Transition to adulthood: delays and unmet needs among adolescents and young adults with asthma.

OBJECTIVE: To examine the effect of the transition to adulthood on financial and non-financial barriers to care in youth with asthma. STUDY DESIGN: With National Health Interview Survey data from 2000 to 2005, we examined delays and unmet needs because of financial and non-financial barriers, evaluating the effect of adolescent (age, 12-17 years; n = 1539) versus young adult age (age, 18-24 years; N = 833), controlling for insurance, usual source of care, and sociodemographic characteristics. We also simulated the effects of providing public insurance to uninsured patients and a usual source of care to patients without one. RESULTS: More young adults than adolescents encountered financial barriers resulting in delays (18.6% versus 8%, P < .05) and unmet needs (26.6% versus 11.4%, P < .05), although delays caused by non-financial barriers were similar (17.3% versus 14.9%, P = not significant). In logistic models young adults were more likely than adolescents to report delays (odds ratio [OR], 1.45; 95% CI, 1.02-2.08) and unmet needs (OR, 1.8; 95% CI, 1.29-2.52) caused by financial barriers. CONCLUSIONS: Delays and unmet needs for care caused by financial reasons are significantly higher for young adults than they are for adolescents with asthma.

Factors associated with overweight among urban American Indian adolescents: findings from Project EAT.

OBJECTIVES: To determine the prevalence of overweight in a sample of urban American Indian adolescents and identify associated behavioral, personal, and socioenvironmental factors. DESIGN AND PARTICIPANTS: Participants were 246 American Indian boys and girls from the Saint Paul-Minneapolis metropolitan area of Minnesota who completed classroom surveys and anthropometric measurements as part of Project EAT (Eating Among Teens), a population-based study of adolescent nutrition and weight. MEASURES: Survey items assessed behavioral factors (physical activity, television/video viewing, snacking and meal patterns, weight control behaviors), personal factors (body satisfaction, nutrition knowledge, nutrition/fitness attitudes, self-efficacy to make healthy food choices, perceived benefits/barriers to healthy eating), and socioenvironmental factors (family meal routines, family connectedness, parental attitudes regarding nutrition/fitness, availability of household foods, peer attitudes about weight and fitness). RESULTS: Overweight prevalence (body mass index > or =85th percentile) was 43% and 39% for American Indian boys and girls. Compared to nonoverweight American Indian youth, overweight American Indian youth reported watching more hours of television/videos, greater use of weight control behaviors, less frequent snacking, caring less about fitness, lower body satisfaction, and greater parental concern about weight. CONCLUSION: Obesity prevention programs targeting American Indian adolescents should focus on reducing time spent watching television/videos, screening for unhealthy weight-control behaviors, improving body satisfaction, and providing support for families to integrate healthy eating into their busy lifestyles.

Communication with our teens: associations between confidential service and parent-teen communication.

PURPOSE: Many recent attempts have been made to eliminate health services minors can receive without parental consent or notification. One argument is that these "confidential" services undermine the parent-teen relationship. The objective of this study was to evaluate whether confidential services impact adolescent's communication with parents about their health. METHODS: This cross-sectional study included 59 adolescents (ages 12-21) seeking health services at an urban teen clinic in Minneapolis, MN. Participants were divided based on reasons for presenting at the clinic; confidential or non-confidential services. The main outcome variables were the following: discussion of clinic visit with parent, discussion of reason for clinic visit with parent, and communication with parent if diagnosed with a potentially serious health condition. RESULTS: The two groups were equally divided; 42.4% came for non-confidential services and 57.6% came for confidential services. Of the 59 participants, 69.5% told their parents they were coming to clinic. However, only 43.1% reported they would not tell their parent if they had a serious health problem; there was an equal split between the confidential services and non-confidential services groups. A statistical difference was not found between the confidential services and non-confidential services groups for any of the outcome variables. CONCLUSIONS: Obtaining confidential services was not a barrier to discussion with parents about clinic visit, reasons for coming to clinic, or telling their parent if they had a serious health care problem. Clinicians should continue to advocate for confidential services while encouraging open communication between adolescents and their parents.

Individual and environmental impacts on sexual health of Caribbean youth.

Individual health risk behaviors among Caribbean youth account for the majority of adolescent morbidity and mortality in that area. This study explores the associations between individual factors, socioenvironmental factors, and sexual health-related behaviors in Caribbean youth. Data from the 1995 Caribbean Youth Health Survey, a nine-country, cross-sectional study completed by 15,695 in-school youth 10-18 years of age were analyzed. One-third of the sample (n = 5,060) reporting sexual activity was analyzed. This study examined age at first sexual intercourse, number of sexual partners, history of pregnancy, and condom use. The predictor variables were rage, depressed mood, expectation of early death, self-reported school performance, parental mental health or substance abuse problems, and family connectedness. Bi- and multivariate analyses were done separately for males and females, controlling for age, to examine associations between individual and socioenvironmental factors and sexual health behaviors. In the multivariate model, there were associations between rage, abuse, family mental health and substance use, anticipation of early death, and many of the outcome variables in males and females. Family connectedness and positive self-reported school status were correlated with greater condom use at last intercourse in males. Family connectedness was correlated with older age at first sexual intercourse. Depressed mood was not correlated with any of the outcome variables. The findings of the study demonstrate an association between individual and socioenvironmental factors and sexual health behaviors in the lives of Caribbean youth. Strong associations between rage and physical/sexual abuse and risky sexual behaviors are of notable concern.

Primary and secondary sexual abstinence in high school students.

PURPOSE: To assess reasons for choosing not to have sexual intercourse among two groups: virgins (primary abstainers) and already sexually experienced youth (secondary abstainers). METHODS: 73,464 Minnesota ninth- and twelfth-grade adolescents completed the 1998 Minnesota Student Survey. Respondents identified reasons for abstinence from a checklist from which they could nominate all relevant items. Reasons for each group were analyzed using Chi-square with a conservative criterion value (p <.001) owing to large sample size. Logistic regression was used to examine the associations of gender, grade, and their interactions, with reasons for abstinence. RESULTS: Sixty-six percent reported never having had intercourse (primary abstainers). Among sexually experienced youth, 7.8% reported choosing not to have intercourse (secondary abstainers). Fear of pregnancy was the reason endorsed most often, more by girls than by boys (OR = 26 for primary abstainers, 6.9 for secondary abstainers). Fear of other adverse consequences, such as sexually transmitted infections, parental disapproval, or fear of getting caught, were generally selected by more girls than boys, and by more primary than secondary abstainers. Similarly, more girls and primary abstainers than boys or secondary abstainers generally selected statements reflecting normative beliefs on youth or their friends having intercourse. CONCLUSIONS: Fear of adverse consequences and normative beliefs about the appropriateness of having sexual intercourse were most frequently endorsed as important reasons by both groups of abstainers.

Prevalence and risk and protective factors related to disordered eating behaviors among adolescents: relationship to gender and ethnicity.

PURPOSE: To examine the current prevalence of disordered eating behaviors in a large sample of adolescents, by gender and ethnicity, and to identify gender and ethnic-specific risk and protective factors. METHODS: The study population included 81,247 9th- and 12th-graders who completed the 1998 Minnesota Student Survey, a self-report, school-based survey which included questions about disordered eating behaviors and a variety of psychosocial characteristics. RESULTS: Fifty-six percent of 9th-grade females and 28% of 9th-grade males report disordered eating behaviors (i.e. one or more of the following to lose or control weight: fasting or skipping meals, diet pills, vomiting, laxatives or smoking cigarettes; and binge-eating), with slightly higher rates among 12th-grade females and males, 57% and 31%, respectively. Among both genders, Hispanic and American Indian youth reported the highest prevalence of disordered eating. Risk factors for disordered eating among both males and females included cigarette smoking, appearance concerns, and alcohol use. Protective factors for both males and females were positive self-esteem, emotional well-being, school achievement, and family connectedness. While risk and protective factors were similar across gender, they differed across ethnicity particularly among females. CONCLUSIONS: Health professionals working with youth need to be aware of the high prevalence of these subclinical disordered eating behaviors, ask appropriate screening questions, and provide resources and referral, if necessary, for youth reporting these behaviors. Knowledge of risk and protective factors can serve to guide intervention and prevention efforts, particularly as they apply across ethnicity.

Unhealthy behaviors and psychosocial difficulties among overweight adolescents: the potential impact of familial factors.

PURPOSE: To compare overweight and non-overweight youth on a selection of self-reported eating, physical activity, dieting, educational, and emotional variables and identify familial factors that serve as protective forces against unhealthy behaviors and psychosocial difficulties among overweight adolescents. METHODS: Data were taken from a 1996 cross-sectional school-based survey of 9957 adolescents in grades 7, 9, and 11. Based on self-reported heights and weights, respondents were categorized as "overweight" (body mass index) > or =85th percentile or "non-overweight." Student's t-tests were used to compare the non-overweight and overweight sample on the self-reported health-related behaviors and psychosocial variables. Logistic and linear regressions were used to identify familial factors associated with a reduced risk of engaging in unhealthy behaviors and experiencing psychosocial distress. RESULTS: Overweight adolescents reported engaging in significantly more unhealthy behaviors and experiencing more psychosocial distress than their non-overweight peers. Among the overweight youth, higher levels of reported family connectedness and parental expectations and moderate levels of parental monitoring were associated with the lowest levels of unhealthy behaviors and psychosocial distress. CONCLUSIONS: Satisfying and developmentally appropriate parent-adolescent relationships are associated with reduced behavioral and psychosocial risk factors associated with overweight during adolescence.

Violence risk and protective factors among youth held back in school.

OBJECTIVE: To identify risk and protective factors for violence perpetration among youth with a history of grade retention. DESIGN: Longitudinal analysis of in-home interviews of 13,781 adolescents in grades 7 through 12 conducted in 1995 and 1996. METHODS AND MEASURES: Serious interpersonal violence perpetration at time 2 by time 1 independent variables including measures of community and school context, family context, and individual characteristics. RESULTS: The 20% of girls and 28% of boys who had repeated 1 or more grades were more likely than those who had not to be in the top quintile of violence perpetration at time 2 (P <.001). For both girls and boys with a history of grade repetition, predictive risk factors with an odds ratio of 3 or greater (P <.001) included time 1 violence perpetration, violence victimization, weapon carrying, school problems, and alcohol and marijuana use. Although a high grade point average was a significant protective factor against violence perpetration for both girls (odds ratio, 0.36; P <.05) and boys (odds ratio, 0.23; P <.001), performance on a validated measure of verbal knowledge was not associated with violence perpetration over the study period. School connectedness, parent-family connectedness, and emotional well-being were also significant universal protectors against violence perpetration. CONCLUSIONS: Youth who are held back in school are at heightened risk for violence perpetration. Violence-related behaviors and substance use considerably increase the likelihood of this outcome. The findings suggest that schools can participate in violence prevention by providing youth with a positive community and academic experience.

Pelvic inflammatory disease in adolescents: high incidence and recurrence rates in an urban teen clinic.

STUDY OBJECTIVE: To determine pelvic inflammatory disease (PID) incidence and recurrence rates in an urban teen clinic. DESIGN/SETTING: A retrospective chart review of female patients seen as outpatients over an 18-month period at an urban teen clinic. 192 patients were diagnosed with PID, and the charts of these patients were reviewed in depth. MAIN OUTCOME MEASURES: PID incidence and recurrence rates. RESULTS: A PID incidence of 9.7% was identified. Of the adolescent females diagnosed with PID, 47% had recurrent PID. Of the females with recurrent PID, 27% had three or more episodes. Only 36% of adolescent females diagnosed with PID ever reported that their partners had been treated. CONCLUSIONS: This study suggests a higher incidence of PID as well as PID recurrence in the present clinic-based adolescent population than previously reported. More accurate monitoring of incidence and recurrence rates in well-defined populations of adolescents should be conducted with the hope of identifying effective avenues of intervention.

Preparing residents to counsel about smoking.

The objective of this study was to evaluate the effects of an innovative, multicomponent, theory-based educational intervention for pediatric residents on prevention of tobacco use counseling for cessation. Before and 3 months after intervention residents in a large urban midwestern pediatric residency program completed a self-assessment of measures of their attitudes and counseling behaviors. The intervention was a 3-hour multicomponent program including presentations, case discussions, role-plays and support material based on concepts from Motivational Interviewing (MI). Participants reported increased confidence in their ability to counsel, as well as greater frequency of counseling (standardized effect size (d) = 0.57). Residents also reported an increased use of principal components of MI, assessing how important quitting is to patients (d = .66), and how confident patients are in their ability to quit (d = .78). This brief educational intervention taught theory-based counseling techniques to pediatric residents. After the study, participants reported significant increases in their frequency of counseling as well as greater use of the MI principles.

Correlates of emotional distress in out-of-home youth.

PROBLEM: Adolescents in out-of-home placement have a high prevalence of mental health distress, and their vulnerability to poor mental health outcomes continues during placement. Risk and protective factors may influence mental health outcomes; however, little is known about their relationship to mental health distress in this population. METHODS: Using data from a population-based survey conducted in schools, mental health distress, along with other risk and protective factors, was evaluated in young people who reported living in out-of-home placements (n = 5,516) and a comparison group (n = 5,500). Multivariate analysis was used to determine the strength of association between risk and protective factors and mental health distress in the youth reporting out-of-home placement. FINDINGS: Comparisons of risk and protective factors indicated that out-of-home youth had greater risks (suicidal risk, mental health distress) and fewer protective factors (feeling parents care about them, other adults care, and school connectedness) than those in the comparison group. Multivariate analyses showed significant associations (38% explained variance) between mental health distress and the risk and protective factors, with the exception of other adult connectedness. CONCLUSIONS: Findings from this population-based school survey of young people reiterate that youth in out-of-home placements have higher levels of mental health distress and lower levels of protective factors compared to other youth. These results offer insights for those working with out-of-home or precariously housed young people.

Can a community-based intervention improve the home food environment? parental perspectives of the influence of the delicious and nutritious garden.

OBJECTIVE: To examine changes in parental report of the home food environment during the course of a garden-based fruit and vegetable (FV) intervention for grade school children. METHODS: Self-administered pre-post surveys were completed by parents/caregivers (n = 83). Main outcome measures included: child asking behavior, FV availability/accessibility, parental encouragement, and value of FV consumption. RESULTS: Process evaluation results indicate children shared their garden experiences at home, and as a result, the children's home food environment became increasingly supportive of FV consumption. Parents reported an increase (P < .01) in the frequency that their child asked for FVs. Parental value for FV consumption also improved (P < .01), as did home availability of fruit (P < .05), vegetables (P < .001), and parental encouragement of FVs (P = .06). CONCLUSIONS AND IMPLICATIONS: Community-based interventions that provide activities to engage parents may provide added benefit by improving the home food environment.

Characteristics of gastroesophageal reflux in adults with cystic fibrosis.

BACKGROUND: Gastroesophageal reflux (GER) in adults with cystic fibrosis (CF) is poorly characterized. This study examines the frequency and predictors of GER symptoms and their relationship to lung function in adults with CF. METHODS: Cross-sectional study of adults at the University of Minnesota CF Clinic using two validated self report surveys: The Mayo GER questionnaire and the GERD Symptom Assessment Scale (GSAS). RESULTS: Of 274 invited patients, 201 (73%) completed the surveys and 173 performed spirometry at the same visit. Frequent symptoms (at least weekly) were reported by 24% of the patients and an additional 39% experienced occasional symptoms. Heartburn, acid regurgitation and dysphagia were the most common symptoms and 18% reported that GER symptoms worsened their respiratory condition. Females and patients reporting weight loss had more symptoms (mean GSAS symptom score 4.9 vs. 4.0, p=0.025 and 5.3 vs. 4.2, p=0.04) and more severe symptoms (mean GSAS distress score 5.6 vs. 3.8, p=0.005 and 6.8 vs. 4.0, p=0.01) compared to males and those who did not report weight loss. Patients on acid suppression (n=122, 61%) continued to report heartburn (n=80, 66%) and acid regurgitation (n=47, 23%). GER symptoms and severity of symptoms were not predictive of FEV(1) or FVC. CONCLUSIONS: GER symptoms were present in a majority of patients. Females and patients with weight loss require special attention to their GER symptoms. Many patients on acid suppression continued to be report symptoms.

Complementary alternative medicine for children with autism: a physician survey.

Previous studies suggest over half of children with autism are using complementary alternative medicine (CAM). In this study, physicians responded (n = 539, 19% response rate) to a survey regarding CAM use in children with autism. Physicians encouraged multi-vitamins (49%), essential fatty acids (25%), melatonin (25%) and probiotics (19%) and discouraged withholding immunizations (76%), chelation (61%), anti-infectives (57%), delaying immunizations (55%) and secretin (43%). Physicians encouraging CAM were more likely to desire CAM training, inquire about CAM use, be female, be younger, and report greater autism visits, autism education and CAM knowledge. Physicians were more likely to desire CAM training, inquire about CAM and view CAM as a challenge for children with autism compared to children with other neurodevelopmental and chronic/complex conditions.

A garden pilot project enhances fruit and vegetable consumption among children.

Fruit and vegetable intake among children is inadequate. Garden-based nutrition education programs may offer a strategy for increasing fruit and vegetable intake in children. A 12-week pilot intervention was designed to promote fruit and vegetable intake among 4th to 6th grade children (n=93) attending a YMCA summer camp. Children participated in garden-based activities twice per week. Weekly educational activities included fruit and vegetable taste tests, preparation of fruit and vegetable snacks, and family newsletters sent home to parents. The pilot intervention was evaluated using a pre and post survey to determine participant satisfaction and the short-term impacts of the program. The process evaluation focused on program satisfaction, whereas the short-term impact evaluation assessed fruit and vegetable exposure, preference, self-efficacy, asking behavior, and availability of fruits and vegetables in the home. Data from the impact evaluation were compared from baseline to follow-up using McNemar's test (dichotomous variables) and Wilcoxon signed rank test (scales/continuous variables). Children reported high levels of enjoyment in the intervention activities. Most children (97.8%) enjoyed taste-testing fruits and vegetables. Children also liked preparing fruit and vegetable snacks (93.4%), working in their garden (95.6%), and learning about fruits and vegetables (91.3%). Impact data suggest that the intervention led to an increase in the number of fruits and vegetables ever eaten (P<0.001), vegetable preferences (P<0.001), and fruit and vegetable asking behavior at home (P<0.002). Garden-based nutrition education programs can increase fruit and vegetable exposure and improve predictors of fruit and vegetable intake through experiential learning activities. Participation in the "seed to table" experience of eating may help promote healthful eating behaviors among youth. Food and nutrition professionals should consider garden-based nutrition education programs that connect children with healthful foods through fun, hands-on activities.

Medical homes for children with autism: a physician survey.

BACKGROUND: Primary care physicians can enhance the health and quality of life of children with autism by providing high-quality and comprehensive primary care. OBJECTIVE: To explore physicians' perspectives on primary care for children with autism. METHODS: National mail and e-mail surveys were sent to a random sample of 2325 general pediatricians and 775 family physicians from April 2007 to October 2007. RESULTS: The response rate was 19%. Physicians reported significantly lower overall self-perceived competency, a greater need for primary care improvement, and a greater desire for education for children with autism compared with both children with other neurodevelopmental conditions and those with chronic/complex medical conditions. The following barriers to providing primary care were endorsed as greater for children with autism: lack of care coordination, reimbursement and physician education, family skeptical of traditional medicine and vaccines, and patients using complementary alternative medicine. Adjusting for key demographic variables, predictors of both higher perceived autism competency and encouraging an empirically supported therapy, applied behavior analysis, included having a greater number of autism patient visits, having a friend or relative with autism, and previous training about autism. CONCLUSIONS: Primary care physicians report a lack of self-perceived competency, a desire for education, and a need for improvement in primary care for children with autism. Physician education is needed to improve primary care for children with autism. Practice parameters and models of care should address physician-reported barriers to care.

Health status and behavioral outcomes for youth who anticipate a high likelihood of early death.

OBJECTIVE: The relationship between adolescents' perceived risk for dying and their involvement in risk behaviors is unknown. We sought to determine the proportion of US youth who anticipate a high likelihood of early mortality and relationships with health status and risk behaviors over time. METHODS: We analyzed data from times 1 (1995), 2 (1996), and 3 (2001-2002) of the National Longitudinal Study of Adolescent Health, a nationally representative sample of youth in grades 7 through 12. The relationship between perceived risk for premature mortality and health behaviors/outcomes was assessed by using bivariate and multivariate analyses. RESULTS: At time 1, 14.7% of the 20594 respondents reported at least a 50/50 chance that they would not live to age 35. In adjusted models, illicit drug use, suicide attempt, fight-related injury, police arrest, unsafe sexual activity, and a diagnosis of HIV/AIDS predicted early death perception at time 2, time 3, or both (adjusted odds ratios: 1.26-5.12). Conversely, perceived early mortality at time 1 predicted each of these behaviors and outcomes, except illicit drug use, at time 2 or time 3, most strongly a diagnosis of HIV/AIDS (adjusted odds ratios: 7.13 [95% confidence interval: 2.50-20.36]). CONCLUSIONS: Adolescent involvement in risk behaviors predicted a belief in premature mortality 1 and 7 years later. Reciprocally, adolescents' perceived risk for early death predicted serious health outcomes, notably a diagnosis of HIV/AIDS in young adulthood. Given its frequency and influence on behavior and health, adolescents' perceived risk for early death should be incorporated into psychosocial assessments and interviews.

BMI percentiles and body image discrepancy in black and white adolescents.

The purpose of this study was to investigate the relationship between body image discrepancy (BID) and weight status as measured by BMI percentiles (BMI%) among adolescents. A cross-sectional survey was conducted among 265 adolescents at an urban clinic (females: 116 blacks and 63 whites; males: 62 blacks and 24 whites). BID was the difference between ideal and current body images selected from a 13-figure rating scale, and BMI% were calculated from measured weight and height. Regression analyses were conducted separately for girls and boys. Over half of the female and one-third of male adolescents wanted a thinner body. BID was positively related to BMI% with a one-unit increase in BID associated with a 4.84-unit increase in BMI% among females and a 3.88-unit increase in BMI% in males. Both female and male adolescents reported BID beginning at a BMI% corresponding to a normal weight. At zero BID, white females had a BMI% of 62.6, statistically different from black females (BMI% 69.7). At zero BID, white males had a mean BMI% of 69 and black males at a BMI% of 75.8, not statistically different. While black and white differences exist in BID, black female adolescents like their white counterparts are reporting BID at a weight range that is within the "normal". Our study portends the increase in BID with the increasing prevalence of obesity and highlights the need for interventions to help adolescents develop a healthy and realistic body image and healthy ways to manage their weight.

Parental expectations, physical punishment, and violence among adolescents who score positive on a psychosocial screening test in primary care.

OBJECTIVE: We sought to examine the relationship between perceived and stated parental expectations regarding adolescents' use of violence, parental use of physical punishment as discipline, and young adolescents' violence-related attitudes and involvement. METHODS: Surveys were completed by 134 youth and their parents attending 8 pediatric practices. All youth were 10 to 15 years of age and had scored positive on a psychosocial screening test. RESULTS: Multivariate analyses revealed that perceived parental disapproval of the use of violence was associated with a more prosocial attitude toward interpersonal peer violence and a decreased likelihood of physical fighting by the youth. Parental report of whether they would advise their child to use violence in a conflict situation (stated parental expectations) was not associated with the adolescents' attitudes toward interpersonal peer violence, intentions to fight, physical fighting, bullying, or violence victimization. Parental use of corporal punishment as a disciplining method was inversely associated with a prosocial attitude toward interpersonal peer violence among the youth and positively correlated with youths' intentions to fight and fighting, bullying, and violence victimization. CONCLUSIONS: Perceived parental disapproval of the use of violence may be an important protective factor against youth involvement in violence, and parental use of physical punishment is associated with both violence perpetration and victimization among youth. Parents should be encouraged to clearly communicate to their children how to resolve conflicts without resorting to violence and to model these skills themselves by avoiding the use of physical punishment.