate has plateaued (20, 35, 62, 73, 74). AIDS has emerged as a formidable problem among young children and adolescents (4). It is estimated that by the mid-1990s we will have 10,000 to 20,000 HIY-infected children in the US, thereby making AIDS a significant cause of childhood morbidity and mortality (11, 43, 56). Homelessness has come to include children and their parents in increasing numbers in the 1980s. It is estimated that on any given night 100,000 children are among the homeless (62).

In this chapter, we attempt to identify and to present a synthesis of current morbidity and mortality trends in the United States; we also focus on health needs that are of greatest concem-often referred to as the "new morbidities" of childhood. Since many health issues are intrinsically linked to environmen tal and sociodemographic factors, we review these issues briefly. The per vasive impact of poverty on health and family integration is necessarily central to our discussion.

OUR CHILDREN: WHO ARE THEY? There are approximately 63 million children in the United States under the age of 18. The total number is expected to stabilize at around 67 million by the tum of the century. This will represent 25% of the total population (53). By the year 2000 the number of preschool children will decrease from 18.1 million (1986) to approximately 17 million; adolescent numbers have fallen from 16 million in 1980 to approximately 15 million in 1986, and this trend is expected to continue through the next decade. The number of children in the 5-13 age group is expected to increase slightly during the 1990s (65).


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Our youth of tomorrow are more likely to be poorly educated, non-English speaking, and located in metropolitan areas. (Indeed, the 1990s may become known as the "urban decade" for child health.) Other trends include the certainty that by the end of the next decade, a larger percentage of our children will be of minority-group background, due to high birth rates and immigration (3); more are likely to be raised in a single-parent family (12, 14, 31); and increasing numbers of children will spend large amounts of time in care facilities outside their homes (34). Thus health programs should be planned and implemented that focus on specific populations, with an added emphasis on urban areas. These programs will also need to be sensitive to the attitudes, behaviors, and lifestyles of cultures of a particular population (1a, 22, 55, 77).

MORTALITY AND MORBIDITY: THE HEALTH STATUS OF TODAY'S CHILDREN For the past three decades, childhood mortality has declined. This decrease is reflected in every cause of death with the exception of suicide, cardiovascular diseases, renal diseases, and, of course, AIDS (20). The five leading causes of death in children 1-4 years of age are injuries, congenital anomalies, malignant neoplasms, cardiovascular disease, and homicide; it is predicted that AIDS will be one of the top five causes of death by 1992 (43). The AIDS epidemic has become a major public health problem for children as well as adults. The three leading causes of death during adolescence are injuries, homicide, and suicide (20, 31, 62, 69). The leading cause of death for all age groups is injuries, with significant increases occurring during the adolescent years. For example, motor vehicle accidents account for more than 70% of deaths each year in the 15-19-year old age group (53, 64).

LOOKING AHEAD: MAJOR HEALTH ISSUES FOR THE COMING DECADE

Infant Mortality In the "1990 Health Objectives for the Nation" of 1979, a major goal was to reduce infant mortality to fewer than 9 deaths per 1000 live births by 1990 (66). Figures for 1987 show the rate to be 10 deaths per 1000, suggesting that we might just attain this goal (73). The rate of decline has slowed over the past three years (35), thus indicating that the federal reductions in ex penditures for social and health programs of the early 1980s have begun to have an impact on infant mortality rates, long regarded as a sensitive indicator of the state of public health. Although technologic progress continues, we can

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no longer depend exclusively on this factor to lower our infant mortality rate. We must also confront unattended issues of prematurity and low birth weight if we are to reduce the rate of infant mortality. In addition, we should not neglect the potential for further reducing infant mortality rates by paying closer attention to the post-neonatal period. Post-neonatal mortality-infant death that occurs between the 28th day of life and the end of the first year-accounts for 30% of all infant deaths (36). There have been no signifi


cant reductions in post-neontal mortality in recent years, rather there has been an increase, which implies that many deaths are not being prevented but rather, delayed (36). Interventions for saving infants during the first month of life are highly technological. Effective interventions for post-neonatal mortal ity are even more complex, and their use often relates to much larger social issues and public health practices that affect the ability of young children not only to survive, but to lead a healthy life. That this country lags so far behind many other industrialized countries in reducing infant mortality has become a matter of public concern (36). Cur rently, a child born in Japan, Sweden, France, Belgium, Canada, or any of

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other nations has a better chance of surviving the first year of life than a child born in the United States

(73).

SOCIOECONOMIC AND RACIAL DISPARITY

Disparities in death rates be

tween minority and non-minority infants continue to persist. Explanations for the gap are inconclusive, though it is accepted that they are predominantly social in nature (18). Currently a black baby is half as likely as a white baby to survive the first years of life (37, 62, 73). Black infants are also twice as likely as whites to be born with low birth weights (weighing less than 2500 g) (75). The percentage of black teenagers giving birth is twice that of white teenagers (38). Inadequate prenatal care is three times as common among black teens as among white teens (54). Throughout the years, the decline in the black neonatal mortality rate has been slower than that among whites,and the gap between the two has steadily widened (72). For example,in 1983,the ratio between black and white neonatal mortality rates had reached 1.94 against a figure of 1.43 in 1950 (72). From 1985 to 1986, the white neonatal mortality rate declined by 16%, whereas the black rate decreased only 3.3% (73). Poverty increases the probability that a pregnancy will end in the delivery of a low-birth weight baby (20,24,28, 72,76). Obviously, a mother's health prior to conception and during her pregnancy is important to the birth of a healthy infant; poor nutrition, substance abuse, and a high level of stress during pregnancy are not uncommon among women living in poverty. Womcn in poverty are also more likely to begin prenatal care after the first trimester.

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Infant mortality rates are highest in isolated rural areas in the South and in major urban areas; of the 13 states with the highest infant mortality rates, ten are in the South and four fifths of the largest cities have infant mortality rates greater than the national average (36).

GEOGRAPHIC

Prenatal care is an important determinant of birth out comes. There is evidence to support the proposition that inadequate prenatal care correlates with low-birth-weight infants and premature delivery (20a, 53). Although the numbers of pregnant women obtaining prenatal care in the first trimester steadily improved during the 1970s, by 1978 the numbers leveled off and little improvement has occurred since then. In 1986 21% of white mothers and 38% of black mothers did not receive their first prenatal care visit in the first trimester (73). Prenatal care can introduce effective interventions. As presently provided, however, it has a limited role in achieving desired outcomes for infants and mothers. To reach its potential, new approaches at the provider level, as well as additional funding, are needed. To be effective, prenatal care should be comprehensive and coordinated with other health care. Fortunately, an expert panel on the content of prenatal care has just published a report that details appropriate practices (67a). The report empha sizes preconception health issues and health care, as well as on-going risk assessment and medical intervention, when needed, throughout pregnancy. Health promotion, such as sex education, education on drug abuse and AIDS, contraceptives, and smoking cessation counseling, are important components of comprehensive prenatal care. Prenatal care provides an opportunity to link a mother, infant, and other family members to the health-care system; thus, follow-up and continued care for all family members are more likely to occur. We cannot expect prenatal care alone to reduce preterm delivery when social issues such as poverty among young families, homelessness, and crack and other addictions are impacting on so many people's lives. Clearly, even though we do not know precisely why prenatal care is associated with improved outcomes, we should continue to build on the experience and knowledge that has been developed. Until we know the differential impacts of the various components of prenatal care, we should continue to emphasize the importance of effective and accessible prenatal care, especially for families in high-risk groups.


PRENATAL CARE

TO PRENATAL CARE Many women living in poverty report multiple barriers to receiving prenatal care; the most common is a lack of financing to pay for care (36, 76). Presently Medicaid is the largest single source of health care financing for the poor, though a large proportion of poor

BARRIERS


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women are not covered by Medicaid (2, 30). Health interview data from 1978 and 1980 showed that Hispanic and black people are more likely than whites to lack health insurance of any type. In a 1977 survey supported by the National Center for Health Services Research, 22% of persons in the 18-24 age group had no health insurance coverage, and the situation has changed little in the intervening years (24). The current health care system is afflicted with major problems, including over-burdened clinics, often a time-consuming and complex bureaucratic process to obtain care, insufficient and, at times, insensitive maternity care providers, and language and cultural barriers. In the late 1980s, some 15 million women in their childbearing years lacked coverage for medical ex penses; poor, minority, and unmarried women were overrepresented among the uninsured (53). As noted above, the lack of comprehensive prenatal care contributes to babies of low birth weight, a condition that may result in costs as high as $400,000 over a lifetime in care (29). Improved maternal and child health programs, especially for poor and minority groups, that reduce finan cial, bureaucratic, geographic, and other barriers are essential to minimizing the frequency and health impacts of low birth weight. Numerous reports here emphasized the importance of a healthy start for the development of the child (2, 23, 36, 37). Too many babies continue to come into the world too soon and too small. We need a program that assures every family ready access-free of barriers-to prenatal and child care. What the nation must demonstrate at all levels of government is the commitment to attain this goal.

Immunizations EROSION OF PROGRESS Common childhood diseases have been greatly reduced and/or eradicated with the development and use of vaccines, but some of the currently achievable goals have not been reached. Over the past 25 years, immunization programs in this country have resulted in a 98% decline in the incidence of measles, mumps, rubella, diphtheria, and polio (53). Because of a world-wide vaccination program under the auspices of the World Health Organization, small pox has been eradicated from the world (69). The campaign to eradicate measles illustrates the irregular progress that characterizes many immunization efforts. The goal of eradicating measles by 1982 was set in 1979; during the week ending January 15, 1983, no measles morbidity was reported for the first time in the Morbidity and Mortality Weekly Report (5). But there has been some erosion of this progress. For example, 3411 cases were reported in 1988 (7), compared to a total of 1497 cases in 1983 (6). This is probably due to gaps in the health care delivery



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system, cutbacks in federal and state funding for immunizations, and the increasing costs of vaccines. Outbreaks have occurred among high school and college students who received an inadequate vaccine as children and among preschoolers living in inner cities who were not immunized with the newer, more stable vaccine or who were not immunized at all. Vaccines have proven to be one of the most cost-effective methods of preventing illness and reducing mortality from infectious disease, yet the growing numbers of non-immunized preschoolers threaten a return of out breaks of communicable disease (62). Estimates are that in some poor, urban areas only about 50% of preschool children are immunized (40). And in 1985 the percentage of preschoolers not immunized against major childhood dis eases ranged from 26% for rubella to 13% for diphtheria, tetanus, and pertussis (62). The National Vaccine Advisory Committee has emphasized the need of a coordinated effort to enhance the use of existing vaccines, to develop improved and new vaccines, and to continue educational programs regarding the benefits of immunizing children. In order to maintain our immunization programs, and to prevent illnesses and death from the acute infectious diseases, funding necessary to carry out these goals will have to be appropriated. Thus, the federal government should support state and local efforts to provide immunizations to children. The state statutes that require that children be immunized as a condition for entering school should be enforced and expanded to include children in day care and college students. We need more aggressive programs for children who are at greater risk, namely those below five years of age who are poor, often of a minority group, and living in urban areas (53).

REGAINING IMMUNIZATION MOMENTUM

AIDS Because it is difficult to determine how wide spread HIV-related illness is in children, projections for the future vary widely. Official figures include only cases reported to the Centers for Disease Control; these indicate a cumulative total of 1561 cases in children under 13 years of age and a total of 858 children having died through April 1989 (4). One of the major barriers to projecting the prevalence of AIDS is the high variability in the incubation period of the disease. The incubation period in the congenitally infected infant is about four to six months; however, the disease can appear as long as eight to ten years after a child has been infected (27, 44, 52). Most cases of pediatric AIDS occur in very young children; 50% of pediatric AIDS is diagnosed before age one and 82% by the age of three (44). Although there have been significant increases in reported cases in the last VARIATIONS IN FORECASTS

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few years, whether these increases are because of increased occurrence, improved diagnosis, or better surveillance remains unclear. Some research workers believe the disease will begin to decline in the next decade (27); however, the majority believe that the cases of AIDS in children will continue to increase and be a significant public health concern throughout the next decade. For example, it is estimated that by 199 1 one of every ten pediatric hospital beds will be occupied by a child with AIDS (43). AIDS is one of the health concerns of children with deep social roots. There is close association of the disease with intravenous drug use by parents, with poverty, social disorganization, and a lack of regular medical services. It is estimated that 35% of the children born of infected mothers will develop the infection (53). The disease is also disproportionately high among minority children. Currently 53% of all child hood cases of AIDS occur in black and 22% in Hispanic children (43, 52). Incidence is also slightly higher in males than females. Most of the children reported to have AIDS are of pre-school age and live in urban areas. States reporting the highest number of AIDS cases among children are New York, New Jersey, Florida, and California (42, 52, 53). When a child is diagnosed with AIDS, the entire family is affected and many of the families are not provided with adequate support to deal with this difficult disease. Children with AIDS have often been excluded from day care, and public and private schools as well. S ome families have been forced out of housing and turned away by family and friends. Older siblings must face the possibility of losing not only a sibling, but sometimes both parents as well.

RELATION TO SOCIAL CONDITIONS

Adequate research support is essential to learn more about the biology of the disease and to develop treatments and perhaps a vaccine that will prevent HIV infection in individuals. Prevention requires increased efforts to educate the public about the nature of disease. Efforts directed at primary prevention and the reduction of stigmatization are key to the control of the epidemic (11). High-risk groups like adolescents should be targeted for aggressive and innovative education. Research for the development of a vaccine is destined to proceed slowly. Efforts to develop therapeutic agents hold some promise but thus far do not cure or adequately control the disease. Because of the unique implication for the entire family when a child is found to have HIV infection, the health care professions are faced with a magnitude of multiple health and psychological issues unparalleled in modem medicine. Issues related to death, the number of people in families infected, sexuality, IV drug use, school, foster care, respite care, and housing are

INCREASED RESEARCH AND EDUCATIONAL EFFORTS


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examples of the complexity of the problem. Other issues that further com plicate care are the needs of HIV-negative children born to HIV-positive parents; by definition there will be at least twice as many of these children as those actually infected. Also, as increasing resources are needed to care for these children and families, policy issues related to funding and allocation of resources emerge. All of these needs place complex demands on the child health delivery system, which overall has been unable to deal adequately with


the challenge of AIDS. The multiple issues point to the need for a continued, comprehensive approach in research, patient care, and education to find some more effective approaches to controlling the AIDS epidemic-one of the most formidable health challenges in history.

New Morbidity An increasing proportion of children's health needs are related to behavioral,

(17, 46, 59). These health problems often seem intractible, in part because

social, and educational problems-the new morbidity mentioned above 33,

they correlate with low achievement, low self-esteem, truancy, and school drop-out and often become more visible during adolescence. As a conse quence, many adolescents become designated as "high-risk youth" (13). From 1960 to 1981, adolescents were the only subgroup to show an increase in mortality rates (3). The shift from traditional biological concerns of children to those more behaviorally and environmentally rooted will place greater demands on health care providers and others involved in the care of children during the 1990s. The new morbidity health concerns that are likely to need greater attention throughout the next decade are those associated with violence, depression, substance abuse, teenage pregnancy, school problems, sexually transmitted diseases, and eating disorders (50). So that health care providers can be prepared to address these complex health needs of children, training programs must place greater emphasis on behavioral and psycho-social issues. VIOLENCE-RELATED HEALTH CONCERNS

Homicide and suicide

Violent behavior leads to more deaths of young

people through suicide, homicide, and injuries than any of the biologic causes of mortality in the 5-24-year age range (20). Higher rates of violence-related deaths are noted among males and black young people; however, most of the interracial variance can be explained by socioeconomic variables. Currently, homicide and suicide are leading causes of death among older adolescents

(62). Homicide was the eleventh leading cause of death in the United States in 1983, and it takes its greatest toll among young persons aged 15-34 (69). In 1983, homicide was the leading cause of death for blacks in this age group; firearms accounted for three out of five homicides among all victims ( 20, 69).


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Suicide rates have continued to increase in the 15-19-year age group. Suicide is a leading cause of death among the 15-24-year age group (62). White males constitute the highest group in this age range (48). Decrease in suicide was one of the targeted goals set in the 1990 Objectives for the Nation that will not be met. Suicide rates increased significantly between 1980 and 1985. In the 15-19 age group, an increase of 18% was reported (53). Although more research is needed to understand the causes of suicide, there is good reason to believe that the increased stresses to which young people are exposed in their families, peer groups, schools, and communities, along with the use of alcohol or drugs, are contributing factors to the increases (21). The social support systems, health services, and socio-economic conditions that help to promote a better quality of life and emotional well-being have not been adequate to promote improved quality of life for many of our youth. The media probably have also played a significant, though still largely un explored, role in influencing violent behaviors. One study reported that the rate of suicide increased for a seven-day period after a locally televised news story about a suicide was broadcast on at least two news programs (48). Child abuse Child abuse continues to be a major concern for the nation. Estimates are that 2000 to 5000 children die each year as a result of abuse (53). Although there are indications that child abuse may be decreasing, abuse and neglect of children will continue to be a predominant health concern for the 1990s. Between 1980 and 1986, cases of abuse and neglect rose 150%; in 1986, 1.6 million children were reported to be abused or neglected (62). Reported child deaths from abuse and neglect jumped 23% nationally between 1985 and 1986. There is also increasing evidence suggesting a significant overlap of child abuse with woman battering in the;family (29). With the likelihood of significant numbers of children continuing to live in families with high levels of stress and abuse, the emphasis on prevention must be increased during the next decade. Professional workers are moving from a predominant emphasis on child abuse prevention programs designed for individual children and families to one of community orientation with cultural appropriateness and sensitivity. Programs to promote healthy, nonabusive interaction between parents and children merit expansion for the widest possible audience. For example, there is need for educational programs for all new parents and for parenting courses during high school. SUBSTANCE USE AND ABUSE The widespread use of tobacco, alcohol, and illegal drugs among young people will continue to be a significant health problem in the 1990s. We now know that chronic use of these substances seriously affects the health and well-being of our adolescent population.



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Substance abuse is correlated with adolescent pregnancy, school drop-out, delinquency, violence, and death. Each year some 48,000 youngsters die or are injured in drug- or alcohol-related highway accidents (53). With the exception of cocaine, adolescent substance abuse has declined somewhat since 1980, after increases during the previous two decades. Still, alcohol, marijuana, and tobacco are commonly used by many high school students. Surveys indicate that 60% of the senior class of 1986 reported they had tried an illicit drug, more than two thirds had used cigarettes, and approximately 92% had used alcohol (26, 58). Although national surveys do not yet have adequate data for the use of cocaine in the form of crack, recent surveys do show a substantial increase in numbers of adolescents who have smoked cocaine, and the problem is increasing in younger adolescents (26). Smoking rates among young people have not declined at the same rates as smoking among adults. Many children and adolescents are unaware of, or underestimate, the addictive nature of smoking. Most smokers start smoking as teenagers and then become addicted (68). Female adolescents surpassed their male peers in tobacco use in the 1970s and this trend continues (53). If 20 million of our 70 million children smoke cigarettes as adults, predictions are that at least 5 million will ultimately die of smoking-related diseases (68). Great efforts must be forthcoming in the 1990s to prevent and combat the problems of substance abuse among our youth. Education targeted at preven tion is the most promising intervention at this time, particularly newer models based on social learning theory, which have had some impact on the preven tion of smoking among adolescents (47). Very little is known about the population of young people currently receiving treatment for alcohol and drug problems, and the long-term effectiveness of these programs has not been adequately assessed. High-risk youngsters-those who are poor, living in urban areas, largely minority, and many who are school drop-outs--have not generally had effective drug treatment programs available to them. The magnitude of the problem is emphasized in the funding of appropriate and effective efforts. Over the past few years, the federal government has in creased funding for drug law enforcement more than $700 million, while funds for drug education, prevention, and treatment have been reduced by 40% (63). TEENAGE PREGNANCY Major changes in the sexual mores of adolescents in the United States occurred over the past two decades. In adolescents under age 15, 5% of girls and 1 7% of boys report having had intercourse (39); by age 18,44% of girls and 64% of boys report being sexually active (39); and by age 20, 74% of females and 83% of males reported that they had engaged in sexual activity. Fewer than half of these sexually active teenagers report having used contraceptives consistently (12, 34).


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Teen birth rates have fallen significantly in the 1980s. The decrease is attributed to increased use of contraceptives and the availability of abortions (12). Nonetheless, teenagers still had approximately 470,000 births in 1986, and there have not been decreases in births to teenagers 14 years of age and younger (69). In 1985 there were approximately 323,000 births to white teens, 140,000 births to black teens, and 62,000 births to Hispanic teens (53). By their eighteenth birthday, 22% of black females and 8% of white females have become mothers (69). Those of minority-group background are dis proportionately likely to be unmarried. Children having children will continue to be a troubling health concern for the 1990s. We can feel somewhat encouraged with fewer births among older adolescents. We will continue to struggle with (a) consequences to the babies of these school-age mothers-a teenager is less likely to have had adequate prenatal care; thus these babies are at increased risk of low birth weight and of dying before their first birthday; (b) consequences to the mother-increased risk of dropping out of school, difficulties in raising children as a single parent (percentage of births to teens that occur to unmarried women doubled between 1970 and 1985 from 11 to 22%) (53), and poverty; and (c) consequences to society-studies in 1979 and 1985 indicated that 60% of the Aid to Families with Dependent Children (AFDC) budget was going to the families of teenage mothers, and total public assistance benefits paid to families in which the mother was a teenager at first birth was $16.5 billion in 1985. This did not account for housing, special education, health care, foster care, day care, and other social services (32). SCHOOL DROP-OUT The prospects for many of our children attaining basic educational skills over the next decade are not encouraging (55). In 1988, approximately 25% of US high school students left public schools without graduating (37). In some urban areas, drop-out rates are over 40% (19). And thousands who graduate are still as deficient in basic skills and work habits as most dropouts. There is a growing perception of crisis concerning the state of education in the US, as was evident in the unprecedented convening of a Conference of Governors in September 1989 by President Bush.

Long-term Disabilities and Chronic Illnesses Somewhere between 5 and 15% of American children have a moderately to severely handicapping condition, i.e. a chronic illness, physical disability, or sensory deficit (9, 15, 56). Only about 5% of children under 18 suffer a chronic condition that limits their activity (56). Conditions include rheuma toid arthritis, asthma, leukemia and other malignancies, spina bifida, seizure disorders, neuromuscqlar disease, AIDS, and other chronic conditions. In creasing numbers of these children now survive to adulthood.



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As we approach a new decade, we can do so with some degree of optimism for children with special needs. Certainly there is greater awareness of the needs of these children and broader acceptance from society of the need to provide services appropriate for their care and development. National legisla tion has mandated specific rights and provision of services for handicapped children (60). More attention is being given to involving and working with families of handicapped youngsters, teaching them how to give care and provide needed services in the home setting. In addition, we are seeing greater coordination among health care providers, schools, and the many agencies often involved in the care of handicapped children (10, 45). Thus, our tasks over the next ten years will involve our building and expanding on the progress made during the last two decades. The emphasis on prevention first began in 1965 with the Head Start program (49). In 1977, the Education for All Handicapped Children Act was passed. It provided an educational bill of rights for handicapped children ages 3 to 21 (10). It guarantees a free and appropriate education in the least restrictive setting with improved availability of related health services in schools. There is also a mandate to identify children who had not previously been served. Parents' rights to due process is an integral part of the bill and parents are urged to be active participants in the multi-professional teams that evaluate and design an individual educational plan for each child considered to be handicapped. In 1986 Public Law 99--457, known as the Education of the Handicapped Act Amendments, was passed (60). This law establishes a new federal discretionary program to assist states in developing and implementing com prehensive programs for infants and toddlers, from birth to three years of age, who are at risk or suspected of having a handicapping condition. A unique feature of the bill is its emphasis on very early intervention for children who may not yet display significant developmental delays, but whose environmen tal condition suggests delays will occur if no intervention takes place. The law shifts the focus from the child alone to the family, which is seen as the center for interventions that support the development of the child (51). A second federal and state initiative in the 1980s, in addition to P.L. 99-457, was the Surgeon General's emphasis on community-based, family focused care for children with special health care needs (67). This suggests proactive programs that involve families in the decision-making process and in the care of their children. For handicapped children, especially, there has been a growing recognition that health care must be family-centered. Trends suggest that professionals from a variety of health care disciplines should be trained in all aspects of care for special-needs children (45). Interdisciplinary training programs are helpful in achieving this goal (10). Therefore, as professionals and families envision the next decade, strengthen-

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ing the bonds of their partnership in providing appropriate care for special needs children will become a central issue. Finally, an overarching goal for children with special health care needs in the 1990s is to assure the provision of continuing and comprehensive primary care.


SOCIODEMOGRAPHIC TRENDS FOR THE 1990s

Changing Family Structure Many children in this country have not fared well in the changing family patterns of the past two decades, for example, the long-term effects ex perienced by children of divorce (71). Children are increasingly raised in families in which both parents work, or in which there is only one parent and the family composition experiences frequent change (53) (an estimated 13 00 new step-families are formed every day). Between 1959 and 1985, the number of female-headed households with children more than tripled, while families with adult males present rose less than 10%. Roughly one quarter of America's children live in single-parent families. The poverty rate for chil dren in these families exceeds 50% (12). Not only is the poverty rate higher in female-headed, single-parent families, but the poverty rate lasts much longer than it does in two-parent families.

Mothers Working The 1990s will be the ftrst decade to begin with a majority of mothers of children under age six in the labor force. In 1988, 65% of all women with children under 18, 73.3% of mothers with school-age children 6 to 17, 56.1% of women with preschool children, and 51.1 % of mothers with infants under age one were in the labor force (53). The majority of mothers are working out of economic necessity. The need is obvious for economic improvement in female-headed, single-parent households. With the absence of fathers from families and only a small minority of absent fathers' contributing consistent child support, single mothers often have to combine their own wages, welfare checks, and other means to support themselves and their children.

Need for Child Care With the increasing number of mothers with young children in the labor force, greater numbers of these children are in need of some program of child care. By the early 1990s projections indicate that 10.5 million children under age six will have mothers who work and 6.3 million of these children will be in need of child care (22). With these increases, adequate child care will not be available for many in need over the next decade. The supply falls short of current demands.



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The lack of child care options diminishes work productivity and often prevents parents who seek work from participating in the labor force. Over one third of mothers not in the labor force and with incomes under $15,000 reported that they would seek work if child care were available (12). Although working mothers are the norm, the public and private sectors have not responded to this new reality. In fact, federal budget reductions in the 1980s have resulted in fewer children served,less state responsibility,and lost work opportunities for parents. In 1989 Congress passed a bill for child care (8,57) in order to support family efforts to obtain child care. But this is only a beginning. We cannot afford another decade of neglect by federal and state gov ernments, local communities, and the business community of the realities of child-rearing in today's society. More parents with young children are work ing, and we should try to prevent unfortunate developmental impacts on the children through inadequate child care arrangements. Thus federal and state regulations relating to health care in day care facilities for preventive services will need to be strengthened, and parents will need more and better informa tion about child care programs. Providing environments in which children can receive health care and develop and learn should be a high priority of the nation for the 19908.

Need for Improved Health Services Over a decade ago, a Select Panel for the Promotion of Child Health issued a report,Better Health/or Our Children: A National Strategy (54). This report noted that existing programs for children's health care were inadequate. Specifically, there was inadequate access to needed health care, services were fragmented and duplicated, and accountability in the health care system was lacking (54). In addition,low-income families were suffering most from these problems. They were less likely to have health insurance, continuity in health care, and adequate prenatal care. To address these needs, the Select Panel recommended changes in Medicaid eligibility, increased enrollment of chil dren in organized health care systems, and changes in provider practice and payment. Some of these goals have been met, e.g. as of 1987, 25 states had expanded Medicaid eligibility above AFDC levels,and enrollment of families in the health care system has also increased (56). Unfortunately, much of the progress has not been maintained during the 1980s. Although Medicaid is our country's health care safety net for the poor. their coverage has eroded disproportionately over the past 15 years. The National Association of Children's Hospitals' recent report stated that the average state's eligibility threshold for a child in a family of three was over 70% of poverty in 1975 and has fallen under 50% of poverty in 1989 (33a). The report also noted that almost half of the 12.6 million children under 18 in

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families below the poverty line do not have Medicaid, even though it was designed as a last-resort health care program for the poor (33a). There is a national consensus that children must receive adequate health care early in their lives. Therefore, comprehensive reform in our health care financing is critical. The relative lack of financing for health services for children in low-income families is receiving significant attention. The American Academy of Pediat rics has recently released a proposal to address "access problems" for the uninsured to provide health services for all uninsured children (1).

Interrelatedness of Health Needs We can no longer ignore the reality that health, education, and social prob lems are inextricably linked and that, therefore, health concerns cannot be addressed in isolation of other factors. The interrelatedness of children's health needs is evident. For example, teenagers are more likely to give birth to babies with low birth weight, who are predisposed to developmental disabili ties, and subsequently are also at higher risk for abuse and neglect. In addition, they are often in families that experience a high level of stress, substance abuse, low income, violence, and poor access to and erratic use of health care. Childhood poverty is linked to morbidity outcomes involving chronic illnesses, abuse and neglect, behavioral problems, and, of increasing concern, AIDS (41, 76). Children from low-income households are more frequently reported to be limited in their usual activities because of chronic health problems, spend more days in bed because of injury or illness, have fewer physician contacts, and are more likely to be reported to be in only fair or poor overall health by their parents (41). The impact of multiple morbidit ies appears especially severe for children from low-income families. Because of the complexities of the problem, they need greater access to health ser vices. Thus, comprehensive interventions will be required to address the multiple causes of poor health in children.

CONCLUSIONS As we consider prospects for the 1990s, we should take note of the efforts of the US Public Health Service to update the health goals for the nation for the year 2000. The setting of goals provides significant impetus for all health workers-in the private as well as the public sector-to review their programs and efforts to be congruent with the national consensus that has emerged. These efforts are divided into the categories of health promotion, health protection, and preventive services (the more detailed goals are attached in the appendix).



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In recent years there has been a distinct shift in the character of child health problems and programs. As the acute infectious diseases of childhood have been largely controlled, we have moved from predominantly medically oriented programs to those multifactorial in origin and that require additional disciplines, often working in comprehensive settings. This shift in orientation is not yet reflected fully in our programs, particu larly in their financing. The financing of health services has developed predominantly in a fee-for-service model in the US. Yet services, to meet modem needs, often need to be community based, comprehensive, and intensive. The mismatch between funding in the health care sector and the needs of families must be addressed in the next decade if child care pro fessionals are to become more functional. Funding for programs becomes even more complex when we consider that meeting family health needs generally cannot be accomplished exclusively through health services, but requires educational and welfare support services as well. Communities are increasingly working toward programs that inte grate resources and services at the local level to serve families more effective ly. Yet history, tradition, legislation, turf, and bureaucracies often make this difficult. Solving these problems is one of the creative challenges facing child care professionals and citizens across the country who are struggling to improve programs in their communities. In the introduction, we pointed to a renewed awareness in the nation concerning the problems of children. This should give reason for some optimism for the 1990s. During the 1980s, the notion was widely purveyed by some that the social programs of the 1960s and 1970s had failed and that governmental programs especially did not serve us well. In the light of the lack of evidence for such pronouncements, it is astounding that they gained such widespread currency and credibility. Fortunately, critical appraisals are now appearing that indicate the many successes we have had (27). The task is now to build on the models demonstrated to have worked and to disseminate them more widely. This will happen only if our renewed awareness is translated into a renewed commitment from private and public sources to move forward with comprehensive, intensive community-based services that will improve the quality of life for children and their families. ACKNOWLEDGMENTS This work was supported in part by funds from the Ronald McDonald Children's Charities Physician's Award. We thank Paul Wise, George A. Lamb, Magda G. Peck, Susan Brink, Susan Barkan, and Nina Wampler for helpful support in the formulation and conduct of the research.

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ApPENDIX: YEAR 2000 NATIONAL HEALTH OF CHILDREN AND YOUTH

OBJECTIVES-PROMOTING THE


HEALTH

Health Promotion Improve nutrition for children. Increase physical activity and fitness among children. Reduce tobacco use among children. Reduce alcohol and other drug abuse among children. Promote responsible sexual behavior among youth. Reduce violent and abusive behavior among children. Health Protection Improve environmental health. Prevent unintentional injuries among children. Preventive services Improve maternal and infant health. Prevent infectious diseases among children. Prevent HIV infection among youth. Prevent sexually transmitted diseases among youth. Prevent high blood pressure and high blood cholesterol. Prevent cancer. Prevent other chronic diseases. Improve oral health among children. Prevent emotional and behavioral disorders among children.

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The future of public health: prospects in the United States for the 1990s.

National health planning in the United States: prospects and portents.

Nutrition: prospects for the 1990s.

Prospects for cancer control in the 1990s.

Paediatrics or child health in the 1990s?

Prospects for ancillary treatment of sinusitis in the 1990s.

National Health Insurance for the United States.

History of regulatory requirements for poultry biologics in the United States, 1970s to 1990s.

Setting objectives for public health in the 1990s: experience and prospects.

Immigration to the United States: Recent Trends and Future Prospects.

HIV and AIDS among adolescents in the United States: increasing risk in the 1990s.

Injury prevention and control: prospects for the 1990s.

Health education manpower in the United States.

Transforming public health in the United States.

Health system reform in the United States.

Public health in the United States.

Reforming health care in the United States.

Oral health care for underserved children in the United States.

Advancing preconception health in the United States: strategies for change.

Income inequality and child maltreatment in the United States.

Valuation of Child Health-Related Quality of Life in the United States.

Occupational health in the 1990s.

Public health policy for the 1990s.

The politics of mental health advocacy in the United States.