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.

"It Doesn't Die Within You": Outdoor Recreation Participation Following Spinal Cord Injury.

Although some people with spinal cord injury (SCI) return to outdoor recreation, many have low activity levels and encounter significant environmental barriers. The purpose of the study was to describe how people with SCI engage in outdoor recreation activities, what meaning they attribute to these, and to inform occupational therapists in promoting outdoor recreation post-SCI. The study used qualitative, descriptive phenomenology. Thirteen participants completed semi-structured interviews, and data were analyzed using thematic analysis. Outdoor recreation contributes to personal well-being. It is a way to share life with loved ones and other disabled people. Having the right equipment and using a trial-and-error approach facilitated participation, which was sometimes supported and frequently constrained by physical, built, and information environments. Findings suggest implications for occupational therapists in the areas of direct intervention, entrepreneurship, and advocacy. These are consistent with the American Occupational Therapy Association Vision 2025 to collaborate for inclusion and accessibility in occupational performance.

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.

An experimental protocol for a double-blind placebo-controlled evaluation of the effectiveness of oral naltrexone in management of adolescent eating disorders.

BACKGROUND: This double-blind, placebo-controlled study evaluates the effectiveness of oral naltrexone in adolescents and young adults with eating disorders (EDs) characterized by purging with or without binge-eating behaviors. We hypothesize that participants receiving oral naltrexone will demonstrate greater improvements in body mass index in underweight participants and self-reported ED symptomatology compared to placebo. METHODS: Thirty individuals receiving treatment in a partial hospitalization program for EDs with diagnoses of anorexia nervosa binge-eating/purging type, bulimia nervosa, or purging disorder will receive six weeks of either placebo or oral naltrexone. Participants will complete a battery of self-report measures and laboratory safety monitoring every three weeks in addition to standard of medical care for treatment environment. RESULTS: Analysis will compare outcomes at weeks three and six, and follow-up at nine weeks and six-months across the oral naltrexone and placebo groups. Main effects for time will examine improvements over the course of treatment for all participants, while group × time interactions will examine differences in the rate of change over time between study arms. CONCLUSIONS: We hypothesize that participants receiving oral naltrexone will experience more rapid improvements in symptom severity and weight restoration compared to placebo across study time points. There are very few medications with high-quality data demonstrating both safety and efficacy in the treatment of eating disorders. The authors theorize this study will demonstrate a clinically significant effect of oral naltrexone on impulsive-type EDs and support its use as an effective option for treatment augmentation.

The adolescent and young adult with Klinefelter syndrome:ensuring successful transitions to adulthood.

As many adolescent and young adult males with Klinefelter syndrome move into young adulthood, they will require long-term medical and mental health care for their complex and specific health care needs. Adult general medical providers and endocrinologists may feel ill-prepared to meet the medical needs of this population. In turn, many pediatric primary care and subspecialty providers may find themselves struggling to determine how best to transition the older adolescent to adult-oriented services. Working with families and their teens to consider and address current and future medical, mental health, educational and vocational needs will enhance that young adult's independence and functioning. This chapter addresses general transition issues and those that are specific to adolescents with Klinefelter syndrome. The prognosis for these young patients is good, and can be further enhanced by supportive families and a medical team that is informed about how best to facilitate the transition to adult-oriented services.

Reducing Alcohol and Opioid Use Among Youth in Rural Counties: An Innovative Training Protocol for Primary Health Care Providers and School Personnel.

BACKGROUND: Given that youth alcohol use is more common in rural communities, such communities can play a key role in preventing alcohol use among adolescents. Guidelines recommend primary care providers incorporate screening, brief intervention, and referral to treatment (SBIRT) into routine care. OBJECTIVE: The aim is to train primary care providers and school nurses within a rural 10-county catchment area in Pennsylvania to use SBIRT and facilitate collaboration with community organizations to better coordinate substance use prevention efforts. METHODS: To build capacity to address underage drinking and opioid use among youth aged 9-20 years, this project uses telehealth, specifically Project ECHO (Extension for Community Healthcare Outcomes), to train primary care providers and school nurses to address substance use with SBIRT. Our project will provide 120 primary care providers and allied health professionals as well as 20 school nurses with SBIRT training. Community-based providers will participate in weekly virtual ECHO sessions with a multidisciplinary team from Penn State College of Medicine that will provide SBIRT training and facilitate case discussions among participants. RESULTS: To date, we have launched one SBIRT ECHO project with school personnel, enrolling 34 participants. ECHO participants are from both rural (n=17) and urban (n=17) counties and include school nurses (n=15), school counselors (n=8), teachers (n=5), administrators (n=3), and social workers (n=3). Before the study began, only 2/13 (15.5%) of schools were screening for alcohol use. CONCLUSIONS: This project teaches primary care clinics and schools to use SBIRT to prevent the onset and reduce the progression of substance use disorders, reduce problems associated with substance use disorders, and strengthen communities' prevention capacity. Ours is an innovative model to improve rural adolescent health by reducing alcohol and opioid use. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/21015.

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.

Evaluation of a Pediatric Resident Skills-Based Screening, Brief Intervention and Referral to Treatment (SBIRT) Curriculum for Substance Use.

PURPOSE: To evaluate a screening, brief intervention and referral to treatment curriculum for alcohol and other substance use developed, implemented and integrated into a pediatric residency program. METHODS: During a 1-month adolescent medicine rotation, pediatric, and medicine/pediatric residents in an urban teaching hospital completed a 2 1/2-hour formal curriculum including a didactic lecture, a 40-minute video describing the Brief Negotiation Interview (BNI), and a skill-based session practicing the BNI and receiving individualized feedback. Access to a website with didactic material was provided. Outcome measures were pre- and post-training knowledge, BNI performance measured with a standardized patient using a validated BNI adherence scale, satisfaction with training, and adoption of BNI into clinical practice. RESULTS: Of the 106 residents trained, 92(87%) completed both pre- and post-test evaluations. Significant improvements were found in pre- versus post-test scores of knowledge, (20.0 [2.4 SD] vs. 24.1 [3.5 SD], p <.001) and BNI performance comparing pre- and post BNI adherence scale total scores, (5.14 [1.8 S.D.] vs. 11.5 [.96], p<.001). Residents reported high satisfaction with training, [1.4, SD .5, immediately and 1.6, SD .6, 30-days post training)with scores ranging from 1 to 5 with lower score=greater satisfaction. During the 12-month follow-up period, we received 83 responses from residents reporting a total of 129 BNIs in actual clinical settings. CONCLUSIONS: A screening, brief intervention and referral to treatment curriculum was successfully integrated into an adolescent medicine elective in a pediatric residency program. Residents demonstrated significant improvements in knowledge and skills performing the BNI, with high satisfaction and adoption of the BNI into clinical practice.

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.

Potentially protective factors associated with healthful body mass index in adolescents with obese and nonobese parents: a secondary data analysis of the third national health and nutrition examination survey, 1988-1994.

OBJECTIVE: To identify factors potentially protective against obesity in 12- to 16-year-olds with one or two obese parents, and those with no obese parents. DESIGN: A secondary analysis of the Third National Health and Nutrition Examination Survey, 1988-1994. SUBJECTS/SETTING: A nationally representative sample of healthful weight, at-risk, or overweight adolescents with measured heights and weights (n=1,890). Subsamples with any obese parent (body mass index > or =30) and no obese parents (both with body mass index <25) were analyzed. STATISTICAL ANALYSES PERFORMED: Bivariate analyses examined the association of predictor variables (demographics, nutrient intake, and physical activity) on the outcome. Logistic regressions examined the likelihood of being healthful weight. SUDAAN software (release 7.5, 1997, Research Triangle Institute, Research Triangle Park, NC) was used to account for the sample design. RESULTS: Overall, 71% of subjects had a healthful weight, 29% were at risk or overweight. Factors associated with healthful weight included having two nonobese parents (odds ratio [OR]=5.4), only father obese (OR=4.9), only mother obese (OR=3.3), higher reading scores (OR=1.02), lower water consumption (OR=1.8), more exercise programs (OR=2.8), and higher energy intake (OR=2.0). For adolescents with any obese parent, factors potentially protective against obesity included being female (OR=2.2), higher household education (OR=1.1), lower water consumption (OR=2.0), and eating breakfast some days (OR=3.1) or everyday (OR=4.0). For adolescents with no obese parents, potentially protective factors included older age (OR=1.2), not having asthma (OR=2.6), more exercise programs (OR=6.1), and higher energy intake (OR=2.9). All P<.05. CONCLUSIONS: Interventions targeted at adolescents who are at risk because they have parents with obesity should employ a family approach focused on regular breakfast consumption.

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.

The impact of marijuana policies on youth: clinical, research, and legal update.

This technical report updates the 2004 American Academy of Pediatrics technical report on the legalization of marijuana. Current epidemiology of marijuana use is presented, as are definitions and biology of marijuana compounds, side effects of marijuana use, and effects of use on adolescent brain development. Issues concerning medical marijuana specifically are also addressed. Concerning legalization of marijuana, 4 different approaches in the United States are discussed: legalization of marijuana solely for medical purposes, decriminalization of recreational use of marijuana, legalization of recreational use of marijuana, and criminal prosecution of recreational (and medical) use of marijuana. These approaches are compared, and the latest available data are presented to aid in forming public policy. The effects on youth of criminal penalties for marijuana use and possession are also addressed, as are the effects or potential effects of the other 3 policy approaches on adolescent marijuana use. Recommendations are included in the accompanying policy statement.

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.