Serum zinc levels in youth with avoidant/restrictive food intake disorder and anorexia nervosa: Clinical correlation with weight and psychopathology.

BACKGROUND: Avoidant/restrictive food intake disorder (ARFID) and anorexia nervosa (AN) are characterized by restrictive eating and micronutrient deficiencies. While zinc deficiency has been identified in AN, zinc level in ARFID has not been systematically assessed. AIM: Examine serum zinc levels and their association with eating pathology, psychopathology, and executive functioning in youth with ARFID and AN. METHODS: This study included 28 adolescents (Mage = 13, 75% female) receiving treatment for ARFID (n = 13) and AN (n = 15). Demographic data and intake mood metrics were obtained via chart review. Participants completed the Delis-Kaplan Executive Functioning Systems and their mothers completed the behavior rating inventory of executive function (BRIEF-2). Zinc level was collected via blood draw. Independent samples t-tests, Pearson's chi-square, and Pearson's correlations were used to evaluate between-group differences and the relationship between zinc level and clinical correlates. RESULTS: No between-groups differences emerged in zinc levels, though half the sample demonstrated low levels for their ages. No significant correlations were found between zinc level and demographic data, mood measures, or executive functioning tasks. AN had relatively lower zinc levels, higher eating pathology, and anxiety, though ARFID had a longer duration of illness. Correlations between zinc and BRIEF-2 scores were mixed. CONCLUSION: This is the first study to systematically assess zinc levels in ARFID. While there were no group differences for zinc levels, 50% of the sample had low zinc levels. Zinc level did not correlate with higher psychopathology. Monitoring zinc levels throughout treatment in the context of anabolic processes can inform treatment strategies.

Screening, brief intervention, and referral to treatment (SBIRT) for alcohol and other drug use among adolescents: evaluation of a pediatric residency curriculum.

The objective of this study was to evaluate the integration of a screening, brief intervention, and referral to treatment (SBIRT) curriculum for alcohol and other drug use into a pediatric residency program. Pediatric and medicine/pediatric residents in an adolescent medicine rotation located in an urban teaching hospital participated in the study. Main outcome measures were pre- and post-training knowledge scores, performance of the Brief Negotiation Interview (BNI), training satisfaction, and adoption of the BNI into clinical practice. Thirty-four residents were trained. Significant pre- to post-training improvements were seen in knowledge scores (P < .001) and performance as measured by the BNI Adherence Scale (P < .001). Residents reported high satisfaction immediately post-training and at 30 days on a 1-5 Likert scale: mean 1.41 to 1.59 (1 = very satisfied) (P = 0.23). Over a 9-month period, 53% of residents documented performing at least 1 BNI, of which 2/3 reported ≥2 BNIs in a subsequent clinical setting. The results show that integrating a SBIRT curriculum into a pediatric residency program increases residents' knowledge and skills.

Developing and implementing a multispecialty graduate medical education curriculum on Screening, Brief Intervention, and Referral to Treatment (SBIRT).

The authors sought to evaluate the feasibility and acceptability of initiating a Screening, Brief Intervention, and Referral to Treatment (SBIRT) for alcohol and other drug use curriculum across multiple residency programs. SBIRT project faculty in the internal medicine (traditional, primary care internal medicine, medicine/pediatrics), psychiatry, obstetrics and gynecology, emergency medicine, and pediatrics programs were trained in performing and teaching SBIRT. The SBIRT project faculty trained the residents in their respective disciplines, accommodating discipline-specific implementation issues and developed a SBIRT training Web site. Post-training, residents were observed performing SBIRT with a standardized patient. Measurements included number of residents trained, performance of SBIRT in clinical practice, and training satisfaction. One hundred and ninety-nine residents were trained in SBIRT: 98 internal medicine, 35 psychiatry, 18 obstetrics and gynecology, 21 emergency medicine, and 27 pediatrics residents. To date, 338 self-reported SBIRT clinical encounters have occurred. Of the 196 satisfaction surveys completed, the mean satisfaction score for the training was 1.60 (1 = very satisfied to 5 = very dissatisfied). Standardized patient sessions with SBIRT project faculty supervision were the most positive aspect of the training and length of training was a noted weakness. Implementation of a graduate medical education SBIRT curriculum in a multispecialty format is feasible and acceptable. Future efforts focusing on evaluation of resident SBIRT performance and sustainability of SBIRT are needed.

Cocaine Use in Adolescents and Young Adults.

Cocaine use by adolescents and young adults continues to be a significant public health issue and the cause of medical and psychological morbidity and mortality. Although use rates are lower than those seen with alcohol, tobacco, and other illicit substances such as marijuana, cocaine is highly addictive and presents significant acute and long-term medical and psychological effects. This article reviews the epidemiology of cocaine use among adolescents and young adults, discusses the pharmacology and neurobiology of cocaine use and dependence, provides information regarding acute intoxication and systemic effects seen with more chronic use, and describes current assessment and treatment approaches.

Alcohol Use by Youth.

Alcohol use continues to be a major concern from preadolescence through young adulthood in the United States. Results of recent neuroscience research have helped to elucidate neurobiological models of addiction, substantiated the deleterious effects of alcohol on adolescent brain development, and added additional evidence to support the call to prevent and reduce underage drinking. This technical report reviews the relevant literature and supports the accompanying policy statement in this issue of Pediatrics.

Marijuana Use During Pregnancy and Breastfeeding: Implications for Neonatal and Childhood Outcomes.

Marijuana is one of the most widely used substances during pregnancy in the United States. Emerging data on the ability of cannabinoids to cross the placenta and affect the development of the fetus raise concerns about both pregnancy outcomes and long-term consequences for the infant or child. Social media is used to tout the use of marijuana for severe nausea associated with pregnancy. Concerns have also been raised about marijuana use by breastfeeding mothers. With this clinical report, we provide data on the current rates of marijuana use among pregnant and lactating women, discuss what is known about the effects of marijuana on fetal development and later neurodevelopmental and behavioral outcomes, and address implications for education and policy.

The Treatment of Dysmenorrhea.

Menstrual disorders and abnormal uterine bleeding are common concerns of young women. Complaints include menses that are: too painful (dysmenorrhea), absent or occur irregularly (amenorrhea or oligoamenorrhea), or prolonged and heavy (menorrhagia, or excessive uterine bleeding). In providing optimal reproductive care, the medical provider must be able to distinguish between normal developmental patterns or symptoms requiring education and reassurance from pathologic conditions requiring prompt assessment and treatment. This article discusses the normal menstrual patterns seen in adolescent females and provides an evaluation and management approach to primary and secondary dysmenorrhea.

Counseling Parents and Teens About Marijuana Use in the Era of Legalization of Marijuana.

Many states have recently made significant changes to their legislation making recreational and/or medical marijuana use by adults legal. Although these laws, for the most part, have not targeted the adolescent population, they have created an environment in which marijuana increasingly is seen as acceptable, safe, and therapeutic. This clinical report offers guidance to the practicing pediatrician based on existing evidence and expert opinion/consensus of the American Academy of Pediatrics regarding anticipatory guidance and counseling to teenagers and their parents about marijuana and its use. The recently published technical report provides the detailed evidence and references regarding the research on which the information in this clinical report is based.

National Trends in Hospitalizations for Opioid Poisonings Among Children and Adolescents, 1997 to 2012.

Importance: National data show a parallel relationship between recent trends in opioid prescribing practices and hospitalizations for opioid poisonings in adults. No similar estimates exist describing hospitalizations for opioid poisonings in children and adolescents. Objective: To describe the incidence and characteristics of hospitalizations attributed to opioid poisonings in children and adolescents. Design, Setting, and Participants: Retrospective analysis of serial cross-sectional data from a nationally representative sample of US pediatric hospital discharge records collected every 3 years from January 1, 1997, through December 31, 2012. The Kids' Inpatient Database was used to identify 13 052 discharge records for patients aged 1 to 19 years who were hospitalized for opioid poisonings. Data were analyzed within the collection time frame. Main Outcomes and Measures: Poisonings attributed to prescription opioids were identified by codes from the International Classification of Diseases, Ninth Revision, Clinical Modification. In adolescents aged 15 to 19 years, poisonings attributed to heroin were also identified. Census estimates were used to calculate incidence per 100 000 population. The Cochran-Armitage test for trend was used to assess for changes in incidence over time. Results: From 1997 to 2012, a total of 13 052 (95% CI, 12 500-13 604) hospitalizations for prescription opioid poisonings were identified. The annual incidence of hospitalizations for opioid poisonings per 100 000 children aged 1 to 19 years rose from 1.40 (95% CI, 1.24-1.56) to 3.71 (95% CI, 3.44-3.98), an increase of 165% (P for trend, <.001). Among children 1 to 4 years of age, the incidence increased from 0.86 (95% CI, 0.60-1.12) to 2.62 (95% CI, 2.17-3.08), an increase of 205% (P for trend, <.001). For adolescents aged 15 to 19 years, the incidence increased from 3.69 (95% CI, 3.20-4.17) to 10.17 (95% CI, 9.48-10.85), an increase of 176% (P for trend, <.001). In this age group, poisonings from heroin increased from 0.96 (95% CI, 0.75-1.18) to 2.51 (95% CI, 2.21-2.80), an increase of 161% (P for trend, <.001); poisonings involving methadone increased from 0.10 (95% CI, 0.03-0.16) to 1.05 (95% CI, 0.87-1.23), an increase of 950% (P for trend, <.001). Conclusions and Relevance: During the course of 16 years, hospitalizations attributed to opioid poisonings rose nearly 2-fold in the pediatric population. Hospitalizations increased across all age groups, yet young children and older adolescents were most vulnerable to the risks of opioid exposure. Mitigating these risks will require comprehensive strategies that target opioid storage, packaging, and misuse.

Demographic, intrinsic, and extrinsic factors associated with weapon carrying at school.

BACKGROUND: Recent incidents of school violence have heightened the need to identify societal, interpersonal, and adolescent characteristics that contribute to weapon carrying. OBJECTIVES: To assess the prevalence of weapon carrying at school and to determine associated risk factors for adolescent males and females. DESIGN: A cross-sectional study using the 1994-1995 National Longitudinal Study of Adolescent Health data. PARTICIPANTS: A nationally representative sample of 6504 adolescents and their parents. MAIN OUTCOME MEASURE: Whether adolescents have ever carried a weapon at school. STATISTICS: chi(2) Analyses and hierarchical regressions were done using SPSS (SPSS Inc, Chicago, Ill) and SUDAAN (Research Triangle Park, NC) software. Regression models included demographic, intrinsic, and extrinsic factors. RESULTS: Of the overall sample, 9.3% (n = 595) reported having carried a weapon at school. Of these, 77% were male (male vs female adjusted odds ratio [AOR], 3.1; 95% confidence interval [CI], 2.3-4.1). Substance use, school problems, perpetration of violence, and witnessing violence were significantly associated with weapon carrying for both males and females. However, for males, extrinsic factors were more important in mediating the effects of substance use and perpetration of physical violence on school weapon carrying, while intrinsic factors mediate these variables for females. CONCLUSION: These findings suggest that interventions for violence prevention for males and females need to be targeted toward different areas.

Body piercing and high-risk behavior in adolescents.

PURPOSE: To evaluate the association of body piercing with sociodemographic factors, peer substance use, and high-risk behaviors. METHODS: Cross-sectional analysis using Wave II of the National Longitudinal Study of Adolescent Health (Add Health) Public Use Dataset, a nationally representative, school-based sample of 4337 adolescents, aged 13-18 years, surveyed in 1996. The major predictor variable was body piercing at locations other than the ears. The outcome variables were selected from five areas of high-risk behaviors including sexual intercourse, substance use (problem drinking, smoking, and marijuana use), violent behavior (fighting and inflicting injuries), antisocial behavior (truancy, shoplifting, and running away), and mood problems (depression, suicidal ideation and suicide attempts). The association between body piercing and peer substance use was also examined. RESULTS: Females (7.2% vs. 1.5%) and older adolescents were more likely to report piercing (all p's <.01) In linear regression analysis, controlling for sociodemographic factors, body piercing was significantly associated with higher levels of peer substance use (beta = 1.40 [99% CI.57-2.23]). In logistic regression analyses, controlling for sociodemographic factors, piercing was associated with sexual intercourse (OR = 4.5 [99% CI 2.1-10.0]), smoking (3.1 [1.6-5.9]), marijuana use (3.0 [1.6-5.9]), truancy (2.6 [1.3-5.3]), running away from home (3.0 [1.2-7.2]), suicidal ideation (2.5 [1.2-4.9]), and suicide attempts (3.0 [1.2-7.5]). CONCLUSIONS: Clinically, body piercing may serve as a marker for higher levels of peer substance use and potential problem behavior.

Visits to complementary and alternative medicine providers by children and adolescents in the United States.

OBJECTIVE: Determine the prevalence, patterns, costs, and predictors of visits to complementary and alternative medicine (CAM) providers and subsequent remedy use in a nationally representative pediatric sample. METHODS: The 1996 Medical Expenditure Panel Survey provided data on 7371 subjects < or =21 years of age. The primary outcome variable was CAM provider visits as defined by consulting a CAM provider "for health reasons." Predictors included sociodemographics, family resources, health status, parental CAM use, and perceptions and use of conventional medical care. Bivariate analyses and logistic regression determined independent factors associated with CAM use. RESULTS: Overall, 2.0% used CAM. Only 12.3% disclosed this use to their usual source of care (USC). The most common providers were chiropractors and clergy or spiritualists. The most common therapies were herbal remedies and spiritual healing. Mean amount spent per person on CAM visits was 73.40 US dollars and on remedies was 13.06 US dollars. Weighted estimates to the national pediatric population of annual expenditures on CAM visits and remedies were 127 million US dollars and 22 million US dollars, respectively. Significant factors independently associated with CAM visits were female gender, older age, good and very good perceived physical health as compared with excellent health, parental CAM use, and dissatisfaction with the quality of care received from the USC. CONCLUSIONS: Two percent of parents reported that their children consulted a CAM provider and rarely disclosed this use to their USC. While dissatisfaction with the quality of care by the USC and less good perceived physical health predicted CAM visits, parental CAM use was the most predictive.

Parents' views on human papillomavirus vaccination for sexually transmissible infection prevention: a qualitative study.

UNLABELLED: Background Human papillomavirus (HPV) is the most common sexually transmissible infection (STI) in the United States (US) and an important cause of several cancers. Vaccines that prevent HPV infections are now recommended for routine use in adolescents but coverage remains suboptimal in the US. Because they are often promoted as cancer prevention vaccines, little is known about parents' views on vaccination for prevention of an STI. METHODS: In this qualitative study, parents and caregivers of children ages 10-18 years completed an in-depth interview. Participants (n=38) were recruited from an urban hospital-based primary care centre serving a low-income population in the north-eastern US during May 2013-February 2014. Interviews were transcribed and coded using a thematic content approach. RESULTS: Five major themes emerged with relevance to the topic of HPV vaccination for STI prevention: (1) low awareness of HPV as an STI; (2) favourable opinions about STI prevention messages for vaccination, including at young ages; (3) salience of sexual mode of transmission, given the unpredictability of adolescent sexual behaviour and high rates of other STIs and teen pregnancy; (4) recognition that sexual health is a topic of conversation between adolescents and health care providers; and(5) relevance of personal experience. CONCLUSIONS: Discussing STI prevention in the context of HPV vaccination appears to be well accepted by urban, low-income minority families. In addition to providing information on cancer prevention, these messages may help to raise awareness, acceptability and uptake of HPV vaccines.

Testing for drugs of abuse in children and adolescents.

Drug testing is often used as part of an assessment for substance use in children and adolescents. However, the indications for drug testing and guidance on how to use this procedure effectively are not clear. The complexity and invasiveness of the procedure and limitations to the information derived from drug testing all affect its utility. The objective of this clinical report is to provide guidance to pediatricians and other clinicians on the efficacy and efficient use of drug testing on the basis of a review of the nascent scientific literature, policy guidelines, and published clinical recommendations.

Short-term persistence of high health care costs in a nationally representative sample of children.

OBJECTIVES: Little is known about the persistence of health care costs in children. Determining whether children with high health expenses continue to have high expenses over time can help in the development of targeted programs and policies to decrease costs, plan equitable health insurance strategies, and provide insights into the effects of costly conditions on families. The objectives of this study were to (1) identify the characteristics of children who are in the top 10th percentile for health costs, (2) investigate whether those in the top percentiles for costs in 1 year continue in the same percentiles the next year, and (3) identify factors that predict whether a child stays in the top percentiles. METHODS: Data from 2 consecutive years (2000-2001) of the Medical Expenditure Panel Survey were analyzed. Changes in a child's position in the expenditure distribution were examined. An estimated multivariate model conditional on insurance was developed to predict the true resource costs of providing services. Statistical analyses, including logistic-regression and multivariate linear-regression modeling, were done to account for the weighted sampling used in Medical Expenditure Panel Survey. RESULTS: A total of 2938 children were included in the survey for both years. In 2000, the top 10% of the children accounted for 54% of all costs. They had a mean total expenditure of 6422 dollars with out-of-pocket expenditures of 1236 dollars; 49% of the children in the top decile in 2000 persisted in the top decile in 2001, whereas 12% dropped into the bottom half. Children who had been in the top 10% in 2000 were 10 times more likely than other children to be in the top 10% for 2001. Other characteristics in 2000 that predicted membership in the top decile for 2001 included age (11-15 and 16-17 years), having any insurance (public and private), being positive on the standardized Children With Special Health care Need screener, and having a functional limitation. CONCLUSIONS: Almost half of the children in the top 10% for costs in 2000 persisted in the top 10% in 2001. Older children, children with special health care needs, and children with functional limitations were more likely to be in the top decile. These findings do not support the belief that black and Latino children who are on Medicaid account for a disproportionate share of costs or expenditures. Because the children who were among the top 10% used health care services in a variety of inpatient, emergency department, outpatient, and ancillary venues, providing care coordination throughout the entire health care system is important to address both the cost and the quality aspects of health care for the most costly children. Targeted programs to decrease expenditures for those with the greatest costs have the potential to save future health care dollars. Assessment of the factors that predict persistence of high expenditures can be used to help in the planning of equitable health insurance strategies such as catastrophic care, carve-outs, reinsurance, and risk adjustment. Clinicians should review regularly the extent of care coordination that they are providing for their high-need and high-cost patients, especially preteens and adolescents. Studies that examine the persistence of expenditures over longer periods and include assessment of quality of care are needed.

Tattooing and high-risk behavior in adolescents.

OBJECTIVES: We sought to determine the prevalence and sociodemographic characteristics of tattooed adolescents in a nationally representative sample and to evaluate the association between tattooing and several high-risk behaviors. METHODS: This is a secondary analysis of the National Longitudinal Survey of Adolescent Health Public Use Dataset, which provides a nationally representative sample of 6072 adolescents collected in 1995 and 1996. The association among permanent tattoos, sociodemographic factors, and high-risk behaviors was evaluated using bivariate and logistic regression analyses using SUDAAN. RESULTS: Of the total sample of youths, 4.5% reported having permanent tattoos. Tattooing was significantly associated with older age, living in a single-parent household, and lower socioeconomic status but was not significantly associated with gender, ethnicity, or neighborhood type. Tattooing was strongly associated with peer substance use. Adjusting for sociodemographic factors and peer substance use, tattooing in adolescents was independently and significantly associated with reported sexual intercourse, substance use, violent behaviors, and school problems. CONCLUSION: Permanent tattoos are strongly associated with high-risk behaviors among adolescents. In the clinical setting, the presence of a tattoo noted during clinical examination of an adolescent should prompt in-depth assessment for a variety of high-risk behaviors.

Prevalence of, and factors associated with, adolescent physical fighting while under the influence of alcohol or drugs.

PURPOSE: To determine: (a) the prevalence of physical fighting while under the influence of alcohol or drugs, and (b) the associations among demographic factors, other risk behaviors, and physical fighting while under the influence of substances. METHODS: Cross-sectional analysis of The National Longitudinal Study of Adolescent Health (Add Health) 1994-1995, a school-based, nationally representative survey of 6504 7th to 12th graders. The dependent outcome variables of interest were: "The most recent time you got into a fight, had you been drinking?" and "Have you ever gotten into a fight when you had been using drugs?" Independent variables included: demographics, adolescent characteristics and risk behaviors, home environment, and peer substance use. Univariate and bivariate analyses, and logistic regressions, using SUDAAN, were performed for the two outcome behaviors for the overall sample (p