Cardiovascular deaths in children: general overview from the National Center for the Review and Prevention of Child Deaths.

BACKGROUND: Cardiovascular conditions rank sixth in causes of death in 1- to 19-year-olds. Our study is the first analysis of the cardiovascular death data set from the National Center for the Review and Prevention of Child Deaths, which provides the only systematic collection of cardiovascular deaths in children. METHODS: We developed an analytical data set from the National Center for the Review and Prevention of Child Deaths database for cardiovascular deaths in children 0 to 21 years old, reviewing 1,098 cases from 2005 to 2009 in 16 states who agreed to participate. RESULTS: Cardiovascular cases were aged 4.8 ± 6.6 years; 55.3%, ≤1 year; 24.6%, ≥10 years; male, 58%; white, 70.5%; black, 22.3%; Hispanic, 19.5%. Prior conditions were present in 48.5%: congenital heart disease, 23%; cardiomyopathies, 4.6%; arrhythmia, 1.7%; and congestive heart failure, 1.6%. Deaths occurred most frequently in urban settings, 49.2%; and in the hospital, 40.4%; home, 26.1%; or at school/work/sports, 4.8%. Emergency medical services were not evenly distributed with differences by age, race, ethnicity, and area. Autopsies (40.4%) occurred more often in those >10 years old (odds ratio [OR] 2.9), blacks (OR 1.6), or in those who died at school/work/sports (OR 3.9). The most common cardiovascular causes of death included congenital heart disease, 40.8%; arrhythmias, 27.1%; cardiomyopathy, 11.8%; myocarditis, 4.6%; congestive heart failure, 3.6%; and coronary artery anomalies, 2.2%. CONCLUSIONS: Our study identified differences in causes and frequencies of cardiovascular deaths by age, race, and ethnicity. Prevention of death may be impacted by knowledge of prior conditions, emergency plans, automated external defibrillator programs, bystander cardiopulmonary resuscitation education, and by a registry for all cardiovascular deaths in children.

Development of a data set of national cardiovascular deaths in the young.

BACKGROUND: The only systematic collection of cardiovascular (CV) deaths in children resides in the database derived from the Case Reporting System of the National Center for the Review and Prevention of Child Deaths (NCRPCD). We describe the process used to develop an analytical data set to inform our understanding of CV deaths in children from this database. METHODS: Twenty-five states reporting natural CV deaths during 2005 to 2009 were contacted. Sixteen states agreed to participate. Cases experienced a natural CV death and were 0 to 21 years. Challenges to building a final analytical data set were identified and included reclassification, recategorization, and the development of new variables from existing data, including an algorithm to identify sudden cardiac deaths. RESULTS: The final data set included 1,098 cases. Missing data comprised a mean of 41.7% for most key variables. Cardiovascular cases were aged 4.8 ± 6.6 years; 55.3%, ≤1 year, 24.6%, ≥10 years; male, 58%; white, 70.5%; black, 22.3%; and Hispanic, 19.5%. CONCLUSIONS: This manuscript provides the first description of the natural CV death data set from the NCRPCD. We identify potential beneficial changes in the NCRPCD Case Reporting System and review process. Analysis of these data will help determine characteristics of CV deaths and allow the assessment of risk factors that can be used to prevent CV death in the young. The rate of CV death can be lowered using knowledge of associations that can be gleaned from this robust database. Best practices for prevention hold promise for a future with fewer deaths that will need to be reviewed.

Preventing young children's injuries: analysis of data from a population-based surveillance.

The objective of this study is to determine prevention strategies for potentially serious injury events among children younger than 3 years of age based upon circumstances surrounding injury events. Surveillance was conducted on all injuries to District of Columbia (DC) residents less than 3 years old that resulted in an Emergency Department (ED) visit, hospitalization, or death for 1 year. Data were collected through abstraction of medical records and interviews with a subset of parents of injured children. Investigators coded injury-related events for the potential for death or disability. Potential prevention strategies were then determined for all injury events that had at least a moderate potential for death or disability and sufficient detail for coding (n = 425). Injury-related events included 10 deaths, 163 hospitalizations, and 2,868 ED visits (3,041 events in total). Of the hospitalizations, 88% were coded as moderate or high potential for disability or death, versus only 21% of the coded ED visits. For potentially serious events, environmental change strategies were identified for 47%, behavior change strategies for 77%, and policy change strategies for 24%. For 46% of the events more than one type of prevention strategy was identified. Only 8% had no identifiable prevention strategy. Prevention strategies varied by specific cause of injury. Potential prevention strategies were identifiable for nearly all potentially serious injury events, with multiple potential prevention strategies identified for a large fraction of the events. These findings support developing multifaceted prevention approaches informed by community-based injury surveillance.

Cross-national variation of gender differences in adolescent subjective health in Europe and North America.

The cross-national consistency and variation of gender differences in subjective health complaints was examined in a sample of 125732 11- to 15-year-olds from 29 European and North American countries, participating in the WHO collaborative study 'Health behaviour in school-aged children (HBSC) 1997/98'. Health complaints were measured with the Health Behaviour in School-aged Children Symptom Checklist. Gender differences in health complaints were analysed through multilevel logistic regression analysis. The results indicated a very robust pattern of increasing gender differences across age, with 15-year-old girls as a group at increased risk for health complaints across all countries. The magnitude of gender differences varied across countries, with some countries showing a consistently strong gender difference across age group and different health complaints, and other countries showing a consistently weak gender difference. The gender difference in health complaints was stronger in countries with a low gender development index score. The findings underscore the need to incorporate socio-contextual factors in the study of gender health inequalities during adolescence.

School connectedness in the health behavior in school-aged children study: the role of student, school, and school neighborhood characteristics.

School connectedness includes liking school and positive relations with teachers and peers. School connectedness is associated with a variety of positive health outcomes. The goal of this study was to identify characteristics of students, schools, and school neighborhoods that are related to school connectedness. In the Health Behavior in School-Aged Children (HBSC) Study, school connectedness was reported by 13,207 students (grades 6-10) in 340 schools. HBSC measured a variety of student characteristics. Characteristics of schools were culled from data maintained by Quality Education Data, and school neighborhood characteristics were derived from the 2000 decennial census. Associations between connectedness and student, school, and school neighborhood characteristics were estimated using hierarchical linear models. Characteristics of students, schools, and school neighborhoods were associated with school connectedness. Connectedness was greater among younger students, females, students with better academic performance and greater extracurricular involvement, students with greater self-rated physical attractiveness, students with more friends, students from 2-parent families, and students whose parents were more involved with school. Connectedness was greater in smaller schools, more racially homogeneous schools, and schools with more students from relatively wealthy households. School connectedness was higher in neighborhoods with a greater percentage of non-US citizens. As the percent of renters in the neighborhood increased beyond 20%, school connectedness tended to decrease. The findings point to possible strategies for fostering school connectedness.

Relationships between bullying and violence among US youth.

OBJECTIVE: To determine the extent to which bullying and being bullied, both in and away from school, is associated with involvement in violent behavior. DESIGN, SETTING, AND PARTICIPANTS: A US representative cross-sectional sample of 15 686 students in grades 6 through 10 in public and private schools completed the World Health Organization's Health Behaviour in School-aged Children survey in 1998. MAIN OUTCOME MEASURES: Self-report of weapon carrying, weapon carrying in school, physical fighting, and being injured in a physical fight. RESULTS: Involvement in each of the violence-related behaviors ranged from 13% to 23% of boys and 4% to 11% of girls. Bullying others and being bullied were consistently related to each violence-related behavior for both boys and girls. Greater odds of involvement occurred with bullying others than being bullied, and greater odds of involvement occurred with bullying that took place away from school than that occurring in school. For example, the adjusted odds ratio for weapon carrying associated with being bullied in school weekly was 1.5, for bullying others in school 2.6, for being bullied away from school 4.1, and for bullying others away from school 5.9. CONCLUSION: Bullying should not be considered a normative aspect of youth development, but rather a marker for more serious violent behaviors, including weapon carrying, frequent fighting, and fighting-related injury.

Body mass index and overweight in adolescents in 13 European countries, Israel, and the United States.

OBJECTIVE: To compare the body mass index (BMI) (calculated as weight in kilograms divided by the square of height in meters) and the prevalence of BMI at or above the 85th centile and 95th centile (overweight) in adolescents. DESIGN: Cross-sectional, nationally representative school-based surveys in 1997-1998 by means of identical data collection methods. SETTING: Austria, Czech Republic, Denmark, Flemish Belgium, Finland, France, Germany, Greece, Lithuania, Ireland, Israel, Portugal, Slovakia, Sweden, and the United States. PARTICIPANTS: A total of 29 242 boys and girls, aged 13 and 15 years. MAIN OUTCOME MEASURES: The BMI, BMI at or above the 85th centile, and BMI at or above the 95th centile (overweight) from self-reported height and weight. RESULTS: The highest prevalence of overweight was found in the United States and the lowest in Lithuania. On the basis of the study reference standard, the prevalence of overweight (percentage) in the United States was 12.6% in 13-year-old boys, 10.8% in 13-year-old girls, 13.9% in 15-year-old boys, and 15.1% in 15-year-old girls, all significantly increased. Prevalence of overweight in Lithuania was significantly below the expected 5%, with 1.8% in 13-year-old boys, 2.6% in 13-year-old girls, 0.8% in 15-year-old boys, and 2.1% in 15-year-old girls. Relative rankings among countries were similar for BMI at or above the 85th centile, although there were less dramatic differences at this level. CONCLUSIONS: The highest prevalences of overweight were found in the United States, Ireland, Greece, and Portugal.

Cross-national consistency in the relationship between bullying behaviors and psychosocial adjustment.

OBJECTIVE: To determine whether the relationship between bullying and psychosocial adjustment is consistent across countries by standard measures and methods. DESIGN: Cross-sectional self-report surveys were obtained from nationally representative samples of students in 25 countries. Involvement in bullying, as bully, victim, or both bully and victim, was assessed. SETTING: Surveys were conducted at public and private schools throughout the participating countries. PARTICIPANTS: Participants included all consenting students in sampled classrooms, for a total of 113 200 students at average ages of 11.5, 13.5, and 15.5 years. MAIN OUTCOME MEASURES: Psychosocial adjustment dimensions assessed included health problems, emotional adjustment, school adjustment, relationships with classmates, alcohol use, and weapon carrying. RESULTS: Involvement in bullying varied dramatically across countries, ranging from 9% to 54% of youth. However, across all countries, involvement in bullying was associated with poorer psychosocial adjustment (P<.05). In all or nearly all countries, bullies, victims, and bully-victims reported greater health problems and poorer emotional and social adjustment. Victims and bully-victims consistently reported poorer relationships with classmates, whereas bullies and bully-victims reported greater alcohol use and weapon carrying. CONCLUSIONS: The association of bullying with poorer psychosocial adjustment is remarkably similar across countries. Bullying is a critical issue for the health of youth internationally.

Prevalence of and risk factors for depressive symptoms among young adolescents.

OBJECTIVE: To determine the prevalence, risk factors, and risk behaviors associated with depressive symptoms in a nationally representative, cross-sectional sample of young adolescents. DESIGN: A school-based survey collected through self-administered questionnaires in grades 6, 8, and 10 in 1996. SETTING: Schools in the United States. PARTICIPANTS: 9863 students in grades 6, 8, and 10 (average ages, 11, 13, and 15). MAIN OUTCOME MEASURES: Depressive symptoms, substance use, somatic symptoms, scholastic behaviors, and involvement in bullying. RESULTS: Eighteen percent of youths reported symptoms of depression. A higher proportion of females (25%) reported depressive symptoms than males (10%). Prevalence of depressive symptoms increased by age for both males and females. Among American Indian youths, 29% reported depressive symptoms, as compared with 22% of Hispanic, 18% of white, 17% of Asian American, and 15% of African American youths. Youths who were frequently involved in bullying, either as perpetrators or as victims, were more than twice as likely to report depressive symptoms than those who were not involved in bullying. A significantly higher percentage of youths who reported using substances reported depressive symptoms as compared with other youths. Similarly, youths who reported experiencing somatic symptoms also reported significantly higher proportions of depressive symptoms than other youths. CONCLUSIONS: Depression is a substantial and largely unrecognized problem among young adolescents that warrants an increased need and opportunity for identification and intervention at the middle school level. Understanding differences in prevalence between males and females and among racial/ethnic groups may be important to the recognition and treatment of depression among youths.

Headache, stomachache, backache, and morning fatigue among adolescent girls in the United States: associations with behavioral, sociodemographic, and environmental factors.

BACKGROUND: Data on the prevalence and co-occurrence of multiple somatic symptoms among US adolescent females as they are influenced by sociodemographic, behavioral, and environmental factors is limited. OBJECTIVES: To describe the health status of adolescent US females measured by the prevalence, frequency, and co-occurrence of headache, stomachache, backache, and morning fatigue and to investigate associations between selected risk and protective factors. DESIGN, SETTING, AND PARTICIPANTS: School-based, cross-sectional, nationally representative survey of adolescents in the 6th through 10th grades in the US. Data collected between 1997 and 1998. MAIN OUTCOME MEASURES: Prevalence of headache, stomachache, backache, and morning fatigue. RESULTS: Among US adolescent girls, 29.1% experience headaches, 20.7% report stomachaches, 23.6% experience back pain, and 30.6% report morning fatigue at the rate of more than once a week. Co-occurrence of somatic complaints is common. Among girls who experienced headaches more than once a week, 3.2 million (53.3%) also reported stomach pain more than once a week and 4.1 million (74.3%) reported morning fatigue more than once a week. Heavy alcohol use, high caffeine intake, and smoking cigarettes every day were strongly associated with all symptoms, while parent and teacher support served as protective factors. CONCLUSIONS: Somatic complaints of headache, stomachache, backache, and morning fatigue are common among US adolescent girls and co-occur often. Effective clinical treatment of this population requires comprehensive assessment of all female adolescents presenting with seemingly isolated somatic complaints.

A cross-national study of violence-related behaviors in adolescents.

BACKGROUND: Violent behavior among adolescents is a significant problem worldwide, and a cross-national comparison of adolescent violent behaviors can provide information about the development and pattern of physical violence in young adolescents. OBJECTIVES: To determine and compare frequencies of adolescent violence-related behaviors in 5 countries and to examine associations between violence-related behaviors and potential explanatory characteristics. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional, school-based nationally representative survey at ages 11.5, 13.5, and 15.5 years in 5 countries (Ireland, Israel, Portugal, Sweden, and the United States). MAIN OUTCOME MEASURES: Frequency of physical fighting, bullying, weapon carrying, and fighting injuries in relation to other risk behaviors and characteristics in home and school settings. RESULTS: Fighting frequency among US youth was similar to that of all 5 countries (nonfighters: US, 60.2%; mean frequency of 5 countries, 60.2%), as were the frequencies of weapon carrying (noncarriers: US, 89.6%; mean frequency of 5 countries, 89.6%) and fighting injury (noninjured: US, 84.5%; mean frequency of 5 countries, 84.6%). Bullying frequency varied widely cross-nationally (nonbullies: from 57.0% for Israel to 85.2% for Sweden). Fighting was most highly associated with smoking, drinking, feeling irritable or bad tempered, and having been bullied. CONCLUSIONS: Adolescents in 5 countries behaved similarly in their expression of violence-related behaviors. Occasional fighting and bullying were common, whereas frequent fighting, frequent bullying, any weapon carrying, or any fighting injury were infrequent behaviors. These findings were consistent across countries, with little cross-national variation except for bullying rates. Traditional risk-taking behaviors (smoking and drinking) and being bullied were highly associated with the expression of violence-related behavior.

Multiple risk behavior and injury: an international analysis of young people.

BACKGROUND: Multiple risk behavior plays an important role in the social etiology of youth injury, yet the consistency of this observation has not been examined multinationally. OBJECTIVE: To examine reports from young people in 12 countries, by country, age group, sex, and injury type, to quantify the strength and consistency of this association. SETTING: World Health Organization collaborative cross-national survey of health behavior in school-aged children. PARTICIPANTS: A multinational representative sample of 49 461 students aged 11, 13, and 15 years. MAIN EXPOSURE MEASURES: Additive score consisting of counts of self-reported health risk behaviors: smoking, drinking, nonuse of seat belts, bullying, excess time with friends, alienation at school and from parents, truancy, and an unusually poor diet. MAIN OUTCOME MEASURE: Self-report of a medically treated injury. RESULTS: Strong gradients in risk for injury were observed according to the numbers of risk behaviors reported. Overall, youth reporting the largest number (> or =5 health risk behaviors) experienced injury rates that were 2.46 times higher (95% confidence interval, 2.27-2.67) than those reporting no risk behaviors (adjusted odds ratios for 0 to > or =5 reported behaviors: 1.00, 1.22, 1.48, 1.73, 1.98, and 2.46, respectively; P<.001 for trend). Similar gradients in risk for injury were observed among youth in all 12 countries and within all demographic subgroups. Risk gradients were especially pronounced for nonsports, fighting-related, and severe injuries. CONCLUSIONS: Gradients in risk for youth injury increased in association with numbers of risk behaviors reported in every country examined. This cross-cultural finding indicates that the issue of multiple risk behavior, as assessed via an additive score, merits attention as an etiological construct. This concept may be useful in future injury control research and prevention efforts conducted among populations of young people.

Material deprivation and self-rated health: a multilevel study of adolescents from 22 European and North American countries.

This cross-sectional study examined the combined and interactive effects of material deprivation and area deprivation on adolescent self-rated health, using data from the World Health Organization collaborative study 'Health Behaviour in School-aged Children 1997/1998'. Included in the present study were 94,915 11-15-year-old students from a total of 22 European and North American countries. Multilevel logistic regression analyses revealed significant additive main effects of individual material deprivation and area deprivation, but not interactive effects. The most deprived students had an odds ratio for self-rated poor health almost three times higher than the least deprived students. Area deprivation effects were stronger at the country level than at the school level, and stronger among 11-year-olds than among 13- and 15-year-olds. A combined 'individual and area deprivation' model predicted that the most disadvantaged 11-year-old students were eight times more likely to have poor self-rated health compared to the least disadvantaged student (OR (95% CI) = 7.96 (3.38, 18.75)). The findings highlight the multilevel effects of deprivation at the individual, local, and national level.

Acculturation and the health and well-being of U.S. immigrant adolescents.

PURPOSE: To examine the association of acculturation, as measured by language spoken at home, with the health, psychosocial, school, and parental risk factors of adolescents of various racial/ethnic groups. METHODS: Using the U.S. component of the 1997-98 World Health Organization Study of Health Behavior in School Children, bivariate and multiple logistic regression analyses were conducted of records for adolescents in four racial/ethnic groups to explore the relationship between the language spoken at home and outcome variables regarding health status and risks, psychosocial and school risk factors, and parental factors. Data were analyzed using Software for the Statistical Analysis of Correlated Data (SUDAAN). RESULTS: Adolescents of all racial and ethnic groups who primarily speak a language other than English at home are at elevated risk for psychosocial risk factors such as alienation from classmates and being bullied, and parental risk factors such as feeling that their parents are not able or willing to help them. Those who speak a combination of languages are also at risk for being bullied and for high parental expectations. Language spoken at home is generally not associated with health and safety measures for adolescents across racial/ethnic groups. CONCLUSIONS: Adolescents whose primary language at home is not English experience higher psychosocial, school, and parental risks than non-Hispanic white English-speakers. New immigrant youths of all races and ethnic groups would potentially benefit from preventive and risk-reduction services.

Association of language spoken at home with health and school issues among Asian American adolescents.

The study examined the association of language spoken at home with the school and health risks and behaviors of Asian American adolescents. Using the United States component of the 1997-1998 World Health Organization Study of Health Behavior in School Children, bivariate and multiple logistic regression analyses were conducted of records for Asian children to explore the relationship between language spoken at home and outcome variables regarding health behaviors, psychosocial and school risk factors, and parental factors. Compared to those who usually speak English at home, adolescents who usually speak another language, or who speak two languages equally, face a greater risk for health risk factors, psychosocial and school risk factors, and parental risk factors. Not speaking English at home was associated with higher health risks, including not wearing seat belts and bicycle helmets; higher psychosocial and school risk factors, including feeling that they do not belong at school, difficulty making new friends, and lacking confidence; and higher parental risks, including reporting that parents were not ready to help them or willing to talk to teachers. Adolescents less acculturated to the United States experience a variety of physical and psychosocial risks. School-based interventions such as early identification and outreach, needs assessment, and counseling and support services should be provided to immigrant students and their families.

Cross-national time trends in bullying behaviour 1994-2006: findings from Europe and North America.

OBJECTIVES: To identify trends over 12 years in the prevalence of bullying and associated victimization among adolescents in North American and European countries. METHODS: Cross-sectional self-report surveys were obtained from nationally representative samples of 11-15 year old school children in 21 countries in 1993/94 and in 27 countries in each of 1997/98, 2001/02 and 2005/06. Measures included involvement in bullying as either a perpetrator and/or victim. RESULTS: Consistent decreases in the prevalence of bullying were reported between 1993/94 to 2005/06 in most countries. Geographic patterns show consistent decreases in bullying in Western European countries and in most Eastern European countries. An increase or no change in prevalence was evident in almost all English speaking countries participating in the study (England, Scotland, Wales, Ireland and Canada, but not in the USA). CONCLUSION: Study findings demonstrated a significant decrease in involvement in bullying behaviour in most participating countries. This is encouraging news for policy-makers and practitioners working in the field of bullying prevention.

A cross-national profile of bullying and victimization among adolescents in 40 countries.

OBJECTIVES: (1) To compare the prevalence of bullying and victimization among boys and girls and by age in 40 countries. (2) In 6 countries, to compare rates of direct physical, direct verbal, and indirect bullying by gender, age, and country. METHODS: Cross-sectional self-report surveys including items on bullying and being bullied were obtained from nationally representative samples of 11, 13 and 15 year old school children in 40 countries, N = 202,056. Six countries (N = 29,127 students) included questions about specific types of bullying (e. g., direct physical, direct verbal, indirect). RESULTS: Exposure to bullying varied across countries, with estimates ranging from 8.6% to 45.2% among boys, and from 4.8% to 35.8% among girls. Adolescents in Baltic countries reported higher rates of bullying and victimization, whereas northern European countries reported the lowest prevalence. Boys reported higher rates of bullying in all countries. Rates of victimization were higher for girls in 29 of 40 countries. Rates of victimization decreased by age in 30 of 40 (boys) and 25 of 39 (girls) countries. CONCLUSION: There are lessons to be learned from the current research conducted in countries where the prevalence is low that could be adapted for use in countries with higher prevalence.

High caffeine intake in adolescents: associations with difficulty sleeping and feeling tired in the morning.

The objective of this study was to examine the association between caffeine usage in U.S. adolescents and the frequency that feeling tired in the morning and having difficulty sleeping is reported. In this study we found that feeling tired in the morning and having difficulty sleeping was experienced more commonly in those adolescents that have a high intake of caffeine.

Television viewing and forms of bullying among adolescents from eight countries.

PURPOSE: Based on theories suggesting that frequent television viewers act and react in hostile, malicious, malevolent, or verbally aggressive ways rather than being physically violent, the present study investigates relationships between television viewing and different forms of bullying. METHODS: Multilevel regression models were estimated based on cross-sectional data from 31,177 adolescents aged 11, 13, and 15 years from Canada, Estonia, Israel, Latvia, Macedonia, Poland, Portugal, and the United States who participated in the 2001-2002 Health Behavior in School-aged Children Survey. RESULTS: Although all different forms of bullying were associated with television viewing in bivariate analyses, only the verbal forms (i.e. "calling mean names" and "spreading rumors") remained significant in multiple regression models. These relationships were observed consistently in all eight participating countries. However, the association between television viewing and physical forms of bullying such as kicking, pushing, or shoving around, varied across countries. In most weekend TV viewing cultures, frequent television viewers were prone to kick or push another student in addition to verbal forms of bullying, which was not the case in weekday viewing cultures. CONCLUSIONS: These results demonstrate the importance of limiting adolescents' time engaged in unsupervised television watching, and the need to motivate adolescents to engage in joint family activities or organized after-school activities.