Cluster and regional influences on suicide in a Southwestern American Indian tribe.

Suicide is the second leading cause of death among American Indian youth. Elevated rates of suicide in Indian communities have been attributed both to outbreaks and to regional trends. We assessed the contribution of these two factors for a single tribe, and attempted to define a profile of individuals at risk. Data came from the tribe's registry of suicide attempts and completions for 1990-1993 and analysis of death certificates for the period 1985-1996. Using combined tribal and death certificate data, the average annual (age-adjusted) rate of completed suicide among tribal members was 44.7/100,000 for 1990-1993. Within the 45 suicide deaths and serious attempts in this time period, we identified one grouping of seven cases taking place in a 40-day period. All seven involved hanging and youth (13-28 years old). Using death certificate data alone, the average annual rate of suicide death for non-natives in the surrounding county in the period 1985-1996 was 22.7/100,000. Age-adjusted to the county population, the tribal rate for the same period was not significantly different (24.6/100,000). Tribal and county suicide patterns differed by age distribution and method but not by gender. We concluded that both regional trends and clustering contribute to suicide in this community. Further prevention efforts may need to focus on both unique tribal characteristics and shared factors among non-native neighbors.

Ethnicity, income, and parenting contexts of physical punishment in a national sample of families with young children.

Nearly half of U.S. parents use physical punishment for child discipline. Although some studies relate physical punishment and later dysfunction, others suggest that its effects depend on the context in which it is used. The authors analyzed data from the Commonwealth Fund Survey of Parents With Young Children, a national sample of 2,017 parents with children younger than 3. Parents reported their use of spanking, five other disciplinary practices, and four nurturing interactions. The authors used cluster analysis to define four groups of parents with distinct patterns of discipline and nurturing. Two groups with above-average use of spanking shared a high prevalence of parent depressive symptoms and a low level of nurturing but had markedly different demographic profiles and use of nonphysical punishment. Parents who used average levels of spanking made frequent use of nonphysical disciplinary strategies and had high levels of nurturing interactions. Parents who reported below-average spanking had relatively low levels of both disciplinary and nurturing interactions.

Mothers and daughters from breast cancer families: a qualitative study of their perceptions of risks and benefits associated with minor's participation in genetic susceptibility research.

OBJECTIVES: To determine: 1) the views of daughters at increased risk of developing breast cancer regarding the benefits and risks of participating in genetic susceptibility research; 2) mothers' views about enrolling their daughters in genetic susceptibility research; and 3) any important areas of agreement and disagreement between mothers and daughters in their assessment of risks and benefits. METHODS: We conducted separate interviews of mothers and daughters from 12 breast cancer families recruited primarily through the Breast Center at Johns Hopkins University. Daughters were between the ages of 10 and 17. Interviews were transcribed and coded and analyzed qualitatively. RESULTS: We observed that mothers and daughters had a range of reactions to the prospect of enrolling children and adolescents in genetic susceptibility research, that perceptions of benefits and risks were fairly concordant between mothers and daughters, and that daughters initially identified no risks of participating, but their perceptions of the risks and benefits of genetic susceptibility research evolved over the course of conversation. CONCLUSION: These findings underscore the view that informed consent ought to be a "process" rather than a single event, and that children's first reactions to the prospect of participating in genetic testing research should not be taken as evidence that they have adequately considered the risks and benefits of participation.

Adolescent patients--healthy or hurting? Missed opportunities to screen for suicide risk in the primary care setting.

CONTEXT: Adolescent suicide rates have increased dramatically in recent decades. Suicide is the third leading cause of mortality among persons aged 10 to 19 years. Several official guidelines recommend screening for suicidal behavior in the primary care setting. OBJECTIVES: To determine the prevalence of adolescent suicidal behavior known to primary care providers and to determine the knowledge, attitudes, and practice of primary care physicians in Maryland regarding screening for risk factors for adolescent suicide. DESIGN: Cross-sectional study using mailed survey. SETTING: Maryland from May to July 1995. PARTICIPANTS: All pediatrician (n = 816) and family physician (n = 592) members of the state chapter of the American Academy of Pediatrics and the American Academy of Family Physicians, respectively, who were actively providing ambulatory care. MAIN OUTCOME MEASURES: Adolescent suicidal behavior known to primary care providers and predictors of routine screening for risk factors for adolescent suicide. RESULTS: The response rate was 66%. Three hundred twenty-eight physicians (47%) reported that 1 or more adolescent patients attempted suicide in the previous year, but only 158 (23%) either frequently or always screened adolescent patients for suicide risk factors. Significant factors correlating with routine screening for suicide risk factors included frequently or always counseling about the safer storage of firearms in the home (odds ratio [OR], 5.3; 95% confidence interval [CI], 2.8-10.2); agreeing or strongly agreeing that they were sufficiently trained and knew how to screen for risk factors (OR, 3.2; 95%/CI, 1.7-6.3); agreeing or strongly agreeing that they had enough time during the well visit to screen for mental health problems (OR, 2.9: 95% CI, 1.6-5.3); frequently or always counseling about child passenger safety (OR, 2.7; 95% CI, 1.6-4.7); spending more than 5 minutes in anticipatory guidance during the well visit (OR, 2.7: 95% CI, 1.5-4.6); practicing in an urban setting (OR, 2.3; 95)% CI, 1.2-4.7); agreeing or strongly agreeing that physicians can be effective in preventing adolescent suicide and that what they do during an office visit may help prevent adolescent suicide (OR, 2.0; 95% CI, 1.2-3.4); and female sex (OR. 1.9; 95% CI, 1.1-3.2). CONCLUSION: Despite the substantial proportion of primary care providers who encountered suicidal adolescent patients, most providers still do not routinely screen their patients for suicidality or associated risk factors. More training is needed and desired by the survey respondents. Patient confidentiality issues must be addressed. Development and widespread use of a short, easily administered, reliable, and valid screening tool are recommended to help busy clinicians obtain more complete information during all visits.

Parenting and physical punishment: primary care interventions in Latin America.

Physical punishment is a form of intrafamilial violence associated with short- and long-term adverse mental health outcomes. Despite these possible consequences, it is among the most common forms of violent interpersonal behavior. For many children it begins within the first year of life. The goal of this study was to determine the feasibility of involving public sector primary health care providers to inform parents about alternatives to physical punishment. The study used a qualitative design utilizing focus groups and survey questionnaires with parents and providers at six clinic sites chosen to be representative of public sector practice settings in Costa Rica and in metropolitan Santiago, Chile. The data were collected during 1998 and 1999. In the focus groups and surveys the parents voiced a range of opinions about physical punishment. Most acknowledged its common use but listed it among their least preferred means of discipline. Frequency of its use correlated positively with the parents' belief in its effectiveness and inversely with their satisfaction with their children's behavior. Some parents wanted to learn more about discipline; others wanted help with life stresses they felt led them to use physical punishment. Parents reported they chose other family members more frequently as a source of parenting information than they did health care providers. Some parents saw providers as too rushed and not knowledgeable enough to give good advice. Providers, in turn, felt ill equipped to handle parents' questions, but many of the health professionals expressed interest in more training. Parents and providers agreed that problems of time, space, and resources were barriers to talking about child discipline in the clinics. Many parents and providers would welcome a primary-care-based program on physical punishment. Such a program would need to be customized to accommodate local differences in parent and provider attitudes and in clinic organization. Health care professionals need more training in child discipline and in the skills required to interact with parents on issues relating to child behavior.

Sexual orientation and risk of suicide attempts among a representative sample of youth.

OBJECTIVE: To examine whether sexual orientation is an independent risk factor for reported suicide attempts. DESIGN: Data were from the Massachusetts 1995 Centers for Disease Control and Prevention Youth Risk Behavior Survey, which included a question on sexual orientation. Ten drug use, 5 sexual behavior, and 5 violence/ victimization variables chosen a priori were assessed as possible mediating variables. Hierarchical logistic regression models determined independent predictors of suicide attempts. SETTING: Public high schools in Massachusetts. PARTICIPANTS: Representative, population-based sample of high school students. Three thousand three hundred sixty-five (81%) of 4167 responded to both the suicide attempt and sexual orientation questions. MAIN OUTCOME MEASURE: Self-reported suicide attempt in the past year. RESULTS: One hundred twenty-nine students (3.8%) self-identified as gay, lesbian, bisexual, or not sure of their sexual orientation (GLBN). Gender, age, race/ethnicity, sexual orientation, and all 20 health-risk behaviors were associated with suicide attempt (P<.001). Gay, lesbian, bisexual, or not sure youth were 3.41 times more likely to report a suicide attempt. Based on hierarchical logistic regression, female gender (odds ratio [OR], 4.43; 95% confidence interval [CI], 3.30-5.93), GLBN orientation (OR, 2.28; 95% CI, 1.39-3.37), Hispanic ethnicity (OR, 2.21; 95% CI, 1.44-3.99), higher levels of violence/ victimization (OR, 2.06; 95% CI, 1.80-2.36), and more drug use (OR, 1.31; 95% CI, 1.22-1.41) were independent predictors of suicide attempt (P<.001). Gender-specific analyses for predicting suicide attempts revealed that among males the OR for GLBN orientation increased (OR, 3.74; 95% CI, 1.92-7.28), while among females GLBN orientation was not a significant predictor of suicide. CONCLUSIONS: Gay, lesbian, bisexual, or not sure youth report a significantly increased frequency of suicide attempts. Sexual orientation has an independent association with suicide attempts for males, while for females the association of sexual orientation with suicidality may be mediated by drug use and violence/victimization behaviors.

Patient-provider communication during the emergency department care of children with asthma. The National Cooperative Inner-City Asthma Study, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD.

OBJECTIVES: Poor children's reliance on emergency facilities is one factor implicated in the rise of morbidity attributed to asthma. Although studies have examined doctor-patient communication during routine pediatric visits, little data are available about communication during emergency care. This study sought to describe communication during emergency treatment of childhood asthma to learn if a "patient-centered" provider style was associated with increased parent satisfaction and increased parent and child participation. METHODS: This cross-sectional, observational study examined 104 children aged 4 to 9 years and their guardian(s) attending emergency departments in seven cities. Quantitative analysis of provider-family dialogue was performed. Questionnaires measured satisfaction with care, provider informativeness, and partnership. RESULTS: Providers' talk to children was largely supportive and directive; parents received most counseling and information. Children spoke little to providers (mean: 20 statements per visit versus 156 by parents). Providers made few statements about psychosocial aspects of asthma care (mean: three per visit). Providers' patient-centered style with parents was associated with more talk from parents and higher ratings for informativeness and partnership. Patient-centered style with children was associated with five times the amount of talk from children and with higher parent ratings for "good care," but not for informativeness or partnership. CONCLUSIONS: Communication during emergency asthma care was overwhelmingly biomedical. Children took little part in discussions. A patient-centered style correlated with increased parent and child participation, but required directing conversation toward both parents and children.

Toward effective discussion of discipline and corporal punishment during primary care visits: findings from studies of doctor-patient interaction.

Corporal punishment is widely practiced despite evidence of its harm to children. Clinicians can more effectively counsel alternatives if they: are clear in their own minds about the risks of corporal punishment and its boundaries with reportable child maltreatment; appreciate parents' justifications for corporal punishment and offer corresponding alternatives; demonstrate their interest and expertise in matters of child behavior and family dynamics; practice communication techniques that elicit discussion of psychosocial topics and facilitate mutual problem solving; let parents take the lead in tailoring alternative disciplinary strategies to the family's unique needs; start early helping parents understand child behavior in general and their child's temperament and development in particular. Clinicians as a group should demonstrate a united stand against the use of violence within families. Both undergraduate and continuing medical education should involve training in communication skills in general and problem-solving techniques in particular. Pediatricians need more time during their training to learn about child behavior and family dynamics.

Pediatrician interview style and mothers' disclosure of psychosocial issues.

OBJECTIVE: Primary care pediatricians play an important role in the detection, diagnosis, treatment, and referral of children with mental health problems. Some parents, however, are reluctant to discuss behavioral and emotional symptoms with their child's pediatrician. Studies of patient-physician communication suggest that specific aspects of pediatrician interview style (asking questions about psychosocial issues, making supportive statements, and listening attentively) increase disclosure of sensitive information. We hypothesized that disclosures of parent and child psychosocial problems would be more likely to occur during visits when pediatricians used these techniques. DESIGN: Cross-sectional analysis of a systematic sample of pediatric primary care visits. POPULATION: Two hundred thirty-four children ages 6 months to 14 years and their mothers or female guardians attending an inner-city hospital-based pediatric primary care clinic; 52 physicians in their second or third year of pediatric residency training. METHODS: Visits audiotaped and dialogue coded using the Roter Interactional Analysis System. Independent variables included counts of pediatrician utterances in the following categories: (a) questions about psychosocial issues, (b) statements of support and reassurance, and (c) statements indicating sympathetic and attentive listening. Dependent variables were the disclosure of information about: (a) parental medical or emotional impairment, (b) family disruption, (c) use of physical punishment, and (d) aggressive or overactive child behavior. RESULTS: Use of psychosocially oriented interviewing techniques was associated with a greater likelihood of disclosure for all four of the topic areas studied. Odds ratios for disclosure, adjusted for parental concerns and child age, ranged from 1.09 to 1.22 depending on the interview technique and outcome involved. Positive associations were observed both for topics raised primarily in response to pediatrician questions (family and parent problems) and for topics raised primarily by mothers (behavior and punishment). CONCLUSIONS: Three simple communication skills were associated with disclosure of specific concerns relevant to child mental health. Training pediatricians to use these skills would help to better detect and diagnose children's mental health problems.

Family violence and the evaluation of behavioral concerns in a pediatric primary care clinic.

The goals of this study were to determine 1) the prevalence of exposure to intrafamilial violence among children attending a pediatric primary care clinic; 2) the prevalence of psychosocial distress among mothers bringing their children to the clinic; 3) the extent to which pediatricians are aware of family violence and maternal distress among their patients; and 4) whether families reporting violence are more likely to report behavioral or emotional problems with their children. The study focused on 243 mothers and their children who made scheduled visits to an inner-city, hospital-based pediatric residents' continuity clinic. The children ranged in age from 6 months to 14 years, with 69% of the children 2 years of age or younger. Parents answered questions about their own and their child's psychosocial functioning, including a modified version of the Conflict Tactics Scale, an instrument used to measure the prevalence of intrafamilial violence. Physicians independently rated parent and child psychosocial health and the likelihood of violence in the family. Forty percent of mothers said their family in the past year had experienced at least one episode of the five most serious types of violence described on the Conflict Tactics Scale. Mothers reporting these levels of violence were more likely to report psychosocial distress in their own lives as well as those of their children. Furthermore, family violence predicted maternal concern for child behavior even after accounting for the increased maternal distress associated with violence. Physicians had difficulty predicting which mothers would report violence (sensitivity 27%, specificity 81%) or which mothers would report concern about child behavior and emotional health. The authors concluded that an instrument like the Conflict Tactics Scale might both add to physicians' awareness of family violence and help explain some parental concerns about the behavior or emotional health of apparently asymptomatic children.

Use of epidemiological data in the diagnosis of physical child abuse: variations in response to hypothetical cases.

This study was undertaken to determine whether epidemiological data describing the injuries associated with unintentional trauma could help physicians differentiate intentional from unintentional injury. The authors also wished to determine if case and physician-specific factors altered how epidemiological data were used. Study subjects were 280 physicians who had registered for an advanced course in pediatric life support. Responses were received from 166 (59%); 48% were pediatricians and 37% had trained in emergency medicine. Case vignettes were written describing a child's fall from a highchair. The vignettes systematically varied the type of injury sustained, the presence of a social risk factor, and whether the child was followed by a primary care provider. Vignettes were administered with and without provision of epidemiological data describing injuries associated with highchair falls. Each study participant received one vignette, and was asked to mark, on a 0-100 scale, their confidence in the injury history given. In vignettes where the presenting injury (femur fracture) would not be expected based on the epidemiological data, the availability of data appropriately decreased confidence that the injury was unintentional (average decrease = 14.3, 95% confidence limits = 3.8 to 25.9). When the presenting injury (skull fracture) matched the epidemiological data, its availability did not alter confidence (average change = 0.5, 95% to -13.1 to + 12.1). The impact of a contrast between presenting injury and data varied with specialty: It caused a marked drop in confidence among pediatricians but caused no change among emergency room/intensive care unit (ER/ICU) physicians. Data did, however, lead ER/ICU physicians to respond more strongly to a social risk cue (mean confidence 14.9 vs. 42.4, p less than .05) than they had in the absence of data. We concluded that epidemiological data has the potential for influencing physician decision-making in cases of suspected maltreatment, but that its impact may vary among physicians with differing training.

Effectiveness of an antihistamine-decongestant combination for young children with the common cold: a randomized, controlled clinical trial.

We tested the hypothesis that antihistamine-decongestant combinations cause no clinically significant relief of the symptoms of upper respiratory tract infections in young children by randomly assigning 96 children to one of three treatment groups: antihistamine-decongestant, placebo, and no treatment. There were no differences among the three study groups in the proportion of children considered "better" overall by the parent 48 hours after the initial assessment (drug, 67%; placebo, 71%; no treatment, 57%; p = 0.53). There were no differences among groups in individual or composite symptom score changes. Two thirds of parents whose children were eligible for the drug trial believed that their child needed medicine for cold symptoms. In the proportion of parents believing that their child needed medicine, there was no difference between those who consented to participate and those who refused. Parents who wanted medicine at the initial visit reported more improvement at follow-up, regardless of whether the child received drug, placebo, or no treatment. We conclude that there is no clinically significant improvement in symptoms of upper respiratory tract infection, including no significant placebo effect, in young children for whom an antihistamine-decongestant is prescribed.

Case management and quality assurance to improve care of inner-city children with asthma.

Case management and quality assurance techniques were used in a program designed to improve the process and outcomes of care for inner-city children with asthma. The program had three major elements: assessment of the care of individual patients and feedback to their primary care providers, periodic contact with parents, and provision of educational materials about asthma to parents. Telephone interviews with parents were used to assess knowledge of home asthma care and the type of care prescribed by the child's physician. Medicaid and hospital records were used to measure acute care utilization. Eighty-eight children (aged 0 to 5 years) who had made more than two emergency room visits for asthma were recruited by telephone. Fifty-six prescribing errors were identified, 24 being failure to prescribe an additional drug for short-term use by children receiving continuous therapy. Acute care use dropped 50% compared with a control period. This type of program is feasible but may require in-person recruiting to reach high-risk families without telephones.

Poverty, race, and hospitalization for childhood asthma.

This study uses Maryland hospital discharge data for the period 1979-82 to determine whether Black children are more likely to be hospitalized for asthma and whether this difference persists after adjustment for poverty. The average annual asthma discharge rate was 1.95/1000 children aged 1-19; 3.75/1000 for Black children, and 1.25/1000 for White. Medicaid-enrolled children of both races had increased discharge rates for asthma compared to those whose care was paid for by other sources: 5.68/1000 vs 2.99/1000 for Blacks, and 3.10/1000 vs 1.11/1000 for Whites. When ecologic analyses were performed, populations of Black and White children had nearly equal asthma discharge rates after adjustment for poverty. The statewide adjusted rate was 2.70/1000 (95% CL = 1.93, 3.78) for Black children and 2.10/1000 (1.66, 2.66) for White children. Among Maryland counties and health planning districts, variation in asthma discharge rates was not associated with the supply of hospital beds or the population to primary-care physician ratio. We conclude that Black children are at increased risk of hospitalization for asthma, but that some or all of this increase is related to poverty rather than to race.