Community-Based Prevalence of Externalizing and Internalizing Disorders among School-Aged Children and Adolescents in Four Geographically Dispersed School Districts in the United States.

The Project to Learn About Youth-Mental Health (PLAY-MH; 2014-2018) is a school-based, two-stage study designed to estimate the prevalence of selected mental disorders among K-12 students in four U.S.-based sites (Colorado, Florida, Ohio, and South Carolina). In Stage 1, teachers completed validated screeners to determine student risk status for externalizing or internalizing problems or tics; the percentage of students identified as being at high risk ranged from 17.8% to 34.4%. In Stage 2, parents completed a structured diagnostic interview to determine whether their child met criteria for fourteen externalizing or internalizing disorders; weighted prevalence estimates of meeting criteria for any disorder were similar in three sites (14.8%-17.8%) and higher in Ohio (33.3%). PLAY-MH produced point-in-time estimates of mental disorders in K-12 students, which may be used to supplement estimates from other modes of mental disorder surveillance and inform mental health screening and healthcare and educational services.

Physical activity and self-concept: the SEARCH for diabetes in youth case control study.

In this study, the relationship between physical activity (PA) and 3 self-concept constructs (physical abilities, physical appearance, and general self-concept) was examined. Youth with type 1 diabetes (n = 304), type 2 diabetes (n = 49), and nondiabetic controls (n = 127) aged 10-20 years wore pedometers over 7 days. Youth completed the Self-Description Questionnaire and correlation coefficients were calculated. Mean steps/day were 7413 ± 3415, 4959 ± 3474 and 6870 ± 3521 for type 1, type 2 and control youth, respectively. Significant correlations were found between steps/day and perception of physical abilities (r = .29; r = .31; r = .31) for type 1, type 2, and control youth, respectively. The other correlations were not significant. Among youth with type 2 diabetes, steps/day were significantly correlated with physical appearance (r = .46). The positive correlation between PA and physical abilities suggests a reciprocal relationship between behavior and perception.

Association between barracks type and acute respiratory infection in a gender integrated Army basic combat training population.

BACKGROUND: Acute respiratory infections (ARIs) are the leading cause of acute morbidity and lost work time in the United States. Few studies have looked at building design and transmission of ARIs. OBJECTIVES: This study explores the association of ventilation design, room occupancy numbers, and training week with ARI rates in Army Basic Combat Training barracks. METHODS: This observational study captured the overall incidence of ARI in a cohort of 16,258 individuals attending basic combat training at Fort Jackson, South Carolina. RESULTS: ARI risk was higher among trainees living in the 60-person room barracks compared with those living in 8-person rooms, which increased rapidly for the first few weeks of training and then declined to baseline. CONCLUSIONS: Findings support direct contact as primary ARI transmission mode in this study population based on observed lower ARI risk in smaller room barracks and similar risk in large room barracks despite heating, ventilation, and air conditioning system variability.

Logistic quantile regression for bounded outcomes.

When research interest lies in continuous outcome variables that take on values within a known range (e.g. a visual analog scale for pain within 0 and 100 mm), the traditional statistical methods, such as least-squares regression, mixed-effects models, and even classic nonparametric methods such as the Wilcoxon's test, may prove inadequate. Frequency distributions of bounded outcomes are often unimodal, U-shaped, and J-shaped. To the best of our knowledge, in the biomedical and epidemiological literature bounded outcomes have seldom been analyzed by appropriate methods that, for one, correctly constrain inference to lie within the feasible range of values. In many respects, continuous bounded outcomes can be likened to probabilities or propensities. Yet, what has long been heeded when modeling the probability of binary outcomes with the widespread use of logistic and probit regression, so far appears to have been overlooked with continuous bounded outcomes with consequences at times disastrous. Logistic quantile regression constitutes an effective method to fill this gap.

ADHD and Psychiatric Comorbidity: Functional Outcomes in a School-Based Sample of Children.

Objective: Investigate the prevalence and impact of psychiatric comorbidities in community-based samples of schoolchildren with/without ADHD. Method: Teachers and parents screened children in South Carolina (SC; n = 4,604) and Oklahoma (OK; n = 12,626) for ADHD. Parents of high-screen and selected low-screen children received diagnostic interviews (SC: n = 479; OK: n = 577). Results: Psychiatric disorders were increased among children with ADHD and were associated with low academic performance. Conduct disorder/oppositional defiant disorder (CD/ODD) were associated with grade retention (ODD/CD + ADHD: odds ratio [OR] = 3.0; confidence interval [CI] = [1.5, 5.9]; ODD/CD without ADHD: OR = 4.0; CI = [1.7, 9.7]). School discipline/police involvement was associated with ADHD alone (OR = 3.2; CI = [1.5, 6.8]), ADHD + CD/ODD (OR = 14.1, CI = [7.3, 27.1]), ADHD + anxiety/depression (OR = 4.8, CI = [1.6, 14.8]), and CD/ODD alone (OR = 2.8, CI = [1.2, 6.4]). Children with ADHD + anxiety/depression had tenfold risk for poor academic performance (OR = 10.8; CI = [2.4, 49.1]) compared to children with ADHD alone. This should be interpreted with caution due to the wide confidence interval. Conclusion: Most children with ADHD have psychiatric comorbidities, which worsens functional outcomes. The pattern of outcomes varies by type of comorbidity.

Cross-sectional assessment of diet quality in individuals with a lifetime history of attempted suicide.

Increased evidence indicates an association between psychiatric disorders and dietary pattern. The objective of this study is to describe the differences in food consumption between suicide attempters and non-attempters. We analyzed the dietary information retrospectively collected from 6803 adults, aged 17 to 39 years, who also completed a mental disorder diagnostic interview as a part of the Third National Health and Nutrition Examination Survey, 1988-1994. The Healthy Eating Index score was used to measure the degree of compliance with the national diet guidelines. In men, attempters (n=92) had a high odds of low consumption of vegetables (OR=2.47, 95%CI=1.19, 5.15). In women, attempters (n=275) had a high odds of insufficient fruit consumption (OR=2.36, 95%CI=1.15, 4.85). For both men and women, the component scores for meat were lower in non-attempters compared with attempters. On a scale of zero (no serving) to 10 (meeting the serving recommendations), the scores were 6.74 (SE: 0.39) and 7.76 (0.10), respectively, for attempters and non-attempters among men, and 5.81 (0.33) and 6.43 (0.07), respectively, for attempters and non-attempters among women. It was further observed that female attempters ate significantly less fish and seafood. These results were obtained after adjustment for various factors, including the history of medical and psychiatric illnesses. The data suggest that fruits, vegetables and meat were significantly under-consumed in adults who had ever attempted suicide. The deleterious contribution of insufficient consumption of these foods to physical and psychiatric status in attempters merits investigation. In clinical practice, psychiatrists should pay more attention to what patients eat.

The Association Between Race/Ethnicity and Socioeconomic Factors and the Diagnosis and Treatment of Children with Attention-Deficit Hyperactivity Disorder.

OBJECTIVE: Assessing race/ethnicity and socioeconomic status (SES) relationships with Attention-Deficit/Hyperactivity Disorder (ADHD) diagnosis, treatment, and access to care has yielded inconsistent results often based only on parent-report. In contrast, this study used broader ADHD diagnostic determination including case-definition to examine these relationships in a multisite elementary-school-based sample. METHOD: Secondary analysis of children with and without ADHD per parent and teacher-reported Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria evaluated SES, race/ethnicity, and other variables through simple bivariate/multivariable models within and across: parent-reported diagnosis, medication treatment, and meeting ADHD study case-definition. RESULTS: The total sample included 51.9% male, 51.3% White, and 53.1% with private insurance; 10% had parent-reported ADHD diagnoses while 8.3% met ADHD study case-definition. In multivariable models, White children had higher odds of parent-reported diagnoses than Black, Hispanic, and Other Race/Ethnicity children (p < 0.05), but only Hispanic children had lower odds of being case-positive (<0.05); males and children in single-parent households had higher odds of parent-reported diagnoses and being case-positive (p < 0.05); and children who were White, male, and had health insurance had higher odds of taking medication (p < 0.05). Among children who were case-positive, those with Medicaid, White, and 2-parent statuses had higher odds of parent-reported diagnoses (p < 0.05). CONCLUSION: Children with underlying ADHD appear more likely to have assessment/medication treatment access if they are White, male, have health insurance (particularly Medicaid), and live in 2-parent households. While boys and children raised by single parents may have higher rates of ADHD diagnoses, false-positive diagnostic risk also appeared higher, inviting further investigation.

Stress-related mental disorders in childhood cancer survivors.

BACKGROUND: This report evaluated the association between surviving pediatric cancer and receiving a diagnosis of a stress-related mental disorder (SRMD) (i.e., post-traumatic stress disorder (PTSD), acute stress disorder, or adjustment disorders). PROCEDURE: The dataset comprised a cohort of Medicaid eligible children, ages birth to 15 years during baseline years 1996-2001 and followed at least 1 year until age 19 years or the end of 2003. Childhood cancer survivors (N = 390) identified from the SC Central Cancer Registry were frequency matched within age groups at each baseline year to children with no history of malignancy (N = 1,329). Survival curves and cumulative incidence of SRMD were estimated using the Kaplan-Meier method. Cox proportional hazards models were used to estimate hazard ratios (HR) and 95% confidence intervals (CI) for pediatric cancer survival and selected covariates. RESULTS: The 8-year incidence of SRMD was 18.6% (95% CI: 12.47, 24.8) among childhood cancer survivors and 7.3% (5.0, 9.6) among children with no history of malignancy, HR = 3.22 (2.17, 4.76). Significant covariates for this group included race, sex, and previous mental disorder, adjusted HR = 3.00 (2.02, 4.45). Significant predictors among the childhood cancer survivors included cancer type, age group, treatment, and previous mental disorder. CONCLUSIONS: Given the potential benefit of interventions for those with prior psychopathology, that children are less likely to verbalize emotional problems, and the detrimental implications of undiagnosed mental disorders, the health evaluations of childhood cancer patients and the follow-up visits for the survivors should incorporate assessment for mental disorders, especially SRMD.

Do antenatal religious and spiritual factors impact the risk of postpartum depressive symptoms?

OBJECTIVES: Previous research has identified an inverse relationship between religiosity/spirituality and depressive symptoms. However, prospective studies are needed. This study investigates the association between antenatal religiosity/spirituality and postpartum depression, controlling for antenatal depressive symptoms, social support, and other potential confounders. METHODS: This is a prospective cohort study. Women receiving prenatal care were enrolled from three obstetrics practices. Follow-up assessment was conducted at the 6-week postpartum clinic visit. Four measures of religiosity and two measures of spirituality were assessed at baseline. A measure of overall religiosity/spirituality was also created using principal component factor analysis. Depressive symptoms were measured at baseline and again at follow-up using the Edinburgh Postnatal Depression Scale (EPDS). A cutoff score of >or=13 was used to identify women with significant depressive symptoms. RESULTS: Four hundred four women were enrolled, and 374 completed follow-up. Thirty women experienced pregnancy loss, leaving 344 with postpartum assessment; 307 women had complete data and were used for analyses. Thirty-six women (11.7%) scored above the EPDS screening cutoff. Controlling for significant covariates (baseline EPDS score and social support), women who participated in organized religious activities at least a few times a month were markedly less likely (OR = 0.18, 95% CI) to exhibit high depressive symptom scores. No other religiosity/spirituality measure was statistically significant. CONCLUSIONS: Organized religious participation appears to be protective from postpartum depressive symptoms. Because this association is independent of antenatal depressive symptoms, we hypothesize that religious participation assists in coping with the stress of early motherhood.

Predicting depressive symptoms and grief after pregnancy loss.

Women who experience pregnancy loss are at high risk for depression and grief. We conducted a prospective cohort study to identify antenatal predictors of depressive symptoms and grief following pregnancy loss. Particular emphasis was given to the potential role of religiosity and spirituality. In multivariable linear regression models, depressive symptoms were significantly positively associated with baseline depression score and a history of mental illness. Depression scores were significantly inversely associated with age. Increasing age was also protective against post-pregnancy loss grief, as was participation in organized religious activities. Clinicians should be particularly alert to signs of depression following pregnancy loss in younger women and in women with a history of mental illness during or before pregnancy. The inverse association between religious attendance and grief following pregnancy loss merits further study.

US suicide rates by age group, 1970-2002: an examination of recent trends.

US suicide rates have declined in recent years, reversing earlier trends. We examined suicide rates among 4 age groups from 1970 to 2002 and the factors that may have contributed to the decline. We paid particular attention to newer anti-depressants because of recent concerns and controversy about a possible association with suicidal behaviors. These trends warrant more extensive analysis of suicide rates among specific subgroups, including consideration of additional variables that may influence rates differentially. The relative contributions of depression diagnosis and treatment, postsuicide attempt care, and other contextual factors (e.g., overall economic conditions) also deserve attention. If the decline is associated with contextual factors, clarifying these associations will better inform public policy decisions and contribute to more effective interventions for preventing suicide.

Persistence of Parent-Reported ADHD Symptoms From Childhood Through Adolescence in a Community Sample.

OBJECTIVE: To examine ADHD symptom persistence and factors associated with elevated symptom counts in a diverse, longitudinal community-based sample. METHOD: Parents reported demographics and completed a diagnostic interview repeatedly over a 6-year period. At Time 1, 481 interviews were completed about children (5-13 years); all participants were invited to four annual follow-up interviews, and 379 (79%) completed at least one. Inattentive (IA) and hyperactive-impulsive (HI) symptom counts were modeled with logistic quantile regression, while accounting for study design complexities. RESULTS: The prevalence of seven IA symptoms remained stable from early childhood through late adolescence. The prevalence of eight HI symptoms decreased by more than half over time. After demographic adjustment, the upper quartile of HI symptom counts decreased with age (p < .01). High HI symptom counts persisted more among those with high IA symptom counts (p = .05). CONCLUSION: This study further characterizes and provides insights into ADHD symptom trajectory through adolescence.

Gender differences in risk factors for attempted suicide among young adults: findings from the Third National Health and Nutrition Examination Survey.

PURPOSE: To identify the significant factors associated with attempted suicide among men and women, and determine whether socioeconomic status (SES) and social support indictors, health risk factors, and lifetime history of medical and psychiatric illnesses can explain gender differences in attempted suicide. METHODS: We used data from 3357 men and 4004 women aged 17 to 39 years, who completed a mental disorder diagnostic interview as a part of the Third National Health and Nutrition Examination Survey, 1988-1994. Adjusted odds ratios (ORs) were calculated for the association between risk factors and attempted suicide. RESULTS: The prevalence of lifetime attempted suicides was 7.58% (SE, 0.66) in women and 3.69% (SE, 0.49) in men. In men, low income and smoking were associated with attempted suicide, while attempted suicide in women was associated with poor self-evaluated health, low educational attainment, and drug use. A history of medical and psychiatric illnesses was associated with attempted suicide in both genders, for cancer/pulmonary disease, OR=2.89 (95% CI, 1.25-6.67) in men and 1.94 (1.09-3.45) in women; for major depressive disorder, OR=9.86 (5.08-19.14) in men and 5.00 (3.19-7.83) in women. The significant gender difference of attempted suicide prevalence remained after being adjusted for risk factors selected. CONCLUSION: There were significant gender differences in the risk factors for attempted suicide among young adults, and the gender difference in the prevalence of lifetime attempted suicides could not be explained by differential exposure to risk factors selected.

Brief report: attitudes toward hormone therapy after the Women's Health Initiative: a comparison of internists and gynecologists.

In the Women's Health Initiative (WHI), postmenopausal women receiving combination hormone therapy (HT) experienced more adverse outcomes than placebo recipients. To determine whether gynecologists and internists interpreted the WHI differently, we conducted a survey in which physicians responded to a hypothetical asymptomatic woman who asks whether to continue HT. In response to this scenario, gynecologists were more likely than internists to hold permissive views about prescribing HT (66% vs 35%; P<.001). These results suggest that gynecologists may be less concerned than internists about the adverse events associated with HT, or that gynecologists have stronger beliefs about benefits of HT.

Family and psychosocial risk factors in a longitudinal epidemiological study of adolescents.

OBJECTIVE: To study the association of family and social risk factors with psychopathology in a longitudinal study of adolescents. METHOD: From 1986 to 1988, 3,419 seventh through ninth graders were screened with the Center for Epidemiologic Studies Depression Scale. The top decile scorers and a random sample of the remainder were interviewed using the Schedule for Affective Disorders and Schizophrenia for School-Age Children (n = 581). Follow-up interviews were completed 6 years later (mean age = 18.65; n = 490). Baseline variables are associated with baseline and follow-up diagnoses. Diagnoses are grouped by affective, disruptive, and anxiety disorders. RESULTS: The frequency of psychiatric diagnosis decreased from 19.9% (baseline) to 5.7% (follow-up). In multivariable logistic regression analyses controlling for race, gender, and socioeconomic status, baseline undesirable life events and low family cohesion are associated with any disorder and affective disorder at baseline. Not living with both biological parents at baseline increases the odds ratio (OR) for affective disorder at baseline (OR 3.45; 95% confidence interval [CI] = 1.68-7.08) and follow-up (OR 4.40; CI = 1.26-15.40). At baseline and follow-up, anxiety and affective disorders are associated with being white and anxiety disorder with being female. CONCLUSIONS: Family structure and cohesion and stressful life events are associated with affective disorders in adolescents.

Low HDL cholesterol is associated with suicide attempt among young healthy women: the Third National Health and Nutrition Examination Survey.

BACKGROUND: Serum cholesterol is reported to be associated with suicidality, but studies conducted among general healthy population are rare. We examined the association between serum cholesterol and suicidality in a national sample of the general population of US. METHODS: We used the data of 3237 adults aged 17 to 39 years, who completed a mental disorder diagnostic interview and had blood specimens collected after a 12-h fast, as a part of the Third National Health and Nutrition Examination Survey, 1988-1994. The serum concentrations of total cholesterol, high-density lipoprotein cholesterol (HDL-C), and low-density lipoprotein cholesterol (LDL-C) were dichotomized according to the recommended levels of the National Cholesterol Education Program. A polytomous logistic regression was employed to control for covariates. RESULTS: Independent of socio-demographic variables, health risks and nutrition status, and a history of medical and psychiatric illness (including depression), a significant association between low HDL-C (< or = 40 mg/dl) and increased prevalence of suicide attempts was observed in women (OR=2.93, 95% CI=1.07-8.00). No significant evidence was found to support an association between cholesterol and suicide ideation in women. Serum cholesterol was unrelated with either suicide ideation or attempts in men. LIMITATION: The inherent limitation of cross-sectional design prevented the authors from investigating causality. CONCLUSIONS: Low HDL-C is significantly associated with suicide attempts in women. Further studies are necessary to explore the clinical application of serum cholesterol as an indicator for suicide attempts among high risk population.

Prevalence and correlates of ADHD symptoms in the national health interview survey.

OBJECTIVE: Study the prevalence and correlates of ADHD symptoms in the National Health Interview Survey (NHIS). METHODS: NHIS includes 10,367 children ages 4 to 17. Parents report lifetime diagnosis of ADHD and complete the Strengths and Difficulties Questionnaire (SDQ). Prevalences of clinically significant ADHD and comorbid symptoms by race and ethnicity, gender, and age are presented. RESULTS: Prevalence of clinically significant SDQ ADHD symptoms is 4.19% (males) and 1.77% (females). Male prevalence by race is 3.06% for Hispanics, 4.33% for Whites, and 5.65% for Blacks. Significant differences in prevalence occur across gender (p < .01) and among males across race (p < .01), age (p < .01), and income (p < .02). In the full sample, 6.80% of males and 2.50% of females have a parent-reported lifetime ADHD diagnosis but are negative for SDQ ADHD. Likewise, 1.59% of males and 0.81% of females are positive for SDQ ADHD but negative for parent report of ADHD diagnosis. SDQ ADHD positive children have substantially higher proportions of elevated scores on other SDQ subscales. CONCLUSION: ADHD symptoms vary by race and ethnicity, gender, and age and are associated with other emotional and behavioral difficulties. Both overdiagnosis and underdiagnosis of ADHD may be issues in the U.S. population of 4- to 17-year-olds.

The impact of case definition on attention-deficit/hyperactivity disorder prevalence estimates in community-based samples of school-aged children.

OBJECTIVE: To determine the impact of varying attention-deficit/hyperactivity disorder (ADHD) diagnostic criteria, including new DSM-5 criteria, on prevalence estimates. METHOD: Parent and teacher reports identified high- and low-screen children with ADHD from elementary schools in 2 states that produced a diverse overall sample. The parent interview stage included the Diagnostic Interview Schedule for Children-IV (DISC-IV), and up to 4 additional follow-up interviews. Weighted prevalence estimates, accounting for complex sampling, quantified the impact of varying ADHD criteria using baseline and the final follow-up interview data. RESULTS: At baseline 1,060 caregivers were interviewed; 656 had at least 1 follow-up interview. Teachers and parents reported 6 or more ADHD symptoms for 20.5% (95% CI = 18.1%-23.2%) and 29.8% (CI = 24.5%-35.6%) of children respectively, with criteria for impairment and onset by age 7 years (DSM-IV) reducing these proportions to 16.3% (CI = 14.7%-18.0%) and 17.5% (CI = 13.3%-22.8%); requiring at least 4 teacher-reported symptoms reduced the parent-reported prevalence to 8.9% (CI = 7.4%-10.6%). Revising age of onset to 12 years per DSM-5 increased the 8.9% estimate to 11.3% (CI = 9.5%-13.3%), with a similar increase seen at follow-up: 8.2% with age 7 onset (CI = 5.9%-11.2%) versus 13.0% (CI = 7.6%-21.4%) with onset by age 12. Reducing the number of symptoms required for those aged 17 and older increased the overall estimate to 13.1% (CI = 7.7%-21.5%). CONCLUSION: These findings quantify the impact on prevalence estimates of varying case definition criteria for ADHD. Further research of impairment ratings and data from multiple informants is required to better inform clinicians conducting diagnostic assessments. DSM-5 changes in age of onset and number of symptoms required for older adolescents appear to increase prevalence estimates, although the full impact is uncertain due to the age of our sample.

Gender differences in the association between food insecurity and insulin resistance among U.S. adults: National Health and Nutrition Examination Survey, 2005-2010.

PURPOSE: To examine gender-specific associations between food insecurity and insulin resistance in a representative U.S. METHODS: Data on 5533 adults of 20 years of age or more (2742 men and 2791 women) without diabetes from the 2005-2010 National Health and Nutrition Examination Survey were analyzed. Respondents were categorized as having full, marginal, low, or very low food security using a validated scale. Insulin-resistant individuals were defined as those with a homeostasis model assessment of insulin resistance value 2.5 or more. RESULTS: Insulin resistance was higher in both normal-weight (P = .001) and overweight or obese (P < .001) women with lower food security, but no linear trend was found in men. In multiple logistic regression analyses, however, very low food security-compared with full food security-was associated with insulin resistance in normal-weight men (odds ratio, 3.99; 95% confidence interval, 1.71-9.33), and marginal food insecurity was associated with insulin resistance in overweight or obese men (odds ratio, 2.07; 95% confidence interval, 1.18-3.64) after adjusting for potential confounders. In women, the association between food insecurity and insulin resistance was no longer significant after adjustment. CONCLUSIONS: Food insecurity is associated with insulin resistance in adults without diabetes, and this effect varies by gender in normal-weight and overweight or obese populations. Improving food security status may help reduce insulin resistance, an underlying risk factor for diabetes and cardiovascular disease.