Effect of Primary Care Parent-Targeted Interventions on Parent-Adolescent Communication About Sexual Behavior and Alcohol Use: A Randomized Clinical Trial.

Importance: Adolescent well care visits provide opportunities for clinicians to facilitate parent-adolescent communication (PAC) to reduce pregnancy, sexually transmitted infections, and alcohol-related harm among adolescents. Objective: To test the effect of brief parent-targeted interventions delivered in primary care settings on PAC about sexual and alcohol use behaviors. Design, Setting, and Participants: Randomized clinical trial conducted at a primary care pediatric practice from January 4, 2016, to April 10, 2017. Adolescents who were scheduled for a well care visit were recruited, along with their parent or guardian. Data analyses continued through April 30, 2018. Interventions: During well care visits, parents in sexual health intervention and alcohol prevention intervention groups received coaching to discuss written intervention materials encouraging PAC about sex or alcohol, respectively, with their adolescent within 2 weeks, followed by a brief clinician endorsement. After 2 weeks, parents received a follow-up telephone call. Control group parents received usual care. Main Outcomes and Measures: Participants were surveyed 4 months after the well care visit. Parent-reported and adolescent-reported quality of PAC was measured using the 20-item Parent-Adolescent Communication Scale, in which a higher score indicates better PAC; and frequency of PAC about sex or alcohol was measured using a 4-point Likert-type scale with 1 indicating not at all or never, and 4 indicating a lot or often. Results: Of 196 parent-adolescent dyads assessed for eligibility, 118 (60.2%) were eligible to participate. These 118 dyads were randomized to 1 of 3 groups: (1) sexual health intervention (n = 38 [32.2%]); (2) alcohol prevention intervention (n = 40 [33.9%]); and control (n = 40 [33.9%]); 104 parents (88.1%) and 99 adolescents (83.9%) completed the study. Parents included 112 women (94.9%) and had a mean (SD) age of 45.8 (6.9) years. Adolescents included 60 girls (50.9%); 67 adolescents (56.8%) were aged 14 years, and 51 adolescents (43.2%) were aged 15 years. Participant race/ethnicity reflected that of the practice (63 black adolescents [53.4%]; 46 white adolescents [38.9%]; 111 non-Hispanic adolescents [94.1%]). At baseline, 15 adolescents (12.7%) reported a history of sexual behavior and 16 adolescents (13.6%) reported a history of alcohol use. Intention-to-treat analyses found that 4 months after the intervention, adolescents in the sexual health intervention group reported a higher mean frequency score for PAC about sex compared with those in the control group (2.32 [95% CI, 1.97-2.66] vs 1.79 [95% CI, 1.50-2.08]; P = .02); adolescents in the alcohol prevention intervention group reported a higher mean frequency score for PAC about alcohol compared with those in the control group (2.93 [95% CI, 2.60-3.25] vs 2.40 [95% CI, 2.08-2.72]; P = .03). Parent-reported frequency scores for PAC about sex or alcohol did not differ by group. Conclusions and Relevance: Brief parent-targeted interventions in primary care settings increased adolescent-reported frequency of PAC about sexual health and alcohol use and may be an important strategy for parents to influence adolescent behaviors and health outcomes. Trial Registration: ClinicalTrials.gov identifier: NCT02554682.

Intrauterine Device Insertion Procedure Duration in Adolescent and Young Adult Women.

STUDY OBJECTIVE: Intrauterine device (IUD) utilization in the United States is low among adolescent and young adult women. Longer procedure duration has been proposed as one potential barrier to IUD insertion in this population. We hypothesized that procedure duration would be longer in adolescents compared to young adult women. DESIGN, SETTING, AND PARTICIPANTS: This study was a secondary analysis of a randomized clinical trial comparing the effectiveness of a lidocaine vs sham paracervical nerve block for pain control during levonorgestrel 13.5 mg IUD insertion. Adolescent and young adult women ages 14-22 years were recruited from 3 outpatient academic sites in Philadelphia, Pennsylvania. INTERVENTIONS AND MAIN OUTCOME MEASURES: Pain scores were recorded at 7 steps during the procedure from speculum insertion through removal. Time stamps associated with each step were used to calculate the overall procedure duration. Cumulative IUD insertion procedure duration was estimated using the Kaplan-Meier method. RESULTS: Ninety-five women enrolled. Nineteen (19/95, 20%) were ages 14-17 and 76 (76/95, 80%) were ages 18-22 years. The median procedure duration (seconds ± interquartile range) was longer for adolescents than for young adults (555 ± 428 seconds vs 383 ± 196 seconds; P = .008). After adjusting for study site, the difference in expected median procedure duration between age groups was not significant (P = .3832). CONCLUSION: The difference in duration of IUD insertion procedures in adolescent and young adult women is not clinically or statistically significant. Providers should not withhold IUDs from appropriate adolescent and young adult women on the basis of age alone.

Psychometric Properties of Two Developmental Screening Instruments for Hispanic Children in the Philadelphia Region.

OBJECTIVE: To assess the validity of Spanish versions of the Survey of Well-being of Young Children (SWYC) Milestones and the Ages & Stages Questionnaire, Third Edition (ASQ-3), and to document the rates of developmental delays in an urban cohort of children with Hispanic parents. METHODS: Spanish-speaking families with a child 9 to 60 months of age (N = 991) were initially screened using Spanish translations of the SWYC Milestones and the ASQ-3. A stratified random sample of 494 of these children subsequently received standardized clinical assessment to confirm the presence of developmental delays. Reverse weighting corrected for the selection bias inherent in the stratification scheme. RESULTS: Fifty-five percent of toddlers (9 to 41 months of age) and 34.8% of preschoolers (42 to 60 months of age) scored in the moderately to severely delayed range, most frequently in language. Sensitivity and specificity for toddlers with severe delays associated with the SWYC were 0.69 and 0.64, respectively, and 0.55 and 0.75 for the ASQ-3. Sensitivity and specificity for preschoolers with severe delays associated with the SWYC were 0.87 and 0.58, respectively, and 0.71 and 0.86 for the ASQ-3. CONCLUSIONS: Although psychometric properties of the Spanish translated versions are not as strong as the English versions, the findings suggest that both the SWYC Milestones and ASQ-3 represent promising tools for identifying Hispanic children with developmental delays. The rate of delays were consistent with other studies showing a high percentage of Hispanic children with developmental delays, most frequently in language skills.

Adolescents Spending Time Alone With Pediatricians During Routine Visits: Perspectives of Parents in a Primary Care Clinic.

PURPOSE: To increase understanding of parental perspectives on time alone and of factors that influence adolescent communication with physicians in a pediatric clinic. METHODS: The sample consisted of 91 parents of adolescents aged 14-17 years who attended a well child visit at one primary care pediatric practice and completed a 2-week follow-up phone call as part of a larger study on adolescent health and communication. Parents reported whether their child met alone with the pediatrician, rated the importance of him or her having time alone with the physician, and responded to open-ended questions regarding barriers and facilitators of adolescent-physician communication. Bivariate and multivariate analyses tested associations of parent and adolescent characteristics with perceived parental importance of time alone. We conducted content analyses of responses to open-ended questions. RESULTS: Slightly more than half of parents (n = 53, 58%) indicated that it was "a lot" important for their adolescents to meet alone with the pediatrician; parents of males were more likely than parents of females to select this highest rating (73% vs. 43%, χ2(1) = 8.34, p = .004; adjusted odds ratio 4.88, 95% confidence interval 1.84-12.96). Responses to open-ended questions identified numerous adolescent, parent, and provider factors that parents perceived to influence adolescent-physician communication during well child visits, such as preparation for visit, rapport and familiarity with the pediatrician, privacy concerns, time alone with the pediatrician, emotional comfort, trust, and support. CONCLUSIONS: Most parents thought time alone was highly important for their own adolescent in a primary care setting, and parents described additional strategies to facilitate adolescent communication.

Satisfaction With the Intrauterine Device Insertion Procedure Among Adolescent and Young Adult Women.

OBJECTIVE: To evaluate satisfaction with intrauterine device (IUD) insertion procedures among adolescent and young adult women. METHODS: This secondary analysis of data from a multisite, single-blind, sham-controlled randomized trial of women having a levonorgestrel 13.5-mg IUD inserted enrolled participants from March 2015 through July 2016 at three family planning clinics in Philadelphia, Pennsylvania. Eligible participants were 14-22 years of age, nulliparous, not pregnant, and English-speaking. Randomization was computer-generated allocation in block sizes of four to a 1% lidocaine paracervical or sham block. Only patients were blinded. Satisfaction was measured with three items that assessed overall satisfaction with the procedure, whether participants would recommend the IUD to a friend, and the perception that the IUD was worth the discomfort. Predictors included demographics, sexual and reproductive history, pain after IUD insertion, and treatment group. RESULTS: Ninety-five women enrolled; 93 (97.9%) were included in the analysis. Forty-five (47.4%) were white, 34 (36.0%) were black, 62 (66.0%) were privately insured, and 75 (79.0%) had used contraception previously. Most (n=73 [76.8%]) reported high overall satisfaction with the procedure, 64 (67.4%) would recommend an IUD to a friend, and 79 (83.2%) perceived the IUD was worth the discomfort. The odds of reporting high overall satisfaction were lower among adolescents compared with young adults (odds ratio [OR] 0.07, 95% CI 0.008-0.68); those who never had a gynecologic examination compared with those who had (OR 0.26, 95% CI 0.07-0.99); and decreased as pain score increased (OR 0.96, 95% CI 0.94-0.99). Higher pain scores were negatively correlated with the odds of recommending an IUD to a friend and perceiving the IUD was worth the discomfort. CONCLUSION: Adolescent and young adult women report high levels of satisfaction after the IUD insertion procedure. Young age, lack of experience with gynecologic examinations, and high pain were inversely related to satisfaction. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT02352714.

Reducing Pain During Intrauterine Device Insertion: A Randomized Controlled Trial in Adolescents and Young Women.

OBJECTIVE: To estimate the effect of a 1% lidocaine paracervical nerve block on pain during intrauterine device (IUD) insertion compared with a sham block in adolescents and young women. METHODS: We conducted a multisite, single-blind, sham-controlled randomized trial in adolescents and young women having a 13.5-mg levonorgestrel IUD inserted. Enrollment occurred at three family planning clinics in Philadelphia, Pennsylvania. Eligible adolescents and young women were aged 14-22 years, nulliparous, not currently or recently pregnant, and English-speaking. Participants were randomized using computer-generated allocation in block sizes of four to receive a 10-mL 1% lidocaine paracervical block or a sham block (1 cm depression of the vaginal epithelium at paracervical block sites with a wooden cotton-tipped applicator). Only patients were blinded. The primary outcome was pain after IUD insertion measured with a 100-mm visual analog scale. Using a two-sided t test and assuming a 20-mm difference in visual analog scale scores, a SD of 28 mm, an α of 0.05, and 90% power, a sample of 43 participants per group was estimated. RESULTS: Between March 2015 and July 2016, 95 participants enrolled (47 lidocaine block group; 48 sham block group). All were included in the analysis. Forty-four percent were white, 36% black, 65% privately insured, and 79% previously used contraception. The median visual analog scale score after IUD insertion was 30.0 (95% CI 20.0-58.0) in the lidocaine block group and 71.5 (95% CI 66.0-82.0) in the sham block (P<.001). CONCLUSION: A 10-mL 1% lidocaine paracervical nerve block reduces pain during IUD insertion in adolescents and young women compared with a sham block with pressure on the vaginal epithelium. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT02352714.

Evaluating predictive screening for children's post-injury mental health: New data and a replication.

BACKGROUND: Recommended approaches for secondary prevention of posttrauma mental health difficulties in children require empirically sound predictive screening to determine which children require more intensive monitoring or targeted intervention. Although there are several promising screening tools for injured children, none has emerged as the gold standard, and little replication data are available regarding their performance. OBJECTIVE: To evaluate a predictive screening protocol for risk of later posttraumatic stress (PTS) and depression outcomes and address a crucial lack of replication studies by examining performance of two previously published screening tools (Screening Tool for Early Predictors of PTSD [STEPP] and Child Trauma Screening Questionnaire [CTSQ]). METHOD: The study enrolled 290 children hospitalized after acute injury. A three-part screening protocol, including acute PTS and depression symptoms and other empirically derived risk factors, was administered in hospital as part of a stepped care study. PTS and depression symptoms and health-related quality of life (HRQoL) were assessed 6 months post-injury.

Design and implementation of a randomized controlled trial of genomic counseling for patients with chronic disease.

We describe the development and implementation of a randomized controlled trial to investigate the impact of genomic counseling on a cohort of patients with heart failure (HF) or hypertension (HTN), managed at a large academic medical center, the Ohio State University Wexner Medical Center (OSUWMC). Our study is built upon the existing Coriell Personalized Medicine Collaborative (CPMC®). OSUWMC patient participants with chronic disease (CD) receive eight actionable complex disease and one pharmacogenomic test report through the CPMC® web portal. Participants are randomized to either the in-person post-test genomic counseling-active arm, versus web-based only return of results-control arm. Study-specific surveys measure: (1) change in risk perception; (2) knowledge retention; (3) perceived personal control; (4) health behavior change; and, for the active arm (5), overall satisfaction with genomic counseling. This ongoing partnership has spurred creation of both infrastructure and procedures necessary for the implementation of genomics and genomic counseling in clinical care and clinical research. This included creation of a comprehensive informed consent document and processes for prospective return of actionable results for multiple complex diseases and pharmacogenomics (PGx) through a web portal, and integration of genomic data files and clinical decision support into an EPIC-based electronic medical record. We present this partnership, the infrastructure, genomic counseling approach, and the challenges that arose in the design and conduct of this ongoing trial to inform subsequent collaborative efforts and best genomic counseling practices.

Personalized genomic results: analysis of informational needs.

Use of genomic information in healthcare is increasing; however data on the needs of consumers of genomic information is limited. The Coriell Personalized Medicine Collaborative (CPMC) is a longitudinal study investigating the utility of personalized medicine. Participants receive results reflecting risk of common complex conditions and drug-gene pairs deemed actionable by an external review board. To explore the needs of individuals receiving genomic information we reviewed all genetic counseling sessions with CPMC participants. A retrospective qualitative review of notes from 157 genetic counseling inquiries was conducted. Notes were coded for salient themes. Five primary themes; "understanding risk", "basic genetics", "complex disease genetics", "what do I do now?" and "other" were identified. Further review revealed that participants had difficulty with basic genetic concepts, confused relative and absolute risks, and attributed too high a risk burden to individual single nucleotide polymorphisms (SNPs). Despite these hurdles, counseled participants recognized that behavior changes could potentially mitigate risk and there were few comments alluding to an overly deterministic or fatalistic interpretation of results. Participants appeared to recognize the multifactorial nature of the diseases for which results were provided; however education to understand the complexities of genomic risk information was often needed.

Boosting restraint norms: a community-delivered campaign to promote booster seat use.

OBJECTIVE: The objective of this study was to evaluate the effectiveness of a theoretically grounded community-delivered marketing campaign to promote belt-positioning booster seat (BPB) use among vulnerable populations when disseminated by community members. METHODS: A prospective, nonrandomized community intervention trial was conducted to evaluate the "Boosting Restraint Norms" social marketing campaign delivered by community partners in Norristown, Pennsylvania (intervention community), between October 2008 and November 2008. York, Pennsylvania, served as the comparison community. In total, 800 vehicles with 822 children aged 4 to 7 years were observed for BPB use, the primary outcome of interest, at baseline (September 2008) and at 6 months after intervention (April 2009). RESULTS: During the study period, a 28 percent increase in the prevalence of BPB use at 6 months was observed in the intervention community with no change in the prevalence of BPB use in the comparison community. After adjustment for child age and gender, vehicle type, driver gender, and driver level, BPB use increased from 39 to 50 percent in the intervention community. CONCLUSIONS: The "Boosting Restraint Norms" social marketing campaign, distributed through community organizations combined with caregiver education and a one-time free distribution of BPBs, was effective in increasing BPB use. This study demonstrates the feasibility of utilizing community organizations with established audiences to spread the "No Regrets" messaging of the campaign in the community. This study also indicates that spreading evidence-based messages in this manner may effectively change behavior in populations that are often hard to reach. Future studies are needed in which this methodology is tested in additional communities and rural settings.

Anticipated increases in medically attended injuries by children and young adults with the Affordable Care Act: the growing role of primary care in the pediatric trauma system.

OBJECTIVES: To guide implementation of the Affordable Care Act 2010 by estimating anticipated increases in medically attended injuries and site of care by the young who are currently uninsured. METHODS: The 2008 National Health Interview Survey was used to estimate injury episodes and care site for uninsured and insured youth ≤26 years old. Increases in medically attended injuries were estimated by assuming that rates and care site for the currently uninsured would match those of the currently insured once the uninsured receive coverage. RESULTS: In 2008, approximately 11 938 800 episodes of medically attended injuries occurred for youth ≤26 years. An anticipated 6.1% increase in medically attended injuries (737 081; 95% confidence interval = 564 000-879 000), the majority of which would be seen in the outpatient setting, could occur once all uninsured youth become insured. CONCLUSIONS: Injury prevention strategies and additional injury care training for primary care physicians may help ensure appropriate triage and optimal outcomes while containing costs.

Comparative Performance of Rear Facing Child Restraint Systems on the CMVSS 213 Bench and Vehicle Seats.

The purpose of this study was to compare the dynamic response of rear-facing child restraint systems (RFCRS) installed on the CMVSS 213 sled bench and a selection of vehicle seats. Thirty-six sled tests were conducted: three models of rear facing CRS with an anthropomorphic test device (ATD) representing a 12 month old child (CRABI) were affixed via lower anchors (LATCH), 3 point belt without CRS base, and 3 point belt with CRS base to one of three vehicle seats or the CMVSS 213 bench seat. All CRS were subjected to an identical sled acceleration pulse. Two types of matched pair analysis: "bench-to-vehicle" and "method of attachment" were conducted. Statistically significant differences were observed in the kinematic responses of the ATD and the CRS.This is the first study to quantify differences between the regulatory bench and vehicle seats on a system level and evaluate the influence of attachment method. Our results show that the difference in RFCRS forward excursion between 3-point belt with base and LATCH installations was between 1 and 7 percent on the bench and 22 to 76 percent on the vehicle seats. When evaluating the dynamic performance of RFCRS, the use of real vehicle seats from vehicles that commonly carry children may provide valuable insight. The findings would require further confirmation using a broader selection of RFCRS and vehicle seats, before generalizable conclusions can be drawn.

An assessment of clinical performance measures for pediatric emergency physicians.

The objectives were to evaluate clinical performance measures used for pediatric emergency medicine (PEM) physicians for reliability, correlation with one another, and relationship with clinical experience. This retrospective cohort study collected performance data for PEM physicians working at an urban children's hospital emergency department (ED) for each of 7 consecutive 6-month periods. Low correlations were seen between patients per hour or admission rate and 72-hour revisit rates. No significant association existed between level of experience and any performance measure. Physician treatment times appeared to be most reliable, and revisit rates were least reliable. Increase in number of patients seen per hour or lower admission rates in the ED are not significantly associated with an increase in revisit rates. Provider experience did not affect performance measures. Physician treatment time, patients per hour, admission rate, and charges per hour are reliable measures to assess the clinical performance of PEM physicians working at a single center.

Kinematic Comparison of the Hybrid III and Q-Series Pediatric ATDs to Pediatric Volunteers in Low-Speed Frontal Crashes.

Previous research has suggested that the rigid pediatric ATD spine may not adequately represent the relatively mobile, multi-segmented spine of the child and thus may lead to important differences in the head trajectory of the ATD relative to a human. Recently we compared the responses of size-matched child volunteers to the Hybrid III 6-year-old ATD in low-speed frontal sled tests, illustrating differences in head, spinal, and pelvic kinematics as well as seating environment reaction loads. This paper expands this line of work to include comparisons between size-matched restrained child volunteers to the Hybrid III 10-year-old and the Q-series 6 and 10-year-old ATDs tested in the same low speed frontal environment. A 3-D near-infrared video target tracking system quantified the position of markers on the ATDs and volunteers(head top, nasion, external auditory meatus, C4, T1, and pelvis). Angular velocity of the head, seat belt forces, and reaction loads on the seat pan and foot rest were also measured. The Hybrid III 6 and Q6 exhibited significantly greater belt reaction loads compared to the pediatric volunteers, which exhibited greater seat pan shear. Compared to children, the Hybrid III 6 exhibited increased head rotation and similar head top and pelvic excursion, whereas the Q6 exhibited reductions in all three metrics. The Hybrid III 10 and Q10 ATDs exhibited reaction loads similar to the volunteers; however, excursions and head rotation were significantly reduced compared to volunteers. All pediatric ATDs exhibited significant reductions in C4 and T1excursions compared to the volunteers, likely due to the rigidity of the ATD thoracic spine. These analyses provide insight into aspects of ATD biofidelity in low-speed crash environments and illustrate differences in responses of the Hybrid III and Q-series pediatric ATDs.

Homogenization of vehicle fleet frontal crash pulses from 2000-2010.

Full-scale vehicle crash tests are performed globally to assess vehicle structure and restraint system performance. The crash pulse, captured by accelerometers mounted within the occupant compartment, measures the motion of the vehicle during the impact event. From an occupant's perspective, the crash pulse is the inertial event to which the vehicle's restraint systems must respond in order to mitigate the forces and accelerations that act on a passenger, and thus reduce injury risk. The objective of this study was to quantify the characteristics of crash pulses for different vehicle types in the contemporary North American fleet, and delineate current trends in crash pulse evolution. NHTSA and Transport Canada crash test databases were queried for full-frontal rigid barrier crash tests of passenger vehicles model year 2000-2010 with impact angle equaling zero degrees. Acceleration-time histories were analyzed for all accelerometers attached to the vehicle structure within the occupant compartment. Custom software calculated the following crash pulse characteristics (CPCs): peak deceleration, time of peak deceleration, onset rate, pulse duration, and change in velocity. Vehicle body types were classified by adapting the Highway Loss Data Institute (HLDI) methodology, and vehicles were assigned a generation start year in place of model year in order to more accurately represent structural change over time. 1094 vehicle crash tests with 2795 individual occupant compartment-mounted accelerometers were analyzed. We found greater peak decelerations and and shorter pulse durations across multiple vehicle types in newer model years as compared to older. For midsize passenger cars, large passenger cars, and large SUVs in 56 km/h rigid barrier tests, maximum deceleration increased by 0.40, 0.96, and 1.57 g/year respectively, and pulse duration decreased by 0.74, 1.87, and 2.51 ms/year. We also found that the crash pulse characteristics are becoming more homogeneous in the modern vehicle fleet; the range of peak deceleration values for all vehicle classes decreased from 17.1 g in 1997-1999 generation start years to 10.7 g in 2009-2010 generation years, and the pulse duration range decreased from 39.5 ms to 13.4 ms for the same generation year groupings. This latter finding suggests that the designs of restraint systems may become more universally applicable across vehicle body types, since the occupant compartment accelerations are not as divergent for newer vehicles.

Safety belt laws and disparities in safety belt use among US high-school drivers.

OBJECTIVES: We compared reported safety belt use, for both drivers and passengers, among teenagers with learner's permits, provisional licenses, and unrestricted licenses in states with primary or secondary enforcement of safety belt laws. METHODS: Our data source was the 2006 National Young Driver Survey, which included a national representative sample of 3126 high-school drivers. We used multivariate, log-linear regression analyses to assess associations between safety belt laws and belt use. RESULTS: Teenaged drivers were 12% less likely to wear a safety belt as drivers and 15% less likely to wear one as passengers in states with a secondary safety belt law than in states with a primary law. The apparent reduction in belt use among teenagers as they progressed from learner to unrestricted license holder occurred in only secondary enforcement states. Groups reporting particularly low use included African American drivers, rural residents, academically challenged students, and those driving pickup trucks. CONCLUSIONS: The results provided further evidence for enactment of primary enforcement provisions in safety belt laws because primary laws are associated with higher safety belt use rates and lower crash-related injuries and mortality.

Adult-supervised practice driving for adolescent learners: The current state and directions for interventions.

INTRODUCTION: The aim of this study was to quantify and identify correlates to the amount of parent-supervised behind-the-wheel practice hours by novice teen drivers. METHODS: A national survey of 945 parents of recently licensed teen drivers was conducted. Multivariate logistic regression was used to identify factors related to the number of practice hours completed. RESULTS: Sixty-one percent of parents reported practicing 50 or more hours with their teen. Two-parent involvement was associated with more practice hours, though use of a professional driving instructor was not. Parents of teens licensed in states mandating 50 or more hours of practice driving were more likely to report at least 50 practice hours than those in states mandating 20-40 hours or in states without mandates. IMPACT ON INDUSTRY: The findings underscore the integral role of parents in the learning to drive process and provide further support for GDL requirements for practice hours.

Variation in teen driver education by state requirements and sociodemographics.

OBJECTIVES: There is renewed attention on national standardization of formal driver education (DE) instruction and momentum toward realigning DE with its original goal of producing safer teen drivers. However, teen DE participation rates and how they differ among sociodemographic groups and in states with and without DE requirements remain largely unknown. Thus, our objective was to estimate national teen participation rates in formal classroom and behind-the-wheel DE instruction in relevant demographic subgroups and also estimate subgroup-specific participation rates by presence of a state DE requirement. METHODS: Data were collected via the National Young Driver Survey, administered to a nationally representative sample of 5665 public school 9th- through 11th-graders in Spring 2006. Analyses were restricted to 1770 students with driver licenses. Survey data were weighted to reflect national prevalence estimates. RESULTS: Overall, 78.8% of students reported participating in formal DE. However, in states without DE requirements, more than 1 in 3 students had no formal DE before licensure, and more than half had no behind-the-wheel training. Hispanics, blacks, males, and students with lower academic achievement participated in DE at markedly lower levels than counterparts in states with requirements. Notably, 71% of Hispanic students in states with no requirement received a license without receiving formal DE. CONCLUSIONS: Considerable racial/ethnic, socioeconomic, and gender disparities in DE participation may exist in states with no DE requirements. State DE requirements may be an effective strategy to reduce these disparities.

Kinetics of the cervical spine in pediatric and adult volunteers during low speed frontal impacts.

Previous research has quantified differences in head and spinal kinematics between children and adults restrained in an automotive-like configuration subjected to low speed dynamic loading. The forces and moments that the cervical spine imposes on the head contribute directly to these age-based kinematic variations. To provide further explanation of the kinematic results, this study compared the upper neck kinetics - including the relative contribution of shear and tension as well as flexion moment - between children (n=20, 6-14 yr) and adults (n=10, 18-30 yr) during low-speed (<4 g, 2.5 m/s) frontal sled tests. The subjects were restrained by a lap and shoulder belt and photo-reflective targets were attached to skeletal landmarks on the head, spine, shoulders, sternum, and legs. A 3D infrared tracking system quantified the position of the targets. Shear force (F(x)), axial force (F(z)), bending moment (M(y)), and head angular acceleration (θ(head)) were computed using inverse dynamics. The method was validated against ATD measured loads. Peak F(z) and θ(head) significantly decreased with increasing age while M(y) significantly increased with increasing age. F(x) significantly increased with age when age was considered as a univariate variable; however when variations in head-to-neck girth ratio and change in velocity were accounted for, this difference as a function of age was not significant. These results provide insight into the relationship between age-based differences in head kinematics and the kinetics of the cervical spine. Such information is valuable for pediatric cervical spine models and when scaling adult-based upper cervical spine tolerance and injury metrics to children.

Passive cervical spine flexion: the effect of age and gender.

BACKGROUND: Previous studies reported passive cervical range of motion under unknown loading conditions or with minimal detail of subject positioning. Additionally, such studies have not quantitatively ensured the absence of active muscle during passive measurements. For the purpose of validating biomechanical models the loading condition, initial position, and muscle activation must be clearly defined. A method is needed to quantify the passive range of motion properties of the cervical spine under controlled loading conditions, particularly in the pediatric population where normative clinical and model validation data is limited. METHODS: Healthy female pediatric (6-12years; n=10), male pediatric (6-12years; n=9), female adult (21-40years; n=10), and male adult (20-36years; n=9) volunteers were enrolled. Subjects with restrained torsos and lower extremities were exposed to a maximum 1g inertial load in the posterior-anterior direction, such that the head-neck complex flexed when subjects relaxed their neck musculature. Surface electromyography monitored the level of muscle relaxation. A multi-camera 3-D target tracking system captured passive neck flexion angle of the head relative to the thoracic spine. General estimating equations detected statistical differences across age and gender. FINDINGS: Passive cervical spine flexion equaled 111.0° (SD 8.0°) for pediatric females, 102.8° (SD 7.8°) for adult females, 103.8° (SD 12.7°) for pediatric males, and 93.7° (SD 9.9°) for adult males. Passive neck flexion significantly decreased with age in both genders (P<0.01). Females exhibited significantly greater flexion than males (P<0.01). INTERPRETATION: This study contributes normative data for clinical use, biomechanical modeling, and injury prevention tool development.