Long-term Negative Health Outcomes Research Articles

154 A demographic look at Adverse Childhood Experiences in Behavioural Referrals to Consultant Pediatrics

Consultant pediatricians are commonly asked to see children regarding behavior and the potential of a diagnosis of ADHD. If left untreated and children unsupported over the long-term, the overall prognosis is poor, especially in terms of academic achievement and social functioning. Social inequities can create significant barriers to accessing timely and appropriate assessment and care (e.g., difficulty making appointments due to inconsistent contact information; decreased access to transportation to and from appointments). Adverse childhood experiences (ACEs) (exposure to mental illness, addiction and violence in the home to name a few) can influence child behaviour and function, complicating accurate diagnosis and effective treatment. There is evidence that children who are exposed to addiction, mental illness and violence will suffer long-term negative health outcomes and have increased rates of ADHD diagnosis. This study aims to describe the family history and social conditions of children receiving behaviour-related referrals in a consultant pediatric clinic of five pediatricians in a catchment area of approximately 300,000 people, one urban city and including several rural communities. This area reports one of the highest child poverty rates in Canada. Family history of mental illness, learning, addiction, and anger issues, parental education level and employment status, and child demographics will be reported. By better understanding the needs of our referral base, we can make interventions to decrease barriers to care and match care plans to patient needs. Data was collected via phone intake interviews of children being referred to pediatricians for behaviour-related referrals. Interview questions pertained to the child’s medical, academic and family history and other factors. Descriptive statistics were conducted to look at the frequency of potential risk factors that may impact children referred for behavioural assessments in terms of access to care, accurate diagnosis and treatment. These were referenced against the ACE score screening questionnaire. The sample was composed of 483 families, where the referred child was most often male (70.8%). Results indicate that a family history of mental illness (including, but not limited to: anxiety, depression, manic depression, schizophrenia, and bipolar disorder) was common among these families at 69.8%, and that 37.7% of families had at least one parent who reported a learning issue. Also common was a family history of addiction (43.5%) and anger issues (36%). Only 12.5% of mothers and 17.1% of fathers reported not having a high school education. This study demonstrates that many of the children being referred for behavioral referrals are at high-risk for ACEs such as exposure to mental illness, physical or emotional abuse, and addiction in the home. It is important to know these risk factors to inform the approach and considerations of diagnosis, treatment interventions and how to involve the family in a community centred, needs-based approach.

Youth Tackle Football: Perception and Reality.

Recently there has been significant media attention on sports-related concussions, particularly in American football. The focus has been on the risk for long-term negative health outcomes from concussions and subconcussive head impacts that may be sustained while participating in contact sports, especially for young athletes whose brains are still developing.1 In this issue of Pediatrics , Chrisman et al2 present results of their study, “Parents’ Perspectives Regarding Age Restrictions for Tackling in Youth Football,” in which they surveyed a nationally representative sample of ∼1000 parents regarding their perception of concussion risk in youth tackle football and whether they would support age restrictions for tackling. Most parents (61%) would support such an age restriction, and those who are female, college-educated, or reported greater perceived risk for concussion had a higher odds of supporting an age restriction. The most notable finding of this study, however, is that most parents perceive concussion rates in tackle football to be substantially higher than they actually are. The best available and most current injury surveillance data for tackle football players reveal that ∼4 to 7 out of 100 high school players will suffer a concussion during a single season.3,4 For youth players, the incidence tends to be lower at 3 to 5 in 100.3,5,6 However, 83% of parents in this study perceive concussion incidence to be >10 out of 100 high school tackle football players, and 25% estimated it was >50 out of 100. This misperception about concussion risk in youth tackle football is likely due to the fact that most parents form their views on the basis of headlines and stories of former players in the media, rather than from published scientific data. The reality is that the concussion rate in youth tackle football is … Address correspondence to Cynthia LaBella, MD, Division of Orthopedic Surgery and Sports Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, 225 E Chicago Ave, Box 69, Chicago, IL 60611. E-mail: clabella{at}luriechildrens.org

Development of an online secondary prevention programme for stroke survivors: Prevent 2nd Stroke

BackgroundStroke events often result in long-term negative health outcomes. People who experience a first stroke event are 30%–40% more likely to experience a second stroke event within 5 years. An...

The absence of maternal pineal melatonin rhythm during pregnancy and lactation impairs offspring physical growth, neurodevelopment, and behavior

Maternal melatonin provides photoperiodic information to the fetus and thus influences the regulation and timing of the offspring's internal rhythms and preparation for extra-uterine development. There is clinical evidence that melatonin deprivation of both mother and fetus during pregnancy, and of the neonate during lactation, results in negative long-term health outcomes. As a consequence, we hypothesized that the absence of maternal pineal melatonin might determine abnormal brain programming in the offspring, which would lead to long-lasting implications for behavior and brain function. To test our hypothesis, we investigated in rats the effects of maternal melatonin deprivation during gestation and lactation (MMD) to the offspring and the effects of its therapeutic replacement. The parameters evaluated were: (1) somatic, physical growth and neurobehavioral development of pups of both sexes; (2) hippocampal-dependent spatial learning and memory of the male offspring; (3) adult hippocampal neurogenesis of the male offspring. Our findings show that MMD significantly delayed male offspring's onset of fur development, pinna detachment, eyes opening, eruption of superior incisor teeth, testis descent and the time of maturation of palmar grasp, righting reflex, free-fall righting and walking. Conversely, female offspring neurodevelopment was not affected. Later on, male offspring show that MMD was able to disrupt both spatial reference and working memory in the Morris Water Maze paradigm and these deficits correlate with changes in the number of proliferative cells in the hippocampus. Importantly, all the observed impairments were reversed by maternal melatonin replacement therapy. In summary, we demonstrate that MMD delays the appearance of physical features, neurodevelopment and cognition in the male offspring, and points to putative public health implications for night shift working mothers.

Lead Exposure in the Special Operations Shooter How to Prevent Cognitive Decline and Permanent Disability.

Lead toxicity is an important environmental disease and its effects on the human body can be devastating. Unique exposures to Special Operations Forces personnel may include use of firing ranges, use of automotive fuels, production of ammunition, and bodily retention of bullets. Toxicity may degrade physical and psychological fitness, and cause long-term negative health outcomes. Specific effects on fine motor movements, reaction times, and global function could negatively affect shooting skills and decision-making. Biologic monitoring and chelation treatment are poor solutions for protecting this population. Through primary prevention, Special Operations Forces personnel can be protected, in any environment, from the devastating effects of lead exposure. This article offers tools to physicians, environmental service officers, and Special Operations Medics for primary prevention of lead poisoning in the conventional and the austere or forward deployed environments.

Neurological effects of iron supplementation in infancy: finding the balance between health and harm in iron-replete infants

Iron mediates many biochemical processes in neural networks that proliferate during brain development. Insufficient iron causes irreversible neurodevelopmental deficits, and most high-income countries recommend that infants older than 4-6 months receive additional iron via food fortification or supplementation to prevent iron-deficiency anaemia. Now that the prevalence of iron-deficiency anaemia in children has decreased to less than 10% in most developed countries, concerns that the recommended intakes far exceed those required to prevent iron-deficiency anaemia have been raised, and emerging evidence suggests that iron overexposure could be linked to adverse outcomes later in life. In this Viewpoint, we discuss the importance of iron for neurodevelopment, investigate the biochemical markers used to assess iron stores, summarise the disparity in public health policies among high-income countries, and discuss the potential association between iron overexposure and adverse neurological outcomes later in life. We present a case for new studies to establish the optimal amount of iron that both prevents deficiency and reduces the potential risk of long-term negative health outcomes.

Structural, Functional, and Metabolic Brain Markers Differentiate Collision versus Contact and Non-Contact Athletes.

There is growing concern about how participation in contact sports affects the brain. Retrospective evidence suggests that contact sports are associated with long-term negative health outcomes. However, much of the research to date has focused on former athletes with significant health problems. Less is known about the health of current athletes in contact and collision sports who have not reported significant medical issues. In this cross-sectional study, advanced magnetic resonance imaging (MRI) was used to evaluate multiple aspects of brain physiology in three groups of athletes participating in non-contact sports (N = 20), contact sports (N = 22), and collision sports (N = 23). Diffusion tensor imaging was used to assess white matter microstructure based on measures of fractional anisotropy (FA) and mean diffusivity (MD); resting-state functional MRI was used to evaluate global functional connectivity; single-voxel spectroscopy was used to compare ratios of neural metabolites, including N-acetyl aspartate (NAA), creatine (Cr), choline, and myo-inositol. Multivariate analysis revealed structural, functional, and metabolic measures that reliably differentiated between sport groups. The collision group had significantly elevated FA and reduced MD in white matter, compared to both contact and non-contact groups. In contrast, the collision group showed significant reductions in functional connectivity and the NAA/Cr metabolite ratio, relative to only the non-contact group, while the contact group overlapped with both non-contact and collision groups. For brain regions associated with contact sport participation, athletes with a history of concussion also showed greater alterations in FA and functional connectivity, indicating a potential cumulative effect of both contact exposure and concussion history on brain physiology. These findings indicate persistent differences in brain physiology for athletes participating in contact and collision sports, which should be considered in future studies of concussion and subconcussive impacts.

The first week after concussion: Blood flow, brain function and white matter microstructure.

Concussion is a major health concern, associated with short-term deficits in physical function, emotion and cognition, along with negative long-term health outcomes. However, we remain in the early stages of characterizing MRI markers of concussion, particularly during the first week post-injury when symptoms are most severe. In this study, 52 varsity athletes were scanned using Magnetic Resonance Imaging (MRI), including 26 athletes with acute concussion (scanned 1–7 days post-injury) and 26 matched control athletes. A comprehensive set of functional and structural MRI measures were analyzed, including cerebral blood flow (CBF) and global functional connectivity (Gconn) of grey matter, along with fractional anisotropy (FA) and mean diffusivity (MD) of white matter. An analysis comparing acutely concussed athletes and controls showed limited evidence for reliable mean effects of acute concussion, with only MD showing spatially extensive differences between groups. We subsequently demonstrated that the number of days post-injury explained a significant proportion of inter-subject variability in MRI markers of acutely concussed athletes. Athletes scanned at early acute injury (1–3 days) had elevated CBF and Gconn and reduced FA, but those scanned at late acute injury (5–7 days) had the opposite response. In contrast, MD showed a more complex, spatially-dependent relationship with days post-injury. These novel findings highlight the variability of MRI markers during the acute phase of concussion and the critical importance of considering the acute injury time interval, which has significant implications for studies relating acute MRI data to concussion outcomes.

Short and Sweet: The Persuasive Effects of Message Framing and Temporal Context in Antismoking Warning Labels

Current warning labels on cigarette packages are generally focused on long-term losses that can be incurred if one continues smoking. This study compares the effects of these labels against warning labels that stress short-term losses of smoking as well as labels that stress short- and long-term benefits that can be obtained when one quits smoking. A 2 (message frame: gain vs. loss) × 2 (temporal context: short vs. long term) between-subjects experiment was conducted among 132 smokers, with attitude toward quitting smoking and intention to quit smoking, as well as information-seeking behavior and message recall, as the dependent variables. Findings were in line with theory regarding message framing and temporal discounting, showing enhanced effects of gain over loss frames and short-term over long-term consequences on warning labels for attitudes and intentions. In addition, an interaction between message frame and temporal context was found. Especially, gain-framed messages showed stronger effects on intentions to quit smoking than loss-framed messages when warning labels concerned short-term outcomes. Findings suggest that current warning labels, with an emphasis on long-term negative health outcomes, should be reconsidered.

High Risk Obese Pregnancy: Nutritional Program on Maternal Health for Controlling Obesity

Background: The incidence of maternal obesity (BMI>30kg/m²) at the start of pregnancy has been rising over the last world. Obesity during pregnancy represents an important preventable risk factor for adverse pregnancy outcomes and is associated with negative long-term health outcomes for both mothers and off springs. Aim: The aim of this study was to evaluate the effect of a nutritional program on maternal health for controlling obesity. Design: A quasi-experimental design was used. Setting: The study was conducted in two MCH centers, MCH of north Giza and MCH of El-Moneab. Sampling: Purposive samples of 100 obese pregnant women were included; attended MCH centers for their first visit. Those women were divided randomly into 50 women for study group; those chosen randomly and received the nutritional program; and 50 women for the control group; who did not receive the program, with, inclusion criteria; pregnant, obese (BMI ≥ 30 kg/m²) and in the first trimester of pregnancy. Exclusion criteria included severe complications of pregnancy and sever co–morbidities not enabling the women to follow the program. Tools for data collection three tools were used. 1) An interviewing questionnaire which includes five parts; socio-demographic characteristics, obstetric history and medical history, obese pregnant women's knowledge, obese pregnant women's lifestyle practices, and daily intake of various food groups and types. 2) Physical assessment to record initial and follow –up weight assessment of the pregnant women. 3) Pregnancy outcomes records including maternal and neonatal outcomes. Results: The study showed that, obese pregnant women's knowledge of dietary and healthy practices life style issues is low, as well as their practices towards diet, exercises, and rest. Their dietary practice during pregnancy is inadequate. Conclusion: The study answered the research hypothesis stating that nutritional program will improve the health of maternal obesity and their newborn without complications, the nutrition program was effective in improving their dietary and healthy lifestyle knowledge and practices. This is associated with significant improvement in lowering body weight throughout follow-up visits during pregnancy, in addition, the nutrition program led to better maternal outcomes as lower rates difficult labor with fetal distress. Fetal outcomes are also improved in terms of better Apgar scores and less need for NICU admissions. Recommendations: The developed nutritional program should be made available at similar MCH centers, and the maternal nurses should use it in educating attendant obese pregnant women.

Evidence for an immune signature of prenatal alcohol exposure in female rats

Evidence for immune/neuroimmune disturbances as a possible root cause of a range of disorders, including neurodevelopmental disorders, is growing. Although prenatal alcohol exposure (PAE) impacts immune function, few studies to date have examined immune function in relation to long-term negative health outcomes following PAE, and most have focused on males. To fill this gap, we utilized a rat model to examine the effects of PAE on immune/neuroimmune function during early-life [postnatal day 1 (P1), P8, and P22] in PAE and control females. Due to the extensive interplay between the immune and endocrine systems, we also measured levels of corticosterone and corticosterone binding globulin (CBG). While corticosterone levels were not different among groups, CBG levels were lower in PAE offspring from P1 to P8, suggesting a lower corticosterone reservoir that may underlie susceptibility to inflammation. Spleen weights were increased in PAE rats on P22, a marker of altered immune function. Moreover, we detected a unique cytokine profile in PAE compared to control offspring on P8 – higher levels in the PFC and hippocampus, and lower levels in the hypothalamus and spleen. The finding of a specific immune signature in PAE offspring during a sensitive developmental period has important implications for understanding the basis of long-term immune alterations and health outcomes in children with Fetal Alcohol Spectrum Disorder (FASD). Our findings also highlight the future possibility that immune-based intervention strategies could be considered as an adjunctive novel therapeutic approach for individuals with FASD.

Examining weight concern and delay discounting in adolescent females

ObjectivePediatric obesity is a growing public health concern that contributes to high rates of negative long-term physical and mental health outcomes. Research focused on identifying risk for pediatric obesity has linked delay discounting, or an inclination for immediate rewards, as well as weight concern to individuals with greater Body Mass Index (BMI). The current study seeks to fill a void in the literature by examining how these two variables interact to promote higher BMI in female adolescents. MethodAdolescent (n=60) females between the ages of 13–19years (mage=17.45, SD=1.74) of age completed the Eating Disorder Examination Questionnaire (EDE-Q) and the Delay Discounting Questionnaire. ResultsA mediation model examined whether delay discounting accounted for the relationship between weight concern and BMI. Results indicate that in the current study weight concern was negatively related to delay discounting and delay discounting was negatively related to BMI. The overall model revealed that a partial mediation occurred [b=1.28, t(60)=4.92, p<0.01]. DiscussionThese results suggest that while impulsivity is an important factor to consider, other constructs may also be influential in how weight concerns contribute to greater BMI. Nevertheless, the results indicate that prevention and interventions should identify females with high levels of both weight concern and impulsivity as an increased risk for experiencing pediatric obesity and long-term negative health outcomes.

Prevalence of Non-Volitional Sex Types and Associated Factors: A National Sample of Young People.

BackgroundNon-volitional sex (NVS) in young people continues to be a major public health problem with long-term negative health outcomes. For the first time, the prevalence of different types of NVS and associated factors are compared between young people with same-sex sexual activities and those who have not.MethodsWe obtained data from 10,401 young women and men (aged 12 to 25 years) who participated in a population study on sexual health, the Netherlands. We calculated and compared the prevalence of six types of NVS between women who had sex with men (yWSM) or women (yWSW), and men who had sex with women (yMSW) or men (yMSM). In sexually experienced participants (n = 5986) logistic regression analyses were applied to assess associations with NVS by assault or penetration. Analyses were weighted to represent the Dutch population.ResultsThe prevalence of NVS ranged from 1% to 61%, depending on type. Prevalence was higher for young women (any: 40.6%) than men (any: 20.4%), and highest for yMSM and yWSW. Prevalence of NVS by assault or penetration was related to a range of socio-demographic, behavioral and social factors, which were largely similar regardless of sex or same-sex-experiences. The NVS perpetrators were in over 70% of cases known to the victim; 1 in 4 cases of NVS by penetration were accompanied by violence.ConclusionA substantial proportion of young people in the Netherlands have experienced NVS. Medical professionals, educators and caregivers should integrate services to continue to address NVS by targeting young people’s multifaceted risk profiles and evidenced based interventions for doing so are needed.

ADDRESSING THE AFTERMATH OF ADVERSE CHILDHOOD EXPERIENCES IN YOUR PRACTICE: A Call to Implement the ACE Score

In 2012, there were 3.4 million referrals alleging childhood trauma to Child Protective Services in the United States.1 While this number is startling, it does not include the millions of undocumented cases, nor does it portray the long-term consequences of abuse. Providers of pediatric and adolescent care are on the front lines of identification and prevention of childhood trauma, and without proper tools, health care providers may be ill equipped to address the long-term negative health outcomes.2,3 However, the Adverse Childhood Experiences (ACEs) score is an available and perhaps underutilized tool that can better equip providers to recognize and understand the impact of childhood trauma on physical, mental, and behavioral health.

Optimizing Growth and Neurocognitive Development While Minimalizing Metabolic Risk in Preterm Infants

Early aggressive nutrition is associated with improved neurodevelopmental outcomes, and is increasingly becoming the standard of care for preterm infants. Additionally, more rapid growth while in the NICU has been linked to lower risk of abnormal motor and cognitive development. However, as increasing reports of the metabolic consequences of rapid growth in other populations (i.e. appropriately grown and growth-restricted term infants) become available, we must consider the possibility that these negative long-term health outcomes may also affect preterm infants. This becomes especially concerning as studies revealing the prevalence of disproportionate growth and increased adiposity upon discharge from the NICU are published. This article will review the available literature on the impact of nutrition, illness and growth during several different epochs (i.e. first weeks of life, later inpatient weeks and post-discharge) on both neurodevelopmental and metabolic outcomes in preterm infants.

'It has not ruined my life; it has made my life better': a qualitative investigation of the experiences and future aspirations of young mothers from the North West of England.

Teenage pregnancy has been portrayed as problematic and leading to negative long-term health outcomes. However, this assumption has been questioned. This qualitative study explores the experiences and future aspirations of teenage mothers in North West England. Ten in-depth qualitative interviews were conducted with teenage mothers recruited from children's centres located in deprived areas. The young mothers felt motherhood was a positive experience, which provided them with a valued social role. Within the communities they lived, they felt well supported. For many of the young mothers, dislike of school had occurred pre-pregnancy and becoming a mother had led the young women to reassess the value of education and employment. However, in common with many older mothers, while their child is young they choose to prioritize motherhood. The young women relied heavily upon family and the support of trusted professionals. Motherhood can be a positive experience that makes sense in the lives of young women from disadvantaged backgrounds. To be effective, policy must recognize the valued social role motherhood provides for these young women. The negative long-term outcomes observed may largely be a result of their disadvantaged position within society and this should be the focus of interventions.

Injury Outcomes in African American and African Caribbean Women: The Role of Intimate Partner Violence

Intimate partner violence has been linked to increased and repeated injuries, as well as negative long-term physical and mental health outcomes. This study examines the prevalence and correlates of injury in women of African descent who reported recent intimate partner violence and control subjects who were never abused. African American and African Caribbean women aged 18 to 55 years were recruited from clinics in Baltimore, MD, and the US Virgin Islands. Self-reported demographics, partner violence history, and injury outcomes were collected. Associations between violence and injury outcomes were examined with logistic regression. All injury outcomes were significantly more frequently reported in women who also reported recent partner violence than in women who were never abused. Multiple injuries were nearly 3 times more likely to be reported in women who had experienced recent abuse (adjusted odds ratio 2.75; 95% confidence interval 1.98-3.81). Reported injury outcomes were similar between the sites except that women in Baltimore were 66% more likely than their US Virgin Islands counterparts to report ED use in the past year (P = .001). In combined-site multivariable models, partner violence was associated with past-year ED use, hospitalization, and multiple injuries. Injuries related to intimate partner violence may be part of the explanation for the negative long-term health outcomes. In this study, partner violence was associated with past-year ED use, hospitalization, and multiple injuries. Emergency nurses need to assess for intimate partner violence when women report with an injury to ensure that the violence is addressed in order to prevent repeated injuries and negative long-term health outcomes.

Public health approach to child maltreatment

Child maltreatment (neglect, exposure to intimate partner violence, emotional, physical and sexual abuse) is an important Canadian and global health challenge. The Public Health Agency of Canada (PHAC) recognizes the need to use the best evidence to inform policy and practice to remediate short- and long-term negative health outcomes associated with child maltreatment (1). Work within PHAC pertinent to child maltreatment depends on collaboration with provinces, territories, other federal departments, academia and civic communities. The work described in the present commentary spans four areas pertaining to child maltreatment: national surveillance; exploration of associations with negative health outcomes; prevention efforts; and delineation of best practice implications for family physicians, paediatricians and other health professionals. We hope the present commentary will encourage further cross-sectoral partnerships.

P4.065 High Rates of Non-Consensual Sex Ans Association with Sexual Health Among a Large National Sample of Young People in the Netherlands

BackgroundNon-consensual sexual activity between young people continues to be a major public health problem with long-term negative health outcomes. To our knowledge no study has yet evaluated violation and rape...

Increased Risk for School Violence‐Related Behaviors Among Adolescents With Insufficient Sleep

School violence is associated with significant acute and long-term negative health outcomes. Previous investigations have largely neglected the role of pertinent health behaviors in school violence, including sleep. Insufficient sleep is associated with adverse physical, behavioral, and psychosocial consequences among adolescents, many of which are concurrently implicated in youth violence. This study examined the relationship between insufficient sleep and school violence behaviors in a nationally representative sample of high school students. We used data from the 2009 National Youth Risk Behavior Survey (YRBS). Logistic regression analyses evaluated the association between insufficient sleep and school violence behaviors, controlling for demographic factors. In addition to examining main effects, interaction terms were entered into the models to examine whether potential associations varied by sex or race/ethnicity. Students with insufficient sleep had higher odds of engaging in the majority of school violence-related behaviors examined compared to students with sufficient sleep. Males with insufficient sleep were at increased risk of weapon carrying at school, a finding not observed for females with insufficient sleep. White students with insufficient sleep had higher odds of missing school because of safety concerns, a pattern that did not emerge among Black and Hispanic/Latino students. Results highlight the potential value of incorporating sleep education interventions into school-based violence prevention programs and underline the need for further examination of the relationship between sleep and school violence among adolescents.