A-TAPER: A Framework for Deprescribing Medications effectively.

Inappropriate medication use creates avoidable safety issues for older adults. Deprescribing medications that are high risk and/or of minimal benefit is important for reducing morbidity and adverse effects, especially in this population. A variety of deprescribing resources and algorithms are available, but a singular framework to effectively approach and implement the deprescribing of unnecessary medications in practice does not exist. An interprofessional team of pharmacists, geriatricians, and researchers developed a framework to guide providers in deprescribing medications. This framework is represented by the acronym A-TAPER, which stands for Assess medication use, Talk about risks versus benefits, select Alternatives, Plan next steps, Engage patient, and Reduce dose. Within this framework, comprehensive, medication-specific deprescribing toolkits can be created.

The role of family stressors and parent relationships on adolescent functioning.

This study examined the association between cumulative family stressors (divorce, interparental conflict, maternal depression) and adolescent functioning as well as the protective role of the parent-adolescent relationship as perceived by the adolescent when family stressors are present. Two hundred and thirty-one adolescents, their mothers, and their social studies teachers served as the subjects. Results indicated that, as family stressors increased, adolescent functioning deteriorated. Furthermore, a positive parent-adolescent relationship as perceived by the adolescent was associated with less deterioration in all areas of functioning. The role of the relationship in protecting the adolescent supported both a stress buffering model and a main effect model.

Parental divorce during early adolescence in Caucasian families: the role of family process variables in predicting the long-term consequences for early adult psychosocial adjustment.

The relationship between parental divorce occurring during adolescence and young adult psychosocial adjustment was examined, as was the role of family process variables in clarifying this relationship. Participants were young Caucasian adults from divorced (n = 119) and married (n = 123) families. Assessments were conducted during adolescence and 6 years later during early adulthood. Young adults from married families reported more secure romantic attachments than those from divorced families; however, differences were not evident in other domains of psychosocial adjustment after demographic variables were controlled. Three family process variables (parent-adolescent relationship, interparental conflict, and maternal depressive symptoms) were examined as potential mediators and moderators of the association between parental divorce and young adult adjustment. No evidence supporting mediation or moderation was found; however, the parent-adolescent and parent-young adult relationships, particularly when the identified parent was the father, emerged as significant predictors of young adult psychosocial adjustment.

The Family Health Project: psychosocial adjustment of children whose mothers are HIV infected.

The psychosocial adjustment of 87 inner-city African American children 6-11 years old whose mothers were HIV infected was compared with that of 149 children from a similar sociodemographic background whose mothers did not report being HIV infected. Children were not identified as being HIV infected. Mother reports, child reports, and standardized reading achievement scores were used to assess 4 domains of adjustment: externalizing problems, internalizing problems, cognitive competence, and prosocial competence. The results indicated that, on average, children from both groups had elevated levels of behavior problem scores and low reading achievement scores when compared with national averages. Relative to children whose mothers were not infected, those whose mothers were HIV infected were reported to have more difficulties in all domains of psychosocial adjustment. Potential family processes that may explain the findings are discussed.

Traumatic stress in HIV-infected women.

This study assesses the prevalence of specific traumatic stressors that meet criterion A for the Diagnostic and Statistical Manual of Mental Disorders' (DSM-IV) diagnosis of posttraumatic stress disorder (PTSD) and symptoms of PTSD in a representative sample of HIV-infected women. The study also assesses the impact of these stressors and symptoms on the clinical progression of HIV infection. The Life Stressor Checklist and the Impact of Events Scale-Revised were administered via interview to 67 Africa-American women beyond the initial stages of HIV infection. The ratio of CD4 t-cells to CD8 t-cells were abstracted from medical records at dates that approximated psychological interviews and were examined at two points in time 12 to 14 months apart. The prevalence of traumatic stressors and PTSD symptoms were high among HIV-infected women. Traumatic stressors were significantly associated with a lower CD4 to CD8 ratio at the 1-year follow-up. Among women who reported a traumatic event, those who also met criteria for PTSD evidenced a lower CD4 to CD8 ratio at the follow-up assessment. The study concludes that prevention and treatment efforts targeted at HIV-infected women must take into account traumatic stressors and PTSD symptoms and their potential impact on the course of the disease.

Juvenile firesetting: a unique syndrome or an advanced level of antisocial behavior?

The current study examined whether juvenile firesetting represents a unique syndrome or an advanced level of antisocial behavior. Thirty-six incarcerated juvenile delinquents, all of whom met criteria for a diagnosis of Conduct Disorder, served as subjects and were categorized into one of three groups: firesetters, non-firesetters but comparable to firesetters in number of conduct disorder symptoms, and non-firesetters who displayed fewer conduct disorder symptoms than the other two groups. Caregivers completed the Child Behavior Checklist on the youth to provide information about the severity and range of psychopathology. The results indicated that firesetters and non-firesetters who had a comparable number of symptoms did not differ from one another on the CBCL subscales of adolescent psychopathology but both differed from the group with fewer symptoms. These results suggest that firesetting does represent an advanced level of antisocial behavior, but that firesetting is not a unique syndrome, at least not in terms of caretakers' perceptions of the youths' problematic behavior. Implications for treatment of firesetters are presented.

Child resiliency in inner-city families affected by HIV: the role of family variables.

This study examined the role of family variables in child resiliency within a sample of African-American, inner-city children whose mothers are HIV-infected. Variables from three dimensions of the family were included: family structural variables, maternal variables, and mother-child (parenting) variables. The participants were 82 children between the ages of 6 and 11 and their HIV-infected mothers. Correlational analyses indicated that resiliency was associated only with three parenting variables: parent-child relationship, parental monitoring, and parental structure in the home. Hierarchical regression analyses indicated a multiplicative relationship between parental monitoring and parent-child relationship and between parental monitoring and parental structure in the home, suggesting that parenting variables potentiate each other. Clinical implications of the findings are considered.

Predictors of HIV antibody testing among Gay, Lesbian, and bisexual youth.

PURPOSE: To identify factors related to human immunodeficiency virus (HIV) antibody testing among Gay, Lesbian, and bisexual youth. METHODS: Self-reported demographics, risk behaviors, variables related to the Health Belief Model, and HIV testing data were collected at a conference for gay youth, as well as at the Gay and Lesbian Community Center in a Southeastern metropolitan area (n = 117). RESULTS: About one third of participating youth who reported engaging in anal and vaginal sex had done so without a condom. In addition, one in four youth reported at least one other HIV risk factor. Of youth engaging in sexual risk behaviors, one third had not been tested for HIV antibodies. Furthermore, 61% of the youth reported some type of drug use, and only 57% of those using drugs had been tested. To determine factors associated with HIV testing, a hierarchical logistic regression was conducted. A binary variable of HIV testing was regressed first on demographic variables, second on risk factors, and third on variables derived from the Health Belief Model. Results of the logistic regression revealed that unprotected anal sex and the Health Belief Model variables predicted having been tested for HIV. The final model explained 42% of the variance in HIV testing. CONCLUSIONS: Gay, Lesbian, and bisexual youth are at high risk for HIV infection and are often untested for HIV antibodies.

Is adolescent adjustment following parental divorce a function of predivorce adjustment?

This study examined whether adolescent adjustment problems which previously have been attributed to parental divorce exist prior to the divorce. Three groups (to-be-divorced, remain intact, and already divorced) were examined across four domains of adolescent functioning reported by multiple informants. The results indicated that adolescents from the to-be-divorced group functioned similarly to those who would remain in intact families but better than those in the already divorced group, suggesting that differences can be attributed to parental divorce and its accompanying disruption of family processes. Two of these processes, interparental conflict and parenting, were examined and failed to receive support.

The role of family processes and coping strategies in the relationship between parental chronic illness and childhood internalizing problems.

Sixty-nine families (father, mother, and one child) in which the father had hemophilia, approximately half of whom were HIV positive, were assessed in an examination of the relationship between parental chronic illness, family functioning, child coping strategies, and child adjustment. Latent variable path analyses with partial least-squares estimation procedures (PLS) were used to test a model of the relationship between parental chronic illness, family process variables, child coping strategies, and child internalizing behavior problems. The severity of the father's illness predicted family process variables, which predicted the coping style of the child. The use of more avoidant coping strategies was associated with more internalizing problems.

A short-term longitudinal examination of young adolescent functioning following divorce: the role of family factors.

The purposes of this study were to examine young adolescent functioning over a 2-year period after divorce and to assess the role of two family factors, interpersonal conflict and the parent-adolescent relationship, in predicting such functioning. One hundred and twelve young adolescents, their mothers, and their social studies teachers served as participants. One-half of the adolescent were from recently divorced families and one-half were from married families. Mothers completed measures concerning interparental conflict and the parent-adolescent relationship, adolescents completed a measure of the relationship, and teachers completed measures assessing four areas of adolescent functioning. The results indicated that adolescents from divorced families were functioning less well than those from married families. There were no changes in adolescent functioning and the parent-adolescent relationship from the first to second year postdivorce. High levels of interparental conflict in divorced families were associated with more parent-adolescent relationship problems. In turn parent-adolescent relationships problems served as the best predictor of concurrent and subsequent difficulty in adolescent functioning.

Juvenile delinquency entry and persistence: do attention problems contribute to conduct problems?

We examined the role of attention deficit hyperactivity disorder (ADHD) in juvenile delinquency. Forty-two incarcerated male delinquents participated. Thirty of these youths met the criterion for conduct disorder (CD), only while 12 met the criterion for CD and ADHD. The results indicated that the latter group were arrested at an earlier age and had more total arrests than those in the former group; however, they did not have more criminal charges against them. The role of intellectual and academic skills in these findings was considered. It appears that ADHD has an important additive influence on the development and persistence of juvenile delinquency. Implications for the behavior therapist are discussed.

Predicting alcohol and drug use in early adulthood: the role of internalizing and externalizing behavior problems in early adolescence.

Unique and interactive internalizing and externalizing behavior problems in adolescence were examined in relationship to drug and alcohol use in young adulthood. Results indicated that higher externalizing scores in adolescence predicted more alcohol use in young adulthood for both males and females and also predicted more marijuana and hard drug use for males. Lower internalizing scores were found to predict more marijuana and hard drug use in young adulthood for boys, but not for girls.

Hemophilia and AIDS in married men: functioning of family members. Hemophilia PAC Project.

Aspects of functioning in families of 137 hemophilic men who, in 50% of cases, were also HIV seropositive were examined in terms of psychological and physical functioning and economic pressure. Results indicated that HIV-seropositive status, but not severity of hemophilia, was associated with poorer psychological and physical functioning of the husband, a poorer mother-child relationship, less support from outside the family for both spouses, and greater economic pressure on the family.

Coping strategies and behavior problems of urban African-American children: concurrent and longitudinal relationships.

The development and correlates of 82 inner-city African-American children's coping strategies were examined across three years. Results indicated no change in the mean frequency of self-reported coping strategies over the three years, and a significant correlation of emotion-focused strategies with increased self- and mother-reported behavior problems. Child-reported externalizing problems (and, to a lesser degree, internalizing problems) predicted changes in coping strategies across assessments.

Is parental divorce a critical stressor for young adolescents? Grade point average as a case in point.

Previous studies have shown parental divorce to be associated with poor functioning of children and adolescents. Almost all of the studies attempting to delineate these effects, and to shed light on the differences between boys and girls, have limited data collection to postdivorce. This practice has left a void in the picture of divorce--specifically in the area of predivorce effects. The purpose of the present study was to examine academic functioning of young adolescents with respect to both pre- and postdivorce effects. Fifty-eight young adolescents (29 from families which subsequently divorced and 29 from families which remained intact) were studied. Results indicated that boys from subsequently divorcing homes had significantly poorer academic functioning prior to their parents' divorce than did boys whose families remained intact and girls whose parents divorced. Differentially, girls from subsequently divorcing families showed a decline in academic functioning which began prior to divorce and continued beyond the time of divorce. Possible explanations for these gender differences are explored, and the importance of examining predivorce effects is addressed.

Psychopathology in incarcerated juvenile delinquents: does it extend beyond externalizing problems?

The present study attempted to delineate factors that are associated with and may contribute to juvenile delinquency. Delinquents were compared to a matched control group of nonoffenders on a measure of mental health problems. Twenty-four male and female incarcerated juvenile offenders and 24 nonoffending adolescents were evaluated on the Revised Behavior Problem Checklist (RBPC). As expected, the offenders scored higher (an indication of more psychopathology) on the subscales of the RBPC which represent externalizing types of problems. The offenders also scored significantly higher on the subscales reflecting internalizing problems and psychotic behavior. The results of this study point to the importance of assessing and treating offenders, especially those who are incarcerated, for difficulties other than externalizing problems.

Delinquency during the transition to early adulthood: family and parenting predictors from early adolescence.

This longitudinal study examines the prediction of delinquency in early adulthood by family variables and one type of maternal parenting skill during early adolescence. In 132 Caucasian families, family variables (marital status, interparental conflict, mother-adolescent relationship, and maternal depressive mood) and maternal communication/problem-solving skills were assessed through self-report measures and behavioral observations during subjects' early adolescence. Outcome measures (minor and severe delinquency, arrests/convictions) were assessed six years later during early adulthood. Regression analyses revealed relationships between the predictors and severe delinquency and arrests/convictions, but not minor delinquency. The interaction of low levels of maternal communication/problem-solving skills and negative family variables (i.e., high maternal depressive mood) was associated with higher rates of delinquency, whereas the interaction of higher levels of such maternal skills and positive family variables was associated with lower rates of delinquency.

Victimization experiences and HIV infection in women: associations with serostatus, psychological symptoms, and health status.

The present investigation evaluates the relationship between HIV infection and victimization with regard to the interplay of these two factors as they relate to mental and physical health. Eighty eight inner-city low income African-American women who are HIV-infected and a demographically similar comparison group of women who were not HIV-infected were assessed for victimization experiences (rape, physical assault, robbery/attack) via interview. Additionally, the psychological symptoms and health status correlates of victimization within the HIV-infected group are delineated. Results indicated that women in the HIV-infected sample were significantly more likely to report a victimization experience. Additionally, within the HIV-infected group, victims reported higher levels of global psychological distress, depressive symptomatology, and greater distress regarding physical symptoms than nonvictims. Furthermore, HIV-infected victims were diagnosed with higher rates of AIDS-defining conditions than HIV-infected nonvictims. These results underscore the importance of acknowledging the experience of violent victimization in the prevention and treatment of HIV infection in women.

Disclosing HIV status: are mothers telling their children?

OBJECTIVE: Mothers living with HIV face a complex set of child-rearing decisions, often within the context of many competing stressors. One difficult decision for HIV-infected mothers is whether to disclose their HIV status to their children. The purpose of this study is to provide information to HIV-affected families and the professionals working with them as they approach disclosure-related decisions. METHODS: Eighty-seven HIV-infected African American mothers and one of their children who was not HIV-infected were separately interviewed on two occasions. Mothers reported whether they disclosed their HIV status to the child and provided their assessment of the child's functioning. Children also completed an assessment of their functioning. RESULTS: Results revealed that less than one-third of mothers disclosed their HIV status to their children. Disclosure was associated with mother's income level and perceived severity of physical symptoms. In addition, children disclosed to were more often older and female. Contrary to expectation, disclosure was not related to child functioning. CONCLUSIONS: Professionals should note the low rate of disclosure among these families. In the absence of conclusive data regarding impact on child functioning, professionals must remain aware of the complexity of disclosure-related decisions when working with HIV-affected families, particularly in terms of the family and cultural milieu within which families operate.