CDC Grand Rounds: Adolescence - Preparing for Lifelong Health and Wellness.

Approximately 42 million adolescents aged 10-19 years, representing 13% of the population, resided in the United States in 2014 (1). Adolescence is characterized by rapid and profound physical, intellectual, emotional, and psychological changes (2), as well as development of healthy or risky behaviors that can last a lifetime. Parents have strong influence on their adolescent children's lives, and family-based programs can help parents support healthy adolescent development. Because schools are natural learning environments, implementing and improving school-based policies and programs are strategic ways to reinforce healthy behaviors and educate adolescents about reducing risky behaviors. Health care during adolescence should be tailored to meet the changing developmental needs of the adolescent while providing welcoming, safe, and confidential care. Parents, educators, care providers, public health officials, and communities should collaborate in fostering healthy environments for all adolescents, now and into the future.

Relationship of Age for Grade and Pubertal Stage to Early Initiation of Substance Use.

INTRODUCTION: Studies suggest students who are substantially older than the average age for their grade engage in risky health behaviors, including substance use. However, most studies do not account for the distinct reasons why students are old for their grade (ie, grade retention vs delayed school entry) or for their pubertal stage. Thus, whether the association between age for grade and substance use is confounded by these factors is unknown. We sought to determine whether age, grade, or pubertal stage were associated with early substance use. METHODS: Cross-sectional Healthy Passages Wave I survey data from 5,147 fifth graders and their caregivers in Alabama, California, and Texas from 2004 through 2006 were analyzed in 2014. Logistic regressions examined whether older age for grade, grade retention, delayed school entry, or pubertal stage were associated with use of any substance, cigarettes, alcohol, or other drugs. RESULTS: Seventeen percent of fifth graders reported trying at least 1 substance. Among boys, advanced pubertal stage was associated with increased odds of cigarette, alcohol, or other drug use, whereas delayed school entry was associated with lower odds of any substance, alcohol, or other drug use. Among girls, advanced pubertal stage was associated only with higher odds of alcohol use, and delayed school entry was not associated with substance use. Neither older age for grade or grade retention was independently associated with substance use after controlling for potential confounders. CONCLUSION: Advanced pubertal stage may be a more important risk factor for substance use than age for grade. Pediatricians should consider initiating substance use screening earlier for patients with advanced pubertal stage.

The association between youth violence exposure and attention-deficit/hyperactivity disorder (ADHD) symptoms in a sample of fifth-graders.

The purpose of the current study was to examine the association between violence exposures (no exposure, witness or victim only, and both witness and victim) and attention-deficit/hyperactivity disorder (ADHD) symptoms, as well as the potential moderating role of gender. Data from 4,745 5th graders and their primary caregivers were drawn from the Healthy Passages study of adolescent health. Parent respondents completed the DISC Predictive Scales for ADHD, and youth provided information about exposure to violence. Results indicated that youth who reported both witnessing and victimization had more parent-reported ADHD symptoms and were more likely to meet predictive criteria for ADHD. Among those with both exposures, girls exhibited a steeper increase in ADHD symptoms and higher probability of meeting predictive criteria than did boys. Findings indicate that being both victim-of and witness-to violence is significantly associated with ADHD symptoms particularly among girls.

Common Versus Specific Correlates of Fifth-Grade Conduct Disorder and Oppositional Defiant Disorder Symptoms: Comparison of Three Racial/Ethnic Groups.

The extent to which risk profiles or correlates of conduct disorder (CD) and oppositional defiant disorder (ODD) symptoms overlap among youth continues to be debated. Cross-sectional data from a large, representative community sample (N = 4,705) of African-American, Latino, and White fifth graders were used to examine overlap in correlates of CD and ODD symptoms. About 49 % of the children were boys. Analyses were conducted using negative binomial regression models, accounting for several confounding factors (e.g., attention deficit/hyperactivity disorder symptoms), sampling weights, stratification, and clustering. Results indicated that CD and ODD symptoms had very similar correlates. In addition to previously established correlates, several social skills dimensions were significantly related to ODD and CD symptoms, even after controlling for other correlates. In contrast, temperamental dimensions were not significantly related to CD and ODD symptoms, possibly because more proximal correlates (e.g., social skills) were also taken into account. Only two factors (gender and household income) were found to be specific correlates of CD, but not ODD, symptoms. The pattern of common and specific correlates of CD and ODD symptoms was replicated fairly consistently across the three racial/ethnic subgroups. Implications of these findings for further research and intervention efforts are discussed.

Daily violent video game playing and depression in preadolescent youth.

Most studies on the impact of playing violent video games on mental health have focused on aggression. Relatively few studies have examined the relationship between playing violent video games and depression, especially among preadolescent youth. In this study, we investigated whether daily violent video game playing over the past year is associated with a greater number of depressive symptoms among preadolescent youth, after controlling for several well-known correlates of depression among youth. We analyzed cross-sectional data collected from 5,147 fifth-grade students and their primary caregivers who participated in Wave I (2004-2006) of Healthy Passages, a community-based longitudinal study conducted in three U.S. cities. Linear regression was conducted to determine the association between violent video game exposure and number of depressive symptoms, while controlling for gender, race/ethnicity, peer victimization, witnessing violence, being threatened with violence, aggression, family structure, and household income level. We found that students who reported playing high-violence video games for ≥2 hours per day had significantly more depressive symptoms than those who reported playing low-violence video games for <2 hours per day (p<0.001). The magnitude of this association was small (Cohen's d=0.16), but this association was consistent across all racial/ethnic subgroups and among boys (Cohen's d values ranged from 0.12 to 0.25). Our findings indicate that there is an association between daily exposure to violent video games and number of depressive symptoms among preadolescent youth. More research is needed to examine this association and, if confirmed, to investigate its causality, persistence over time, underlying mechanisms, and clinical implications.

School programs and characteristics and their influence on student BMI: findings from healthy passages.

BACKGROUND: Little is known about the contribution of school contextual factors to individual student body mass index (BMI). We set out to determine if school characteristics/resources: (1) are associated with student BMI; (2) explain racial/ethnic disparities in student BMI; and (3) explain school-level differences in student BMI. METHODS: Using gender-stratified multi-level modeling strategies we examined the association of school characteristics/resources and individual BMI in 4,387 5(th) graders in the Healthy Passages Longitudinal Study of Adolescent Health. Additionally, we examined the association of race/ethnicity and individual BMI as well as the between-school variance in BMI before and after adding individual and school characteristics to test for attenuation. RESULTS: The school-level median household income, but not physical activity or nutrition resources, was inversely associated with female BMI (ß = -0.12, CI: -0.21,-0.02). Neither school demographics nor physical activity/nutrition resources were predictive of individual BMI in males. In Black females, school characteristics attenuated the association of race/ethnicity and BMI. Individual student characteristics-not school characteristics/resources-reduced the between-school variation in BMI in males by nearly one-third and eliminated it in females. CONCLUSIONS: In this cohort of 5(th) graders, school SES was inversely associated with female BMI while school characteristics and resources largely explained Black/White disparities in female weight status. Between-school differences in average student weight status were largely explained by the composition of the student body not by school characteristics or programming.

Association between perceived discrimination and racial/ethnic disparities in problem behaviors among preadolescent youths.

OBJECTIVES: We examined the contribution of perceived racial/ethnic discrimination to disparities in problem behaviors among preadolescent Black, Latino, and White youths. METHODS: We used cross-sectional data from Healthy Passages, a 3-community study of 5119 fifth graders and their parents from August 2004 through September 2006 in Birmingham, Alabama; Los Angeles County, California; and Houston, Texas. We used multivariate regressions to examine the relationships of perceived racial/ethnic discrimination and race/ethnicity to problem behaviors. We used values from these regressions to calculate the percentage of disparities in problem behaviors associated with the discrimination effect. RESULTS: In multivariate models, perceived discrimination was associated with greater problem behaviors among Black and Latino youths. Compared with Whites, Blacks were significantly more likely to report problem behaviors, whereas Latinos were significantly less likely (a "reverse disparity"). When we set Blacks' and Latinos' discrimination experiences to zero, the adjusted disparity between Blacks and Whites was reduced by an estimated one third to two thirds; the reverse adjusted disparity favoring Latinos widened by about one fifth to one half. CONCLUSIONS: Eliminating discrimination could considerably reduce mental health issues, including problem behaviors, among Black and Latino youths.

Racial and ethnic health disparities among fifth-graders in three cities.

BACKGROUND: For many health-related behaviors and outcomes, racial and ethnic disparities among adolescents are well documented, but less is known about health-related disparities during preadolescence. METHODS: We studied 5119 randomly selected public-school fifth-graders and their parents in three metropolitan areas in the United States. We examined differences among black, Latino, and white children on 16 measures, including witnessing of violence, peer victimization, perpetration of aggression, seat-belt use, bike-helmet use, substance use, discrimination, terrorism worries, vigorous exercise, obesity, and self-rated health status and psychological and physical quality of life. We tested potential mediators of racial and ethnic disparities (i.e., sociodemographic characteristics and the child's school) using partially adjusted models. RESULTS: There were significant differences between black children and white children for all 16 measures and between Latino children and white children for 12 of 16 measures, although adjusted analyses reduced many of these disparities. For example, in unadjusted analysis, the rate of witnessing a threat or injury with a gun was higher among blacks (20%) and Latinos (11%) than among whites (5%), and the number of days per week on which the student performed vigorous exercise was lower among blacks (3.56 days) and Latinos (3.77 days) than among whites (4.33 days) (P<0.001 for all comparisons). After statistical adjustment, these differences were reduced by about half between blacks and whites and were eliminated between Latinos and whites. Household income, household highest education level, and the child's school were the most substantial mediators of racial and ethnic disparities. CONCLUSIONS: We found that harmful health behaviors, experiences, and outcomes were more common among black children and Latino children than among white children. Adjustment for socioeconomic status and the child's school substantially reduced most of these differences. Interventions that address potentially detrimental consequences of low socioeconomic status and adverse school environments may help reduce racial and ethnic differences in child health. (Funded by the Centers for Disease Control and Prevention.).

Racial/ethnic disparities in health-related quality of life and health in children are largely mediated by family contextual differences.

OBJECTIVE: To examine (1) racial/ethnic disparities in health-related quality of life (HRQOL), and overall health status among African-American, Hispanic, and white 5th graders in the general population and (2) the extent to which socioeconomic status (SES) and other family contextual variables mediate any disparities. METHODS: A total of 4824 African-American, Hispanic, and white fifth-graders participating in a population-based, cross-sectional survey conducted in 3 U.S. metropolitan areas reported their own HRQOL by using the Pediatric Quality of Life Inventory Version 4.0 and supplemental personal and social well-being scales. Parents reported these children's overall health status. SES was indexed by parent education and household income. Other family contextual variables included family structure and degree to which English is spoken at home. RESULTS: Marked racial/ethnic disparities were observed across all measures of HRQOL and health status, favoring white children and especially disfavoring Hispanic children. Most of these disparities were no longer significant after adjusting for SES and other family contextual differences that were observed among these racial/ethnic groups. Only disparities in parent-reported overall health status and self-reported global self-worth remained. CONCLUSIONS: Racial/ethnic disparities in children's health status are substantial but may be mediated by corresponding disparities in SES and other family contextual variables. Race/ethnicity and family context are related to one another and should be considered jointly in efforts to reduce health disparities in children.

A comparative study of interventions for delaying the initiation of sexual intercourse among Latino and black youth.

CONTEXT: Latino and black adolescents are disproportionately affected by STDs, including HIV, and unintended pregnancies. Few parent-based interventions have targeted these youth, focused on early adolescence and had high participation rates. METHODS: Between 2003 and 2009, a randomized clinical trial was conducted with 2,016 Latino and black mother-adolescent dyads in New York City. Adolescents were eligible if they were in grade 6 or 7. Dyads were assigned to one of three conditions: a parent-based intervention, Families Talking Together (FTT); an adolescent-only intervention, Making a Difference! (MAD); or a combined FTT+MAD intervention. Respondents completed questionnaires at baseline and 12 months later. Single-degree-of-freedom contrasts and logistic regression analysis were used to evaluate differences in outcomes by intervention. RESULTS: The proportion of youth who reported ever having engaged in vaginal intercourse increased over the study period by eight percentage points among those in the MAD group, five points in the FTT group and three points in the combined group; the differences among these increases were not statistically significant. Adolescents in the two FTT groups were significantly more likely than those in the MAD group to indicate that their mother had talked to them about not having intercourse (79% vs. 68%). They also scored higher than youth in the MAD group on measures of communication and perceived maternal attributes, and lower on activities that might lead to risky behaviors. CONCLUSIONS: The proportions of adolescents who initiated intercourse during the study period were not significantly different across groups, implying that the interventions were comparable. Findings suggest that FTT may have led to improved parenting behaviors.

The Linking Lives health education program: a randomized clinical trial of a parent-based tobacco use prevention program for african american and latino youths.

OBJECTIVES: We evaluated the effectiveness of a parent-based add-on component to a school-based intervention to prevent cigarette smoking among African American and Latino middle school youths. METHODS: Mother-adolescent dyads (n=1386) were randomly assigned to 2 groups: (1) a school-based smoking-prevention intervention or (2) the same intervention with a parent-based add-on component called Raising Smoke-Free Kids. Mothers in the experimental condition received the parent add-on component. Mothers in the control condition received information on selecting a high school. All adolescents received a version of Project Towards No Tobacco Use (TNT). The primary outcome was a reduction in adolescent cigarette smoking. Follow-up data were obtained from 1096 mother-adolescent dyads at 15 months postintervention. RESULTS: At follow-up, the odds of smoking cigarettes were reduced by 42% for adolescents in the parent add-on condition versus the TNT-only condition. Mothers in the parent add-on condition were more likely than were mothers in the TNT-only condition to set rules about risk-sensitive social activities and to be perceived as trustworthy by their child. Group differences also were found in the frequency and quality of mother-adolescent communication. CONCLUSIONS: Including parent add-on components in school-based smoking prevention programs can reduce smoking behavior on the part of inner-city middle school youths.

The Influence of the VERB campaign on children's physical activity in 2002 to 2006.

OBJECTIVES: We evaluated physical activity outcomes for children exposed to VERB, a campaign to encourage physical activity in children, across campaign years 2002 to 2006. METHODS: We examined the associations between exposure to VERB and (1) physical activity sessions (free time and organized) and (2) psychosocial outcomes (outcome expectations, self-efficacy, and social influences) for 3 nationally representative cohorts of children. Outcomes among adolescents aged 13 to 17 years (cohort 1, baseline) and children aged 9 to 13 years from cohorts 2 and 3 were analyzed for dose-response effects. Propensity scoring was used to control for confounding influences. RESULTS: Awareness of VERB remained high across campaign years. In 2006, reports of children aged 10 to 13 years being active on the day before the survey increased significantly as exposure to the campaign increased. Psychosocial outcomes showed dose-response associations. Effects lessened as children aged out of the campaign target age range (cohort 1, baseline), but dose-response associations persisted in 2006 for outcome expectations and free-time physical activity. CONCLUSIONS: VERB positively influenced children's physical activity outcomes. Campaign effects persisted as children grew into their adolescent years.

Overview of formative, process, and outcome evaluation methods used in the VERB campaign.

Evaluation was an integral part of the VERB campaign. This paper describes the array of evaluation methods used to support the development, implementation, and assessment of campaign activities. The evaluation of VERB consisted of formative, process, and outcome evaluations and involved both qualitative and quantitative methods. Formative evaluation allowed staff to test ideas for messages and to gauge their appropriateness for the intended audiences. Process evaluation allowed staff to test and monitor the fidelity of the campaign's implementation to objectives and to make changes while the campaign was under way. Outcome evaluation allowed staff to determine the campaign's effects on the target audience. Because a comprehensive approach was used, which included formative and process evaluation, the VERB team's ability to interpret the results of the outcome evaluation was enhanced.

All4You! A randomized trial of an HIV, other STDs, and pregnancy prevention intervention for alternative school students.

This study evaluated All4You!, a theoretically based curriculum designed to reduce sexual risk behaviors associated with HIV, other STDs, and unintended pregnancy among students in alternative schools. The study featured a randomized controlled trial involving 24 community day schools in northern California. A cohort of 988 students was assessed four times during an 18-month period using a self report questionnaire. At the 6-month follow-up, the intervention reduced the frequency of intercourse without a condom during the previous 3 months, the frequency of intercourse without a condom with steady partners, and the number of times students reported having intercourse in the previous 3 months. It also increased condom use at last intercourse. These behavioral effects were no longer statistically significant at the 12- and 18-month follow-ups. The All4You! intervention was effective in reducing selected sexual risk behaviors among students in alternative school settings; however, the effects were modest and short term.

Effects of a mass media campaign to increase physical activity among children: year-1 results of the VERB campaign.

OBJECTIVE: To determine the effects of a mass media campaign on the levels of physical activity among children 9 to 13 years of age. DESIGN: A prospective, longitudinal, quasi-experimental design was used. A baseline survey was conducted in April to June 2002, before the launch of VERB advertising. Random-digit-dialing methods were used to survey a nationally representative sample of children and parents. The follow-up survey was repeated with the same cohort of children and parents in April to June 2003. Propensity scoring was used to determine the campaign's effects on awareness and physical activity behaviors. SETTING: United States. PARTICIPANTS: A total of 3120 parent-child dyads. Intervention. The VERB campaign is a multiethnic campaign that combines paid advertisements with school and community promotions and Internet activities to encourage children 9 to 13 years of age to be physically active every day. Launched in 2002 by the Centers for Disease Control and Prevention, VERB uses commercial marketing methods to advertise being physically active as cool, fun, and a chance to have a good time with friends. Using the VERB brand, paid advertising ran nationally from June 2002 through June 2003, targeting 9- to 13-year-old youths. MAIN OUTCOME MEASURES: Children's awareness of the campaign and self-reported estimates of free-time and organized physical activity sessions during nonschool hours in the week before the interview. RESULTS: After 1 year, 74% of children surveyed were aware of the VERB campaign. Levels of reported sessions of free-time physical activity increased for subgroups of children 9 to 13 years of age. A pattern of effects across 2 measures was observed for younger children (9-10 years of age), girls, children whose parents had less than a high school education, children from urban areas that were densely populated, and children who were low active at baseline. These subgroups engaged in more median weekly sessions of free-time physical activity than did children who were unaware of VERB and, as the children's level of VERB awareness was incrementally higher, the children engaged in incrementally more free-time physical activity sessions. The average 9- to 10-year-old youth engaged in 34% more free-time physical activity sessions per week than did 9- to 10-year-old youths who were unaware of the campaign. A pattern of effects for organized activity was found only for children classified as low active at baseline. CONCLUSIONS: The VERB campaign achieved high levels of awareness in 1 year. Higher levels of physical activity were reported for subgroups of US children. Promoting physical activity with child-focused commercial advertising shows promise.

Integrating service learning into a curriculum to reduce health risks at alternative high schools.

Service learning has been identified as a promising approach to reduce sexual risk behavior, among other outcomes. This study used qualitative data analysis to offer suggestions for optimally integrating service learning into a program to reduce sexual risks among alternative school students. Data were collected from student participants in the All4You! Project using classroom materials, focus groups, and individual interviews. Project educators and project staff also provided data through summary forms and field notes. Qualitative data analysis revealed 5 strategies for creating positive service experiences for alternative school students: (1) find appropriate service-learning sites, (2) create staff support, (3) maintain appropriate student participation and behavior; (4) enhance student reflection on service-learning experiences, and (5) address students' self-images.

Local school district adoption of state-recommended policies on HIV prevention education.

BACKGROUND: This study evaluated the extent to which school districts in Massachusetts adopted HIV education policies consistent with state education agency recommendations, and whether adoption of state-recommended policy language was associated with other core components of school-based HIV prevention programs such as staff development, curriculum, and implementation characteristics. METHODS: A census of health coordinators (n = 251) and high school HIV teachers (n = 174) in randomly selected schools in Massachusetts were surveyed. Chi-squares and analysis of variance (ANOVAs) were used to analyze data. RESULTS: Most districts' policies fully incorporated state-recommended language for training HIV teachers (62%), providing HIV education within comprehensive sexuality education (62%), and providing skills-based instruction (57%). Districts adopting state-recommended policies were significantly more likely to have trained more HIV teachers (82% vs. 59% of teachers trained; P < 0.001), provided HIV education to a greater percentage of students (90% vs. 50% of students educated; P < 0.001), and adopted research-based curricula (44% vs. 27%; P < 0.01). High school teachers who received training and those using research-based curricula covered more HIV prevention topics and used more skills-based instructional methods than those who did not receive training or did not use research-based curricula (P < 0.01). CONCLUSIONS: Results suggest that strong, state-level HIV prevention education policy recommendations can help shape local school health policy and, when adopted locally, can positively influence the reach and quality of HIV education.

The "Safer Choices" intervention: its impact on the sexual behaviors of different subgroups of high school students.

PURPOSE: To measure the relative impact of a school-based human immunodeficiency virus (HIV)-, sexually transmitted disease (STD)-, and pregnancy-prevention intervention on sexual risk-taking behaviors of different subgroups of students. METHODS: Twenty schools were randomly assigned to receive Safer Choices or a standard knowledge-based HIV-education program. Safer Choices was designed to reduce unprotected sex by delaying initiation of sex, reducing its frequency, or increasing condom use. Its five components included: school organization, an intensive curriculum with staff development, peer resources and school environment, parent education, and school-community linkages. A total of 3869 9th-grade students were tracked for 31 months. Results are presented for initiation of sex, frequency of unprotected sex, number of unprotected sexual partners, condom use, and contraceptive use. These results are presented separately by gender, race/ethnicity, prior sexual experience, and prior sexual risk-taking. Statistical analyses included multilevel, repeated measures logistic and Poisson regression models. RESULTS: Safer Choices had one or more positive behavioral effects on all subgroups. On four outcomes that could be affected by condom use, it had a greater impact on males than on females. It had greater effects on Hispanics, including a delay in sexual activity, than on other racial/ethnic groups. Its greatest overall effect was an increase in condom use among students who had engaged in unprotected sex before the intervention. CONCLUSIONS: Safer Choices reduced one or more measures of sexual risk taking over 31 months among all groups of youth, and was especially effective with males, Hispanics, and youth who engaged in unprotected sex and thus were at higher risk for HIV, other STD infections and pregnancy.