Ph. D. Child Trends

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Nicholas Zill, Ph.D. Child Trends, Inc.

2100 M-.Street, NW Washington, DC 20037


January 16, 1991

Testimony before the

Subcommittee on Children, Family, Drugs and Alcoholism
United States Senate
Committee on Labor and Human Resources

Good morning. My name is Nicholas Zill. I am a psychologist and the executive director of Child Trends, a non­ profit, non-partisan research organization here in Washington that studies social changes affecting children and works to improve the information we as a nation have about our young people and their families. I have been asked to provide an

overview of the current physical and emotional health of American children, and to describe some recent survey results about children's developmental problems that have raised concerns among health experts and members of the general public.

Let me begin by stating that the child health picture in the United States today is not a monochromatic one. There are bright areas of genuine and significant progress and darker areas where conditions have remained bad or gotten worse. Let us look at a few of the bright areas first.

Signs of Progress
In recent years, there has been so much bad news about AIDS, child abuse, the "crack" epidemic, and other public health problems that it has tended to obscure the progress that has been made over the last several decades in combatting childhood death and disease. Thanks to improved nutrition and sanitation, immunization programs, more stringent safety regulations,

advances in biomedical technology, and Medicaid and other

programs that make medical care available to low-income families, many indicators of child health have shown substantial improvement.

One widely used indicator of health conditions for children is the infant mortality rate -- the proportion of babies who die

within the first year of life. The u.s. infant mortality rate
has fallen greatly. The rate in 1989 -- less than 10 infant deaths per 1,000 live births -- was only about one-third of what it was a recently as 1950 (NCHS1 1990). Death rates for preschool and school-age children have also declined substantially. The death rate in 1989 for children between the ages of 1 and 4 was less than half of what it was in 1960. And

the death rate for children between the ages of 5 and 14 was less
than 55 percent of the 1960 rate. Although mortality rates provide only a partial picture of children's health status, these dramatic declines attest to real improvements in the physical health of U.S. children.

Many communicable diseases that were once common to childhood, such as diphtheria, polio, and measles, have been eradicated or greatly reduced in frequency (NCHS, 1989b). By the time U.S. children enter school, almost 100 percent of them have been immunized against measles, mumps, rubella, diphtheria, and polio (Centers for Disease Control, 1989). Although virtually

all children still have bouts of acute illness or minor injuries
from time to time, most grow up physically healthy. Eight out of

10 children are described by their parents as being in "very good" or "excellent" health, and all but about 3 percent are rated in at least "good" health (NCHS, 1989a).

That is the good news. Unfortunately, indicators of children1 S health and safety also showed a number of troubling trends in the 1980s.

Negative Developments

To begin with, there was no progress in the last decade in increasing the proportion of pregnant women who receive appropriate prenatal care or in decreasing the proportion of low birth-weight babies (U.S. House Select Committee, 1989). In

1988, one birth in 17 was to a mother who received late prenatal
care or no care at all. Among black babies, the ratio was one in
9, and among Hispanics, one in 8 (NCHS, 1990). The proportion of births that resulted from unwanted pregnancies has actually increased during the 1980s (NCHS, 1990b).

Progress in reducing the infant mortality rate slowed in the
course of the 1980s. In addition, the number of pediatric AIDS cases increased dramatically. The number of AIDS cases reported in 1988-89 was five times the number reported between 1981 and

1984. There have also been continued disparities along racial and income-related lines in child health indicators such as life expectancy, infant mortality, low birth-weight, homicide, and overall health status (NBCDI, 1990; NCCP, 1990). These disparities are documented in greater detail in my written

testimony. The written testimony also describes the current nutritional status of young children in the U.S., and recent developments with respect to low-weight births.

Emotional and Developmental Problems Among U.S. Youth

The lack of progress in many aspects of young people's physical health and medical care is troubling. So are recent data about the emotional health and intellectual development of our youth. In 1988, the National Center for Health Statistics

surveyed the parents of more than 17,000 children around the u.s.
The survey produced the following disquieting results:

• One in five children aged 3-17 was reported to have had a serious emotional or behavioral problem, a learning disability, or a delay in growth or development. This projects to more than 10 million children nationwide.

• By the time youngsters enter their teen years, one in four has had one or more of these problems, and for male teenagers, it is nearly one in three.

• In addition, one in five teens aged 12-17 has had to repeat a grade in school, and one in eight has been suspended or expelled from school.

Grade repetition and suspension are often precursors of school dropout, delinquency, premature parenthood, and welfare dependency.

The survey found that developmental difficulties were far more prevalent among children from disrupted and disadvantaged families than among those from stable, middle-class families. For example:

• Children living with their mother and a stepfather were three times as likely to have had a serious emotional or behavioral problem, and twice as likely to have had a learning disability, as those living with both biological parents.

• Children living with their mother only were twice as likely to have had a persistent emotional or behavioral problem as children living with both parents, and about 50 percent more likely to have a learning disability.

• Teenagers from low-income families were twice as likely to have repeated a grade or to have been suspended from school as teens from non-poor families. The higher prevalence of achievement and conduct problems was found both among those from welfare poor and those from working poor families.

• Learning disabilities were nearly twice as prevalent among children whose mothers had not completed high school as among those whose mothers had more than 12 years of education. Children of dropout mothers were also more apt to have repeated a grade in school.

In the 1988 survey, black and Hispanic parents reported fewer developmental, learning, and behavioral problems in their children than did nonminority parents. However, teacher reports and school records suggest that psychological problems are more common among minority children. The disparity between parent­ and school-based data may be due to cultural divergences in the awareness and acceptance of childhood psychological disorders or to differences in survey recall and reporting.

The alarmingly high prevalence of emotional and behavioral problems among today's children and the observed relationship between family conflict and disruption and youthful problem behavior reinforce public concerns about the increasing number of U.S. children who are being raised in something other than harmonious two-parent families. The survey findings also underscore concerns about minority youth and the extent to which their learning and behavioral problems go unrecognized and untreated.

Implications for Indicators of Child and Adolescent Health
Not only do we as parents and citizens need to do more to prevent and treat the mental health problems of young people, we need better and more appropriate information about their health and well-being. We must go beyond traditional indicators of death, disease, and disability, and develop measures of health­ related behavior, knowledge, and attitudes that can be repeated

at regular intervals to track changes in prevalence. Also needed are better measures of problems such as delays in development, learning disabilities and emotional and behavioral problems.

These problems affect not only the current well-being of children but the quality of our future labor force as well.

In order to understand why changes in health and habits are
occurring, factors that shape youthful behavior and well-being should be assessed periodically. These include the composition of the families in which young people are being raised,

characteristics of the home environment, and patterns of parental behavior. Also relevant are conditions in the community and school, peer characteristics, media influences, shifts in the climate of opinion regarding behaviors such as drug and alcohol use, types of medical care available to the youth and family, and participation in health-promotion programs.

Children are both a national treasure and a critical
resource, and we need to learn much more about the factors that enhance and undermine their development.

Disparities in Overall Health Status

The vast majority of young children appear to be in good physical health. However, parents of poor children are notably less positive when describing their children's health than are

the parents of more affluent children. Moreover, the minority of children who are in poor health is twice as large among children in poverty than among other young children.

• When parents are asked to rate their children's health in national health surveys, 95 percent of children under age 5 in poor families are rated as being in "good" to "excellent" health. However, less than half 41 percent -- are rated in "excellent" health, whereas a majority of non-poor children -- 58 percent -- are so described.

The proportion of poor children who are described as being
in "fair" or "poor" health -- 5 percent -- is more than twice as large as the comparable proportion of non-poor children-- 2 percent (NCHS, 1988).

(Although parental ratings of children's health are obviously not the same as a physician's appraisal, they have been found to be reasonably good indicators of general health status, and predictive of future use of medical care.)

Disparities in Health Limitations
Among children under 5, the prevalence of chronic health conditions that limit activity is about the same for poor and non-poor children. Among school-aged children, however, the

proportion of poor children who are reported by their parents to have chronic limitations jumps to nearly twice that of non-poor children.

• About one in every 50 poor children under 5 -- 2.5 percent
- has a chronic health condition that limits the child in playing with other children or other daily activities. This is about the same as the proportion of non-poor children who have limiting conditions -- 2 percent.

Among school-aged poor children (ages 5-17), the proportion
with health conditions that limit them in schoolwork or play is 9.6 percent, nearly twice as large as the proportion of non-poor school-aged children who have limiting conditions,

5.6 percent {NCHS, 1988).

These findings suggest that a substantial minority of young children in low-income families have undiagnosed conditions that are only discovered when they reach school. Many of these conditions are learning disabilities, perceptual disorders, or emotional disturbances that become apparent in the school environment. Children with these conditions could well benefit from earlier diagnosis and treatment of their disorders.

Frequency of Medical Care
Poor children receive less frequent and less appropriate medical care than children from more affluent families. They are also less likely to have their medical care covered by some form of health insurance. Thanks to Medicaid and other child health programs, most poor children are able to receive medical care

when needed. The frequency with which poor children see physicians is lower but not greatly different than that for non­ poor children. Given that poor children have more health problems, however, they should probably be seeing doctors more often than non-poor youngsters.

• In 1988, 79 percent of children aged 1-4 in families with incomes of less than $10,000 had been to the doctor within the last year. However, the proportion of poor children who had not seen a doctor in a year or more 21 percent -- was significantly higher than the comparable proportion for children in families with incomes of $40,000 or more -- 14 percent (Bloom, 1990).

The proportion of young children who had a regular source of
routine care was 88 percent in the low-income families, versus 97 percent in the higher income families.

• Among children aged 8-11, less than half in families with incomes below $10,000 had seen a doctor for routine care within the last year, compared with 56 percent in families with incomes of $40,000 and over.

• In 1987, poor children under age 5 had an average of 5.7 doctor visits per person per year, whereas non-poor children had an average of 7.1 visits (NCHS, 1988). (These figures include both check-ups and treatment visits, and include contacts with physicians over the telephone.)

As far as visits to a physician in the doctor's office (as
opposed to a clinic or hospital setting) were concerned, poor children had an average of 2.7 per person per year in

1987, whereas non-poor children had an average of 4.2 visits

(NCHS, 1988).
• For children aged 5-17, the mean number of doctor visits was
2.9 for those below and 3.5 for those above the official poverty line.

Differences in Place of Care

There is a considerable difference between poor and non-poor children and minority and non-minority children with respect to where they receive medical care. Poor children and black and Hispanic children are more likely to receive their· care in hospital emergency rooms and clinics, and less likely to receive it in private physicians' offices or HMOs.

• In 1988, 40 percent of children aged 1-4 in families with incomes below $10,000 had clinics or hospital emergency rooms as their regular source of care. This was true of

only 7 percent of young children in families with incomes of
$40,000 and more (Bloom, 1990).
• Among black children aged 1-4, 41 percent had clinics or emergency rooms as their regular place of care, as did 26 percent of Hispanic children, but only 11 percent of white children.

• In 1987, nearly a fifth of the doctor visits that poor young children had were in hospital settings, and more than one­ tenth were in emergency rooms. Non-poor children were only half as likely to have received medical care in these settings (NCHS, 1988).

The medical care that a child receives in a hospital emergency room may be perfectly adequate for the treatment of an acute illness or injury. But doctors working in such settings are less able to provide the continuity of care and preventive

counseling that office-based pediatricians and health maintenance organizations (HMOs) can provide. Having always to take the

child down to a clinic or emergency room, as opposed to being
able to talk to a doctor over the telephone about a child's condition, means more of a time burden on the parent. Faced with this burden, the parent may be hesitant about taking the child to get care in cases where she is unsure whether or not it is

needed. Poor and minority mothers also frequently face language and other barriers to receiving suitable medical care for their children.

Health Insurance Coverage
One-quarter of young children who live in lower income families are not eligible for Medicaid coverage, do not get health insurance coverage through their employers, and cannot afford to purchase it on their own. This lack of medical coverage is actually more prevalent among poor children in two­ parent families and children in single-parent families headed by divorced women than among those in single-parent families headed by never-married mothers, because the latter are more likely to be eligible for Medicaid. And the problem is just as prevalent among the near poor (children in families with incomes between

the poverty level and one-and-a-half times the poverty level), as it is among children below the poverty line.

• As of 1988, 26 percent of children aged 1-4 in families with incomes of less than $10,000 were not covered by a health insurance plan or Medicaid. Almost the same figure -- 24 percent -- applied to those in families with incomes between

$10,000 and $24,999 (Bloom, 1990).
• The comparable proportion for all children aged 1-4 was 16 percent, and for those with incomes of $40,000 or more, only

7 percent.

• The proportion with no health insurance coverage was 25 percent among Hispanic children aged 1-4, 16 percent among white children, and 20 percent among black children.

• In 1986, among poor children living in two-parent families,

37 percent had no health insurance. Among those living with divorced mothers, the proportion with no health insurance

was 22 percent, whereas among those living with never­ married mothers, it was 15 percent (U.S. House Select Committee, 1989, pp. 212-213).

Nutritional Status of Young Children in the u.s.
Adequate nutrition in early childhood is critical for normal growth and brain development. In the past, living in poverty often meant not having enough to eat. Indeed, the very defini­ tion of the official government poverty line was originally based on the amount of income needed to provide a family with a minimally adequate diet. Since the advent of the food stamps program in the mid-1960s, however, low-income families whose incomes were insufficient to purchase a subsistence diet (as well as pay for other necessities like shelter, clothing, and transportation) have been able to receive government-provided vouchers that could be used to buy food. Unlike AFDC, two-parent families are eligible for food stamps, and benefits are indexed

to increase with inflation. There are also programs aimed
specifically at bolstering the nutrition of poor children: the School Lunch program and the Special Supplemental Food Program for Women, Infants, and Children (WIC).

In fiscal year 1987, the food stamps program served an average of nearly 21 million people per month, about half of whom

were children. Nearly 17 percent of all children under 18 received food purchased with food stamps, including 60 percent of poor children under 6, and a larger majority of those in very-low income families. In addition, the WIC program provided about 3.4 million infants, young children, and pregnant or nursing women with special dietary supplements in FY 1987 (U.S. House Committee on Ways and Means, 1989, pp. 1102-1120).

Does this mean that most poor children in the United States are getting enough to eat, and enough of the right kinds of food to eat? Government survey data indicate that they are, but that conclusion is contested by food program advocates. The advocates contend that the federal surveys do not measure hunger, and that

a substantial fraction of children in poor families go hungry fairly often. There are some data indicating that poor children under 6 are more likely than other children to exhibit signs of poor nutrition, such as growth retardation and anemia (Klerman & Parker, 1990). These modest but persistent differences in nutritional status between poor and non-poor children may result in part from the failure of federal food programs to reach all eligible children. It is also generally acknowledged that there

are still pockets of malnutrition in the u.s. among groups like
the children of migrant farm workers.

Findings of the Nationwide Food Consumption Survey

The u.s. Department of Agriculture conducts a continuing
Nationwide Food Consumption Survey that includes national samples

of women aged 19 to 50 years of age and their children 1 to 5 years of age. Separate samples are taken of all women and children in these age ranges, and of low-income women and children. The latter oversamples households in high-poverty areas. In 1985 and 1986, these surveys found that the average daily food intakes of young children from poor families met or

exceeded the 1980 Recommended Dietary Allowances (RDAs) for total
food energy, protein, vitamins, and most minerals (USDA, 1987a and 1987b). Only iron and zinc intakes were somewhat deficient, ranging from 70 to BB percent of the recommended levels.

However, average intakes of these minerals were also below recommended levels among young children whose family incomes were above the poverty level.

Unfortunately, the published survey results do not show what proportion of low-income children fall below the Recommended Dietary Allowances. However1 given that the low-income means are quite similar to the overall means, it is unlikely that the proportion with dietary deficiencies would differ greatly across the two samples.

The survey results did show some differences between the dietary patterns and nutrient intakes of poor young children and those of young children from all income groups. Among them were the following:

• The diets of low-income children contained slightly more fat, cholesterol, and sodium per 1,000 kilocalories, and

less dietary fiber, than those of children from all income groups.

• Total meat consumption was slightly higher for low-income children, with intakes of hot dogs and luncheon meats showing the largest difference.

In 1986, low-income children ate more grain products than
did children from all income groups, largely as a result of consuming more grain-mixture items such as pizza, enchiladas, and rice and pasta mixtures.

On average, low-income children drank more whole milk than
did children from all income groups, and whole milk (as opposed to lowfat or skim milk) was a larger proportion of their total milk intake.

• Low-income children ate less fruit than did young children overall.

• Low-income children consumed slightly less candy and sugar than children overall.

• Low-income children drank less soda, but more "Koolaid"-type drinks and fruit-flavored drinks than children overall.

• Young children from low-income families were less likely to be given vitamin and mineral supplements than were all young children.

Low Birth Weight

Nearly 7 percent of all babies born in the U.S. each year are of low birth weight; i.e., they weigh 5 1/2 pounds or less. Slightly more than one percent are of very low birth weight: they weigh 3 1/4 pounds or less (NCHS, August 1990, Table 15). With the total number of births now at 4 million per year, there are roughly 275,000 low-birthweight infants born each year, of whom nearly 50,000 are of very low birth weight.

Low birth weight is one of the leading causes of infant mortality, with 60 percent of all deaths in the first year of life occurring among low-birthweight infants. Low-birthweight babies are nearly twice as likely as other infants to exhibit

severe developmental delays or congenital anomalies, and they are at greater risk of cerebral palsy, autism, mental retardation, vision and hearing impairments, and other developmental disabilities (Public Health Service, 1990, p. 10; Shapiro et al,

Children born at very low birth weights are twice as likely to repeat a grade in school and 3 1/2 times more likely to need special education services as those born at normal birth weights

{McCormick, Gortmaker, & Sobol, 1990; Newman, 1990). Children
born at low, but not very low, birth weights are about 60 percent more likely to repeat a grade, but not significantly more apt to require special education. A recently released study sponsored

by the Robert Wood Johnson Foundation found that the
developmental risks associated with very low birth weight could

be reduced through comprehensive intervention programs {Robert

Wood Johnson Foundation, 1990).
Low birth weight has been linked to several preventable risk factors including teen pregnancy, unintended or unwanted pregnancy, lack of prenatal care, poor nutrition doing pregnancy, maternal smoking and use of alcohol and other drugs (President's Committee on Mental Retardation, 1988; Public Health Service,

1979). Low birth weight babies are more common among low­ education and low-income mothers than among those with more schooling and higher incomes. Black infants are more than twice as likely as white infants to be born at low birth weights (House Select Committee on Children, 1989, pp. 166-167). Puerto Rican infants are more likely to be of low birth weight than infants from other Hispanic groups or non-Hispanic children.

There was a slight decline in the proportion of children
born at low birth weights during the 1970s, but there was no further progress during the 1980s. Indeed, the most recent data indicate a slight upturn in the low birth weight proportion among black infants, coupled with a slight decline in low birth weight among white infants (NCHS, August 1990, p. 6). A major reason

for the lack of improvement in the percent of low-birthweight
babies during the 1980s was a rise in the proportion of preterm births during this period (Taffel, 1989). This proportion rose from 9.4 to 10.2 percent between 1981 and 1988, and almost 40 percent of preterm births were of low birth weight (NCHS, August

1990, p.6).

The u.s. Public Health Service has declared a national "Risk
Reduction Objective" to reduce the overall incidence of low birth weight to no more than 5 percent of live births by the year 2000, and the incidence of very low birth weight to no more than 1 percent of live births (Public Health Service, 1990, p. 373).

For black infants, the national goals are to reduce low birth
weight incidence to 9 percent, and the very low birth weight proportion to 2 percent. It may be difficult to achieve these goals, given the lack of progress in recent years, and the negative effects of the "crack" epidemic on maternal and infant health in low-income, minority populations.


Bloom, B. (1990, October 1). Health insurance and medical care.

Health of our nation's children, United States, 1988.

Advance Data from Vital and Health Statistics of the

National Center for Health Statistics, No. 188.
Centers for Disease Control, Division of Immunization. (1989).

Unpublished data from annual School Enterer Assessment.
Chollet, D. (1988, October 5). Uninsured in the United States: The nonelderly population without health insurance, 1986. Employee Benefit Research Institute.
The Infant Health and Development Program. (1990, June 13).

Enhancing the outcomes of low-birth-weight, premature

infants. A multisite, randomized trial. Journal of the

American Medical Association, 263(22): 3035-3042.
Klerman, L. V., & Parker, M. (1990). Alive and well? A review of health policies and programs for young children. New York, NY: National Center for Children in Poverty. In press, p.


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