Associations between the prenatal environment and cardiovascular risk factors in adolescent girls: Internalizing and externalizing behavior symptoms as mediators.

This longitudinal study examines links among adolescent internalizing and externalizing symptoms, the prenatal environment (e.g., nicotine exposure) and pre/perinatal maternal health, and cardiovascular risk factors. Girls (N=262) ages 11-17 reported internalizing and externalizing behaviors and mothers reported about the prenatal environment and maternal health during and 3 months post-pregnancy. Adolescent cardiovascular risk included adiposity, smoking, blood pressure, and salivary C-reactive protein. Internalizing symptoms mediated relations between prenatal exposures/maternal health and adiposity; externalizing symptoms mediated relations between prenatal exposures and adolescent smoking. Healthcare providers who attend to internalizing and externalizing symptoms in girls may ultimately influence cardiovascular health, especially among those with pre/perinatal risk factors.

Characterizing the longitudinal relations between depressive and menstrual symptoms in adolescent girls.

OBJECTIVE: This study examined the association between depressive and menstrual symptoms in adolescent girls in a 3-year longitudinal study. It was hypothesized that menstrual symptoms would increase in early adolescence and decrease in later adolescence, that girls with greater depressive symptoms would report greater menstrual symptoms, and that effects would persist after adjusting for general somatic complaints. METHODS: A community sample of girls (n = 262) enrolled in an observational study by age cohort (11, 13, 15, 17 years) completed three annual visits. At each time point, girls completed the Menstrual Symptom Questionnaire, Children's Depression Inventory, and the Youth Self Report to assess general somatic complaints. RESULTS: Menstrual symptoms increased significantly across adolescence (p = .006) and began to plateau in later adolescence (p = .020). Depressive symptoms at study entry were significantly associated with menstrual symptoms (p < .001). When general somatic complaints were included in the models, the effect of depressive symptoms on menstrual symptoms remained significant for the sum score (p = .015) and the menstrual somatic symptoms subscale (p = .001). After adjusting for somatic complaints, initial report of depressive symptoms predicted change in menstrual symptoms only for girls with the lowest menstrual symptoms sum score (p = .025). Initial report of somatic complaints predicted change in menstrual symptoms (p = .020). CONCLUSIONS: Girls with higher depressive symptoms and higher somatic complaints are at greater risk for experiencing menstrual symptoms and increasing symptoms across adolescence, with a heightened vulnerability for girls with lower baseline menstrual symptoms.

Salivary cytokines in healthy adolescent girls: Intercorrelations, stability, and associations with serum cytokines, age, and pubertal stage.

Theoretically, the measurement of cytokines in saliva may have utility for studies of brain, behavior, and immunity in youth. Cytokines in saliva and serum were analyzed across three annual assessments in healthy adolescent girls (N = 114, 11-17 years at enrollment). Samples were assayed for GM-CSF, IFNγ, IL-1ß, IL-2, IL-6, IL-8, IL-10, IL-12p70, TNFα, adiponectin, and cotinine. Results revealed: (1) cytokine levels, except IFNγ and IL-10, were detectable in saliva, and salivary levels, except IL-8 and IL-1ß, were lower than serum levels; (2) salivary cytokine levels were lower in older girls and positively associated with adiponectin; (3) compared to serum levels, the correlations between salivary cytokines were higher, but salivary cytokines were less stable across years; and (4) except for IL-1ß, there were no significant serum-saliva associations. Variation in basal salivary cytokine levels in healthy adolescent girls reflect compartmentalized activity of the oral mucosal immune system, rather than systemic cytokine activity.

Longitudinal associations between smoking and depressive symptoms among adolescent girls.

Adolescence is an important period for initiation of smoking and manifestation of depression, which are often comorbid. Researchers have examined associations between depressive symptoms and smoking to elucidate whether those with increased depressive symptoms smoke more to self-medicate, whether those who smoke experience increased subsequent depressive symptoms, or both. Collectively, there have been mixed findings; however, studies have been limited by (1) cross-sectional or short-term longitudinal data or (2) the use of methods that test associations, or only one direction in the associations, rather than a fully-reciprocal model to examine directionality. This study examined the associations between smoking and depressive symptoms in a sample of adolescent girls using latent dual change scores to model (1) the effect of smoking on change in depressive symptoms, and simultaneously (2) the effect of depressive symptoms on change in smoking across ages 11-20. Data were from a cohort-sequential prospective longitudinal study (N = 262). Girls were enrolled by age cohort (11, 13, 15, and 17 years) and were primarily White (61 %) or African American (31 %). Data were restructured by age. Every 6 months, girls reported depressive symptoms and cigarette use. Results indicated that controlling for sociodemographic characteristics, higher levels of smoking predicted a greater increase in depressive symptoms across adolescence. These findings suggest that a higher level of cigarette smoking does contribute to more depressive symptoms, which has implications for prevention of depression and for intervention and future research.

Longitudinal impact of substance use and depressive symptoms on bone accrual among girls aged 11-19 years.

PURPOSE: Osteoporosis is primarily evident in postmenopausal women, but its roots are traceable to periods of growth, including during adolescence. Depression, anxiety, and smoking are associated with lower bone mineral density (BMD) in adults. These associations have not been studied longitudinally across adolescence, when more than 50% of bone accrual occurs. METHODS: To determine the impact of depressive and anxiety symptoms, smoking, and alcohol use on bone accrual in girls 11-19 years, 262 healthy girls were enrolled in age cohorts of 11, 13, 15, and 17 years. Using a cross-sequential design, girls were seen for three annual visits. Outcome measures included total body bone mineral content and BMD of the total hip and lumbar spine using dual energy x-ray absorptiometry. Depressive and anxiety symptoms and smoking and alcohol use were by self-report. RESULTS: Higher-frequency smoking was associated with a lower rate of lumbar spine and total hip BMD accrual from ages 13-19. Higher depressive symptoms were associated with lower lumbar spine BMD across 11-19 years of age. There was no effect of depressive symptoms on total body bone mineral content, and there was no effect of alcohol intake on any bone outcome. CONCLUSION: Adolescent smokers are at higher risk for less than optimal bone accrual. Even in the absence of diagnosable depression, depressive symptoms may influence adolescent bone accrual. These findings have import for prevention of later osteoporosis and fractures.

Longitudinal reliability of self-reported age at menarche in adolescent girls: variability across time and setting.

Age at menarche is critical in research and clinical settings, yet there is a dearth of studies examining its reliability in adolescents. We examined age at menarche during adolescence, specifically, (a) average method reliability across 3 years, (b) test-retest reliability between time points and methods, (c) intraindividual variability of reports, and (d) whether intraindividual variability differed by setting or individual characteristics. Girls (n = 253) were enrolled in a cross-sequential study in age cohorts (11, 13, 15, and 17 years). Age at menarche was assessed using 3 annual, in-person clinician interviews followed by 9 quarterly phone interviews conducted by research assistants. Reliability of age at menarche across time was moderate and varied by method. In-person interviews showed greater reliability (intraclass correlation coefficient [ICC] = .77) versus phone interviews (ICC = .64). Test-retest reliability in reports did not decrease across time. However, average differences in reported age varied as much as 2.3 years (SD = 2.2 years), with approximately 9% demonstrating differences greater than 4.5 years. Pubertal timing category (i.e., early, late) changed for 22.7% if categorized at the final versus the first report of age at menarche. Reliability was moderate, but average differences in reported age were notable and concerning. Using in-person clinician interviews may enhance reliability. Researchers and clinicians should be cognizant of the implications of using different methods measuring age at menarche when interpreting research findings.

Bone mass, depressive, and anxiety symptoms in adolescent girls: variation by smoking and alcohol use.

PURPOSE: The purpose of the study was to examine (a) the association between depressive and anxiety symptoms with bone health, (b) the association of smoking or alcohol use with bone health, and, in turn (c) whether the association between depressive and anxiety symptoms with bone health varied by smoking or alcohol use individually or by combined use. Bone health included total body bone mineral content (TB BMC) and bone mineral density (BMD) of the lumbar spine, total hip, and femoral neck. Previously published data have not examined these issues in adolescence, a period when more than 50% of bone mass is accrued. METHODS: An observational study enrolled 262 healthy adolescent girls by age cohort (11, 13, 15, and 17 years). Participants completed questionnaires and interviews on substance use, depressive symptoms, and anxiety. BMC and BMD were measured by dual-energy X-ray absorptiometry. RESULTS: Higher depressive symptoms were associated with lower TB BMC and BMD (total hip, femoral neck). Those with the lowest level of smoking had higher BMD of the hip and femoral neck, whereas no main effect differences were noted by alcohol use. Regular users of both cigarettes and alcohol demonstrated a stronger negative association between depressive symptoms and TB BMC as compared with nonusers/experimental users and regular alcohol users. Findings were parallel for anxiety symptoms. CONCLUSION: Depressive and anxiety symptoms may negatively influence bone health in adolescent girls. Consideration of multiple substances, rather than cigarettes or alcohol separately, may be particularly informative with respect to the association of depression with bone health.

Morningness/eveningness, pubertal timing, and substance use in adolescent girls.

The purpose of this study was to examine the associations between Morningness/Eveningness (M/E; a measure of sleep-wake preference) and alcohol, cigarette, and marijuana use as well as the interaction of M/E and pubertal timing. The data represent baseline measures from a longitudinal study examining the association of psychological functioning and smoking with reproductive and bone health in 262 adolescent girls (11-17 years). The primary measures used for this study were pubertal timing (measured by age at menarche), the Morningness/Eveningness scale, and substance use (alcohol, cigarettes, and marijuana). Multiple group path modeling showed that there was a significant interaction between pubertal timing and M/E on cigarette use. The direction of the parameter estimates indicated that for the early and on-time groups, Evening preference was associated with more cigarette use. For the late timing group the association was not significant. The results point to the need to consider sleep preference as a characteristic that may increase risk for substance use in adolescents.

Depression and anxiety in adolescent females: the impact of sleep preference and body mass index.

PURPOSE: To examine the differences in depressive symptoms and anxiety between (a) normal weight and overweight, and (b) morning type and evening type (sleep chronotype) adolescent girls. The interaction of sleep chronotype and weight and depressive symptoms and anxiety were also examined. METHOD: The design consisted of a cross-sectional study of 264 adolescent females (mean age = 14.9 +/- 2.2, range 11-17 years). Sleep chronotype, depressive symptoms, and anxiety were obtained by self-report questionnaire. The mean of three measurements of height and weight was used to calculate the body mass index (BMI). BMI was plotted on the CDC BMI-for-age growth charts to obtain percentile ranking. Participants were categorized into two groups according to BMI percentile: normal weight (<85th percentile) and overweight (> or =85th percentile). RESULTS: Compared with normal-weight females, overweight females were more likely to be non-Caucasian, lower socioeconomic status, have more advanced pubic hair and breast stages, and earlier age at menarche. No differences were observed with respect to sleep chronotype, depressive symptoms, and trait anxiety between normal weight and overweight females. Evening chronotype was associated with more depressive symptoms (beta = -.65, p < .01) and higher trait anxiety (beta = -.22, p < .05). Evening chronotype was associated with more depressive symptoms in both normal-weight and overweight females. However, the association was stronger in overweight females. CONCLUSIONS: Individually, sleep and weight impact physical and mental health during adolescence. The combination of evening chronotype and overweight appears to have the strongest association on the emotional health of adolescent females. Further investigations are needed to provide potential biological mechanisms for this relationship.

Menstrual symptoms in adolescent girls: association with smoking, depressive symptoms, and anxiety.

PURPOSE: Dysmenorrhea affects quality of life and contributes to absenteeism from school and work, thereby diminishing opportunities for successful psychosocial and cognitive development during adolescence. In adults, depression, anxiety, and smoking have an impact on menstrual cycles and dysmenorrhea. Associations between these problems have not been examined in adolescents. The purpose of this study was to examine relations between depressive symptoms and anxiety with menstrual symptoms. Smoking was examined as a moderator of this association. METHODS: This study enrolled 154 postmenarcheal girls from a sample of 207 girls age 11, 13, 15, and 17 years (mean = 15.4 years [+/-1.9]). Self-reported measures included the Menstrual Symptom Questionnaire (MSQ), Children's Depression Inventory, State-Trait Anxiety Inventory, and smoking behavior. Generalized linear regression modeled MSQ outcomes separately for depressive symptoms and anxiety. RESULTS: More depressive symptoms/anxiety were related to higher numbers of menstrual symptoms (r = 0.23-0.44, p < .05). Smoking status (ever) was related to higher MSQ scores. Moderating effects of smoking and depressive symptoms or anxiety on menstrual symptoms were consistent across most MSQ factors where effects were stronger in never smokers. CONCLUSION: This is the first study in adolescents showing smoking status and depressive symptoms/anxiety are related to menstrual symptoms, and that the impact of depressive symptoms/anxiety on menstrual symptoms is stronger in never smokers. The dynamic and complex nature of smoking, moods, and dysmenorrhea cannot be disentangled without longitudinal analyses. Efforts to reduce menstrual symptoms should begin at a young gynecological age and include consideration of mood and smoking status.

Association of depressive symptoms and anxiety with bone mass and density in ever-smoking and never-smoking adolescent girls.

OBJECTIVES: To examine (1) the association of depressive and anxiety symptoms with bone mass and density in adolescent girls and (2) to examine this association in subgroups of those who have ever or never smoked. DESIGN: Prospective study using baseline reports. SETTING: Urban teenage health center and the community. PARTICIPANTS: Two hundred seven girls (aged 11, 13, 15, and 17 years). OUTCOME MEASURES: Bone mineral density (BMD) and content (BMC) of the hip, spine, and total body determined by dual-energy x-ray absorptiometry. Independent variables included self-report depressive symptoms, anxiety, and smoking history. RESULTS: Higher depressive symptoms were associated with lower total body BMC and BMD but not hip or spine BMC and BMD. Only in white adolescents was higher state anxiety associated with lower total body BMC and hip BMC and BMD. Ever-smokers were not significantly different than never-smokers in age-adjusted BMC or BMD, but they had higher depressive and anxiety symptoms. Although no significant depression or anxiety by smoking group interactions were found, subgroup analyses suggest that in ever-smokers, higher trait anxiety was related to lower total body BMC. CONCLUSIONS: This is the first study to report that higher depressive and anxiety symptoms are associated with lower total body BMC during adolescence in girls. Knowing that this association is present at a young age is worrisome, as peak bone mass is attained in adolescence. Findings may aid in identifying girls who are at risk for low bone mass and developing intervention/prevention strategies during adolescence. Importantly, mechanisms that explain these associations and the effect of smoking on bone health need longitudinal examination.

Older women's descriptions and understandings of their abusers.

Thirty-eight women who were in abusive relationships since age 55 years were interviewed to understand their abuse stories, ways of coping, and health care experiences. In responding to these questions, women described the nature of the abuse perpetrated by their elderly partners and tried to "make sense" of what they had experienced and to define "who" these men were. This took various forms, from personal theories about aging, to labels (ethnic stereotyping, demonizing, pathologizing) to characterizations of the abuser's private versus public behaviors. The authors explore the implications these findings have for assisting the elderly victim and perpetrator.

A lifetime of intimate partner violence: coping strategies of older women.

Little is known about how older women cope in long-term abusive intimate relationships. Understanding their coping strategies may give insight into how to further support their effective coping efforts. Interviews were conducted with 38 women older than age 55 years. Grounded theory analysis demonstrated that women who remained in their abusive relationships employed mainly cognitive (emotion-focused) strategies to find meaning in a situation that was perceived as unchangeable. By reappraising themselves, their spouses, and their relationships they refocused energies in certain roles, set limits with their abusers, and reached out to others (friends, family, and community organizations). Some women appeared to thrive, others merely survived, but all maintained the appearance of conjugal unity.

The prevalence and incidence of intimate partner violence in older women in primary care practices.

OBJECTIVE: Identify the incidence and prevalence of intimate partner violence (IPV) in women over 55 years of age in primary care offices. DESIGN: Telephone survey conducted between March and June 2003 by trained female interviewers who gathered self-report information about health and abuse. PATIENTS: A total of 3,636 women over 55 years of age had at least 1 visit in the past 12 months to primary care offices affiliated with an academic center in Southwestern Ohio were contacted by phone; 995 were deemed competent and completed the interview. INTERVENTION/INSTRUMENT: Thirty-eight page instrument that explored health, history of psychological (controlling behavior and threat of physical harm), physical, and sexual abuse since age 55 years. Interviews lasted 20 to 45 min. MAIN RESULTS: The mean age was 69 years (SD 8.35). Physical abuse in intimate relationships was reported by 1.52% since age 55 years (prevalence) and 0.41% in the past year (incidence). Prevalence and incidence rates for sexual abuse were 2.14% and 1.12%, threat of physical harm 2.63% and 1.62%, respectively. Less than half of the victims told someone else about the abuse. The mean number of health conditions was 3.84 for victims and 3.21 for nonvictims (P<.055) with significantly larger percentages of IPV victims reporting problems with chronic pain and depression. CONCLUSIONS: Physical and sexual abuse by an intimate partner does occur in women over 55 years, but rates are lower than those of younger women. Health care providers are reminded to think about IPV in older women and to ask about abuse as disclosure is rare.

Physician knowledge and management of children exposed to domestic violence in Ohio: a comparison of pediatricians and family physicians.

Active members of the Ohio chapters of American Academy of Family Physicians (FP=1,498) and American Academy of Pediatrics (Ped=1,725) were surveyed about their knowledge and management regarding children exposed to domestic violence (DV). Characteristics of respondents were analyzed by use of Chi-square analysis. Logistic regression was performed to identify predictors of DV knowledge and management. The response rate was 33.3%. Family physicians were more likely to know their local DV agency and recognize the adult symptoms of DV, such as unexplained injury. Pediatricians were more likely to report the child who saw a fight between parents to child protective services. Continuing work to increase physicians' comfort and ability to assess for DV and manage exposed children is needed.

Intimate partner violence: what are physicians' perceptions?

BACKGROUND: Intimate partner violence (IPV) is common in primary care; 11% to 22% of women experienced physical abuse in the past year. Older women experience IPV as well, but it is often undetected. This study examined primary care providers' awareness about IPV in older women, including their screening practices and management. METHODS: Interviews and focus groups were conducted with 44 primary care providers. Thematic analysis was used to identify common themes. RESULTS: Providers fell along a continuum of thoroughness for identifying and managing IPV in older women, ranging from suboptimal to thorough identification of IPV and suboptimal to thorough management of the patient. In addition to the barriers commonly reported about IPV screening in younger women, providers described limited understanding of the diagnoses commonly associated with IPV, frustration with older women's unwillingness to disclose problems and ask for help, and limited community services that accommodate older women with IPV. Providers recommended that communities sponsor public awareness campaigns about IPV as a problem for all women and that aging and IPV agencies work together. CONCLUSIONS: Continued provider training about IPV should include information on identifying older victims and appropriate management options. Participants stressed the importance of community efforts to raise awareness and improve resources available for older women who are victims of IPV.

Hidden victims: the healthcare needs and experiences of older women in abusive relationships.

BACKGROUND: Intimate partner violence (IPV) is a problem in older women, but older victims of IPV are often unidentified in the medical setting because providers think of IPV as a problem of younger women. The experiences of older women with IPV are unknown. This study reports on the healthcare experiences and needs of older victims of IPV. METHODS: Interviews were conducted with 38 women > 55 years who responded to an advertisement recruiting "women who had been in an abusive relationship since age 55." Interviews were audiotaped, transcribed, and analyzed for themes. RESULTS: The median age of participants was 58 years (range 55-90). The majority were Caucasian with annual incomes over dollar 40,000. The median relationship length was 24 years (range 2-67), and 39% remained in their abusive relationships. About half had discussed IPV with a healthcare provider. The themes that were identified included disclosure about IPV and both negative and positive experiences with healthcare providers. Reasons for nondisclosure were similar to those of younger women but were compounded by the generational mores of privacy about domestic affairs and society's lack of understanding and resources for IPV. Some of the women who disclosed IPV to their providers felt discounted and unsupported. Others reported receiving valuable help, including empathy, referrals to resources, assistance in naming the abuse, linking the stress of IPV to health, and respect for their decisions to continue their abusive relationships. CONCLUSIONS: Older women victims have difficulty initiating discussions about IPV with their providers. Providers are encouraged to identify signals of potential abuse and to create privacy with all patients to discuss difficult issues, such as IPV, and to be knowledgeable about appropriate referrals.