The Need to Rethink Harm Reduction for People Using Drugs Alone to Reduce Overdose Fatalities.

Background: During the ongoing opioid epidemic, Cuyahoga County (second largest in Ohio) reported overdose mortality rates (54/per 100,000) higher than the national average. Prior research demonstrates that people who use drugs often use alone but there is minimal research on people who died of overdose while using alone. The objective of this study is to examine sociodemographic, toxicologic, and injury characteristics, and emergency medical response to overdose decedents who died using drugs alone. Method: Data from the Cuyahoga County Medical Examiner's Office (2016-2020, N = 2944) on unintentional overdose deaths in adults was tabulated including socio-demographic, toxicologic, and injury-related information. Decedents using drugs alone were identified and compared to those not using alone via Chi-square and Fisher's exact tests. We further fit a multivariate logistic regression model to evaluate socio-demographic, toxicologic, and injury-related factors associated with increased odds of using alone. All results are reported with 95% confidence intervals. Result: Among decedents, 75% (n = 2205) were using drugs alone. Decedents using alone were more likely to be using drugs at home (p = 0.001) or be found dead at the scene (p < 0.001) and less likely to receive naloxone (p < 0.001) have other person/bystander, not using, present (p = 0.002). Using drugs at home (aOR = 1.61[1.19-2.20]) was associated with higher odds of using alone; and being married (aOR = 0.57[0.38-0.86]), having history of illicit drug use (aOR = 0.25[0.08-0.81]) and other person present, who was not using (aOR = 0.58[0.42-0.79]) were associated with lower odds of using alone. Conclusion: New harm reduction approaches targeting people using drugs alone are needed to reduce overdose deaths.

A case study for local data surveillance in opioid overdose fatalities in Cuyahoga County, OH 2016-2020.

Introduction: Fentanyl and fentanyl analogs have increased the overdose mortality rates in the United States, significantly impacting states like Ohio. We examined carfentanil overdose deaths, other contributing Cause of Death (COD) drugs, and drug seizure trends from 2016 to 2020 in Northeast Ohio. Materials and methods: We studied death investigation data from the Cuyahoga County, Ohio Medical Examiner's Office (CCMEO) of all fatal accidental opioid overdoses as well as drug seizure data from Cuyahoga County Regional Forensic Science Laboratory (CCRFSL). We also compared decedents' race, gender, age, residential locality, drugs contributing to the COD in opioid cases, and for carfentanil, fentanyl, and cocaine seizures in Cuyahoga County from 2016 to 2020 (N = 2948). Results: Decedents' had an average of three different drugs contributing to their COD. A bimodal carfentanil spike was observed in fatal accidental overdoses in Cuyahoga County for the years 2017 and 2019. Decedents in urban residency, who were Non-Hispanic, White and younger, significantly predicted the presence of carfentanil contributing to the COD. In 2020, decedents who were Black and older were significantly associated with cocaine contributing to the COD. Carfentanil and carfentanil-related overdoses were significantly correlated. Discussion: The pervasiveness of illicitly manufactured fentanyl and fentanyl analog (e.g., carfentanil) mixtures with other drugs are changing the demographics of persons who fatally overdose in Cuyahoga County, OH. Significant trending shifts can also be observed for the presence of carfentanil in decedent and seizure county data. Conclusions: Local data of drug-related overdose deaths and drug seizures from a medical examiner's office and affiliated forensic laboratory lab can be used for timely public health surveillance, and informing prevention, and intervention at the county level.

Feasibility and acceptability of a mobile model of environmental enrichment for patients with mixed medical conditions receiving inpatient rehabilitation: a mixed methods study.

OBJECTIVES: To investigate the feasibility and acceptability of a mobile model of environmental enrichment (EE), a paradigm that promotes activity engagement after stroke, in patients with mixed medical conditions receiving inpatient rehabilitation. DESIGN: A mixed methods study design was used. An online qualitative survey assessed staff perspectives of acceptability of the mobile EE model including perceived barriers and enablers pre-implementation and post implementation. An A-B quasi-experimental case study of patient activity levels over a 2-week observational period provided feasibility data. This included recruitment and retention rates, completion of scheduled patient activity observations and validated baseline questionnaires, and number of adverse events. SETTING: A 30-bed mixed medical ward in a public hospital that services Brisbane's southern bayside suburbs. The rehabilitation programme operates with patients co-located throughout the medical/surgical wards. PARTICIPANTS: Nursing and allied health professionals working across the rehabilitation programme completed pre-implementation (n=19) and post implementation (n=16) qualitative questions. Patients admitted to the ward and who received the inpatient rehabilitation programme from June to November 2016 were also recruited. INTERVENTIONS: The mobile EE intervention included activities to primarily promote social and cognitive stimulation (eg, puzzles, board games) delivered by hospital volunteers and was designed to be moved throughout the wards. RESULTS: Four themes emerged from staff reports, suggesting that the role of patient, staff and intervention characteristics, and the ward environment were important barriers and enablers to implementation. Of the 12 eligible patients, six consented to the study, and five completed the intervention. All patients completed the baseline measures. No adverse events were reported. CONCLUSIONS: As interest grows in human EE models, it will be important to tailor EE interventions to the unique demands of hospital rehabilitation services. A mobile EE model delivered in a small, mixed rehabilitation ward appears feasible and acceptable to study in a larger controlled feasibility trial.

Randomized trial of a web-based nurse education intervention to increase discussion of clinical trials.

BACKGROUND: Clinical trials are a critical source of evidence for oncology care, yet very few patients participate. Among healthcare providers, nurses spend the most time with cancer patients and are the most highly trusted professionals. We developed and evaluated an educational program for oncology nurses targeting knowledge, attitudes, self-efficacy and perceived norms to facilitate discussion about clinical trials and support patient decision making. METHODS: A nationwide sample of oncology nurses were randomly assigned to receive general clinical trials education delivered as text (attention control) vs. tailored video vignettes (intervention) in a web-based continuing education program. Participants completed a baseline assessment and follow up assessments immediately after the educational program and three months later. The primary outcome was intention to discuss clinical trials with patients. Secondary outcomes were knowledge and attitudes about clinical trials, self-efficacy, and perceived norms. RESULTS: 1393 nurses enrolled and completed the educational program and post-intervention assessment (720 control, 673 video). Both text education and tailored video education increased intention to discuss clinical trials with patients, with a greater effect in the video group (p < .0001). Likewise, knowledge, attitudes, perceived behavioral control, and perceived norms were all improved with education in both groups, and the magnitude of benefit was greater (p < .001) for the video group in all outcomes except knowledge. CONCLUSION: A one-time online educational program for oncology nurses improves knowledge, attitudes, self-efficacy and intention to engage patients in discussions about clinical trials. A tailored video format was associated with a greater effect than standard text only material.

Recruitment Strategies for Nurse Enrollment in an Online Study.

BACKGROUND: Although there is a great deal of literature regarding effective recruitment and challenges of recruiting specific patient populations, there is less known about best practices for recruitment of nurses as study subjects. OBJECTIVES: The purpose of this article is to report our experience with recruitment and retention for a randomized trial of an online educational program to prepare oncology nurses to discuss oncology clinical trials with patients. METHODS: The study population included currently employed oncology nurses with direct patient interaction. There were three phases of this study: (1) qualitative interviews, (2) a pilot test, and (3) the randomized trial. Phase 3 was rolled out in five waves of recruitment. The distinct phases of the study-and the gradual roll out of recruitment during Phase 3-allowed us to test and refine our recruitment and retention methods for the randomized trial. Upon analysis of our response rate and attrition after the first wave of recruitment in Phase 3, we made several changes to improve recruitment and retention, including adding incentives, shortening the survey, and increasing the number of reminders to complete the program. RESULTS: The response rate was higher when we used both e-mail and U.S. postal mail solicitations. After the first wave of recruitment in the final phase, changes in our strategies did not increase our overall response rate significantly; however, the rate of attrition following baseline declined. DISCUSSION: Recruitment planning is an important component of successful clinical research. The use of the Internet for both recruitment of subjects and testing of interventions remains a cost-effective and potentially high yield methodology. Our research demonstrated several successful approaches to yield increased participation and retention of subjects, including seeking formal relationships with professional organizations as sponsors or supporters, providing meaningful incentives to participants, keeping surveys or questionnaires as short as possible, and planning multiple follow-up contacts from the outset.

A National Study of Oncology Nurses Discussing Cancer Clinical Trials With Patients.

In the United States less than 10% of cancer patients engage in clinical trials. Although most oncology nurses have multiple opportunities to discuss clinical trials with patients, barriers including attitudes and social norms may impede these discussions. Guided by the Theory of Planned Behavior, we developed and evaluated measures for attitudes, subjective norms, and perceived behavioral control of nurses for discussing clinical trials with cancer patients. Of the 18,000 Oncology Nurse Society members invited, 1,964 completed the survey. Structural equation modeling and internal consistency reliability were used to evaluate items and constructs. We found that overall model fit and reliability was good: Confirmatory Fit Index (CFI) = 0.91, Root Mean Square Error of Approximation (RMSEA) = 0.05; attitudes, 21 items, alpha = 0.84; perceived behavioral control, 10 items, alpha = 0.85; and subjective norms, 9 items, alpha = 0.89. These measures of attitudes, subjective norms, and perceived behavioral control show good reliability and initial evidence of validity.

The Role of Oncology Nurses in Discussing Clinical Trials.

PURPOSE/OBJECTIVES: To describe oncology nurses' experiences discussing clinical trials with their patients, and to assess barriers to these discussions.
. RESEARCH APPROACH: A qualitative study designed to elicit narratives from oncology nurses. 
. SETTING: Community- and academic-based oncology clinics throughout the United States.
. PARTICIPANTS: 33 oncology nurses involved in direct patient care in community-based and large hospital-based settings. The sample was drawn from members of the Oncology Nursing Society. 
. METHODOLOGIC APPROACH: In-depth interviews were conducted and analyzed using a immersion/crystallization approach to identify themes and patterns. The analyses highlight specific issues, examples, and contexts that present challenges to clinical trial discussions with patients.
. FINDINGS: Oncology nurses view their roles as patient educators and advocates to be inclusive of discussion of clinical trials. Barriers to such discussions include lack of knowledge and strategies for addressing patients' common misconceptions and uncertainty about the timing of discussions.
. INTERPRETATION: These data indicate that enabling nurses to actively engage patients in discussions of clinical trials requires educational interventions to build self-efficacy and close knowledge gaps. 
. IMPLICATIONS FOR NURSING: Oncology nurses can play a critical role in advancing cancer care by supporting patients in decision making about clinical trial participation. This will require training and education to build their knowledge, reduce barriers, and increase their self-efficacy to fulfill this responsibility in various clinical settings.

Motor delays in MDMA (ecstasy) exposed infants persist to 2 years.

BACKGROUND: Recreational use of 3,4 methylenedioxymethamphetamine (ecstasy, MDMA) is increasing worldwide. Its use by pregnant women causes concern due to potentially harmful effects on the developing fetus. MDMA, an indirect monoaminergic agonist and reuptake inhibitor, affects the serotonin and dopamine systems. Preclinical studies of fetal exposure demonstrate effects on learning, motor behavior, and memory. In the first human studies, we found prenatal MDMA exposure related to poorer motor development in the first year of life. In the present study we assessed the effects of prenatal exposure to MDMA on the trajectory of child development through 2 years of age. We hypothesized that exposure would be associated with poorer mental and motor outcomes. MATERIALS AND METHODS: The DAISY (Drugs and Infancy Study, 2003-2008) employed a prospective longitudinal cohort design to assess recreational drug use during pregnancy and child outcomes in the United Kingdom. Examiners masked to drug exposures followed infants from birth to 4, 12, 18, and 24 months of age. MDMA, cocaine, alcohol, tobacco, cannabis, and other drugs were quantified through a standardized clinical interview. The Bayley Scales (III) of Mental (MDI) and Motor (PDI) Development and the Behavior Rating Scales (BRS) were primary outcome measures. Statistical analyses included a repeated measures mixed model approach controlling for multiple confounders. RESULTS: Participants were pregnant women volunteers, primarily white, of middle class socioeconomic status, average IQ, with some college education, in stable partner relationships. Of 96 women enrolled, children of 93 had at least one follow-up assessment and 81 (87%) had ≥ two assessments. Heavier MDMA exposure (M=1.3±1.4 tablets per week) predicted lower PDI (p<.002), and poorer BRS motor quality from 4 to 24 months of age, but did not affect MDI, orientation, or emotional regulation. Children with heavier exposure were twice as likely to demonstrate poorer motor quality as lighter and non-exposed children (O.R.=2.2, 95%, CI=1.02-4.70, p<.05). DISCUSSION: Infants whose mothers reported heavier MDMA use during pregnancy had motor delays from 4 months to two years of age that were not attributable to other drug or lifestyle factors. Women of child bearing age should be cautioned about the use of MDMA and MDMA-exposed infants should be screened for motor delays and possible intervention.

Developmental outcomes of 3,4-methylenedioxymethamphetamine (ecstasy)-exposed infants in the UK.

OBJECTIVE: This paper aims to review findings from a longitudinal study of prenatal methylenedioxymethamphetamine (MDMA, "ecstasy") on infant development. METHODS: In a prospective, longitudinal cohort design, we followed 28 MDMA-exposed and 68 non-MDMA-exposed infants from birth to 2 years of age. Women recruited voluntarily into a study of recreational drug use during pregnancy were interviewed to obtain type, frequency, and amount of recreational drug use. Their children were followed for a 2-year period after birth. A large number of drug and environmental covariates were controlled. Infants were seen at 1, 4, 12, 18, and 24 months using standardized normative tests of mental and motor development. RESULTS: There were no differences between MDMA-exposed and non-MDMA-exposed infants at birth except that MDMA-exposed infants were more likely to be male. Motor delays were evident in MDMA infants at each age and amount of MDMA exposure predicted motor deficits at 12 months in a dose-dependent fashion. CONCLUSIONS: Prenatal MDMA exposure is related to fine and gross motor delays in the first 2 years of life. Follow-up studies are needed to determine long-term effects.

Psychiatric profiles of mothers who take Ecstasy/MDMA during pregnancy: reduced depression 1 year after giving birth and quitting Ecstasy.

BACKGROUND: The recreational drug MDMA (3,4-methylenedioxymethamphetamine) or 'Ecstasy' is associated with heightened psychiatric distress and feelings of depression. The Drugs and Infancy Study (DAISY) monitored the psychiatric symptom profiles of mothers who used Ecstasy/MDMA while pregnant, and followed them over the first year post-partum. METHODS: We compared 28 young women whom took MDMA during their pregnancy with a polydrug control group of 68 women who took other psychoactive drugs while pregnant. The Brief Symptom Inventory (BSI) was completed for several periods: The first trimester of pregnancy; and 1, 4 and 12 months after childbirth. Recreational drug use was monitored at each time point. RESULTS: During the first trimester of pregnancy, MDMA-using mothers reported higher depression scores than the polydrug controls. At 1 year after childbirth, their BSI depression scores were significantly lower, now closer to the control group values. At the same time point, their self-reported use of MDMA became nearly zero, in contrast to their continued use of Cannabis/marijuana, nicotine and alcohol. We found significant symptom reductions in those with BSI obsessive-compulsive and interpersonal sensitivity, following Ecstasy/MDMA cessation. CONCLUSIONS: The findings from this unique prospective study of young recreational drug-using mothers are consistent with previous reports of improved psychiatric health after quitting MDMA.

One-year outcomes of prenatal exposure to MDMA and other recreational drugs.

OBJECTIVE: A widely used illicit recreational drug among young adults, 3,4-methylenedioxymethamphetamine (MDMA) or ecstasy, is an indirect monoaminergic agonist/reuptake inhibitor affecting the serotonin system. Preclinical studies found prenatal exposure related to long-term learning and memory impairments. There are no studies of sequelae of prenatal MDMA exposure in humans, despite potential harmful effects to the fetus. METHODS: A total of 96 women in the United Kingdom (28 MDMA users; 68 non-MDMA) were interviewed about recreational drug use during pregnancy. Their infants were seen at 12 months using standardized assessments of cognitive, language, and motor development (Preschool Language Scale, Bayley Mental and Motor Development and Behavior Rating Scales [Mental Development Index, Psychomotor Development Index, Behavioral Rating Scale]). Mothers completed the Child Domain Scale of the Parenting Stress Index, The Home Observation of the Environment Scale (in interview), the Brief Symptom Inventory, and the Drug Abuse Screening Test. Women were primarily middle class with some university education, in stable partner relationships, and polydrug users. MDMA and other drug effects were assessed through multiple regression analyses controlling for confounding variables, and analysis of covariance comparing heavier versus lighter and nonexposed groups. RESULTS: Amount of prenatal MDMA exposure predicted poorer infant mental and motor development at 12 months in a dose-dependent manner. Heavily exposed infants were delayed in motor development. Lighter-exposed infants were comparable to nonexposed infants. There were no effects on language, emotional regulation, or parenting stress. CONCLUSIONS: Findings document persistent neurotoxic effects of heavier prenatal MDMA exposure on motor development through the first year of life.

Neurobehavioral outcomes of infants exposed to MDMA (Ecstasy) and other recreational drugs during pregnancy.

3,4-methylenedioxymethamphetamine (MDMA) or "Ecstasy" is one of the most widely used illicit recreational drugs among young adults. MDMA is an indirect monoaminergic agonist and reuptake inhibitor that primarily affects the serotonin system. Preclinical studies in animals have found prenatal exposure related to neonatal tremors and long-term learning and memory impairments. To date, there are no prospective studies of the sequelae of prenatal exposure to MDMA in humans, despite concerns about its potential for harmful effects to the fetus. The present study is the first to prospectively identify MDMA-using women during pregnancy and to document patterns and correlates of use with neonatal and early infancy outcomes of offspring. All mothers and infants were prospectively recruited through the Case Western Reserve University (CWRU) and University of East London (UEL) Drugs and Infancy Study (DAISY) that focused on recreational drug use in pregnant women. Women were interviewed about substance use prior to and during pregnancy and infants were seen at 1 and 4 months using standardized, normative assessments of neonatal behavior, and cognitive and motor development, including the NICU Network Neurobehavioral Scale (NNNS), the Bayley Mental and Motor Development Scales (MDI, PDI), and the Alberta Infant Motor Scales (AIMS). The sample was primarily middle class with some university education and in stable partner relationships. The majority of women recruited had taken a number of illicit drugs prior to or during pregnancy. Group differences between those polydrug using women who had specifically used MDMA during pregnancy (n=28) and those who had not (n=68) were assessed using chi-square and t-tests. MDMA and other drug effects were assessed through multiple regression analyses controlling for confounding variables. Women who used MDMA during pregnancy had fewer prior births and more negative sequelae associated with their drug use, including more health, work, and social problems. MDMA exposed infants differed in sex ratio (more male births) and had poorer motor quality and lower milestone attainment at 4 months, with a dose-response relationship to amount of MDMA exposure. These findings suggest risk to the developing infant related to MDMA exposure and warrant continued follow-up to determine whether early motor delays persist or resolve.

Longitudinal predictors of maternal stress and coping after very low-birth-weight birth.

OBJECTIVE: To determine longitudinal outcomes and contributors to parental stress and coping in mothers of very low-birth-weight (VLBW) children. DESIGN: Prospective cohort follow-up of high-risk VLBW children (n = 113), low-risk VLBW children (n = 80), and term children (n = 122) and their mothers from birth to 14 years. SETTING: Recruitment from level III neonatal intensive care and term nurseries in a large Midwestern region with follow-up at an academic medical center. PARTICIPANTS: A total of 315 mother-infant dyads enrolled from November 8, 1989, to February 22, 1992. MAIN EXPOSURES: High-risk VLBW infants had bronchopulmonary dysplasia. Comparison groups were demographically similar low-risk VLBW children (without bronchopulmonary dysplasia) and term children. MAIN OUTCOME MEASURES: Child IQ and self-report measures of parenting stress, family impact, maternal coping, education, and social support. RESULTS: After VLBW birth, mothers attained fewer additional years of education than term mothers (P = .04). Mothers of high-risk VLBW children felt more personal stress (P = .006) and family stress (P = .009) under conditions of low social support and had greater child-related stress than term mothers; however, they also expressed the highest levels of parenting satisfaction at 14 years. They became less likely to use denial (P = .02) and mental disengagement (P = .03) as coping mechanisms over time. Except for education attainment, mothers of low-risk VLBW infants did not differ from mothers of term children and at 14 years reported the lowest stress. CONCLUSIONS: Parenting a VLBW child had both positive and negative outcomes, dependent on child medical risk, child IQ, social support, and maternal coping mechanisms, suggesting that mothers experience posttraumatic growth and resilience after significant distress post partum.

During pregnancy, recreational drug-using women stop taking ecstasy (3,4-methylenedioxy-N-methylamphetamine) and reduce alcohol consumption, but continue to smoke tobacco and cannabis: initial findings from the Development and Infancy Study.

While recreational drug use in UK women is prevalent, to date there is little prospective data on patterns of drug use in recreational drug-using women immediately before and during pregnancy. A total of 121 participants from a wide range of backgrounds were recruited to take part in the longitudinal Development and Infancy Study (DAISY) study of prenatal drug use and outcomes. Eighty-six of the women were interviewed prospectively while pregnant and/or soon after their infant was born. Participants reported on use immediately before and during pregnancy and on use over their lifetime. Levels of lifetime drug use of the women recruited were high, with women reporting having used at least four different illegal drugs over their lifetime. Most users of cocaine, 3,4-methylenedioxy-N-methylamphetamine (MDMA) and other stimulants stopped using these by the second trimester and levels of use were low. However, in pregnancy, 64% of the sample continued to use alcohol, 46% tobacco and 48% cannabis. While the level of alcohol use reduced substantially, average tobacco and cannabis levels tended to be sustained at pre-pregnancy levels even into the third trimester (50 cigarettes and/or 11 joints per week). In sum, while the use of 'party drugs' and alcohol seems to reduce, levels of tobacco and cannabis use are likely to be sustained throughout pregnancy. The data provide polydrug profiles that can form the basis for the development of more realistic animal models.

Developmental sequelae in preterm infants having a diagnosis of bronchopulmonary dysplasia: analysis using a severity-based classification system.

OBJECTIVE: To investigate the relationship between the severity-based definition of bronchopulmonary dysplasia (BPD), choice of treatment, and neurocognitive outcomes at age 3 and 8 years. DESIGN: This is a secondary analysis of data collected from a prospective, longitudinal sample of 99 children with a history of BPD. SETTING: Children born with BPD admitted to 3 hospitals from February 1, 1989, to November 31, 1991. PARTICIPANTS: Ninety-nine children with BPD were longitudinally assessed at age 3 and 8 years. Three severity groups (mild, moderate, and severe) were formed based on gestational age and need for supplemental oxygen therapy. MAIN EXPOSURES: Supplemental oxygen therapy for 28 days or longer, birth weight less than 1500 g, and radiographic evidence of lung disease. MAIN OUTCOME MEASURES: Neurologic and medical outcomes; type of medical management; and language, achievement, and cognitive functioning were compared among the 3 severity groups. RESULTS: Severity classification of BPD was associated with poorer outcomes. Compared with children with mild or moderate BPD, children with severe BPD performed more poorly on IQ tests (Mental Development Index, 90 vs 76.4; and Psychomotor Development Index, 92.5 vs 73.9) and language measures (total, 95 vs 82) at age 3 years and performance IQ (86 vs 75) and perceptual organization (86 vs 76) at age 8 years. Severity of BPD was not associated with choice of medical management but was related to educational interventions. Children with severe BPD received more special education services (69% vs 44%) than did children with mild BPD. CONCLUSIONS: The severity-based classification clarifies the relationship between BPD and developmental sequelae. Children with severe BPD required more interventions at age 8 years than did children with mild or moderate BPD.

Parenting very low birth weight children at school age: maternal stress and coping.

OBJECTIVE: To compare severity and determinants of stress and coping in mothers of 8-year-old very low birth weight (VLBW) and term children varying in medical and developmental risk. STUDY DESIGN: Three groups of mothers/infants were prospectively compared in a longitudinal study from birth to 8 years (110 high-risk VLBW, 80 low-risk VLBW, and 112 term). Maternal psychological distress, coping, parenting/marital stress, child health, and family impact were measured in the children at age 8 years. RESULTS: Mothers of VLBW children differed from term mothers, reporting less consensus with partners, more concern for their children's health, less parent-child conflict, and fewer years of education attained. Mothers of high-risk VLBW children experienced the greatest family and personal strains and used less denial and disengagement coping. The groups exhibited no differences in the sense of parenting competence, divorce rate, parenting/marital satisfaction, family cohesion, and psychological distress symptoms. Multiple birth, low socioeconomic status, and lower child IQ added to maternal stress. CONCLUSIONS: VLBW birth has long-term negative and positive impacts on maternal/family outcomes related to the infant's medical risk.

Factor structure of coping: two studies of mothers with high levels of life stress.

Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were used to investigate the factor structure of coping in mothers with high levels of life stress. In Study 1, EFA of the Coping Orientation to Problems Experienced (C. S. Carver, M. F. Scheier, & J. K. Weintraub, 1989) in a sample of mothers of full-term or very low birth weight 2-year-old children yielded 7 reliable coping factors. Each factor accounted for significant variance in at least 1 of 6 outcomes measuring maternal-child well-being. In Study 2, CFA was used to cross-validate the EFA model on the basis of the responses of mothers of 2-year-old children with prenatal polysubstance exposure. CFA results revealed a moderately good fit, confirming the factor structure in a 2nd, independent sample of mothers with high levels of life stress.

Cognitive and academic consequences of bronchopulmonary dysplasia and very low birth weight: 8-year-old outcomes.

OBJECTIVE: To examine the effects of bronchopulmonary dysplasia (BPD) and very low birth weight (VLBW) on the cognitive and academic achievement of a large sample of 8-year-old children. METHODS: Infants who were VLBW and had BPD (n = 98) or did not have BPD (n = 75) and term infants (n = 99) were followed prospectively to age 8. Groups were compared on measures assessing 4 broad areas of functioning: intelligence, achievement, gross motor, and attentional skills. Measures included the Wechsler Intelligence Scale for Children III, the Woodcock Johnson Test of Achievement-Revised, the Bruininks-Oseretsky Test of Motor Proficiency, the Tactual Performance Test (spatial memory), and the Continuous Performance Test (attention). School outcomes were assessed by parent and teacher report, as well as from school records. Groups were comparable on socioeconomic status, sex, and race. The total sample of BPD, VLBW, and term children was compared on all outcome measures. In addition, neurologic risk was assessed in the present sample and included the following: intraventricular hemorrhage, echodense lesions, porencephaly, hydrocephalus, ventriculoperitoneal shunt, meningitis, and periventricular leukomalacia. Individual difference analyses were conducted for neurologically intact children in all 3 groups. Finally, treatment effects were examined by comparing BPD children who had received steroids as part of their treatment with BPD children who had not. RESULTS: The BPD group demonstrated deficits compared with VLBW and term children in intelligence; reading, mathematics, and gross motor skills; and special education services. VLBW children differed from term children in all of the above areas, except reading recognition, comprehension, and occupational therapy. Attentional differences were obtained between BPD and term children only. The BPD group (54%) was more likely to be enrolled in special education classes than VLBW (37%) or term children (25%). In addition, more BPD children (20%) achieved full-scale IQ scores <70, in the mental retardation range, compared with either VLBW (11%) or term (3%) children, with all VLBW children significantly more likely than term children to achieve IQs in the subaverage category. After controlling for birth weight and neurologic problems, BPD and/or duration on oxygen predicted lower performance IQ, perceptual organization, full-scale IQ, motor and attentional skills, and special education placement. The qualitative classification of BPD (present or absent) was a significant predictor for lower scores on measures of applied problems; motor skills; and incidence of speech-language, occupational, and physical therapies. Individual difference analyses were performed to ascertain whether differences between the risk groups were primarily attributable to neurologic complications. Even with the neurologically intact sample of BPD and VLBW children, differences between the term comparison group and both the BPD and VLBW groups were found for many outcome measures. When birth weight and neurologic complications were controlled, BPD and severity of BPD were associated with lower performance and full-scale IQ, poorer perceptual organization, attention, and motor skills, as well as lower school achievement and greater participation in special education, including occupational, physical, and speech-language therapies. Treatment protocol may in part be responsible for differences observed in our BPD sample. Steroid and nonsteroid groups of BPD children differed significantly in performance IQ (72.8 vs 84.8) and full-scale IQ (77.0 vs 85.2); perceptual organization (74.0 vs 85.2); Bruininks-Oseretsky Test of Motor Proficiency score (36.6 vs 44.7); and participation in special education (78% vs 48%), occupational therapy (71% vs 44%), and physical therapy (71% vs 41%). In every instance, BPD children who received steroids fared more poorly than BPD children who did not receive steroids. CONCLUSIONS: BPD and duration on oxygen have long-term adverse effects on cognitive and academic achievement above and be beyond the effects of VLBW. The problems that have been identified at 8 years of age highlight the need for continued monitoring of the learning, behavior, and development of BPD children to intervene with children who are at risk for school problems.