Children and Adolescents

Preface. Part I. General Issues. 1. Overview of Behavioral Assessment with Children and Adolescents-David Reitman, Heather Christiansen, and Julie Snyder. 2. Diagnostic Issues- Amanda Jensen Doss, Krystal T. Cook, and Bryce D. McCleod. 3. Behavioral Conceptualization- Paul S. Strand, Lisa W. Coyne, and Kerry Silvia. 4. Developmental Issues- Christopher T. Barry and Jessica D. Pickard. 5. Overview of Behavioral Treatment with Children and Adolescents- Elizabeth Kolivas, Patrick Riordan, and Alan M. Gross. 6. The Role of Family in Treatment- Elizabeth V. Brestan and Lorraine E. Ridgeway. 7. Medical and Pharmacological Issues- Scott Kollins and Joshua M. Langberg. 8. Ethical Issues- Ian M. Evans. Part II. Assessment, Conceptualization, and Treatment of Specific Disorders. 9. Depressive Disorders- Benjamin L. Hankin, Kathryn E. Grant, Catherine Cheely, Emily Wetter, Farahnaz Farahmand, and Robert Westerholm. 10. Anxiety Disorders- Jennifer S. Baldwin and Mark R. Dadds. 11. Posttraumatic Stress Disorder- Abby H. Friedman, Sara B. Stevens and Tracy L. Morris. 12. Oppositional Defiant and Conduct Disorders- Lee Kern and Talida State. 13. Learning, Motor, and Communication Disorders- T. Steuart Watson, Tonya S. Watson, and Jennifer Ret. 14. Attention-Deficit Hyperactivity Disorder- Mark D. Rapport, Michael J. Kofler, R. Matt Alderson, and Joseph S. Raiker. 15. Childhood Psychosis- Ian Kodish and Jon McClellan. 16. Substance Use Disorders- Eric F. Wagner and Ashley Austin. Part III. Special Populations and Issues. 17. Neglected, Physically Abused, and Sexually Abused Children- Jan Faust, Sara Chapman, and Lindsay M. Stewart. 18. Neurologically Impaired Children- Charles J. Golden. 19. Habit Disorders- Doug Woods, Christopher A. Flessner, and Christine A. Conelea. 20. Juvenile Firesetting- Timothy R. Stickle and Laurie B. Kaufman. 21. Enuresis and Encopresis- Patrick C. Friman. 22. Sleep Disorders- Emerson M. Wickwire, Jr., Malcolm M. S. Roland, T. David Elkin and Julie A. Schumacher. Author Index. Subject Index.


Why It Is Important
The population living below 100% of the federal poverty level (FPL) is considered to be in poverty. Nationwide, 17% of children-nearly 13 million-live in families with incomes below the federal poverty level. The number of children living in poverty increased 11% between 2000 and 2006. Official poverty rates are highest for young children with 20% of children under age 6 and 16% of children age 6 or older living in poor families. Food insecurity, lack of affordable housing and other hardships affect millions of American children and many poor children lack health insurance. 43

Why It Is Important
Health insurance is an important component of access to health care. People with medical insurance are more likely to have a primary care doctor and to receive adequate preventive care as compared to those without health insurance. 44 Children with health insurance are better able to receive timely check-ups ensuring they are healthy and developing appropriately. Children with health insurance also have more access to care for more chronic conditions such as asthma and diabetes.  San Joaquin County 2001 N: 180,000;2003 N: 187,000;N: 199,000. California 20012003 N: 9,488,000;2005 N: 9,759,000.

Why It Is Important
In response to the increasing number of uninsured children, the Federal Government created a health insurance program for children whose parents earn up to 250% of the Federal Poverty Level. Administered in California as "Healthy Families" since 1998, it has provided health insurance for the first time to many children who were not eligible for other programs. This program seems to be working to insure more children as according to CHIS 2005, 92% of County children under age 18 were insured in 2005 (please see the Children and Adolescents section for more information on this topic). It is likely that without the Healthy Families program and the new Healthy Kids program, many of these children would go without health insurance coverage.

Annual Health Assessments
Why It Is Important Regular and timely screenings for children and adolescents can detect health conditions at their early stages when they are most easily treated, as well as uncover potential risk factors for chronic disease that can be managed with lifestyle changes. 45 Since children undergo significant changes as they grow, regular health assessments can help determine whether or not the child is developing normally in the areas of physical, mental and emotional health.

Why It Is Important
Timely medical visits help residents get appropriate preventive care and treatment for common and chronic conditions. Parents and caregivers with a place to take their child or children for health care may be more likely to access care and to feel more comfortable accessing care when their children are sick or they need health advice.  San Joaquin County 2001 N: 178,000;2003 N: 187,000;N: 199,000. California 2001N: 9,267,000, 2003

Why It Is Important
The American Academy of Pediatric Dentistry and U.S. Health Resources and Services Administration (HRSA) recommends that parents take children to the dentist twice annually, but according to a study from the U.S. Department of Health and Human Services, almost one-quarter of U.S. children do not receive the recommended number of dental checkups and 21% of all children do not visit the dentist at all. 46 Regular dental visits for children are important for preventing, diagnosing and treating oral diseases and having dental insurance makes getting adequate dental care easier. Children who don't see dental professionals miss the opportunity to have problems caught early before they escalate into larger, more expensive problems to treat.

Why It Is Important
Teen girls face a greater risk of delivering low birth weight babies and their babies have a higher risk of infant mortality. 47 Teen mothers are less likely to complete high school and go on to college than teens who delay childbirth. Only one-third of teen mothers receive a high school diploma and only 1.5% attains a college degree by the age of 30. 48 Due in parts to an interruption in the mother's education, babies born to teen mothers are more likely to live in poverty. 49

What The Data Tell Us
Each year between 1997 and 2006, over half of San Joaquin County teen mothers received prenatal care in the first trimester of their pregnancy. During this same time period, between 6% and 10% of teen births were born under 5.5 pounds, which is considered low birth weight. Additionally, during this same time period, a higher percentage of births to teen mothers were at low birth weight compared to births to mothers of all ages. 52

Go Before You Show
The "Go Before You Show" message is being communicated to San Joaquin County residents in an effort to encourage women to see a doctor within the first three months of pregnancy. This message is being delivered in several ways, including an Internet website, posters, and the following radio announcement: If you're pregnant, or even just think you might be, remember one thing:

Why It Is Important
Since the 1970s, the percentage of overweight children and adolescents in the United States has more than doubled. In 2007, 10% of 2-to 5-year-olds and more than 15% of children between the ages of 6 and 19 were overweight. If the percent of youth who are overweight or at risk of becoming overweight are combined, about one out of three children are affected. Overweight children are at risk for serious health problems like type 2 diabetes, high blood pressure and high cholesterol -all once considered exclusively adult diseases. Risk factors present in childhood can lead to serious adult medical conditions like heart disease, heart failure and stroke. Preventing or treating obesity in children may reduce the risk of developing these conditions as they get older. 54 Young people who are underweight (less than 5 th percentile for Body Mass Index) may be that way for a variety of reasons, including dietary, health or emotional problems. An under-nourished child is more likely to become sick, may feel weak or tired, have trouble focusing and concentrating, may have stunted growth or a delay in the onset of puberty. It has been estimated that 12 million children live in foodinsecure households, meaning that they have limited availability of nutritious and safe foods. 55

Youth Physical Activity
Why It Is Important Regular physical activity helps children maintain a healthy weight. Children who are physically fit are less likely to suffer from chronic diseases in childhood and adulthood, and are more likely to become physically active adults, which in turn helps reduce the risks of heart disease and diabetes.

What The Data Tell Us
From the 2002-03 to the 2006-07 school year, student "fitness" improved by a small margin for all grades in San Joaquin County. In 2006-07, over half of 5 th , 7 th and 9 th graders achieved five or more standards while 7 th graders had the highest percentage of students achieving at least five fitness standards, at 55%.
California consistently had a higher percentage of students achieving at least five standards than did the County from 2002-03 to 2006-07; over half of California students achieved five or more standards each year. In 2006-07 specifically, 7 th graders had the highest percentage of students achieving five or more fitness standards (57%).
According to the California Healthy Kids Survey, the majority of San Joaquin County 7 th and 9 th graders (over 70%) reported exercising or doing a physical activity for at least 20 minutes that made them sweat and breathe hard during the 1999-00, 2002-03, 2004-05, and 2006-07 school years. The percentage of students who reported exercising for at least 20 minutes was lowest among 11 th graders each year (61%-63%).

HEALTHY PEOPLE 2010 OBJECTIVE:
Increase the proportion of adolescents who engage in vigorous physical activity that promotes cardiorespiratory fitness.

Child and Adolescent Nutrition
Why It Is Important Research shows that good nutrition can help to lower people's risk for many chronic diseases, including heart disease, stroke, some cancers, diabetes and osteoporosis. 56 The United States Department of Agriculture (USDA), the National Academy of Sciences, the American Cancer Society and the National Cancer Institute recommend that people consume between 5 to 9 serving of fruits and vegetables each day to help maintain good health and reduce the risk of cancer and heart disease. 57 It is widely noted that fast food restaurants serve foods that are full of calories, saturated fats and carbohydrates. Eating fast food on a regular basis can contribute to high cholesterol, diabetes and weight problems. Saturated fats have been directly linked to heart disease, sugar to diabetes and sodium to high blood pressure. A steady diet of these non-nutrients can lead to many health problems. 58  Note: Totals may not equal 100% due to respondents answering "Don't know."

What The Data Tell Us
From 2002-03 to 2006-07 there were no large changes in the percentage of San Joaquin County students who reported consuming five or more portions of fruits or vegetables in the past 24 hours. In each survey year, 7 th graders had the highest percentage of students eating fruits or vegetables in the past day (54%-57%). They were followed by 9 th graders (47%-49%) and 11 th graders (41%-44%). In 2006-07, the percentage of students who reported eating five or more servings of fruits or vegetables in the past 24 hours was 57% for 7 th graders, 48% for 9 th graders and 44% for 11 th graders.
When asked how many times in the past week their children have eaten fast food, the greatest percentage of respondents to the 2007 Healthier San Joaquin County telephone survey replied "one time" (37%) followed by "never" (32%) and then "two times" (17%). The greatest percentage of 2007 face-to-face survey respondents indicated their children had never eaten fast food in the past week (30%), which was followed by "one time" (27%) and then "two times" (17%).

Community Medical Centers, Inc.
Community Medical Centers, Inc. (CMC) has developed a preventative health program geared towards patient selfmanagement. CMC provides clinic-based health and nutrition education that includes one-to-one education and small group classes in asthma, diabetes, cholesterol, obesity, cardiovascular illness, and other health topics. Services provided by Health Educators are geared towards initiating patient behavior change.

Stories of Health Education Successes
Carlos, a four year old boy, was referred by his pediatrician to the Health Educator due to his weight problem. His family was very worried about his weight due to their family history of diabetes, heart attack, and stoke. They didn't understand why he kept gaining weight. Both Carlos and his parents attended the Nutrition classes, where they learned how to prepare their meals in a healthy way. They were taught how to read food labels and what types of food to avoid. They learned a lot about trans fat and non-trans fat. The Health Educator encouraged the family to drink low-fat or nonfat milk and to opt for water instead of juice. They also learned a lot about food servings, and Carlos' parents asked many questions about what each portion looks like. The Food Pyramid materials were utilized to help them learn how to prepare well balanced meals. Most importantly, the Health Educator also stressed the importance of eating healthy snacks.
She gave a list of different snacks that they could buy instead of candies and cakes. She also explained how walking together could help Carlos significantly reduce his weight, and the benefits to the entire family. At the end of the 4th class Carlos lost 8 lbs. and they were very happy. The family continues to improve their eating habits and still comes to Nutrition classes seeking new low-calorie recipes that they can try.

Why It Is Important
The National School Lunch Program qualifies low-income children living in families below 185% of the Federal Poverty Level for reduced-cost meals and those below 130% of the Federal Poverty Level to qualify for free meals.
Free and reduced cost meal programs serve children who might otherwise go without meals or choose nutritionally inferior food because of cost. School breakfasts and lunches also provide a nutritionally balanced and appropriately portioned meal at the lowest possible price. Moreover, studies have shown that when children's nutritional needs are met they have fewer attendance and discipline problems and are more attentive in class. 59

Why It Is Important
Asthma is a chronic disease that causes the airways in the lungs to become sore and swollen. In the United States, about 9 million children have asthma. Children have smaller airways than adults, which makes asthma especially serious for them. Children with asthma may experience wheezing, coughing, chest tightness and trouble breathing. 60 Asthma is the leading cause of activity restriction among children and is the second most common chronic childhood condition. 61 Note: Questions about treatment and about management plan was asked only of those respondents who reported that their children had been diagnosed with asthma. About a fourth of adult respondents to the Healthier San Joaquin County telephone survey reported that their children had asthma in 2004 and 2007. Seven out of every ten children diagnosed with asthma (about 72%) were receiving treatment each year while a smaller percentage had been given a management plan by their doctor (53% in 2004 and 59% in 2007).

HEALTHY PEOPLE 2010 OBJECTIVE:
At least 30% of people with asthma will receive patient education.

Why It Is Important
Most children with diabetes have type I diabetes. Type 1 diabetes is a disease of the immune system where the immune system attacks and kills the insulin-producing cells of the pancreas. People with type 1 diabetes must take insulin daily to survive. In comparison, type 2 diabetes occurs when the body is no longer able to use insulin well and this type of diabetes occurs most frequently in overweight adults ages 40 and older. As the number of children who are overweight, obese and/or inactive rises, more children are being diagnosed with type II diabetes. 62

HEALTHY PEOPLE 2010 OBJECTIVE:
Fewer than 2.5% of people will have diabetes.

What The Data Tell Us
In 2003 and 2005, a small percentage of children ages 12-17 in both San Joaquin County and California had been diagnosed with diabetes. Unfortunately, due to the low number of respondents in both CHIS years, the San Joaquin County data are statistically unreliable. However, less than 1% of California children ages 12-17 were diagnosed with diabetes each survey year. There is no specific Healthy People 2010 Objective for childhood diabetes, but the overall objective is that fewer than 2.5% of people will have diabetes.

Give Every Child a Chance
Sometimes, families have to compromise the quality or quantity of nutrition and exercise for a variety of reasons.
Lack of knowledge about nutrition and time constraints of today's living often leave children at the short end of the stick for a healthy meal. "Inadequate nutrition and exercise can have its effect on a child's behavior and performance in school," said Carol Davis, President and CEO of Give Every Child a Chance (GECAC). "We offer handson activity-driven education combining classroom instruction with outdoor activities around a healthier family theme. We're seeing results in learning and school attendance."

Why It Is Important
Smoking and secondary smoke have serious health consequences for people of all ages; however, tobacco use by young people is particularly problematic as the earlier a person uses tobacco the more heavily he or she is likely to use tobacco as an adult. 63 Nearly all first use of tobacco takes place before high school graduation; almost 90% of adult smokers started at or before the age 19. For the most part, people who do not start using tobacco when they are teens never start using it. 64 Cigarette smoking causes serious health problems among children and teens, including coughing, shortness of breath, respiratory illnesses, reduced physical fitness, poor lung growth and function, worse overall health and addiction to nicotine.

What The Data Tell Us
According to the California Healthy Kids Survey conducted in both 2004-05 and 2006-07, 30-day and lifetime cigarette usage increased as students got older. In 2006-07, 16% of 7 th graders have ever smoked compared to 29% of 9 th graders and 40% of 11 th graders. These percentages have decreased since 2004-05.
In 2006-07, 4% of 7 th graders have smoked in the past 30 days compared to 9% of 9 th graders and 13% of 11 th graders. These percentages were slightly lower than the percentages for 2004-05.

Why It Is Important
Youth who engage in substance abuse are more likely to also engage in risky or unhealthy behavior that can result in serious diseases, chronic health conditions, injuries and even death. Drug use is also linked to educational failure, family and social problems. Unfortunately, most drug use is cyclical as children with parents who have a history of use are more likely to use themselves. 65

What The Data Tell Us
Marijuana use increased by grade, but within each grade, has remained consistent between 2004-05 and 2006-07. In both 2004-05 and 2006-07, 8% of 7 th graders, 24% of 9 th graders and 37% of 11 th graders used marijuana. In 2006-07, the percentage of students who used inhalants was fairly similar across grade. Eleven percent (11%) of 7 th graders, 12% of 9 th graders, and 11% of 11 th graders used inhalants. In 2006-07, 5% of 9 th graders used cocaine compared to 8% of 11 th graders, and 4% of 9 th graders used methamphetamine compared to 6% of 11 th graders. Seventh graders were not asked whether or not they used cocaine or methamphetamine.

Why It Is Important
Alcohol is the leading drug of abuse by American youth. The National Center on Addiction and Substance Abuse connects youth alcohol consumption to dangerous sexual activity, school drop outs, overdose deaths and suicides. Moreover, the center indicates that teens who experiment with alcohol are "virtually certain" to continue using alcohol in the future. 66 Figure 129:

What The Data Tell Us
As with tobacco use, the percentages of students who had ever consumed alcohol and who had used alcohol in the past 30 days increased with age in both 2004-05 and 2006-07. In 2006-07, 21% of 7 th graders, 42% of 9 th graders and 62% of 11 th graders had ever used alcohol. These percentages either did not change or changed very little from 2004-05 where 21% of 7 th graders, 45% of 9 th graders, and 61% of 11 th graders had ever used alcohol. The percentages of students who had used alcohol in the past 30 days in 2006-07 decreased slightly from 2004-05. In 2006-07, 11% of 7 th graders, 24% of 9 th graders and 34% of 11 th graders used alcohol in the past 30 days.

Why It Is Important
Youth who engage in illegal activities are a risk to themselves, their friends and family and the larger community. Moreover, young offenders recidivate at a high rate, often returning to criminal activity even after becoming adults. Juvenile arrest rates may also indicate other risk-taking behavior and be a sign of substance abuse, poverty, gang involvement and mental health issues. 67

Why It Is Important
In 2001, suicide was the third leading cause of death among teenagers ages 15-19. 68 Because the death of a young person is usually only called a suicide if there is a suicide note, many health professionals believe suicides are underreported. Further, injuries are not tracked systematically unless they result in hospitalization or death. Thus, these nonfatal self-inflicted injury hospital data only represent the most serious injuries among children. Suicidality, including intentional self-harm and completed suicide, is indicative of serious mental health problems and may signal other traumatic life events such as depression, social isolation, discrimination and physical or substance abuse. A growing body of research estimates that gay, lesbian, bisexual and transgendered youth attempt suicide at a rate 2-3 times higher than their heterosexual peers. 69

What The Data Tell Us
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Why It Is Important
Many experts estimate that violence in adolescent dating relationships is a large-scale problem and may result in long-term trauma and psychosocial problems for victims. Further, violence in dating relationships among youth may be viewed as a precursor to violence in adult relationships. Statistics indicate that there may be a progression from hurtful gossiping and teasing to serious forms of violence such as pushing, hitting and punching a boyfriend or girlfriend. 70 Relationship violence has been associated with other serious health-risk behaviors, such as alcohol and drug abuse, eating disorders, depression, risky sexual behavior, poor school performance and suicidal behavior. 71

Homeless Youth
Why It Is Important The majority of homeless families consist of a single mother and her children. However, homeless youth also consist of runaways and other youth who do not come from homeless families. Homeless children face significant health challenges and are more likely than non-homeless youth to go hungry. Further, homeless youth are 12 times as likely to end up in foster care and 20% of these children do not attend school. 72 Those who do attend school may face challenges such as having to repeat a grade or being suspended.
Homeless children are guaranteed enrollment in school by the federal McKinney-Vento Act and California state law. Children and youth are considered homeless if they live: In a shelter (family, domestic violence or youth shelter or transitional living program) In a motel, hotel or weekly rate housing In a house or apartment with more than one family because of economic hardship or loss In an abandoned building, in a car, at a campground or on the street In temporary foster care or with an adult who is not your parent or guardian In substandard housing (without electricity, water or heat) With friends or family because you are a runaway or an unaccompanied youth 73

What The Data Tell Us
During the 2003-04 school year, there were 222 homeless students enrolled in San Joaquin County schools. Students in elementary school (kindergarten to 5 th grade) accounted for most of those students (165) followed by pre-kindergarten students (30) and 6 th to 8 th grade students (22