3.1. Infant Mortality Rate (IMR)
In the U.S., the infant mortality rate (the number of deaths of infants under one year of age per 1,000 live births) has declined rather steadily throughout the twentieth century, largely due to improvements in control of infectious diseases, health care (particularly neonatal intensive care), and nutrition. In 1900, the rate was about 162 deaths per 1,000 births (Linder and Grove, 1947); by the year 2000 it had declined to 6.9 (Iyasu, et al., 2002). Although marked improvements in infant survival have occurred among all racial and ethnic groups, higher infant mortality rates are seen among many minority groups and the magnitude of the disparity has in some cases increased (Arias, et al., 2003). For example, between 1980 and 2000, infant mortality among whites declined 47.7% (from 10.9 to 5.7), while infant mortality among blacks declined only 36.9% (from 22.2 to 14.0). Consequently, the black-white ratio of infant mortality increased 25% (from 2.0 to 2.5) over this time period (Iyasu, et al., 2002).
Cities have high infant mortality rates (IMR) because their residents share certain high-risk characteristics. The variability in IMR among the nation's 60 largest cities tends to segregate by race, ethnicity, and other characteristics common to the urban environment. For example, those cities with the highest infant mortality rates tend to have a larger proportion of black births and a smaller proportion of latino births. Conversely, cities with the lowest infant mortality rates tend to have a smaller proportion of black births and a larger proportion of latino births. Additionally, cities with higher IMRs were more commonly in the more urbanized Midwest, Southeast, and Northeast, and those with lower IMRs were clustered in the less urban Pacific West and West Central regions (Haynatzka, et al., 2002). Several factors including low birth weight (Iyasu, et al., 2002), low socioeconomic status, teen motherhood, single motherhood (Forssas, et al,. 1999), low maternal educational attainment, poor access to prenatal care (Barros, et al., 2001), maternal tobacco use (Matthews, et al., 2002), and biologic or genetic factors have been suggested as important causes of these unequal urban disparities in infant mortality.
Biologic and genetic factors do not appear to exert significant independent effects on infant mortality rates in the U.S. population (Ekwo and Moawad, 2000). While the primary reason for infant mortality disparities appears to be attributable to a higher proportion of low birth weight deliveries among minority and particularly black women, the etiology of black-white disparities in low birth weight is complex and not explained entirely by demographic risk factors such as maternal age, education, or income (Schoendorf, et al., 1992; Buka, et al., 2003). Other factors that might contribute to the disparity include racial differences in maternal medical conditions, stress, lack of social support, bacterial vaginosis, other co-morbidities, previous preterm delivery, and maternal health experiences that might be unique to black women (Hogan, et al., 2001; Milligan, et al., 2002; Buka, et al., 2003).
In 1991, the U.S. Department of Health and Human Services began the national Healthy Start Initiative. This was a five year, $170 million infant mortality prevention demonstration program for communities with very high infant mortality rates (Boroff and O'Campo, 1996). This program funded 15 sites (mostly urban) in communities with infant mortality rates that were 1.5 - 2.5 times the national average. The program began with a five-year demonstration phase to identify and develop community-based system-level approaches to reducing infant mortality by 50% over the five-year period and to improve the health and well-being of women, infants, children, and their families. Healthy Start projects address multiple issues, including: providing adequate prenatal care, promoting positive prenatal health behaviors, meeting basic health needs (nutrition, housing, psychosocial support), reducing barriers to access, and enabling client empowerment.
While a formal national evaluation of the program showed mixed results, analyses of data from specific sites are promising (Devaney, et al., 2000). One such evaluation detailed the Baltimore City Healthy Start's impact on medical reform, a component of the healthy start program, which works in conjunction with prenatal clinics, pediatric clinics, and family planning clinics in an effort to improve community access to services. Although obtaining long-term funding remains a challenge, preliminary data indicate that Healthy Start has begun to increase the utilization of prenatal and pediatric care, improve linkages between providers, and increase male involvement in perinatal care. In turn, these activities are helping to improve birth outcomes among very high risk inner city Baltimore women.
The observation that urban air pollution is a potential cause of asthma and respiratory disease dates back to Greek and Roman antiquity (Holgate, et al., 1999). In the early to mid twentieth century acute exacerbations of air pollution in urban centers of Belgium, London, Germany, and the Netherlands were all associated with increases in coughing, wheezing, shortness of breath, hospitalizations, and cardiopulmonary mortality among children and adults (Alberg and Samet, 2003). Towards the later half of the twentieth century, during the last three decades, the prevalence of asthma has increased significantly in all age and race/ethnicity groups across the world, with disproportional increases among impoverished, minority children living in urban inner cities (Shapiro and Stout, 2002; Mannino, et al., 1998; 2002; Eggleston, et al., 1999). The prevalence of asthma in children under the age of 18 is approximately seven percent in the U.S. However the rates may be as high as 20-25% among certain inner city census tracts in the northeast and Midwest (Graham, 2004; Aligne, et al., 2000; Webber, et al., 2002).
Many interrelated factors contribute to the epidemiology of urban childhood asthma. Individual and community level factors including exposure and sensitiza-tion to cockroach, rat and mouse allergens, dust mites, environmental tobacco smoke, cat dander, ozone, particulate matter, outdoor air pollution, lead, deteriorated urban housing stock and diesel exhaust, and poor access to care are all important (Eggleston, et al., 1999; Shapiro and Stout, 2002; Holgate, et al., 1999; Litonjua, et al., 2001; Rosenstreich, et al., 1997; Rauh, et al., 2002; Kattan, et al., 1997; Phipatanakul, et al., 2000; Perry, et al., 2003; Stevenson, et al., 2001). These asthma determinants may operate via direct and indirect mechanisms. For example ambient air toxicants may act as direct irritants of bronchial mucosa. Alternatively an indirect pathway is also being increasingly recognized where toxicants act as immunmodulators via affecting the production of IgE and TH2 (Thymus-derived helper), thereby modulating the inflammatory response to alveolar antigens in genetically predisposed children (Shapiro and Stout, 2002; Eggleston, et al., 1999).
Along with these individual and community level factors certain more global associations have been demonstrated between asthma and the urban environment. For example, rising levels of carbon dioxide (CO2) trap atmospheric heat, promote plant pollen production, and alter species composition by favoring growth of ragweed, opportunistic weeds and molds. The combination of air pollutants, aeroallergens, heat waves and unhealthy air masses are increasingly associated with a changing climate and are collectively thought to contribute to global warming, in addition to causing damage to the respiratory systems, particularly for growing children and minority groups living in the inner cities (Epstein and Rogers, 2004).
Childhood morbidity and mortality associated with asthma and the urban environment have generally been on the increase for at least the last two to three decades. Over this time period the number of physician office and outpatient visits, emergency department visits, and hospitalizations have steadily increased, with children under the age of 18 consistently having the highest rates (Mannino, et al., 1998; 2002; Webber, et al., 2002).
The ultimate prevention and control of urban childhood asthma will require a comprehensive multifaceted approach. While appropriate medical management is important, its ultimate effectiveness is limited to the degree of success achieved at improving asthma determinants found in the urban environment (Clark, et al., 1999).
School-based asthma education and prevention programs are an area of active research. According to the 2002 State Survey of School-Based Health Center Initiatives, there are 1,498 school-based health centers in the U.S. 61% of these centers are in schools located in urban areas. Most of them (63%) being in urban high schools (Lear, 2004). The potential efficacy of this strategy is supported by studies that suggest providing asthma self management education during school time can reduce symptoms and improve school performance (Webber, et al., 2003; Lurie, et al., 1998; Evans, et al., 1997). Unfortunately the utilization of these sites as asthma education, prevention and control sites appears to be low. In a recent survey, none of nearly 1,500 school-based health centers listed asthma as a top priority (Lear, 2004).
National injury mortality data are not readily available by level of urbanization (Frattaroli, et al., 2002). However, injury rates are greatest in those areas with low socioeconomic status residents, especially urban black children (Centers for Disease Control and Prevention, 2004). In the literature, two of the most commonly described forms of injury outcomes for children in urban areas are pedestrian accidents and youth violence.
Overall, motor vehicle traffic injuries occur more often among rural than urban children (National Center for Health Statistics, 1997). These rural children are usually injured as passengers (Lapidus, et al., 1998; King, et al., 1994), reflecting the fact that rural children spend more time in cars and drive longer distances. Urban children, however, are injured by motor vehicles more often as pedestrians than as occupants (Laraque, et al., 1995). Nationally 18,000 children under age 15 were injured as pedestrians, and 434 died in 2002 (National Highway Traffic Safety Administration, 2002).
Environmental factors associated with childhood motor vehicle pedestrian injuries include two types of factors; 1) social, societal, systems and cultural factors and 2) physical characteristics like the home, streets, and playground (Grossman and Rivara, 1992). The concentration of poverty in inner cities, along with recent increases in residential segregation by income and race in U.S. metropolitan areas, create circumstances that lead to worse motor vehicle related injury outcomes for children in poor neighborhoods (Katz, et al., 2001). Specifically, poverty in the urban child's social environment can create conditions that promote pedestrian injuries. For example, higher average and posted speed limits are likely to occur in areas of low socioeconomic status (Rivara, 1990). These higher speeds inevitably lead to more significant pedestrian motor vehicle injury.
Poverty also influences the physical environment in pedestrian accidents. Children from regions of concentrated poverty generally experience greater traffic exposure. This is because lower rates of parental home and car ownership are associated with more streets to cross on foot per day per child, and less likelihood of being driven home from school (Rao, et al., 1997). Higher traffic volumes and increased traffic density are also associated with low SES neighborhoods (Rivara, 1990). Children from poor families are fivefold less likely to live in private houses or have adequate play space in their yards (Grossman and Rivara, 1992). Thus, urban children have fewer alternatives to street and sidewalk play (Posner, et al., 2002). Finally, fewer pedestrian control devices occur in impoverished areas, and a recent review demonstrated that many sites of pediatric pedestrian trauma in Miami were located in long intervals between marked intersections (Hameed, et al., 2004). These larger distances allow greater vehicle acceleration and more random pedestrian crossing patterns, which in turn predispose children to injury when they "dart-out" mid-block, between areas of obstructed view (DiMaggio and Durkin, 2002).
One strategy being investigated to lessen pedestrian injuries among urban children is based on community behavioral education. Unfortunately the scientific evidence suggests that community-based education alone is insufficient to improve traffic safety behavior among young children (Klassen, et al., 2000). Recently the urban physical environment has emerged as a potentially more effective interven-
tional target to prevent pedestrian injury. Creating safe playgrounds was one aspect of the Safe Kids/Healthy Neighborhood Coalition program, which brought together city agencies, volunteer organizations, and citizen groups in Central Harlem to try to improve child health outcomes (Davidson, et al., 1994; Laraque, et al., 1994). After two years of the intervention, injuries such as trauma from motor vehicles decreased 23% from baseline, and this was attributable to the increased availability of safe play areas for the urban children (Laraque, et al., 1995). Other aspects of the urban physical environment can be manipulated through "traffic calming" engineering strategies. These include speed bumps, which by design are passive prevention strategies that work without any direct action on the part of the individual. A recent matched case-control study discovered that speed humps in Oakland, CA were associated with a 53% to 60% reduction in the odds of pediatric pedestrian injury or death within a child's neighborhood (Tester et al., 2004). Intentional, or violence-related injuries include assault by firearms, blunt trauma and cutting or piercing (Centers for Disease Control and Prevention, 1997). Analysis of data from 88 cities across 33 states reveals 645 homicides reported in 2000 for children under age 18 (Department ofJustice, 2003). In the past, numerous studies have shown that homicide rates are higher in urban centers than in rural areas (National Center for Health Statistics, 1997; Czerwinski and Moloney-Harmon, 1997; Zavoski, et al., 1995; Weesner, et al., 1994). Trend data from Boston, however, are encouraging and suggest a 12% annual decline in pediatric violence-related injuries, over a four year period (Sege, et al., 2002).
Among childhood violence-related injuries, firearms are most commonly used. Fifty-seven percent of homicides nationwide in 2001 among children 10-14 years of age involved firearms (National Center for Health, 2001). Firearms are widely available in cities and may be unsafely stored (Weesner, et al., 1994). Concentrated poverty in the urban environments can create fear for safety and promote weapon carrying. A survey in 1993 of ten inner city high school students showed that 22% of respondents reported possession of any type of firearm (Smith, 1996). The urban environment also generates child exposure to community and family violence, where violence can become a learned behavior (Czerwinski and Moloney-Harmon, 1997).
Strategies to intervene in violence-related injuries among children in cities including school-based education programs and peer mentoring have been able to change childhood attitudes towards violence (Sheehan, et al., 1999). However, evaluations of other violence outcomes are needed for these interventions.
Policy and regulatory interventions represent another approach to firearm injury control among urban children. Available options include required designs that limit access of unauthorized, high-risk users (Frattaroli, et al., 2002), like urban children. Intervention legislation and programs, such as tracing crime guns, strengthening the regulation of licensed firearm retailers, and screening prospective gun buyers (Wintemute, 2002), can decrease firearm availability, especially for urban youth. Community coalitions may even improve the urban environment as evidenced by the Safe Kids/Healthy Neighborhoods program, which showed a 44% decrease in injury risk for all targeted injuries, including physical assault and firearm mechanisms (Davidson et al., 1994). Finally, the Moving to Opportunity Demonstration Program is a federal initiative that chose poor inner city participants, at random, to receive moving assistance to enable them to relocate to wealthier neighborhoods. Early results document a 56% decrease in violent crime perpetrated by juvenile's aged 11-16 in Baltimore, MD (Ludwig, et al., 2001) and a 42% decrease in behavior problems among boys, as well as a 74% reduction in child injuries requiring medical attention, in Boston, MA (Katz, et al., 2001). These studies suggest that the seemingly intractable problems of urban violence may indeed be amenable to improvement among urban youths.
Across the world the incidence and prevalence of childhood obesity is on the rise (Wang, et al., 2002; Wang, 2001). In the U.S., the percentage of school-age children six through eleven that are overweight more than doubled between the late 1970s and the year 2000, rising from 6.5% to 15.3%. The percent of overweight adolescents aged 12 - 19 tripled from 5.0% to 15.5% during the same time period (National Center for Heath Statistics, 2003). The increase in overweight prevalence is highest among non-latino black and Mexican-origin adolescents (Strauss and Pollack, 2001), where more than 23% of non-latino black and Mexican-origin adolescents were overweight in 1999-2000 (Ogden, et al., 2002). In a population of urban kindergarten school children in Chicago, IL, approximately 25% of the predominately Mexican-American children were already overweight (Ariza, et al., 2004). Among urban populations as a whole, as many as 40% of children may be overweight or obese (Nelson, et al., 2004; Johnson-Down, et al., 1997).
Childhood obesity can lead to adult obesity and all its complications (Satcher, 2001). It may also negatively impact the pathogenesis or epidemiology of other childhood chronic diseases such as asthma. Several studies now point to childhood obesity as a risk factor for asthma prevalence and increased asthma morbidity among urban youths (Gennuso, et al., 1998; Luder, et al., 1998; 2004).
From an economic standpoint childhood obesity is related to the large increase in the percentage of hospital discharges with obesity related diseases. These include hypertension, diabetes gallbladder disease, sleep apnea, and asthma. Obesity associated hospital costs increased by threefold from $35 million in the late 1970s and early 1980s to $127 million in the late 1990s (Wang and Dietz, 2002).
The determinants of childhood obesity are complex and involve multiple factors including over-nutrition, inadequate physical activity, and other socio-environmental and physical characteristics associated with the urban inner city (Goran and Treuth, 2001; Strauss and Knight, 1999; O'Loughlin, et al., 2000; 1998; Gordon-Larsen, 2001; Stettler et al., 2000). It has been suggested that limited access to safe outdoor play and recreational facilities in the urban environment might be associated with obesity levels particularly among low income urban children (Cummins and Jackson, 2001; Burdette and Whitaker, 2004). The excess consumption and access to fast food restaurants located within the urban environment has also been hypothesized to contribute to the obesity problem among urban children and youths. However much more work is needed to fully characterize and confirm this potential association (Burdette and Whitaker, 2004).
Several public health approaches to childhood obesity reduction especially among those living in the urban environment are under investigation. Preliminary data suggest that such strategies as behavior modification (Moon, et al., 2004), reduction in TV and movie watching, and decreased video gaming (Robinson, 1999), and early initiation of breast feeding (Armstrong and Reilly, 2002) may be beneficial in reducing overweight and obesity levels in children (Campbell, et al., 2001). Experience with obesity prevention is limited, and the need for more research remains a priority.
Finally, interest and investigation in the association of community and neighborhood design (the built environment) and obesity is rapidly emerging. It is hypothesized that design strategies such as community sidewalks, walk-to-school programs, and reducing traffic speeds could facilitate physical activity, and thus reduce child obesity particularly in the urban environment (Cummins and Jackson, 2001). Currently there is insufficient data to draw valid evidence-based conclusions regarding these hypotheses.
Recently several lines of evidence have converged to kindle growing public concern about the mental health of children and adolescents in the U.S. In 1999, the Surgeon General's Report on Mental Health suggested that the prevalence of psychological disorders might be significantly higher in the U.S. than is generally appreciated. The report indicates that 20% of children suffer from a psychiatric or substance abuse disorder (NIH, 1999). Additionally, the American Psychiatric Association estimated that 15 to 25% of children evaluated in primary care settings have significant psychosocial disorders requiring some type of intervention (American Psychiatric Association, 2004).
Because childhood and adolescence are inherently characterized by biological, psychological, and socio-emotional developmental changes, it is often challenging to uncover mental health issues and accurately determine a youth's psychological well-being. This problem is further complicated because of environmental factors including family, peers, community, schools, impoverished conditions, violence, drug abuse, crime, and gang-related activities, which can profoundly influence teen psychological well-being. Over two decades ago Rutter first suggested an association between child mental health and the urban environment (Rutter and Quinton, 1977). In the years that followed several other studies (Raine, et al., 1998; 1997; 1996) documented associations between a child's individual health status, social/environmental risk factors, and the development of mental disorders, particularly in the areas of depression, suicide substance abuse, and addiction.
Depression affects up to 2.5% of children and 8.3% of adolescents in the U.S. at any given time. Lifetime prevalence for adolescents has been estimated at 15% to 20%, mirroring the rate seen in adults. Although in childhood the rates of depression are approximately the same for girls and boys, by adolescence girls are twice as likely as boys to develop depression (Lagges and Dunn, 2003). Children with depression are at risk for several other psychiatric disorders. Before the onset of depression, children may develop ADHD, oppositional defiant disorder, or conduct disorder, while adolescents are at increased risk for developing anxiety disorders after the onset of depression (Lagges and Dunn, 2003). Depressed adolescents are also at an increased risk for suicidal behavior and substance abuse (Birmaher, et al., 1998; Weissman, et al., 1999). More than 90% of children and adolescents who committed suicide had a history of a psychological disorder before their death. The most common disorder observed was depression (Gould, et al., 2003).
While the actual numbers of youths who successfully kill themselves are relatively small (1.5 per 100,000 among 10- to 14-year-olds and 8.2 per 100,000 among 15- to 19-year-olds), data from several sources document a much larger problem. The Youth Risk Behavior Survey conducted by the CDC indicated that during the past year, 19% of high school students "seriously considered attempting suicide,"
nearly 15% made a specific plan to attempt suicide, 8.8% reported any suicide attempt, and 2.6% made a medically serious suicide attempt that required medical attention (Gould, et al., 2003).
These data suggests a significant increase in the youth/adolescent suicide problem over the course of the last 30 years. Typically the highest rates are seen among American Indians and the lowest among Asians. In addition, the gap between those at high risk and low risk is narrowing particularly between low risk blacks and high risk whites. The reasons for the increase overall or among blacks is not entirely clear however the increased exposure to drugs and alcohol as well as the increased availability of firearms, both of which are common to the urban environment, have been postulated as causative (Gould, et al., 2003).
Current treatment for depression in children and adolescents begins with either behavioral therapy or medications. Several forms of behavioral psychotherapy administered individually or in group settings have been shown to be effective as a clinical intervention (Shaffer and Craft, 1999). For suicide, much of the preventive studies have evaluated interventions in school and community-based settings. School-based interventions tend to employ the utilization of suicide awareness curricula with children and adolescents. Despite the widespread use of these materials the efficacy has not been validated (Guo and Hartsall, 2002).
A positive relationship has been said to exist between youth and adolescent substance abuse or addiction and the residence in an urban environment (Gracey, 2002; Freudenberg, 2001). Several studies however have called this notion into question asserting that urban populations are no more likely than rural populations to engage in high risk behaviors or even that rural populations are at highest risk for these activities (Judd, et al., 2002; Levine and Coupey, 2003). Although the policy implications of determining "who's worse" will ensure that this debate is likely to continue for the foreseeable future, one aspect of this debate may be a bit more straightforward.
Local, state, and federal crime data indicate that the incidence of substance abuse and addiction is related to incarceration rates among users. In fact, the burgeoning of the U.S. correctional facility population over the last 2 decades has largely been the result of mandatory sentencing for substance abuse offenses (Glaser and Greifinger, 1993; Zanis, et al., 2003). Among youths and adolescents, those entering the correctional system may be at higher risk than un-incarcerated youths for sexually transmitted diseases, drug abuse, issues regarding pregnancy and parenting, human immunodeficiency virus (HIV) infection, and preexisting mental health disorders (AAP Committee on Adolescence, 2001).
In this country, jails and prisons are disproportionately located in urban communities. Because the average length of stay at U.S. jails is a few weeks (Freudenberg, 2001; Glaser and Greifinger, 1993), the turnover rates are very high. Thus significant numbers of adults and adolescents cycle through the correctional system each year. Some estimates put the number as high as ten million individuals including three quarters of a million juveniles every year (Glaser and Greifinger, 1993; AAP Committee on Adolescence, 2001). As such, the existence of a jail or prison in a given community can significantly impact the health of incarcerated and ultimately non-incarcerated residents living in that community (Freudenberg, 2001).
The availability of treatment and intervention services for incarcerated, detained, and recently released adolescents and juveniles is inadequate. Over two decades ago Knitzer concluded that children and adolescents in the juvenile justice system were largely neglected and ignored (Soler, 2002). Today questions still linger regarding an adolescents "right" to treatment, the proper interventional treatment to use and who should fund such treatments (Soler, 2002). These issues only serve to complicate the fact that many juveniles involved with the correctional system lack a regular source of medical care or private physician and many with a preexisting medical problem come from families that seem to be unable or unwilling to assist in ensuring that the adolescent receive proper medical care after release (AAP Committee on Adolescence, 2001).
The science of intervention and treatment of youth and adolescent mental health issues is under flux and continually developing. In fact, it has been estimated that even under the best of circumstances, where the number of people seeking treatment is maximized, clinician competence and patient compliance were also all maximized. Moreover, approximately half the burden of substance abuse, depression, and anxiety disorders among youth could not be averted with current interventions and knowledge, irrespective of the funding availability (Andrews and Wilkinson, 2002). For this reason, preventive interventional approaches among the youngest possible cohorts of children has been advocated (Andrews and Wilkinson, 2002), and the efficacy of such preventive, school-based cognitive behavior therapy administered by teachers or clinicians has been demonstrated (Andrews and Wilkinson, 2002). However, while efficacy can be demonstrated under controlled settings, similar levels of effectiveness in population-based environment have yet to be achieved (Andrews and Wilkinson, 2002).
School-based therapeutic programs have generally targeted certain maladap-tive behaviors most prominent in the school setting (disruptive behavior, violence, substance abuse etc) rather than treating distinct identifiable clinical syndromes like anxiety, ADHD, and depression (Rones and Hoagwood, 2000). Programs show a wide variability in scope, intensity and duration with some programs requiring parental involvement over the school year and others being brief student interventions (Rones and Hoagwood, 2000). Despite this programmatic heterogeneity, a significant literature exists documenting the efficacy of therapeutic approaches administered in the school based-setting (Rones and Hoagwood, 2000).
Even though clinicians have efficacious interventions at their disposal, the practical and widespread administration of these mental health services remain fragmented and uncoordinated for most youth living in the urban environment (Pratt, et al., 2000). To improve this situation, the American Psychiatric Association recently suggested that child and adolescent mental health services should be community-based and family-centered with access to services facilitated through school-based and primary care settings (APA Taskforce for the vision for the mental health system, 2003). While this approach may be desirable, living in the urban environment presents significant challenges to the realization of this vision. Urban public school systems are generally under funded and under staffed. Many have only part-time health personnel or no health personnel at all on site. It is difficult to see how, under current fiscal constraints, schools or many urban public school systems could dedicate resources or staff to gain the skills and resources needed to be adequately equipped to handle these health issues. While teachers may perform mental health interventions in the setting of a trial or research study, many are reluctant to integrate these services into the daily activities of the classroom (Rones and Hoagwood., 2000). Thus advocates of family centered, school-clinic coordinated services must overcome several social, financial, and practical barriers before this is likely to occur. In the end, significant impact on the mental health of children living in urban environments will likely require much more policy and interventional research, increased funding of current programs, and the creation of new and innovative treatment programs at schools and other community based sites.
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