Pew Charitable Trusts

By now, Karen Wilk thought she would have sold her five-bedroom house in Colts Neck, New Jersey, and downsized to a smaller home. But she has had to put those plans on hold because her 23-year-old daughter, who is finishing her college degree while working part-time, still lives with her. Wilk’s 27-year-old son moved out two years ago.

“I don’t want to chase my kids out, but I expected them to be more independent by now,” Wilk, 54, said. “I don’t see my kids affording our neighborhood for a long time.”

Almost a third of young adults — 18 to 34 — lived with a parent in 2014, making it the most common living arrangement for that age group for the first time in modern history, according to a study published earlier this year by the Pew Research Center. (The Pew Charitable Trusts funds both the Pew Research Center and Stateline.)

Multiple reasons are behind the trend, lingering effects of the Great Recession, high housing costs and student debt among them. Whatever the causes, millennials in some states are living with their parents in far greater numbers than in others.

In New Jersey, a whopping 43.9 percent of young people are living with at least one parent, according to a Stateline analysis of 2014 census data from IPUMS at the University of Minnesota. Connecticut (38.8 percent) was second and New York (37.4 percent) was third, followed by Florida (37.2 percent) and California (36.7 percent).

States with the fewest young people living with a parent were North Dakota (15.6 percent), Wyoming (18.7 percent), South Dakota (19.7 percent) and Nebraska and Iowa (both 20.7 percent).

Expensive Housing

In New York City and surrounding states, scarce and expensive rental housing is a major factor pushing young adults to return home, said Dowell Myers, a professor of urban planning and demography at the University of Southern California, who wroteabout the economic impact of stay-at-home millennials in a study published earlier this year.

Full nests are also prevalent in other areas where renters are severely burdened by housing costs of more than half of their income, such as Los Angeles, Miami and Orlando.

The high cost of homeownership is also a factor. Renters who might otherwise be homeowners end up renting longer, tying up the supply for those coming up behind them.

“Millennials were doubled up at entry levels of their housing life cycle, blocked by older peers who were unable to turn over their apartments for better homes,” Myerswrote in another study he published this year.

Millennials are the most educated generation ever. But in areas where housing is extraordinarily expensive, a college degree is not necessarily a ticket out of your childhood bedroom.

Lisa Jacobs holds two bachelor’s degrees, one in photography and one in graphic design. But work has been sporadic, so this year she moved back in with her parents in Somerset, New Jersey.

“My parents have a lovely home, but nobody’s happy to be living at home at 32,” Jacobs said, adding that she needs to make at least $20 an hour to afford an apartment. “There are plenty of places that would pay me $15 an hour. But that’s not getting me any closer to moving out.”

A Question of Culture?

But financial stress may be only part of the story. More young people were living with their parents even before the Great Recession hit. Some see cultural factors at work.

Debbie Pincus, a psychotherapist who has counseled parents and adult children who live together in New York City and its suburbs, said many of the parents she helps have a tendency to overshelter their offspring.

“You just have to be careful that you’re not enabling them to avoid going out on their own when they’re ready,” Pincus said. “We baby boomers are very protective of our children. We are less likely to put the kids out and say, ‘Figure it out for yourselves.’ ”

Resurgent ethnic traditions may be another factor: In the New York metropolitan area, most adult children of Italian heritage live with parents.

Jason Cerillo, 28, still lives with his parents in the predominantly Italian-American suburb of West Harrison, New York. He said there’s a cultural understanding that he can stay until he gets married.

“My dad is Italian, and he says, ‘Oh, stay as long as you want, but we do want to retire.’ So I am under some pressure here,” Cerillo said, adding that many of his high-school classmates in the neighborhood also live with their parents.

In the New York area, “co-residence” rates are also high for people with Irish, Dominican, Puerto Rican and African-American roots.

Debt and Underemployment

Cerillo said his monthly student loan payment — $500 — has made it hard for him to move out of his parents’ place, despite having made as much as $42,000 a year working for a software company. He said he hopes to pay down his debt to $20,000 before striking out on his own.

Student loan and credit card debt keeps many young adults at home.

And underemployment among young people like Jacobs in New Jersey, who can’t find the work they trained for, is also a factor, said Christopher McCarty, director of Florida’s Bureau of Economic and Business Research.

Florida’s official unemployment rate is 5 percent. But McCarty points out that 10.6 percent of workers are unemployed or underemployed, with low-paid jobs they are overqualified for or part-time jobs when they would rather work full-time.

The underemployment rate is 11.7 percent in California, where Kelley Lonergan, 28, said she had to move back to her parents’ home near Los Angeles four years ago. She lived in a room still decorated with her brother’s video-game posters and kept her clothes on the floor because his closets were still full.

With an English degree from Brown, Lonergan said she got a part-time school communications job but couldn’t find full-time work.

The house got even more crowded when her older brother moved back in for a spell. She wrote about the comfort and frustration of living with her parents.

She said she was relieved to finally move out earlier this year. “I had been living with four people and now I’m living alone and it’s great.”

Numbers Game

Myers, the USC professor, predicts that a coming dip in the number of young adults may allow a greater percentage of them to finally find their own housing.

The number of 25-year-olds has increased every year since 2005, but is projected to start decreasing next year and for the next five years. That’s likely to free up apartments and jobs for younger people at an increasing rate until 2022.

Robert Dietz, an economist for the National Association of Home Builders, said some cities were slow to adapt to the growth by building more apartments, but are catching up now. He expects older millennials to start buying single-family homes and freeing up apartments.

“Housing is like a ladder — when there are blockages, it backs up the whole thing, and the millennials are having a hard time getting onto the bottom rung,” Dietz said.

What if lowering student debt was as easy as sending students a letter?

Indiana University officials say borrowing by undergraduates at the school has dropped 18 percent since 2012. That’s when the university began sending students annual letters that estimate their total loan debt and future monthly payments, as part of a push to boost their financial literacy.

Inspired by the results at IU, Indiana last year began requiring all colleges that accept state aid to send letters. Nebraska followed with a similar law this spring.

Republican Rep. Casey Cox, the author of the Indiana legislation, says he gets phone calls from officials in other states interested in the idea. And U.S. Sen. Joe Donnelly, an Indiana Democrat, has proposed requiring the federal Department of Education to keep a list of financial literacy best practices, perhaps including student loan letters.

A growing number of students need to borrow — and borrow heavily — to finance their college educations. And giving them more information about their debt may help change their borrowing habits. Research suggests that students say no to loans when they’re told how much they’re borrowing and how loans could weigh on them in the future.

But the approach carries risks, too. In some cases, borrowing less may make it harder for students to graduate. They might have to spend more time working and less time studying. Or they might opt for less expensive institutions that do less to guide them.

Although IU officials think financial literacy makes a difference, they haven’t actually proven that the letters — or any other initiative — drove borrowing down.

“From a research perspective, we haven’t gotten to the point where we can say it had an impact,” said Victor Borden, professor of educational leadership and policy studies at IU Bloomington. He and a team of researchers are scouring data to find out exactly what worked.

Students Who Borrow Too Much

Cox, the author of the Indiana law, is one of the youngest members of the Legislature. The 30-something is still paying off his law school loans.

He said he was inspired by his alma mater’s efforts and his own memories of how tempting it was for students to borrow as much as possible. “At a young age, you may not really understand the consequences of that debt,” he said.

Some students may not know they’re borrowing at all. Researchers at the Brookings Institution, a centrist Washington, D.C., think tank, dug into federal survey data in 2014 and found that over a quarter of first-year college students with federal student loans didn’t know their loans came from the federal government. About half of those students had no idea they were borrowing money to pay for college.

Students can be confused for a number of reasons. Their parents may be handling the financial aid details, for example. The way student loans are packaged and disbursed doesn’t help, said Andrew Kelly of the American Enterprise Institute, a conservative-leaning Washington think tank.

A few months after a student sends a financial aid application to the federal government, an award letter arrives from the college, which may knock a chunk of money off the tuition bill — or cover it entirely. “It just kind of arrives, like manna from heaven,” Kelly said of financial aid.

Behind the scenes, two things happen: The government calculates how much the student’s family can afford to pay for the education. And the college calculates the total cost of attendance, including living expenses. Both of those calculations determine how much federal and state need-based grants, work-study aid and loans the student can receive. The college may provide scholarships, too.

Students usually accept whatever aid colleges award them without questioning whether they could live more cheaply — and borrow less. And, Cox has said, some students may borrow extra money to fund a better lifestyle.

The temptation to borrow too heavily may be particularly strong for part-time students, who can borrow the same amount for living expenses as full-time students. The students may end up borrowing for many years, racking up more debt or even hitting federal loan limits before they manage to graduate.

More Information May Help

When the news broke that borrowing at IU had fallen, students there told Bloombergthe loan letters had spurred them to avoid debt by working more, looking for scholarships, and avoiding spending on living expenses like new cellphones.

But it’s not clear that IU’s letters are driving the decrease in borrowing. The letters were part of a bigger push to educate students about money that included counseling, a podcast, and a new website that offers quizzes and calculators. The university also has changed its financial aid process to make it easier for students to say no to loans.

Before all the financial literacy work began, said Phil Schuman, the university’s director of financial literacy, “I don’t think students actually knew they had the option to take less.”

IU also has been pushing its 94,000 undergraduates to enroll in 15 credits each semester — the pace necessary for graduation in four years. “It might not necessarily be that students are taking out less money each semester, but that they’re graduating on time,” Schuman said.

Across IU’s seven main campuses, 42 percent of full-time students seeking a bachelor’s degree graduate in four years, up from 38 percent five years ago according to the latest data. This past year, the cost of attendance — including tuition, fees, room and board —ran to $21,412 for in-state IU students.

A team led by IU’s Borden will use statistical analysis to parse all the factors that could be affecting borrowing, from the availability of state grants to student wealth. They will try to determine whether the financial aid letters, the literacy push, or the change in loan processing did the most to lower overall debt. The university made other changes during the period, such as increasing institutional grant aid, which also could have made a difference.

Other research shows that a combination of letters and counseling can change students’ borrowing and academic behavior.

Montana State University students with high debt who received letters alerting them to that debt and encouraging them to seek counseling borrowed an average of one-third, or $1,360, less the next semester, according to a 2015 analysis by Montana State and Federal Reserve researchers.

The students went on to take more credits and earn better grades the following semester, the study found. The same research team found in a forthcoming study that students who received the letters were 2 percentage points more likely to switch to a major associated with higher-paying jobs.

Students with lower grades tended to switch their majors to business, while students with higher grades tended to switch to majors in science, technology, engineering or math.

The federal government mandates that students undergo counseling twice, once before they receive loans and once after they leave the institution. (Most colleges provide this information online.) The Indiana and Nebraska laws don’t require colleges to add additional counseling, although many colleges already offer services similar to IU’s.

Students Who Borrow Too Little

Yet student loan letters can also have a downside. They can deter students from taking out loans they really need to finance their education.

“It’s just a really complex issue,” said Robert Kelchen, an assistant professor at Seton Hall University who studies student debt. “The policy discussion is that students need to borrow less. And the reality is that some students may be able to borrow less, but some may need to borrow more.”

Students may choose to work their way through college to graduate debt-free. But by working rather than studying, they may find it harder to graduate on time — or to graduate at all.

“The one thing we don’t want is students who are so stressed about their finances they can’t focus on their academics,” Schuman said.

Whether a student is borrowing too much or too little depends on a range of factors, from family wealth to the chosen degree and whether the student graduates, said Kelly of the American Enterprise Institute. “Someone who borrows the maximum amount for a solid program at a community college or a four-year college and finishes — it’s hard to say that they overborrowed,” he said.

Schuman said he has had to tell students that debt isn’t necessarily a bad thing, particularly when they’re working toward a degree that will lead to a high-paying job. He recently talked to a chemical engineering major at another institution who had about $10,000 in debt and was scared it was too much. “She was going to be fine!” he said.

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What Happens When You Warn Students About Their Loan Debt?

Fueled by sexual abuse allegations against comedian Bill Cosby and the Catholic Church, and other high-profile cases dating back decades, state legislators across the country are considering lengthening or eliminating statutes of limitations on rape.

Statutes of limitations, which exist for most crimes besides murder, are intended to encourage the timely reporting of crimes. As time passes, evidence deteriorates or gets lost, memories fade and witnesses die.

But it can take years for sexual abuse victims to find the courage to come forward. Advocates for victims say statutes of limitations for rape and sexual assaults are arbitrary and outdated, and note that police departments across the country are still digging through a backlog of rape kits, some of which are three decades old.

Forty-three states have statutes of limitations for sex crimes, according to the Rape, Abuse and Incest National Network. Of the states with statutes, 27 include an exception that allows prosecutors to file charges when there is DNA evidence. State statutes of limitations often range from three years to 12 years, but in some states, accusers have more time to come forward when they say they were abused as children — until they are 21 in some states or as old as 50 in others. Some states don’t start the clock until the victim turns 18.

Legislators in states such as California, Illinois, New York, Oklahoma and Pennsylvania are currently considering bills that would extend statutes of limitations for rape and sexual assault or eliminate them entirely.

In Pennsylvania, where the statute of limitations is 12 years in adult rape and sexual assault cases, prosecutors late last year beat the deadline by just weeks when they charged Cosby for a crime he allegedly committed in 2004. Backers of a bill that would eliminate the statute of limitations for people abused as children have pointed to the Cosby case, and to an attorney general’s report released last month alleging decades of abuse by Catholic priests.

Democratic Attorney General Kathleen Kane accused previous bishops in the Roman Catholic Diocese of Altoona-Johnstown of ignoring or hiding decades of sexual abuse by priests, but Kane said that nearly all of the allegations were too old to be prosecuted.

Nevada last year extended its statute of limitations on rape cases from four years to 20 after a woman who alleges that Cosby raped her in 1989 in Las Vegas pushed for the bill. And Oregon recently approved a law allowing prosecutors to file rape charges beyond the statute of limitations if there is new corroborating evidence or multiple victims come forward.

In Illinois, where former U.S. House Speaker Dennis Hastert admitted molestingstudents when he was a high school teacher and wrestling coach in the 1970s, lawmakers are considering eliminating the statute of limitations for people abused as children. Under current law, prosecutors may file charges up to 20 years after the victim turns 18.

Illinois state Sen. Scott Bennett, a former prosecutor, proposed the measure after Hastert was indicted for related financial crimes rather than for the actual sexual abuse.

“He admitted that he did things with children and you can’t do anything about it, but you can get him on money laundering charges. That seems wrong,” said Bennett, a Democrat.

Changes in public policy often follow cases like Hastert’s, according to Polly Poskin with the Illinois Coalition Against Sexual Assault. “Most law and public policy is really a response to an event,” she said. “Why it’s so critical is because when one person comes forward, if there are other survivors — and inevitably there are — it gives courage to other victims to come forward … you see a pattern.”

In the last several years, Hawaii and Minnesota have approved “window” laws that lift the statute of limitations for two and three years, respectively, to allow people to sue their alleged abusers in civil court.

The Pennsylvania bill also includes a “window” provision, because lawmakers can only eliminate the statute of limitations for future crimes, not ones that have already occurred.

“We’re going to put the liability back on the people who caused this. We need to be able to go back and sue the perpetrators and institutions who covered it up,” said Democratic state Rep. Mark Rozzi, who shepherded the bill through the House and says he was abused by a priest when he was 13.

Tough to Tell

Victims of rape and sexual abuse are often reluctant to report the crime. According to the U.S. Department of Justice, nine out of 10 child sexual abuse victims are abused by someone close to them, and may be hesitant to report them. Many initially feel it is their fault or they will not be believed. For others it may take years, or even decades, to come to terms with what happened and to tell others about it.

“It wasn’t until the last year and a half that I was able to use that word and call it what it really was — rape,” said Victoria Valentino, who says she was raped by Cosby in 1969 in California — a state where the current statute of limitations on rape is 10 years. Calls to Cosby’s attorney were not returned.

Barbara Blaine, president of the Illinois chapter of the Survivors Network of those Abused by Priests, which has advocated for the bill pending in the Illinois Legislature, long blamed herself for the abuse she says she experienced as a child. She didn’t tell anyone about it until she was nearly 30 and a therapist asked her about her first kiss.

“Well, I was in seventh or eighth grade, and it was the priest at my church,” she said.

Blaine said she spent years working with the church to try to keep her alleged abuser away from children. But, she said, by the time it became clear that legal action was necessary, the statute of limitations on her case had run out.

Making a Case

But critics, including some prosecutors and defense attorneys, say efforts to eliminate the statutes are misguided.

Natasha Minsker of the American Civil Liberties Union of California is opposing a bill that would scrap the state’s 10-year statute of limitations for rape. Minsker points out that California already allows extra time to file charges if there is DNA evidence. She said the accused affected by the change would have a hard time mounting a defense.

“When you’re talking decades later trying to reconstruct what you were doing and finding witnesses to testify on your behalf it becomes nearly impossible,” Minsker said.

In Oklahoma, where a pending bill would allow prosecutors to file charges up to 18 years after the crime becomes known to a third party, prosecutors have expressed concerns.

Trent Baggett with the Oklahoma District Attorneys Council said crimes become harder to prosecute the more time passes. Evidence gets destroyed or lost, witnesses’ memories fade, and prosecutors may doubt their ability to persuade jurors “beyond a reasonable doubt.”

It’s understandable that victims want to have their day in court, Baggett said, but the likelihood of a conviction is low. “You hate for that person to get their hopes raised and then feel they’ve gotten victimized again by the state.”

Even some victims are worried about scrapping the statutes.

Sujatha Baliga, who said she was sexually abused as a child, now works in restorative justice, a process in which victims and offenders come together to talk about the incident and reconcile.

She said many victims may be hesitant to use the process if there’s a chance that something said during it might be reported to police. Many victims don’t report what happened to them because they don’t want their abuser, who may be a relative, to get in trouble, Baliga said.

“They need to hear it wasn’t their fault and that the other person is sorry,” she said. “Because the only option is punitive, I suffered in silence for a decade.”

But Susan Howley of the National Center for Victims of Crime said prosecutors should be free to determine whether to pursue each individual case, regardless of how much time has lapsed since the crime occurred.

“If in a given case the prosecutor believes the available evidence is strong enough to prove the charges beyond a reasonable doubt, there should be no arbitrary time limitation prohibiting the case from going forward,” Howley said.

Bennett, the Illinois legislator and former prosecutor, said when victims don’t report crimes right away it can make it harder to win cases, “but that’s true whether it’s been a year after it happened or 20 years after it happened. You’ve got to take more time to explain to jurors why they didn’t come forward.”

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High-Profile Cases Spur States to Reconsider Statutes of Limitations for Rape

Federal health officials recommend that preschoolers with attention deficit hyperactivity disorder receive psychological counseling before they are put on medication. But states striving to promote the use of behavioral therapy have been hamstrung by a shortage of mental health providers.

They also have struggled to convince providers who are used to prescribing drugs first to shift strategies — especially in the face of what some state health officials and ADHD advocates describe as aggressive marketing by the pharmaceutical industry.

The Centers for Disease Control and Prevention released statistics this month suggesting that many states have a long way to go when it comes to promoting greater use of the therapy, which largely relies on teaching parents to reinforce positive behavior while avoiding confrontations.

In 10 states, fewer than half of preschoolers in Medicaid with ADHD were receiving psychological counseling, according to the CDC data. Among children ages 2 through 5 with private insurance, the numbers were even worse: In 26 states, fewer than half of those kids with ADHD were receiving behavioral therapy.

In contrast, more than three-fourths of all preschoolers with ADHD were on medication, generally stimulants such as Adderall and Ritalin.

The Medicaid numbers are from 2011, the most recent year for which the CDC could collect reliable data, and the private insurance numbers are from 2014. The CDC was able to collect Medicaid data from 34 states and private insurance data from 33 states.

Behavioral therapy “may require more time, energy and resources than medicine but its effect can be more long-lasting,” CDC Deputy Director Anne Schuchat said when her agency released the numbers. “We are missing opportunities for young children with ADHD to receive behavioral therapy.”

Some state officials said they are hopeful the CDC’s focus on the issue will promote progress. “To have the CDC shine a spotlight on this … creates the momentum that states need in order to transform practices and prescribing,” said Mary Mayhew, commissioner of the Maine Department of Health and Human Services.

Increasingly Prevalent

Children with ADHD have more trouble paying attention and are more impulsive than other kids. The consequences of the disorder can be life-altering. Children with ADHD are more likely to struggle academically and to drop out of school, and one-third of them continue to be affected as adults. One study cited by the CDC estimates that the health care and educational costs of kids with ADHD totals between $38 billion and $72 billion a year.

The number of children diagnosed with ADHD is rising. As of 2012, the most recent year for which numbers are available, 6.4 million children in the U.S. were diagnosed, up 42 percent from 2003.

In 2011, the American Academy of Pediatricians (AAP) recommended that children with ADHD who are younger than six receive behavioral therapy before they take stimulants, and the CDC backed those recommendations. The American Academy of Child and Adolescent Psychiatry recommended a therapy-first approach for young children at least a decade earlier.

Studies suggest that behavioral therapy is more effective than medicine for younger kids. Furthermore, the CDC notes that the long-term impact of ADHD drugs on young children is unknown, and the medications can cause side effects such as poor appetite, stomach aches, irritability, sleep problems and slowed growth.

For older children, however, AAP recommends both therapy and medication.

State Disparities

According to the CDC survey, which is based on tens of thousands of claims filed, the percentages of children with ADHD who receive behavioral therapy vary greatly from state to state.

Among Medicaid beneficiaries, the percentages ranged from 74 percent in Maryland to lows of 32 percent in Florida and 29 percent in New York. Overall, 54 percent of young children with ADHD in Medicaid received therapy in 2011, according to the CDC.

Among children with private insurance, Wisconsin had the highest percentage of children receiving behavioral therapy in 2014, at more than 61 percent, while Mississippi was lowest, at 23 percent. The overall rate for children in employer-sponsored plans in 2014 was 42 percent, compared to 45 percent in 2011, the year the AAP published its guidelines.

CDC officials said the private insurance numbers are lower because many mental health providers in private practice do not accept insurance, and because many state Medicaid programs provide extensive mental health coverage to children.

More Providers

In the last several years, some states have taken steps to expand the use of behavioral therapy by increasing the number of counselors who can provide it.

In Pennsylvania, the effort grew out of a larger campaign to reduce juvenile delinquency in the state. Since 2010, the Pennsylvania Commission on Crime and Delinquency has handed out nearly $5 million in grants to mental health clinics around the state to provide training in the kinds of behavioral therapy recommended for young children with ADHD.

“If we can address a child’s ADHD symptoms early, they are less likely to have school failure, which we know can have an effect on delinquency,” said Lee Ann Cook of Penn State’s Evidence-based Prevention and Intervention Support Center, which works with the state crime and delinquency commission.

One challenge in Pennsylvania is that its Medicaid program will not pay for therapy sessions that involve the parents of the child with ADHD, Cook said.

All Medicaid beneficiaries in Louisiana are covered under managed care plans (in which providers receive a lump sum for a patient’s total care, rather than being paid for each service). The state is asking those plans to connect pediatricians and primary care doctors to behavioral health specialists who can diagnose and treat ADHD. The state also has enlisted Louisiana State University and Tulane University to train therapists in every part of the state in ADHD therapy.

In Louisiana and many other states, pediatricians often turn to medication because they have no alternatives to offer. “Doctors don’t know who to refer these kids to and stimulants are all they can offer in a 10-minute window,” said James Hussey, interim assistant secretary in the Office of Behavioral Health in the Louisiana Department of Health & Hospitals.

In New York state, two in three counties (capturing 16 percent of the population) have been determined by the federal and state governments as having a shortage of mental health providers. The relatively low percentage of New York children who receive behavioral therapy likely is related to that shortage, said Hal Meyer, founder of the New York chapter of the national ADHD advocacy organization Children and Adults with Attention-Deficit/Hyperactivity Disorder. Rather than waiting months for appointments for therapies, Meyer said, parents are eager for the immediate help that medicines promise.

Because of the way Medicaid services are delivered and financed in New York, however, the CDC data probably did not capture all of the behavioral therapy in the state’s Medicaid program, according to an official from the state Office of Mental Health. The state has also taken steps, including the development and expansion of programs that link pediatricians with mental health professionals, to increase the amount of behavioral therapy for young children with ADHD, the official said.

At the other end of the spectrum, state officials say Maryland’s success in expanding access to behavioral therapy is the result of an aggressive approach by the state’s health and education departments, which began in the early 2000s when the state created a steering committee on better diagnosing and treating young children with mental illnesses. Since 2008, the state has provided training for mental health providers in ADHD behavioral therapy and made efforts to educate pediatricians about diagnosing and treating ADHD.

Overprescribing?

Other states are focusing on discouraging doctors from prescribing ADHD drugs to Medicaid patients.

The Medicaid programs in 16 states (Arizona, Arkansas, Florida, Idaho, Illinois, Maine, Massachusetts, Mississippi, Missouri, Nevada, New Hampshire, New York, Oregon, Utah, Virginia and West Virginia) won’t cover ADHD medication prescriptions unless the prescriber explains the need for medicine in the particular case. Louisiana and Nevada require doctors to confirm that they have rejected other treatable causes for the patient’s symptoms before prescribing ADHD drugs. And seven states (Arizona, Florida, Illinois, Louisiana, Massachusetts, Virginia and West Virginia) require physicians to confirm that they have considered treatment other than medicine, such as behavioral therapy, before Medicaid will cover ADHD drugs.

In recent years, most private insurers have also required doctors to receive permission from health plans before prescribing ADHD drugs for children.

One challenge in reducing the use of medication is that many parents of children with ADHD are desperate for the immediate help the drugs may provide. Behavioral therapy takes longer — and requires hard work on the part of parents.

“By the time a parent comes to meet with me, they are tired and worried about their child. They are concerned their child might jump down a flight of stairs, that the child could get lost in a grocery store, or that the child could be kicked out of preschool,” said Georgina Peacock, director of the CDC’s division of human development and disability.

CDC’s Schuchat acknowledged that behavioral therapy “just might not work for some parents. We think it’s a good investment of time, but we know that it may not be practical for every situation.”

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Some States Lag Behind on ADHD Therapy

A year ago, Laura Hall felt tired all the time, was losing weight and had a bad cough.

The 41-year-old Spanish teacher from Shelburne, Vermont, went to doctors for three months before they finally nailed the diagnosis: active tuberculosis.

“I was scared. I was horrified. Oh my gosh, how did I get this? Where did I get it?” Hall said in a video about TB survivors’ experiences. “I didn’t think that I could get TB, ever.”

While Hall underwent treatment — isolation at home and a demanding regimen of antibiotics and other drugs — the Vermont Department of Health tested about 500 students and co-workers who might have been exposed to her. Nineteen children and two adults tested positive for latent TB. (People with latent TB aren’t sick or contagious, but they carry a greater lifetime risk of developing active TB.)

Hall’s was one of seven active cases in Vermont last year, up from two the year before. Twenty-nine states and the District of Columbia also reported more active TB cases last year than in 2014, the Centers for Disease Control and Prevention reported in March.

After two decades of steady decline, the number of active tuberculosis cases in the U.S. inched up last year. Hall’s was one of 9,563 TB cases reported last year, up from 9,406 cases the year before. The CDC is still trying to determine the reason for the uptick.

The goal set by the CDC, in 1989, of eliminating TB by 2010 — defined as less than one case in a million people — remains elusive. Even if the trend of declining cases had continued, the United States would not have eliminated TB by the end of this century, the CDC said.

“We are not yet certain why TB incidence has leveled off, but we do know it indicates the need for a new, expanded approach to TB elimination,” said Dr. Philip LoBue, director of the CDC’s Division of Tuberculosis Elimination, in an email.

A dual approach is needed: continue to find and treat cases of disease and evaluate their contacts as well as identify and evaluate other high-risk persons for latent TB infection, he said.

In Vermont, health officials aren’t sure whether last year’s increase was just a statistical anomaly or the beginning of a trend. In case it is the latter, the state Health Department is considering contracting with an outside firm to help it test contacts for exposure. Last year, the shorthanded department brought in health staff from around the state as well as volunteers from the Vermont Medical Reserve Corps to test contacts for exposure.

“We were lucky it wasn’t worse,” said Laura Ann Nicolai, deputy state epidemiologist and head of the tuberculosis control program.

Airborne Bacteria

TB is an airborne infectious disease caused by bacteria that spreads through the air, person to person, when someone coughs or sneezes. One in three people worldwide have latent TB, according to the World Health Organization. In the United States, up to 13 million people have been exposed to TB and could develop the disease.

Every year, tuberculosis claims 1.5 million lives worldwide and 500 to 600 in this country.

In the United States, Asians have the most cases and the highest rate of disease — 17.9 out of 100,000 persons. The top five countries of origin for foreign-born TB patients are Mexico, the Philippines, Vietnam, India and China.

Immigrants and refugees are screened for TB and treated before entering the United States. Tourists, students and temporary workers are not screened. The CDC does not recommend across-the-board screening for everyone entering the United States, the CDC’s LoBue said.

Because TB hits some ethnic and racial groups harder than others, TB patients can face discrimination and social isolation. Public health officials worry about finding ways to target high-risk populations with TB education and treatment without stigmatizing those groups.

“Given the stigmatization of TB, our ability to do targeted interactions is limited,” said Dr. Jeffrey Starke, a pediatric tuberculosis physician at Texas Children’s Hospital in Houston. Starke is a member of the federal Advisory Council for the Elimination of Tuberculosis, which makes policy recommendations. “We’ve got to find a nonpejorative way to do it so others don’t perceive discrimination,” he said.

Going in the Wrong Direction

State and local health departments are the front line of defense for a disease that many think has already been eradicated. In the late 1800s and early 1900s, TB was a leading cause of death in this country and Europe. With no cure for the disease, patients were urged to “go west.”

More people flocked to Colorado as TB patients looking for dry air and sun than stormed the state as prospectors during the gold rush. Among them: Doc Holliday, friends with gunslinger Wyatt Earp and a participant in the shootout at the O.K. Corral.

“Colorado historically has been on the forefront of TB work,” said Dr. Robert Belknap, director of the Denver Metro TB program. “At the turn of the century, one-third of the state was here because of TB — seeking care for themselves or family members,” he said.

Some of Colorado’s first hospitals were TB sanatoriums, later closed and repurposed. Local and state support for TB prevention and control remains strong in Colorado, said Belknap, president of the National Tuberculosis Controllers Association.

Today four states — California, New York, Texas and Florida — have more than half the nation’s active TB cases, though they have only a third of the country’s population. The four states have the highest numbers of foreign-born residents. The number of cases in Texas rose 5 percent to 1,334 last year.

“We’re clearly going in the wrong direction,” Starke said.

He pointed out that TB is “a social disease with medical implications” because living conditions put someone at risk. TB is associated with poverty, overcrowding and being born outside the United States.

California, with 2,137 cases in 2015, has more than one in five of the new U.S. cases each year and a TB rate nearly twice the national average. Its TB prevention and control program is the nation’s largest — a $17.2 million annual budget split roughly in half between federal and state general funds, and a 40-person central office staff that works with TB contacts in the state’s 61 local health jurisdictions.

In addition to state TB control efforts in California, local health department programs in the counties of Los Angeles, San Diego and San Francisco also receive federal TB control grants from the CDC. Those grants total $7.7 million this year.

About 2.5 million people are infected with TB in California, but most don’t know it, said Dr. Jennifer Flood, chief of California’s TB control program.

While California has several programs aimed at latent TB, she said, “Smaller states are often challenged to test and treat latent TB” because they lack the resources.

Labor Intensive Treatment

Treating TB patients is labor intensive. To ensure that TB patients complete the course of drugs that lasts six months or longer, Directly Observed Therapy programs require a health care worker — not a family member — to watch patients with active TB swallow every dose. If a patient cannot get to a clinic, a health care worker goes to the person’s home. The worker monitors patients for side effects and other problems.

Care also involves communication and cultural challenges. In Michigan, where the number of active TB cases rose from 105 in 2014 to 130 last year, the health department reaches out to Detroit’s large Arab and Bangladeshi populations. In other parts of the state, Burmese immigrants have different needs, said Peter Davidson, Michigan TB control manager.

“Some local health departments have strong partnerships with translation services. Some rely on a less formal mechanism — a private physician or someone on staff at the hospital who speaks the language,” Davidson said.

The cost of treating an active TB case that is susceptible or responsive to drugs averages $17,000, according to the CDC. Care of patients with drug-resistant TB, which can result from taking antibiotics prescribed before TB was properly diagnosed, costs many times more: $134,000 for a multidrug-resistant patient and $430,000 for an extensively drug-resistant one.

Advocates say TB suffers from a lack of urgency and funding.

“TB isn’t as exciting a topic because it’s been around so long. It doesn’t get as much attention as Ebola and Zika, and its advocates aren’t as active as those for HIV/AIDS,” said Belknap. “We’re jealous.”

The federal Tuberculosis Elimination Act, the chief federal funding for TB programs, is authorized at $243 million a year but has received an appropriation of far less for the last several years — $142 million this year, for example.

Most of the money goes to the 50 states, the District of Columbia, 10 major cities and eight territories in grants under a formula based on the number of cases, their severity and other factors. The grants are used to pay salaries for nurses, doctors and epidemiologists, as well as for education and outreach services. Treatment costs are paid by insurance, Medicaid and state and local governments.

Funding at the authorized level could support research on a vaccine and better drugs and treatment of more cases of latent TB, advocates say. For now, no TB vaccine is approved for use in the United States. The medicines that cure TB and brought down the disease rate were developed in the mid-20th century. They require months of treatment and can have serious side effects, including hearing loss. A promising new drug may be able to prevent TB with only 12 doses over three months.

“The tools we have are inadequate,” Belknap said. “It’s a federal and a global problem.”

A Story of Success

In many ways, though, the story of TB prevention and treatment in the United States is one of success.

“We often say we’re our own worst enemy,” said Donna Wegener, executive director of the National TB Controllers Association. “We had such success in reducing TB after the resurgence in the 1990s that people think we don’t need additional dollars.”

Patients with diabetes, cancer and especially HIV infection are more likely to contract active TB because their immune systems are less able to fight off TB germs. During the HIV/AIDs epidemic, from the mid-1980s to the early 1990s, the number of TB cases jumped by 19 percent. From 1992 to 2014, the number of cases dropped 65 percent.

There were nearly as many cases of Lyme disease in Pennsylvania in 2014 (7,457) as there were TB cases in the United States (9,406).

But, Wegener said, “If we were reporting 10,000 new cases of polio a year in the U.S., that would be unacceptable. It’s criminal that we are OK with 10,000 cases of TB.”

Among those infected in the early 1990s was a young physician who volunteered to treat TB patients at a clinic in New York City. He tested positive for exposure but his latent TB did not progress to active disease. Tom Frieden now is director of the CDC, leading the fight against TB.

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Is Tuberculosis Making a Comeback?

Jonathan Mossberg has already made a smart gun — a shotgun that can only be discharged by someone wearing a ring that communicates with a chip inside the weapon, unlocking it.

The gunmaker’s smart guns, there are about 25 of them, are nearly 20 years old. They have been tested repeatedly and kept in the homes of his friends and family for self-defense. But Mossberg’s Florida-based company, iGun Technology Corp., has never scaled the high-tech components to a handgun. And cultural and political barriers have stood in the way of selling the guns commercially.

Gun safety advocates have pushed for commercially available smart, personalized guns that could only be fired by a specific person through radio frequency chips, fingerprint scans or other technology, for more than three decades. They argue that the technology could make guns safer by reducing accidental shootings and suicides, and by rendering stolen guns inoperable by crooks — if they were widely available and became more commonplace.

Now, there are signs that a commercial market for smart guns maybe has arrived. The federal government is quietly encouraging gunmakers to submit smart weapons for military-grade testing. New Jersey lawmakers are seeking to revise a law that has kept manufacturers and retailers from selling the guns for over a decade. And federal appeals court judges in the West are deciding whether states can require gunmakers to manufacture weapons with specific safety features.

“We’re getting so close,” said Stephen Teret, a longtime gun safety advocate and founder of the Center for Gun Policy and Research at Johns Hopkins University in Baltimore. “I can almost taste it now.”

Last month, the White House announced that it will work with state and local law enforcement agencies to draft baseline specifications for smart guns that could guide manufacturers in producing the weapons for police work. The Obama administration also plans to award grant money to law enforcement agencies to purchase smart guns once they’re available.

The federal government has tried since the mid-1990s to spur development of smart guns, though many of the projects it funded were abandoned because it was difficult to work the technology into handguns without compromising their function, according to an April report from the departments of Justice, Homeland Security and Defense.

The report notes that Mossberg’s shotgun was “possibly the first ever production-ready firearm equipped with user-authorization technology.”

Mossberg said he’s ready to put his technology into a handgun, but lacks the money needed to develop it. He estimates he will need $5 million to build 25 to 30 handguns for testing. Another $15 million could launch him into full production.

The iGun’s chip technology only works within centimeters and makes it impossible for anyone other than the person wearing the ring to fire it. It is more reliable than fingerprint identification, which has been tested by other gun manufactures, Mossberg said.

“You don’t need to think. You don’t need to whisper into it, ‘Rumpelstilskin’ or ‘Open Sesame,’ ” Mossberg said. “You don’t want to swipe your finger on it and say, ‘Please try again.’ There is no try again.”

Hurdles to Development

The biggest hurdles to bringing smart guns to market are political and cultural, Teret, the smart-gun advocate, said. Gun rights advocates worry their emergence will lead to government mandates dictating what kind of guns could be bought and sold, and politicians have been reluctant to counter the powerful firearms groups.

But Teret said that with federal interest in the technology, the guns could soon be available — and especially attractive to families who want to keep guns for self-defense, but have small children at home and want to ensure they will be safe from accidents.

“We make aspirin bottles that 4-year-olds can’t use,” Teret said. “Why are we making guns 4-year-olds can use?”

Between 2010 and 2014, 527 children under 18 were unintentionally killed by a firearm, according to the latest data compiled by the Centers for Disease Control and Prevention. In 2014, 33,599 people were killed by guns. Most of those deaths were suicides.

But smart guns won’t be a quick lifesaver because traditional guns are so prevalent, said James Pasco Jr., executive director for the Fraternal Order of Police.

Although it is impossible to know how many guns exist, the National Opinion Research Center at the University of Chicago reports that in 2014, 31 percent of U.S. households reported having a firearm.

“It would be centuries at the rate we’re going before it had any material effect on crime or even on accidental shootings,” Pasco said.

Pasco’s group doesn’t oppose a move to smart guns, but argues that law enforcement agencies shouldn’t be forced to adopt them.

Avoiding Mandates

Mossberg, the gunmaker, said he doesn’t want his products to be mandated either, which is exactly what many say a 2002 New Jersey law does.

“I’m first an American, second a businessman,” Mossberg said. “And that’s just wrong. Nobody should be told what to buy.”

Under the law, three years following the retail sale of a smart gun anywhere in the U.S., all guns sold in New Jersey would have to be smart guns. Lawmakers in California tried to pass a similar law in 2014, but it failed.

But Teret, who worked on the New Jersey law, admits that the mandate may have discouraged gunmakers and dealers from bringing smart guns to market across the country because they did not want to trigger the New Jersey directive. So now, he and other supporters are trying to revise the law to allow stores to carry traditional guns as long as they carry at least one smart gun model.

Opponents of revising the law, such as the National Shooting Sports Foundation and other gun groups, say it will still be expensive for retailers to comply and won’t change criminal behavior.

Gun ownership groups aren’t trying to block the technology, but gun owners should not be limited to a specific kind of gun, said Scott Bach, director of the New JerseyAssociation of Rifle and Pistol Clubs.

“If you want this technology to develop, take the mandate out,” Bach, also a National Rifle Association board member, told a New Jersey Senate committee last fall. “Take government hands off the process and let the technology develop naturally. Let’s see if there’s a market.”

Federal officials say they are trying to spur innovation and create a market for smart guns, not mandate them. And the 9th Circuit Court of Appeals in San Francisco soon may decide whether states can mandate their sale.

The court is considering a challenge to a 2003 California statute that requires that gunmakers produce firearms that indicate when there is a bullet in the chamber and won’t discharge when a gun’s magazine is detached.

Will They Work for Police?

Some local law enforcement leaders, like the San Francisco police chief, say they will welcome the opportunity to test smart guns. But it’s unclear whether police officers will embrace the technology.

Pasco, for instance, questions whether smart guns will be practical for police officers who may need to fire with the hand not wearing the radio frequency device or potentially use a colleague’s gun in an emergency.

“What do you do if your partner is down and your partner’s gun is available, but yours isn’t? You pick the gun up and you can’t shoot it,” Pasco said.

Mossberg acknowledged his guns likely won’t take off with police departments. He and Teret say they think the guns will have success with people who work by themselves and carry guns in public, such as air marshals, security guards and some school teachers — and who don’t want their guns to get in the wrong hands.

“I would hate to see some crazy guy take the air marshal’s gun when you’re 35,000 feet in the air and have the gun be able to work for him,” Teret said.

Parents who want to keep guns at home might also be eager to buy smart guns. A survey conducted last year by Teret and his colleagues found that 59 percent of Americans would be willing to buy a childproof smart gun, if they were going to purchase a new handgun.

What doesn’t appear to be in dispute is that smart guns likely could save some lives. “It’s just like airbags in cars,” Teret said. “We knew they would save lives, but we couldn’t tell how many until they got into the cars.”

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Is America Finally Ready for Smart Guns?