Mental-Physical Multimorbidity in Youth: Associations with Individual, Family, and Health Service Use Outcomes.

Prevalence, correlates, and outcomes of youth with comorbid mental and physical conditions (i.e., multimorbidity) were examined in this cross-sectional study. Participants were 92 youth (14.5 years [SD 2.7]; 69.6% female) and their parents. Mental disorder was assessed using structured interviews and physical health using a standardized questionnaire. Twenty-five percent of youth had multimorbidity and no child or parent demographic or health characteristics were correlated with multimorbidity. Youth with multimorbidity reported similar quality of life and better family functioning [B = - 4.80 (- 8.77, - 0.83)] compared to youth with mental disorder only (i.e., non-multimorbid). Youth with multimorbidity had lower odds of receiving inpatient services [OR = 0.20 (0.05, 0.85)] and shorter stays in hospital for their mental health [OR = 0.74 (0.57, 0.91)] over the past year. Family functioning was found to mediate the association between youth multimorbidity and length of stay [αß = 0.14 (0.01, 0.27)]. Findings reinforce the need for family-centered youth mental health care.

Exposure to overprotective parenting and psychopathology in extremely low birth weight survivors.

BACKGROUND: Extremely low birth weight (ELBW; <1,000 g) infants are the most vulnerable babies and are at higher risk for experiencing overprotective (i.e., controlling and intrusive) parenting, which is hypothesized to contribute to the risk for mental disorders. Despite the increased risk for anxiety disorders and decreased risk for alcohol or substance use disorders seen in ELBW survivors, no research has examined the impact of parenting. This study investigated if overprotective parenting mediates links between ELBW birth status and psychiatric disorders in adulthood. STUDY DESIGN: Participants included ELBW survivors born in 1977-1982 and matched normal birth weight (≥2,500 g) control participants (ELBW n = 81; normal birth weight n = 87) prospectively followed in Ontario, Canada. These individuals retrospectively reported on whether either of their parents was overprotective using the Parental Bonding Instrument. Presence of a current anxiety disorder and of current alcohol or substance use disorders was assessed using the Mini International Neuropsychiatric Interview at age 29-36 years. RESULTS: Path analysis showed that overprotective parenting was a significant mediator of the association between ELBW status and risk for an anxiety disorder in adulthood and the risk for an alcohol or substance use disorder in adulthood in ELBW survivors. Overprotective parenting accounted for 53% of the association between ELBW status and the risk for an anxiety disorder in adulthood and 26% of the association between ELBW status and alcohol or substance use disorders. CONCLUSIONS: Overprotective parenting accounted for a substantial proportion of the increased risk for anxiety and alcohol or substance use disorders in adulthood in ELBW survivors. Despite their perceived vulnerabilities, it is important that the parents of ELBW survivors be supported in their attempts to facilitate their children's pursuit of independence during childhood and beyond.

Environmental chemical exposure may contribute to uterine cancer development: studies with tetrabromobisphenol A.

Tetrabromobisphenol A (TBBPA), a widely used flame retardant, caused uterine tumors in rats. In this study, TBBPA was administered to male and female Wistar Han rats and B6C3F1/N mice by oral gavage in corn oil for 2 years at doses up to 1,000 mg/kg. TBBPA induced uterine epithelial tumors including adenomas, adenocarcinomas, and malignant mixed Müllerian tumors (MMMTs). In addition, endometrial epithelial atypical hyperplasia occurred in TBBPA-treated rats. Also found to be related to TBBPA treatment, but at lower incidence and at a lower statistical significance, were testicular tumors in rats, and hepatic tumors, hemangiosarcomas (all organs), and intestinal tumors in male mice. It is hypothesized that the TBBPA uterine tumor carcinogenic mechanisms involve altered estrogen levels and/or oxidative damage. TBBPA treatment may affect hydroxysteroid-dehydrogenase-17ß (HSD17ß) and/or sulfotransferases, enzymes involved in estrogen homeostasis. Metabolism of TBBPA may also result in the formation of free radicals. The finding of TBBPA-mediated uterine cancer in rats is of concern because TBBPA exposure is widespread and endometrial tumors are a common malignancy in women. Further work is needed to understand TBBPA cancer mechanisms.

Meeting report: Urinary Pathology; sixth Research Triangle Park Rodent Pathology Course.

Urinary system toxicity is a significant concern to pathologists in the hazard identification, drug and chemical safety evaluation, and diagnostic service industries worldwide. There are myriad known human and animal urinary system toxicants, and investigatory renal toxicology and pathology is continually evolving. The system-specific Research Triangle Park (RTP) Rodent Pathology Course biennially serves to update scientists on the latest research, laboratory techniques, and debates. The Sixth RTP Rodent Pathology Course, Urinary Pathology, featured experts from the government, pharmaceutical, academic, and diagnostic arenas sharing the state of the science in urinary pathology. Speakers presented on a wide range of topics including background lesions, treatment-related non-neoplastic and neoplastic lesions, transgenic rodent models of human disease, diagnostic imaging, biomarkers, and molecular analyses. These seminars were accompanied by case presentation sessions focused on usual and unusual lesions, grading schemes, and tumors.

The influence of immigrant status and concentration on psychiatric disorder in Canada: a multi-level analysis.

BACKGROUND: Many studies have reported an increased incidence of psychiatric disorder (particularly psychotic disorders) among first generation adult immigrants, along with an increasing risk for ethnic minorities living in low-minority concentration neighborhoods. These studies have depended mostly on European case-based databases. In contrast, North American studies have suggested a lower risk for psychiatric disorder in immigrants, although the effect of neighborhood immigrant concentration has not been studied extensively. METHOD: Using multi-level modeling to disaggregate individual from area-level influences, this study examines the influence of first generation immigrant status at the individual level, immigrant concentration at the neighborhood-level and their combined effect on 12-month prevalence of mood, anxiety and substance-dependence disorders and lifetime prevalence of psychotic disorder, among Canadians. RESULTS: Individual-level data came from the Canadian Community Health Survey (CCHS) 1.2, a cross-sectional study of psychiatric disorder among Canadians over the age of 15 years; the sample for analysis was n=35,708. The CCHS data were linked with neighborhood-level data from the Canadian Census 2001 for multi-level logistic regression. Immigrant status was associated with a lower prevalence of psychiatric disorder, with an added protective effect for immigrants living in neighborhoods with higher immigrant concentrations. Immigrant concentration was not associated with elevated prevalence of psychiatric disorder among non-immigrants. CONCLUSIONS: The finding of lower 12-month prevalence of psychiatric disorder in Canadian immigrants, with further lessening as the neighborhood immigrant concentration increases, reflects a model of person-environment fit, highlighting the importance of studying individual risk factors within environmental contexts.

Psychopathology in young adults born at extremely low birth weight.

BACKGROUND: Little is known about the long-term mental health of extremely low birth weight (ELBW) (<1000 g) survivors. We test whether young adults aged 22 to 26 years born at ELBW differ from normal birth weight (NBW) controls in self-reported levels of psychopathology. METHOD: Participants included 142 ELBW survivors (86% response) born between 1977 and 1982 to residents of central-west Ontario, Canada and 133 NBW control subjects (92% response). The Young Adult Self-Report measure was used to create five DSM-IV oriented scales aggregated to form internalizing (depressive problems, anxiety problems, avoidant personality problems) and externalizing (attention deficit-hyperactivity disorder problems and antisocial personality problems) scales. RESULTS: After adjusting for family background characteristics, mean scores for ELBW survivors were 3.02 [95% confidence interval (CI) 0.78-5.26] points higher for internalizing problems and no different, i.e. 0.00 (95% CI -1.17 to 1.17), for externalizing problems. There was a sex × group statistical interaction such that being male muted the risk for externalizing problems among those born at ELBW: -2.11 (95% CI -4.21 to -0.01). Stratifying ELBW adults as born small for gestational age (SGA) versus appropriate weight for gestational age (AGA) revealed a significant gradient of risk for levels of internalizing problems that was largest for SGA, i.e. 4.75 (95% CI 1.24-8.26), and next largest for AGA, 2.49 (95% CI 0.11-4.87), compared with NBW controls. CONCLUSIONS: Depression, anxiety and avoidant personality problems (internalizing problems) are elevated in young adulthood among ELBW survivors. This effect is relatively small overall but noticeably larger among ELBW survivors born SGA.

Susceptibility to smoking among South East Asian youth: a multilevel analysis.

OBJECTIVE: To estimate the extent to which susceptibility to smoking is associated with between-context differences (schools and classes) and to identify factors at school, class and individual levels that influence individual susceptibility to smoking among young never-smokers in South East Asia. METHODS: Cross-sectional data from the Global Youth Tobacco Survey conducted in Cambodia (2002), Laos (2003) and Vietnam (2003) are used to conduct multilevel analyses that account for the nesting of students in classes and classes in schools. The outcome variable is smoking susceptibility, defined as the absence of a firm decision not to smoke. Explanatory variables include school-level (current tobacco use prevalence in school, exposure to anti-smoking media messages and exposure to tobacco billboard advertising), class-level (classroom prevention) and individual-level influences (parents' and friends' smoking behaviour, knowledge of the harmful effects of and exposure to secondhand smoke at home, age, sex and pocket income). RESULTS: Multilevel analyses indicate that 4.5% and 4.2% of the variation in smoking susceptibility is associated with school and class differences, respectively. Students who have parents or friends who smoke, who are exposed to secondhand smoke at home and those who have access to pocket income are found to be more susceptible while greater knowledge of the harmful effects of secondhand smoke appears to diminish susceptibility to smoking. For girls only, billboard tobacco advertising increases the risk of susceptibility and classroom prevention decreases risk while for boys only, attendance at schools with higher prevalence of tobacco use increases risk of susceptibility and anti-smoking media messages decreases risk. CONCLUSIONS: This study highlights a number of modifiable factors associated with smoking susceptibility and identifies interactions between teen sex and several factors associated with the susceptibility to smoking. This finding provides support for the call to move beyond gender-blind tobacco control policies.

Childhood cognition and lifetime risk of major depressive disorder in extremely low birth weight and normal birth weight adults.

In general population samples, better childhood cognitive functioning is associated with decreased risk of depression in adulthood. However, this link has not been examined in extremely low birth weight survivors (ELBW, <1000 g), a group known to have poorer cognition and greater depression risk. This study assessed associations between cognition at age 8 and lifetime risk of major depressive disorder in 84 ELBW survivors and 90 normal birth weight (NBW, ⩾2500 g) individuals up to 29-36 years of age. The Wechsler Intelligence Scale for Children, Revised (WISC-R), Raven's Coloured Progressive Matrices and the Token Test assessed general, fluid, and verbal intelligence, respectively, at 8 years of age. Lifetime major depressive disorder was assessed using the Mini International Neuropsychiatric Interview at age 29-36 years. Associations were examined using logistic regression adjusted for childhood socioeconomic status, educational attainment, age, sex, and marital status. Neither overall intelligence quotient (IQ) [WISC-R Full-Scale IQ, odds ratios (OR)=0.87, 95% confidence interval (CI)=0.43-1.77], fluid intelligence (WISC-R Performance IQ, OR=0.98, 95% CI=0.48-2.00), nor verbal intelligence (WISC-R Verbal IQ, OR=0.81, 95% CI=0.40-1.63) predicted lifetime major depression in ELBW survivors. However, every standard deviation increase in WISC-R Full-Scale IQ (OR=0.43, 95% CI=0.20-0.92) and Performance IQ (OR=0.46, 95% CI=0.21-0.97), and each one point increase on the Token Test (OR=0.80, 95% CI=0.67-0.94) at age 8 was associated with a reduced risk of lifetime depression in NBW participants. Higher childhood IQ, better fluid intelligence, and greater verbal comprehension in childhood predicted reduced depression risk in NBW adults. Our findings suggest that ELBW survivors may be less protected by superior cognition than NBW individuals.

Adequacy of interviews vs checklists for classifying childhood psychiatric disorder based on parent reports.

BACKGROUND: The advantages and disadvantages of lay-administered structured interviews and self-administered problem checklists for estimating prevalence and associated features of childhood psychiatric disorder have attracted little comment. This article compares the scientific adequacy of these 2 instruments for classifying DSM-III-R categories of childhood psychiatric disorder in general population samples. METHODS: Study data are from parental assessments of 251 children aged 6 to 16 years participating in a 2-stage measurement evaluation study. Reliability and validity were compared between the Diagnostic Interview for Children and Adolescents (the structured interview in the study) and the revised Ontario Child Health Study scales (the self-administered problem checklist used in the study). RESULTS: Reliability estimates based on the kappa statistic were comparable for the 2 instruments and ranged from 0.21 (conduct disorder) to 0.70 (depression) on the lay interview and from 0.17 (depression) to 0.61 (oppositional defiant disorder) on the self-administered checklist. Validity coefficients tended to favor the checklist categories, but only marginally. CONCLUSIONS: On balance, differences in reliability and validity were small between the 2 instruments. These differences would appear to have no discernible impact on the knowledge about prevalence and associated features of disorder generated by use of such instruments in general population surveys.

Ontario Child Health Study. I. Methodology.

We developed the methodology for a community survey to determine the prevalence of emotional and behavioral disorders among children 4 to 16 years of age in Ontario, Canada. Our discussion includes the objectives of the survey, the measurement of disorder, sampling methods and survey design, and a description of the data collected and instrumentation. Among 2052 households with eligible children, 1869 (91%) participated in the survey. The results can be used to help plan the future allocation of mental health resources in Ontario.

Ontario Child Health Study. II. Six-month prevalence of disorder and rates of service utilization.

We studied the six-month prevalence of four child psychiatric disorders (conduct disorder, hyperactivity, emotional disorder, and somatization) and patterns of service utilization for mental health and social services, ambulatory medical care and special education by different regions of Ontario, urban-rural residence, and age and sex groupings. Among children 4 to 16 years of age, the overall six-month prevalence rate of one or more of these disorders was 18.1%. The prevalences of hyperactivity and one or more disorders were significantly higher in urban areas than rural areas. The utilization data indicated that children with these psychiatric disorders, compared with children without these disorders, were almost four times more likely to have received mental health or social services in the six months preceding this study. However, five of six of these children had not received these specialized services in the previous six-month period. Over 50% of the children in the province had received ambulatory medical care in the last six months. Over 15% of the children in the province had received special education services at some time thus far in their school careers. Implications of these findings, especially for the provision of child mental health services, are discussed.

Evaluation of sex differences in health-related quality of life outcomes associated with child abuse: Results from the Ontario Child Health Study.

AIMS: Despite the advances in child maltreatment research, there is still the need for comprehensive information about how abuse affects a broad range of categories of young adult functioning, and the extent to which these vary by sex. We examined the associations between child physical abuse (PA) and sexual abuse (SA) and six areas of functioning (mental health, physical health, life satisfaction, illegal substance use, alcohol problems and daily smoking). METHODS: Data were obtained from the 1983 Ontario Child Health Study and follow-up in 2000/2001 (n = 1893). Multilevel regression estimated the adjusted associations for PA (with severity) and SA with each of the outcomes. Estimates with an entire sample were presented with sex-by-abuse interactions to examine sex differences and then presented separately by sex. RESULTS: In the adjusted model, severe PA and SA were associated with impairment in mental health, and both forms of PA (severe and non-severe) and SA were associated with low life satisfaction. In addition, severe PA was associated with illegal substance use. Child abuse variables were not associated with poor physical health, alcohol problems or smoking. Although sex-stratified analyses revealed different patterns, there was no significant sex difference in the integrated sample. CONCLUSIONS: This is among the first community-based studies to show a strong association between child PA and SA and low life satisfaction in young adults. The abuse effects were similar for both sexes.

Familial aggregation of emotional and behavioral problems of childhood in the general population.

OBJECTIVE: This study sought to evaluate the existence and implications of familial aggregation of emotional and behavioral problems of childhood in a general population sample. METHOD: The children included in the study were chosen with the use of a sampling technique that identified households in which there were two or more children aged 4-16 years living at home at the time of the survey. Ratings on checklists of emotional and behavioral problems were obtained from parents, teachers of children in elementary school, and the children themselves if they were adolescents aged 12-16. Children were classified as having problems if their scores on scales of conduct, attention deficit, or emotional problems were in the top 10% of the distribution of scores from any informant. RESULTS: There was evidence for familial aggregation of these problems, particularly conduct and emotional problems. However, this was largely derived from the parents' reports of symptoms, not the teachers' or adolescents' reports. The degree of familial aggregation varied according to certain sibship characteristics and patterns of comorbidity. CONCLUSIONS: Familial aggregation of emotional and behavioral problems does exist in a community population and is not simply an artifact of clinic attendance.

Ontario Child Health Study: suicidal behavior in youth age 12-16 years.

The authors report on the prevalence and correlates of suicidal behavior in youth age 12-16 years. The data, from a community prevalence survey, show that 5%-10% of the male and 10%-20% of the female youth reported suicidal behavior within a 6-month period. Suicidal behavior in youth appeared to be related to psychiatric disorder in general as well as to family dysfunction and parental arrest.

Childhood abuse and psychiatric disorders among single and married mothers.

OBJECTIVE: This study examined the prevalence of, and association between, childhood abuse and psychiatric disorders in single and married mothers. METHOD: Single and married mothers who participated in the Ontario Health Survey, a province-wide study derived from a probability sample of the general population of Ontario aged 15 years and older (N=1,471), were included. Sociodemographic and mental health characteristics were collected by means of interviewer-administered questionnaires. A self-administered questionnaire was used to collect information on childhood physical and sexual abuse. RESULTS: Compared with married mothers, single mothers reported substantially lower incomes as well as higher rates of childhood abuse and all psychiatric morbidities examined (current and lifetime affective or anxiety disorders and substance use disorders). Childhood abuse had a consistent and significant association with adult mental health, even when other risk variables were controlled. No interaction among childhood abuse and marital status and outcome was found. CONCLUSIONS: Single mothers reported more childhood abuse and experienced higher levels of poverty and psychiatric disorders than married mothers. Childhood abuse was associated with more psychiatric problems in both single and married mothers. Research, clinical, and policy implications of these findings are discussed.

Predicting substance use in late adolescence: results from the Ontario Child Health Study follow-up.

OBJECTIVE: The purpose of this study was to evaluate the relationship between use of tobacco, alcohol, marijuana, and hard drugs (substance use) and psychiatric disorder in early adolescence and substance use in late adolescence. METHOD: Adolescents included in the study were identified by means of a household sampling frame and participated in the Ontario Child Health Study in 1983 and the follow-up in 1987. There were 726 12-16-year-olds (369 boys and 357 girls) in 1983 who had complete information in 1987. Data on substance use were collected from adolescents by using a structured, self-administered questionnaire. Data on psychiatric disorder were collected in 1983 from both adolescents and their parents by using problem checklists to assess conduct disorder, attention deficit disorder, and emotional disorder. RESULTS: Prior substance use in 1983 was associated strongly with subsequent use in 1987. Among the psychiatric disorders assessed in 1983, only conduct disorder made an independent contribution to predicting use of marijuana (relative odds = 3.46) and other hard drugs (relative odds = 6.82) in 1987, after prior use of these substances and coexisting attention deficit and emotional disorders were controlled. Corresponding estimates of attributable risk (the expected contribution of exposure to conduct disorder to the development of substance use) were 5.7% and 11.1%, respectively. CONCLUSIONS: Although a statistically significant relationship existed between conduct disorder in early adolescence and use of marijuana and hard drugs in late adolescence, the potential is limited for preventing substance use in the general population by treating conduct disorder early on.

Childhood abuse and lifetime psychopathology in a community sample.

OBJECTIVE: The authors assessed lifetime psychopathology in a general population sample and compared the rates of five psychiatric disorder categories between those who reported a childhood history of either physical or sexual abuse and those who did not. METHOD: A modified version of the Composite International Diagnostic Interview and a self-completed questionnaire on child abuse were administered to a probability sample (N=7,016) of Ontario residents 15 to 64 years of age. RESULTS: Those reporting a history of childhood physical abuse had significantly higher lifetime rates of anxiety disorders, alcohol abuse/dependence, and antisocial behavior and were more likely to have one or more disorders than were those without such a history. Women, but not men, with a history of physical abuse had significantly higher lifetime rates of major depression and illicit drug abuse/dependence than did women with no such history. A history of childhood sexual abuse was also associated with higher rates of all disorders considered in women. In men, the prevalence of disorders tended to be higher among those who reported exposure to sexual abuse, but only the associations with alcohol abuse/dependence and the category of one or more disorders reached statistical significance. The relationship between a childhood history of physical abuse and lifetime psychopathology varied significantly by gender for all categories except for anxiety disorders. Although not statistically significant, a similar relationship was seen between childhood history of sexual abuse and lifetime psychopathology. CONCLUSIONS: A history of abuse in childhood increases the likelihood of lifetime psychopathology; this association appears stronger for women than men.

Highly somatizing young adolescents and the risk of depression.

OBJECTIVE: To determine if high levels of somatization symptoms in 13- to 16-year-olds from the general population predict risk of major depression and other psychiatric disorders 4 years later. METHOD: Cohort study, using interview and self-report survey data from the 1983 Ontario Child Health Study (OCHS) and 1987 OCHS Follow-up. The study population included 1015 13- to 16-year-olds from the general community within Ontario. Baseline levels of somatization and emotional disorder were measured by the Survey Diagnostic Instrument, a checklist based on DSM-III criteria. Data were also collected for a range of sociodemographic factors, as well as the presence of chronic health problems. Major depression, anxiety disorders, and substance abuse and dependency at follow-up were measured using a self-administered questionnaire derived from the Diagnostic Interview Schedule. Bivariate and multiple logistic regression techniques were used to assess the relationship between high levels of somatization symptoms (>90th percentile) and later emotional morbidity, with adjustment for potential confounding factors, including gender and baseline disorders. RESULTS: Highly somatizing adolescents are at increased risk of major depression 4 years later, an association that is not explained by detectable emotional disorder at baseline or gender differences between groups. There is an important interaction between somatization and emotional disorder in predicting risk of major depression. It is primarily the group of 13- to 16-year-olds not recognized as being emotionally disordered at the initial OCHS survey in which somatization symptoms increased risk of later depression. The young teen with high levels of somatic complaints had as much risk of later depression as his/her peer with more typical symptoms of emotional disorder. Highly somatizing adolescents were also more likely to describe panic attacks at 4-year follow-up. There was no increased risk of substance abuse/dependency in the highly somatizing group or in generalized anxiety. CONCLUSIONS: High levels of somatic symptoms identified in young adolescents in the community represent a significant risk factor for major depression 4 years later, particularly in those individuals who do not present with more typical symptoms of emotional disorder. To detect the emergence of this serious emotional morbidity, adequate follow-up and continuity of care for these challenging patients are needed.

Mortality and morbidity of 500- to 1,499-gram birth weight infants live-born to residents of a defined geographic region before and after neonatal intensive care.

All very low-birth-weight infants live-born to residents of an urban southern Ontario county were studied before (1964 to 1969) and after (1973 to 1977) the introduction of neonatal intensive care. Mortality at hospital discharge decreased from 89.4% to 77.6% among infants whose birth weights were 500 to 999 gm and from 37.6% to 22.8% among infants with birth weights of 1,000 to 1,499 gm. The families of 121/150 (81%) and 134/151 (89%) of all children from the two cohorts who were discharged from the hospital alive were surveyed. At follow-up 7/121 (6%) and 4/134 (4%) had died. Major damage was reported for 13/121 (11%) and 18/134 (13%) of the children. Neonatal intensive care was associated with a significant reduction in mortality but there has not been a significant change in morbidity.

Ontario Child Health Study: patterns of ambulatory medical care utilization and their correlates.

Data from a large epidemiologic survey of Ontario children 4 to 16 years of age are presented concerning the frequency and correlates the use of ambulatory medical care services during a 6-month period in which a universal, first-dollar health insurance plan was used. Patterns of use of ambulatory medical care are described for three settings: doctor's offices, emergency rooms, and hospital outpatient departments. A group of children who are frequent users of ambulatory medical care (defined as using three or more services in 6 months) consumed nearly two thirds of all services. Two regression equations are presented--one predicting use/nonuse of ambulatory medical care and the other predicting the total number of visits for medical care. Although only a small proportion of the variance in use/nonuse and amount of use was explained, the major determinant of both ambulatory medical care use and frequency of use was the child's physical health status as perceived by the parent. Younger child, urban area of residence, the number of chronic medical problems of the child, and higher level of maternal education also contributed to the explanation of use v nonuse. Among ambulatory medical care users, high users were more likely to be described as having mental health problems and have parents who had been treated for "nerves." Family size and socioeconomic variables were not important factors in use, suggesting that universal health insurance reduces some barriers to ambulatory medical care for children.