Developmental implications of prenatal opioid exposure among school-aged children: a mixed methods and community-initiated analysis.

BACKGROUND: Growing research points to potential long-term developmental implications of prenatal opioid exposure for children. Yet, polysubstance use and adverse childhood experiences are raised as potential confounders. Further, there is a lack of data on school-age children and the children's strengths. METHODS: Parents and caregivers of children with prenatal opioid exposure worked with the study team to design, collect, and descriptively analyze mixed method data. Data were collected through survey (n = 148) and two focus groups (n = 15) from a convenience sample in mostly West Virginia and Massachusetts. RESULTS: Nearly half of the children in the sample were diagnosed with multiple developmental delays, behavioral health conditions, and specific learning disorders. Roughly 85% of children have behavioral challenges. Associations between prenatal opioid exposure and negative developmental outcomes did not vary by type of opioid nor by polysubstance use, while controlling for adverse childhood experiences. Importantly, over 80% of families also reported their child's strengths, including empathy, social magnetism, and their resilience. CONCLUSIONS: The challenges for children born with prenatal opioid exposure may extend into school-age. The results are consistent with prior research on younger children, suggesting a need for best practices for caring for these children beyond the neonatal stage.

Addressing Barriers to Primary Care Screening and Referral to Prevention for Youth Risky Health Behaviors: Evidence Regarding Potential Cost-Savings and Provider Concerns.

Despite growing evidence and support for co-locating behavioral services in primary care to prevent risky health behaviors, implementation of these services has been limited due to a lack of reimbursement for services and negative perceptions among providers. We investigated potential to overcome these barriers based on new developments in healthcare funding and screening and referral to prevention (SRP) in primary care based on the Consolidated Framework for Implementation Research (CFIR), which could guide future SRP implementation strategies. To investigate the economic need for healthcare-based SRP, we quantified hospital charges to healthcare payors for services arising from adolescent risky behaviors (e.g., substance use, risky sex). Annual North Carolina (NC) hospital charges for these services exceeded $327 M (2019 dollars), suggesting high potential for cost savings if SRP can curb hospital services associated with risky behaviors. To investigate provider barriers and facilitators, we surveyed 151 NC pediatricians and 230 NC family therapists about their attitudes regarding a recently developed well-child visit SRP with family-based prevention. Both sets of professionals reported widespread need for and interest in the SRP but cited barriers of lack of reimbursement, training, and referrals to/from each other. Physicians, but not family therapists, reported concerns with poor patient or parent compliance. Many barriers could be resolved by co-locating family therapists in pediatric clinics to conduct well-child SRP. Our results support further research to develop business models for payor-funded SRP and CFIR-guided research to develop implementation strategies for primary care SRP to prevent adolescent risky health behaviors.

Describing associations between child maltreatment frequency and the frequency and timing of subsequent delinquent or criminal behaviors across development: variation by sex, sexual orientation, and race.

BACKGROUND: Child maltreatment has been linked to lower health, education, and income later in life, and is associated with increased engagement in delinquent or criminal behaviors. This paper explores trajectories of these behaviors from adolescence into early adulthood and tests maltreatment as a predictor, and whether observed patterns are consistent across different demographic groups. METHODS: Using data from the National Longitudinal Study of Adolescent to Adult Health, a longitudinal study of a nationally representative sample of U.S. adolescents (in grades 7-12 in the 1994-95 school year), we ran linear mixed effects models to estimate growth curves of two dependent variables: violent and nonviolent offending behavior. We tested if maltreatment altered the intercept or slope of the curves and how the curves of these behaviors and the associations between them and maltreatment varied by sex, race/ethnicity, and sexual orientation. RESULTS: The sample (n = 10,613) had equal proportions males and females, approximately one third identified as a race/ethnicity other than white, and over 10% were non-heterosexual. Experiences of maltreatment were highest for Native Americans and lowest for whites. Models indicated that males were more likely than females to engage in both violent and nonviolent offending and respondents who identified as non-heterosexual were more likely than their heterosexual peers to engage in nonviolent offending behavior. When maltreatment was included in models as a predictor, adolescents who experienced maltreatment had a more rapid increase in their non-violent offending behavior. For violent offending behavior, adolescents who experienced maltreatment had higher levels of offending and the levels progressively increased as maltreatment frequency did. Sex was a moderator; the relationship between maltreatment and predicted nonviolent offending was stronger for males than it was for females. Race/ethnicity and sexual orientation did not moderate the associations between maltreatment and offending behavior. CONCLUSIONS: This study provides insights from a nationally representative sample into the pattern of both delinquent and criminal behaviors in adolescence and young adulthood, describing not only how the pattern varies over time, but also by sociodemographics and offending type. Additionally, it highlights how the association between maltreatment and these behaviors varies by both offending type and sex.

Disrupting the link between maltreatment and delinquency: how school, family, and community factors can be protective.

BACKGROUND: Past experiences of childhood maltreatment are common for youth involved in the juvenile justice system. This paper explores potential protective factors at the peer, family, school, and neighborhood levels that disrupt the relationship between maltreatment and later non-violent and violent offending behavior and how these protective effects vary by a number of different sociodemographics. METHODS: We used data from the National Longitudinal Study of Adolescent to Adult Health (Add Health), a nationally representative longitudinal study of adolescents who were in grades 7-12 in the 1994-95 school year. Pulling data from Add Health respondents from ages 13 to 30, we used linear mixed effects modeling to create growth curves of predicted violent and non-violent offending frequency from adolescence into young adulthood, with maltreatment frequency as a predictor. Next, we tested whether potential protective factors including time with friends, a high-quality relationship with a parent figure, school connection, or neighborhood collective efficacy moderated the intercept or slope of the growth curves. Finally, we tested if sex, race/ethnicity, or sexual orientation moderated these protective effects. RESULTS: For violent offending, school connection, high-quality relationships with mother or father figures, and neighborhood collective efficacy were all generally protective, meaning they were associated with lower levels and shallower slopes of predicted violent offending, but they were not more or less protective for those who experienced maltreatment. For non-violent offending, the same was true of school connection, high-quality relationships with a mother figure, and neighborhood collective efficacy, which were all generally protective. We found no evidence of a protective effect for time spent with friends, though this is likely due to measurement constraints, as simply measuring time spent with friends may have heterogeneous effects on delinquent behaviors. We found no evidence that any of these protective effects varied by sociodemographics. CONCLUSIONS: This paper identifies factors that teachers, juvenile corrections officers, policymakers and others can intervene on to prevent engagement (or re-engagement) in delinquency and offending among youth and young adults who experienced maltreatment. As they are also protective for youth who have not experienced maltreatment they also inform general delinquency prevention efforts.

Adherence to gender-typical behavior and high frequency substance use from adolescence into young adulthood.

Substance use is prevalent among adolescents in the U.S., especially males. Understanding the cross-sectional and longitudinal associations between gender norms and substance use is necessary to tailor substance use prevention messages and efforts appropriately. This study investigates the relationship between adherence to gender-typical behavior (AGB) and substance use from adolescence into young adulthood. Participants in the National Longitudinal Study of Adolescent to Adult Health completed self-report measures on the frequency of binge drinking, cigarette smoking and marijuana use as well as various behaviors and emotional states that captured the latent construct of AGB. Sex-stratified logistic regression models revealed cross-sectional and longitudinal relationships between AGB and high frequency substance use. For example, an adolescent male who is more gender-adherent, compared to less adherent males, has 75% higher odds of high frequency binge drinking in adolescence and 22% higher odds of high frequency binge drinking in young adulthood. Sex-stratified multinomial logistic regression models also revealed cross-sectional and longitudinal relationships between AGB and patterns of use. For example, a more gender-adherent adolescent male, compared to one who is less adherent, is 256% more likely to use all three substances in adolescence and 66% more likely to use all three in young adulthood. Cross-sectional and longitudinal results for females indicate greater gender-adherence is associated with lower odds of high frequency substance use. These findings indicate adherence to gender norms may influence substance use behaviors across the developmental trajectory, and inform strategies for prevention efforts.

Screening for and Treating Postpartum Depression and Psychosis: A Cost-Effectiveness Analysis.

Objectives Postpartum depression impacts 6.5-12.9% of U.S. women. Postpartum depression is associated with impaired bonding and development, marital discord, suicide, and infanticide. However, the current standard of care is to not screen women for postpartum depression. This study modeled the cost-effectiveness of physicians screening for and treating postpartum depression and psychosis in partnership with a psychiatrist. Methods This study follows a hypothetical cohort of 1000 pregnant women experiencing one live birth over a 2-year time horizon. We used a decision tree model to obtain the outcomes of screening for and treating postpartum depression and psychosis using the Edinburgh Postnatal Depression Scale. We use a Medicaid payer perspective because they cover approximately 50% of births in the U.S. The cost-effectiveness of the intervention is measured in cost per remission achieved and cost per quality-adjusted life-year (QALY) gained. We conducted both deterministic and probabilistic sensitivity analyses. Results Screening for and treating postpartum depression and psychosis produced 29 more healthy women at a cost of $943 per woman. The incremental cost-effectiveness ratios of the intervention branch compared to usual care were $13,857 per QALY gained (below the commonly accepted willingness to pay threshold of $50,000/QALY gained) and $10,182 per remission achieved. These results were robust in both the deterministic and probabilistic sensitivity analyses of input parameters. Conclusions for Practice Screening for and treating postpartum depression is a cost-effective intervention and should be considered as part of usual postnatal care, which aligns with the recently proposed recommendations from the U.S. Preventive Services Task Force.

The employment environment for youth in rural South Africa: A mixed-methods study.

South Africa has high youth unemployment. This paper examines the predictors of youth employment in rural Agincourt, Mpumalanga Province. A survey of 187 out-of-school 18-24 year olds found only 12% of women and 38% of men were currently employed. Men with skills/training were significantly more likely to report employment, mostly physical labour (aOR: 4.5; CI: 1.3, 15.3). In-depth interviews with 14 of the youth revealed women are perceived more suitable for formal employment, which is scarce informing why women were more likely to pursue further education and yet less likely to be employed. Ten key informants from local organisations highlighted numerous local youth employment resources while, in contrast, all youth in the sample said no resources were available, highlighting a need for the organisations to extend their services into rural areas. As these services are focused on entrepreneurship, programs to increase financial literacy and formal employment opportunities are also needed.

Directions of the relationship between substance use and depressive symptoms from adolescence to young adulthood.

PURPOSE: Both substance use and depression are common in adolescence and often comorbid. Past research has produced conflicting results on whether there is a temporal relationship and if so, in which direction it operates and how it may vary by sex. The purpose of this paper is to explore the longitudinal, potentially bidirectional, relationships between high-frequency substance use and depressive symptoms from adolescence into young adulthood for males and females. METHODS: Using data from the National Longitudinal Study of Adolescent to Adult Health we investigated longitudinal associations between high frequency substance use (alcohol, cigarettes, and marijuana) and depressive symptoms. The linear mixed effects models were stratified by sex and used a lagged measure of the dependent variable to test temporal relationships. A random intercept was used for respondent ID. RESULTS: Increases in depressive symptoms were significantly associated with a later increase of about a half day in marijuana use frequency for males and nearly a two day increase in smoking frequency for females. Conversely, increases in smoking frequency were significantly associated with approximately a 0.6-point increase for females and 0.4-point increase for males in depressive symptoms at a later wave. CONCLUSIONS: Results indicate a bidirectional relationship between smoking and depressive symptoms for females. For males, there was evidence supporting self-medication with marijuana and for smoking being associated with later increases in depressive symptoms. Results inform how substance use and depression screening, prevention and treatment efforts should be paired and targeted for males and females.

Testing Longitudinal Relationships Between Binge Drinking, Marijuana Use, and Depressive Symptoms and Moderation by Sex.

PURPOSE: Both substance use and depression are common in adolescence and often comorbid. Past research has produced conflicting results on whether there is a temporal relationship, and if so, in which direction it operates and how it may vary by sex. We examined the longitudinal associations between substance use frequency and depressive symptoms from adolescence into young adulthood and whether the associations were moderated by sex. METHODS: With data from Waves I, III, and IV of the National Longitudinal Study of Adolescent to Adult Health (n = 9,816), we used growth curve models to test if depressive symptoms predicted marijuana use or binge drinking frequency (Self-Medication Model) or if substance use frequency predicted depressive symptoms (Stress Model). Moderation by sex and age was tested for both potential pathways. RESULTS: Increases in adolescent depressive symptoms, compared to no symptoms, were associated with a steeper predicted increase in marijuana use frequency from adolescence to young adulthood. Increases in persistent binge drinking or marijuana use frequency had concurrent positive associations with depressive symptoms from adolescence to young adulthood, and these associations were significantly stronger for females compared to males. CONCLUSIONS: The results not only support the Self-Medication Model for marijuana use but also provide modest support for the Stress Model, that substance use is associated with depressive symptoms, especially for females.

Breast cancer screening in an insured population: whom are we missing?

INTRODUCTION: Kaiser Permanente Colorado is an integrated health care system that uses automatic reminder programs and reduces barriers to access preventive services, including financial barriers. Breast cancer screening rates have not improved during the last five years, and rates differ between subgroups: for example, black and Latina women have lower rates of mammography screening than other racial groups. METHODS: We retrospectively evaluated data from 47,946 women age 52 to 69 years who had continuous membership for 24 months but had not undergone mammography. Poisson regression models estimated relative risk for the impact of self-identified race/ethnicity, socioeconomic characteristics, health status, and use of health care services on screening completion. RESULTS: The distribution of race/ethnicity among unscreened women was 55.5% white, 7.0% Latina, and 3.7% black, but race/ethnicity data were missing for 29%. Of these, no record of race/ethnicity was available for 86.7%, and for 5.1%, the data request was recorded but the women declined to identify their race/ethnicity. Nonwhite ethnicity increased risk of screening failure if black, Latina, "other" (eg, American Indian), or missing race/ethnicity. Population-attributable risks were low for minorities compared with the group for whom race/ethnicity data was missing. A greater number of office visits in any setting was associated with greater likelihood of undergoing mammography. Women with missing race/ethnicity data had fewer visits and were less likely to have an identified primary care physician. CONCLUSIONS: Greater improvement in mammography screening rates could be achieved in our population by increasing screening among women with missing race/ethnicity data, rather than by targeting those who are known to be of racial/ethnic minorities. Efforts to address screening disparities have been refocused on inreach and outreach to our "missing women."

Diurnal variation in nicotine sensitivity in mice: role of genetic background and melatonin.

Despite the evidence that there is a daily rhythm in smoking behavior and that the effects of drugs of abuse exhibit diurnal variations, very few studies have explored the extent to which sensitivity to the effects of nicotine vary over the course of the day. In the studies described in this report, the melatonin proficient mouse strain C3H/Ibg and the melatonin deficient mouse strains C57BL/6J and DBA/2J were assessed for diurnal variations in sensitivity to the effects of nicotine. Results indicated that there is significant variation in sensitivity to both activity and body temperature depressant effects of nicotine in the melatonin proficient C3H/Ibg strain with maximal sensitivity occurring during the latter third of the light period of the light cycle and minimal sensitivity taking place during the last third of the dark phase of the light cycle. The melatonin deficient strains did not exhibit diurnal differences in sensitivity to the effects of nicotine suggesting a potential role for melatonin in modulating the effects of nicotine. Experiments with knockout mice lacking both the Mtnr1a and Mtnr1b melatonin receptors confirmed that the reduced sensitivity observed during the dark phase is melatonin dependent. Diurnal variation in nicotinic receptor expression also was measured in cortex, hippocampus, hypothalamus and striatum using [(125)I]-α-bungarotoxin and [(125)I]-epibatidine. [(125)I]-α-bungarotoxin binding in hypothalamus of C3H mice exhibited a diurnal pattern with maximal binding observed in the latter third of the light portion of the light cycle. No other significant differences in binding were detected.