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Lesson 2.3

Health and Learning:
What Can Schools Do?

Physical and Mental Health Affect Learning.

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Students learn when they are well. When they aren't well, well...

Learning is mental work. It requires presence and concentration, and a lot of things can get in the way. There is a powerful connection between education and health. This lesson summarizes many of the ways that schools play a role in health, and the ways that health plays a role in school.

Why do schools provide free lunch?

Children cannot concentrate on learning when they are hungry.  Food aid is one of the oldest and most basic interventions in public school systems — it began at scale in cities and states during the Great Depression era. The National School Lunch Program was authorized in 1946. Over the years the program has been expanded and modified multiple times. About half of California’s students qualify for free or reduced-price lunch, and many children in poverty depend on school for at least five meals a week. Schools provide free or discounted meals for students well above the official poverty line, but statistics from the meal program are often used as a proxy measure of poverty. Beginning in 2022-2023, all California public schools, charter schools, and county offices of education must provide universal meals. This means each student is now eligible for free breakfast and lunch daily, regardless of household income.

Too many Americans do not eat well. Poor diet, combined with lack of exercise, contributes to obesity, which has long term health implications. Obesity rates in all states have risen, though less so in California.


Though obesity rates for adults have increased in many states, there is some good news for children. Increasing rates in obesity in preschool and school age children have slowed or reversed in recent years in many states including California. (For details, have a look at The Weight of the State, a report of the California Department of Public Health. It includes county-by-county data.)

Milestones in California nutrition policy
2004 Banned sales of sugary beverages on school grounds
2008 Limited calories and fats in school snacks
2008 Created the Fresh Fruit and Vegetable Program, a supplement to the nutrition programs supported by the federal and state government
2013 Research confirmed health impact of soda bans
Source: Centers for Disease Control and Prevention (Data from 2008 to 2011)

Source: Centers for Disease Control and Prevention (Data from 2008 to 2011)

Many organizations work to improve child nutrition including Nourish California and the Child Nutrition Program of Southern California. During the Pandemic, school food services scrambled to adapt. Although the work of serving food is thoroughly local, the money for it is mostly federal. It can be complicated.

Do schools have nurses?

Budget cuts have had a severe impact on the ability of schools to hire nurses. School nurses — if you have them — take care of a lot more than cuts and scrapes. They administer medications and vaccines, provide health counseling, support school wellness programs, and make health referrals.

The Robert Wood Johnson Foundation warns that the lack of nurses weakens school health services and puts children at risk. In every school, some children suffer from life-threatening conditions and diseases such as diabetes, seizures, asthma, bleeding disorders, mental health problems, and severe allergies. Medical advances have rendered many of these conditions treatable or manageable, but they do not manage or treat themselves.

California lags the nation in school nurses. According to, in California there were 2,410 children per school nurse in 2019. The National Association of School Nurses recommends a ratio of 750:1 for well children and 225:1 for student populations with special needs. And children with acute health care needs may require even more help to remain in school. School Health Services for Children With Special Health Care Needs in California, a report from PACE, points out the challenges facing our children and our schools, such as this eye-opener: "In the absence of nurses, a range of school personnel are being called on to provide health services, such as administering medication, treating life-threatening allergic reactions, performing gastrostomy tube feeding, injecting insulin, suctioning tracheostomies, and providing urinary catheterization."

School-based health care

Most children receive health care from whatever insurance their family can afford, which for many families is little or nothing. Schools would seem an obvious place to offer screening and basic care, but fewer than 20% of elementary schools in California offer health services for children.In 2018 Columbia University economics professor Randall Reback estimated in an important study of student health for the Getting Down to Facts II project that it would cost less than $100 per pupil annually for the state to provide basic physical and mental health coverage at all public schools. This figure includes "approximately $31 per student to provide enough counselors to provide basic mental health services at all K-12 schools and $59 per student for every public school to have either a school nurse at least one day per week, a school-based health center, or a mobile health van visiting for three to four hours per week.

Medicaid funding to support such investments is available, Reback notes, but school districts and county health offices rarely coordinate their efforts to take advantage of it. As of 2021, out of 10,000 California schools, KidsData identified only 291 school-based health centers.

What is the role of schools in vaccinations?

Vaccinations are a safe and effective way to prevent humanity from devastating diseases. They are a cornerstone of public health policy in California, which requires vaccinations for all students with very few exceptions. Prior to 2016, the law had allowed families to cite personal beliefs to opt out of vaccinations, a policy that led to outbreaks. The arrival of the COVID-19 pandemic increased public awareness vaccination policy. The Centers for Disease Control tracks disease outbreaks.

Certain exemptions are still allowed for a home-based private school or an independent study program with no classroom-based instruction. The California Department of Health provides a web site aptly titled Shots for School that enables you to check the immunization rate at your school.

California's vaccination requirements protect students from school-based outbreaks of the following deadly and disfiguring diseases: Diphtheria, Pertussis, Tetanus, Polio, Measles, Mumps, Rubella, Hepatitis B and Chickenpox. For additional information about vaccinations in California schools, including a map that estimates your community's vulnerability to outbreaks, see this blog post.

Physical activity and "P.E."

Even though California mandates physical education (P.E.) for virtually every child virtually every day, most children do not get the daily physical activity they need.

According to the Centers for Disease Control and Prevention, physical inactivity is consistently linked to poor grades and lowered educational attainment. Among the campaigns to address this are ShapeUP SF and California Project LEAN. The Centers for Disease Control provides school health guidelines to promote healthy eating and physical activity.

P.E. classes aren't just for running around. For more about the role of P.E. in education, see Lesson 6.9.

Sex education

Most people agree that schools need to teach sex ed. But they don't necessarily agree about what sex education should include, what the goals of sex ed programs should be, and whether specific programs can achieve those goals.

In 2015 the California legislature updated its policies for sex education and HIV/STD prevention. In doing so it significantly clarified what schools are obligated to teach. The California Healthy Youth Act requires public schools to provide all students in grades 7-12 with age-appropriate sexual health education that is "comprehensive and medically accurate," meaning that it includes content about human development, sexuality, pregnancy, contraception, and sexually transmitted infections including HIV. This definition still leaves plenty of wiggle room for big variations among schools because the minimum legally required "dosage" of sex ed is just one class session in junior high school and another in high school.

For more about sex education in California have a look at the Ed100 blog post on the subject. The post explores how California schools are dealing with puberty education, teen pregnancy, consent and other topics.

A healthy environment for learning

Health issues go far beyond a school nurse, healthy meals and physical activity. They include indoor air quality, asthma management and sun safety measures at school.

If you see peeling paint, suspect the worst. In a Reuters study of 29 communities all over the state of California, up to 13% of children were found to have elevated levels of lead in their blood. In one school in the Fresno area, blood data obtained showed that children had rates nearly three times higher than those in Flint, Michigan. You shouldn't assume that water at your school is safe, either. California regulations generally require that schools have at least one drinking fountain for every 150 students. In 2013, EdSource exposed data about lead in school drinking fountains across the state. By 2019 hundreds of schools had tested their taps, but gaps remained.

In order to increase overall family health and wellness, some communities use school sites to provide low-cost health services such as immunization and toddler wellness checks. (The most celebrated example is the Harlem Children’s Zone in New York). 


School calendars and hours are under the control of school districts, but in 2019 California enacted laws that limit on how early schools may start. Beginning with the 2022-23 school year, middle schools must begin no earlier than 8:00 am, and high schools no earlier than 8:30 am. This was a significant policy change, requiring perhaps 90% of California schools serving those grade levels to revamp their schedule.

Compelling research confirms the educational value of sleep. Children need 8.5 to 9.5 hours of it, and they learn poorly when they are fatigued. According to research by RAND corporation, starting school before 8:30am cost the state of California at about $1 billion per year (for perspective, that's about $150 per student per year). The laws enacted in 2019 were designed to be phased in over three years because school calendars are tied to everything from after-school programs to bus schedules. See the blog post for more information.

Mental health

Other than parents and family, faculty in schools are in the best position to notice mental health issues in children and take supportive action, if they know how. Anxiety and depression are common maladies for adolescents, especially girls. Not all childhoods are happy. Some children come to school with symptoms of trauma, and few schools prepare their faculty to offer the help children need.

Untreated, mental health problems can completely derail learning, or worse. Suicide is the second leading cause of death for adolescents, a topic we explore in greater depth in the Ed100 blog.

Unhealthy California

Health is vitally important to learning, but there are many ways that health can go wrong, especially for students living in poverty.

The separation of health services and school services is not a church-and-state issue. Schools already play a major role in student health through food aid and vaccination, and they could play a significant role in basic health screening, at an incremental cost of about $100 per student according to Randall Reback, who examined the issue for the 2018 Getting Down to Facts II project. The state has not stepped up in a big way to impose program requirements on school districts, but there is no fundamental barrier blocking school districts from including student health in their mission. Under the Local Control Funding Formula, school districts can choose to spend on school-based health programs if they want to.

Drugs, Tobacco and Vaping

Many life habits are formed in youth. Unfortunately, young people don't always make healthy choices.

The good news is that the long-term trends in this area have been mostly good for the last several decades. Since 1975 the National Institute on Drug Abuse (NIDA) at the National Institutes of Health has measured drug and alcohol use and related attitudes among adolescent students nationwide through a huge annual study called Monitoring the Future. Over time, teen usage rates of many very dangerous drugs have been trending downward.

The bad news is that some of these trends seem to be reversing. Teen smoking has largely been replaced with vaping, which is cheaper and stealthier than cigarettes, but every bit as addictive. The legalization of marijuana in California for adults 21 and older has changed public attitudes about the drug and its derivatives. Vaping products make nicotine and marijuana consumption harder for schools to detect and discourage.

The Ed100 blog contains much more information about vaping.

Next Steps

All school districts that participate in the National School Lunch Program are now required to have a school wellness policy developed with community input. These policies set goals for nutrition as well as physical activity and other school-based activities that promote student wellness. If you are trying to boost wellness in your school, reviewing this policy can be a place to start.

Updated August 2017, June 2018, Sept 2018, October 2018, October 2019, December 2020, May 2021, August 2022


California has implemented which of the following health interventions in schools?

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Questions & Comments

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user avatar
Carol Kocivar August 24, 2023 at 2:28 pm
CA Meals for Kids Mobile Application
user avatar
Jeff Camp - Founder September 7, 2022 at 10:23 am
Parents in California can prevent their children from receiving some vaccinations, including for COVID. Teen advocates came close to seeing this policy changed in 2022.
user avatar
Carol Kocivar August 4, 2022 at 1:29 pm

The state 2022-23 Budget includes $600 million one-time available over three years for school kitchen infrastructure upgrades and equipment, food service employee training, and compensation for work related to serving universal meals using more fresh, minimally processed California-grown foods.

The Budget also includes $100 million one-time to support local educational agency procurement practices for plant-based or restricted diet meals, to procure California-grown or California-produced, sustainably grown, whole or minimally processed foods, including for use in plant-based or restricted-diet meals, or to prepare meals fresh onsite.
user avatar
Carol Kocivar August 4, 2022 at 1:25 pm

The 2022-23 state Budget includes $596 million to fund universal access to subsidized school meals. It also includes an additional $611.8 million ongoing to augment the state meal reimbursement rate sufficient to maintain meal reimbursement rates beginning in 2022-23.

This higher rate of reimbursement will enable local educational agencies to continue offering higher-quality and more diverse meals for students.

If the federal government extends the waiver that allows for the allocation of higher federal reimbursement rates, any unused state funding for rate increases in 2022-23 would instead be made available for food procurement grants.
user avatar
Carol Kocivar June 14, 2022 at 12:44 pm
The 2022-23 Budget: School Nutrition: Legislative Analyst
February 8, 2022 - This post provides background on various child nutrition programs and requirements and offers associated assessments and recommendations to the Legislature.
user avatar
Carol Kocivar November 1, 2021 at 6:05 pm
The AAP, American Academy of Child and Adolescent Psychiatry (AACAP) and Children’s Hospital Association have declared a national emergency in children’s mental health, citing the serious toll of the COVID-19 pandemic on top of existing challenges.
user avatar
Selisa Loeza October 22, 2021 at 6:57 pm
Are there any examples of parent groups successfully advocating to their districts and receiving more programming/support for the health topics mentioned? I plan on begin doing this research into my district, but would love to hear of others who may have pioneered this in their district.
user avatar
Carol Kocivar October 19, 2021 at 12:57 pm
Beginning in 2022-2, all public schools must provide two free meals per day to any student who requests a meal, regardless of income eligibility.
user avatar
amy su November 5, 2020 at 8:41 pm
We definitely need more nurses and availability of health care for students while at school.
user avatar
Emily Cruz October 29, 2020 at 6:47 pm
Its very concerning that the district is considering hybrid learning despite our lack of nurses, its paradoxical. Im glad California began to introduce healthier meals, I do think they could improve a lot however. We need to teach our students from a young age that healthy meals can taste good too. We are currently not doing that.
user avatar
Sonya Hendren July 11, 2020 at 1:37 pm
When we read this lesson in our school Ed100 "book club," we were surprised to read that school nurses can administer vaccinations. Anybody go to a school that does that? Maybe it is more common in higher grades? (We're a K-6th school.)
Perhaps when a COVID-19 vaccine is available, districts with school nurses will be able to help quickly vaccinate our student population.
user avatar
Jeff Camp September 18, 2018 at 12:38 am
Is your school community struggling to overcome antivax sentiment? You might be tempted to show some of the (horrifying) images of children afflicted with nonfatal cases of the diseases that vaccines prevent. Unfortunately, there is evidence that this strategy can backfire, done clumsily. Antivax bias is a sufficiently dangerous public health problem that there is some helpful research about how to overcome it. The short version: doctors have to speak up, with conviction. ‘If you can't do this, I can't see you. I can't stand that your child is at risk like this.’
user avatar
Jeff Camp September 18, 2018 at 12:12 am
Teaching Sex Ed is tricky, and norms differ from place to place. The 2015 California Healthy Youth Act requires a set of minimum standards, and sets a process for parents to opt their children out of sex ed. EdSource reports on how that's working out differently in different communities, including some that resist teaching kids about sex. Charter schools have so far been exempt from the requirement to provide sex ed, but perhaps not for long: AB2601 awaits the governor's signature.
user avatar
Carol Kocivar March 3, 2018 at 6:54 pm
One of our readers passed along a very interesting article:

30 Remarkable Health Benefits of Sleep (Backed up by Science)

Take a Look!
user avatar
Robert Crowell May 2, 2018 at 9:18 am
Super interesting. We need to do something about the "Zero Period classes."
user avatar
Carol Kocivar December 5, 2017 at 11:18 am

From the Harvard Graduate School of Education:
When the Nurse's Office is a Refuge
The vital, overlooked role of school nurses in combatting student anxiety
user avatar
Carol Kocivar June 20, 2016 at 9:50 am
Summer Meals
According to the National School Boards Association:
"....(M)ore than 80 percent of the children who qualify for summer meal programs do not participate. State boards can do two things to expand the reach of summer nutrition programs: They can support the adoption of state mandates for participation, and they can partner with other state organizations to improve community outreach."
user avatar
Jeff Camp - Founder January 20, 2016 at 11:57 am
Sex education is an important element of the health curriculum schools in California are required by law to deliver. In 2015, California's legislature passed SB695 (the "affirmative consent law.") In 2016 the curriculum requirements were expanded to include sexual health, HIV/AIDS, gender identity, sexual orientation as well as "negotiation, refusal and decision making skills."
user avatar
Disappointed by Public School October 2, 2015 at 1:03 am
Jenny, are you in California? b/c there are laws that PE has to be taught by someone who knows what they are doing, that it has to be about gaining skills and improving. It canNOT just be recess. They are supposed to provide 200 minutes/10 days of school in 1-6th grade.
If your school is not providing that, you can contact Don Driscoll JD who is suing the Dept of Ed for not complying with the law and sign on...
What has happened with PE, I think, is that there is all this focus on "no child left behind" Pass the tests. So the money is spent on testing and taken away from PE.
At least your school has the breakfast. Our school does not provide breakfast although 5% of our students quality for it. (I know that's not a huge % but no child should be left hungry and could account for a lot of the "adhd" in our classes)
Our school went from a healthy vendor to an unhealthy one that doesn't understand the nutritional regulations.
user avatar
Jenny N September 28, 2015 at 4:48 pm
Our school provides breakfast for every student, regardless of income. We're fortunate in that. But, we only get a school nurse once per week and physical education is not what it was when I was a kid. No PE teachers, not even a gymnasium at our school. I'm new to the current system and am really curious to learn what has lead to things changing so dramatically in the past 30 years.
user avatar
Tara Massengill April 18, 2015 at 6:53 pm
Why is it that the government (read "tax payers") provide free meals to jailed criminals, but many school kids still have to pay for their lunches? Does this seem unreasonable to anyone else?
user avatar
Disappointed by Public School October 2, 2015 at 1:11 am
if kids are indigent then they get free or reduced price lunch. reduced price is for the less indigent.
user avatar
geecookie2011 April 18, 2015 at 7:21 am
(please forgive all the typos)
I'm not sure how accurate a lot of things that are coming out in school about concerned with obesity but I do know that our children are starving more then ever. When My Granddaughter and also in children her own grade and younger comes home who in her case is very very petite. She is more hungry than before. she is hungry I need you don't want to snack she wants to eat and then later want to eat dinner and she says it's because she is extremely hungry. Due to she have breakfast at 8:20am and then she eat lunch at 12 and still in school for another 3.4 hours afterward. Then come home at 4:pm what to eat then eat dinner the rest of the Family when we all come home at 6:30pm. I find there should be a more concern eating at that time more a risk of obesity because they're not as active as they are doing school hours because they are in school 90% of the Daylight hours.
Also my concern is if this is my granddaughter who most of the time is blessed to have some type of food in the home, I wonder about children who has little to no foods or resources in their home. So what happened to those children, who if they can get a solid meal at school, like a real breakfast and lunch. Who don't get or alittle dinner. I can't help to wonder if my granddaughter comes home hungry. Then what is it like for the students who is not provide a better meals at home. Because what I see in our cafeteria these days look like a snacks, truly not a lunch or breakfast. Especially in low poverty locations, title 1 students who are being funded so that they can have decent meals at school while learning. I have seen that if a child is hungry he or she will not be suitable to properly get a fair quality education just thinking out loud. Ms Cookie G
user avatar
jenzteam February 27, 2015 at 9:18 am
"In 2005, California banned sales of sugared beverages on school grounds."
This is a complete myth since my kids have access to Gatorade (which contains as much sugar and chemicals as soda) and sugared cookies and snacks every single day. I had to battle the school district to disallow my kids from purchasing anything on their "account". I finally stopped paying into the school lunch program and packing lunches in order to control their diets. You DEFINITELY don't see schools selling organic veggies and whole grain foods. It's still pizza, fries, cheeseburgers, chips, and other cheap foods - which they profit from selling. What is most irritating is that the schools still profit from selling these items as "add ups" from the free/reduced lunch program. So again, I can pay $.40 for lunch and $2 for a Gatorade or bottle of water. It's about profits. I have yet to see a salad bar or fresh/steamed vegetables included on the school lunch menu.
As for physical activity, we take care of that in our home. As for the school, my kids tell me they are allowed to "walk" the mile if they want instead of run it. They are not required to meet any standards and both have A+ in PE. Why are we requiring PE for 4 years in CA if there are no expectations to perform?
user avatar
Disappointed by Public School October 2, 2015 at 1:11 am
There are regulations to have certain # of minutes physical education. If your school is not meeting them, you should contact who is suing the DOE for being complicit in districts not meeting the PE requirements if you want to sign onto the suit.

Your school is NOT allowed to sell unhealthy foods/drinks by law for profit, until after school. They are violating the regulations.
here are the requirements..
You can file a report with the DOE by emailing or calling Shirley Rhodes 916-323-8521
user avatar
Brandi Galasso February 9, 2015 at 10:44 am
Schools have to care enough about their students to notice where the problems are. Schools are responsible to a certain extent, because after all they are providing our students with breakfast and lunch 5 days a week. that's more then they are home. So they should be making healthy choices and then teaching students why they are healthy and over what foods that are not. Involve the kids in discussions about what they are eating. Also they should be providing some physical activity and teaching them from an early age the importance of exercise and how to do it without hurting yourself or others. Schools like ours that don't provide balls because they are too lazy to blow them up for students is not right. It took me 2 years to fight just to get them to give balls they already had to students is not right and those people should work in another area if kids are too much trouble for them, that can really effect a school negatively.
user avatar
Carol Kocivar - Ed100 October 26, 2014 at 3:40 pm
Schools play a role in protecting public health through required vaccinations. Here is a checklist that can help.
Immunization and Health Checkup - CalEdFacts
Want to see where there have been preventable disease outbreaks?
Here’s a link to a map that provides detail for California, US and the world.
user avatar
Jeff Camp - Founder October 2, 2014 at 6:40 pm
Vaccinations: Schools play a vital role in public health by ensuring that all children are immunized against serious contagious diseases. Universal vaccination has been so successful at eradicating disease that it faces the risk of being taken for granted; in some communities parents have used "personal belief exemptions" to opt out of vaccinating their children at rates that have permitted diseases to re-emerge. Is your child attending a school that is vulnerable to an outbreak? Find out here:
user avatar
Richard Rothstein March 14, 2011 at 7:45 am
A distinguished and diverse coalition of education, health, and social service experts, in a their campaign for a “Broader, Bolder Approach to Education,” have issued a statement calling for the establishment of school-based clinics in schools serving disadvantaged children as one of the most important strategies for raising the achievement of disadvantaged children. The California School Health Centers Association (CSHC) is a statewide organization that advocates for, disseminates information about, and provides training and other resources for operators of, and those interested in starting, school-based health centers.

Overall, lower-class children are in poorer health.

-> Those with vision problems have difficulty reading. In the United States, 50 percent of poor children have vision impairment that interferes with academic work, twice the normal rate. Lower-class children may be more likely to have vision problems because of less adequate prenatal development than middle-class children whose pregnant mothers had better medical care and nutrition. Visual deficits also arise from disadvantaged children being placed in inexpensive low-quality child care settings where they watch too much television, activity that does not develop hand-eye coordination and depth perception - 42 percent of black fourth graders watch six hours or more of television a day, compared to 13 percent of whites. Middle-class children more likely have manipulative toys that develop such coordination. A longitudinal study of entering kindergarteners reveals that fine motor skill development at age 5 is a stronger predictor of later mathematics and reading performance than is kindergartners' pre-literacy knowledge (of the alphabet, of counting numbers, of phonemes).

-> Lower-class children also have more hearing difficulties, possibly because of untreated ear infections that occur in children whose overall health is less robust. Ear infections are easily treatable for children with access to regular pediatric care. But lower-class children with less access to such treatment are less attentive, on average, in school.
Children without dental care have more toothaches; untreated cavities are nearly three times as prevalent among poor as among middle-class children. Although only some cavities produce toothaches, children with toothaches pay less attention in class and are more distracted during tests, on average.
Children who live in older buildings have more lead dust exposure that harms cognitive functioning and behavior. High lead levels also contribute to hearing loss. Low-income children have dangerously high blood lead levels at five times the rate of middle-class children.

->Lower-class children, particularly those who live in densely populated city neighborhoods, are also more likely to contract asthma – the asthma rate is substantially higher for urban children, for those whose families are on welfare, and for those from single parent or poor families. Asthma is provoked partly from breathing fumes from low-grade heating oil, diesel trucks, and buses (school buses idling at schools are a serious problem); excessive dust and allergic reactions to mold, cockroaches, and secondhand smoke also contribute. In neighborhoods with high asthma rates, children suffering from the disease are more likely to live in homes where adults smoke.
Asthma keeps children awake at night. If attending school, asthmatics are more likely to be drowsy and inattentive, more irritable and with more behavioral problems, and more likely to refrain from exercise and thus be less physically fit. Middle-class children typically get treatment for symptoms, while low-income children get treatment less often. Asthma has become the biggest cause of chronic school absence, with sufferers from low-income families more likely to miss school than those from middle-class families.

->Youngsters whose mothers consumed alcohol during pregnancy have more difficulty with academic subjects, are less able to focus attention, have poorer memory skills, less ability to reason, lower I.Q.’s, less social competence and more aggression in the classroom. In adolescence, these children continue to have difficulty learning. Fetal alcohol syndrome, a collection of the most severe cognitive, physical and behavioral difficulties experienced by children of prenatal drinkers, is ten times more frequent for low-income black than for middle-class white children.

->Smoking in pregnancy also contributes to lower achievement. Children of mothers who smoked prenatally do more poorly on cognitive tests, and their language develops more poorly. They have more serious behavioral problems, more h
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