Pathways from witnessing community violence to mental health problems among South African adolescents.

BACKGROUND: The intersection of violence exposure and mental health problems is a public health crisis for South African (SA) adolescents. Understanding the impact of community violence on adolescent mental health can inform future interventions. OBJECTIVES: To assess pathways between community violence exposure and internalising and externalising problems in SA adolescents receiving mental healthcare, and the roles of parent and peer relationships in these associations. METHODS: Participants (N=120 parent-adolescent pairs) were recruited from four mental health clinics in Western Cape Province to participate in a pilot test of a family-based HIV prevention study. Adolescents reported on their exposure to community violence, parental attachment, peer support of risk behaviour, and mental health. Parents reported on adolescents' internalising and externalising mental health problems. Participants received transport money (ZAR30 = USD3) and a shopping voucher or cash (ZAR50 = USD5) for their time. RESULTS: Adolescents were 12 - 18 years old (mean (standard deviation) 14.39 (1.82) years), 53% were male, and 67% and 33% reported black African and mixed-race ethnicity, respectively. Parents were 94% female and reported an average monthly income of ZAR3 973 (USD397). Boys reported significantly higher rates of witnessing community violence than girls. Among boys, significant paths emerged from community violence and low parent attachment to externalising symptoms and from community violence to peer support of risky behaviour. For girls, the only significant path was from low parent attachment to peer support of risky behaviour. CONCLUSIONS: This cross-sectional study sheds new light on the possible pathways from witnessing community violence to mental health problems among SA adolescents. Identifying factors that drive and mitigate psychological distress in the context of persistent community violence is critical to SA's future and can inform the selection and delivery of appropriate and targeted evidence-based interventions.

Risk of neurosyphilis in HIV-infected persons with syphilis lacking signs or symptoms of central nervous system infection.

OBJECTIVES: People living with HIV (PLWH) are at increased risk of asymptomatic neurosyphilis; thus, it has been common practice to perform a lumbar puncture (LP) in all PLWH presenting with syphilis regardless of stage, signs or symptoms. However, this practice varies widely among clinicians. Our objective was to elucidate the number of LPs required to diagnose a single case of asymptomatic neurosyphilis. METHODS: We performed an electronic health record (EHR) review of PLWH who were diagnosed with syphilis of any stage over a 10-year period. EHRs were reviewed to determine the number of subjects who had an LP performed, what proportion had neurological signs or symptoms, and whether a diagnosis of neurosyphilis was made at presentation or follow-up. RESULTS: In 261 separate episodes of syphilis in 230 subjects, we found the major risk factors for asymptomatic neurosyphilis to be low CD4 T-cell count (P = 0.0007), high rapid plasma reagin (RPR) titre (P = 0.019) and lack of HIV virological suppression (P = 0.003). The majority of our subjects (78%) with neurosyphilis presented with central nervous system (CNS) symptoms. We estimate, if standard practice is to perform LP in all patients, that the number needed to test (NNTT) = 38. CONCLUSIONS: This large number of potentially unnecessary LPs, along with heterogeneity of presentation, and the never-nil risk of asymptomatic neurosyphilis should be incorporated into clinical decision-making. The majority of PLWH presenting with a serological diagnosis of syphilis, but no neurological signs or symptoms, do not necessarily require an LP for an evaluation of asymptomatic neurosyphilis.

Longitudinal determinants of consistent condom use by partner type among young injection drug users: the role of personal and partner characteristics.

We investigated the longitudinal influence of individual-, relationship- and social-level factors on condom use by partner type among young injections drug users (IDUs) enrolled in the Collaborative Injection Drug Users Study-III/Drug Users Intervention Trial (CIDUS-III/DUIT) from 2002 to 2004. Based on longitudinal analysis using generalized estimating equations (GEE), consistent condom use with main partners was more commonly reported among males and those with greater self-efficacy for condom use; main partner's desire for pregnancy and needle sharing were negatively associated with consistent condom use. Among those with casual partners, having fewer sex partners was associated with consistent condom use. Positive attitudes toward condom use and partner norms supporting condom use were associated with greater consistent condom use with both partner types. These findings suggest that intervention strategies targeting individual- and partner-level factors may provide avenues for intervening upon sexual risks among young IDUs.

Trends in inhalant use among high school students in Illinois: 1993-1995.

Data were analyzed from two years (1993 and 1995) of a statewide survey of high school students on drug use. Changes in the rates of inhalant use, and associations between inhalant use and sociodemographic variables, were examined across the two survey years. Measures of inhalant use included lifetime use, past year use, and past month use. Analyses showed no significant difference in the rates of inhalant use across years. Associations with sex, ethnicity, and age were partly consistent with previous research findings. Both lifetime and recent inhalant use were more prevalent among males than females. Blacks were less likely to use inhalants (lifetime and recent) than other racial/ethnic groups in both survey years. Native Americans showed elevated rates of recent inhalant use in 1993, but not in 1995. While age trends in the 1993 survey were consistent with expectations, age trends in the 1995 survey were not. Recent inhalant use was constant across age groups in the 1995 sample. Also contrary to expectations, inhalant use was not more prevalent in low-income or high-poverty areas. The associations of inhalant use with family intactness and academic performance varied by race/ethnicity. Family intactness was a significant protective factor only for whites and Hispanics. Poor grades were not a significant predictor of lifetime inhalant use for blacks, and the protective effect of high grades was found only for whites. Poor grades were highly predictive of lifetime inhalant use for Asians.

Decreased drug reporting in a cross-sectional student drug use survey.

PURPOSE: Prior longitudinal cohort studies have suggested that reinterviews about drug use often lead to decreased reports of lifetime substance use (recanting). Respondents may edit their answers on reinterview because of perceptions regarding question threat. Since reinterviews usually occur after long periods of time, the influence of inadequate recall (memory), cannot be ruled out. In order to evaluate the relative importance of editing and memory on recanting, we examined a cross-sectional survey administered in 1993 to a probability sample of Illinois students who were in the 7th through 12th grade. METHODS: Two sets of self-administered survey questions assessed drug use: the I-SAY drug-use questionnaire, and a supplemental questionnaire asked at the end of the main survey. We compared the rates of "new use" (no use for a drug reported in the I-SAY, use reported for a drug on the supplement) with rates of recanting (use for a drug reported on the I-SAY, no use for a drug reported on the supplement). RESULTS: Recanting was generally more pronounced than new use, especially for cocaine, heroin, marijuana, and inhalants. Those classified as light or inconsistent users on the I-SAY were significantly more likely to recant their drug use reports.

A mass-distributed CD-ROM for school-based suicide prevention.

Recent violent events in schools in the United States have underscored the need for an examination of efforts aimed at mass education of school professionals on issues related to violence prevention and crisis intervention. A CD-ROM ("Team Up to Save Lives: What Your School Should Know About Preventing Youth Suicide") was mass mailed to schools throughout the United States in January 1997. We conducted an initial evaluation of this intervention in the Chicago area and found that the scope of the CD's impact was relatively narrow: Only 39% of all schools with informants that were contacted actually reviewed the CD-ROM and provided feed back for the evaluation. Insufficient time, computer equipment, and training were the major obstacles to CD-ROM use and to participation in the evaluation. Among those reviewing the CD-ROM, overall perceptions regarding its utility were extremely favorable. Multiple instances in which the CD had been used to address actual crisis situations were identified.

Inhalant use and delinquent behavior among adolescents: a comparison of inhalant users and other drug users.

AIMS: To evaluate the association between inhalant use and delinquent or criminal behavior. DESIGN: A large statewide sample of high school students participated in a survey on drug use. Five groups were identified based on reported drug use: inhalant experimenters, other drug experimenters, inhalant users, other drug users and non-users. Inhalant users were compared with other drug users and inhalant experimenters with other drug experimenters on three measures of problem behavior. PARTICIPANTS: Over 13,000 students in grades 7-12 participated in the 1993 survey on drug use. MEASUREMENTS: Three measures of problem behavior: drinking and drug-taking, "trouble behavior" and minor criminal activity. FINDINGS: Among upper (9-12) grade level students only, both inhalant users and inhalant experimenters reported more minor criminal activity than other drug users and other drug experimenters, respectively. A similar trend was noted for trouble behavior. The same was not found for drinking and drug-taking behavior. CONCLUSIONS: The findings suggest that inhalant use is categorically different from other drug use, and that it has more in common with general delinquency than with general drug use. Prevention and treatment strategies should take this into consideration.

Sequence of drug use among serious drug users: typical vs atypical progression.

Sequence of drug use was examined in a secondary analysis of two samples of serious drug users: one of 152 men and one of 133 women. The proportions of drug users following specified patterns of drug use onset were compared to proportions obtained in previous research in samples of high school youth, and serious drug users. The serious drug users were substantially different from high school samples in their progression of drug use. The serious drug users were less likely to follow the typical sequence identified in previous studies (alcohol, then marijuana, followed by other illicit drugs). They were more likely to have used marijuana before using alcohol, and more likely to have used other illicit drugs before using marijuana. We also found that atypical sequencing was associated with earlier initiation of the use of illicit drugs other than marijuana and greater lifetime drug involvement. These findings suggest that for a large number of serious drug users, marijuana does not play the role of a 'gateway drug'. We conclude that prevention efforts which focus on alcohol and marijuana may be of limited effectiveness for youth who are at risk for serious drug abuse.

Childhood abuse and the use of inhalants: differences by degree of use.

OBJECTIVES: Using two existing ethnographic studies of drug-involved adults, this study evaluates the association between child-abuse victimization and levels of involvement in inhalant use. METHODS: Historical accounts of childhood exposure to physical or sexual abuse were compared among nonusers of inhalants (n = 197), light inhalant users (n = 64), and heavy inhalant users (n = 24). Crude and adjusted odds ratios were used to compare informants with no history of inhalant use with those having a history of light inhalant use and those having a history of heavy inhalant use. RESULTS: Heavy inhalant use was associated with history of any child abuse (adjusted odds ratio [OR] = 4.6) and physical abuse (adjusted OR = 3.8). Light inhalant use showed no association with child-abuse history. CONCLUSIONS: Child abuse may be an important correlate of extensive involvement in inhalant use. The findings invite speculation with respect to a hypothetical causal role for child abuse in the etiology of inhalant use. The lack of support for causality in this study underscores the need for replication and more carefully designed longitudinal research.

The reliability and consistency of drug reporting in ethnographic samples.

Findings are addressed concerning the reliability of reporting on drug dealing and drug use. Reports provided in retrospective life history interviews are compared with reports gathered and summarized from eight prospective weekly interviews. Most subjects reporting involvement in drug dealing during the weekly interviews, also reported involvement in this behavior during the life history report. There was a tendency for subjects to deny current involvement in drug dealing during the life history reports, even though they reported involvement in drug dealing in the weekly interviews. Binary indicators derived from life history interviews about current drug use were consistent with reports provided prospectively. Subjects reported considerably higher use quantities and frequencies for substances in the life history reports than they did in the weekly interview reports. These results are examined in the context of other recent work examining the reliability of retrospective substance involvement reports. Implications for ethnographic research on drug use are discussed.

Assessment of knowledge gains in proactive training for postvention.

This paper describes the development of a knowledge measure for the evaluation of a proactive training program for suicide postvention and analyses of its psychometric properties. The 25-item true-false knowledge test was administered before and after each of 12 training sessions; a total of 205 school personnel participated in the training and evaluation. Participants showed significant improvement in overall test scores and on several individual items following the training. Analyses suggested that the measure has construct validity, and that it taps a single underlying dimension. Strengths and weaknesses of the measure, and measurement issues in program evaluation are discussed.

Substance involvement among juvenile murderers: comparisons with older offenders based on interviews with prison inmates.

We evaluated substance involvement among incarcerated juvenile offenders convicted of murder of manslaughter. Patterns of substance involvement among juvenile offenders were compared with patterns found in older offenders. Irrespective of age group, close to one-third of all homicide perpetrators reported that they were affected by alcohol prior to the offense. In every age group, alcohol was the substance showing the highest rate of "regular" lifetime use and the highest rate of ingestion in the week preceding the homicide. In many respects, the reported substance use patterns in the 16-17-year-old age group were closer to the patterns demonstrated by the oldest (36+) age group than they were to the adjacent 18-20-year-old group. Juvenile offenders were generally less substance involved than all but the oldest group of offenders. Almost all of the juveniles who were substance involved prior to the homicide attributed the homicide to the effects of those substances. Narrative accounts suggest that substances (almost always alcohol) escalated impulsive, spontaneous violent outbursts. Implications for the interpretation of self-reports about substance use provided by murderers are also discussed.

Strategies for school-based response to loss: proactive training and postvention consultation.

The suicide of a student or staff member is one of the most difficult crisis confronting a high school. This article describes the first year of a school-based postvention program to train and consult with crisis personnel in a structured response to this crisis. Responding to Loss (RTL) is one program offered by Community Action for Youth Survival, a project of the Ronald McDonald Children's Charities. Serving a contiguous three county urban area, this program integrates public health, epidemiological, psychiatric, and prevention paradigms to provide a comprehensive approach to the aftermath of adolescent suicide. RTL provides an interdisciplinary model for comprehensive, school-based postvention programs based on the guidelines developed by the Centers for Disease Control and national and local psychological autopsy data. It highlights the significance of responding to increased rates of suicide in minority youth, suicide witnessed by peers, and suicide victims who have dropped out of school. Organizational issues, such as systematic school entry, development of a computerized school database, proactive training, and collaboration with the offices of medical examiners and coroners, are described. Initial evaluation data from year 1 indicate significant gains in participants' knowledge and skills, as well as a high rate of consumer satisfaction.

Inconsistencies in lifetime cocaine and marijuana use reports: impact on prevalence and incidence.

We evaluated inconsistencies in responses to questions about lifetime cocaine and marijuana use asked of nearly 10,000 respondents from the United States in the National Longitudinal Survey of Youth in 1984 and 1988. Our analyses showed that 14% of all responses on cocaine use and 17% of all responses on marijuana use were inconsistent in some way. The types of inconsistencies varied according to the substance; cocaine reports yielded more inconsistencies with regard to timing of first use, while for marijuana most of the inconsistencies were with respect to use disclosure. For both substances, lower level users were more likely to be inconsistent in their reports of drug use. Alternative methods for handling inconsistencies affected estimates of incidence and prevalence. Inconsistencies also varied according to respondent race/ethnicity. Implications of these findings for program evaluation are discussed.