Studying the epidemiology of attention-deficit hyperactivity disorder: screening method and pilot results.

OBJECTIVE: As part of a larger epidemiologic study of risk factors for attention-deficit hyperactivity disorder (ADHD), this pilot study combined parent and teacher information to estimate ADHD prevalence among elementary school children in a North Carolina county. The methods developed for this study and the pitfalls we encountered illustrate the challenges involved in conducting population-based studies of ADHD. METHODS: We employed 2-stage screening using DSM-IV criteria. Teachers completed behaviour-rating scales for all children. We then administered a structured telephone interview to parents of potential cases. We screened 362 of 424 (85%) children in grades 1 to 5 in 4 schools. RESULTS: According to parent reports, 43 children (12%) had previously been diagnosed with ADHD by a health professional. Thirty-four children (9%) were taking ADHD medication. Forty-six children (12.7%) met study case criteria for ADHD, based on combined teacher and parent reports. Of the 46 cases, 18 (39%) had not been previously identified. Eight previously diagnosed children, however, did not meet case criteria. After we adjusted for nonresponse, the estimated prevalence was 16% (95%CI, 12% to 20%). CONCLUSIONS: These data suggest that the DSM-IV prevalence of ADHD has been substantially underestimated, although the true prevalence in this population may be less than the 16% estimated here. Population-based studies of ADHD are feasible and may provide important information about practice and treatment patterns in community settings, as well as a broader understanding of the etiology and life course of this common disorder.

The new senior volunteer: a bold initiative to expand the supply of independent living services to older adults.

This article presents findings of the evaluation of the Experience Corps for Independent Living (ECIL) initiative. The ECIL initiative was a two-year demonstration program designed to test innovative ways to use the experience, time, and resources of volunteers over 55 to significantly expand the size and scope of volunteer efforts on behalf of independent living services for frail elders and their caregivers in specific communities. Six demonstration sites were selected to participate in this initiative. The intensive volunteers, the critical component of the program, were more highly skilled than typical volunteers from existing senior volunteer programs. ECIL volunteers collaborated with agency partners to develop new programs, supervise direct service activities, and enhance the performance of the agencies being served. The ECIL initiative was particularly successful in meeting its goals of expanding the supply of independent living services to frail elders and their families in the communities served.

Early attention problems and children's reading achievement: a longitudinal investigation. The Conduct Problems Prevention Research Group.

OBJECTIVES: To determine whether attention problems predict the development of reading difficulties and examine whether screening for attention problems could be of practical value in identifying children at risk for reading underachievement. METHOD: Three hundred eighty-seven children were monitored from kindergarten through fifth grade. Standardized assessments of attention problems and reading achievement were conducted at multiple time points. RESULTS: Attention problems predicted reading achievement even after controlling for prior reading achievement, IQ, and other behavioral difficulties. Inattentive first graders with normal reading scores after kindergarten were at risk for poor reading outcomes. CONCLUSIONS: Attention problems play an important role in the development of reading difficulties for some children, and screening for attention problems may help identify children at risk for reading difficulties.

Rediscovering the patient's role in receiving health promotion services.

OBJECTIVE: This study examined differences in the odds of receiving health promotion/disease prevention services recommended by the US Preventive Services Task Force among three subgroups of patients. It tested the hypotheses that those most uninvolved in their own health (as exemplified by the lack of knowledge of blood pressure and cholesterol levels despite having been tested) would receive the least other health promotion services, and those being treated for both high blood pressure and hyperlipidemia would receive the most additional services. METHODS: A mail survey was sent to a random sample of 68,422 veterans who had obtained primary care from any of the 153 Veterans Health Administration facilities in 1996. The adjusted response rate was 68%. Subgroup analyses were performed on three subgroups who reported having been tested for both hypertension and hyperlipidemia in the previous year (n = 5,113). RESULTS: Both hypotheses were supported. Uninvolved patients were the least likely subgroup to report obtaining other recommended health promotion services, and the dually treated were most likely. The uninvolved subgroup was significantly more likely to report being female, physically inactive, current smokers, and heavy alcohol drinkers, and to report having a problem with alcohol, and significantly less likely to report being > or =50 years of age and overweight, to almost always wear seat belts, and to obtain at least 90% of their health care at the Veterans Health Administration. CONCLUSIONS: Clinicians need to encourage all patients to receive health promotion services, but in particular they should be aware that those who do not know their last hypertension and cholesterol levels despite having been tested are particularly in need of attention.

Predicting boys' social acceptance and aggression: the role of mother-child interactions and boys' beliefs about peers.

Seven- to 9-year-old boys (N = 177) and their mothers participated in this study in which the associations between boys' experiences with their mothers, their beliefs about familiar and unfamiliar peers, and their peer adjustment were examined across a 2-year period. Boys' negative behavior with mothers was associated with their having more negative beliefs about familiar and unfamiliar peers and with their being more aggressive and less well-liked. Beliefs about familiar peers predicted changes in boys' social acceptance, whereas negative beliefs about unfamiliar peers predicted changes in aggression. In addition, boys' beliefs about peers changed in response to their social experience. The implications of these findings for children's social development are discussed.

Patient factors related to the odds of receiving prevention services in Veterans Health Administration medical centers.

OBJECTIVE: To examine the association between patient characteristics and the odds of receiving 13 health promotion/disease prevention services recommended by the US Preventive Services Task Force (USPSTF) for average-risk individuals. METHODS: A mail survey was sent to a random sample of 68,422 veterans who obtained primary care from any of the 153 Veterans Health Administration facilities in 1996; 44,304 responded (adjusted response rate was 68%). Multivariate logistic regression models were used. RESULTS: Demographic factors, health risk behaviors, and self-reported health were associated with the odds of receiving prevention services. Current smokers, heavy alcohol drinkers, and females were less likely to receive many health promotion services, whereas regular exercisers, overweight individuals, males, those reporting poorer health, individuals reporting high or controlled blood pressure, and those reporting high or controlled cholesterol levels were more likely to receive USPSTF-recommended prevention services. CONCLUSION: Substantial proportions of veterans were likely to obtain prevention services recommended by the USPSTF for average-risk individuals. Nevertheless, veterans who reported being current smokers, heavy drinkers, or female were less likely to obtain these services. These subgroups may benefit from additional initiatives.

The receipt of prevention services by veterans using VA versus non-VA facilities.

OBJECTIVES: This paper compares the health promotion/disease prevention services received by veterans who reported receiving 90%+ of their care inside Veterans Health Administration (VA) facilities with counterparts who reported receiving 90%+ of their care outside VA facilities. Results are compared with the U.S. Healthy People 2000 goals. METHODS: Random samples were drawn of 300 men and 150 women visiting primary care clinics in six VA facilities. A 66% adjusted response rate was achieved after two mailings (n = 1,703). For this analysis, those veterans who reported receiving 90%+ of their care inside VA facilities (n = 909) were compared with veterans who reported receiving 90%+ of their care outside VA facilities (n = 185). RESULTS: Of the 13 health promotion¿disease prevention services, 6 were significantly influenced by source of care. Five of the significant differences reflected statistically higher prevalence rates for those receiving 90%+ of their care inside the VA (mammograms and counseling for alcohol, nutrition, exercise, and seatbelt use). One reflected a higher prevalence rate for those receiving 90%+ of their care outside the VA system (tetanus boosters). CONCLUSIONS: Veterans receiving 90%+ of their care in VA facilities obtained more preventive services than counterparts using non-VA providers. Assessment and counseling services need to be targeted to more veterans to comply more fully with U.S. Preventive Services Task Force recommendations and Healthy People 2000 objectives.

Prevention services received by veterans visiting VHA facilities.

OBJECTIVES: This paper presents rates with which veterans report receiving 13 recommended health promotion and disease prevention services. Results were compared with the U.S. Healthy People 2000 goals. METHODS: Random samples of 300 men and 150 women visiting primary care clinics in six Veterans Health Affairs facilities were drawn. A 66% adjusted response rate was achieved after two mailings (n = 1,703). Weighted averages for each prevention service were calculated. RESULTS: For preventive services targeted to all age groups, both male and female veterans currently exceed the Year 2000 goal in hypertension detection and tobacco counseling. Female veterans also exceed the Year 2000 goal in "almost always" using seat belts. For prevention services targeted to specific age-gender subgroups, both male and female veterans currently exceed the Year 2000 goals for four of the six primary and secondary prevention services. CONCLUSIONS: Both male and female veterans exceed Year 2000 goals for the receipt of nearly half of the preventive services. Nevertheless, additional screening and counseling services should be made available to veterans of all age categories.

Interorganizational factors affecting the delivery of primary care to older Americans.

OBJECTIVE: To discuss different types and forms of interorganizational linkages involved in the provision of primary care to older Americans, along with their distinguishing characteristics. RESEARCH STRATEGY: To take advantage of these linkage characteristics. The strategy requires a partnership with health services organizations and providers actually involved in the provision of services along with a planned sequence of activities involving hypotheses and methods development, intervention trials, and finally, demonstration and implementation. CONCLUSION: Because older Americans are frequent users of health services, their need for continuity and access provides an opportunity to examine changes to the delivery system and to monitor the system's capability for meeting their healthcare needs.

Predicting mortality from community surveys of older adults: the importance of self-rated functional ability.

Using data from the 1990 baseline of the National Survey of Self-Care and Aging (NSSCA), and nearly three years of follow-up mortality data, we examined the association between self-rated functional ability, a global measure of perceived ability of function independently, and mortality among a national sample of older adults. The study included 3,485 subjects selected from the Medicare Beneficiary Files according to a stratified random sampling design, with approximately equal numbers of adults by gender in each of three age categories, 65-74, 75-84, and 85 and over. Self-rated functional ability was found to have an independent contribution to the subsequent risk of death among older adults. Using multivariate models that accounted for self-rated health, age, gender, medical conditions, functional status, and assistance from others, poor self-ratings on this single item nearly doubled the risk of death during the follow-up period. These findings suggest the importance, for both researchers and clinicians, of measuring the potential prognostic importance of self-ratings of health and self-ratings of functional ability among older adults.

Metropolitan versus nonmetropolitan differences in functional status and self-care practice: findings from a national sample of community-dwelling older adults.

The objective of this study was to use a recent national probability survey of the noninstitutionalized older adult population to compare the functional status and self-care practices of older adults residing in metropolitan and nonmetropolitan communities and to identify differences associated with residential location. The survey used in this study was the National Survey of Self-care and Aging (NSSCA). A cross-sectional design was employed using weighted bivariate and multivariate logistic regression analyses to examine the relationship between metropolitan and nonmetropolitan residential location and self-reported ability to perform basic, mobility, and instrumental activities of daily living (ADLs), as well as to assess the degree to which the levels and types of functional limitations affect metropolitan versus nonmetropolitan older adults' performance of self-care activities. The bivariate logistic analyses pointed to modest, often insignificant metropolitan versus nonmetropolitan differences in the ability to perform functional tasks. However, larger positive effects of nonmetropolitan residence were generally observed once other factors likely to account for some of these differences were taken into account. Older adults from nonmetropolitan areas were more likely to report being able to perform functional activities but also were more likely to report performing self-care activities both in the presence and absence of disability. This study, therefore, concluded that nonmetropolitan older adults may discount the significance of declining functional status, thus normalizing the trajectory of aging in a different way than do their metropolitan counterparts. If this process occurs, it may affect how nonmetropolitan persons use primary health care and/or long-term care services, challenging the economists' concept of demand, the clinicians' concept of need, and the policy analysts' concept of equity. Additional work is required to assess whether such a normalization process actually occurs and, if so, to explore its distribution, causes, correlates, and consequences.

The perceived availability, quality, and cost of long-term care services in America.

This study gathered primary data on the patterns and predictors of home-based, community-based, and institutional long-term care services for older adults residing in the United States. A stratified random sample of policymakers and agency representatives (n = 153; response rate 67.1%) completed a comprehensive mail survey to provide detailed information on the perceived availability, quality, and costs of long-term care services in their community settings. Descriptive analyses revealed that there are significant differences in perceived access, use, quality, and costs of care by service type and agency affiliation. The results present an interesting dilemma for policymakers as many of the services found to be most widely available and of the highest quality were considered too costly. Implications for public policy and suggestions for further research are highlighted.

Older adults as a community resource: results from the National Survey of Self-Care and Aging.

Using data collected from the first wave of a longitudinal data set collected in the late fall and winter of 1990-1991, the National Survey of Self-Care and Aging (NSSCA), we examined the extent and type of assistance older people provided to others. Age, gender, and perceived health status were the most consistent predictors of the four types of assistance: personal care, child care, volunteer work, and listening/offering advice and support. Help with instrumental activities of daily living either alone or in combination with other activities of daily living was the most common type of personal care provided.

Attitudes toward and use of subsequent nursing home services among a national sample of older adults.

This study was designed to examine the relationship between attitudes toward nursing homes and subsequent nursing home utilization, and assess the impact of prior nursing home utilization on subsequent attitudes among a national sample of older Americans. Multivariate estimation procedures for complex survey designs were performed on the National Long-Term Care Survey data set. Although prior nursing home use did not directly affect subsequent attitudes toward nursing homes, having favorable attitudes about nursing homes increased the odds of using subsequent nursing home services by 1.5 and increased the total nursing home length of stay by 17%. Implications of this research for public policy and long-term care treatment planning are discussed.

Patterns and predictors of noninstitutional health care utilization by older adults in rural and urban America.

Noninstitutional long-term care is not often included in policy studies or recommendations in the United States even though there have been recent efforts to include this type of care in health reform proposals. This study was designed to provide insight into the patterns and predictors of noninstitutional medical, home-, and community-based services utilization by older adults in rural and urban America. The National Long Term Care Survey (NLTCS) was used to explore the relationship between residential setting and subsequent noninstitutional services utilization. Weighted logistic regression procedures for complex survey designs were used to guide the analysis. Living in the Northeast and residence in moderately densely populated areas (towns, small cities, and suburbs) were significant positive predictors of subsequent medical, home-, and community-based services utilization. Because some differentials were found in access to and use of services by regional and geographic setting, policy-makers need to develop alternative strategies to eliminate inequities in the distribution of noninstitutional long-term care services in more remote areas.

The effect of channeling on home care utilization and satisfaction with care.

This study examined the relationship between participation in two home and community-based long-term care case management interventions (collectively known as the Channeling demonstration), use of formal in-home care, and satisfaction with care. Maximum likelihood estimation techniques were used to analyze the National Long-Term Care Demonstration data set. It was hypothesized that participation in the two Channeling interventions would indirectly (rather than directly) enhance satisfaction by operating through the increased use of formal in-home care. However, both Channeling models were found to have favorable direct and indirect effects on patient satisfaction.

The effect of Channeling on in-home utilization and subsequent nursing home care: a simultaneous equation perspective.

OBJECTIVE: This study explored the relationship between participation in a home/community-based long-term care case management intervention (known as the Channeling demonstration), use of formal in-home care, and subsequent nursing home utilization. STUDY DESIGN: Structural analysis of the randomized Channeling intervention was conducted to decompose the total effects of Channeling on nursing home use into direct and indirect effects. DATA COLLECTION METHOD: Secondary data analysis of the National Long-Term Care Data Set. PRINCIPAL FINDINGS: The use of formal in-home care, which was increased by the Channeling intervention, was positively associated with nursing home utilization at 12 months. However, the negative direct effect of Channeling on nursing home use was of sufficient magnitude to offset this positive indirect effect, so that a small but significant negative total effect of Channeling on subsequent nursing home utilization was found. CONCLUSIONS: This study shows why Channeling did not have a large total impact on nursing home utilization. The analysis did not provide evidence of direct substitution of in-home care for nursing home care because the direct reductions in nursing home utilization due to other aspects of Channeling (including, but not limited to case management) were substantially offset by the indirect increases in nursing home utilization associated with additional home care use.

The relationship between program participation, use of formal in-home care, and satisfaction with care in an elderly population.

This study used data from the Channeling Demonstration to investigate the relationship between program participation, utilization of formal in-home services, and client satisfaction in an elderly population. Age, being male, severe ADL dependency, living alone with no informal support, provision of basic case management services, and utilization of formal in-home services were significant predictors of satisfaction.