CHAPTER 10 Twenty-first Century Health Challenges

School Trends and Phenomena

School Start Time and Adolescents

Computer-Related Child Exploitation

Commercialism of Public Schools

Media and Health

Schools as Community Health Centers

Home Schooling and Alternative Education

School Social Issues

Youth Gambling

Precocious Puberty

Emerging incidences and prevalence of certain developmental variations and behavioral disorders are becoming more common in the school setting. This chapter includes frequently discussed and documented occurrences by school nurses and other staff on elementary and secondary school campuses. These issues affect the health and learning ability of students at all ages.

The conditions in this chapter are presented in two different formats. Backpack Complications and Computer Ergonomics are presented in the manual’s traditional outline format. The other health-related issues are in paragraph format with the nursing management processes listed for quick access. These issues, some of which are new, are current health challenges for the nurse in the school setting and include school start time and adolescents, computer-related exploitation, commercialism of public schools, media and health, schools as community health centers, home schooling and alternative education, youth gambling, and precocious puberty.

BACKPACK COMPLICATIONS

I. Definition

A. Backpacks are used by the school-age student to carry schoolbooks and supplies, other articles, and equipment. Students often carry between 10 and 40 lb, sometimes more, on their backs to and from school and between classes. Backpacks should not weigh more than 15% of a student’s body weight. Table 10-1 provides backpack weight limits, and Figure 10-1 demonstrates correct and incorrect ways to wear a backpack.

II. Etiology

A. Human beings have used their backs for centuries to carry heavy loads, and mothers often carry infants and babies on their backs. Now, backpacks can be a threat to the health of students when the load is too heavy and when these loads are packed, lifted, or worn improperly, or if these factors are combined. Students carry their backpacks in a variety of positions that can adversely affect the spinal column and other bone structures that are not fully developed (APTA, 2006). Studies on children discuss the use of backpacks and their relationship to back or shoulder pain (Siambanes et al, 2004).

B. Wearing backpacks alters the mobility of the spine, leading to passive movement—involuntary movement from an outside force—which is a risk factor for back pain (AOTA, 2006; Vacheron et al, 1999). Low back pain during the adolescent years can result in low back pain in adulthood (Salminen et al, 1999). Adjusting to a heavy load leads to incorrect postures that include bending forward, leaning to one side, or arching the back; all of these can lead to improper spinal alignment. This misuse may impede functioning of the discs that provide shock absorption to the system (APTA, 2006). Long-term incorrect, heavy, and chronic backpack use may trigger back pain in students that may continue into adulthood, even more so in individuals with a genetic predisposition or an existing disease process.

III. Characteristics

A. Poor posture.

B. Tingling or numbness in arms.

C. Headache, fatigue, or both.

D. Low back pain that may become chronic.

E. Discomfort, pain, or both in the neck and shoulders.

F. Muscle spasms of the neck and shoulders.

G. Redness, pressure sores, or blisters on the back or shoulders from strap wear resulting from heavy or inappropriately packed loads.

IV. Health Concerns/Emergencies

A. Heavy backpacks.

1. May cause chronic health issues resulting from soreness, fatigue, and neck, shoulder, and back pain.

2. Improper positioning and weight of backpack may cause muscles and soft tissue to work harder, leading to back strain.

3. Headaches, red marks, neck and low back pain, numbness, and tingling in the upper arm area.

4. Heavy backpacks interfere with balance and may cause falling.

V. Effects on Individual

A. Poor posture and pain resulting from leaning forward with neck thrust forward.

B. Shoulder and arm strain from dragging a backpack.

C. Strain and stress on one side of the body caused by using only one shoulder strap.

D. Fatigue.

E. Prepubescent girls appear to be most vulnerable to postural imbalance, specifically the forward head position, when a backpack weighs over 15% of body weight (APTA, 2006).

VI. Management/Treatment

A. Teach the proper techniques for packing, lifting, and carrying backpacks; warn of health concerns resulting from improper use. Determine maximum backpack load.

B. Warn against using a backpack as a weapon; encourage storage of backpack in a safe area to prevent injuries from tripping.

C. Teach back-strengthening exercises.

D. Always choose a lightweight backpack; look for one with padding in the back and multiple compartments to facilitate distribution of weight and for organization. Consider reflective strips or lights to increase visibility at night. Backpacks are now available with an inflatable air chamber to reduce pressure on the back and protect it.

E. Briefcases and backpacks on wheels for heavy loads are helpful but may be difficult to use in schools with multiple floors.

F. Use care when moving about in tight spaces, such as on a school bus, to avoid hitting others with the backpack.

G. Discuss safety hazards and placement of backpacks during evacuation of school buildings with administration and staff. See Box 10-1 for further information on backpack safety.

VII. Additional Information

A. Several conditions have arisen from backpack use that may cause complications:

1. Students are multitasking from early morning until late evening, causing them to carry not only their classroom needs, but also items ranging from food to sports equipment to computers.

2. The short time intervals between classes do not permit students to go to their lockers.

3. Some schools have eliminated lockers because of security, safety, or budget constraints.

B. Occasionally, students may need special accommodations or assistance carrying supplies. They may need to leave class early to go to their lockers, or they may require a second set of books to meet their individualized needs. Some schools require that backpacks be made of see-through vinyl or mesh to discourage the transport of weapons, alcohol, or drugs. This demand seems to forgo the adolescent’s need for privacy but focuses on safety.

C. New technology may eliminate the need to carry heavy books between classes and to and from home. Small technological devices (e.g., USB flash drives, CDs) are available to store and transfer data to a home computer. Computerized textbooks are available for use on a lightweight device similar to a laptop computer, allowing students to highlight and take notes as they would with a textbook.

Table 10-1 Backpack Weight Limits

Student’s Weight (lb.)	Backpack Maximum Weight (lb.)
60	5
70	10
100	15
125	18
150	20
200 or more	25^*

* 25 pounds is the maximum suggested safe limit.

Adapted from American Chiropractic Association (ACA) and American Physical Therapy Association (APTA).

FIGURE 10-1 Appropriate and inappropriate backpack positioning.

A, Incorrect. Wearing the backpack over one shoulder tends to make one side of the body bear all the weight. This can cause an asymmetry of the spine and potential back pain, shoulder and/or neck strain, and loss of balance. B, Appropriate. Both shoulders bear the weight of the backpack load. Reduces symptoms of a heavy, unbalanced pack. C, Incorrect. Leaning forward with shoulders bending inward is observed when the pack is too low on the back and the load is not distributed evenly, producing bad posture, improper spine alignment, causing fatigue and/or back and neck strain. D, Appropriate. The backpack should rest evenly in the middle of the curve of the back. Wear chest straps and waist belt for appropriate weight distribution, stabilization, and reduction of potential pain or injury. See Box 10-1 for further information on backpack safety.

Box 10-1 EUPAC: Encourage Use of Proper Packing and Caution

1. Encourage weighing the pack and contents, limiting weight to no more than 15% of body weight to prevent neck and back strain.

2. Use wide and padded shoulder straps to avoid shoulder pressure and possible nerve damage.

3. Avoid slinging pack over one shoulder, which can cause loss of balance, muscle spasms, and low back pain.

4. A waist belt and chest straps provide good support and help with weight distribution and stabilization: fasten them. Adjust straps to allow arms to move freely.

5. Pack should not be longer than the distance between the shoulders and hips and not wider than the rib cage. It should rest in the curvature of the back.

6. Proper packing puts heaviest items close to the body and lighter items farther away or in small sections to distribute weight evenly, ease carrying, and prevent injury and strain.

7. Keep pack high up on the back. Do not wear low near the hips, because this shifts posture forward, producing back and neck strain.

8. Use caution when lifting a backpack. If the pack is very heavy, it should be placed on a desk or table before pulling it onto the back. Only pack what is needed for the day.

WEB SITES

American Occupational Therapy Association (Consumer tip sheets) http://www.aota.org

Backpack Safety America http://www.backpacksafe.com

International Chiropractic Pediatric Association, Research Foundation http://www.icpa4kids.org/index.htm

American Physical Therapy Association http://www.apta.org

COMPUTER ERGONOMICS

I. Definition

A. Ergonomics is the science that uses current knowledge of human abilities and limitations to design or organize systems, products, machines, or tools for efficient, comfortable, and safe use by human beings.

B. The computer monitor and workstation are used for academic learning, communication, and entertainment. Computers include both desktop and laptop styles. The physical arrangements (i.e., ergonomics) in the computer environment can have a negative impact on visual health and body mechanics.

II. Etiology

A. Using a computer workstation poses a threat to the individual’s health because of stress and fatigue from inappropriate body positioning, work environment, and repetitive activity. Health hazards from inappropriate or cumulative use of computers include carpal tunnel syndrome, back and neck pain, and computer vision syndrome (CVS).

1. CVS symptoms occur as a result of a variety of factors: glare or reflections, failure to blink frequently enough to maintain moisture on the surface of the eyes, increased tear evaporation, corrective lenses that are inappropriate for the individual’s distance and position from the screen, minor visual defects that manifest after intense computer use, and poor body positioning in relationship to the monitor or workstation.

2. See Box 10-2 for tips on how to avoid eyestrain and body fatigue.

III. Characteristics

A. Visual symptoms:

1. Temporary myopia.

2. Eye fatigue and strain.

3. Blurry vision at near and far distances.

4. Dry, watery, or irritated eyes (itching, burning).

5. Sensitivity to light.

6. Trouble refocusing from screen to paper or book work.

7. Double vision.

B. Physical symptoms:

1. Neckaches, backaches, muscle spasms.

2. Headaches.

3. Carpal tunnel syndrome with chronic use; development of this type of injury may take 5 to 10 years to manifest.

C. Referral:

1. If any of these symptoms persist, refer to parent, HCP, eye specialist, or physical therapist.

IV. Health Concerns/Emergencies

A. Delayed socialization skills can result from computer use that begins at too early an age. Supervision by an adult is especially critical for children younger than age 7 to establish appropriate and healthy ergonomics. Software is now available for infants.

B. Temporary damage to vision or upper body muscles, nerves, or tendons.

C. No current data suggest permanent visual damage.

D. No current evidence exists that indicates computer displays emit hazardous radiation (ultraviolet or ionizing radiation), nor do data suggest a health risk from exposure to electromagnetic fields associated with monitor use (Occupational Safety and Health Administration [OSHA], 2005).

V. Effects on Individual

A. Complaints of aching or pain, tenderness, swelling, cracking, numbness or tingling, loss of strength, decreased coordination in the injured area, or loss of joint movement of the fingers, shoulders, back, or neck; strain is most commonly seen in the hand, wrist, or arm. These complaints usually are called repetitive strain injuries (RSIs; see Additional Information).

B. In young children, excessive computer use may impede the development of critical skills, such as creativity, imagination, and attention span; a decrease in pretending skills, motivation, and desire to persevere may also be evident. Select high-quality developmental software versus rote learning or drill-and-practice software.

C. Weight gain can be an issue at all ages. Excessive time at the computer without set limits or exercise breaks can be a contributing factor to becoming overweight. Software programs and other tools are available to assist parents in limiting electronic media time and providing exercise breaks (e.g., Stretch Break for Kids, http://www.paratec.com/sbform/kidsform.htm).

VI. Management/Treatment

A. For home or school:

1. Students should wear prescribed eyeglasses. Computer glasses may be ideal when computer use lasts several hours per day.

2. Determine and record extent of computer use during vision screening.

3. Check display screen position for viewing without neck tilted either backward or forward. If screen position is too high, the individual will tip the neck backward; if the screen is too low, the individual will bend forward for easier viewing (see Figure 10-2 for suggested computer workstation positioning).

4. Maintain glare-free screen and reposition computer screen as appropriate for each child. Screen should be at a right angle to windows, and awning or blinds can be used to decrease glare. Check for glare by turning the screen off and observing any reflection of lights or lightly colored objects on the screen. Adjust the brightness of room lighting or use an antiglare filter approved by the American Optometric Association (AOA) or a three-sided computer hood. Clean the screen often with antistatic cloth.

5. Use a document holder. Place the text document or book in the holder and move it as close to the screen as possible. Maintain sufficient light on any paper documents by using a freestanding, adjustable-brightness task light. The light should not be exposed directly to the eyes. Light in the work area within 25 degrees of the screen should be approximately the same as the background illumination of the screen.

6. Ensure that appropriate workstation equipment and furniture are used. Use a height-adjustable chair with good back support. The work surface should be stable. Use a negative-slope or tilt-down keyboard system or a height-adjustable mouse or keyboard platform. The keyboard and mouse should be appropriate for the child’s or adult’s hand size; smaller hands need a smaller keyboard (e.g., LittleFingers keyboard).

7. Schedule timely work breaks, because postural problems associated with computer use depend on the length of continual use time. Breaks every 20 to 30 minutes are ideal for younger students. Software can be programmed to remind the user to take a break by providing on-screen alerts (see Web Sites); many provide guidance on simple exercises. Adolescents can focus on a distant object for about 2 minutes. Frequent blinking of the eyes also is necessary. Computer users should stretch frequently (e.g., make a fist and spread fingers wide apart for 10 seconds; tilt head to shoulder, side to side; turn head to each shoulder and hold for 10 seconds; lean over and put hands on the floor while seated; clasp hands together overhead and move arms side to side).

8. Apply ergonomic guidelines for computer use (see Web Sites). The neutral work posture applies to children, adolescents, and adults. It ensures comfortable and ergonomically correct computer use. Applying principles of ergonomics (i.e., fitting the workspace to the individual’s body) can alleviate many of the health risks associated with computer use.

B. Problem postures and keyboard positions:

1. An upward-sloping keyboard increases muscle loads in upper arms, shoulders, and neck. Positioning the keyboard on the desk makes maintenance of neutral position difficult, because the forearms tire and sag. This puts the wrists into greater extension. The elbows, usually flexed, compress the median and ulnar nerves at the elbow, thus restricting blood flow to the hands.

C. Laptop computer use:

1. Keyboard and screen cannot be adjusted, making decisions about head and neck posture and hand and wrist position difficult, because one or the other will be compromised using a laptop.

2. Use a wireless or detachable keyboard to allow for proper positioning of keyboard and screen.

3. Tip screen back 100 to 110 degrees; a desktop screen is typically at 90 degrees; print will become more crisp.

4. When transporting a laptop, be aware of other items placed in bag and the overall weight. Carry only computer items needed.

VII. Additional Information

A. The effects of computer use on infants and young children are unknown, and research in this area is limited.

B. RSIs involve muscles, tendons, and nerves that are overused or misused. The damage is caused by repetitive tasks, forceful movements, awkward or fixed postures, or insufficient relaxation time between activities. RSIs may include carpal tunnel syndrome, ganglionic cysts, tendonitis, tenosynovitis and epicondylitis (tennis elbow), trigger finger, thoracic outlet syndrome, De Quervain’s disease (a painful condition affecting the tendons at the base of the thumb), and computer vision syndrome.

Box 10-2 Tips to Avoid Eyestrain and Body Fatigue

1. Blink frequently to moisten eyes.

2. Wear computer glasses, as needed.

3. Focus on distant objects periodically.

4. Use relaxation and stretching exercises.

5. Move away from the computer occasionally.

6. Follow 20/20/20 rule: Every 20 minutes, take 20 seconds and look 20 feet.

7. BBB Rule: Blink, breathe, and break.

20/20/20/ Rule and BBB Rule: From Dr. Jeff Anshel, personal conversation, Jan 25, 2007.

FIGURE 10-2 Suggested computer workstation positioning.

WEB SITES

Computer Ergonomics for Elementary School http://www.orosha.org/cergos/index.html

Cornell University Ergonomics Web http://ergo.human.cornell.edu

Corporate Vision Consulting http://www.cvconsulting.com

Stretch Break for Kids (Computer Ergonomics Exercises) http://www.paratec.com/sbform/kidsform.htm

SCHOOL TRENDS AND PHENOMENA

SCHOOL START TIME AND ADOLESCENTS

Adolescents experience a shift in circadian rhythms, the natural cycle of sleep–wake patterns, which causes a change in the secretion of the hormone melatonin. This change causes the adolescent to stay awake later at night and sleep later in the morning (National Sleep Foundation, 2006). Early school start times reduce the amount of sleep for most adolescents, and this lack of sleep impairs their cognitive and motor functioning, eye–hand coordination, accuracy, concentration, and short-term memory; it also shortens attention span and lengthens reaction time. Sleep deprivation affects specific areas of the brain and impacts how people learn. The brain needs more sleep than any other part of the body; during sleep, information received during the day is sorted out and consolidated (Peigneux et al, 2004; Spencer, Sunm, and Ivry, 2006). Lessons taught and learned at school—that is, new neuronal connections—are strengthened during sleep.

An adolescent requires 8.5 to 9.25 hours of sleep each night to function adequately (National Sleep Foundation, 2006). The most recent National Sleep Foundation Study reports that only 20% of adolescents get 9 hours of sleep, and almost 50% state that they get less than 8 hours, making them sleep deprived. Twelfth graders report that they get only 6.9 hours of sleep a night, making the senior year a particularly difficult time for adequate rest and sleep. Students find various coping mechanisms for sleep deprivation: 38% of high school students report taking at least two naps per week, they sleep later on weekends, and they frequently consume caffeine to stay awake—31% drank two or more caffeine drinks per day. Another sad consequence is that many give up exercising; they report being too sleepy or tired to do it. More than half (51%) of students who drive have driven while drowsy (National Sleep Foundation Study, 2006).

Sleep deprivation causes a negative mood: behavior and attitude of students lacking sleep show signs of anxiety, depression, hopelessness, and acting-out behaviors. They also have decreased focus, attention, and concentration in the classroom; 28% of students fall asleep during class at least once a week; 14% arrive late for morning class, skip that class, or miss school altogether. Most schools start between 7 a.m. and 8 a.m., so the average adolescent’s day starts between 6 a.m. and 7 a.m. (National Sleep Foundation Study, 2006). More than half of all high school students (55%) go to bed after 11 p.m. on school nights, robbing them of many needed hours of sleep. Those with optimal sleep (20%) receive more A and B grades (34%), and those with less sleep generally achieve lower grades (National Sleep Foundation Study, 2006).

Over 80 school districts throughout the United States (e.g., Minnesota, Massachusetts, Rhode Island, Iowa) have a delayed start-time in high school. They found attendance improved, daytime alertness increased, and tardiness decreased. Students also reported less depression, fewer trips to the school nurse’s office, more frequent breakfasts, and the ability to complete more of their homework during school hours (Wahlstrom, 2002). Sleep is one factor among many that affects learning.

If advocating for later school start times, it is imperative that the school nurse: