Sion Kim Harris

Association of adolescent risk behaviors with mental health symptoms in high school students

PURPOSE To examine the hypothesis that self-reported symptoms of depression and stress may be associated with other risk behaviors. METHODS A secondary data analysis of the 1992 Massachusetts Adolescent Health Survey involving a representative sample of 2,224 ninth and twelfth grade students was performed. The dichotomous dependent variable was positive if the adolescent reported feeling depressed or stressed for 10 or more days in the past month. Potential independent variables examined were age, gender, race/ethnicity, and 14 risk or protective behaviors: each scored on a seven point scale representing increasing frequency of a behavior in the past month. A four-level sexual risk variable was constructed as well. Associations were assessed using Chi-square, and phi/contingency coefficients, and logistic regression analyses to predict the odds of reporting depression/stress. RESULTS The mean age of the sample was 16.2 +/- 1.6 years; 52% males; 78% were white, 9% black, 6% Latino, 2% Asian, and 4% other racial/ethnic heritage; 35% reported feeling depressed/stressed > or = 10 days in the past month. A logistic regression model found that feelings of depression/stress were associated with increasing age (OR = 1.09 with each additional year [95% CI, 1.02-1.18]), female gender (3.28 [2.62-4.12]); increasing levels of tobacco use (1.07 [1.01-1.12]), physical fights (1.19 [1.11-1.28]); and non-use of birth control compared with never having been sexually active (1.81 [1.31-2.49]). Independent variables of reporting depression/stress for males included increasing age (1.15 [1.03-1.28]), and physical fights (1.20 [1.10-1.30]), and non-use of birth control compared with never sexually active (1.91 [1.28-2.92]). Independent risk and protective factors for females included tobacco use (1.10 [1.02-1.19]), healthy diet (0.89 [0.83- 0.96]), and always (1.49 [1.03-2.28]) or sometimes used birth control (1.56 [1.03-1.28]) compared with never sexually active. CONCLUSIONS Female gender had greater than threefold increased odds of reporting depression/stress. Other associations, with some gender differences, include older age, physical fights, non-use of birth control, lack of a healthy diet, and use of tobacco.

Neighborhood Environment Walkability Scale for Youth (NEWS-Y): Reliability and Relationship With Physical Activity

OBJECTIVES To examine the psychometric properties of the Neighborhood Environment Walkability Scale-Youth (NEWS-Y) and explore its associations with context-specific and overall physical activity (PA) among youth. METHODS In 2005, parents of children ages 5-11 (n=116), parents of adolescents ages 12-18 (n=171), and adolescents ages 12-18 (n=171) from Boston, Cincinnati, and San Diego, completed NEWS-Y surveys regarding perceived land use mix-diversity, recreation facility availability, pedestrian/automobile traffic safety, crime safety, aesthetics, walking/cycling facilities, street connectivity, land use mix-access, and residential density. A standardized neighborhood environment score was derived. Self-reported activity in the street and in parks, and walking to parks, shops, school, and overall physical activity were assessed. RESULTS The NEWS-Y subscales had acceptable test-retest reliability (ICC range .56-.87). Being active in a park, walking to a park, walking to shops, and walking to school were related to multiple environmental attributes in all three participant groups. Total neighborhood environment, recreation facilities, walking and cycling facilities, and land use mix-access had the most consistent relationships with specific types of activity. CONCLUSIONS The NEWS-Y has acceptable reliability and subscales were significantly correlated with specific types of youth PA. The NEWS-Y can be used to examine neighborhood environment correlates of youth PA.

State Behavioral Scale: a sedation assessment instrument for infants and young children supported on mechanical ventilation.

Objective: To develop and test the reliability and validity of the State Behavioral Scale for use in describing sedation/agitation levels in young intubated patients supported on mechanical ventilation. Design: In this prospective, psychometric evaluation, pairs of trained pediatric critical care nurse evaluators simultaneously and independently assessed a convenience sample of pediatric intensive care unit patients along eight state/behavioral dimensions and a numeric rating scale (NRS) of 0 (extremely sedated) to 10 (extremely agitated). The eight dimensions were derived from the sedation/agitation literature and expert opinion and included respiratory drive, response to ventilation, coughing, best response to stimulation, attentiveness to careprovider, tolerance to care, consolability, and movement after consoled, each with 3–5 levels. Setting: An 18-bed pediatric medical–surgical intensive care unit and 26-bed pediatric cardiovascular intensive care unit in a university-affiliated academic children’s hospital. Patients: A total of 91 intubated mechanically ventilated patients 6 wks to 6 yrs of age provided a median of two observations (interquartile range, 1–3) for a total of 198 sets of observations. Excluded were postoperative patients or those receiving neuromuscular blockade. Interventions: Patients were observed for 1 min, and then incremental levels of stimulation were applied until patient response. After 2 mins of consoling, the state behavioral assessment and NRS were completed. Measurements: Weighted kappa and intraclass coefficients were generated to assess interrater reliability of the eight dimension and NRS ratings. Distinct state behavior profiles were empirically identified from the dimension ratings using hierarchical cluster analysis using a squared Euclidean distance measure and between-groups linkage. Construct validity of these profiles was assessed by comparing group mean NRS scores using one-way analysis of variance. Main Results: Weighted kappa scores for all 198 dimension ratings ranged from .44 to .76, indicating moderate to good interrater reliability. The intraclass coefficient of .79 was high for NRS ratings. Cluster analysis revealed five distinct state profiles, with mean NRS ratings of 1.1, 2.5, 4.0, 5.3, and 7.6, all of which differed significantly from each other (F = 75.8, p < .001), supporting the profiles’ construct validity. Conclusions: Based on empirically derived state behavior profiles, we have constructed the State Behavioral Scale to allow systematic description of the sedation–agitation continuum in young pediatric patients supported on mechanical ventilation. Further studies including prospective validation and describing the effect of State Behavioral Scale implementation on clinical outcomes, including the quality of sedation and length of mechanical ventilation, are warranted.

The Withdrawal Assessment Tool-1 (WAT-1): An assessment instrument for monitoring opioid and benzodiazepine withdrawal symptoms in pediatric patients*

Objective: To develop and test the validity and reliability of the Withdrawal Assessment Tool–1 for monitoring opioid and benzodiazepine withdrawal symptoms in pediatric patients. Design: Prospective psychometric evaluation. Pediatric critical care nurses assessed eligible at-risk pediatric patients for the presence of 19 withdrawal symptoms and rated the patient’s overall withdrawal intensity using a Numeric Rating Scale where zero indicated no withdrawal and 10 indicated worst possible withdrawal. The 19 symptoms were derived from the Opioid and Benzodiazepine Withdrawal Score, the literature and expert opinion. Setting: Two pediatric intensive care units in university-affiliated academic children’s hospitals. Patients: Eighty-three pediatric patients, median age 35 mos (interquartile range: 7 mos−10 yrs), recovering from acute respiratory failure who were being weaned from more than 5 days of continuous infusion or round-the-clock opioid and benzodiazepine administration. Interventions: Repeated observations during analgesia and sedative weaning. A total of 1040 withdrawal symptom assessments were completed, with a median (interquartile range) of 11 (6–16) per patient over 6.6 (4.8−11) days. Measurements and Main Results: Generalized linear modeling was used to analyze each symptom in relation to withdrawal intensity ratings, adjusted for site, subject, and age group. Symptoms with high redundancy or low levels of association with withdrawal intensity ratings were dropped, resulting in an 11-item (12-point) scale. Concurrent validity was indicated by high sensitivity (0.872) and specificity (0.880) for Withdrawal Assessment Tool–1 > 3 predicting Numeric Rating Scale > 4. Construct validity was supported by significant differences in drug exposure, length of treatment and weaning from sedation, length of mechanical ventilation and intensive care unit stay for patients with Withdrawal Assessment Tool–1 scores > 3 compared with those with lower scores. Conclusions: The Withdrawal Assessment Tool–1 shows excellent preliminary psychometric performance when used to assess clinically important withdrawal symptoms in the pediatric intensive care unit setting. Further psychometric evaluation in diverse at-risk groups is needed.

Community Food Environment, Home Food Environment, and Fruit and Vegetable Intake of Children and Adolescents

OBJECTIVES To determine (1) reliability of new food environment measures; (2) association between home food environment and fruit and vegetable (FV) intake; and (3) association between community and home food environment. METHODS In 2005, a cross-sectional survey was conducted with readministration to assess test-retest reliability. Adolescents, parents of adolescents, and parents of children (n = 458) were surveyed in San Diego, Boston, and Cincinnati. RESULTS Most subscales had acceptable reliability. Fruit and vegetable intake was positively associated with availability of healthful food (r = 0.15-0.27), FV (r = 0.22-0.34), and ratio of more-healthful/less-healthful food in the home (r = 0.23-0.31) and was negatively associated with less-healthful food in the home (r = -0.17 to -0.18). Home food environment was associated with household income but not with community food environment. CONCLUSIONS AND IMPLICATIONS A more healthful home food environment was related to youth FV intake. Higher income households had more healthful food in the home. The potential influence of neighborhood food outlets warrants further study.

Relation of School Environment and Policy to Adolescent Physical Activity

BACKGROUND Physical activity (PA) declines as children and adolescents age. The purpose of this study was to examine how specific school factors relate to youth PA, TV viewing, and body mass index (BMI). METHODS A sample of 12- to 18-year-old adolescents in 3 cities (N = 165, 53% females, mean age 14.6 +/- 1.7 years, 44% nonwhite) completed surveys assessing days of physical education (PE) class per week, school equipment accessibility, after-school supervised PA, and after-school field access. Regression analyses were conducted to examine relationships between these school factors and PA at school facilities open to the public (never active vs active), overall PA level (days per week physically active for 60 minutes), BMI z score, and TV watching (hours per week). RESULTS Adjusting for demographics, days of PE per week and access to school fields after school were correlated with overall PA (beta= 0.286, p = .002, semipartial correlation .236 and beta= 0.801, p = .016, semipartial correlation .186, respectively). The association between after-school field access and overall PA was mediated by use of publicly accessible school facilities for PA. After-school supervised PA and school PA equipment were not associated with overall PA. In adjusted regression analyses including all school factors, days of PE remained correlated to overall PA independent of other school factors (beta= 0.264, p = .007, semipartial correlation = .136). There were no associations between school factors and BMI or TV watching. CONCLUSIONS Based on these study findings, PE is a promising intervention to address improving overall adolescent PA within the school setting.

Computer-Facilitated Substance Use Screening and Brief Advice for Teens in Primary Care: An International Trial

OBJECTIVE: Primary care providers need effective strategies for substance use screening and brief counseling of adolescents. We examined the effects of a new computer-facilitated screening and provider brief advice (cSBA) system. METHODS: We used a quasi-experimental, asynchronous study design in which each site served as its own control. From 2005 to 2008, 12- to 18-year-olds arriving for routine care at 9 medical offices in New England (n = 2096, 58% females) and 10 in Prague, Czech Republic (n = 589, 47% females) were recruited. Patients completed measurements only during the initial treatment-as-usual study phase. We then conducted 1-hour provider training, and initiated the cSBA phase. Before seeing the provider, all cSBA participants completed a computerized screen, and then viewed screening results, scientific information, and true-life stories illustrating substance use harms. Providers received screening results and “talking points” designed to prompt 2 to 3 minutes of brief advice. We examined alcohol and cannabis use, initiation, and cessation rates over the past 90 days at 3-month follow-up, and over the past 12 months at 12-month follow-up. RESULTS: Compared with treatment as usual, cSBA patients reported less alcohol use at follow-up in New England (3-month rates 15.5% vs 22.9%, adjusted relative risk ratio [aRRR] = 0.54, 95% confidence interval 0.38–0.77; 12-month rates 29.3% vs 37.5%, aRRR = 0.73, 0.57–0.92), and less cannabis use in Prague (3-month rates 5.5% vs 9.8%, aRRR = 0.37, 0.17–0.77; 12-month rates 17.0% vs 28.7%, aRRR = 0.47, 0.32–0.71). CONCLUSIONS: Computer-facilitated screening and provider brief advice appears promising for reducing substance use among adolescent primary care patients.

Validation of the Individualized Numeric Rating Scale (INRS): A pain assessment tool for nonverbal children with intellectual disability

&NA; Clinical observations suggest that nonverbal children with severe intellectual disability exhibit pain in a wide variety yet uniquely individual ways. Here, we investigate the feasibility and describe the initial psychometrics properties of the Individualized Numeric Rating Scale (INRS), a personalized pain assessment tool for nonverbal children with intellectual disability based on the parents knowledge of the child. Parents of 50 nonverbal children with severe intellectual disability scheduled for surgery were able to complete the task of describing then rank ordering their childs usual and pain indicators. The parent, bedside nurse and research assistant (RA) triad then simultaneously yet independently scored the patients post‐operative pain using the INRS for a maximum of two sets of pre/post paired observations. A total of 170 triad assessments were completed before (n = 85) and after (n = 85) an intervention to manage the childs pain. INRS inter‐rater agreement between the parents and research nurse was high (ICC 0.82–0.87) across all ratings. Parent and bedside nurse agreement (ICC 0.65–0.74) and bedside nurse and research nurse agreement (ICC 0.74–0.80) also suggest good reliability. A moderate to strong correlation (0.63–0.73) between INRS ratings and NCCPC‐PV total scores provides evidence of convergent validity. These results provide preliminary data that the INRS is a valid and reliable tool for assessing pain in nonverbal children with severe intellectual disability in an acute care setting.

Outreach, Mental Health, and Case Management Services: Can They Help to Retain HIV-Positive and At-Risk Youth and Young Adults in Care?

Objectives: To assess the impact of outreach, mental health, and case management services on retention in primary care of HIV+ and at-risk youth and young adult clients of the Boston HAPPENS program, a comprehensive adolescent HIV prevention and care network of agencies. Methods: Providers at 8 urban sites used standard data forms at each visit to collect background and service receipt information on at-risk clients aged 12–24 years. Data were aggregated across all visits for each client to create summary variables for the number of times each client received each type of service. The retention measure was the number of days between a clients first and last visits during the 4-year data collection period. Kaplan–Meier survival curve and Cox proportional hazards regression analyses were used to assess the association between receipt of the support services of interest and the retention measure. Results: The median retention times were 21 days for male clients (range, 0–1406, N = 512), and 26 days for female clients (range, 0–1577, N = 914). Among males, 45% were retained beyond a month, 24% beyond a year, and 10% beyond 2 years. Similar proportions of females were retained beyond a month and a year, but more females were retained beyond 2 years (15%). After adjusting for other covariates, both male and female clients had significantly longer retention times if they received ≥q2 outreach contacts, or case management at ≥q3 visits. Among males, receipt of mental health counseling at ≥q2 visits also increased retention times. Conclusions: These findings suggest that provision of outreach, mental health, and case management services can improve retention in care of at-risk youth and young adults.

The meaning of cost for families of children with congenital heart disease.

INTRODUCTION The purpose of this study was to describe the cost burden of congenital heart disease (CHD) and the associated social impact as experienced by families. METHOD Qualitative methods were used to collect and interpret data. Semi-structured interviews were conducted with parents of children with various degrees of CHD complexity and socioeconomic status currently admitted for congenital heart surgery at a large tertiary care regional center. RESULTS The meaning of cost burden as defined by participants resulted in the emergence of two major categories, lifestyle change and uncertainty. Cost was described beyond monetary terms and as a result, data in each category were further clustered into three underlying subcategories labeled financial, emotional, and family burden. The childs disease complexity and parents socioeconomic status seem to be linked to higher levels of stress experienced in terms of finances, emotional drain, and family member burden. Prenatal diagnosis was noted to trigger early discussion of financial uncertainty, often resulting in altered personal spending prior to birth. DISCUSSION The cost experienced by parents of children with complex CHD was described as both life-changing and uncertain. Informing families of these types of additional stressors may allow issues of finances to be considered early in the overall preparation of caring for a child with complex CHD.