*"It doesn't matter if the cat is black or white as long as it catches
mice."*

Deng Hsaio P'ing 1904-1997

This a page for sharing "what works" as seen in the published literature
as well as what is done at sites that care for American Indian/Alaskan
Native children. If you have any comments contact Steve Holve, MD, Chief
Clinical Consultant in Pediatrics at sholve@tcimc.ihs.gov

IHS Child Health Notes

November 2006

# Quote of the month

*A long habit of not thinking a thing wrong, gives it a superficial
appearance of being right, and raises at first a formidable outcry in
defence of custom. But the tumult soon subsides. Time makes more
converts than reason."*

Thomas Paine 1776

**Article of Interest**

Tall girls: the social shaping of a medical therapy.\
Arch Pediatr Adolesc Med. 2006 Oct;160(10):1035-9.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17018462&query_hl=2&itool=pubmed_docsum>

During the latter half of the 20^th^ century estrogen therapy was given
to prevent otherwise healthy girls with tall stature from becoming tall
adults by inhibiting future linear growth. Estrogen therapy represented
the logical application of scientific knowledge regarding the role of
estrogen for closure of the growth plates, but it also reflected
prevailing societal and political beliefs about what it meant to be a
tall girl. The authors also discuss the rise and fall in popularity of
this therapy and suggest that it has implications for the current
therapy of short stature with growth hormone.

**Editorial Comment**

Here was a medical therapy being applied to what was clearly not a
medical problem. Especially interesting is how the definition of
"unacceptable" height for girls changed over time while this therapy was
never applied to males to make them less tall. The article reminds us
how medical knowledge and therapy is always applied within a particular
social context.

**Infectious Disease Updates**.

Rosalyn Singleton, MD, MPH

 **Rotavirus Vaccine licensed: How do diarrhea-associated
hospitalization rates among American Indian and Alaska Native children
compare with the rates for children in the US general population?**

It often appears that that AI/AN children have higher rates of just
about any infectious disease. But what's the story with gastroenteritis
and rotavirus?

In 1980-1982, the rate of diarrhea-associated hospitalizations in
American Indian and Alaska Native (AI/AN) children \<5 years (236 per
10,000) was nearly twice as high as the US rate (136). However, by
1993-1995, the AI/AN hospitalization rate (71) was similar to the US
rate (89). An updated analysis reveals that the hospitalization rate for
2000-2004 for AI/AN children \<5 years of age (66) is similar to or
lower than the 2003 US childhood rate (79). The AI/AN hospitalization
rate varied by region, with the highest rate in the Southwest region
(93), followed by the East (79) and Alaska (77).

However, there are still areas of disparity. The 2000-2004 AI/AN
hospitalization rate in infants (262) is significantly higher than the
US rate (154), and the rate of outpatient visits for AI/AN children \<5
years (2,255 per 10,000) is also higher than the US outpatient rate
(1,648).

What about the burden of rotavirus disease? Unfortunately, only 2.7% of
the AI/AN diarrhea-associated hospitalizations and 0.2% of outpatient
visits were coded as rotavirus. This proportion underestimates the true
burden of rotavirus. Epidemiologic characteristics, such as the age
range and seasonal peak of diarrhea-associated hospitalizations, suggest
that the proportion of diarrhea-associated hospitalizations caused by
rotavirus among AI/AN children may be similar to proportion seen in the
US population (\~ 30-50% of diarrhea-associated hospitalizations).
RotaTeq™, a live oral pentavalent rotavirus vaccine, is now licensed and
available for use in infants 6-32 weeks of age.

**Recent literature on American Indian/Alaskan Native Health**

Doug Esposito, MD

**[Article]{.underline}**

Prevalence and comorbidity of mental disorders among American Indian
children in the Northern Midwest. *J Adolesc Health.* 2006
Sep;39(3):427-34. Epub 2006 Jul 10.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16919807&query_hl=7&itool=pubmed_DocSum>

**Summary**

The authors report on the prevalence of 11 mental disorders in
10-12-year old American Indian children in the Northern Midwest. This
study compliments a previous article published by the same group of
researchers which described the 12-month and lifetime prevalence of five
mental disorders seen in the caretakers of these same children. That
article was reviewed for the August 2006 edition of the *IHS Child
Health Notes*
(<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/ICHn806.doc>).

Information on the 11 disorders was gathered from DISC-R diagnostic
surveys conducted by trained non-clinician community members who
interviewed the children and their parents/caretakers. Study subjects
resided on or near one of four rural American Indian reservations in the
Northern Midwest or one of five rural or remote Canadian First Nations
reserves in Ontario. All sites are of one culture and language, with
only minor dialectic variations. The disorders investigated were
substance abuse disorders (alcohol abuse, alcohol dependence, marijuana
abuse, marijuana dependence, and nicotine dependence), major depressive
episode, dysthymic disorder, general anxiety disorder, oppositional
defiant disorder, conduct disorder, and inattention/hyperactivity
disorder.

The authors report that 22.8% of the children satisfied the 12-month
diagnostic criteria for at least one of the 11 mental disorders under
investigation, while 9% met criteria for two or more disorders. The most
prevalent disorder was conduct disorder (8.6%), followed by
oppositional/defiant disorder (7.9%), and then inattention/hyperactivity
disorder (7.6%) and general anxiety disorder (4.1%). Major depressive
disorder (3.6%) rounded out the top five most prevalent conditions. The
reported prevalence rates represent a combination from both caretaker
and child reports. The rationale behind this methodology is discussed in
detail in the article, but is beyond the scope of this review.
Obviously, however, rates combined from both data sources will exceed
those reported individually by either the caretaker or the child.

The authors contend that their results support the contemporary theory
that ineffective parenting plays a pivotal role in the development of
mental and behavioral disorders in offspring. Conditions and realities
that negatively influence the effectiveness of parenting would be
expected to increase the likelihood that children would develop these
mental conditions. In multivariate analysis, they found an association
between female caretaker depression and alcohol abuse with mental
disorders in their children. As reported in their initial published
article of mental disorders among the parents/caretakers of these same
children (see link above), lifetime alcohol abuse was found to be nearly
five times that observed in a national cohort. Thus, they contend,
children in this study are at increased risk of exposure to "nonoptimal
parenting," and by association, a high prevalence of certain mental
disorders would be expected. Additionally, approximately 20% of the
female caretakers of these children were found to have a lifetime
prevalence of major depression in the previous report. Given that
depression is known to be disruptive of the parenting process, the
authors imply that the development of mental disorders in children
exposed to a depressed female caretaker would be more likely to occur.

The authors warn about the generalizability of their results to other
American Indian cultures. Other limitations of the data are discussed,
and can be examined by the interested reader in the article itself.

**Editorial Comment**

There seems to be a recent proliferation of articles scrutinizing mental
and behavioral health problems in American Indian/Alaska Native (AI/AN)
communities. Individually, I believe many of these papers simply point
out some of the things we perhaps already intuitively know. *In toto*,
however, I am hopeful that this body of data and knowledge will serve to
focus attention on the mental and behavioral problems and needs of these
populations. Ultimately, this might lead to an increase in resources and
programs devoted to dealing with the prevalent mental health issues of
AI/AN populations. OK, I can dream, can't I?!

**[Article]{.underline}**

QuickStats: adolescent death rates by race/ethnicity and sex\-\--United
States, 2001-2003. *MMWR Morb Mortal Wkly Rep*. 2006 Sept 1;55(34):943.

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5534a5.htm>

**Editorial Comment**

Just an "FYI." American Indian/Alaska Native children ages 15-17 years
as a group lead the pack in both male and female death rates. Although
AI/AN females are nearly twice as likely to die as the next closest
ethnic group (White, non-Hispanic, 60.4 vs. 36.6 deaths/100,000
population), males are barely ahead of Black, non-Hispanic youth (89.6
vs. 89.3 deaths/100,000 population). As acknowledged in the footnotes of
the *QuickStats*, AI/AN death rates are known to be underestimated,
often by sizeable margins. Translation: the disparity might be a whole
lot more dramatic in reality than this nifty little bar graph suggests.

# Announcements from the AAP Indian Health Special Interest Group 

Sunnah Kim, MS

**Locums Tenens and Job Opportunities**

If you have a short or long term opportunity in an IHS, Tribal or Urban
facility that you'd like for us to publicize (i.e. AAP Web site or
complimentary ad on Ped Jobs, the official AAP on-line job board),
please forward the information to <indianhealth@aap.org> or complete the
on-line locum tenens form at <http://www.aap.org/nach/locumtenens.htm>

.