Transformational narrative changes as a community-level approach to the prevention of adverse childhood experiences and substance use

There is increasing scientific evidence linking substance use, childhood adversity, and social determinants of health. However, little research has considered the evaluation of community-level strategies to reduce substance use by increasing awareness and implementation of evidence-based strategies for preventing adverse childhood experiences (ACEs). This article lays out the conceptual framework for a $2.9 million demonstration project designed to raise awareness of the impact of ACEs on substance use, including primary prevention strategies. Communities used transformational narrative change-with an emphasis on the voices of those most impacted by ACEs and substance use-to highlight the importance of addressing social determinants of health along with primary prevention strategies. The conceptual background highlighted in this article informed media, public health, and local efforts in the three accompanying articles and invited commentary. These findings may help inform future efforts to promote community-level strategies and strengthen the evidence-base for transformational narrative change efforts.

Increasing support for the prevention of adverse childhood experiences and substance use: Implementation of narrative change strategies in local health departments

Adverse childhood experiences (ACEs) are potentially traumatic but preventable experiences that occur before the ages of 18, including child abuse, witnessing violence, and parental substance use. ACEs have been linked with increased risk for substance use, along with a variety of other negative health outcomes. However, there is limited evidence of community-level strategies that link ACEs and substance to increase awareness of prevention efforts. This article reports on a $2.9 million program to promote health equity and inform narratives for the prevention of ACEs and substance use within three Midwestern communities. Program partners sought to create new transformational narratives that linked ACEs and substance use, while underscoring the importance of addressing social determinants of health (SDOH) that lead to disparities in ACEs and substance use. A mixed-methods evaluation design included document review, in-depth interviews with program staff (N = 8) and community liaisons (N = 2), and site reports from program staff (N = 8) and their community partners (N = 17). Analyses showed that successful implementation efforts had early leadership buy-in and support, set clear and manageable expectations at the outset of implementation, and developed strong relationships with organizations that engage in health equity work. Training and technical assistance were critical to helping community partners build trust, recognize each other's perspectives, broaden and reframe their world view, and better understand narrative efforts for the primary prevention of ACEs and substance use.

Differences in Health Care Experiences among Transgender and Gender Diverse Youth by Gender Identity and Race/Ethnicity

Transgender and gender diverse (TGD) youth experience significant risk for negative health outcomes, yet few studies exist that address TGD youth's experiences of health care. This paper explores the equitable access and utilization of health care in a sample of TGD youth of diverse gender and racial/ethnic identities. Data for this analysis are from the TGD subsample (n = 1415) of the 2018 Survey of Today's Adolescent Relationships and Transitions (START) Project. We assessed five health care experiences: being insured, having a current health care provider, being out to one's provider, believing your provider was knowledgeable about transgender issues, and barriers to accessing care due to gender identity/expression. We examined the proportion of TGD youth who reported each of these outcomes and within-group differences by gender identity and race/ethnicity using descriptive statistics, logistic regression, and predicted probabilities. When differences were examined by gender identity, barriers to equitable care were consistently more present among transgender females than youth of other gender identities. There were few significant differences by race/ethnicity; however, dual referent models demonstrated barriers to equitable care were particularly evident among Black and Hispanic transgender women. We discuss these findings through the lens of intersectionality and highlight the importance of research and intervention work focused on reducing barriers to equitable care for TGD youth.

Hostile home environment predicting early adolescent sexual harassment perpetration and potential school-related moderators

Using family systems theory, this longitudinal study of middle school youth examined the effects of abuse, family conflict, and sibling aggression on sexual harassment perpetration (N = 1563; Mage 11.2, 51% boys; 39% Hispanic, 29% Black, and 19% White). Boys reported more sexual harassment than girls; perpetration increased for both. The association between a hostile home environment and sexual harassment perpetration was moderated by school experiences. School belonging buffered effects of hostile home environment on baseline sexual harassment perpetration for boys who experienced abuse and White adolescents with high sibling aggression. Academic grades moderated change in perpetration over time, but effects differed by sex and race. It is important to understand how early violence exposures relate to sexual violence perpetration during early adolescence.

Witnessing Community Violence, Gun Carrying, and Associations with Substance Use and Suicide Risk Among High School Students - Youth Risk Behavior Survey, United States, 2021

Community violence, including homicides involving firearms, is a significant public health concern. From 2019 to 2020, firearm-related homicides increased by 39% for youths and young adults aged 10-24 years, and rates of suicide by firearm increased by approximately 15% among the same age group. Findings from the nationally representative 2021 Youth Risk Behavior Survey were used to analyze disparities and correlates of witnessing community violence and gun carrying among a nationally representative sample of high school students. Chi-square tests and logistic regression accounting for the complex sampling of the survey were used to assess demographic differences by student sex, race and ethnicity, age, and sexual identity in ever witnessing community violence, gun carrying in the past 12 months, and their associations with substance use and suicide risk. Measures of substance use included current binge drinking and marijuana use and lifetime prescription opioid misuse and illicit drug use. Suicide risk included seriously considered attempting suicide and attempted suicide in the past 12 months. Overall, approximately 20% of students witnessed community violence and 3.5% of students carried a gun. American Indian or Alaska Native, Black, and Hispanic students were more likely to witness community violence and to report carrying a gun than their White peers. Males were more likely to witness community violence and carry a gun than females. Lesbian, gay, or bisexual students were more likely to witness community violence than their heterosexual peers. Also, witnessing community violence consistently was associated with increased odds of gun carrying, substance use, and suicide risk for both males and females and when comparing Black, White, and Hispanic students. These findings highlight the importance of comprehensive violence prevention strategies that incorporate health equity to mitigate the effects of violence exposure on substance use and suicide risk among youths.

A systems science approach to identifying data gaps in national data sources on adolescent suicidal ideation and suicide attempt in the United States

BACKGROUND

Suicide is currently the second leading cause of death among adolescents ages 10-14, and third leading cause of death among adolescents ages 15-19 in the United States (U.S). Although we have numerous U.S. based surveillance systems and survey data sources, the coverage offered by these data with regard to the complexity of youth suicide had yet to be examined. The recent release of a comprehensive systems map for adolescent suicide provides an opportunity to contrast the content of surveillance systems and surveys with the mechanisms listed in the map.

OBJECTIVE

To inform existing data collection efforts and advance future research on the risk and protective factors relevant to adolescent suicide.

METHODS

We examined data from U.S. based surveillance systems and nationally-representative surveys that included (1) observations for an adolescent population and (2) questions or indicators in the data that identified suicidal ideation or suicide attempt. Using thematic analysis, we evaluated the codebooks and data dictionaries for each source to match questions or indicators to suicide-related risk and protective factors identified through a recently published suicide systems map. We used descriptive analysis to summarize where data were available or missing and categorized data gaps by social-ecological level.

RESULTS

Approximately 1-of-5 of the suicide-related risk and protective factors identified in the systems map had no supporting data, in any of the considered data sources. All sources cover less than half the factors, except the Adolescent Brain Cognitive Development Study (ABCD), which covers nearly 70% of factors.

CONCLUSIONS

Examining gaps in suicide research can help focus future data collection efforts in suicide prevention. Our analysis precisely identified where data is missing and also revealed that missing data affects some aspects of suicide research (e.g., distal factors at the community and societal level) more than others (e.g., proximal factors about individual characteristics). In sum, our analysis highlights limitations in current suicide-related data availability and provides new opportunities to identify and expand current data collection efforts.

Associations Between School Absence and School Violence by Sexual Identity

INTRODUCTION

Sexual minority youth are disproportionately exposed to school violence compared with their heterosexual peers. It is unknown whether the associations between school absence and exposure to school violence vary by sexual identity.

METHODS

In 2021, data were combined from the 2015, 2017, and 2019 national Youth Risk Behavior Surveys to produce nationally representative samples of U.S. high-school students who identified as gay/lesbian (n=1,061), identified as bisexual (n=3,210), were not sure of their sexual identity (n=1,696), or identified as heterosexual (n=35,819). Associations were examined between 3 school violence exposures (being threatened/injured with a weapon at school, being bullied at school, and being in a physical fight at school) and school absence due to safety concerns. In each sample, multivariable logistic regression models were used to calculate adjusted prevalence ratios adjusted for sex, race/ethnicity, grade, current substance use, being offered/sold drugs at school, feeling sad/hopeless, and suicidal thoughts. Adjusted prevalence ratios were considered statistically significant if 95% CIs did not include 1.0.

RESULTS

Exposure to school violence and school absence due to safety concerns were more prevalent among sexual minority students than among heterosexual students. Associations between exposure to school violence and school absence due to safety concerns were similar across sexual identity groups. For example, school absence was associated with being threatened/injured with a weapon at school among gay/lesbian (adjusted prevalence ratio=3.00), bisexual (adjusted prevalence ratio=3.66), those not sure (adjusted prevalence ratio=4.56), and heterosexual (adjusted prevalence ratio=3.75) students.

CONCLUSIONS

Associations between school absenteeism and school violence exist in each sexual identity group. Therefore, programs providing safe and supportive school environments may result in reduced absenteeism among all students.

Association Between LGBTQ Student Nondiscrimination Laws in Selected States and School District Support for Gay-Straight Alliances

PURPOSE

To examine the association between state laws protecting lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) students and school districts' recommendations or requirements for establishing gay-straight alliances (GSAs) in schools. Beginning in fall 2013, 19 state education agencies (SEAs) engaged in HIV/STI and pregnancy prevention activities in "priority" school districts. SEAs provided support to priority districts to require or recommend GSAs in their schools.

METHODS

This study used semi-annually collected program evaluation data and state law data from the Gay, Lesbian, and Straight Education Network. We assessed whether increases in the percentage of priority districts recommending or requiring schools to provide GSAs varied by the presence of nondiscrimination or enumerated antibullying laws with a difference-in-difference design.

RESULTS

States with nondiscrimination laws began with more priority districts recommending or requiring schools to provide GSAs (52.5%) compared to states without laws (47.5%). We found a significant interaction (p < .01) between increases in the percentage of priority districts recommending or requiring a GSA and having a state nondiscrimination law. Across the first 3 years of program implementation, there was a 30% increase (p < .01) in priority districts recommending or requiring schools to provide GSAs in states with nondiscrimination laws, compared to a 12% increase (p < .01) in states without laws. There was no significant interaction between states with enumerated antibullying laws and districts recommending or requiring a GSA.

DISCUSSION

State LGBTQ nondiscrimination laws for students may facilitate school district support of GSAs, which may decrease health risks among LGBTQ youth.

Overwhelming Support for Sexual Health Education in U.S. Schools: A Meta-Analysis of 23 Surveys Conducted Between 2000 and 2016

PURPOSE

Surveys suggest that the general public (i.e., adults or parents) supports sexual health education in schools. However, the number of schools providing sex education continues to decline in the United States. The purpose of this study is to conduct a meta-analysis of U.S.-based representative surveys to provide a pooled estimate of public support for sexual health education delivered in schools.

METHODS

A systematic search of three databases (Medline, PsycInfo, and ERIC) was conducted to identify survey measuring adult and parent attitudes toward sexual health education in school between 2000 and 2016. Meta-analyses were conducted in OpenMetaAnalyst via the metaphor package in R using a DerSimonian-Laird random effect models to account for heterogeneity between surveys.

RESULTS

A total of 23 citations met study inclusion and exclusion criteria, representing 15 unique probability surveys conducted with the public. Among the included surveys, 14 were nationwide and 11 included parents or an overrepresentation of parents. Across all survey findings, 88.7% (95% confidence interval = 86.2-91.2) of respondents supported sexual health education. Among surveys that only included parents or oversampled for parents, 90.0% (95% confidence interval = 86.5-93.4) supported sexual health education, and among nationally representative surveys, 87.7% (95% confidence interval = 85.1-90.6) of respondents supported sexual health education.

CONCLUSION

These findings demonstrate overwhelming support for sexual health education delivered in schools. Additional research is needed to determine individual differences in support for specific sexual health education topics and skills delivered through classroom-based instruction.

Protective Environments, Health, and Substance Use Among Transgender and Gender Expansive Youth

Purpose: Transgender and gender expansive (TGE) youth experience elevated risk for substance use and other health inequities compared to cisgender peers. The purpose of this study was to examine associations between protective environments-perceived community tolerance, perceived family support, and housing stability-and recent binge drinking, lifetime high-risk substance use (HRSU; cocaine, methamphetamines, and/or heroin), and self-rated health in a sample of TGE youth. Methods: This secondary analysis of 1567 TGE youth aged 13-24 years draws from the Centers for Disease Control and Prevention's 2018 web-based Survey of Today's Adolescent Relationships and Transitions, which used a nonprobabilistic recruiting strategy via social media. Logistic regression was used to test the associations between protective environments and substance use and health outcomes. Results: Overall, 28.1% of participants reported that people who lived near them were tolerant of transgender people, 32.8% reported that their family was at least somewhat supportive of their TGE identity, and 77.0% were stably housed. In the logistic regression models, community tolerance and housing stability were associated with lower odds of self-rated poor health. Housing stability was associated with lower odds of recent binge drinking and lifetime HRSU. Conclusion: Perceived community tolerance and housing stability were associated with several health outcomes among TGE youth in this study. Protective factors, including safe, stable, nurturing relationships and environments, are critical to youth health and wellbeing. The findings in this study highlight the need for prevention strategies to promote protective environments and reduce known substance use and overall health inequities among TGE youth.

Mapping the Complexity of Suicide by Combining Participatory Modeling and Network Science

Suicide rates are steadily increasing among youth in the USA. Although several theories and frameworks of suicide have been developed, they do not account for some of the features that define suicide as a complex problem, such as a large number of interrelationships and cycles. In this paper, we create the first c omprehensive m ap o f a dverse c hildhood experiences (ACEs) and suicide for youth, by combining a participatory approach (involving 15 subject-matter experts) and network science. This results in a map of 946 edges and 361 concepts, in which we identify ACEs to be the most important factor (per degree centrality). The map is openly shared with the community to support further network analyses (e.g., decomposition into clusters). Similarly to the high-impact Foresight Map developed in the context of obesity, the largest map on suicide and ACEs to date presented in this paper can start a discussion at the crossroad of suicide research and network science, thus bringing new means to address a complex public health challenge.

Impact of Medicaid expansion and methadone coverage as a medication for opioid use disorder on foster care entries during the opioid crisis

Between 2012 and 2018, incidents of opioid-involved injuries surged and the number of children in foster care due to parental drug use disorder increased. Treatments for opioid use disorder (OUD) might prevent or reduce the amount of time that children spend in the child welfare system. Using administrative data, we examined the impact of Medicaid expansion and state support for methadone as a medication for opioid use disorder (MOUD) on first-time foster care placements. Results show that first-time foster care entries due to parental drug use disorder experienced a reduction of 28 per 100,000 children in Medicaid expansion states with methadone MOUD covered by their state Medicaid programs. The largest reduction was found among non-Hispanic Black children and the youngest children (age 0-1 years). Policies that increase OUD treatment access may reduce foster care placements by reducing parents' drug use, a risk factor for child abuse/neglect and subsequent home removal.

Nonvoluntary or Forced Sex Among Women, by Sexual Identity, Attraction, and Behavior - National Survey of Family Growth, United States, 2011-2017

Nonheterosexual (sexual minority) women report experiencing more sexual violence than heterosexual (sexual majority) women (1,2). Sexual minority women are often categorized as a collective whole, which fails to capture the nuances in sexual violence among subgroups of sexual minority women, such as bisexual and lesbian women (3). To estimate the prevalence of lifetime forced vaginal intercourse (forced sex) and of nonvoluntary first vaginal intercourse among women aged 18-44 years in the United States, CDC analyzed data from female respondents who were interviewed during 2011-2017 for the National Survey of Family Growth (NSFG); respondents were stratified by self-reported sexual identity, attraction, and behavior. Log-binomial regressions and analyses of variance (ANOVAs) were performed to compare experiences across each dimension of sexual orientation, controlling for demographic characteristics. Compared with sexual majority women,* prevalence of any male-perpetrated nonvoluntary first vaginal intercourse or forced sex (nonvoluntary or forced sex) was higher among women who identified as bisexual (36.1% versus 17.5%), reported attraction to the opposite and same sex (30.3% versus 15.8%), and reported sexual behavior with the opposite and same sex (35.7% versus 15.9%). These sexual minority women reported that their earliest experience of nonvoluntary or forced sex occurred at younger ages than did that of sexual majority women. Among women who were unsure of their sexual attraction, the prevalence of nonvoluntary first vaginal intercourse was also higher than among sexual majority women. These findings underscore the need for comprehensive prevention approaches tailored for sexual minority women and prevention of child sexual abuse, given the average ages at earliest nonvoluntary or forced sex experience among sexual minority women (range = 12.5-16.3 years). Additional research is needed into the circumstances of and norms or attitudes that influence perpetration of nonvoluntary or forced sex and broader sexual violence against sexual minority women. Prevention of nonvoluntary or forced sex victimization among sexual minority women will require comprehensive approaches to prevent sexual violence and child sexual abuse. Engaging sexual minority women in the development of sexual violence prevention efforts and research would help ensure that the experiences of sexual minority women across the spectrum are represented.

Transgender Youth Experiences and Perspectives Related to HIV Preventive Services

BACKGROUND

In the United States, transgender youth are at especially high risk for HIV infection. Literature regarding HIV prevention strategies for this vulnerable, often-hidden population is scant. Before effective, population-based HIV prevention strategies may be adequately developed, it is necessary to first enhance the contextual understanding of transgender youth HIV risk and experiences with HIV preventive services.

METHODS

Two 3-day, online, asynchronous focus groups were conducted with transgender youth from across the United States to better understand participant HIV risk and experiences with HIV preventive services. Participants were recruited by using online advertisements posted via youth organizations. Qualitative data were analyzed by using content analysis.

RESULTS

A total of 30 transgender youth participated. The average age was 18.6 years, and youth reported a wide range of gender identities (eg, 27% were transgender male, 17% were transgender female, and 27% used ≥1 term) and sexual orientations. Four themes emerged: (1) barriers to self-efficacy in sexual decision-making; (2) safety concerns, fear, and other challenges in forming romantic and/or sexual relationships; (3) need for support and education; and (4) desire for affirmative and culturally competent experiences and interactions (eg, home, school, and health care).

CONCLUSIONS

Youth discussed experiences and perspectives related to their gender identities, sexual health education, and HIV preventive services. Findings should inform intervention development to improve support and/or services, including the following: (1) increasing provider knowledge and skills to provide gender-affirming care, (2) addressing barriers to services (eg, accessibility and affordability as well as stigma and discrimination), and (3) expanding sexual health education to be inclusive of all gender identities, sexual orientations, and definitions of sex and sexual activity.

Variability in Condom Use Trends by Sexual Risk Behaviors: Findings from the 2003-2015 National Youth Risk Behavior Surveys

OBJECTIVE

This study aimed to examine variability in condom use trends by sexual risk behavior among US high school students.

METHODS

Data were from the 2003-2015 national Youth Risk Behavior Surveys conducted biennially among a nationally representative sample of students in grades 9 to 12. We used logistic regression to examine variability in trends of condom use during last sexual intercourse among female and male students by 4 sexual risk behaviors: drank alcohol or used drugs before last sexual intercourse, first sexual intercourse before age 13 years, 4 or more sex partners during their life, and 2 or more sex partners during the past 3 months.

RESULTS

Between 2003 and 2015, significant declines in self-reported condom use were observed among black female (63.6% in 2003 to 46.7% in 2015) and white male students (69.0% in 2003 to 58.1% in 2015). Among female students, declines in self-reported condom use were significant only among those who drank or use drugs before last sexual intercourse, had 4 or more sex partners during their life, or had 2 or more sex partners during the past 3 months. There was a significant interaction between trends in condom use and first sexual intercourse before age 13 years, suggesting more pronounced declines among female students who initiated first sexual intercourse before age 13 years compared with their female peers. Trends did not vary by sexual risk behavior for male students.

CONCLUSIONS

Results suggest that declines in self-reported condom use have occurred among female students at greater risk for acquiring a sexually transmitted disease.

School Environment Is Related to Lower Health and Safety Risks Among Sexual Minority Middle and High School Students

PURPOSE

The objective of this study was to examine the relationship between school involvement and connectedness with measures of sexual risk, substance use, and experience of violence among students who had sexual contact with the same sex or with both sexes.

METHODS

A sample of middle school and high school students who participated in a study conducted in a large urban school district were selected based on their reported experience of having initiated sexual activity with same-sex partners. In classroom-based surveys, we assessed self-reported involvement in school-based activities and feelings of school connectedness, as well as self-reported sexual risk, substance use, and experience of violence.

RESULTS

Significant protective associations were found between school involvement and lifetime alcohol and marijuana use, and between school connectedness and ever having been in a fight, feeling safe at school, and drug use other than marijuana (all p < .05).

CONCLUSIONS

Findings suggest that efforts to increase school involvement and connectedness provide a starting point for addressing significant health and safety concerns among students with same-sex sexual activity.

Health risks among discordant heterosexual high school students

Limited information exists on heterosexual youth with sexual contact with same-sex partners in the United States (i.e., discordant heterosexual). We compared the prevalence of health risks between discordant heterosexual, heterosexual with only opposite-sex sexual contact, lesbian/gay, and bisexual students using the 2015 national Youth Risk Behavior Survey (YRBS). Nationwide, 3.2% of students were identified as discordant heterosexuals. The prevalence of several risk behaviors was significantly higher among discordant heterosexual students than their heterosexual peers with only opposite-sex sexual contact. Clinicians should consider sexual identity and sex of sexual partners when conducting risk-assessments to ensure they appropriately target populations for intervention.

Structural Intervention With School Nurses Increases Receipt of Sexual Health Care Among Male High School Students

PURPOSE

Adolescent males are less likely to receive health care and have lower levels of sexual and reproductive health (SRH) knowledge than adolescent females. The purpose of this study was to determine if a school-based structural intervention focused on school nurses increases receipt of condoms and SRH information among male students.

METHODS

Interventions to improve student access to sexual and reproductive health care were implemented in six urban high schools with a matched set of comparison schools. Interventions included working with school nurses to improve access to sexual and reproductive health care, including the provision of condoms and information about pregnancy and sexually transmitted disease prevention and services. Intervention effects were assessed through five cross-sectional yearly surveys, and analyses include data from 13,740 male students.

RESULTS

Nurses in intervention schools changed their interactions with male students who visited them for services, such that, among those who reported they went to the school nurse for any reason in the previous year, those in intervention schools reported significant increases in receipt of sexual health services over the course of the study compared with students in comparison schools. Further, these results translated into population-level effects. Among all male students surveyed, those in intervention schools were more likely than those in comparison schools to report increases in receipt of sexual health services from school nurses.

CONCLUSIONS

With a minimal investment of resources, school nurses can become important sources of SRH information and condoms for male high school students.

Changes in the Distribution of Sex Partners in the United States: 2002 to 2011-2013

OBJECTIVE

The purpose of the current analysis is to examine subgroup differences in the distribution of opposite-sex sex partners in the United States across an approximate 10-year period to identify patterns that may inform sexually transmitted infection research and prevention.

METHODS

Data were drawn from the 2002 and 2011-2013 National Survey of Family Growth, a US probability-based household survey focusing on sexual and reproductive health. The measures included in this analysis were lifetime opposite-sex sex partners and opposite-sex sex partners in the past year. Analyses were conducted separately for men and women. All analyses were conducted in R and R-studio with the "survey" package, focusing on medians, the 80th, and 95th quartile.

RESULTS

In 2002, there were significant differences between men and women in median number of lifetime sex partners with men reporting more lifetime partners. However, in the 2011-2013 data, these differences are no longer significant. Still, the findings suggest that the top 20% and top 5% of men are reporting significantly more lifetime partners than their female counterparts. In comparison, partners in the past year remain relatively unchanged for both men and women.

CONCLUSIONS

These findings suggest that there were important changes in the distribution of sex partners between 2002 and 2011-2013 that have implications for sexually transmitted infection prevention. Median lifetime partners are no longer different for women and men: however, the distribution of lifetime partners among men is becoming even more skewed.

The Longitudinal Impact of Perceptions of Parental Monitoring on Adolescent Initiation of Sexual Activity

PURPOSE

The association between parental monitoring and adolescent behavior is well established. Past research suggests that parents monitor adolescent activities through parental control, solicitation of information, and youth disclosure, which increase parents' knowledge of youth activity leading to decreased risk behavior. However, there is mixed evidence of the impact of these efforts on sexual behavior. We examined these strategies from the adolescent perspective and assessed their impact on the initiation of sexual activity across the transition from middle school to high school.

METHODS

Analyses include 533 primarily Latino adolescents, who had not yet had sex in eighth grade and were surveyed yearly through 10th grade.

RESULTS

Adolescents who in eighth grade reported greater parental knowledge and more family rules about dating were less likely to initiate sex between eighth and 10th grade. Exchange of information, through parental solicitation and youth disclosure, and parental control, through rules about friends and dating, as well as maternal relationship satisfaction were significant predictors of parental knowledge. There were no gender differences in the impact of dating rules and parental knowledge on sexual initiation, but the paths to acquiring knowledge did differ by gender.

CONCLUSIONS

Results suggest that parental monitoring at earlier ages has an impact on sexual initiation. Effective monitoring is an active process within a family that includes setting boundaries and exchanging information. Interventions that encourage family rules, provide strategies for improving parental solicitation of information, and increase youth disclosure by enhancing the maternal-child relationship may be more likely to impact sexual initiation.

High School Students' Self-Reported Use of School Clinics and Nurses

Access to school health clinics and nurses has been linked with improved student achievement and health. Unfortunately, no studies have examined how many students report using school clinics or nurses and for which services. This study addressed this gap with data from a nationally representative sample of 15- to 25-year-olds. Respondents who reported being in high school were provided a list of services and asked whether they had gone to a school nurse or clinic for any of the listed services. Nearly 90% reported having access to a school clinic or nurse. Among students with access, 65.6% reported using at least one service. Non-White students and younger students were more likely to report having access to a clinic or nurse. These results show many students have access to clinics or nurses and are using these services, although not uniformly for all services.

Leveraged resources and systems changes in community collaboration

Most models of community collaboration emphasize the ability of diverse partners to come together to enact systematic changes that improve the health of individuals and communities. The ability of these groups to leverage resources is thought to be an important marker of successful collaboration and eventual improvements in community health. However, there is a paucity of research addressing linkages between systems change activities and leveraged resources. This study used a sample of collaboratives (N = 157) that received technical assistance and funding through the Georgia Family Connection Partnership (GaFCP) between 2006 and 2007. Data were collected from collaborative report of activities and funding, member ratings of collaborative functioning, and characteristics of the communities served by the collaboratives drawn from US Census data. Cross-lagged regression models tested longitudinal associations between systems change activities and leveraged dollars. The results indicated that systems change activities predict increased leveraging of resources from state/federal and private partners. However, there was no evidence that systems changes were linked with leveraging resources from local groups and agencies. These findings have important implications for providing technical assistance and training to health partnerships. Furthermore, future research should consider the relative strength of different systems change activities in relation to the ability of coalitions to leverage resources.

Testing effects of community collaboration on rates of low infant birthweight at the county level

Interorganizational collaboration has become a popular strategy for addressing population health and well-being. However, evidence for its effectiveness in achieving outcomes at the population level is limited, at least in part due to a variety of methodological challenges such as reduced sample size at the population level, the availability of suitable comparison groups of communities, and study durations that are too short to detect slowly emerging outcomes. The present study addresses these challenges by retrospectively examining the effectiveness of a mature network of community collaboratives, using latent growth modeling of longitudinal change in an archival community-level outcome, low infant birthweight, and propensity score matching of comparison communities. A group of 25 Georgia counties with collaboratives targeting low infant birthweight was compared to a weighted comparison group of counties from other southeastern states, using propensity score matching. We report results of full matching methods and outcome analyses examining differences in change in county rates of low infant birthweight from 1997 to 2004 between intervention and comparison counties. Results indicated significantly smaller increases in low weight birth rates in intervention counties than in comparison counties.

The fats of life: the role of omega-3 fatty acids in the prevention of coronary heart disease

Epidemiological and clinical trial evidence suggests that omega-3 polyunsaturated fatty acids (PUFAs) might have a significant role in the prevention of coronary heart disease. Dietary sources of omega-3 PUFA include fish oils rich in eicosapentaenoic acid and docosahexaenoic acid along with plants rich in alpha-linolenic acid. Randomized clinical trials with fish oils (eicosapentaenoic acid and docosahexaenoic acid) and alpha-linolenic acid have demonstrated reductions in risk that compare favorably with those seen in landmark secondary prevention trials with lipid-lowering drugs. Several mechanisms explaining the cardioprotective effect of omega-3 PUFAs have been suggested, including antiarrhythmic, hypolipidemic, and antithrombotic roles. Although official US guidelines for the dietary intake of omega-3 PUFAs are not available, several international guidelines have been published. Fish is an important source of omega-3 PUFAs in the US diet; however, vegetable sources, including grains and oils, offer an alternative source for those who are unable to regularly consume fish.

Affective illness in children and adolescents: patterns of presentation in relation to pubertal maturation and family history

Affective illness is now recognized as a common problem in all age groups, and the various patterns have been well documented in adults. The objective of this study was to evaluate the patterns of affective illness in children and determine changes with increasing age and family history. One hundred children/adolescents with affective illness (72 boys and 28 girls; age range 2-20 years; mean age 10 years), who were consecutively referred to the Pediatric Behavioral Neurology Program, Children's Medical Center at Dallas, were evaluated for the pattern and course of affective illness symptoms, family history, and pubertal stage. Seven patterns of affective illness were identified. In the 65 prepubertal children (Tanner stage 1), disorders with hypomanic/manic symptomatology were most common (47/65, 72%): mania (2/65, 3%), hypomania (8/65, 12%), cyclothymia (11/65, 17%), juvenile rapid-cycling bipolar disorder/ultradian cycling bipolar disorder (8/65, 12%), and dysthymia with bipolar features (18/65, 28%). In contrast, the 26 fully pubertal adolescents (Tanner stages 3-5) had a predominance of patterns with only depressive symptomatology (16/26, 61%): dysthymia (4/26, 15%) and depression (12/26, 46%), along with juvenile rapid-cycling bipolar disorder/ultradian cycling bipolar disorder (6/26, 23%). Affective illness, alcoholism, and drug abuse were prominent in the family histories, regardless of the child's pattern of symptoms. Family histories of character disorder and Briquet's syndrome were also common, but thought disorder, suicide, and homicide were infrequent. This study supports the clinical observation that the presentation of affective illness changes with age: manic features predominate in younger children, whereas depressive symptomatology is more evident with pubertal maturation.

Properties of crimpable archwire hooks: a laboratory investigation

The aim of the present study was to utilize a strain gauge, which enabled the force applied to produce firmly attached crimpable hooks to rectangular stainless steel arch wires, to be measured. In vitro testing of two hooks, American Orthodontic (AO) and TP Orthodontic (TP), and two dimensions of stainless steel archwire, 0.019 x 0.025 and 0.018 x 0.025-inch, was carried out using an Instron Universal Testing machine. The results demonstrate that there was a significant difference in the behaviour of the two types of crimpable hooks, with almost twice the force needed to dislodge the TP hooks compared with the AO hooks (11.7 and 6.22 N, respectively). When using TP hooks attached to either 0.019 x 0.025 or 0.018 x 0.025-inch stainless steel wires, the archwire size makes little difference to the force required to produce movement. The clinical significance of these findings is discussed.

New perspectives on the management of low levels of high-density lipoprotein cholesterol

A low serum high-density lipoprotein cholesterol (HDL-C) level is a potent predictor of coronary heart disease (CHD). It has been estimated that 11% of US men have isolated low HDL-C levels, and there is uncertainty regarding the management of these patients. A cause-and-effect relationship between low HDL-C levels and CHD is supported by epidemiological, animal, and human clinical studies. We reviewed the structure and function of HDL-C and its role in preventing atherosclerosis. We then suggested an approach to the patient with isolated low HDL-C that may be useful to the primary care physician. An algorithm was proposed for use in patients with existing CHD, while the decision to treat patients without CHD was based on their score on the Framingham Heart Study risk prediction chart.

Use of the Symbol Language and Communication Battery in the physician's office for assessment of higher brain functions

Higher brain functions are readily observable within the office setting. The Symbol Language and Communication Battery offers a systematic approach to evaluation, with resultant reproducible findings. It should be part of the neurologic evaluation for children who are having difficulty in their environments, with the differences in communication skills categorized into specific syndromes.

Vigilance and its disorders

Vigilance has been defined as steady-state alertness-wakefulness. The right cerebral hemisphere, predominantly the right inferior parietal lobule and posterior parietal cortices, seems specialized for vigilance. Studies of the primary disorder of vigilance, a genetically determined condition, should provide a better understanding of the neurobiology of vigilance. Common causes of secondary hypovigilance (depression, learning disability, narcolepsy, and acquired focal right cerebral hemisphere brain lesions) explain the symptom complex of ADHD. If these specific entities producing hypovigilance are correctly identified, treatment is successful and with favorable outcome. The neuroanatomic substrate of lowered vigilance seems to be loss of modulating influence of the right cerebral hemisphere on the diencephalon and select brain stem nuclei. We propose that the right (more than the left) cerebral hemisphere is responsible for alertness and wakefulness (vigilance) with the reticular formation being accountable for sleep.

A practical approach to children failing in school

The most likely causes of failure in school in otherwise capable children who come from homes in which they are loved and cared for are learning disabilities, affective illness, primary disorder of vigilance and, on occasion, narcolepsy. The various learning disabilities are often accompanied by problems of attention, concentration, organization, mood and feelings, and social interaction. These latter problems are reflections of biochemical disorders that respond effectively to judicious pharmacologic intervention. When this type of medical management is combined with constructive counseling and suitable curriculum adjustments, the child can attain his or her maximum education potential and become a productive and contributing adult member of society.

Airline pilot alcoholism: one airline's experience

The rehabilitation program at United Airlines strives for early identification of alcoholics, with constant monitoring by an educated team consisting of the flight surgeon, flight manager, and union representative. Confidentiality is essential and great caution and planning are required before confronting a suspected alcoholic pilot. UAL now has over 120 recovering pilots with an average rehabilitation time of 4 months and remission time of 3 years, by which time the probability of relapse has returned to baseline.