Reducing secondhand smoke exposure among children and adolescents: emerging issues for intervening with medically at-risk youth

Objective To summarize information on rates of secondhandsmoke (SHS) exposure among healthy and medically at-risk pediatricpopulations, discusses the clinical manifestations of pediatricdisease that are exacerbated by exposure, and provide an overviewof promising strategies for reducing SHS in vulnerable pediatricpopulations. Methods The success of exposure reductionand smoking cessation interventions implemented with parentsof healthy children and those with respiratory disease, in thecontext of their child's health care, is reviewed. Results Concurrentimplementation of multiple levels of intervention, includingclinical interventions within the medical setting, will helpto maximize the reduction in childhood SHS exposure. Conclusion Ongoingintervention research and identification of strategies to capitalizeon opportunities for providing effective SHS counseling in primarycare and specialty clinics will be critical for effective tobaccocontrol among medically at-risk children.     

Tobacco-refusal skills and tobacco use among high-risk adolescents

Psychosocial tobacco use prevention programs are based on the assumption that refusal skills training will have a suppressive effect on the onset of use by enabling non-using adolescents to refuse offers of cigarettes and smokeless tobacco. The present study investigated this assumption with 389 high-risk junior high-school students involved in a prevention program during their seventh, eighth, and ninth-grade years. Direct behavioral measures of refusal skills were taken by having subjects respond to audiotaped offers of tobacco and then rating the quality of their responses. These ratings were then linked to tobacco use measures obtained at the end of each of the 3 study years. Results showed that the comprehensive prevention program produced a favorable trend in delaying or preventing the onset of tobacco use. However, the refusal skills training, which was carried out throughout the 3-year intervention period, produced significant differences in overall refusal skill quality only at the seventh grade. Moreover, refusal skill quality was not related to overall tobacco use or cigarette use at any grade.This work was supported by Grant R01-CA44921 from the National Cancer Institute.     

Developing smoking cessation programs for chronically ill teens: lessons learned from research with healthy adolescent smokers

OBJECTIVE: Medically fragile teens who smoke need access to smoking cessation programs, because they are at even higher risk than their healthy peers for smoking-related complications. METHODS: To date, no studies on the outcome of smoking cessation programs for medically ill teens have been conducted. To suggest directions for future research, we turn to the literature on smoking cessation in the general population of teens and occasionally to the literature on adult smokers. RESULTS: Four areas are explored: (a) the prevalence of unaided cessation in healthy teens; (b) the outcomes of various treatments for smoking cessation in healthy adolescents; (c) special issues that should be considered when designing programs for medically ill teens; and (d) lessons learned from previous research. CONCLUSIONS: Medically ill teens face a number of medical, emotional, social, and developmental challenges that can affect the quitting process. Research is sorely needed to address the unique needs of this population.     

Physical health correlates of Type A behavior in children and adolescents

A physical examination including resting blood pressure, heart rate, Tanner scales, height, and weight was administered to 184 students in the fifth, seventh, and ninth grades. They completed the Physical Symptoms of Stress Inventory, Health Habits Inventory, and two self-monitoring logs of physical symptoms. School absenteeism, medical records, physician ratings, and family health history data were collected. No significant differences between high-and low-Type A behavior pattern (TABP) subjects were found on any of the physical measurements. However, retrospective and prospective reports of physical symptoms revealed a consistent pattern: high TABP subjects reported significantly more physical symptoms than low-TABP subjects. Self-ratings of stress and tension were significantly higher for high-TABP subjects. High-TABP subjects, however, neither missed more school because of illness nor used physician services more often than low subjects. Further, expected relationships between physical symptoms and illness behavior, including school absence, were evident only for low subjects.Support for this research was provided by a grant from the John D. and Catherine T. MacArthur Foundation. We gratefully acknowledge the assistance of our project secretary, Donna Juds Gomola.     

Sleep disruptions in parents of children and adolescents with chronic illnesses: prevalence, causes, and consequences

OBJECTIVE: Provide a comprehensive review of the existing literature on the prevalence, causes, and consequences of sleep disruptions in parents of youth with chronic illnesses. METHODS: A comprehensive literature search of PsychInfo, MEDLINE, and CINAHL for articles related to sleep in parents of youth with chronic illnesses yielded 59 potential articles, with 19 meeting inclusion criteria. RESULTS: Parents of children with eczema were the most commonly studied group. The prevalence of sleep disruptions was 15-86%. Potential causes of parent sleep disruptions included nighttime caregiving, monitoring of the child's illness, and stress related to the child's illness. Consequences included poor sleep quality, depression, and anxiety. CONCLUSIONS: Parents of youth with chronic illnesses experience sleep disruptions, providing a potential mechanism to explain elevated rates of negative daytime functioning found in previous studies. To provide interventions and support for these parents, additional research is needed to address the limitations of the existing literature.     

Living with a chronic illness: a measure of social functioning for children and adolescents

OBJECTIVE: To describe the development and initial psychometric evaluation of a measure of social functioning in children and adolescents with chronic medical conditions, Living with a Chronic Illness (LCI), designed to distinguish social difficulties related to the illness from those social difficulties associated with other factors (e.g., limited income). METHODS: Parents (n = 108) and youths (n = 115) completed the LCI, along with other psychological measures (e.g., Youth Self-Report). Teachers completed the Teacher Report Form and provided grade and absence data. Health care utilization data were obtained from medical charts. RESULTS: Statistical analyses supported the internal consistency and initial validity of LCI scores. Correlational results strongly point to the distinction made between illness-related and non-illness-related social difficulties and suggest that the LCI has some relation to existing measures (e.g., Child Behavior Checklist), while still providing a unique perspective on children's social functioning. Univariate and regression analyses revealed significant relations between LCI scores and health care utilization. CONCLUSIONS: These findings support the initial psychometric properties and clinical utility of the LCI scores. We discuss strengths and limitations of this study, as well as potential clinical applications for the LCI questionnaire.     

Gender differences in associations between depressive symptoms and patterns of substance use and risky sexual behavior among a nationally representative sample of U.S. adolescents

Summary Objective: This study uses a cluster analysis of adolescents, based on their substance use and sexual risk behaviors, to 1) examine associations between risk behavior patterns and depressive symptoms, stratified by gender, and 2) examine gender differences in risk for depression. Methods: Data are from a nationally representative survey of over 20,000 U.S. adolescents. Logistic regression was used to examine the associations between 16 risk behavior patterns and current depressive symptoms by gender. Results: Compared to abstention, involvement in common adolescent risk behaviors (drinking, smoking, and sexual intercourse) was associated with increased odds of depressive symptoms in both sexes. However, sex differences in depressive symptoms vary by risk behavior pattern. There were no differences in odds for depressive symptoms between abstaining male and female adolescents (OR = 1.07, 95% CI 0.70–1.62). There were also few sex differences in odds of depressive symptoms within the highest-risk behavior profiles. Among adolescents showing light and moderate risk behavior patterns, females experienced significantly more depressive symptoms than males. Conclusions: Adolescents who engage in risk behaviors are at increased risk for depressive symptoms. Girls engaging in low and moderate substance use and sexual activity experience more depressive symptoms than boys with similar behavior. Screening for depression is indicated for female adolescents engaging in even experimental risk behaviors.     

Effects of written emotional disclosure on caregivers of children and adolescents with chronic illness

OBJECTIVE: Tested feasibility of a written emotional disclosure intervention with caregivers of youths with chronic illness and its effects on measures of mood, physical symptoms, health-related quality of life, distress, and caregiver appraisal of stress and efficacy. METHODS: Measures were administered prior to and immediately after writing and 4 months later. Experimental group (n = 29) wrote about traumas and stressors while the control group (n = 25) wrote about summer activities for 20 minutes on three different days. RESULTS: Consistent with hypotheses, the experimental group experienced less positive affect, F(1, 54) = 4.68, p <.05, and more negative affect, F(1, 54) = 7.92, p <.01, and physical symptoms, F(1, 54) = 4.30, p <.05, immediately following writing than the control group. There were no significant Group x Time interactions on long-term mood, distress, health-related quality of life, or caregiver appraisal. Contrary to hypotheses, the control group had more vitality over time, F(1, 53) = 21.29, p <.001, than the experimental group. CONCLUSIONS: Recommendations include modifying the procedures to attain more control in applied settings and identifying specific processes that contribute to the efficacy of written emotional disclosure on well-being.     

Psychological and cognitive functioning in children and adolescents with congenital heart disease: a meta-analysis

OBJECTIVE: Findings in the literature are inconsistent on the impact of congenital heart disease (CHD) on the psychological and cognitive functioning of children and adolescents. The aim of the present study was to systematically review this empirical body of literature. METHODS: We conducted a meta-analysis to review studies on behavior problems and cognitive functioning in CHD. RESULTS: Only older children and adolescents with CHD displayed an increased risk of overall, internalizing, and to a lesser extent externalizing behavior problems. In addition, patients with severe CHD exhibited lower cognitive functioning than patients with less severe CHD, specifically with respect to performance intelligence. Moreover, decreased cognitive functioning remained relatively stable across different age groups. CONCLUSIONS: Children with severe heart disease may benefit from interventions specifically targeting perceptual organizational abilities, such as visual-spatial abilities. Moreover, older children and adolescents with CHD may benefit from psychological interventions reducing anxiety symptoms and depression.     

Opportunities and challenges in the prevention and control of cancer and other chronic diseases: children's diet and nutrition and weight and physical activity

OBJECTIVE: The purpose of this article is to review the role of behavioral research in disease prevention and control, with a particular emphasis on lifestyle- and behavior-related cancer and chronic disease risk factors--specifically, relationships among diet and nutrition and weight and physical activity with adult cancer, and tracking developmental origins of these health-promoting and health-compromising behaviors from childhood into adulthood. METHOD: After reviewing the background of the field of cancer prevention and control and establishing plausibility for the role of child health behavior in adult cancer risk, studies selected from the pediatric published literature are reviewed. Articles were retrieved, selected, and summarized to illustrate that results from separate but related fields of study are combinable to yield insights into the prevention and control of cancer and other chronic diseases in adulthood through the conduct of nonintervention and intervention research with children in clinical, public health, and other contexts. RESULTS: As illustrated by the evidence presented in this review, there are numerous reasons (biological, psychological, and social), opportunities (school and community, health care, and family settings), and approaches (nonintervention and intervention) to understand and impact behavior change in children's diet and nutrition and weight and physical activity. CONCLUSIONS: Further development and evaluation of behavioral science intervention protocols conducted with children are necessary to understand the efficacy of these approaches and their public health impact on proximal and distal cancer, cancer-related, and chronic disease outcomes before diffusion. It is clear that more attention should be paid to early life and early developmental phases in cancer prevention.     

Brief report: Development and pilot testing of a coping questionnaire for children and adolescents with chronic health conditions

OBJECTIVE: The current paper describes the development, pilot testing, and item reduction process of a coping questionnaire for children and adolescents with chronic health conditions. METHODS: A pilot test with 188 children and adolescents was conducted in six European countries. Included in the test were children and adolescents (ages ranging 8-18 years) with various chronic health conditions-asthma, epilepsy, diabetes, arthritis, atopic dermatitis, cerebral palsy, or cystic fibrosis. Based on the focus groups with the children and adolescents and on expert consulting, items were developed and translated into the participants' respective languages. Data were analyzed according to predefined psychometric and content criteria. RESULTS: Analyses resulted in a selection of 29 out of 50 items for the final coping questionnaire with six domains: Acceptance alpha = .83, Avoidance alpha = .72, Cognitive-Palliative alpha = .69, Distance alpha = .70, Emotional Reaction alpha = .82, and Wishful Thinking alpha = .81. CONCLUSIONS: This study developed a short reliable international questionnaire to assess coping strategies of children and adolescents with chronic health conditions. Ongoing research will investigate the validity of this new coping questionnaire.     

Parental management of fear in chronically ill and healthy children

This study was undertaken to determine the impact of children's health status on parental management of fear and avoidance, as well as the relationship between parenting strategies and children's fear and anxiety levels. Thirty-one children with a chronic life-threatening illness, 30 children with chronic non-life-threatening conditions, and 28 healthy children, and their mothers, were studied. Children's health status, by diagnosis, was not a significant determinant of maternal fear-management strategies. For chronically ill children, clinical health status, in terms of illness course, prognosis, physical impairment, and time since diagnosis were related to maternal parenting strategies and to children's levels of medically related fears. For the sample as a whole, maternal fear-management strategies were related to child sex, socioeconomic status, and mothers' trait anxiety. These results are discussed in terms the interactive effects of child characteristics, health status, fear/anxiety, and parenting strategies.     

Saliva cotinine and thiocyanate: Chemical indicators of smokeless tobacco and cigarette use in adolecents

Recent attempts to measure smoking behavior using chemical tests may have been confounded by the use of smokeless tobacco. An objective measure of smokeless tobacco use is needed, particularly among adolescents who may not provide accurate self-reports of tobacco usage. Saliva cotinine was used to distinguish self-reported tobacco users from nonusers and a combination of saliva cotinine and thiocyanate (SCN) tests was used to distinguish smokers from smokeless tobacco users. The subjects were 471 students in grades 7 through 11 who lived in a high-tobacco production area. Approximately 89% of reported nonusers had no detectable cotinine and 99% of nonusers had levels <25 ng/ml. Of those who had used tobacco within the last 12 hr, 95% had detectable levels of cotinine. Samples that tested positive for cotinine were also tested for SCN. Eighty-six percent of smokers and 74% of mixed users had SCN values of >1000 mol/liter, while only 14% of smokeless users had SCN values at that level. The combination of cotinine and SCN was effective in distinguishing smokers from smokeless users but was not effective in distinguishing mixed use from the other two types of use.Funded by the National Cancer Institute CA 44004-01.     

Psychological adjustment of children and adolescents with chronic arthritis: a meta-analytic review

OBJECTIVE: To review studies of psychological adjustment among children and adolescents with chronic arthritis to determine whether they are at more risk for development of adjustment problems than controls. METHODS: We used meta-analytic techniques to review 21 studies reporting overall adjustment problems, internalizing symptoms, externalizing symptoms, or self-concept among youths with arthritis. RESULTS: Youths with arthritis displayed increased risk for overall adjustment problems and internalizing symptoms, but not for externalizing symptoms or poor self-concept. Risk was greater in studies making comparisons to study controls rather than to norms and in studies including mixed disease samples (arthritis plus other rheumatic diseases) rather than samples of youths with arthritis only. CONCLUSIONS: Results suggest the importance of assessing for internalizing problems among youths with chronic arthritis. Future research may benefit from inclusion of child self-report of adjustment problems, diagnostic specificity in reporting results, and use of adjustment measures without somatic items.     

Quantifying practice effects in longitudinal research with the WISC-R and WAIS-R: a study of children and adolescents with hemophilia and male siblings without hemophilia

OBJECTIVE: To quantify practice effects associated with annual administrations of WISC-R and WAIS-R in children and adolescents with and without hemophilia. METHODS: Participants were young men (age: 7-19; 80 with hemophilia, 30 siblings) enrolled in the Hemophilia Growth and Development Study. Participants with hemophilia completed age-appropriate Wechsler scales at baseline and at four annual follow-ups; the siblings, at baseline and one 2-year follow-up. Regression analyses were used to quantify average changes in scores, adjusting for variables related to test performance. RESULTS: Consecutive annual evaluations were free of significant practice effects for 4 years with the Verbal Scale and for 2 years with the Performance Scale. VIQ decreased, and PIQ increased over time. Baseline VIQ was related to changes in VIQ; baseline PIQ and number of test-specific retests were related to changes in PIQ. CONCLUSIONS: The findings support use of Wechsler scales for annual evaluations to monitor cognitive development in children and adolescents.     

Unmet needs in the treatment of asthmatic children and adolescents: 2

The five main unmet needs in the treatment of asthma in children and adolescents are the treatment of infants, the treatment of adolescents, the efficacy of medication, the lack of clinical trials in children and the need for prevention. Asthma is a dynamic disease that changes over time and there are several patterns of asthma in children. One of the greatest needs is to identify those children with chronic asthma where undertreatment is more of a problem than overtreatment. Although the treatment of asthma in children is the same in principle as adults, there are several practical difficulties with infants, such as accurately assessing lung function and administering drugs. Teenage asthma creates a distinct management problem. Not only is asthma underdiagnosed but acceptance of diagnosis and compliance is often poor. Existing therapies need to be used more effectively in adolescents. It is particularly important to establish a partnership with teenage asthmatics and motivate them to create their own treatment goals. This requires passing on knowledge. The efficacy of asthma medication may be different in children than in adults and clinical studies should be performed to optimize therapy with existing drugs. The only proven primary preventive measure to prevent wheezing and asthma is to avoid passive tobacco smoke exposure. Possible intervention strategies include early intervention with anti-inflammatory therapy, allergen avoidance and vaccine approaches but more of them have proven efficacious. Although modern asthma treatment has improved patient quality of life and long-term prognosis, there is still a need for further improvement.     

Measuring marital distress in couples with chronically ill children: the Dyadic Adjustment Scale.

The idea that couples with chronically ill children are particularly at risk for marital distress has been supported by clinical observation and empirical research. Three recent controlled studies, however, did not find evidence for this increased risk. A possible explanation for the discrepant findings is that these three studies employed Spanier's Dyadic Adjustment Scale (DAS) as a unidimensional measure of marital adjustment. To develop a better understanding of the discrepant findings of risk for marital distress in couples with chronically ill children, the present study examined both the appropriateness of the DAS's published norms as well as the criterion validity of the DAS for use in this population of couples. Three hundred and sixteen parents (158 couples) from a large urban pediatric health care setting completed a survey investigating interest and need to participate in an intervention program for marital distress. Results indicated that this instrument can reliably predict marital distress in this population of couples, however, mean DAS scores are higher than those established by Spanier.     

Smokeless tobacco use in adolescent females: Prevalence and psychosocial factors among racial/ethnic groups

From a stratified, random sampling of Southeastern, nonurban high schools, survey data on smokeless tobacco use and potential psychosocial risk factors were obtained from 5683 adolescent females. Of the 15.3% who reported trying smokeless tobacco, most (75%) reported only experimental use. Factor analysis of the psychosocial items resulted in four factors: perceived negative consequences, substance use, modeling, and active lifestyle. Discriminant analysis on use indicated that modeling influences and use of other substances were the strongest predictors of initial smokeless tobacco use. Level of use, however, was most strongly associated with lower perceived negative consequences for use and the use of other substances. Separate analyses on American Indian, Black, and White subgroups suggested that factors associated with initial use were similar but that substantial differences exist between subgroups on risk factors for level of smokeless tobacco use.The research was funded by a grant from the American Society of Dentistry for Children.     

Asthma-specific predictors of smoking onset in adolescents with asthma: a longitudinal study

Objective Despite even occasional smoking being more riskyfor adolescents with asthma, the smoking rate in this vulnerablepopulation remains high. This is the first longitudinal studyinvestigating asthma-specific predictors of smoking initiation. Methods Athree-wave longitudinal survey study (22 months) among 257 adolescentswith asthma was conducted. The effects of asthma-specific factors[symptom severity, medication adherence, coping, attitude towardsasthma, and quality of life (QOL)] on smoking onset were testedwith logistic regression models. Results Poorer self-reportedadherence and the maladaptive coping strategy of hiding asthmapredicted smoking onset. Poorer QOL predicted smoking in boysonly. Conclusions Our findings underscore the importanceof recognizing and addressing adherence problems during adolescenceas low adherence is a risk factor for smoking initiation. Moreover,psychosocial factors, such as coping and QOL for boys, wereassociated with smoking initiation. This highlights the importanceof attending to the psychosocial needs of youth with asthma.     

Risk and resistance factors in the adaptation of mothers of children with cystic fibrosis.

Examined 35 mothers of children with cystic fibrosis (CF) to assess the relationship of risk and resistance factors to level of psychological adjustment. Dimensions of maternal adaptation, disease severity, family adaptability and cohesion, family life stress, and intrapersonal coping style were assessed. As a group, mothers evidenced significant levels of general psychological distress, and appear to constitute an at-risk population. Multiple regression analyses indicated higher levels of maternal distress were associated with increased levels of stressful family life events and an escape-avoidance coping style. Disease severity, family financial resources, and family adaptability and cohesion did not significantly contribute to the regression model.