Risk behavior in a community sample of children and adolescents

Attachment Representation Moderates the Effectiveness of Behavioral Parent Training Techniques for Children with ADHD: Evidence from a Randomized Controlled Microtrial

Behavioral parent training is an evidence-based intervention for children with attention-deficit/hyperactivity disorder (ADHD), but knowledge on the differential effects of behavioral techniques for specific subgroups of children is very limited. Attachment representations of children with ADHD may affect how receptive children are to changes in parenting. In this study, we investigated whether specific behavioral techniques were more or less effective for children with ADHD in relation to their attachment representations. We included parents of 74 children with ADHD (4-11 years, M = 8.15) who took part in a larger randomized controlled microtrial in which they were randomized to a two session training in antecedent-based techniques (i.e., stimulus control techniques: rules, instructions; n = 26), a two session training in consequent-based techniques (i.e., contingency management techniques: praise, rewards, ignoring; n = 25) or a waitlist control condition (n = 23). We examined whether attachment representation moderated the effectiveness of a) training versus waitlist, and b) antecedent- versus consequent-based techniques. Attachment representations were measured with a story stem task, the intervention outcome was daily parent-rated problem behaviors of the children. Attachment representation did not moderate the effects of the training compared to the waitlist. However, compared to antecedent-based techniques, consequent-based techniques were less effective for more securely and less disorganized attached children, and particularly effective for more disorganized attached children. This was the first study examining attachment as a moderator of behavioral techniques for ADHD. If replicated, the findings of this study can be used for treatment development and tailoring.

Evaluating the Cross-Sectional and Longitudinal Relationships Predicting Suicidal Ideation Following Traumatic Brain Injury

OBJECTIVE

Characterize relationships among substance misuse, depression, employment, and suicidal ideation (SI) following moderate to severe traumatic brain injury (TBI).

DESIGN

Prospective cohort study.

SETTING

Inpatient rehabilitation centers with telephone follow-up; level I/II trauma centers in the United States.

PARTICIPANTS

Individuals with moderate to severe TBI with data in both the National Trauma Data Bank and the Traumatic Brain Injury Model Systems National Database, aged 18 to 59 years, with SI data at year 1 or year 2 postinjury (N = 1377).

MAIN OUTCOME MEASURE

Primary outcome of SI, with secondary employment, substance misuse, and depression outcomes at years 1 and 2 postinjury.

RESULTS

Cross-lagged structural equation modeling analysis showed that year 1 unemployment and substance misuse were associated with a higher prevalence of year 1 depression. Depression was associated with concurrent SI at years 1 and 2. Older adults and women had a greater likelihood of year 1 depression. More severe overall injury (injury severity score) was associated with a greater likelihood of year 1 SI, and year 1 SI was associated with a greater likelihood of year 2 SI.

CONCLUSIONS

Substance misuse, unemployment, depression, and greater extracranial injury burden independently contributed to year 1 SI; in turn, year 1 SI and year 2 depression contributed to year 2 SI. Older age and female sex were associated with year 1 depression. Understanding and mitigating these risk factors are crucial for effectively managing post-TBI SI to prevent postinjury suicide.

Lifestyle risk indices in adolescence and their relationships to adolescent disease burden: findings from an Australian national survey

BACKGROUND

The current study investigates the extent to which an adolescent-specific lifestyle risk factor index predicts indicators of the leading causes of adolescent morbidity and mortality.

METHODS

Data came from 13 to 17 year-old respondents from the 2013-2014 nationally representative Australian Child and Adolescent Survey of Mental Health and Wellbeing (n = 2314). Indicators of adolescent disease burden included Major Depressive Disorder, psychological distress, self-harm and suicide attempt. Risk factors included risky alcohol use, drug use, unprotected sex, smoking, BMI and sleep duration. The extent to which these risk factors co-occurred were investigated using tetrachoric correlations. Several risk indices were then constructed based on these risk factors. Receiver Operating Characteristic curves determined the precision with which these indices predicted the leading causes of adolescent disease burden.

RESULTS

Risky alcohol use, drug use, smoking, unprotected sex, and sleep were all highly clustered lifestyle risk factors, whereas BMI was not. A risk index comprising risky alcohol use, drug use, unprotected sex and sleep duration predicted the disease burden outcomes with the greatest precision. 31.9% of the sample reported one or more of these behaviours.

CONCLUSIONS

This lifestyle risk factor index represents a useful summary metric in the context of adolescent health promotion and non-communicable disease prevention. Lifestyle risk factors were found to cluster in adolescence, supporting the implementation of multiple health behaviour change interventions.

Indigenous Approaches to Health Promotion: Challenges for Education Support in South Africa

This article explores whether and how an integrated approach to health promotion, which draws on indigenous and other worldviews and approaches, can be developed to address more effectively biopsychosocial challenges that constitute barriers to learning and development in education contexts. More specifically, the article aims to investigate whether and how indigenous perspectives to health promotion have been incorporated into support services in Native American contexts and what lessons can be learnt from this for the South African context. An analysis of relevant literature and interviews with 25 key informants in Native American contexts in the United States highlighted the following key challenges relating to incorporating different views of and approaches to health promotion in education in South Africa: facilitating ‘paradigm shifting’ or mindset change; addressing power dynamics relating to ongoing colonialism; developing culturally responsive education support services and life skills education curricula; and developing strong school–community partnerships. The article argues that these challenges could be successfully pursued within a South African health promoting schools framework that reflects the different perspectives of role players in this context.

A newly identified group of adolescents at "invisible" risk for psychopathology and suicidal behavior: findings from the SEYLE study

This study explored the prevalence of risk behaviors (excessive alcohol use, illegal drug use, heavy smoking, reduced sleep, overweight, underweight, sedentary behavior, high use of Internet/TV/videogames for reasons not related to school or work, and truancy), and their association with psychopathology and self-destructive behaviors, in a sample of 12,395 adolescents recruited in randomly selected schools across 11 European countries. Latent class analysis identified three groups of adolescents: a low-risk group (57.8%) including pupils with low or very low frequency of risk behaviors; a high-risk group (13.2%) including pupils who scored high on all risk behaviors, and a third group ("invisible" risk, 29%) including pupils who were positive for high use of Internet/TV/videogames for reasons not related to school or work, sedentary behavior and reduced sleep. Pupils in the "invisible" risk group, compared with the high-risk group, had a similar prevalence of suicidal thoughts (42.2% vs. 44%), anxiety (8% vs. 9.2%), subthreshold depression (33.2% vs. 34%) and depression (13.4% vs. 14.7%). The prevalence of suicide attempts was 5.9% in the "invisible" group, 10.1% in the high-risk group and 1.7% in the low-risk group. The prevalence of all risk behaviors increased with age and most of them were significantly more frequent among boys. Girls were significantly more likely to experience internalizing (emotional) psychiatric symptoms. The "invisible" group may represent an important new intervention target group for potentially reducing psychopathology and other untoward outcomes in adolescence, including suicidal behavior.

Depression, delinquency, and suicidal behaviors among college students

BACKGROUND

Liu (2004) investigated the interaction between delinquency and depression among adolescents and found that delinquency moderated the relationship between depression and suicidal behaviors.

AIMS

This study also explored the relationship between depression, delinquency, and suicidal behaviors, although delinquency was expected to mediate, as opposed to moderate, the relationship between depression and suicidal behaviors.

METHOD

The participants comprised 354 college students. The students completed a series of questionnaires measuring delinquent behavior, depressive symptoms, and suicidal thoughts and behaviors.

RESULTS

Contrary to Liu's (2004) findings, delinquency was found not to moderate but rather to partially mediate the relationship between depression and suicidal behaviors.

CONCLUSION

The findings suggest that for some college students, depression is associated with delinquent behaviors, which, in turn, are associated with suicidal behaviors.

Illegal yet developmentally normative: a descriptive analysis of young, urban adolescents' dating and sexual behaviour in Cape Town, South Africa

BACKGROUND

In South Africa, it is illegal for adolescents under age 16 years to engage in any sexual behaviour whether kissing, petting, or penetrative sex, regardless of consent. This cross-sectional study investigated the extent to which young adolescents engage in various sexual behaviours and the associations between dating status and sexual behaviours.

METHOD

Grade 8 adolescents (N = 474, ages 12-15 years, mean = 14.14 years) recruited from Cape Town schools completed surveys providing information about their sociodemographic backgrounds, dating experience, sexual behaviour, and substance use.

RESULTS

Lower hierarchy sexual behaviours, such as kissing (71.4% of girls; 88.4% of boys), were more common than oral (3.9% of girls; 13.8% of boys), vaginal (9.3% of girls; 30.0% of boys), or anal (1.4% of girls; 10.5% of boys) sex. Currently dating girls and boys were more likely to engage in sexual behaviours including several risk behaviours in comparison to their currently non-dating counterparts. These risk behaviours included penetrative sex (21.1% of dating vs. 4.5% of non-dating girls; 49.4% of dating vs. 20.2% of non-dating boys), sex with co-occurring substance use (22.2% of dating vs. 0 non-dating girls; 32.1% of dating vs. 40% of non-dating boys), and no contraceptive use (26.1% of sexually experienced girls; 44.4% of sexually experienced boys). Among girls, there were significant associations between ever having penetrative sex and SES (OR = 2.592, p = 0.017) and never dating (OR = 0.330, p = 0.016). Among boys, there were significant associations between ever having penetrative sex and never dating (OR = 0.162, p = 0.008). Although the currently dating group of young adolescents appear to be a precocious group in terms of risk behaviour relative to the currently non-dating group, teenagers in both groups had experience in the full range of sexual behaviours.

CONCLUSIONS

Many young adolescents are engaging in a variety of sexual behaviours ranging from kissing and touching to intercourse. Of particular concern are those engaging in risky sexual behaviour. These findings indicate that adolescents need to be prepared for sexual negotiation and decision-making from an early age through comprehensive and accessible education and health services; sections of current legislation may be a barrier to adopting such policies and practices.

The use of mental health services by adolescent smokers: a nationwide Israeli study

In this study, we aimed to evaluate the utilization of mental health services by adolescent smokers, the presence of untreated mental disorders in this young population and the associated emotional and behavioral difficulties. We performed a nationwide survey study of an Israeli representative sample of 906 adolescents and their mothers. Mental disorders were assessed using the Development and Well-Being Assessment (DAWBA) Inventory. Emotional and behavioral difficulties were evaluated using the Strengths and Difficulties Questionnaire (SDQ). Mental health services use and smoking habits were evaluated by relevant questionnaires. Adolescent smokers were using significantly more mental health services than non-smokers (79% vs. 63%, respectively, P<0.001), independently of their mental health status or ethnic group. Adolescent smokers also reported more emotional and behavioral difficulties in most areas (P<0.001), which are consistent with their mothers' reports, except in the area of peer relationships. The treatment gap for the smoking adolescents was 53% compared to 69% in the non-smokers (P<0.001). This is the first study characterizing the use of mental health services and the related emotional and behavioral difficulties in a nationally-representative sample of adolescents. The findings of a wide treatment gap and the rates of the associated emotional and behavioral difficulties are highly relevant to the psychiatric assessment and national treatment plans of adolescent smokers.

Diagnostic Profiles among Urban Adolescents with Unmet Treatment Needs: Comorbidity and Perceived Need for Treatment

The goal of this study was to document comorbidity profiles of psychiatric disorder and perceived need for treatment among urban adolescents with unmet behavioral health needs. Participants were 303 community-referred adolescents and their primary caregivers. Adolescents included both boys (54%) and girls and were primarily Hispanic (58%), African American (23%), and multiracial (13%). Home-based interviews with both adolescents and caregivers were used to assess DSM-IV diagnoses and perceived treatment needs. Most adolescents (80%) were diagnosed with multiple disorders and most families (66%) reported a need to treat more than one disorder. Latent class analysis of endorsed DSM-IV disorders identified five distinct diagnostic profiles: Parental Concern, Adolescent Distress, Basic Externalizers, Severely Distressed, and Comorbid Externalizers. Diagnostic profiles were compared on perceived treatment need and related psychosocial risk characteristics. Implications for behavioral health care policy and practice for youth with unmet treatment needs are discussed.

Sensation seeking as risk factor for suicidal ideation and suicide attempts in adolescence

BACKGROUND

High sensation seeking in adolescence is associated with engagement in risk-taking behaviors, especially substance use. Although depressed adolescents are prone to increased risk-taking, and suicidal behavior can be considered within the spectrum of risk-taking behaviors, the relationships between sensation seeking, depression, and suicidal behavior have not been explored.

METHODS

A self-report questionnaire assessing sensation seeking, depression, substance use problems, and suicidal ideation and suicide attempts was completed by 9th- through 12th-grade students (n=2189) in six New York State high-schools from 2002 through 2004. Logistic regression analyses were conducted to examine main and interaction effects between sensation seeking and the four clinical variables.

RESULTS

High sensation seeking was positively associated with depressive symptoms and substance use problems. The main effects of sensation seeking on suicidal ideation and suicide attempts remained significant after controlling for depression and substance use. The association between sensation seeking and suicide attempts was moderated by substance use problems.

LIMITATIONS

The schools were suburban and predominantly white, limiting the generalizability of the results. Other mental disorders with potential implications for sensation seeking and for suicidal behavior, such as bipolar disorders, were not assessed.

CONCLUSIONS

The finding that sensation seeking makes an independent contribution to the risk of suicidal ideation and attempts is consistent with findings in literature on novelty seeking and impulsivity. The associations between sensation seeking, depressive symptoms and suicidal behavior may be compatible with the presence of an underlying temperamental dysregulation. Screening for sensation seeking may contribute to the reduction of adolescent suicide risk.

Gender differences in emotional and behavioral disorders and service use among adolescent smokers: a nationwide Israeli study

Marked gender differences have been identified in cigarette smoking. In this study, we aimed to identify the gender-specific emotional and behavioral disorders among adolescent smokers and their consequent utilization of mental health services. We performed a nationwide survey study of an Israeli representative sample of 906 adolescents and their mothers. Mental disorders were assessed using the Development and Well-Being Assessment (DAWBA) Inventory. Levels of emotional and behavioral difficulties were evaluated using the Strengths and Difficulties Questionnaire (SDQ). Mental health services use and smoking habits were also assessed. Among non-smoker adolescents there were significant gender differences in almost all SDQ scales: emotional problems, pro-social, hyperactivity/inattention and conduct problems, whereas in the smoker group there was a difference only in the SDQ emotional problems scale (both self- and maternal-rated, P<0.001 and P=0.002, respectively). Only marginal difference was noted between males and females in help-seeking for emotional or behavioral problems. Over 50% of both male and female smokers in the study had untreated mental disorders (non-significant gender difference). The well-established gender differences in psychiatric symptomatology narrowed markedly in adolescent smokers; the typical gender difference in disruptive behaviors was lost in the adolescent smoking population. The implications of these findings are particularly relevant to developing more effective gender-specific programs to prevent youth smoking, to facilitate quitting and prepare primary care practitioners to identify mental disorders and behavioral problems in adolescents with a smoking history.

Discerning reported suicide attempts within a youthful offender population

With suicide being the third leading cause of death among young people, early identification of risk is critical, particularly for those involved with the juvenile courts. In this study of court-involved youth (N = 433) in two Midwest counties, logistic regression analysis identified some expected and unexpected findings of important demographic, educational, mental health, child welfare, and juvenile court-related variables that were linked to reported suicide attempts. Some of the expected suicide attempt risk factors for these youth included prior psychiatric hospitalization and related mental health services, residential placement, and diagnoses of depression and alcohol dependence. However, the most unexpected finding was that a court disposition to shelter care (group home) was related to a nearly tenfold increased risk in reported suicide attempt. These findings are of importance to families, mental health professionals, and juvenile court personnel to identify those youth who are most at risk and subsequently provide appropriate interventions to prevent such outcomes.

The relationship between dating violence and suicidal behaviors in a national sample of adolescents

Relationship violence is a common problem faced by adolescents in the United States. In general, adolescents are at higher risk for relationship victimization than adults (Silverman, Raj, Mucci, & Hathaway, 2001), and females between the ages of 16 and 24 years are at the highest risk of relationship victimization (Rennison, 2001). This study uses data from the 2007 Youth Risk Behavior Surveillance (YRBSS) System (or referred to as Youth Risk Behavior Survey [YRBS]; N = 11,781) of adolescents between the ages of 14 and 17 years to estimate two logistic regression models on the association between relationship violence and suicidal behaviors controlling for variables such as sexual assault and drug use. The findings indicated that victimized adolescents are at higher risk for planning and/or attempting suicide compared to nonvictimized adolescents. Implications for research and practice are explored.

Overlooked and underserved: "action signs" for identifying children with unmet mental health needs

OBJECTIVE

The US Surgeon General has called for new approaches to close the mental health services gap for the large proportion of US children with significant mental health needs who have not received evaluation or services within the previous 6 to 12 months. In response, investigators sought to develop brief, easily understood, scientifically derived "warning signs" to help parents, teachers, and the lay public to more easily recognize children with unmet mental health needs and bring these children to health care providers' attention for evaluation and possible services.

METHOD

Analyses of epidemiologic data sets from >6000 children and parents were conducted to (1) determine the frequency of common but severely impairing symptom profiles, (2) examine symptom profile frequencies according to age and gender, (3) evaluate positive predictive values of symptom profiles relative to Diagnostic and Statistical Manual of Mental Disorders diagnoses, and (4) examine whether children with 1 or more symptom profiles receive mental health services.

RESULTS

Symptom-profile frequencies ranged from 0.5% to 2.0%, and 8% of the children had 1 or more symptom profile. Profiles generated moderate-to-high positive predictive values (52.7%-75.4%) for impairing psychiatric diagnoses, but fewer than 25% of children with 1 or more profiles had received services in the previous 6 months.

CONCLUSIONS

Scientifically robust symptom profiles that reflect severe but largely untreated mental health problems were identified. Used as "action signs," these profiles might help increase public awareness about children's mental health needs, facilitate communication and referral for specific children in need of evaluation, and narrow the child mental health services gap.

Characterization of South African adolescents with alcohol use disorders but without psychiatric or polysubstance comorbidity

BACKGROUND

Individuals who begin drinking during early adolescence and exhibit externalizing pathology and disinhibitory/dysregulatory tendencies are more vulnerable to developing alcohol use disorders (AUDs) in adulthood. Previous research has focused on in-treatment populations with substantial comorbid psychopathology and polysubstance use. Here, we characterize a unique sample of treatment-naïve adolescents without such comorbidity to help identify vulnerable youth who may benefit from early intervention.

METHODS

We compared externalizing propensity, disinhibitory characteristics, and school performance in adolescents with AUDs (but without comorbid psychopathology or other substance use; n = 70) to those of demographically matched controls (n = 70). Within the AUD group, we compared measures of substance use and the disinhibitory syndrome between boys and girls with differing severity of externalizing propensity.

RESULTS

Adolescents with AUDs demonstrated more externalizing propensity and disinhibitory personality traits (impulsivity, novelty seeking, and excitement seeking), poorer self-monitoring and response inhibition, more bullying and sexual risk-taking behavior, poorer first-language performance, and greater use of alcohol, cannabis, and nicotine (p < 0.05). Within the AUD group, participants with higher externalizing propensity began drinking earlier, more frequently, and for a longer duration than those with lower externalizing symptoms (p < 0.05). Disinhibitory features (personality, cognition, and behavior) were, however, not stronger in those with higher externalizing propensity.

CONCLUSIONS

We suggest that the constructs of externalizing propensity and disinhibitory syndrome are useful in characterizing treatment-naïve adolescents with AUDs but without comorbid psychopathology or polysubstance use. These results support the importance of these constructs in understanding adolescent AUDs, even when the frank externalizing diagnoses of childhood (oppositional defiant disorder and conduct disorder) are excluded.

Developmental trajectories of aggression from late childhood through adolescence: similarities and differences across gender

Although numerous investigations of overt aggressive and antisocial trajectories have been undertaken, there is a dearth of literature examining gender differences and similarities in trajectory patterns and their correlates. To address these gaps, we investigated gender differences in the prevalence rates, predictive validity during transition to adulthood, childhood risk factors, and adolescent correlates of different trajectories of teacher-reported overt aggression (i.e., fights, argues, gets in trouble) among 220 participants (116 girls and 104 boys) evaluated annually from grade 4 to grade 12. Four patterns of trajectories were identified: low, increasing (i.e., adolescent-onset), decreasing (i.e., childhood-limited), and high (i.e., childhood-onset). A large proportion of youth, particularly girls, displayed low levels of aggression over time. A small proportion followed the childhood-onset trajectory. Across gender, the childhood-onset trajectory was associated with the highest rates of maladjustment during the transition to adulthood, the highest number of childhood risk factors, and multiple problems during adolescence. The adolescent-onset trajectory was associated with few childhood risk factors, but with high levels of independent status during adolescence. In contrast, the childhood-limited trajectory was associated with several childhood risk factors, but high levels of parental monitoring and school engagement during adolescence. Romantic involvement differentiated the adolescent-onset and childhood-limited trajectories among girls.

Early substance use initiation and suicide ideation and attempts among students in France and the United States

OBJECTIVE

In response to recent research documenting a link between early substance use and suicidal behaviors among youth, the current study sought to examine the associations between ages of substance use initiation and suicidal behavior among students in France and the USA.

METHODS

Cross-sectional logistic regression analyses based on the 2003 European School Survey Project on Alcohol and Other Drugs (ESPAD) survey (France; n = 13,187) and the 2003 Youth Risk Behavior Survey (YRBS) (United States; n = 15,136) assessed associations between early substance use initiation (i.e., alcohol, cigarette and cannabis/marijuana) and suicide ideation and attempts while controlling for potential confounders.

RESULTS

Early alcohol use initiation (OR(adj) = 1.52; 95% CI 1.17-1.97) and early cannabis/marijuana use initiation (OR(adj) = 2.90; 95% CI 2.20-3.83) were associated with suicide attempt in France. Early smoking was associated with suicide attempt in both France (OR(adj) = 1.92; 95% CI 1.55-2.37) and the USA (OR(adj) = 1.53; 95% CI 1.02-2.28). Sex differences were also noted.

CONCLUSIONS

The associations between substance use initiation and suicidal behaviors differed in the United States and France. These findings, placed into context, can assist the development and implementation of prevention strategies that seek to reduce the harmful consequences of early substance use among youth.

Pre-teen alcohol use initiation and suicide attempts among middle and high school students: findings from the 2006 Georgia Student Health Survey

Early alcohol use initiation has been linked to suicide attempts among youth. However, very little is known about the potential impact of alcohol-related norms and beliefs and how these may impact the association between alcohol use and suicide attempt. This study examines the associations between early alcohol use and suicide attempts while controlling for demographic characteristics, and alcohol-related beliefs and norms (e.g., believing alcohol causes harm to health or that adults or friends disapprove of alcohol use) and potential confounders. Analyses were based on the 2006 Georgia Student Health Survey (N=175,311) of students in grades 6, 8, 10 and 12. The current analyses were limited to students in grades 8, 10 and 12, who either began drinking prior to age 13 or who were non drinkers (n=87,349). Pre-teen alcohol use initiation was associated with suicide attempts (Adj.OR=1.51; 95%CI:1.38-1.66) relative to not drinking with similar associations for boys (Adj.OR=1.72; 95%CI:1.52-1.94) and girls (Adj.OR=1.26; 95%CI:1.08-1.45). Students who believed that alcohol was harmful to their health, or that friends or adults disapproved of their alcohol use, or who had been taught about substance use in school were less likely to make a suicide attempt, although findings differed for boys and girls. Pre-teen alcohol use initiation is an important risk factor for suicide attempts among boys and girls in Georgia. Increased efforts to delay and reduce early alcohol use through clinical interventions, education, and policies that impact norms and knowledge related to alcohol use are needed and may in turn reduce suicide attempts.

Saving and empowering young lives in Europe (SEYLE): a randomized controlled trial

Background

There have been only a few reports illustrating the moderate effectiveness of suicide-preventive interventions in reducing suicidal behavior, and, in most of those studies, the target populations were primarily adults, whereas few focused on adolescents. Essentially, there have been no randomized controlled studies comparing the efficacy, cost-effectiveness and cultural adaptability of suicide-prevention strategies in schools. There is also a lack of information on whether suicide-preventive interventions can, in addition to preventing suicide, reduce risk behaviors and promote healthier ones as well as improve young people's mental health.

The aim of the SEYLE project, which is funded by the European Union under the Seventh Framework Health Program, is to address these issues by collecting baseline and follow-up data on health and well-being among European adolescents and compiling an epidemiological database; testing, in a randomized controlled trial, three different suicide-preventive interventions; evaluating the outcome of each intervention in comparison with a control group from a multidisciplinary perspective; as well as recommending culturally adjusted models for promoting mental health and preventing suicidal behaviors.

Methods and design

The study comprises 11,000 adolescents emitted from randomized schools in 11 European countries: Austria, Estonia, France, Germany, Hungary, Ireland, Israel, Italy, Romania, Slovenia and Spain, with Sweden serving as the scientific coordinating center. Each country performs three active interventions and one minimal intervention as a control group. The active interventions include gatekeeper training (QPR), awareness training on mental health promotion for adolescents, and screening for at-risk adolescents by health professionals. Structured questionnaires are utilized at baseline, 3- and 12-month follow-ups in order to assess changes.

Discussion

Although it has been reported that suicide-preventive interventions can be effective in decreasing suicidal behavior, well-documented and randomized studies are lacking. The effects of such interventions in terms of combating unhealthy lifestyles in young people, which often characterize suicidal individuals, have never been reported. We know that unhealthy and risk-taking behaviors are detrimental to individuals' current and future health. It is, therefore, crucial to test well-designed, longitudinal mental health-promoting and suicide-preventive interventions by evaluating the implications of such activities for reducing unhealthy and risk behaviors while concurrently promoting healthy ones.

Trial registration

The German Clinical Trials Register, DRKS00000214.

Stress, substance use and sexual risk behaviors among primary care patients in Cape Town, South Africa

We assessed the relationship between stress, substance use and sexual risk behaviors in a primary care population in Cape Town, South Africa. A random sample of participants (and over-sampled 18-24-year-olds) from 14 of the 49 clinics in Cape Town's public health sector using stratified random sampling (n = 2,618), was selected. We evaluated current hazardous drug and alcohol use and three domains of stressors (Personal Threats, Lacking Basic Needs, and Interpersonal Problems). Several personal threat stressors and an interpersonal problem stressor were related to sexual risk behaviors. With stressors included in the model, hazardous alcohol use, but not hazardous drug use, was related to higher rates of sexual risk behaviors. Our findings suggest a positive screening for hazardous alcohol use should alert providers about possible sexual risk behaviors and vice versa. Additionally, it is important to address a broad scope of social problems and incorporate stress and substance use in HIV prevention campaigns.

Risk factors for suicidality among a nationally representative sample of high school students

Using the 2005 Youth Risk Behavior Surveillance data (n = 13,917) of high school students, we examined the association between four domains of risk factors (alcohol/drug use, aggression, HIV risk-related behaviors, and health problems) and indicators of suicidality (considering a suicide attempt, making a plan to attempt suicide, and actually attempting suicide). Logistic regressions showed that drug use (e.g., recent smoking, drinking before 13), victimization (e.g., threatened at school, hit by girl/boyfriend), risky sexual behavior (e.g., forced to have sex, used a condom) and two health problems (health as fair/poor, has disability/health problem) were associated with all three indicators of suicidality. These findings suggest that programs to prevent alcohol/drug use, address aggression, promote safety, and prevent unsafe sexual practices may also prevent suicidality.

Associations between maternal closeness, suicidal ideation, and risk behaviors in Cape Town

Health compromising behaviors, such as smoking and other risk behaviors tend to co-occur, and contribute to the leading causes of preventable death, disease, and disability among adolescents and young adults worldwide. The present study assesses a model of the direct and indirect effects of maternal closeness with suicidal ideation on smoking and risky behaviors. The sample consisted of 657 South African youth assessed over two time points with comparison of effects between males and females. Maternal closeness had a significant effect on suicidal ideation among females. Suicidal ideation had a significant effect on risky behaviors among males and lifetime smoking among females. A significant indirect effect was observed from maternal closeness to lifetime smoking among females. These results indicate that suicidal ideation is associated with lifetime smoking and risky behaviors separately among male and female adolescents and highlight the need to focus on the development of mental health preventive interventions for both genders.

Age of alcohol use initiation, suicidal behavior, and peer and dating violence victimization and perpetration among high-risk, seventh-grade adolescents

OBJECTIVE

We examined the cross-sectional associations between reports of an early age of alcohol use initiation and suicidal ideation, suicide attempts, and peer and dating violence victimization and perpetration among high-risk adolescents.

METHOD

Data were obtained from the Youth Violence Survey conducted in 2004 and administered to all public school students enrolled in grades 7, 9, and 11/12 (N = 4131) in a high-risk school district in the United States. Our analyses were limited to seventh-grade students who either began drinking before the age of 13 or were nondrinkers, with complete information on all covariates (n = 856). Cross-sectional logistic and multinomial logistic regression analyses were conducted to determine the associations between early alcohol use and each of the 6 outcome behaviors (dating violence victimization and perpetration, peer violence victimization and perpetration, suicidal ideation, and suicide attempts) while controlling for demographic characteristics and other potential confounders (ie, heavy episodic drinking, substance use, peer drinking, depression, impulsivity, peer delinquency, and parental monitoring).

RESULTS

In our study, 35% of students reported alcohol use initiation before 13 years of age (preteen alcohol use initiators). Students who reported preteen alcohol use initiation reported involvement in significantly more types of violent behaviors (mean: 2.8 behaviors), compared with nondrinkers (mean: 1.8 behaviors). Preteen alcohol use initiation was associated significantly with suicide attempts, relative to nondrinkers, controlling for demographic characteristics and all other potential confounders.

CONCLUSIONS

Early alcohol use is an important risk factor for involvement in violent behaviors and suicide attempts among youths. Increased efforts to delay and to reduce early alcohol use among youths are needed and may reduce both violence and suicide attempts.

A one-session human immunodeficiency virus risk-reduction intervention in adolescents with psychiatric and substance use disorders

OBJECTIVE

To explore change in human immunodeficiency virus (HIV) risk among teens in outpatient treatment for substance use disorders (SUDs).

METHOD

From December 2002 to August 2004, 50 adolescents (13-19 years) with major depressive disorder, conduct disorder, and one or more non-nicotine SUD completed the Teen Health Survey (THS) at the beginning and end of 16 weeks of outpatient cognitive behavioral SUD treatment, which included a one-session HIV intervention. Changes in THS scale scores and specific item responses targeted by the intervention were assessed with paired t tests and Wilcoxon signed rank tests.

RESULTS

Pre/post mean THS scores significantly improved for two subscales: Measures of HIV Information (14.8-17.6; p < .001) and Beliefs about Condom Use (17.6-18.5; p < .05). Analyses of specific items showed trends for improvement in intentions to carry condoms and in the number of teens who obtained condoms. Not all of the risks targeted by the intervention showed significant change, but no change was observed in any area that was not specifically targeted.

CONCLUSIONS

Results from this preliminary study are consistent with the need for specific assessment and targeted intervention to reduce HIV risk in outpatient adolescent SUD treatment.

Gender, early alcohol use, and suicide ideation and attempts: findings from the 2005 youth risk behavior survey

PURPOSE

To examine the cross-sectional associations between preteen alcohol use initiation and subsequent suicide ideation and attempts for boys and girls in a nationally representative sample of high school students.

METHODS

Analyses are computed using data from the 2005 national Youth Risk Behavior Survey, which includes a representative sample (n = 13,639) of high-school students in grades 9-12 in the United States. Cross-sectional logistic regression analyses were conducted to determine the associations between early alcohol use and reports of suicide ideation and suicide attempts for boys and girls while controlling for demographic characteristics, substance use, involvement in physical fights, weapon carrying, physical abuse by dating partner, sexual assault, and sadness.

RESULTS

Among study participants, 25.4% reported drinking before age 13 years. Preteen alcohol use initiation was statistically significantly associated with suicidal ideation (adjusted OR = 1.89, 95% CI =1.46-2.44) and suicide attempts (adjusted OR = 2.71, 95% CI =1.82-4.02) relative to nondrinkers. Preteen alcohol use initiation was statistically significantly associated with suicidal ideation and attempts relative to nondrinkers for both boys and girls.

CONCLUSIONS

Alcohol use among adolescents, particularly preteen alcohol use initiation, is an important risk factor for both suicide ideation and suicide attempts among boys and girls. Increased efforts to delay and reduce early alcohol use are needed, and may reduce suicide attempts.

Parental communication and youth sexual behaviour

The role of parental communication and instruction concerning sexual behaviour were studied in a community-based sample of 1083 youth aged 13-17 (mean age of 15 years; 51% girls, 49% White). The Youth Asset Survey was administered along with items measuring demographics and youth risk behaviours. After controlling for demographic factors, multivariate analysis revealed that youth were much less likely to have initiated sexual intercourse if their parents taught them to say no, set clear rules, talked about what is right and wrong and about delaying sexual activity. If youth were sexually active, they were more likely to use birth control if taught at home about delaying sexual activity and about birth control. Having only one sexual partner was associated with having an adult role model who supports abstinence, being taught at home about birth control, and being taught at home how to say no. If parents reported talking with youth about birth control and sexually transmitted disease (STD) prevention, youth were significantly more likely to use birth control. Our conclusion is that parents have the opportunity and ability to influence their children's sexual behaviour decisions.

Adolescent Substance Use and Suicidal Behavior: A Review With Implications for Treatment Research

Adolescent substance use (alcohol and other drugs) and suicidal behavior, independently, pose serious public health problems. Youths who report co-occurring substance use and suicidality are a particularly high-risk group. In this review, we explore four areas that are pertinent to research with substance-abusing and suicidal adolescent populations. First, we review epidemiological research that is relevant to the association between substance use and suicidal behavior. Results suggest that substance use heightens statistical risk for suicidal behavior in adolescent clinical and community populations. Alcohol intoxication may serve as a proximal risk factor for suicidal behavior among distressed youths through its psychopharmacological effects on the brain. Substance use may also serve as a distal risk factor for suicidal behavior by increasing stress and exacerbating co-occurring psychopathology. Second, we propose different theoretical models that might explain the high rates of co-occurring substance use and suicidal behavior among adolescents. Substance use may stem from an underlying syndrome of problem behavior among impulsive suicide attempters with predominant externalizing symptoms. In contrast, nonimpulsive suicide attempters with predominant internalizing symptoms may use substances to cope with negative affective states. Third, we explore the status of treatment research with substance abusing and suicidal adolescent populations. Studies of substance abuse treatment and suicidal behavior have neither adequately assessed nor incorporated treatment of the other co-occurring problem. Finally, we conclude with proposed directions for future research, including the development of integrated interventions tailored to adolescents with these co-occurring problems.

Clustering of Health-Related Behaviors and Their Determinants: Possible Consequences for School Health Interventions

Characterizing school health promotion is its category-by-category approach, in which each separate health-related behavior is addressed independently. Such an approach creates a risk that extra-curricular activities become overloaded, and that teaching staff are distracted by continuous innovations. Within the health promotion sector there are thus increasing calls for an integrative approach to health-related behaviors. However, a meaningful integrative approach to different lifestyles will be possible only if there is some clustering of individual health-related behaviors and if health-related behaviors have a minimum number of determinants in common. This systematic review aims to identify to what extent the four health-related behaviors smoking, alcohol abuse, safe sex and healthy nutrition cluster; and how their determinants are associated. Potentially modifiable determinants that offer clues for an integrative approach of school health-promotion programs are identified. Besides, the direction in which health educators should look for a more efficient instructional design is indicated.

Cigarette smoking in the adolescent children of drug-abusing fathers

OBJECTIVE

This study examined the longitudinal predictors of cigarette smoking in a sample of at-risk adolescents whose fathers were drug abusers (N = 296).

METHODS

At time 1, structured interviews were administered, separately and in private, to male and female youth (X age = 16.3) and their fathers; adolescents were reinterviewed approximately 1 year later (at time 2). Structural equation modeling was used to examine the interrelationship of time 1 paternal tobacco and illicit drug use, father-child relations, adolescent psychological adjustment, and peer group factors and adolescent smoking at time 2. A supplementary analysis assessed the same model with control on the adolescent's age, gender, frequency of contact with the father, and the father's treatment status.

RESULTS

The structural equation model showed a mediational pathway linking paternal tobacco and drug use to a weak and conflictual father-child relationship, which was associated with greater adolescent maladjustment, which in turn was related to deviant peer affiliations, which predicted adolescent smoking at time 2. There was also a direct path from paternal tobacco and drug use to adolescent time 2 smoking. The supplementary analysis found no significant differences between the models with and without control.

CONCLUSIONS

Findings provide evidence of the mechanisms that underlie the association between paternal drug use characteristics and smoking in the adolescent child. Clinical implications suggest the importance of the father-child relationship to smoking prevention programs for at-risk youth.

Early adult outcomes of adolescents who deliberately poisoned themselves

OBJECTIVE

To describe the early adult psychopathological and social outcomes of adolescents who deliberately poisoned themselves.

METHOD

Prospective cohort study with a 6-year follow-up of 132 of 158 (84%) adolescents who, between ages 11 and 16 years, had taken part in a randomized trial of a brief family intervention after deliberate self-poisoning. Comparisons were made with a sample of participants matched for age, gender, and childhood social class. Both groups were assessed using standardized measures of psychopathology and social functioning.

RESULTS

In most cases (93/132 or 70%) self-harm stopped within 3 years. Psychiatric disorders, particularly depression (74/132 or 56%), were prevalent, and self-harm in adulthood was restricted to this subgroup. There was a strong association between childhood adversity, in particular childhood sexual abuse, and self-harming risk in adulthood. Adulthood adversity also added to the risk, especially for those who had experienced index episode major depression. These associations were not mediated by childhood problem solving and hopelessness.

CONCLUSIONS

For some young people, deliberate self-poisoning in adolescence seems to be part of a complex and continuing network of problems, marked by high rates of psychopathology, comorbidity, with other disorders and high psychosocial adversity.

Early intervention in low birth weight premature infants: results at 18 years of age for the Infant Health and Development Program

OBJECTIVE

To assess whether improvements in cognitive and behavioral development seen in preschool educational programs persist, we compared those in a multisite randomized trial of such a program over the first 3 years of life (INT) to those with follow-up only (FUO) at 18 months of age.

METHODS

This was a prospective follow-up of the Infant Health and Development Program at 8 sites heterogeneous for sociodemographic characteristics. Originally 985 children were randomized to the INT (n = 377) or FUO (n = 608) groups within 2 birth weight strata: heavier low birth weight (HLBW; 2001-2499 g) and lighter low birth weight (LLBW; < or = 2000 g). Primary outcome measures were the Peabody Picture Vocabulary Test (PPVT-III), reading and mathematics subscales of the Woodcock-Johnson Tests of Achievement, youth self-report on the Total Behavior Problem Index, and high-risk behaviors on the Youth Risk Behavior Surveillance System (YRBSS). Secondary outcomes included Weschler full-scale IQ, caregiver report on the Total Behavior Problem Index, and caregiver and youth self-reported physical health using the Medical Outcome Study measure. Assessors were masked as to study status.

RESULTS

We assessed 636 youths at 18 years (64.6% of the 985, 72% of whom had not died or refused at prior assessments). After adjusting for cohort attrition, differences favoring the INT group were seen on the Woodcock-Johnson Tests of Achievement in math (5.1 points), YRBSS (-0.7 points), and the PPVT-III (3.8 points) in the HLBW youth. In the LLBW youth, the Woodcock-Johnson Tests of Achievement in reading was higher in the FUO than INT group (4.2).

CONCLUSIONS

The findings in the HLBW INT group provide support for preschool education to make long-term changes in a diverse group of children who are at developmental risk. The lack of observable benefit in the LLBW group raises questions about the biological and educational factors that foster or inhibit sustained effects of early educational intervention.

Depressive symptoms and associated psychopathology in urban adolescents: a cross-cultural study of three countries

The study aimed to compare cross-cultural trends of comorbid internalizing and externalizing psychopathology, prosocial beliefs, and perceptions of risk in adolescents with and without clinical levels of self-reported depressive symptoms. The Social and Health Assessment, a self-report survey, was conducted in a representative sample of 3309 adolescents 14 to 17 years old from urban communities in the United States (N = 1343), Belgium (N = 946), and Russia (N = 1009). In all three countries, girls reported higher levels of depressive symptoms than boys. The findings also demonstrate that in both genders, depressive symptoms were associated with increased levels of internalizing and externalizing problems, as well as lower levels of prosocial beliefs and low perceptions of harm from risk-taking behavior. Depressed boys had relatively higher levels of externalizing problems than depressed girls. Greater levels of internalizing problems observed in depressed youth, as compared with their nondepressed counterparts, were not gender-specific. Current findings suggest that the relationships between depression and comorbid psychopathology are not culture-specific and have similar patterns in different populations.

The proximal association between smoking and alcohol use among first year college students

OBJECTIVE

This study was undertaken to evaluate the association between patterns of day-to-day smoking and drinking among first year college students.

METHOD

Using 210 days of weekly time-line follow-back diary data, the authors examined the within-person relationships between smoking and drinking. Bivariate time series procedures were utilized.

RESULTS

Findings revealed a high degree of significant cross-correlations between smoking and drinking in which the amount of use of one substance could be predicted by current, as well as past and future use of the other. For the majority of participants, smoking and drinking were positively associated with the alternate behavior. The most common pattern of prediction for individuals was within day (i.e. synchronous correlations). When examining rates of individuals showing significant cross-correlations according to their level of either smoking or drinking, those smoking less than one cigarette on average per day were found to be less likely to demonstrate a synchronous cross-correlation between the two behaviors than those smoking at higher rates. No significant association was found between level of drinking and the rate of significant synchronous cross-correlations between smoking and drinking.

CONCLUSIONS

Reports of daily behavior over long periods of time have the potential to provide insight into the more proximal influences of smoking and alcohol use on one another. Future research is needed to establish the specific factors (i.e. third variables) and related mechanisms that may drive both behaviors.

A qualitative study of the relationship between alcohol consumption and risky sex in adolescents

This study examined how alcohol consumption over a single session can affect the likelihood of risky sex in adolescents. Risky sexual behavior, as defined in this study, included sexual intercourse without the use of contraception or aNY sexual behavior that was subsequently regretted. In-depth interviews were conducted with 64 adolescents (aged 14-17 years). Data were analyzed following the principles of Interpretative Phenomenological Analysis. The impact of alcohol consumption upon risky sexual behavior was found to operate through a "continuum of influence." The 5 effects or explanations within this continuum, possibly determined through the level of inebriation, are summarized as follows: (1) alcohol affecting young people's assessment of a person's sexual attractiveness; (2) alcohol used as an "excuse" for socially unacceptable behavior; (3) increased confidence and lowering of inhibitions; (4) impaired judgment in accurately recognizing and controlling a potentially risky situation; and (5) complete loss of control, memory loss, and "black-out." These explanations were ordered with increasing significance. That is, impaired judgment (Explanation 4) and complete loss of control (Explanation 5) arguably represented the most significant effects of drinking alcohol upon risky sexual behavior. For those participants who reported both risky and non-risky sexual behavior, risky events were more likely to occur when alcohol consumption had increased and when the impaired judgment and complete loss of control explanations were applicable. The implications of understanding this complex relationship are outlined, and they will be of interest to academics, practitioners, and policy-makers in the alcohol and sex fields.

Practice parameter for psychiatric consultation to schools

This practice parameter reviews the topic of psychiatric consultation to schools. The review covers the history of school consultation and current consultative models; the process of developing a consultative relationship; school administrative procedures, personnel, and milieu; legal protections for students with mental disabilities; and issues typically arising in consultative situations. The objective of the parameter is to provide an introduction to the special vocabulary, knowledge, and skills that are important prerequisites for successful consultation in school settings.

The clustering of risk behaviors among Caribbean youth

OBJECTIVE

To examine the relationships among risk behaviors for Caribbean youth; and to determine the correlations between initiation of sexual activity and other risk behaviors.

METHODS

The associations between cigarette smoking, alcohol and marijuana use, early initiation of sexual intercourse, involvement in violence and delinquency were examined using odds ratios on data from the Caribbean Youth Health Survey (n = 15, 695). Survival analysis was then used to determine the association between initiation of sexual activity and the risk behaviors.

FINDINGS

There were statistically significant relationships between all pairs of risk behaviors for both male and female adolescents. Even though more males than females had engaged in each of the behaviors, the strengths of association were higher for females. From survival analysis, initiation of sexual activity was associated with gang involvement and weapon carrying among young adolescents and even more risk behaviors among the older adolescents.

CONCLUSION

Health compromising behaviors cluster among Caribbean youth with associations being stronger for females. Initiating sexual activity was a predictor of other risk behaviors with the likelihood increasing among older adolescents and females.

Will I be alive in 2005? Adolescent level of involvement in risk behaviors and belief in near-future death

OBJECTIVE

We examined the association between a belief in one's future mortality and various risk-taking behaviors among urban black adolescents. In particular, we investigated whether adolescents with higher levels of participation in various risk behaviors were more likely to believe in their future death as compared with adolescents with lesser levels of risk-taking behavior.

METHODS

Data obtained from April 1994 to March 1997 were analyzed for a total of 2694 adolescents, aged 12 to 21 years. The odds of believing that one would die within the next 2 years were calculated for various levels of participation in risk behaviors involving alcohol, drugs, and criminal or violent acts.

RESULTS

A total of 160 adolescents (7.1% of all boys and 5.4% of all girls) reported that they believed that they would die within the next 2 years. The adjusted odds of future death belief among adolescents who both actively engaged in and knew others who participated in all of the various risk behaviors, relative to adolescents who neither personally engaged in nor knew others who participated in any of the risk behaviors, was 3.22 (95% confidence interval [CI]: 2.01-5.17) vs 1.14 (95% CI: 0.67-1.95) for drug use and drug selling, 2.01 (95% CI: 1.38-2.92) vs 0.8 (95% CI: 0.39-1.62) for combined alcohol and drug use, and 5.60 (95% CI: 2.03-15.47) vs 1.61 (95% CI: 1.08-2.42) for violent physical behavior. In addition, residence in a foster home was significantly associated with death belief after adjustment for all other variables.

CONCLUSIONS

There is a significant relationship between certain risk behaviors and belief in near-future death. Moreover, higher levels of involvement in risk behaviors were associated with a stronger likelihood of belief in near-future mortality. Identification of adolescents who engage in certain risky behaviors, combined with a recognition of the degree to which the adolescent participates in the particular behavior(s), may be used to facilitate more rapid intervention among youths who either believe in their imminent demise or engage in behaviors that increase the likelihood of their untimely death.

HIGH SCHOOL ATHLETIC PARTICIPATION AND ADOLESCENT SUICIDE: A Nationwide US Study

Suicide is the third leading cause of death among US adolescents aged 15-24, with males incurring higher rates of completion than females. This study used hierarchical logistic regression analysis to test whether athletic participation was associated with lower rates of suicidal ideation and behavior among a nationally representative sample of over 16,000 US public and private high school students. Net of the effects of age, race/ethnicity, parental educational attainment, and urbanicity, high school athletic participation was significantly associated with reduced odds of considering suicide among both females and males, and reduced odds of planning a suicide attempt among females only. Though the results point to favorable health outcomes for athletes, athletic participation was also associated with higher rates of injury to male athletes who actually attempted suicide.

The Life Attitudes Schedule-Short Form: psychometric properties and correlates of adolescent suicide proneness

The goals of the present study were to describe the psychometric properties of the Life Attitudes Schedule-Short Form (LAS-SF) in adolescents and provide criterion and construct validity data, including bivariate and multivariate associations with related risk behaviors. Anonymous questionnaires containing the LAS-SF and related measures were administered to 1,742 high school students in three states. Psychometric properties for LAS-SF items and total score were very good, and the LAS-SF was correlated with almost all of the examined risk behaviors, illustrating the broad range of problems measured by the instrument. LAS-SF total scores were associated with past suicide attempt, even after controlling for the impact of current depression. Clinical and research uses for the LAS-SF are discussed.

Adolescent and parent perspectives on ethical issues in youth drug use and suicide survey research

The contribution of adolescent and parent perspectives to ethical planning of survey research on youth drug use and suicide behaviors are highlighted through an empirical examination of 322 7th-12th graders' and 160 parents' opinions on questions related to 4 ethical dimensions of survey research practice: (a) evaluating research risks and benefits, (b) establishing guardian permission requirements, (c) developing confidentiality and disclosure policies, and (d) using cash incentives for recruitment. Generational and ethnic variation in response to questionnaire items developed from discussions within adolescent and parent focus groups are described. The article concludes with a discussion of the potential contributions and challenges of adolescent and parent perspectives for planning scientifically valid and ethically responsible youth risk survey research.

Sudden infant death syndrome among extremely preterm infants: United States 1997-1999

BACKGROUND

Preterm infants have been reported to be at higher risk than term infants for sudden infant death syndrome (SIDS). Reasons for this higher risk are not clear.

OBJECTIVE

The objective of this study was to analyze medical and demographic characteristics among infants 24 to 32 weeks gestation to identify characteristics more prevalent among infants dying of SIDS in the postneonatal period than among infants of similar gestation who survived or who died of other causes in the postneonatal period.

DESIGN/METHODS

United States linked birth and death certificate period data for 1997 to 1999 were used for this analysis. The population used was limited to infants 24 to 32 weeks gestation weighing 500 to 2500 g. SIDS deaths were limited to the postneonatal period and compared to survivors and infants dying in the postneonatal period of other causes.

RESULTS

There were 469 postneonatal SIDS deaths with complete data (rate=2.2/1000 live births surviving > or =28 days); 3950 other postneonatal deaths (rate=18.7/1000) and 206,640 survivors. Compared with survivors, infants dying of SIDS were more likely to be born to mothers with <12 years of education (odds ratio=2.5, 95% confidence interval (95% CI=1.8, 3.3); be born to mothers < or =17 years of age (OR=2.0, 95% CI=1.4, 2.8); and be born to mothers with >3 previous pregnancies (OR=2.6, 95% CI=1.9, 3.5). Compared with infants dying in the postneonatal period of other causes, these same demographic factors continued to be significant risk factors for SIDS. There were no medical risk factors such as breech presentation, abruptio placenta, Apgar score <4 at 5 minutes, or mechanical ventilation for >30 minutes after birth, for which infants dying of SIDS were at greater risk than survivors or infants dying of other causes.

CONCLUSIONS

Risk factors for SIDS among infants 24 to 32 weeks gestation appear to be more associated with sociodemographic characteristics than medical characteristics. This suggests that for the immediate future, the risk for SIDS among very preterm infants will be best addressed through further modification of the environment and parent behavior.

Substance abuse, suicidality, and self-esteem in South African adolescents

Associations among six different domains of self-esteem (peers, school, family, sports/athletics, body image, and global self-worth) and risk behaviors related to substance use and suicidality were investigated in a sample of South African adolescents. Students enrolled in Grades 8 and 11 at independent secondary schools in Cape Town (N = 116) completed the Self-Esteem Questionnaire (SEQ) and a questionnaire that asked about their participation in a range of risk behaviors. Logistic regression analyses indicated that particular domains of self-esteem were differentially associated with indicators of alcohol, cigarette and drug use and suicidal ideation or behaviors in adolescents. Family self-esteem showed the strongest overall pattern of associations with the risk behaviors. Overall, the findings of this study suggest that interventions which aim to protect adolescents from engaging in risk behaviors by increasing their self-esteem are likely to be most effective and cost-efficient if they are aimed at the family and school domains.