I’ve spent part of the last couple of days reading some of the arguments against the modern U.S. childhood vaccine schedule at places like the National Vaccine Information Center, SafeMinds, and in the medical investigative reporting of Robert F. Kennedy, Jr. One of the statements you run across quite often is that today’s children — going back to children born in early 1990’s — are less healthy and generally much sicker than children of earlier generations. Where does this idea come from? It turns out that one of the places that it comes from is a 2007 commentary published in the Journal of the American Medical Association (JAMA), entitled “The Increase of Childhood Chronic Conditions in the United States.” This commentary, by James Perrin, Sheila Bloom, and Steven Gortmaker — all of Harvard University — got an enormous amount of media attention, so it’s no wonder that it’s cited so often. Unfortunately, one of the most-cited statements from the commentary is an observations about time trends, in which the authors’ interpretations of the data are just downright wrong.

Bloomberg News Service started out their report on the JAMA commentary with the shocker, “The number of American children with chronic illnesses has quadrupled since the time when some of their parents were kids, portending more disability and higher health costs for a new generation of adults, a study estimates.” This is based on the following sentence from the JAMA commentary: “In 1960, only 1.8% of US children and adolescents were noted by their parents to have a limitation of activity due to a health condition of more than 3 months’ duration; in 2004, these rates had increased to more than 7% or more than 5 million children and youth.” This sentence is so loaded with problems that I need to devote a whole post to it, especially since it’s been quoted so often by the media.

If you’re a stickler for exactitude, you might be happy about two things, but not for long. Both the 1960 percentage of 1.8 and the 2004 percentage of 7 come from the same annual survey, The National Health Interview Survey (NHIS) carried out by the National Center for Health Statistics (NCHS). Both refer to the “percentage of children with limitation of activity resulting from one or more chronic health conditions.” Unfortunately, there have been several changes over time in the NHIS that render the two percentages incomparable, but the biggest problems are that:
(1) the definition of “children” in standard NHIS tabulations changed from 0-16 years old to 0-17 years old; and
(2) the NHIS question about activity limitation due to a chronic health condition changed completely between 1996 and 1997.

National Health Interview Survey Questionnaire Probes for Determining Presence of Activity Limitations, 1969-1996

Age under 1 year:
Is __ limited in any way because of his health?
Age 1-5 years:
Is __ able to take part at all in ordinary play with other children?
Is he limited in the kind of play he can do because of his health?
Is he limited in the amount of play because of his health?
Age 6-16 years:
In terms of health would __ be able to go to school?
Does (would) -_ have to go to a certain type of school because of
his health?
Is he (would he be) limited in school attendance because of his health?
Is he limited in the kind or amount of other activities because of his
health?
All ages responding NO to the above probes:
Is __ limited in ANY WAY because of a disability or health? (Added in 1969)
[Note: At one point, the interviewer explains that the health condition or disability must have a duration of three months or more.]

(Source: National Health Interview Survey questionnaire 1980.)

National Health Interview Survey Questionnaire Probes for Determining Presence of Activity Limitations, 1997-present

Age Under 5 years: Parent is asked:
“Is (child’s name) limited in the kind or amount of play activities [he/she] can do because of a physical, mental, or emotional problem?”
[Note: At one point, the interviewer explains that the physical, mental, or emotional problem must be a condition that once acquired is not cured or has a duration of three months or more.]

Age 0-18 years, Parent is asked
(1) “Does (child’s name) receive Special Education Services or Early Intervention Services?”
(2) “Is (child’s name) limited in any activities because of physical, mental, or emotional problems?”

Age 3-17: Parent is also asked:
(3) “Because of a physical, mental, or emotional problem, does (child’s name) need the help of other persons with personal care needs, such as eating, bathing, dressing, or getting around inside the home?“
(4) “Because of a health problem does (child’s name) have difficulty walking without using any special equipment?”
(5) “Is (child’s name) limited in any way because of difficulty remembering or because of periods of confusion?”

(Source: National Health Interview Survey 2006.)*

As I noted above, the JAMA Commentary said: “In 1960…only 1.8% of US children and adolescents were noted by their parents to have a limitation of activity due to a health condition of more than 3 months’ duration…” The actual source for this percentage of 1.8 is an excellent 1984 paper by Paul Newacheck and colleagues in the American Journal of Publlic Health. For the subject of today’s post, the paper by Newacheck et al. is useful for two reasons: First, it has a table (Table 1) showing the year-by-year trend in per cent of children (under 17 years of age) with limitation of activity between 1960 and 1981. During that period the reported percentage increased from 1.8 to 3.8. Second, the authors examine in detail “the hypothesis that increased prevalence of activity limitations can be explained by changes in survey procedures, changes in awareness of illness, and/or changes in the size of the institutional population.” For example:

1. Prior to 1967, only those respondents who had reported a chronic condition in response to probes earlier in the interview were asked about the presence of an activity limitation.
2. Beginning in 1967, questions pertaining to activity limitation were asked of all sample persons.
3. Also beginning in 1967, activity limitation categories were read to the respondent; previously, respondents had been asked to choose an appropriate activity limitation response from a printed card.
4. Beginning in 1969, when persons responded negatively to the usual probes on activity imitation an additional question was asked: “Is __ limited in ANY WAY because of a disability or health?” It was then left to the coder to determine whether the response would be classified as an activity limitation.

Since the Newacheck et al paper is a public access article, I’ll leave it to you to read their thoughts on changes in the awareness of illness during 1960-1981 (”…increased awareness has not been a major contributor to the upward trend.”) and changes in the institutionalized population during the period. I do agree with Newacheck et al. that between the early 1960’s and the early 1980’s there probably was a near doubling of the proportion of children with limitations of activity due to chronic illness.

But what I’d really like to show you is more recent time trends, especially trends in the 1990’s and early part of this decade. Most of the the following data comes from the report, America’s Children: Key National Indicators of Well-Being, which has been published annually by the Federal Interagency Forum on Child and Family Statistics since 1997. For some years, America’s Children did not publish data for 0-4 year old children. For those years, I got the data from Health, United States, an annual report on trends in health statistics published by NCHS.

It seems that the standard NCHS definition of “children” for NHIS tabulations from 1960 through the 1980’s was “under 17 years of age.” I’m not sure why they chose 1984, but the Federal Interagency Forum on Child and Family Statistics seems to have asked NCHS to go back and do special tabulations for 1984, so they could use 1984 as their baseline or “benchmark” year.

TABLE 1. PERCENTAGE OF CHILDREN AGES 0-17 WITH ACTIVITY LIMITATION RESULTING FROM ONE OR MORE CHRONIC HEALTH CONDITIONS BY AGE, 1984

Year Total Age 0-4 Age 5-17
1984 5.0 2.5 6.1

 

Table 2 shows prevalence rates from 1990 to 1996, when the NHIS question about limitation of activity due to chronic disease was the same as in 1984.

TABLE 2. PERCENTAGE OF CHILDREN AGES 0-17 WITH ACTIVITY LIMITATION RESULTING FROM ONE OR MORE CHRONIC HEALTH CONDITIONS BY AGE, 1990-1996

Year Total Age 0-4 Age 5-17
1990 4.9 2.2 6.1
1991 5.8 2.4 7.2
1992 6.1 2.8 7.5
1993 6.6 2.8 7.5
1994 6.7 3.1 8.2
1995 6.0 2.7 7.4
1996 6.1 2.6 7.5

(Source: National Center for Health Statistics, National Health Interview Survey, 1990-1996.)

It looks like there was a jump in the prevalence rate between 1990 and 1991. Then the rates remained essentially stable between 1991 and 1996. Before you get all excited and conclude that “something happened” between 1990 and 1991 to “cause” these rates to increase, sit back and take ten deep breaths while I explain a few things. First, the entire increase occurred in 5 to 17 year-old children — not in infants and pre-schoolers. Second, these are not birth cohorts. The 5-17 year old children in the 1990 NHIS were born duing the period 1973-1985 and the 5-17 year old children in the 1991 NHIS were born in the perid 1974-1986. I hope you get the point.

Table 3 shows prevalence rates after 1996, when two things happened with the NHIS. First, as I mentioned above, the question on limitation of activity due to chronic illness changed enormously. Second, and equally important, between 1996 and 1997 a major NHIS Redesign occurred, which means that the sampling frame, sampling methodology, and many other statistical aspects of the survey changed. In short, both subject matter experts on childhood chronic disease and disability and statisticians agree that prevalence rates calculated from the NHIS in 1996 and before, and in 1997 and after, are not comparable.

TABLE 3. PERCENTAGE OF CHILDREN AGES 0-17 WITH ACTIVITY LIMITATION RESULTING FROM ONE OR MORE CHRONIC HEALTH CONDITIONS BY AGE, 1997-2006

Year Total Age 0-4 Age 5-17
1997 6.6 3.5 7.8
1998 No Data No Data No Data**
1999 6.0 3.1 7.0
2000 6.0 3.2 7.0
2001 6.8 3.3 8.0
2002 7.1 3.2 8.5
2003 6.9 3.6 8.1
2004 7.0 3.5 8.4
2005 7.0 4.3 8.0
2006 7.3 3.9 8.6

(Source: National Center for Health Statistics, National Health Interview Survey, 1997-2006.)

My interpretation of this trend between 1997 and 2006 is that the overall prevalence rate is fairly stable. The same goes for the rate stratified by age: the prevalence for both infants and pre-schoolers and for 5-17 year olds seems pretty stable. I’ve provided tables with the actual prevalence rates, instead of a chart, so you can make your own charts, argue with me, and argue with each other to your heart’s content. (If you’re interested in statistical significance: For American’s Children NHIS staff did significance tests for difference between years for the period 1997 to 2005. No significance differences were found between years (p > 0.05). This means that differences between 1996 and ‘97, ‘97 and ‘98, etc. were all nonsignificant — adjacent years, in other words. As far as I know, no other significance tests have been done, e.g., for non-adjacent years or for trends.)

So my conclusions about the data on time trends in activity limitation due to chronic illness are: first, based on the 1984 paper by Newacheck et al. there was probably nearly a doubling of the prevalence rate between the early 1960’s and the early 1980’s. Second. based, on the data shown above, I think the prevalence rate has remained fairly stable between the mid-1980’s and 2006.

The ramifications of this are extremely important, especially regarding children of the 1990’s.

1. Children who were born and who grew up in the 1990’s aren’t any “sicker” than the previous generation, at least using this particular overall measure of chronic illness. The same thing seems to be true about children born during this decade — at least so far. I cannot disagree with the JAMA Commentary’s statement that chidhood asthma prevalence has doubled since the 1980’s. And there’s no doubt that childhood obesity has more than tripled since the early 1970’s. The JAMA commentary also points out:, “Approximately 6% of school-age children have a reported diagnosis of attention-deficit/hyperactivity disorder (ADHD), which represents a dramatic increase, although changes in diagnostic practices are clearly one reason. For example, there was no entry for ADHD in the American Psychiatric Association manual until 1968…Similar questions arise for autism spectrum disorders; whether or not there have been true changes in prevalence, it is clear that rates of diagnosis have increased.” (The JAMA commentary also cites a great review article entitled, “Is there an epidemic of child or adolescent depression?”, which I highly recommend. The simple answer is NO, there not an epidemic of child or adolescent depression.)

2. The focus of the National Health Interview Survey is obviously health, health care, and illness. The focus is not on neurodevelopmental disabilities such as ADHD, autism, and so forth, even though there definitely are questions that pertain to these health issues. I think that it’s extremely important that in this context, when parents are questioned about limitation of activity, NHIS data do not show a rising trend in line with the marked increase in autism and ADHD — or in the diagnoses of autism and ADHD.

Perhaps I’m making too much of this last point. After all, the reported prevalence of autism is still only 6.6 per 1,000, which is 0.66%. On the other hand, to estimate rates of parent-reported ADHD diagnosis, the CDC analyzed data from the 2003 National Survey of Children’s Health and reported that 7.8% (95% confidence interval 7.4-8.1) of U.S. children aged 4 to 17 years had had ADHD diagnosed at some point. However, according to some additional tabulations in Health, United States, 2007, of the 8.2% of 5 to 17 year old children whose parent reported them to have activity limitation resulting from a chronic health condition in 2004-2005 (see Table 3 above), in about 25% at least one of the chronic health conditions causing the activity limitation was reported to be ADHD. In other words, according to recent NHIS data the prevalence of ADHD that results in activity limitation is about 2% in 5-17 year olds. Contrast this with the overall ADHD prevalence from the CDC study just mentioned above.

Anyway, I stand by my major point above, that the kids growing up today — those born in the 1990’s and in this century — are not a “sickly” generation.

So I’ll leave you with the profound words of Pete Townshend, written in 1965 (and perhaps you can ponder how I wasted my wild, impetuous youth):

I don’t mind other guys dancing with my girl
That’s fine, I know them all pretty well
But I know sometimes I must get out in the light
Better leave her behind with the kids, they’re alright
The kids are alright!

*Note: I’ve shortened the series of questions to make them more readable. For the exact questions, skip patterns, etc., you can see the questionnaire at ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Survey_Questionnaires/NHIS/2006/English/QFAMILY.pdf

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22 Responses to “The Kids Are Alright”  

  1. 1 andrea

    Something that occurs to me — and maybe I’m missing it because I’m still waking up — is that,

    when babies and young children receive better interventions and care for life-threatening conditions, they are more likely to survive.

    More survival means more children who have significant disabilities.

    Which is not a quibble with your very important points about surveying percentages, uneven cohorts, and definitions.

    andrea

  2. 2 EpiWonk

    @Andrea: Very Good Point.

  3. 3 StuV

    Indeed. Just a quick google gives:

    1-4:
    1960: 1.1/1000
    2000 (latest I can find data for right now): 0.3/1000

    Infant mortality is even worse, but I can only find wide ranges.

  4. 4 Joseph

    I assume these surveys don’t take into account children who are institutionalized. I speculate some of the upward trend could be accounted by this. I understand the number of institutionalized children has been dropping for some decades now (and even today this is clear in the California DDS dataset).

  5. 5 EpiWonk

    @Joseph: Yes, you are correct. I should have stated that the National Health Interview Survey is a representative sample of the non-institutionalized population of the U.S. You’re probably right that part of the upward trend is “attributable to a movement of chronically limited children from institutional to noninstitutional settings,” as Paul Newacheck et al. put in in their paper.

  6. 6 Mary Parsons

    It’s a very small point but the Ogden et al. reports that overweight in children and adolescents trebled rather than obesity. I know very little of such matters but:
    * I wonder how sensitive the CDC tracking of the various BMI for growth percentiles is to the pre-pubertal weight gain of girls for whom puberty seems to be so much earlier than it was in the 1960s or 1970s.
    * NHANES collected sufficient and appropriate data to allow the BMI of the children from past surveys to be calculated although prior to 2000 it seems the paediatricians were using charts based on height and weight. After the introduction of BMI-for-age rather than weight-for-stature in 2000, many more children found themselves in the overweight category although they might not have been prior to that switch.

    More than 63% of children had lower weight-for-stature than BMI-for-age percentiles. Children were more likely to be classified as 10th percentile by weight-for-stature than by BMI-for-age, but less likely to be classified as 85th percentile.

    (Further, it seems that BMI index in children and adolescents is not without its difficulties.) So, although it seems as if there have been some retrospective re-calculations and possibly re-categorisations of children who were previously not overweight by historical measures but would be by the contemporary analysis, I’m not entirely sure that the overweight categorisation is comparing like with like (but, I am not good at following this).
    * Children do not follow graceful curve lines in growth, whether on height/weight charts or BMI charts. There are abrupt spurts of height increase followed by a seeming stasis while filling out or weight gain followed by rapid growth. Thalange et al characterised “[h]uman growth over short periods [as] a discontinuous, irregular, and unpredictable process”.
    *My laboured point is that changing social perceptions (and to some extent, medicalisation) of this as children who are overweight/obese and a construal of the quaintly named ‘growing pains’ as a chronic obesity-related issue that is hampering participation in exercise might, in some cases, lead to a re-categorisation of a phenomenon that was previously ignored. Leading to a more apparent health burden of overweight/obesity in children.

    Today’s children seem to be enviably healthy albeit, in some areas, a little over-medicalised.
    .

  7. 7 EpiWonk

    @Mary Parsons: You’re pretty much on target with all this. I actually quoted the JAMA commentary. Perrin et al. used the term “obesity,” which I then incorrectly parroted, as you point out. They — and I — should have said “overweight.”

    The history of the 2000 CDC/NCHS growth curves (http://www.cdc.gov/growthcharts/) is interesting. The original intent back in the early-1990’s had been to just simply use data from children in the 1988-1994 National Health and Nutrition Examination Survey (NHANES III). However, when growth experts on the NHANES staff and at the CDC looked at the raw weight distributions from NHANES III, they were shocked. The weight of the kids was so obviously shifted upward compared to the rest of the world that any charts developed solely from NHANES III would be completely unusable by the WHO (one of the main purposes of new charts). Thus, a long scientific process had to be gone through to develop the new charts. See http://www.cdc.gov/nchs/data/series/sr_11/sr11_246.pdf.

    Speaking of “…girls for whom puberty seems to be so much earlier than it was in the 1960s or 1970s”:
    See “Examination of US Puberty-Timing Data from 1940 to 1994 for Secular Trends: Panel Findings” at http://pediatrics.aappublications.org/cgi/content/abstract/121/Supplement_3/S172. In fact there’s an entire February 2008 supplement to Pediatrics on this topic.

  8. 8 Dr. T

    I was unsurprised by this. The various health-related parts of the federal government have been playing fast and loose with data and interpretations for at least 15 years. They have succumbed to bureaucracy and slant all reports to make their agency, center, office, institute, or council look more important or more necessary. Since 1994, I have trusted nothing that comes from the CDC unless I can confirm it elsewhere. NHANES has such poor data gathering policies that the data has little value, and the staffers (and many outside researchers) deliberately omit survey changes when they report trends.

  9. 9 EpiWonk

    @Dr. T: For my post (above) I found all the information on NHIS survey changes in “America’s Children,” which is co-authored by NHIS staff, and in the NCHS publication “Health United States.” As I understand it, Dr. Gortmaker. the third author on the JAMA commentary, has numerous publications using NHIS data, so he should have known to check for survey changes. Contrast this with Dr. Newacheck, who wrote about 1960-1981 time trends in childhood activity limitations, but clearly took the time to carefully check for all survey changes.

  10. 10 daedalus2u

    The decline in the age of puberty has been going on for 150 years. In figure 1 they show that the age of menarche in 1850 was nearly 17.

    http://www.biolreprod.org/cgi/content/full/60/2/205

    My hypothesis is that it relates to NO physiology, and is the same mechanism by which antibiotics in animal feed make farm animals grow bigger, fatter and mature sooner, by causing low NO by eliminating the bacteria I am working with. Low NO disinhibits the cytochrome P450 enzymes that are the rate limiting steps in androgen synthesis. It is a “stress” response. Under times of stress it is better to be bigger, mature sooner and have more androgens.

    The increase in premature births mentioned earlier may be important too. The gestational age at which premies are surviving keeps getting younger and younger.

  11. 11 EpiWonk

    @Andrea:

    More survival means more children who have significant disabilities.

    I’ve been thinking about your comment and think I may have to do a post about this soon, because it’s such a complex subject. But here’s something worth thinking about. This only pertains to the issue of cerebral palsy among low birth weight children, but it’s interesting. In 1993, Bhushan, Paneth, and Kiely, published a paper in Pediatrics. They got survival rates for very low birth rate (VLBW; <1500 grams), moderately low birth weight (MLBW; 1500-2499 grams), and normal birth weight (>2500 grams) children in the United States from NCHS’s linked birth-infant mortality file reports for 1960 and 1986. They then pooled the data from seven published studies that had tracked cerebral palsy rates over time among survivors in the same birth weight groups. After a whole bunch of calculations, they estimated that the cerebral palsy rate in the 1960 U.S. birth cohort was 1.9 per 1,000 survivors and in the 1986 birth cohort the rate was 2.3 per 1,000 survivors. Note that these refer to entire populations of all birth weights. So between the 1960 birth cohort and the 1986 birth cohort — the period of the first advances in perinatal care technology — Bhushan et al. estimated about a 20% increase in cerebral palsy in the childhood population. Survival among VLBW babies increased markedly during that period. So why so small an increase in the overall cerebral palsy rate? First, the proportion of VLBW among all births was only 1.16% in 1960 and 1.24% in 1986. Second, the vast majority of VLBW survivors don’t have cerebral palsy — the prevalence rate in the seven pooled studies among VLBW survivors was 8.1%.

    Of course, these calculations and estimations need to be updated to this decade. They also need to be broadened to include other disabilities besides cerebral palsy. I only summarized this study to show that this is a complex issue and even the data questions aren’t easy to answer. The ethical questions are even more difficult.

  12. 12 andrea

    Epi Wonk said, “Of course, these calculations and estimations need to be updated to this decade. They also need to be broadened to include other disabilities besides cerebral palsy. I only summarized this study to show that this is a complex issue and even the data questions aren’t easy to answer. The ethical questions are even more difficult.”

    Oh, very definitely true!

    Joseph’s point about de-institutionalization — especially if those who were in institutions were NOT included in surveys — is a very good one. Historically (and even today), being institutionalized dramatically increased the health and development risks. Some of the prognoses still being used for various conditions reflect those poor outcomes, without the condition-dependent and -independent factors well sorted.

    In contrast to the VLBW babies, we have the current situation with Down syndrome children. Because of much better awareness of some of the accessory health issues that can be screened for and treated early in life, their health outlook is vastly improved, as well as the educational and psychosocial factors that affect lifelong health. On the other hand, because of genetic screening, there are many more people who decide to abort because they may be carrying a Down syndrome child, when previously they would not know until the baby was born. This means that the numbers of Down people are dropping steadily. (I’m concerned about this trend; not about abortion per se, but about aborting because the foetus is not what you wanted, and the general social concept that entire categories of people should not exist, which has one foot in the realm of eugenics. But I digress, and should blog on that in the future.) Anywho, better intervention means better health, but recently reduced numbers means that of the entire subpopulation, those who do have associated health problems will skew the percentages.

    As far as assessing trends (e.g. the aforementioned obesity issue), we really need to compare data sets, not data analyses. In other words, get the actual height and weight and age and sex data, rather than percent overweight and obese and age and sex data. But that’s easier said than done for a number of reasons …

    Oh, would you clarify for me, is most of the trend for lower age of menarche related to weight gain factors (overall health improvements, nutrition) and how those affect hormone levels? Or are there other factors at play?

    Man, epidemiology is interesting! Why, it almost makes statistics look fun. (My stats classes were the bane of grad school, but that may have had a lot to do with the profs’ teaching styles and my particular learning difficulties.) Thank you for these posts; I’ve really been enjoying them.

    andrea

  13. 13 Donna

    About Andrea’s comment “More survival means more children who have significant disabilities.” I think an interesting aspect is that if the condition is hereditary, and if those who survive can go on to have offspring, then those conditions would see a compounding effect from survival, and a more rapid increase in levels over time.

    Knowing I’m interested in the idea of greater survival leading to greater numbers of people with a condition, someone emailed me about the idea that decreasing SIDS levels could also have a similar effect (thanks Victoria!). My initial look at this makes it seem like a promising idea.

    From The Neurobiology of Autism (2nd edition) ed. by Margaret Bauman and Thomas Kemper (2005)

    “The literature suggests that autism is associated with reliable differences in the amplitude of respiratory sinus arrhythmia and the transitory heart rate response pattern to various stimuli and task demands.
    An early publication by Hutt et al. (1975) reported that normal children suppressed respiratory sinus arrhythmia more than autistic children did. Similarly, Althaus et al. (1999) found that children with a pervasive developmental disorder not otherwise specified (PDD-NOS) did not suppress respiratory sinus arrhythmia. Consistent with these findings, an early study of children diagnosed with schizophrenia (Piggott et al., 1973) identified significant differences in respiration and in the covariation between respiration and heart rate. The schizophrenic children had significantly faster and more shallow breathing patterns, a pattern consistent with reduced vagal efferent activity.” p. 72

  14. 14 LindaCO

    Just wanted to leave a quick thank you for putting this piece together. I work as a tech, so am a “scientist” to friends and family, and they occasionally ask about things like this. It’s good to see the data presented this way. It’s scary sometimes how much press a sensationalistic, jump-the-gun approach gets, and it’s good to have a counter weight.

    Linda

  15. 15 Hilary Butler

    The problem with studies is often the question that is asked.

    Another way to assess the reality of the problem is to go to teachers now aged 76, who have only just stopped teaching, and ask them to detail the changes they have seen over the decades, as teachers.

    In the country I live in teachers have always had to keep logs. I know, as I’m married to one. Logs, not just about when they cut the school lawn, or filled up the petrol in the school bus tanks, but also keeping the school health records up to date.

    Institutionalisation doesn’t come into it, as in the areas my husband taught, children with any problems were never institutionalised.

    My husband, and many other older teachers who taught their whole lives would disagree with the statement that chronic illnesses have not increased. Whereas at the start is his career my husband would rarely have a child with any chronic condition such as asthma, or allergies, by 1990 he was seeing plenty of them.

    Not only were chronic illness children far more prolific, he ended up spending a lot of time each day, being the medication dispenser/reminder etc.

    By the time he chose to leave, he was spending an inordinate amount of time, babysitting children with chronic serious medical issues.

    In my “travels”, I’ve also collected more recent articles written by long time school “nurses” in USA, saying exactly the same thing.

    There are many ways to play fast and loose with issues.

    And one of them is to rely on data, which may not have been based on asking the right questions to begin with.

  16. 16 EpiWonk

    Hilary,

    You’re missing part of the point of this analysis — or maybe I just didn’t make it clear. This is clearly NOT an analysis of the incidence or prevalence of chronic illness. It’s been several weeks since I wrote this, but I truly did not mean to imply it was. It’s exactly what it says — LIMITATION OF ACTIVITY due to chronic illness.

    So if Johnny has asthma and uses an inhaler, but mom reports that he’s not in special education and he has no activity limitation, then he’s not included in these statistics. Obviously he would be counted as “ill” if we were counting the number of cases of asthma, obesity, diabetes, etc.

    I’m actually more of a social epidemiologist than a medical epidemiologist and to me, this is just as much a “right question” as the one you want: you’re interested in “illness” — in this analysis I was more interested in “disability.” I probably should have used the word disability, but my some of my social science colleagues who study disability go berserk when people use activity limitation as a measure of disability. I’ve never completely understood why.

    Incidentally, this idea is certainly not at original with me. Medical sociologists have written for decades about chronically ill children who aren’t disabled.

    Also, I was correcting a grossly incorrect interpretation of statistics reported in a JAMA article. If yu friends can do it for a JAMA paper on vaccine deaths, why not me for a JAMA paper on limitation on activity?

    Finally, perhaps what really motivated this post: Why so much pessimism about today’s kids? Why not a little optimism? My wife and I have a son born in 1986 and a daughter born in 1988. I did all the traditional school things with them, coached boys’ and girls’ basketball, baseball, and softball, etc. I saw the birth cohort of the late 1980’s and early 1990’s grow up. Obviously I couldn’t miss that there were more inhalers, more kids on Ritalin, and more fat kids than in my generation. But in general they really were ALRIGHT! And they’re getting on fine now! (except economically). I know from my kids that they resent being considered “the sick generation” or “the wimpy generation.” How often do you see blog post like the one above? I do believe you have to look long and hard. And I don’t think I “played fast and loose with issues,” as long as realize what question I was looking at. It’s unfortunate if I didn’t make it more clear, but I think perhaps you were looking for the wrong thing.

  17. 17 Hilary Butler

    I accept that you were correcting stats in Jama, but the incorrect stats have no meaningful relationship to your title or real life.

    I have looked long and hard.

    FACT: there more children being treated in hospital for serious chronic illnesses, and it will cost developing countries a fortune in the not too distant future.

    FACT: this is a huge difference from 1980, or even when you and I were born inthe numbers of children with serious chronic disease of some sort, not in hospital, but in the community at large.

    There is no doubt about those “actual” statistics of the increase in chronic disease, even where I live.

    The numbers of children and young adults being treated for diabetes type 2, has hugely increased, at huge cost to the taxpayer, though you might not consider them to have “activity limitations”. And we know some top sports people with diabetes who are not “activity limited”, but do have minute by mine “minders” to make sure that they aren’t suddenly “activity limited”!

    As you say, no doubt there are some statistics which might need correcting in any issue, just as there are others some other people take issue with.

    But your heading “The Kids are alright” is not alright.

    Activity limitation has nothing to do with the actual issue, which to the average parent is that the kids, overall, are not alright.

    Yours might be, and mine might be, but as a group across a wide sweep, the kids are not alright. and rather than your kids being resentful that “their” generation is lumped as the sick generation, your kids need to face up to the fact that it will take a lot more of their taxes to pay for the benefits to keep their sick peers in a standard of living which they will consider their right to have. if I were your kids, facing that prospect, I would not be happy chappies.

    So to redefine the JAMA stats for activity limitations, for the purpose of a heading, and use that to imply that “the kids are alright” is to my mind, stretching the facts.

    Our kids were born in 81 and 84.

    I was a gymnastics coach from 1969 right through to 1993. In those 25 years, there was a huge increase, as you say, in children on medication. Obviously, you don’t see the children, in sport, with “activity limitation”, particularly one which requires immaculate timing, because they can’t/don’t play competitive sport.

    As a gymastics coach, whereas my analysis of a child’s ability in 1969 would be solely on their physical ability, listening and comprehension skills, obedience quotient and desire, I would not wish to be a gymnastics coach today. (Which is why I am not one.) I would be accused of discrimination for refusing to accept into a gym class anyone on ritalin. Neither would I accept a child who was on any drug which I believed influenced their perception of balance, timing or spacial concepts in any way.

    Gymnastics is far too dangerous a sport at the elite level to allow for any child on drugs which might result in even one ill-timed decision incorporating one-tenths of a second deviation, resulting in serious injury. Okay, gymnastics isn’t basketball, softball or baseball. It’s a whole lot more dangerous. I give you that. But the principle applies.

    When you watch the Olympics, there might be the odd gymnast there using an asthma inhaler, (thought they don’t tend to be good competitors as a whole, so are less likely to get to that level) but I would be very surprised if you found any gymnasts there on Ritalin. The very reason they are on ritalin is the reason gymnastic coaches normally run a mile from them. It would have to be an exception exception for a coach to accept that child into a sport like Gymnastics.

    (Let’s not discuss doping and performance enhancing drugs, though, because I’m positive that goes on.)

    You won’t see too many activity limited kids in basketball, baseball and softball, either. I certain wouldn’t see them at Gymnastics. They can’t take the pace, they know it, and they elect to do activities within their known limitations.

    So while you can correct stats, the impression I got from your correction was that you have a perception that “the kids are alright”. On the cutting face of “life” I don’t share your perception.

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