26.3: Preschool, School-Age, and Adolescent Health
By the end of this section, you should be able to:
- Assess the global and national health status of preschool, school-age, and adolescent health.
- Examine major risk factors influencing the health of the preschool, school-age, and adolescent population.
- Create evidence-based educational interventions to promote self-care for health promotion, illness prevention, and illness management of preschool and school-age children and adolescents.
- Identify Healthy People 2030 goals established for preschool, school-age, and adolescent health.
- Describe health promotion and disease prevention actions applicable to preschool, school-age, and adolescent health.
- Discuss evidence-based strategies for integrating sociocultural and linguistically responsive health promotion and disease prevention interventions in clinical practice of preschool, school-age, and adolescent health.
The preschool, school-age, and adolescent population includes children aged 4 to 17. Health promotion and disease prevention are important for children in this age range as this is a crucial period of growth and development when children form habits and behaviors that will impact their health and well-being throughout their lives. Children who learn healthy habits early are more likely to continue them into adulthood. Many chronic diseases, such as diabetes, heart disease, and obesity, begin in childhood. Helping children develop these healthy habits and behaviors may reduce their risk of such diseases occurring. Children are also building strong bones and muscles, which will reduce their risk of injury as they age. Finally, children in this age group are developing the social and emotional skills they will take into adulthood. For example, children build self-esteem and confidence by participating in physical activity such as sports. Learning good hygiene practices can help build social skills and respect for others (National Center for Chronic Disease Prevention and Health Promotion, 2022b).
National and Global Status of Preschool, School-Age, and Adolescent Health
There are wide differences between children aged 4 and children aged 17. As such, health data for this population are often divided into different groups. Table 26.6 presents some of the health data from the National Center for Health Statistics. Additional U.S. health data for children and adolescents can be seen at the Health, United States, 2020-2021 – Data Finder.
| Children | Adolescents | |
|---|---|---|
| Health Status | ||
| Percent of children who are in fair or poor health (2022) as identified by asking adults “Would you say [child’s name]’s health in general is excellent, very good, good, fair, or poor?” |
2.2%
Ages 5 to 11 |
3.8%
Ages 12 to 17 |
| Percent of children who missed 11 or more days of school in the past 12 months due to illness, injury, or disability (2022) |
8%
Ages 5 to 11 |
9.9%
Ages 12 to 17 |
| Obesity | ||
| Percent of children who are obese (2017–March 2020) |
20.7%
Ages 6 to 11 |
22.2%
Ages 12 to 19 |
| Access to Care | ||
| Percent of children with a usual place of health care (2022) |
97.2%
Ages 5 to 11 |
96.4%
Ages 12 to 17 |
| Mortality | ||
| Number of deaths (2021) |
5,975
Ages 5 to 14 |
13,407
Ages 15 to 19 |
| Deaths per 100,000 population (2021) |
14.3
Ages 5 to 14 |
62.2
Ages 15 to 19 |
Immunization rates affect child and adolescent health. Rates for certain vaccinations (measles, mumps, and rubella; varicella; diphtheria; tetanus; and acellular pertussis) decreased by 1 percent from the 2020–2021 school year to the 2021–2022 school year in incoming kindergarteners (Seither et al., 2022). For 2021–2022, 2.6 percent of kindergarteners were exempted from at least one state-required vaccination per their caregivers’ requests.
The American Academy of Pediatrics interactive map, “ Child Vaccination Across America ,” allows viewers to compare state and national immunization rates.
Visit the map, and do the following:
- Watch the video “How to explore the interactive map.”
- Hover over your state and learn about the percentage of children immunized by the various vaccines. How does your state compare with the national rates?
- Hover over one area designated with a recent disease outbreak, and then click on the area to learn more about this specific disease and outbreak.
- Click on the “Explore Data” button and learn more about vaccination gaps related to insurance, race and ethnicity, poverty, and geographic area.
- Were you surprised by what you learned? Why or why not?
Global health data regarding immunizations is not promising. A 2022 systematic review confirmed a worldwide decline or delay in vaccination during the COVID-19 pandemic (SeyedAlinaghi et al., 2022). This followed indications that 13.5 million children were not vaccinated in 2018 (Vanderslott et al., 2022). Although there has been a global decline in vaccine-preventable diseases (VPDs), they are still responsible for 1.5 million deaths annually. Although studies have found that most people worldwide think that vaccines are important for children to have, support for vaccination varies (Vanderslott et al., 2022). This is described further in Pandemics and Infectious Disease Outbreaks.
Globally, obesity in children aged 5 to 19 is considered a major health concern as it is a significant risk factor for many noncommunicable diseases, including cardiovascular disease, diabetes, and some cancers (endometrial, breast, ovarian, prostate, liver, gallbladder, kidney, and colon) as well as for musculoskeletal disorders. In 2016, the WHO reported that the share of those aged 5 to 19 who are overweight or obese has increased from 4 percent in 1975 to around 18 percent in 2016. Also in 2016, over 340 million children and adolescents aged 5 to 19 were overweight or obese, while 39 million children under age 5 were overweight or obese in 2020 (WHO, 2021).
Once considered a high-income country problem, overweight and obesity are now increasing in low- and middle-income countries, particularly in urban areas. For example, “in Africa, the number of overweight children under age 5 has increased by nearly 24 percent since 2000, and almost half of the children under age 5 who were overweight or obese in 2019 lived in Asia” (WHO, 2021, para. 7). These low- and middle-income countries now face what the WHO refers to as a “double burden” of malnutrition. Children in these countries are more vulnerable to inadequate nutrition prenatally and as newborns and infants, and then they are introduced to “high-fat, high-sugar, high-salt, energy-dense, and micronutrient-poor foods, which tend to be lower in cost” (WHO, 2021, para. 12).
Watch the video, and then respond to the following questions.
- What two lifestyle behaviors put children like Avoca at risk for obesity?
- Children who are overweight or obese are at greater risk for developing which three diseases?
- What is one solution that could decrease the consumption of cheap and unhealthy foods?
In 2020, the global mortality rate for those aged 5 to 14 was 7 per 1,000 children, and in 2021 the rate for those aged 15 to 19 was 4.6 per 1,000 (WHO, 2022b, 2022c). Infectious diseases have declined in the last decade for both groups. For those aged 5 to 14, injuries (including road traffic injuries and drowning) remain the leading causes of death and lifelong disability (WHO, 2022b). In those aged 15 to 19, accidents and injuries, self-harm, and interpersonal violence the leading causes of death (WHO, 2022b, 2022c).
Risk Factors Influencing Preschool, School-Age, and Adolescent Health
As children and adolescents grow and develop, numerous environmental, social, and physical risk factors can influence their health and well-being (see Table 26.7).
| Preschool | School Age | Adolescent | |
|---|---|---|---|
| Environmental |
|
|
|
| Social |
|
|
|
| Physical |
|
|
|
Environmental and social risk factors can have long-lasting effects on the health and development of this population (National Institute of Environmental Health Sciences [NIEHS], 2023). See Social Determinants Affecting Health Outcomes for more information. Physical or biological risk factors can also influence the health of the preschool, school-age, and adolescent population (Negussie et al., 2019). The same prenatal and perinatal factors and genetic factors mentioned previously can continue to affect children as they age. Any developmental delays or disabilities continue to impact cognitive, physical, and socio-emotional development. Infections and communicable diseases can adversely affect physical health acutely and can also lead to long-term health problems. Allergies and asthma have negative effects on respiratory health and quality of life. Other chronic health conditions have long-term health and development consequences. These may include diseases such as diabetes or congenital heart defects. Nutritional deficiencies or imbalances, including obesity, can impact growth, development, and overall health. Sleep disturbances may negatively influence cognitive and behavioral development (Negussie et al., 2019). Hormonal changes during puberty can impact physical, cognitive, and emotional development.
Lifestyle-related risk factors may play a huge role in a child’s risk of developing some conditions, such as childhood cancers, ADHD, and asthma (American Cancer Society, 2019; Cleveland Clinic, 2023a; Mayo Clinic, 2019). As mentioned, childhood cancers are a leading cause of death for preschool and school-age children. Cancer prevention can begin prenatally and continue through early childhood. In addition to getting enough folic acid, avoiding alcohol and tobacco use prenatally, and breastfeeding postpartum, childbearing clients may lower a child’s cancer risk through other behaviors (CDC, 2021k). Safe, stable, and nurturing relationships and environments can help protect children against many harms and ensure they reach their full potential. This includes keeping children away from exposures to secondhand smoke, traffic-related air pollution, carcinogens, and excessive radiation used during medical tests. However, many childhood cancers cannot be prevented (American Cancer Society, 2019).
ADHD and asthma are other common health concerns in this population. While there is no known cause for ADHD, prevention efforts involve addressing maternal substance use and misuse, premature birth, and exposure to environmental toxins (Mayo Clinic, 2019). Researchers have not determined the exact cause of childhood asthma, which often develops when the child’s immune system is developing (Cleveland Clinic, 2023a). Asthma may have genetic components, and exposure to allergens, such as tobacco smoke, and viral infections, such as the common cold, at an early age have also been associated with its development in children (Cleveland Clinic, 2023a). Gender, racial, and geographic disparities also exist with individuals who are assigned male at birth, BIPOC children, and children who live in urban environments or around high amounts of air pollution at higher risk of developing asthma (Cleveland Clinic, 2023a).
Poor mental health can be a risk factor for substance misuse, sexual health issues, and suicide. Suicide is the second most common cause of death in those aged 10 to 14 years and the third most common cause of death in those aged 15 to 24 years (CDC, 2022r). Many factors can increase the risk for suicide or protect against it (Table 26.8). It is often connected to other forms of injury or violence. Those who have experienced violence such as child abuse, bullying, or sexual violence have a higher risk for a suicide attempt.
| Circumstances That Increase Suicide Risk | |
| Individual Risk Factors |
|
| Relationship Risk Factors |
|
| Community Risk Factors |
|
| Societal Risk Factors |
|
| Circumstances That Protect Against Suicide Risk | |
| Individual Protective Factors |
|
| Relationship Protective Factors |
|
| Community Protective Factors |
|
| Societal Protective Factors |
|
Adolescent girls and adolescents identifying as LGBTQIA+ experience high levels of violence, sadness, mental health challenges, and suicide risk (CDC, 2023k). In 2021, among adolescents, almost twice as many girls as boys reported persistent sadness or hopelessness (Figure 26.2), and nearly one in three girls reported that they had seriously considered attempting suicide (CDC, 2023c).
Another area of health risk for this population is concussion or brain injury. Anyone who experiences a bump, blow, or jolt to the head or hit to the body that causes the head and brain to move rapidly back and forth could suffer a concussion, with youth athletes particularly at risk (CDC, 2022b). School and community health nurses may educate youth athletes, caregivers, coaches, and officials in preventing concussions, recognizing their signs and consequences, and identifying a safe return to activity following a concussion.
Risk factors for adolescents related to sexual health include activities that can lead to adverse health outcomes such as HIV infection, other STIs, or pregnancy. Sexual risk behavior is any behavior—typically condom-unprotected oral, vaginal, or anal intercourse—that puts one at risk for these adverse health outcomes (Senn, 2020).
Recognizing these many risk factors that can adversely impact this population’s health and well-being is the first step in promoting health. Children and adolescents from marginalized or disadvantaged backgrounds may be at higher risk for experiencing risk factors. The HEADSS (Home, Education, Activities, Drug use and abuse, Sexual behavior, Suicidality, and depression) for Adolescents tool is a psychosocial risk assessment instrument that health care professionals may find useful in finding out about issues in adolescents’ lives (Cohen et al., 1991).
Educational Interventions to Promote Self-Care in Preschool, School-Age, and Adolescent Populations
Educational interventions geared toward this population and their caregivers should focus on preventing their leading causes of death and morbidity, and the risk factors identified above. To promote self-care and the development of healthy habits, nurses should provide education directly to the child or adolescent. Educating adults on how to support their child’s development can be an effective way of introducing and maintaining the child’s health. Educational interventions may occur as individual instruction, group workshops, or classes (Table 26.9).
| Education for the Caregiver | Education for the Child/Adolescent | Education Techniques for the Child/Adolescent | |
|---|---|---|---|
| Preschool |
|
|
|
| School Age |
|
|
|
| Adolescent |
|
|
|
School nurses and school health programs are ideal for health promotion and disease prevention for this population, as described in Caring Across Practice Settings. Schools have direct contact with 56 million students for at least six hours daily during the most critical years of their development (CDC, 2020c). School health programs can decrease the prevalence of health risk behaviors by delivering quality sexual health education; increasing youth access to sexual health services; establishing healthy, safe, and supportive environments to promote positive mental health; and implementing policies that provide health promotion and disease prevention (CDC, 2020c).
Healthy People 2030 Goals for Preschool, School-Age, and Adolescent Health
Preschoolers and school-age children fall into the Healthy People 2030 overarching goal to “improve the health and safety of children” (ODPHP, n.d.-b, para. 1), as described in the section on toddlers. There are some additional Healthy People Objectives for preschoolers and even more for the school age and adolescent ranges.
Healthy People 2030 children objectives address outcomes for those aged 1 through 19. There are specific objectives geared toward the population in the preschool and school-age years. Some of these are related to vision and developmental screenings; trauma, literacy, early childhood education, nutrition, and other school programs; decreasing obesity; increasing physical activity and promotion of sports; mental health treatment; preventive dental care; and violence prevention.
The overarching goal of Healthy People 2030 related to adolescents is to “improve the health and well-being of adolescents” (ODPHP, n.d.-a, para. 1). Improving adolescent health can prevent some behaviors that can affect health later in life. Adolescents have many risk factors, many of which are preventable, including substance use disorder s, STIs, and injuries from motor vehicle accidents. The physical and mental changes occurring during adolescence can also impact their safety and health. Encouragement of positive health behaviors is essential in this population. Therefore, there are many Healthy People 2030 objectives geared toward adolescents.
Healthy People 2030 addresses outcomes specifically for adolescents . Some are related to school achievement, adult support, family planning, oral care, transition to adult health care, LGBTQIA+ health issues, mental health disease issues, sleep, and the prevention of chronic kidney disease, chronic school absence, infectious diseases, obesity, skin cancer, STIs, tobacco and other substance use, and violence.
Health Promotion and Disease Prevention Activities to Improve the Health of Preschool, School-Age, and Adolescent Populations
Improving the health of this population is an important public health goal. Health promotion activities, such as the education previously described, can play a crucial role in achieving this goal. Nurses can promote positive health outcomes by enabling this population to increase control over their health and its determinants as they age. Activities can include various interventions to promote healthy behaviors, prevent diseases and injuries, and improve health care access and may occur in various settings, including schools, health care facilities, community centers, and homes. Examples include education and awareness campaigns, nutrition and physical activity interventions, mental health interventions, and health care access initiatives. By implementing these interventions, nurses can help promote healthy behaviors and improve children’s and adolescents’ overall health and well-being.
The CDC (2021a, 2021b, 2021d, 2021e) website provides information for caregivers of children ages 4 to 11 and for teens. These pages discuss the topics in greater detail and provide specific schedules for growth charts and immunizations.
Disease prevention promotes healthy growth and development by supporting children’s and adolescents’ physical and cognitive growth and development. By protecting this population from illnesses, the nurse can help them reach their full potential (ODPHP, n.d.-a). Preventing diseases also helps reduce health care costs through a lesser need for medical treatment or hospitalizations. Healthy children and adolescents are more likely to have good academic performance with less absenteeism, positively influencing their academic lives and contributing to their future professional lives. By preventing certain diseases, nurses help to protect this population’s long-term health and the wider community by reducing the spread of infectious diseases (ODPHP, n.d.-a).
Because some of the most common preventable diseases affecting this population include COVID-19, influenza, and obesity, health promotion and applicable prevention efforts should target them. Preventing accidents, homicides, and suicides is also imperative for this population. School-age children must also combat other infectious diseases, most notably chicken pox. Adolescents and their caregivers should receive preventive services related to anxiety and depression, substance misuse, violence, blood clots, cervical cancer, and STDs (CDC, 2021d).
Primary Prevention
Prevention of disease onset occurs through primary prevention. It is an essential way to promote the health and well-being of the preschool, school-age, and adolescent population. Some examples of primary prevention include:
- Immunizations per the recommended schedule (CDC, 2023b). Additional information can be seen at the American Academy of Pediatrics’ Childhood and Adolescent Vaccine Education Series playlist on YouTube.
- Hand hygiene, such as washing hands frequently with soap and water to prevent the spread of germs.
- Healthy eating habits, such as eating plenty of fruits and vegetables to support their immune system and promote growth and development.
- Sun protection to prevent skin damage and cancer from sun exposure.
- Regular physical activity to promote overall health and well-being and prevent the development of obesity.
- Injury prevention, including providing safe play environments for preschoolers, bike safety for school-age children, and driving safety for adolescents.
- Sexual health education to prevent STDs and unintended pregnancies.
- Mental health promotion, including stress management and coping skills to prevent anxiety, depression, and suicide.
- Substance misuse prevention, including the risks and consequences.
- Violence prevention, including adverse childhood experiences (ACEs), child abuse and neglect, child sexual abuse, firearm violence, intimate partner violence, sexual violence, and youth violence prevention to prevent violence before it actually occurs or buffer people from violence.
The CDC’s (2021m) VetoViolence® resources empower people to prevent violence and implement evidence-based prevention strategies in their communities. In particular, the CDC infographic, “We Can Prevent Childhood Adversity,” addresses adverse childhood experiences, or ACEs.
Examine the infographic, and then respond to the following questions.
- What are ACEs?
- What groups are more likely to experience ACEs?
- What are two ways to create positive childhood experiences?
Secondary Prevention
Secondary prevention measures identify problems as early as possible, usually before symptoms arise. Some examples of these for the preschool, school-age, and adolescent population include:
- Regular health checkups, including dental, vision and hearing as applicable, to help identify any health issues early and ensure appropriate medical care is received
- Recommended screenings for the age group as per the American Academy of Pediatrics or the U.S. Preventive Services Task Force guidelines
- Immediately after a violent event, addressing any short-term consequences and focusing on the immediate needs such as emergency services or medical care
Tertiary Prevention
Tertiary prevention involves managing and treating health issues that have already developed to minimize their impact and prevent further complications. Here are some examples of tertiary prevention activities for preschoolers, school-age children, and adolescents:
- Provide early intervention services such as speech therapy or occupational therapy for preschoolers with developmental delays or disabilities
- Manage asthma symptoms and provide treatment to prevent attacks and minimize the impact of the disease
- Provide appropriate mental health treatment to help children or adolescents manage symptoms and improve their quality of life
- Provide emotional support or mental health services long-term following a violent event to decrease trauma to the victim
Youth violence is a significant public health problem affecting thousands of young people each day, including their families, schools, and communities. Youth violence is widespread in the United States and is the third leading cause of death for young people between the ages of 10 and 24. Learn more about youth violence from the CDC’s video “What Is Youth Violence?”
Watch the video, and then respond to the following questions.
- Who experiences youth violence?
- What are two risk factors for experiencing violence?
Part of the CDC’s commitment to injury and violence prevention includes efforts to change social norms about youth violence. Watch its video “Voices of Change: Engage Youth, Prevent Violence” to see how the University of Louisville Youth Violence Prevention Research Center (YVPRC) engages and empowers local youth as subject experts in their own community.
Watch the video, and then respond to the following question.
- What are two strategies taught to prevent violence?
Integration of Sociocultural and Linguistically Responsive Interventions for Preschool, School-Age, and Adolescent Health
Promoting the health and well-being of this population requires consideration of sociocultural factors, such as race, ethnicity, culture, and language. Various challenges and considerations are involved in implementing sociocultural and linguistically responsive interventions in this population. This section provides examples of successful programs that effectively integrate responsiveness into health interventions. Nurses can improve health outcomes and reduce health disparities for children and adolescents from diverse backgrounds through integrations such as these.
Caregivers who identify as BIPOC are less likely than non-Hispanic White parents to report their children receive high-quality health care. Examples of structural inequities these clients experience include racism , xenophobia , and poverty . Okoniweski et al. (2022) reported that children whose caregivers’ primary language is not English face additional disparities and are less likely to have a regular source of medical care. These indications strengthen the need for sociocultural and linguistic interventions to promote better pediatric outcomes.
Sociocultural Interventions
The cigarette smoking rate among Alaska Native adults was 36 percent from 2018 to 2020 (Alaska Department of Health, 2022). This provides Alaska with a unique challenge to protect children from the harmful effects of secondhand smoke exposure. The Alaska Tobacco Prevention and Control Program (TPC) has promoted smoke-free environments through various interventions geared toward the Alaska Native population. The Alaska Tobacco Quit Line provides resources for tobacco cessation. TPC has partnered with the American Lung Association and the Alaska Tobacco Control Alliance to promote smoke-free unit housing and promote policies to prohibit the use of tobacco products on school properties (ODPHP, 2021). Additional partnerships have occurred between TPC and the Alaska Native Tribal Health Consortium to coordinate outreach efforts in rural communities, where as many as 4 in 10 adults smoke (ODPHP, 2021). Rural community health workers, who may reach citizens via boat or snowmobile, provide adults with tobacco cessation education and describe the hazards of secondhand smoke in children.
The CDC’s (2023f) Adolescent Health: What Works in Schools program is a school-based health approach to improve health behaviors and experiences, support mental health, and reduce suicidality. Children and adolescents who identify as LGBTQIA+ are particularly at risk for facing social stigma about their sexual choices or identities, which places their health at risk. Some specific interventions identified by this CDC program to help this population are establishing gender and sexuality alliances (GSA), identifying safe spaces, and implementing anti-harassment policies (CDC, 2023f).
Linguistically Responsive Interventions
The Centers for Medicare and Medicaid Services (CMS) released an updated framework to advance health equity, expand health coverage, and improve health outcomes for people covered by Medicare, Medicaid, CHIP, and the health insurance marketplaces. This framework identified the need to advance language access and health literacy and provide culturally tailored services to all groups. In particular, one priority in the CMS Framework for Health Equity 2022–2032 states, “Each person CMS serves should receive effective, understandable, and respectful care that is responsive to their preferred languages or dialects, health literacy, cultural health beliefs and practices, traditions, and other communication needs” (CMS, 2022, p. 25). The government’s dedication to being linguistically responsive can also be seen regarding child and youth behavioral health crisis care. The Substance Abuse and Mental Health Services Administration’s (SAMHSA, 2022) National Guidelines for Child and Youth Behavioral Health Crisis Care also requires incorporating linguistically responsive care as one of its core values for youth crisis care. This includes care regarding LGBTQIA+ youth who may be unable to access the mental health care they need to prevent suicide (SAMHSA, 2022).
Nurses may use several interventions to overcome language barriers with clients who do not speak English. These typically involve in-person interpreters or interpreter services via telephone. Jackson and Mixer (2017) described the difficulty Spanish-speaking caregivers of clients in acute care experienced and proposed using the UTalk app on an Apple iPad as a solution. The app’s interface design included a split-screen layout with an English statement on one side of the device (facing the nurse) and the same statement in Spanish flipped 180° on the other side of the screen (facing the Spanish-speaking client or family member). The app included many statements or closed-ended questions that could be used for basic communication such as “The interpreter has been called,” “Do you need anything to eat?” and “Are you having any pain?” Participants using the app reported facilitation of communication. They indicated that teaching the caregivers and clients how to use the app was an icebreaker and that it helped nurses develop relationships with the families (Jackson & Mixer, 2017).