Preventing young children's injuries: analysis of data from a population-based surveillance.

The objective of this study is to determine prevention strategies for potentially serious injury events among children younger than 3 years of age based upon circumstances surrounding injury events. Surveillance was conducted on all injuries to District of Columbia (DC) residents less than 3 years old that resulted in an Emergency Department (ED) visit, hospitalization, or death for 1 year. Data were collected through abstraction of medical records and interviews with a subset of parents of injured children. Investigators coded injury-related events for the potential for death or disability. Potential prevention strategies were then determined for all injury events that had at least a moderate potential for death or disability and sufficient detail for coding (n = 425). Injury-related events included 10 deaths, 163 hospitalizations, and 2,868 ED visits (3,041 events in total). Of the hospitalizations, 88% were coded as moderate or high potential for disability or death, versus only 21% of the coded ED visits. For potentially serious events, environmental change strategies were identified for 47%, behavior change strategies for 77%, and policy change strategies for 24%. For 46% of the events more than one type of prevention strategy was identified. Only 8% had no identifiable prevention strategy. Prevention strategies varied by specific cause of injury. Potential prevention strategies were identifiable for nearly all potentially serious injury events, with multiple potential prevention strategies identified for a large fraction of the events. These findings support developing multifaceted prevention approaches informed by community-based injury surveillance.

High caffeine intake in adolescents: associations with difficulty sleeping and feeling tired in the morning.

The objective of this study was to examine the association between caffeine usage in U.S. adolescents and the frequency that feeling tired in the morning and having difficulty sleeping is reported. In this study we found that feeling tired in the morning and having difficulty sleeping was experienced more commonly in those adolescents that have a high intake of caffeine.

Cross-national study of fighting and weapon carrying as determinants of adolescent injury.

OBJECTIVES: We sought to (1) compare estimates of the prevalence of fighting and weapon carrying among adolescent boys and girls in North American and European countries and (2) assess in adolescents from a subgroup of these countries comparative rates of weapon carrying and characteristics of fighting and injury outcomes, with a determination of the association between these indicators of violence and the occurrence of medically treated injury. DESIGN AND SETTING: Cross-sectional self-report surveys using 120 questions were obtained from nationally representative samples of 161082 students in 35 countries. In addition, optional factors were assessed within individual countries: characteristics of fighting (9 countries); characteristics of weapon carrying (7 countries); and medically treated injury (8 countries). PARTICIPANTS: Participants included all consenting students in sampled classrooms (average age: 11-15 years). MEASURES: The primary measures assessed included involvement in physical fights and the types of people involved; frequency and types of weapon carrying; and frequency and types of medically treated injury. RESULTS: Involvement in fighting varied across countries, ranging from 37% to 69% of the boys and 13% to 32% of the girls. Adolescents most often reported fighting with friends or relatives. Among adolescents reporting fights, fighting with total strangers varied from 16% to 53% of the boys and 5% to 16% of the girls. Involvement in weapon carrying ranged from 10% to 21% of the boys and 2% to 5% of the girls. Among youth reporting weapon carrying, those carrying handguns or other firearms ranged from 7% to 22% of the boys and 3% to 11% of the girls. In nearly all reporting countries, both physical fighting and weapon carrying were significantly associated with elevated risks for medically treated, multiple, and hospitalized injury events. CONCLUSIONS: Fighting and weapon carrying are 2 common indicators of physical violence that are experienced by young people. Associations of fighting and weapon carrying with injury-related health outcomes are remarkably similar across countries. Violence is an important issue affecting the health of adolescents internationally.

Peer activity in the evenings and participation in aggressive and problem behaviors.

PURPOSE: Low adult supervision during the after-school hours has been associated with numerous problem behaviors among youth. We examined the extent to which this relationship pertains to the evening hours and aggressive behaviors. METHODS: Cross-sectional self-report data were obtained from a nationally representative sample of 14,818 youth in grades 6-10 in the 2001-2002 Health Behaviors of School-aged Children Survey. The relationship between spending evenings out with friends and involvement in problem behaviors was examined using logistic regression analyses. RESULTS: One-fifth of U.S. youth surveyed reportedly spent five or more evenings out with friends each week. After adjusting for grade, race/ethnicity, parental education, parental involvement, and perception of neighborhood safety, boys and girls who reported spending five or more evenings out were 4.3 and 3.1 times, respectively, than boys and girls who spent less than two evenings out, more likely to be involved in four or more physical fights in the past year; 3.0 and 4.0 times, respectively, more likely to have bullied another at least once a week at school; 2.7 and 4.9 times, respectively, more likely to have carried a weapon 6 or more days in the past month; 3.8 and 4.8 times, respectively, more likely to consume alcohol at least once a month; and 3.3 and 7.2 times, respectively, more likely to have smoked every day. CONCLUSIONS: Although the majority of youth who spend most evenings out do not frequently participate in problem behaviors (69.7%), their consistently increased risk for substance use and aggressive behaviors warrants attention. Further examination of specific evening activities, extracurricular involvement, neighborhood context, adult supervision, and parental monitoring is required.

Cross-national consistency in the relationship between bullying behaviors and psychosocial adjustment.

OBJECTIVE: To determine whether the relationship between bullying and psychosocial adjustment is consistent across countries by standard measures and methods. DESIGN: Cross-sectional self-report surveys were obtained from nationally representative samples of students in 25 countries. Involvement in bullying, as bully, victim, or both bully and victim, was assessed. SETTING: Surveys were conducted at public and private schools throughout the participating countries. PARTICIPANTS: Participants included all consenting students in sampled classrooms, for a total of 113 200 students at average ages of 11.5, 13.5, and 15.5 years. MAIN OUTCOME MEASURES: Psychosocial adjustment dimensions assessed included health problems, emotional adjustment, school adjustment, relationships with classmates, alcohol use, and weapon carrying. RESULTS: Involvement in bullying varied dramatically across countries, ranging from 9% to 54% of youth. However, across all countries, involvement in bullying was associated with poorer psychosocial adjustment (P<.05). In all or nearly all countries, bullies, victims, and bully-victims reported greater health problems and poorer emotional and social adjustment. Victims and bully-victims consistently reported poorer relationships with classmates, whereas bullies and bully-victims reported greater alcohol use and weapon carrying. CONCLUSIONS: The association of bullying with poorer psychosocial adjustment is remarkably similar across countries. Bullying is a critical issue for the health of youth internationally.

Prevalence of and risk factors for depressive symptoms among young adolescents.

OBJECTIVE: To determine the prevalence, risk factors, and risk behaviors associated with depressive symptoms in a nationally representative, cross-sectional sample of young adolescents. DESIGN: A school-based survey collected through self-administered questionnaires in grades 6, 8, and 10 in 1996. SETTING: Schools in the United States. PARTICIPANTS: 9863 students in grades 6, 8, and 10 (average ages, 11, 13, and 15). MAIN OUTCOME MEASURES: Depressive symptoms, substance use, somatic symptoms, scholastic behaviors, and involvement in bullying. RESULTS: Eighteen percent of youths reported symptoms of depression. A higher proportion of females (25%) reported depressive symptoms than males (10%). Prevalence of depressive symptoms increased by age for both males and females. Among American Indian youths, 29% reported depressive symptoms, as compared with 22% of Hispanic, 18% of white, 17% of Asian American, and 15% of African American youths. Youths who were frequently involved in bullying, either as perpetrators or as victims, were more than twice as likely to report depressive symptoms than those who were not involved in bullying. A significantly higher percentage of youths who reported using substances reported depressive symptoms as compared with other youths. Similarly, youths who reported experiencing somatic symptoms also reported significantly higher proportions of depressive symptoms than other youths. CONCLUSIONS: Depression is a substantial and largely unrecognized problem among young adolescents that warrants an increased need and opportunity for identification and intervention at the middle school level. Understanding differences in prevalence between males and females and among racial/ethnic groups may be important to the recognition and treatment of depression among youths.

Headache, stomachache, backache, and morning fatigue among adolescent girls in the United States: associations with behavioral, sociodemographic, and environmental factors.

BACKGROUND: Data on the prevalence and co-occurrence of multiple somatic symptoms among US adolescent females as they are influenced by sociodemographic, behavioral, and environmental factors is limited. OBJECTIVES: To describe the health status of adolescent US females measured by the prevalence, frequency, and co-occurrence of headache, stomachache, backache, and morning fatigue and to investigate associations between selected risk and protective factors. DESIGN, SETTING, AND PARTICIPANTS: School-based, cross-sectional, nationally representative survey of adolescents in the 6th through 10th grades in the US. Data collected between 1997 and 1998. MAIN OUTCOME MEASURES: Prevalence of headache, stomachache, backache, and morning fatigue. RESULTS: Among US adolescent girls, 29.1% experience headaches, 20.7% report stomachaches, 23.6% experience back pain, and 30.6% report morning fatigue at the rate of more than once a week. Co-occurrence of somatic complaints is common. Among girls who experienced headaches more than once a week, 3.2 million (53.3%) also reported stomach pain more than once a week and 4.1 million (74.3%) reported morning fatigue more than once a week. Heavy alcohol use, high caffeine intake, and smoking cigarettes every day were strongly associated with all symptoms, while parent and teacher support served as protective factors. CONCLUSIONS: Somatic complaints of headache, stomachache, backache, and morning fatigue are common among US adolescent girls and co-occur often. Effective clinical treatment of this population requires comprehensive assessment of all female adolescents presenting with seemingly isolated somatic complaints.

A cross-national study of violence-related behaviors in adolescents.

BACKGROUND: Violent behavior among adolescents is a significant problem worldwide, and a cross-national comparison of adolescent violent behaviors can provide information about the development and pattern of physical violence in young adolescents. OBJECTIVES: To determine and compare frequencies of adolescent violence-related behaviors in 5 countries and to examine associations between violence-related behaviors and potential explanatory characteristics. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional, school-based nationally representative survey at ages 11.5, 13.5, and 15.5 years in 5 countries (Ireland, Israel, Portugal, Sweden, and the United States). MAIN OUTCOME MEASURES: Frequency of physical fighting, bullying, weapon carrying, and fighting injuries in relation to other risk behaviors and characteristics in home and school settings. RESULTS: Fighting frequency among US youth was similar to that of all 5 countries (nonfighters: US, 60.2%; mean frequency of 5 countries, 60.2%), as were the frequencies of weapon carrying (noncarriers: US, 89.6%; mean frequency of 5 countries, 89.6%) and fighting injury (noninjured: US, 84.5%; mean frequency of 5 countries, 84.6%). Bullying frequency varied widely cross-nationally (nonbullies: from 57.0% for Israel to 85.2% for Sweden). Fighting was most highly associated with smoking, drinking, feeling irritable or bad tempered, and having been bullied. CONCLUSIONS: Adolescents in 5 countries behaved similarly in their expression of violence-related behaviors. Occasional fighting and bullying were common, whereas frequent fighting, frequent bullying, any weapon carrying, or any fighting injury were infrequent behaviors. These findings were consistent across countries, with little cross-national variation except for bullying rates. Traditional risk-taking behaviors (smoking and drinking) and being bullied were highly associated with the expression of violence-related behavior.

Body mass index and overweight in adolescents in 13 European countries, Israel, and the United States.

OBJECTIVE: To compare the body mass index (BMI) (calculated as weight in kilograms divided by the square of height in meters) and the prevalence of BMI at or above the 85th centile and 95th centile (overweight) in adolescents. DESIGN: Cross-sectional, nationally representative school-based surveys in 1997-1998 by means of identical data collection methods. SETTING: Austria, Czech Republic, Denmark, Flemish Belgium, Finland, France, Germany, Greece, Lithuania, Ireland, Israel, Portugal, Slovakia, Sweden, and the United States. PARTICIPANTS: A total of 29 242 boys and girls, aged 13 and 15 years. MAIN OUTCOME MEASURES: The BMI, BMI at or above the 85th centile, and BMI at or above the 95th centile (overweight) from self-reported height and weight. RESULTS: The highest prevalence of overweight was found in the United States and the lowest in Lithuania. On the basis of the study reference standard, the prevalence of overweight (percentage) in the United States was 12.6% in 13-year-old boys, 10.8% in 13-year-old girls, 13.9% in 15-year-old boys, and 15.1% in 15-year-old girls, all significantly increased. Prevalence of overweight in Lithuania was significantly below the expected 5%, with 1.8% in 13-year-old boys, 2.6% in 13-year-old girls, 0.8% in 15-year-old boys, and 2.1% in 15-year-old girls. Relative rankings among countries were similar for BMI at or above the 85th centile, although there were less dramatic differences at this level. CONCLUSIONS: The highest prevalences of overweight were found in the United States, Ireland, Greece, and Portugal.

Relationships between bullying and violence among US youth.

OBJECTIVE: To determine the extent to which bullying and being bullied, both in and away from school, is associated with involvement in violent behavior. DESIGN, SETTING, AND PARTICIPANTS: A US representative cross-sectional sample of 15 686 students in grades 6 through 10 in public and private schools completed the World Health Organization's Health Behaviour in School-aged Children survey in 1998. MAIN OUTCOME MEASURES: Self-report of weapon carrying, weapon carrying in school, physical fighting, and being injured in a physical fight. RESULTS: Involvement in each of the violence-related behaviors ranged from 13% to 23% of boys and 4% to 11% of girls. Bullying others and being bullied were consistently related to each violence-related behavior for both boys and girls. Greater odds of involvement occurred with bullying others than being bullied, and greater odds of involvement occurred with bullying that took place away from school than that occurring in school. For example, the adjusted odds ratio for weapon carrying associated with being bullied in school weekly was 1.5, for bullying others in school 2.6, for being bullied away from school 4.1, and for bullying others away from school 5.9. CONCLUSION: Bullying should not be considered a normative aspect of youth development, but rather a marker for more serious violent behaviors, including weapon carrying, frequent fighting, and fighting-related injury.

Association of language spoken at home with health and school issues among Asian American adolescents.

The study examined the association of language spoken at home with the school and health risks and behaviors of Asian American adolescents. Using the United States component of the 1997-1998 World Health Organization Study of Health Behavior in School Children, bivariate and multiple logistic regression analyses were conducted of records for Asian children to explore the relationship between language spoken at home and outcome variables regarding health behaviors, psychosocial and school risk factors, and parental factors. Compared to those who usually speak English at home, adolescents who usually speak another language, or who speak two languages equally, face a greater risk for health risk factors, psychosocial and school risk factors, and parental risk factors. Not speaking English at home was associated with higher health risks, including not wearing seat belts and bicycle helmets; higher psychosocial and school risk factors, including feeling that they do not belong at school, difficulty making new friends, and lacking confidence; and higher parental risks, including reporting that parents were not ready to help them or willing to talk to teachers. Adolescents less acculturated to the United States experience a variety of physical and psychosocial risks. School-based interventions such as early identification and outreach, needs assessment, and counseling and support services should be provided to immigrant students and their families.

Injury surveillance in the ED: design, implementation, and analysis.

Comprehensive, population-based surveillance for nonfatal injuries requires uniform methods for data collection from multiple hospitals. To show issues related to design and implementation of multihospital, emergency department (ED), injury surveillance, a city-wide system in the United States is discussed. From October 1, 1995 to September 30, 1996 all injury-related ED visits among District of Columbia residents <3 years of age were ascertained at the 10 hospitals where city children routinely sought care. Information was abstracted from 2,938 injury-related, ED visits (132.7 visits/1,000 person-years). Based on this experience, suggestions to facilitate design of multihospital, injury surveillance in other locations are offered. Importantly, injury-related visits were reliably ascertained from ED logs, and for most variables, a systematic sample of injury-related visits was representative of the total injured population. However, there is a need for more complete documentation of circumstances surrounding injuries and for standardization of data elements on ED logs and treatment records.

Black-white differences in health care utilization among US children with frequent ear infections.

OBJECTIVE: To examine differences in patterns of and barriers to health care utilization between black and white children who have frequent ear infections (FEI). METHODS: Analysis was conducted using the 1997 and 1998 National Health Interview Survey-Sample Child Files. Data on 25 497 children under 18 years of age and 1985 who were reported by the parent/guardian to have had "3 or more ear infections during the past 12 months" were analyzed. The data were weighted and analyzed to represent all black and white children nationwide, accounting for the complex survey design. RESULTS: Of white and black children under 18 years of age in the United States, 8.0 and 6.6%, respectively, had FEI in the past year. Among those with FEI, whites and blacks exhibited significantly different patterns in the type of health insurance they had and in the usual source of care. After accounting for sociodemographic factors, health insurance, and usual source of care, there were still significant differences in health care use between whites and blacks. The affected black children had an increased risk of getting delayed care because of transportation problems (odds ratio [OR]: 2.32) and a reduced likelihood of seeing a medical specialist (OR: 0.49) and having surgery (OR: 0.39) in comparison to white children. CONCLUSION: Although black children with FEI were as likely as white children to be covered by health insurance and have a usual place of health care, they were significantly more likely to face barriers in obtaining the care, especially the more specialized care.

Birthweight and gestational age effects on motor and social development.

The number of children at risk for delays in motor and social development (MSD) associated with preterm delivery and low birthweight is increasing, but such children are generally not seen as being in need of evaluation. The objective of these analyses was to determine whether there are independent effects of birthweight and gestational age on MSD and the magnitude of effects. Subjects were a representative sample of 4621 US-born singleton children, aged 2-47 months, examined in the third National Health and Nutrition Examination Survey (1988-94). MSD was assessed using an age-appropriate scale. Birthweight and gestational age were taken from birth certificates. Mexican-American and 'other' race/ethnicity (other than non-Hispanic white, non-Hispanic black or Mexican-American), low parental education level, older maternal age, higher birth order, low birthweight (LBW, <2500 g) and preterm delivery (<37 weeks) were all found to be associated with significant (P < 0.01) delays in MSD. Three per cent of the infants and children were preterm LBW and 2.2% term LBW (<2500 g, 37-44 weeks). Adjusting for socio-demographic factors, preterm LBW children had lower MSD scores (-1.5 +/- 0.3 points, P < 0.0001) through early childhood, as did term LBW children (0.8 +/- 0.4 points, P < 0.03). For females, LBW was the most important perinatal predictor of a lowered score (-0.9 +/- 0.3 points compared with normal birthweight, P < 0.04). For males, scores were additionally decreased by -0.1 +/- 0.03 points/week (P=0.001) of early delivery. LBW children had less muscle mass, but adjusting for muscularity did not diminish the effects of birth size on MSD. LBW status and preterm delivery are associated independently with small, but measurable, delays in MSD through early childhood and should be considered along with other known risk factors for development delays in determining the need for developmental evaluation.

National underascertainment of sudden unexpected infant deaths associated with deaths of unknown cause.

OBJECTIVE: To investigate underascertainment of unexpected infant deaths at the national level as a result of probable classification as attributable to unknown cause. METHODS: Using linked birth and death certificates for all US birth cohorts from 1983-1991 and 1995-1996, we identified 53 470 sudden infant death syndrome (SIDS) fatalities, 9071 unintentional injury deaths, 3473 injury deaths classified with intentional or suspicious intent, and 8097 deaths with unknown underlying cause. For these deaths, we compared relative risks (RRs) for maternal and infant variables available on birth certificates known to be predictive of SIDS, unintentional injury, and homicides. Variables available on death certificates were compared for unlinked and linked records. Factors related to state and national management of cases pending final cause determination are reviewed. RESULTS: For deaths from unknown cause, rates were consistently high among the same risk groups that have been shown to be at increased risk for SIDS, unintentional injury, and homicides. For most risk factors, RRs for deaths attributable to unknown causes were somewhat lower than for RRs for intentional/suspicious injury deaths but higher than for SIDS or unintentional injury, indicating combined contributions from all causes. For example, age at death from unknown cause includes RRs that more strongly resemble patterns of intentional/suspicious injuries than SIDS or unintentional injury. Deaths from unknown cause were more likely to occur during the first week of life for unattended births occurring outside clinical settings or when birth certificates were not found, similar to intentional/suspicious injury deaths. CONCLUSIONS: Risk profiles indicate that deaths of unknown cause are likely to represent a mixture of unexpected deaths. The process for determination of cause of unexpected death affects national underascertainment of SIDS and injury deaths. Better coordination among child fatality review teams and local, state, and national officials should reduce underascertainment and improve documentation of circumstances surrounding deaths for prevention efforts.