Community-Based Prevalence of Externalizing and Internalizing Disorders among School-Aged Children and Adolescents in Four Geographically Dispersed School Districts in the United States.

The Project to Learn About Youth-Mental Health (PLAY-MH; 2014-2018) is a school-based, two-stage study designed to estimate the prevalence of selected mental disorders among K-12 students in four U.S.-based sites (Colorado, Florida, Ohio, and South Carolina). In Stage 1, teachers completed validated screeners to determine student risk status for externalizing or internalizing problems or tics; the percentage of students identified as being at high risk ranged from 17.8% to 34.4%. In Stage 2, parents completed a structured diagnostic interview to determine whether their child met criteria for fourteen externalizing or internalizing disorders; weighted prevalence estimates of meeting criteria for any disorder were similar in three sites (14.8%-17.8%) and higher in Ohio (33.3%). PLAY-MH produced point-in-time estimates of mental disorders in K-12 students, which may be used to supplement estimates from other modes of mental disorder surveillance and inform mental health screening and healthcare and educational services.

ADHD and Psychiatric Comorbidity: Functional Outcomes in a School-Based Sample of Children.

Objective: Investigate the prevalence and impact of psychiatric comorbidities in community-based samples of schoolchildren with/without ADHD. Method: Teachers and parents screened children in South Carolina (SC; n = 4,604) and Oklahoma (OK; n = 12,626) for ADHD. Parents of high-screen and selected low-screen children received diagnostic interviews (SC: n = 479; OK: n = 577). Results: Psychiatric disorders were increased among children with ADHD and were associated with low academic performance. Conduct disorder/oppositional defiant disorder (CD/ODD) were associated with grade retention (ODD/CD + ADHD: odds ratio [OR] = 3.0; confidence interval [CI] = [1.5, 5.9]; ODD/CD without ADHD: OR = 4.0; CI = [1.7, 9.7]). School discipline/police involvement was associated with ADHD alone (OR = 3.2; CI = [1.5, 6.8]), ADHD + CD/ODD (OR = 14.1, CI = [7.3, 27.1]), ADHD + anxiety/depression (OR = 4.8, CI = [1.6, 14.8]), and CD/ODD alone (OR = 2.8, CI = [1.2, 6.4]). Children with ADHD + anxiety/depression had tenfold risk for poor academic performance (OR = 10.8; CI = [2.4, 49.1]) compared to children with ADHD alone. This should be interpreted with caution due to the wide confidence interval. Conclusion: Most children with ADHD have psychiatric comorbidities, which worsens functional outcomes. The pattern of outcomes varies by type of comorbidity.

The Association Between Race/Ethnicity and Socioeconomic Factors and the Diagnosis and Treatment of Children with Attention-Deficit Hyperactivity Disorder.

OBJECTIVE: Assessing race/ethnicity and socioeconomic status (SES) relationships with Attention-Deficit/Hyperactivity Disorder (ADHD) diagnosis, treatment, and access to care has yielded inconsistent results often based only on parent-report. In contrast, this study used broader ADHD diagnostic determination including case-definition to examine these relationships in a multisite elementary-school-based sample. METHOD: Secondary analysis of children with and without ADHD per parent and teacher-reported Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria evaluated SES, race/ethnicity, and other variables through simple bivariate/multivariable models within and across: parent-reported diagnosis, medication treatment, and meeting ADHD study case-definition. RESULTS: The total sample included 51.9% male, 51.3% White, and 53.1% with private insurance; 10% had parent-reported ADHD diagnoses while 8.3% met ADHD study case-definition. In multivariable models, White children had higher odds of parent-reported diagnoses than Black, Hispanic, and Other Race/Ethnicity children (p < 0.05), but only Hispanic children had lower odds of being case-positive (<0.05); males and children in single-parent households had higher odds of parent-reported diagnoses and being case-positive (p < 0.05); and children who were White, male, and had health insurance had higher odds of taking medication (p < 0.05). Among children who were case-positive, those with Medicaid, White, and 2-parent statuses had higher odds of parent-reported diagnoses (p < 0.05). CONCLUSION: Children with underlying ADHD appear more likely to have assessment/medication treatment access if they are White, male, have health insurance (particularly Medicaid), and live in 2-parent households. While boys and children raised by single parents may have higher rates of ADHD diagnoses, false-positive diagnostic risk also appeared higher, inviting further investigation.

Persistence of Parent-Reported ADHD Symptoms From Childhood Through Adolescence in a Community Sample.

OBJECTIVE: To examine ADHD symptom persistence and factors associated with elevated symptom counts in a diverse, longitudinal community-based sample. METHOD: Parents reported demographics and completed a diagnostic interview repeatedly over a 6-year period. At Time 1, 481 interviews were completed about children (5-13 years); all participants were invited to four annual follow-up interviews, and 379 (79%) completed at least one. Inattentive (IA) and hyperactive-impulsive (HI) symptom counts were modeled with logistic quantile regression, while accounting for study design complexities. RESULTS: The prevalence of seven IA symptoms remained stable from early childhood through late adolescence. The prevalence of eight HI symptoms decreased by more than half over time. After demographic adjustment, the upper quartile of HI symptom counts decreased with age (p < .01). High HI symptom counts persisted more among those with high IA symptom counts (p = .05). CONCLUSION: This study further characterizes and provides insights into ADHD symptom trajectory through adolescence.

Gender differences in the association between food insecurity and insulin resistance among U.S. adults: National Health and Nutrition Examination Survey, 2005-2010.

PURPOSE: To examine gender-specific associations between food insecurity and insulin resistance in a representative U.S. METHODS: Data on 5533 adults of 20 years of age or more (2742 men and 2791 women) without diabetes from the 2005-2010 National Health and Nutrition Examination Survey were analyzed. Respondents were categorized as having full, marginal, low, or very low food security using a validated scale. Insulin-resistant individuals were defined as those with a homeostasis model assessment of insulin resistance value 2.5 or more. RESULTS: Insulin resistance was higher in both normal-weight (P = .001) and overweight or obese (P < .001) women with lower food security, but no linear trend was found in men. In multiple logistic regression analyses, however, very low food security-compared with full food security-was associated with insulin resistance in normal-weight men (odds ratio, 3.99; 95% confidence interval, 1.71-9.33), and marginal food insecurity was associated with insulin resistance in overweight or obese men (odds ratio, 2.07; 95% confidence interval, 1.18-3.64) after adjusting for potential confounders. In women, the association between food insecurity and insulin resistance was no longer significant after adjustment. CONCLUSIONS: Food insecurity is associated with insulin resistance in adults without diabetes, and this effect varies by gender in normal-weight and overweight or obese populations. Improving food security status may help reduce insulin resistance, an underlying risk factor for diabetes and cardiovascular disease.

The impact of case definition on attention-deficit/hyperactivity disorder prevalence estimates in community-based samples of school-aged children.

OBJECTIVE: To determine the impact of varying attention-deficit/hyperactivity disorder (ADHD) diagnostic criteria, including new DSM-5 criteria, on prevalence estimates. METHOD: Parent and teacher reports identified high- and low-screen children with ADHD from elementary schools in 2 states that produced a diverse overall sample. The parent interview stage included the Diagnostic Interview Schedule for Children-IV (DISC-IV), and up to 4 additional follow-up interviews. Weighted prevalence estimates, accounting for complex sampling, quantified the impact of varying ADHD criteria using baseline and the final follow-up interview data. RESULTS: At baseline 1,060 caregivers were interviewed; 656 had at least 1 follow-up interview. Teachers and parents reported 6 or more ADHD symptoms for 20.5% (95% CI = 18.1%-23.2%) and 29.8% (CI = 24.5%-35.6%) of children respectively, with criteria for impairment and onset by age 7 years (DSM-IV) reducing these proportions to 16.3% (CI = 14.7%-18.0%) and 17.5% (CI = 13.3%-22.8%); requiring at least 4 teacher-reported symptoms reduced the parent-reported prevalence to 8.9% (CI = 7.4%-10.6%). Revising age of onset to 12 years per DSM-5 increased the 8.9% estimate to 11.3% (CI = 9.5%-13.3%), with a similar increase seen at follow-up: 8.2% with age 7 onset (CI = 5.9%-11.2%) versus 13.0% (CI = 7.6%-21.4%) with onset by age 12. Reducing the number of symptoms required for those aged 17 and older increased the overall estimate to 13.1% (CI = 7.7%-21.5%). CONCLUSION: These findings quantify the impact on prevalence estimates of varying case definition criteria for ADHD. Further research of impairment ratings and data from multiple informants is required to better inform clinicians conducting diagnostic assessments. DSM-5 changes in age of onset and number of symptoms required for older adolescents appear to increase prevalence estimates, although the full impact is uncertain due to the age of our sample.

Psychosocial burden and glycemic control during the first 6 years of diabetes: results from the SEARCH for Diabetes in Youth study.

PURPOSE: To evaluate the psychosocial burden of adolescents with diabetes, determine the trajectory of psychosocial burden, and examine the interdependent relationships between psychosocial burden and glycemic control across the first 6 years of diabetes. METHODS: Data from SEARCH for Diabetes in Youth, an observational study of U.S. children diagnosed with diabetes before the age of 20, were collected during study visits conducted at baseline and then at 12, 24, and 60 months after baseline. Blood was drawn, clinical and demographic information was collected, and psychosocial burden was evaluated using standardized depression and generic and diabetes-specific health-related quality of life (QOL) surveys. RESULTS: Among the 1,307 adolescents (mean age, 14.1±2.5 years) with baseline data, 1,026 had type 1 diabetes and 281 had type 2 diabetes. For those with a 60-month follow-up visit, glycated hemoglobin (A1c) values rose 1.5% from baseline (type 1, 7.7%-9.3% and type 2, 7.3%-8.8%). Adolescents with type 2 diabetes reported more depression and poorer QOL than adolescents with type 1 diabetes. For each diabetes type, there were similar baseline risk factors for higher A1c values: longer diabetes duration, ethnic minority status, and declining diabetes QOL (p < .05). However, youth with type 2 diabetes had higher A1c values with increasing generic QOL, an unexpected finding. Younger adolescents with type 1 diabetes had higher A1c values at the end of the study. CONCLUSIONS: Significant deterioration in glycemic control marks the first 6 years of diabetes for adolescents. Psychosocial burden, particularly poor diabetes-specific QOL, is a contributor to suboptimal glycemic outcomes.

Serum C-reactive protein and immunoglobulin G antibodies to periodontal pathogens may be effect modifiers of periodontitis and hyperglycemia.

BACKGROUND: Serum C-reactive protein (CRP) is elevated in both periodontitis and type 2 diabetes mellitus through inflammation. Aggregatibacter actinomycetemcomitans and Porphyromonas gingivalis have been found in periodontal pockets in patients with diabetes. This study examines effect modification by examining the extent to which the associations between periodontitis and hyperglycemia were different by levels of serum CRP and periodontal pathogens. METHODS: Blood samples with plasma were evaluated for immunoglobulin G antibodies, CRP, and fasting glucose from 5,731 participants ≥ 20 years old receiving oral examinations and providing other health-related data from the National Health and Nutrition Examination Survey III. The study participants were classified into quartiles of probing depth (PD) and clinical attachment level (CAL). The first quartile was the reference. Logistic regression models with survey procedures were used to explore the roles of inflammation levels from serum CRP and periodontal pathogens on the relations with periodontitis, including PD, CAL, and hyperglycemia, and their joint associations with interaction terms. RESULTS: Stronger associations between PD and diabetes existed in people having elevated CRP and titers for P. gingivalis; odds ratios comparing extreme quartiles of PD were 1.31 and 3.40 in the groups with low and high CRP, respectively, and 1.28 and 2.96 in groups with low and high titers for P. gingivalis, respectively. The joint association patterns were similar for CAL and diabetes. CONCLUSIONS: The strengths of association between periodontitis and diabetes were stronger in people having elevated serum CRP and P. gingivalis titers. This may suggest that chronic inflammatory conditions could increase the impact of periodontitis on hyperglycemic status.

Use of quantile regression to investigate the longitudinal association between physical activity and body mass index.

OBJECTIVE: To examine associations among age, physical activity (PA), and birth cohort on body mass index (BMI) percentiles in men. METHODS: Longitudinal analyses using quantile regression were conducted among men with ≥ two examinations between 1970 and 2006 from the Aerobics Center Longitudinal Study (n = 17,759). Height and weight were measured; men reported their PA and were categorized as inactive, moderately, or highly active at each visit. Analyses allowed for longitudinal changes in PA. RESULTS: BMI was greater in older than younger men and in those born in 1960 than those born in 1940. Inactive men gained weight significantly more rapidly than active men. At the 10th percentile, increases in BMI among inactive, moderately active, and highly active men were 0.092, 0.078, and 0.069 kg/m(2) per year of age, respectively. The 10th percentile increased by 0.081 kg/m(2) per birth year and by 0.180 kg/m(2) at the 90th percentile, controlling for age. CONCLUSION: Although BMI increased with age, PA reduced the magnitude of the gradient among active compared to inactive men. Regular PA had an important, protective effect against weight gain. This study provides evidence of the utility of quantile regression to examine the specific causes of the obesity epidemic.

The prevalence of ADHD: its diagnosis and treatment in four school districts across two states.

OBJECTIVE: To describe the epidemiology of ADHD in communities using a DSM-IVTR case definition. METHOD: This community-based study used multiple informants to develop and apply a DSM -IVTR-based case definition of ADHD to screening and diagnostic interview data collected for children 5-13 years of age. Teachers screened 10,427 children (66.4%) in four school districts across two states (SC and OK). ADHD ratings by teachers and parent reports of diagnosis and medication treatment were used to stratify children into high and low risk for ADHD. Parents (n = 855) of high risk and gender frequency-matched low risk children completed structured diagnostic interviews. The case definition was applied to generate community prevalence estimates, weighted to reflect the complex sampling design. RESULTS: ADHD prevalence was 8.7% in SC and 10.6% in OK. The prevalence of ADHD medication use was 10.1% (SC) and 7.4% (OK). Of those medicated, 39.5% (SC) and 28.3% (OK) met the case definition. Comparison children taking medication had higher mean symptom counts than other comparison children. CONCLUSIONS: Our ADHD estimates are at the upper end of those from previous studies. The identification of a large proportion of comparison children taking ADHD medication suggests that our estimates may be conservative; these children were not included as cases in the case definition, although some might be effectively treated.

Social contacts and depression in middle and advanced adulthood: findings from a US national survey, 2005-2008.

AIM: Empirical evidence has linked social contacts with mental stability. The aim is to assess how social contacts are associated with depression among the general population. METHODS: We analysed the data of 5,681 adults aged 40 or older, who completed a depression screening as a part of the National Health and Nutrition Examination Survey, 2005-2008. Depression was ascertained using the Patient Health Questionnaire (PHQ), a nine-item screening instrument asking about the frequency of depression symptoms over the past two weeks. A PHQ score of 10 or higher was defined as depression. RESULTS: The prevalence of depression was 5.54% (SE = 0.64) and 8.49% (SE = 0.71), respectively, among men and women. The association between social contacts and depression were more salient among men than women. The odds ratios (ORs) of depression were 2.43 (95% CI = 1.44-4.10), 2.42 (95% CI = 1.37-4.28), 1.00 (reference) and 1.94 (95% CI = 0.80-4.71), respectively, among men who never attended church, attended occasionally, weekly and more than weekly. The corresponding ORs were 1.79 (95% CI = 1.10-2.91), 1.72 (95% CI = 1.06-2.80), 1.00(reference) and 0.98 (95% CI = 0.52-1.84) for women. Compared with the respondents who had 10 or more friends, the ORs of depression were 4.01 (95% CI = 1.89-8.50) and 1.86 (95% CI = 0.92-3.79), respectively, for men and women who had no close friends. CONCLUSIONS: The current study concluded that traditional social contacts remain strongly associated with depression in the digital era. Digital social networking is one of the biggest growing industries, creating a new platform to make social contacts. There is an urgent need to explore how to maximize the potential of digital social networking to strengthen social bonds while minimizing its negative effects.

Is epidemiology correcting its vision problem? A perspective on our perspective: 2012 presidential address for American College of Epidemiology.

Epidemiology, like all disciplines, exists within and is shaped by a culture that frames its ways of understanding. In the last 60 years epidemiology as a discipline and scientific approach has undergone major transition, but remains challenged by vestiges of the limiting frameworks of our origins which shape the way we approach questions, and even the questions we choose to investigate. A part of the current transformation is a reframing of our perspective and a broadening of our methods to encourage creativity and to encompass new types of evidence and new approaches to investigation and interpretation. Epidemiologists are developing innovative ways to approach increasingly complex problems and becoming more open to multi-disciplinary approaches to solving epidemiologic challenges.

Identification of device-associated infections utilizing administrative data.

BACKGROUND: Health care-associated infections are a cause of significant morbidity and mortality in US hospitals. Recent changes have broadened the scope of health care-associated infections surveillance data to use in public reporting and of administrative data for determining Medicare reimbursement adjustments for hospital-acquired conditions. METHODS: Infection surveillance results for catheter-associated urinary tract infections (CAUTI), central line-associated bloodstream infections (CLABSI), and ventilator-associated pneumonia were compared with infections identified by hospital administrative data. The sensitivity and specificity of administrative data were calculated, with surveillance data considered the gold standard. RESULTS: The sensitivity of administrative data diagnosis codes for CAUTI, CLABSI, and ventilator-associated pneumonia were 0%, 21%, and 25%, respectively. The incorporation of additional diagnosis codes in definitions increased the sensitivity of administrative data somewhat with little decrease in specificity. Positive predictive values for definitions corresponding to Centers for Medicare and Medicaid services-defined hospital-acquired conditions were 0% for CAUTI and 41% for CLABSI. CONCLUSIONS: Although infection surveillance methods and administrative data are widely used as tools to identify health care-associated infections, in our study administrative data failed to identify the same infections that were detected by surveillance. Hospitals, already incentivized by the use of performance measures to improve the quality of patient care, should also recognize the need for ongoing scrutiny of appropriate quality measures.

Body mass index and suicidal behaviors: a critical review of epidemiological evidence.

INTRODUCTION: Obesity has been associated with an elevated risk of depression and other mental health symptoms. An increasing number of robust prospective studies, however, counter-intuitively and consistently suggested that body mass index (BMI) was inversely associated with the risk of completed suicide in a dose-response fashion. The current contribution appraised the epidemiological evidence and examined the nature of the purported relationship. METHOD: We conducted a systematic review of English publications of original studies using the terms "obesity", "overweight", "body mass index", "BMI", "attempted suicide", "completed suicide", "suicide ideation", "suicidal behaviors" and "suicide". Data were extracted primarily through MEDLINE and PUBMED databases. RESULTS: Almost all cohort studies reported an inverse relationship between BMI and the risk of completed suicide irrespective of region of origin and the gender of study participants. Overall, among men, a high BMI was associated with a low risk of attempted or completed suicide. There was a paradox among women, namely, a high BMI was associated with an elevated risk of attempted suicide but a low risk of completed suicide. LIMITATIONS: As a narrative review, the current report was interpretive and qualitative in nature. CONCLUSION: Consideration of observational data, methodological issues stemmed from the rarity of deaths by suicide, homogeneity of study populations, heterogeneity of suicide methods, and the corresponding neurobiological changes made interpretation difficult. Intercultural cohort observations across countries may help to weigh the contributions from biological and socio-cultural factors. The purported association not only represents a scientific challenge, it's also an opportunity potentially leading to important insights into prevention of suicide death.

Physical activity and self-concept: the SEARCH for diabetes in youth case control study.

In this study, the relationship between physical activity (PA) and 3 self-concept constructs (physical abilities, physical appearance, and general self-concept) was examined. Youth with type 1 diabetes (n = 304), type 2 diabetes (n = 49), and nondiabetic controls (n = 127) aged 10-20 years wore pedometers over 7 days. Youth completed the Self-Description Questionnaire and correlation coefficients were calculated. Mean steps/day were 7413 ± 3415, 4959 ± 3474 and 6870 ± 3521 for type 1, type 2 and control youth, respectively. Significant correlations were found between steps/day and perception of physical abilities (r = .29; r = .31; r = .31) for type 1, type 2, and control youth, respectively. The other correlations were not significant. Among youth with type 2 diabetes, steps/day were significantly correlated with physical appearance (r = .46). The positive correlation between PA and physical abilities suggests a reciprocal relationship between behavior and perception.

Association between barracks type and acute respiratory infection in a gender integrated Army basic combat training population.

BACKGROUND: Acute respiratory infections (ARIs) are the leading cause of acute morbidity and lost work time in the United States. Few studies have looked at building design and transmission of ARIs. OBJECTIVES: This study explores the association of ventilation design, room occupancy numbers, and training week with ARI rates in Army Basic Combat Training barracks. METHODS: This observational study captured the overall incidence of ARI in a cohort of 16,258 individuals attending basic combat training at Fort Jackson, South Carolina. RESULTS: ARI risk was higher among trainees living in the 60-person room barracks compared with those living in 8-person rooms, which increased rapidly for the first few weeks of training and then declined to baseline. CONCLUSIONS: Findings support direct contact as primary ARI transmission mode in this study population based on observed lower ARI risk in smaller room barracks and similar risk in large room barracks despite heating, ventilation, and air conditioning system variability.

Association between periodontitis and impaired fasting glucose and diabetes.

OBJECTIVE: Many studies have reported that periodontal disease is associated with diabetes, but its relation with impaired fasting glucose (IFG) has been understudied. This study investigated the relationship between chronic periodontitis, IFG, and diabetes in the U.S. population. RESEARCH DESIGN AND METHODS: Participants in the National Health and Nutrition Examination Survey III, aged ≥ 20 years, who received periodontal examinations and provided blood samples (n = 12,254) were grouped into quintiles of mean clinical attachment loss (CAL) and pocket depth, with the lowest category being the reference. Plasma fasting glucose was categorized into three groups (normal, <100 mg/dL; IFG, ≥ 100 but <126 mg/dL; and diabetic, ≥ 126 mg/dL). Sociodemographic factors and other potential risk factors were obtained by interview or examination. SAS 9.1 was used for statistical analysis accounting for the complex weighted sampling. RESULTS: Participants in the top quintile category of CAL had higher prevalence odds of IFG (odds ratio [OR] 1.55 [95% CI 1.16-2.07]) and diabetes (4.77 [2.69-8.46]) after adjustment for related confounders, compared with those in the bottom quintile. The highest quintile of pocket depth was positively associated with IFG (1.39 [1.00-1.92]) and diabetes (1.63 [1.10-2.42]) compared with the lowest quintile. ORs for CAL increased from the lowest to the highest quintile (P value test for trend <0.01) for all outcomes. The ORs for pocket depth also tended to rise across quintiles. CONCLUSIONS: Chronic periodontitis measured by CAL and pocket depth was positively associated in a linear relation with IFG and diabetes in U.S. adults.