Longitudinal predictors of depressive symptoms among low income injection drug users.

Effects of changes in physical health status and drug use, and prior social support on depressive symptoms were assessed in low income injection drug users. Data are from participants (n = 503) enrolled at baseline (1994-1995) who remained at one-year follow-up (79%), of whom 37% were HIV-positive and 36% female. Physical health was measured by HIV symptoms, AIDS, CD4 count and functional limitation (IADLs). One-third scored high on depressive symptoms (CES-D > or = 16) at one-year follow-up, representing no statistically significant change from baseline (38%). In multiple logistic regression, after controlling for baseline depression scores (OR = 6.11, p < 0.001) and drug use (OR = 1.20, p = 0.192), baseline functional limitation (OR = 3.28, p < 0.001) and declining functioning (OR = 3.60, p < 0.001) were positively, and quitting drug use was negatively, associated with depressive symptoms at follow-up. Low social support at baseline (OR = 0.58, p < 0.10) was marginally predictive of depressive symptoms. Depressive symptoms did not differ by gender. For HIV-positive respondents, functional limitation was predictive of depressive symptoms, but HIV illness and drug use were not. Facilitating drug treatment and preventive medical care may aid in reducing depression in this population. For HIV-positive drug users, drug treatment prior to AIDS may help reduce depressive symptoms, with potential implications for HIV service utilization and medical adherence.

The influence of patterns of welfare receipt during the child-rearing years on later physical and psychological health.

This study examined interrelations among welfare receipt, social integration, and later physical and mental health in a cohort of African American mothers from the Woodlawn neighborhood on the south side of Chicago. These women (N = 681) have been followed prospectively from 1966-67 to 1997-98. Findings indicate that receiving welfare during the child-rearing stage of life is related to both social integration and later health, with those who had received welfare in young to middle adulthood being more socially isolated and having more health problems twenty to thirty years later. Findings provided no support for the hypothesis that social integration mediated the relationship between welfare receipt and later physical and psychological health problems. Welfare receipt had a direct detrimental effect on later health outcomes. Attending church regularly was protective for later physical and psychological health. The relationship between early welfare and later health remained even when the women's current poverty was added to the model.

The health profile of incarcerated male youths.

OBJECTIVE: To identify the health needs of adolescent males incarcerated in a juvenile justice facility and to compare their health profiles with those of male adolescents in the community. METHODS: Cross-sectional surveys were conducted of incarcerated (N = 202) and school (N = 379) samples of male youths. Questionnaires were self-administered and completed before admission health screens (incarcerated youth) or in classrooms (school sample). Health status was assessed by the Child Health and Illness Profile, Adolescent Edition, using scale and item means and by categorizing each youth's pattern of health into 1 of 13 mutually exclusive health profile types. RESULTS: Compared with school counterparts, incarcerated male youths had significantly worse health status as demonstrated by poorer health and functioning scores in perceived well being, self-esteem, physical discomfort, acute, chronic, and psychosocial disorders, family involvement, physical activity, interpersonal problem-solving, risk behaviors, and academic performance. Three profile types-High Risks, High Risks/Low Resilience, and Worst Health-accounted for patterns of health for 69.8% of incarcerated youth versus 37.3% of an age-matched school sample. Just 6.4% of incarcerated males were in the Excellent/Good Health profile types, which contrasted with 34.2% of the age-matched school sample. CONCLUSIONS: The health profiles of incarcerated male youths were worse than those of male youths in school. Our results indicate that rehabilitation programs will need to address incarcerated youth's basic health needs as well as modifying their risk and antisocial behaviors.

A taxonomy of adolescent health: development of the adolescent health profile-types.

OBJECTIVES: The aim of this study was to develop a taxonomy of health profile-types that describe adolescents' patterns of health as self-reported on a health status questionnaire. The intent was to be able to assign individuals to mutually exclusive and exhaustive groups that characterize the important aspects of their health and need for health services. METHODS: Cluster analytic empirical methods and clinically based conceptual methods were used to identify patterns of health in samples of adolescents from schools and from clinics that serve adolescents with chronic conditions and acute illnesses. Individuals with similar patterns of scores across multiple domains were assigned to the same profile-type. Results from the empirical and conceptually based methods were integrated to produce a practical system for assigning youths to profile-types. RESULTS: Four domains of health (Satisfaction, Discomfort, Risks and Resilience) were used to group individuals into 13 distinct profile-types. The profile-types were characterized primarily by the number of domains in which health is poor, identifying the unique combinations of problems that characterize different subgroups of adolescents. CONCLUSIONS: This method of reporting the information available on health status surveys is potentially a more informative way of identifying and classifying the health needs of subgroups in the population than is available from global scores or multiple scale scores. The reliability and validity of this taxonomy of health profile-types for the purposes of planning and evaluating health services must be demonstrated. That is the purpose of the accompanying study.

Reliability and validity of the adolescent health profile-types.

OBJECTIVES: The purpose of this study was to demonstrate the preliminary reliability and validity of a set 13 profiles of adolescent health that describe distinct patterns of health and health service requirements on four domains of health. METHODS: Reliability and validity were tested in four ethnically diverse population samples of urban and rural youths aged 11 to 17-years-old in public schools (N = 4,066). The reliability of the classification procedure and construct validity were examined in terms of the predicted and actual distributions of age, gender, race, socioeconomic status, and family type. School achievement, medical conditions, and the proportion of youths with a psychiatric disorder also were examined as tests of construct validity. RESULTS: The classification method was shown to produce consistent results across the four populations in terms of proportions of youths assigned with specific sociodemographic characteristics. Variations in health described by specific profiles showed expected relations to sociodemographic characteristics, family structure, school achievement, medical disorders, and psychiatric disorders. CONCLUSIONS: This taxonomy of health profile-types appears to effectively describe a set of patterns that characterize adolescent health. The profile-types provide a unique and practical method for identifying subgroups having distinct needs for health services, with potential utility for health policy and planning. Such integrative reporting methods are critical for more effective utilization of health status instruments in health resource planning and policy development.

Social role functioning by adolescents with psychiatric disorders.

OBJECTIVE: To identify aspects of social role functioning that are impaired in adolescents with specific psychiatric disorders in order to improve the psychiatric taxonomy and clinical knowledge base. METHOD: Adolescents in four urban public schools were screened for mental health problems. Structured psychiatric interviews (National Institute of Mental Health Diagnostic Interview Schedule for Children Version 2.2) with 288 adolescents and their mothers were used to identify youths with psychiatric disorders, and 10 aspects of social role functioning were assessed. Aspects of social role functioning that discriminated between youths with and without psychiatric disorders and between those with emotional disorders and those with disruptive disorders were identified for boys and for girls. RESULTS: Boys with any type of disorder and all youths with disruptive disorders had significant, consistent impairment in academic performance and several other areas of functioning. Youths with emotional disorders, especially girls, demonstrated impairment in social activity participation and peer acceptance, but girls with disorders were not as consistently different from those without as were the boys with emotional disorders. CONCLUSIONS: Role functioning differs in important ways between youths with and without psychiatric disorders and between girls and boys with disorders. The results underscore the importance of investigating observable aspects of role behavior in order to improve the timely detection and effective management of psychiatric disorders in youth.

The association of educational achievement and school dropout with risk of alcoholism: a twenty-five-year prospective study of inner-city children.

OBJECTIVE: This prospective study is focused on the characteristics leading to alcohol use disorders in early adulthood among a cohort of black children. The principal aim of this work is to examine the impact of educational attainment, school dropout and early school adaptation on the development of alcohol abuse and dependence in adulthood. METHOD: From a population that consisted of 1,242 first graders in 1966-67, a total of 953 were interviewed at age 32-33 about their current alcohol and drug use, educational attainment, employment and family situation. RESULTS: Diagnoses of alcohol abuse and dependence were defined according to DSM-III-R criteria resulting in identification of 13.5% as having a lifetime alcohol use disorder. Early predictions of an alcohol use disorder in adulthood included early reports of underachievement in first grade by the child's teacher, dropping out of high school, whether the family set definite rules about school during adolescence, and how often the adolescent worked on homework with his/her family. CONCLUSIONS: The results suggest that educational achievement and some early adaptive behaviors in school are associated with risk for alcohol use disorders. The public health importance of the findings are discussed.

Adolescents' knowledge of their health insurance coverage.

PURPOSE: To determine the accuracy of adolescents' self-report of health insurance coverage, using parents' report as a comparison standard. METHODS: Two separate samples of urban, school-based adolescents and their parents completed self-administered questionnaires about type of health insurance coverage. Sample 1 included 123 and Sample 2 included 93 adolescent-parent pairs. Percent agreement and the kappa statistic were determined for each of the sample groups, and for males versus females and older (> 14 years) versus younger (< or = 14 years) adolescents. RESULTS: In Sample 1, 33% of adolescent respondents responded "don't know" to the question about type of insurance coverage, and 4% left the question blank; in Sample 2, 3% answered "don't know," with none leaving the question blank. For Sample 1, we found a 57% rate of agreement of adolescents with their parents, and a corresponding kappa of .21. Females and older subjects demonstrated greater accuracy, with kappa's all in the range .13-.29. In Sample 2, 73% of subjects agreed with parents' report, with a kappa of .48. Females and older subjects also demonstrated greater accuracy, with the highest kappa of .59 demonstrated by older females. Excluding those responding with "don't know," we found overall percent agreement with parents of 87% in Sample 1 and 73% in Sample 2; the corresponding kappas were .47 and .51. Females demonstrated higher agreement with parents in both samples. The results stratifying by age were inconsistent. In Sample 1, privately insured subjects were more accurate reporters than those either on medical assistance or uninsured. In Sample 2, no differences were seen by type of insurance. CONCLUSIONS: Many adolescents do not know their health insurance coverage status. However, for those who did claim to know, acceptable rates of accuracy using both percent agreement and the kappa statistic were demonstrated. Further research is needed to determine how information about insurance is communicated to adolescents and how this knowledge affects access to and use of health services.

Childhood, adolescent, and young adult predictors of suicidal behaviors: a prospective study of African Americans.

This study examined the lifetime prevalence of suicidal behaviors and their relation to social integration, depression, and aggression/substance use in a cohort of African Americans followed prospectively from first grade to age 32. Lifetime depressive moods in adulthood, lifetime use of cocaine, and frequent mobility were associated with suicidal behaviors for both males and females. For males, having been in a mother-alone or mother-absent family at age 6, childhood psychopathology, and not being married were related to suicidal behaviors. Females who reported high assault behavior in adolescence were more likely to report suicide attempts. The results suggest that social integration, depression, and aggression/drug use are important risk factors for suicidal behaviors in this African American population.

Self-sufficiency at ages 27 to 33 years: factors present between birth and 18 years that predict educational attainment among children born to inner-city families.

OBJECTIVES: Some inner-city infants grow to be successful, self-sufficient adults. This study is designed to identify characteristics from early childhood that foster or impede favorable outcomes and are useful for formulation of public policy. POPULATION: 2694 children (G-2s), born 1960 through 1965, to 2307 inner-city women (G-1s) enrolled in the Johns Hopkins Collaborative Perinatal Study. DATA: 1) prospective observations (birth through 8 years) of neurologic and cognitive development, health, behavior, and family and neighborhood socioeconomic characteristics and 2) completed interviews with 1758 G-2s (age 27 to 33) and 1552 G-1s, bridging the period from age 9 to present status. An intergenerational, life course model of development identified significant characteristics and events associated with G-2 outcome (education, physical and mental health, healthy lifestyle, and financial independence of public support, emphasizing educational attainment of a high school diploma or a graduate equivalency degree). Multiple logistic regression equations identified independent, predictive variables during infancy, preschool and early school years, and adolescence. The probability of a good outcome was estimated in the presence of combinations of the six variables most strongly associated with that outcome. RESULTS: Among G-2s, 79% had a successful outcome for education, 60% health, 70% lifestyle, and 76% for financial independence. Black G-2s had more favorable outcomes than white G-2s in education and lifestyle, whites for financial outcome; health did not differ by race. The six variables most predictive of adult education were: G-1 education at G-2 birth and G-2 attainment of honor roll, average or better reading skills at 8 years, avoidance of regular smoking, and pregnancy before age 18, and not repeating a grade in school. CONCLUSIONS: Substantial proportions of inner-city children become successful adults. Attention to improving public education, particularly language and reading skills, and the prevention of smoking and adolescent pregnancy are clearly indicated.

The inner city and drug use: initial findings from an epidemiological study.

Although scientific and policy statements regarding drugs often suggest that there are grave problems of drug use within America's inner cities, the evidence that supports these statements is often based on anecdotal or incomplete data. This study of African-American adults from the Woodlawn study followed longitudinally partially fills that gap, at least for learning more about those who spend some or all of their childhood within an inner city neighborhood. We found few differences between the lifetime prevalence of drug use and a national representative sample of adults of the same age range. Furthermore, a national household survey of African-Americans of similar age living in six central cities also reported low lifetime rates of illicit drug use. Nevertheless, those from the Woodlawn cohort had higher rates of use of illicit drugs in the past year than the national sample, especially those still living in areas with high rates of poverty. Additionally, reports of heavy drug trafficking were much greater in the inner city areas than in the suburbs.

Health status of well vs ill adolescents.

BACKGROUND: Accountability of health services in meeting needs and assessing outcomes is hampered by the absence of tools to assess health, especially in children and youth. Because it is no longer adequate to assess health by a narrow focus on biological and physiological measures, instruments that assess functional status, person-focused general health status, and overall well-being in a more comprehensive way are needed. OBJECTIVE: To examine whether a health status instrument we have developed discriminates between teenagers in schools and teenagers attending clinics for acute or chronic conditions. METHODS: Teenagers (aged 11-17 years) in schools and in general medical and specialty clinics completed a questionnaire The Child Health and Illness Profile-Adolescent Edition (CHIP-AE), comprehensively covering aspects of health in 6 domains: discomfort, satisfaction with health, disorders, achievement of social expectations, risks, and resilience. RESULTS: Acutely ill teenagers reported more physical discomfort, minor illnesses, and lower physical fitness; chronically ill teenagers reported more limitations of activity, long-term medical disorders, dissatisfaction with their health, and less physical fitness than teenagers in the school samples. Age, sex, and social class did not explain the differences. Teenagers within the acutely and chronically ill clinic populations differed substantially in their health status. IMPLICATIONS: Availability of a comprehensive instrument (CHIP-AE) to assess adolescent health provides a means of documenting health needs and outcomes in populations of teenagers with acute or chronic illness. The heterogeneity within these groups provides support for a person-focused (rather than a disease-focused) approach to assessing both needs for care and the influence of care on promoting health.

Behavior and injury in urban and rural adolescents.

OBJECTIVES: This study investigates the consistency of factors associated with adolescent injury in separate urban and rural samples. SAMPLES: Adolescents, 11-17 years old, in public schools in urban and rural Maryland (n = 2,712). METHODS: Separate bivariate and logistic regression analyses were conducted for each sample to determine individual and environmental factors associated with major and minor injuries experienced in the previous year. RESULTS: Multivariate analyses revealed that, for both samples, the probability of a major injury was highest for boys and, among both boys and girls, for those who played several team sports. Among rural youth, other significant covariates of both major and minor injuries were a tendency to engage in risky behavior and to use alcohol. For urban youth, being white, carrying a weapon for protection, attending an unsafe school, and working for pay were also significant covariates. Interactions were important and complex. CONCLUSIONS: The consistency of predictive factors, such as multiple sports team participation and risky and aggressive behaviors in completely different physical environments, underscores the need to address the contexts of heightened injury risk that some adolescents create wherever they live by playing sports and/or behaving in an antisocial, aggressive manner. Moreover, the perception of lack of safety in schools and neighborhoods is associated with increased injury rates, suggesting the need for policy interventions to target social environments as well as behavior.

School leaving: a longitudinal perspective including neighborhood effects.

Using 1970 and 1980 census data from 202 tracts in the Chicago metropolitan region, we examine whether neighborhoods influence the likelihood of high school graduation for a cohort of African-American children followed from 1966 to 1993. Neighborhood-level variables included percent living below poverty and percent in white collar occupations. We test for the possible direct, indirect, and interactive effects of these neighborhood indicators on the likelihood of school dropout. Our examination found the advantage of living in a neighborhood characterized by a high percentage of residents who work in white-collar occupations. Male adolescents who lived in a middle-class neighborhood were more likely to graduate from high school, even with family background, early school performance, adolescent family supervision, and adolescent marijuana use controlled. These findings are consistent with findings from three other studies. However, living in a poverty census tract did not seem to influence the likelihood of high school graduation or school leaving over and above the impact of family and individual characteristics. There also were no neighborhood effects for females.

Inhalants to heroin: a prospective analysis from adolescence to adulthood.

Recent cross-sectional studies have indicated that inhalant use might be a vulnerability marker for the development of heroin use. This study is the first prospective investigation of the hypothesized association between early inhalant use and later heroin use. Analyses were conducted using longitudinal data from a community sample of Woodlawn (an all African American community on the South side of Chicago). Six-hundred subjects participated in both the adolescent and the adult assessments (approximately ages 16 and 32, respectively). Youths with a history of inhalant use by age 16 were over nine times more likely to begin heroin use by age 32, even when other plausible risk factors for the development of heroin use were held constant (RR = 9.3; 95% C.I. = 1.3 - 51.3). These findings add to and are consistent with prior cross-sectional evidence from data based on treatment samples and national survey data. The results from this longitudinal assessment support the idea that youthful inhalant use should be regarded as a vulnerability marker for the development of more serious drug use involvement in the form of heroin use.

Welfare and psychological distress: a longitudinal study of African American urban mothers.

This paper examines the psychological impact of receiving welfare. The prospective longitudinal data are from a cohort of African American mothers (N = 833). Four explanations structured the analyses: social selection; chronic burdens; a failure hypothesis; and earlier life conditions of welfare recipients. Psychological distress was assessed by women's reports of depressed and anxious moods. Women were categorized into one of four welfare conditions by receipt of welfare when their children were first-graders and 10 years later. Concurrent and longitudinal relationships existed between the women's welfare status and reports of psychological distress. Welfare recipients had more chronic burdens--including perceived ill health--which helped to explain these relationships. Measures of failure did not "explain'' the greater psychological distress. Women who grew up receiving welfare were more likely to report psychological distress and lower self-esteem later in life. The women's education influenced welfare and physical and psychological well-being.

Mechanisms for maternal age differences in birth weight.

The authors studied three hypothesized explanations for reduced birth weights of infants born to US adolescent mothers--social disadvantage, biologic immaturity, and unhealthy behaviors during pregnancy. A hierarchical regression analysis was pursued to evaluate these explanations using data from the National Longitudinal Study of Youth on 1,754 first births between 1979 and 1983 to women aged 14-25 years at the time of birth. The birth weights of infants of mothers aged 14-17, 18-19, and 20-23 years were 133, 54, and 88 g less than for infants of mothers aged 23-25. The regression results indicate that the reduced birth weights of infants born to young mothers, particularly women aged 14-17, were related to their disadvantaged social environment. When adjustment was made for poverty and minority status, there were no maternal age differences in birth weight. The reduced birth weights were not related to the young woman's health behaviors during pregnancy or her biologic characteristics. Ethnicity, poverty status, age at menarche, maternal height, net maternal weight gain, and smoking during pregnancy had an independent effect on birth weight in this sample of young women.

The adolescent child health and illness profile. A population-based measure of health.

This study was designed to test the reliability and validity of an instrument to assess adolescent health status. Reliability and validity were examined by administration to adolescents (ages 11-17 years) in eight schools in two urban areas, one area in Appalachia, and one area in the rural South. Integrity of the domains and subdomains and construct validity were tested in all areas. Test/retest stability, criterion validity, and convergent and discriminant validity were tested in the two urban areas. Iterative testing has resulted in the final form of the CHIP-AE (Child Health and Illness Profile-Adolescent Edition) having 6 domains with 20 subdomains. The domains are Discomfort, Disorders, Satisfaction with Health, Achievement (of age-appropriate social roles), Risks, and Resilience. Tested aspects of reliability and validity have achieved acceptable levels for all retained subdomains. The CHIP-AE in its current form is suitable for assessing the health status of populations and subpopulations of adolescents. Evidence from test-retest stability analyses suggests that the CHIP-AE also can be used to assess changes occurring over time or in response to health services interventions targeted at groups of adolescents.

Using social network analysis to study patterns of drug use among urban drug users at high risk for HIV/AIDS.

Few studies have examined the current social relationships of injecting drug users. This paper examines the structural and relationship characteristics of the social networks of injecting drug users, and the relation of social network characteristics to the HIV infection risk behavior of frequency of injecting heroin and cocaine. The study sample was comprised of 293 inner city injecting drug users in Baltimore, Maryland. Most participants (89%) reported at least one family member in their social network, and 44% listed their mother or step-mother in their network. Presence of family members in personal social networks was not related to patterns of drug use examined here; however, those who reported a partner in their personal social network injected significantly less often than those who did not report a partner. Network density and size of drug subnetworks were positively associated with frequency of drug injection. The results of this study suggest that social network analysis may be a useful tool for understanding the social context of HIV/AIDS risk behaviors.

Gender differences in injuries among rural youth.

GOAL: This paper presents injury data from the first year of a three year longitudinal study of risk taking behaviors among adolescents. SAMPLE: Study subjects were a cohort of 758 rural students from Maryland's Eastern Shore who were in the eighth grade in 1987. METHODS: Students completed a 45 minute, self administered survey in which they reported numbers of injuries experienced in the past year, risk taking behaviors, anger expression, delinquency, alcohol and drug use, physical exercise, work experience, and level of parental supervision. In addition, students had their height and weight measurements taken by trained research staff and completed a self rating of pubertal development using Tanner drawings. RESULTS: Slightly more than half (53.2%) of the boys and over one third (37.7%) of the girls reported experiencing one or more medically attended injuries during the last year. Poisson regression analyses were conducted to estimate the extent to which gender differences in injuries could be accounted for by adolescent behaviors. Gender effects became non-significant when adjustments were made for risk taking, school discipline problems, and exercise frequency. Gender differences in injuries were reduced but remained significant when substance use, employment, and anger were controlled. Poisson regression analyses were conducted separately for males and females to assess whether factors associated with injuries were similar across genders. For boys, risk taking, anger, and school discipline problems were significantly related to number of injuries. Boys with a low body mass index and late pubertal development (mean ratio 3.09), as well as those with high body mass index and early pubertal development (mean ratio 2.16), reported greater numbers of injuries than average boys. For girls, substance use, cruising, risk taking, anger, and exercise frequency were significantly associated with injuries. Girls with an early onset of menses reported, on average, twice the number of injuries than those who were on time. Girls with high body mass index who were late in their pubertal development reported, on average, five times more injuries than other girls. CONCLUSIONS: Although gender is a significant risk factor for injuries, certain behaviors like risk taking, school related delinquency, and physical exercise partially explain the higher number of injuries among adolescent males in this study. For both males and females, indicators of pubertal and physical development are important factors to consider in studies of injuries during early adolescence.