Faculty Bibliography

OBJECTIVE: To better understand the epidemiology and behavioral correlates of bed-wetting in a nationally representative sample of children. METHODS: Bivariate and multivariate logistic regression analyses of cross-sectional data regarding 10 960 children aged 5 through 17 years from the 1981 Child Health Supplement to the National Health Interview Survey. Behavior problems were determined by extreme scores on a 32-item Behavior Problem Index (BPI, > 90th percentile). RESULTS: Bed-wetting was reported in 33% of 5-, 18% of 8-, 7% of 11-, and 0.7% of 17-years-olds. At all ages, infrequent bed-wetting (fewer than six episodes per year) accounted for half of all reported bed-wetting. Lower age, male gender, and extreme scores on the BPI all were independently associated with both infrequent and frequent bed-wetting. Extreme scores on the BPI were more common among children with bed-wetting than those who did not wet the bed, and the risk for this was similar among children with infrequent and frequent bed-wetting (adjusted odds ratios, 1.8 and 1.7, respectively). Parents' perceived need for help with emotional and behavioral problems, however, was increased only among children with frequent bed-wetting. CONCLUSIONS: Bed-wetting in children aged 5 years and older, irrespective of its frequency, is associated with increased rates of behavior problems. Thus, although infrequent bed-wetting may not warrant medical intervention, this condition should prompt health care providers to explore behavioral issues in greater depth

OBJECTIVE: In 1991, the Centers for Disease Control and Prevention (CDC) decreased the blood lead level of concern to 10 micrograms/dL (0.48 mumol/L) and recommended universal screening. Because these guidelines continue to provoke controversy, we conducted a study to: 1) estimate the proportion of pediatricians who are members of the American Academy of Pediatrics (AAP) who report screening for elevated blood lead levels; 2) describe their clinical practices regarding screening for elevated blood lead levels; 3) compare attitudes of universal screeners, selective screeners, and nonscreeners; and 4) identify characteristics of pediatricians who universally screen. DESIGN: Confidential, cross-sectional survey of a nationally representative random sample of 1610 pediatricians conducted through the AAP Periodic Survey. SUBJECTS: The study included 1035 responders (64% response rate). Analysis was limited to the 734 pediatricians who provide well-child care (ie, primary-care pediatricians). RESULTS: Fifty-three percent of pediatricians reported screening all their patients aged 9 to 36 months, 39% reported screening some, and 8% reported screening none. Among those who screen, 96% use a blood lead assay. The primary risk factors for which selective screeners screen are: history of pica (94%); living in an older home with recent renovations (92%); living in an older home with peeling paint (93%); and having a sibling who had an elevated blood lead level (88%). Among primary-care pediatricians, 73% agree that blood lead levels > or = 10 micrograms/dL should be considered elevated, and 16% disagree. However, 89% of primary-care pediatricians believe that epidemiologic studies should be performed to determine which communities have high proportions of children with elevated blood lead levels, and 34% of primary-care pediatricians believe that the costs of screening exceed the benefits. CONCLUSIONS: Three years after the Centers for Disease Control and Prevention issued new guidelines for the management of elevated blood lead levels, a slight majority of primary-care pediatricians in the United States who are members of the AAP report that they universally screen their appropriately aged patients, while most of the remaining pediatricians report screening high-risk patients. Many pediatricians may want additional guidance about circumstances under which selective screening should be considered

OBJECTIVES: To analyze data from a nationally representative sample of high school students to investigate the relationship between substance use and violent behavior among adolescents and to examine this relationship in both male and female adolescents. DESIGN: Cross-sectional analyses of the 1991 Centers for Disease Control and Prevention's Youth Risk Behavior Survey. SETTING: Public and private schools in the 50 states. PARTICIPANTS: The participants were 12,272 high school students. MAIN OUTCOME MEASURE: To determine the prevalence of weapon carrying and physical fighting among male and female adolescents. RESULTS: A significant increase in the number of male and female adolescents carrying weapons and physically fighting was associated with all forms of substance use. Reports of carrying a weapon increased with recent alcohol consumption (34% vs 17%, P < .001) and use of marijuana (48% vs 22%, P < .001), cocaine (71% vs 25%, P < .001), and anabolic steroids (62% vs 25%, P < .001). The prevalence of physical fighting was also significantly higher among adolescents who used illicit substances than among adolescents who denied drug use. The risk of violent behavior increased significantly, and was of equal magnitude, for adolescent females and males who were illicit substance users. CONCLUSIONS: Alcohol and illicit substance use are highly associated with an increased risk of violent behavior. These data also demonstrate that the risk of violence by adolescent females who are substance users is substantial

OBJECTIVE. Dust control is recommended as one of the cornerstones of controlling childhood lead exposure; however, the effectiveness of dust control has not been demonstrated for children who have low to mild elevations in blood lead (ie, less than 25 micrograms/dL). The objective of this study was to determine whether dust control, as performed by families, had an effect on children's blood lead levels and dust lead levels in children's homes. DESIGN. Randomized, controlled trial. SETTING. Community-based trial in Rochester, NY. PARTICIPANTS. One hundred four children, 12 to 31 months of age at baseline. INTERVENTION. Families and children were randomized to one of two groups. Families of children in the intervention group received cleaning supplies, information about cleaning areas that are often contaminated with lead, and a cleaning demonstration. Families in the control group received only a brochure about lead poisoning prevention. OUTCOME MEASURES. Baseline measurements of lead in blood, house dust, soil, water, and paint were taken from both groups. Seven months after enrollment, a second blood lead assay was obtained, and lead levels in household dust were measured. The main outcome measures were change in blood lead levels and dust lead levels by treatment group. RESULTS. The median blood lead level of children enrolled in the study was 6.7 micrograms/dL (range, 1.7 to 30.6 micrograms/dL). There was no significant difference in the change of children's blood lead levels or dust lead levels by treatment group. The median change in blood lead levels among children in the intervention group was -0.05 micrograms/dL compared with -0.60 micrograms/dL among those in the control group. There also was no significant difference in the change of dust lead by group assignment, although there was a trend toward a significant difference in the percentage of change in dust lead levels on noncarpeted floors, which was greater among houses in the intervention group. CONCLUSIONS. These data suggest that an intervention that consists only of providing cleaning supplies and a brief description of dust control is not effective at reducing blood lead levels among urban children with low to mild elevations in blood lead levels at a 7-month follow-up

OBJECTIVES: To (1) compare preventive health visits by poor and nonpoor adolescents, (2) describe adolescent users of community health centers (CHCs), (3) investigate adolescent preventive visits to CHCs, and (4) determine factors independently associated with timely preventive visits. DESIGN: Analysis of the nationally representative sample of 6635 adolescents aged 11 to 17 years in the Child Health Supplement to the 1988 National Health Interview Survey. RESULTS: Overall, 4% of US adolescents used CHCs for routine health care, and the percentage was higher for poor compared with nonpoor adolescents (11% vs 3%, P < .01). Although CHC users were more likely to be poor (41% vs 10%, P < .001), uninsured (23% vs 10%, P < .001), and to have behavior (16% vs 9%, P = .02) and school problems (56% vs 43%, P < .001), they were as likely to have had timely preventive visits (83% vs 81%, P = .61) as adolescents who used private practices. Using logistic regression, timely adolescent preventive visits were independently associated with having a source for routine care (odds ratio, 4.1; 95% confidence interval, 3.3-5.2), a chronic health condition (odds ratio, 1.2; 95% confidence interval, 1.0-1.5), and the use of seat belts all or most of the time (odds ratio, 1.4; 95% confidence interval, 1.2-1.6), but no independent association was observed between poverty status and timely preventive visits. CONCLUSIONS: Community health centers are an important source of preventive care for impoverished adolescents. Although those who use CHCs have greater psychosocial problems, they seek preventive care as regularly as those using private practices. Thus, periodic comprehensive visits may be an effective strategy for CHCs to provide preventive services to adolescents

OBJECTIVE: To determine whether students older than most other students at their grade level ('old for grade') are more likely to report engaging in alcohol, tobacco, and drug-related behaviors. DESIGN: Cross-sectional analyses of the Centers for Disease Control and Prevention Youth Risk Behavior Survey. SETTING: Monroe County, New York. PARTICIPANTS: A total of 1396 high school students from selected classrooms; 68 classrooms randomly selected within schools with the number of students per school proportionally selected from the 28 schools in the county. MAIN OUTCOME MEASURE: Rates of drug-related behaviors by age-for-grade status. RESULTS: Thirty-six percent of adolescents surveyed were old for grade. Adjusting for multiple potential confounders, old-for-grade high school students were more likely to report being regular smokers, chewing tobacco, drinking alcoholic beverages, driving in a car with someone who had been drinking, using alcohol or other drugs before last sexual intercourse, using cocaine in the past month, ever using crack, and using injected or other illicit drugs. CONCLUSIONS: Old-for-grade status is a potentially important marker for drug-related behaviors in adolescents. The antecedents of adolescent risk-taking behavior may begin before the teen years, and prevention of school failure or interventions targeted toward old-for-grade children could affect their propensity to experiment with or use drugs during adolescence

OBJECTIVES. To determine the prevalence of elevated blood lead levels among children living in a rural area and to determine the effectiveness of the Centers for Disease Control and Prevention (CDC) Lead Risk Assessment Questionnaire and additional questionnaire items in correctly identifying rural children having elevated blood lead levels. RESEARCH DESIGN. Comparison of results of a questionnaire that is intended to identify children as being at low or high risk for lead poisoning with children's blood lead levels. SETTING. The three practice sites of the only pediatric group in a rural county of upstate New York. PATIENTS. A consecutive sample of 705 children ages 6 to 72 months who were seen for health supervision visits between June and September 1993. RESULTS. Sixty-nine percent of the children were considered to be at high risk for lead poisoning by the CDC questionnaire. Overall, 8.4% of the children in the study had blood lead levels of 10 micrograms/dL (0.48 mumol/L) or higher, and 2.1% had blood lead levels of 15 micrograms/dL (0.72 mumol/L) or higher. No significant difference was noted between the percentages of high- and low-risk children who had elevated blood lead levels. To devise a more effective lead risk assessment tool for children in this setting, the two items from the CDC questionnaire and the two additional items that had the greatest predictive utility were combined to form a short alternative questionnaire. The alternative questionnaire thus consisted of items concerning whether the child has a sibling or playmate with lead poisoning, whether the child lives near an industry that potentially may release lead, whether the child lives in rented or owner-occupied housing, and whether the child has a parent who is a migrant farm worker. Children categorized as high risk with the alternative questionnaire were much more likely to have elevated blood lead levels than those who were categorized as low risk. The alternative questionnaire was very effective in correctly identifying children with elevated blood lead levels. Eighty-eight percent of children having blood lead levels of 10 micrograms/dL or higher and 100% of children having blood lead levels of 15 micrograms/dL or higher were classified as high risk by the questionnaire. Children classified as low risk were very unlikely to have elevated blood lead levels; 98% of low-risk children had blood lead levels of less than 10 micrograms/dL, and 100% had blood lead levels of less than 15 micrograms/dL. CONCLUSIONS. These results suggest that the CDC lead risk assessment questionnaire is of limited benefit in identifying rural children with blood lead levels 10 micrograms/dL or higher or 15 micrograms/dL or higher. An alternative questionnaire, however, seems to have marked clinical utility for identifying rural children with elevated blood lead levels