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Background There is evidence in school-age children that physical activity enhances cognitive performance, but experimental evidence of this relationship in early childhood is lacking. This study's aims were to test if active versus sedentary time differentially influences preschoolers' short-term executive functioning. Methods Three-to five-year-old children participated at their childcare center. Using a pre-post cross-over design, each child wore an accelerometer and was randomly assigned to a 15-minute sedentary or active condition. Following the condition, children performed in-person tasks measuring inhibitory control (Day/Night), behavioral inhibitory control (Bear/Dragon), and working memory (Head-Toes-Knees-Shoulders). A subset also performed iPad based tasks (either NIH Toolbox or Early Years Toolbox). One to two weeks later, each child was re-tested after the other condition. We conducted a within-subjects comparison of outcomes and examined effect modification by gender and age. Results Seventy-three children (mean age = 4.2 years, 45% girls) participated. Accelerometry confirmed 70% MVPA time for the active condition and 90% sedentary time for the sedentary condition. Inhibitory control, assessed using the Bear/Dragon task, was statistically significantly higher after the sedentary compared to the active condition (89% vs 84%, p = 0.003). When stratified by age, this difference was only seen in 3 year olds. No other significant differences by condition were noted for the cognitive assessments. Conclusions Short-term executive functioning was generally similar in preschoolers after sedentary versus physically active periods. Given the other known benefits of physical activity, active play promotion should be supported in early childhood education settings.

OBJECTIVE: To evaluate the odds of a behavioral health diagnosis among youth with a difference of sex development (DSD) or congenital adrenal hyperplasia (CAH) compared with matched controls in the PEDSnet database. STUDY DESIGN: All youth with a diagnosis of DSD (n=1,216) or CAH (n=1,647) and at least one outpatient encounter were extracted from the PEDSnet database and propensity-score matched on 8 variables (1:4) to controls (n=4,864 and 6,588, respectively) using multivariable logistic regression. The likelihood of having behavioral health diagnoses was examined using generalized estimating equations. RESULTS: Youth with a DSD had higher odds of a behavioral health diagnosis (OR: 1.7 [95% CI: 1.4, 2.1], p

Organophosphate flame retardants (OPFRs), including Tris (1,3-dichloro-isopropyl) phosphate (TDCPP), triphenyl phosphate (TPP), and isopropylated triphenyl phosphate (ITP), are increasingly used in consumer products because of the recent phase out of polybrominated diphenyl ether (PBDE) flame retardants. OPFRs have been widely detected in adults and have been linked to reproductive and endocrine changes in adult males. Carcinogenicity and damage to immunologic, neurologic and developmental systems have been observed in human cell lines. Young children are especially vulnerable to OPFR exposure, but little is known about exposure levels or exposure risk factors in this population. We examined parent-reported demographic and dietary survey data in relation to OPFR urinary metabolite concentrations in 15- to 18-month old toddlers (n = 41). OPFR metabolites were detected in 100% of subjects. The metabolite of TPP, diphenyl phosphate (DPP) was detected most commonly (100%), with TDCPP metabolite, bis(1,3-dichloro-2-propyl) phosphate (BDCPP), detected in 85-95% of samples, and ITP metabolite, monoisopropylphenyl phenyl phosphate (ip-DPP), detected in 81% of samples (n = 21). Toddlers of mothers earning$10,000 annually had geometric mean DPP concentrations 66% higher (p = 0.05) than toddlers of mothers earning$10,000/year (7.8 ng/mL, 95% CI 5.03, 12.11 and 4.69 ng/mL, 95% CI 3.65-6.04, respectively). While no dietary factors were significantly associated with OPFR metabolite concentrations, results suggested meat and fish consumption may be associated with higher DPP and BDCPP levels while increased dairy and fresh food consumption may be associated with lower DPP, BDCPP, and ip-DPP levels. Research with larger sample sizes and more detailed dietary data is required to confirm these preliminary findings.

The authors review trends in adoption of new digital technologies (eg, mobile and interactive media) by families with young children (ages 0-8 years), continued use of television and video games, and the evidence for learning from digital versus hands-on play. The authors also discuss continued concerns about health and developmental/behavioral risks of excessive media use for child cognitive, language, literacy, and social-emotional development. This evidence is then applied to clinical care in terms of the screening questions providers can use, tools available to providers and parents, and changes in anticipatory guidance.

Current trends suggest that adolescents and young adults typically maintain a social media "portfolio" of several sites including Facebook and Twitter, but little is known regarding how an individual chooses to display risk behaviors across these different sites. The purpose of this study was to investigate college students' displayed alcohol references on both Facebook and Twitter.Among a larger sample of college students from two universities, we identified participants who maintained both Facebook and Twitter profiles. Data collection included evaluation of 5 months of participants' Facebook and Twitter posts for alcohol references, number of social connections (i.e., friends or followers), and number of posts. Phone interviews assessed participants' frequency of Facebook and Twitter use and self-reported alcohol use. Analyses included Fisher's exact test, Wilcoxon matched pair sign test, Friedman rank-sum tests, and logistic regression.Of 112 eligible participants, 94 completed the study. Participants were more likely to display alcohol references on Facebook compared with those on Twitter (76% vs. 34%, p = .02). Participants reported more social connections on Facebook versus Twitter (average 801.2 friends vs. 189.4 followers, p.001) and were more likely to report daily use of Facebook versus Twitter (94.6% vs. 50%, p.001). Current alcohol use was predictive of both Facebook and Twitter displayed alcohol references, but mediators differed in each model.College students were more likely to display alcohol references on Facebook compared with those on Twitter. Understanding these patterns and predictors may inform prevention and intervention efforts directed at particular social media sites.

OBJECTIVE: Problematic Internet use (PIU) is an emerging health concern that lacks screening measures validated for use with adolescents and young adults. This study aimed to validate the Problematic and Risky Internet Use Screening Scale (PRIUSS) for use with older adolescents and to increase its clinical utility by determining scoring guidelines and assessing the relationship between PIU and other mental health conditions. METHODS: This cross-sectional survey study took place at a large, public Midwestern university among 330 older adolescents aged 18 to 25 years. Confirmatory factor analysis and Spearman's correlations were used to assess the PRIUSS' structural and construct validity, respectively. A risk-based scoring cutoff was estimated using a Bayesian latent class modeling approach to computing a receiver operating characteristic curve. RESULTS: The confirmatory factor analysis indices for the 3-factor model indicated an acceptable fit (goodness-of-fit index 0.89, root mean square error of approximation 0.07). A cutoff of 25 (sensitivity 0.80, 95% confidence interval [CI] 0.47-0.99; specificity 0.79, 95% CI 0.73-0.84) is proposed for identifying those at risk for PIU. Participants at risk for PIU were at significantly greater odds of also reporting symptoms of attention-deficit/hyperactivity disorder (odds ratio [OR] 2.36 95% CI 1.21-4.62, P =.009), depression (OR 3.25, 95% CI 1.65-6.42, P =.008), and social anxiety (OR 3.77, 95% CI 2.06-6.89, P CONCLUSIONS: The PRIUSS demonstrated validity as a PIU screening instrument for adolescents and young adults. Screening for PIU may also help to identify those at high reciprocal risk for other mental health conditions. Language: en

The goal of this study was to assess biomarkers of exposure to glyphosate and assess potential associations with renal function in children. Glyphosate is used ubiquitously in agriculture worldwide. While previous studies have indicated that glyphosate may have nephrotoxic effects, few have examined potential effects on kidney function in children. We leveraged three cohorts across different phases of child development and measured urinary levels of glyphosate. We evaluated associations of glyphosate with three biomarkers of kidney injury: albuminuria (ACR), neutrophil gelatinase-associated lipocalin (NGAL), and kidney injury marker 1 (KIM-1). Multivariable regression analyses examined associations of glyphosate with kidney injury biomarkers controlling for covariates. We identified glyphosate in 11.1% of the total participants. The herbicide was particularly detected more frequently in the neonate population (30%). Multivariable regression models failed to identify significant associations of log-transformed glyphosate with any of the kidney injury biomarkers, controlling for covariates age, sex, and maternal education. While we confirm detectability of glyphosate in children’s urine at various ages and stages of life, there is no evidence in this study for renal injury in children exposed to low levels of glyphosate. Further studies of larger sample size are indicated to better understand putative deleterious effects of the herbicide after different levels of exposure.

Objective We evaluated the effect of Primary Care Positive Parenting Program (Triple P) training on pediatric residents and the families they serve to test 2 hypotheses: first, training would significantly improve resident skill in identifying and addressing discrete parenting and child behavior problems; and second, parents would report an improvement in their sense of self-efficacy, use of positive discipline strategies, and their child's behavior. Methods Study participants included pediatric residents from 3 community clinics of a pediatric residency program, as well as English-speaking parents of children aged 18 months to 12 years without a diagnosed behavior disorder cared for by study residents. Residents were randomized to receive Primary Care Triple P training either at the beginning or end of the study period. The measured resident outcomes were self-assessed confidence and skills in giving parenting advice. The measured family outcomes were parent sense of self-efficacy, child externalizing behavior, and discipline strategies. Results Primary Care Triple P training had a positive, significant, and persistent impact on residents' parenting consultation skills (mean increase on Parent Consultation Skills Checklist 48.11, 95% confidence interval [CI] 40.07, 57.36). Parents visiting intervention-trained residents demonstrated improved disciplinary practices compared to parents visiting control residents (mean change in Child Discipline Survey 0.322, 95% CI 0.02, 0.71), with stronger differential effects for parents with lower baseline skills (mean Child Discipline Survey change 0.822, 95% CI 0.48, 1.83). No differences were found for child behavior or parenting sense of confidence. Conclusions Training residents in Primary Care Triple P can have a positive impact on consultation skills and parent disciplinary practices. This finding adds strength to the call for increased residency training in behavioral pediatrics.

Problematic Internet use (PIU) is a growing health concern among adolescents and young adults. The purpose of this mixed-methods study was to develop and refine a theoretically-grounded and psychometrically-validated assessment instrument for PIU specifically tailored to adolescents and young adults. An item pool was developed using concept mapping and a review of the literature, and administered to 714 students from two universities between 18 and 25 years of age. Exploratory and confirmatory factor analyses were used in a development subsample (n=500) to construct the scale. A cross-validation sample (n=214) was used to confirm the scale's reliability. The Problematic and Risky Internet Use Screening Scale (PRIUSS) is an 18-item scale with three subscales: Social Impairment, Emotional Impairment, and Risky/Impulsive Internet Use. Based on its strong theoretical foundation and promising psychometric performance, the PRIUSS may be a valuable tool for screening and prevention efforts in this population.

Problematic internet use (PIU) is of growing significance to adolescent health, but lacks a strong conceptual framework to guide ongoing work. We used Concept Mapping methodology to construct a theoretical framework describing PIU. This validated approach includes five steps: preparation, generation (brainstorming), structuring (sort and rank), representation (statistical analysis) and interpretation (focus groups). Analysis included hierarchical cluster analysis over the overall square similarity matrix to determine a cluster map. A total of 193 college students participated in one or more phases of the study. Students were from 13 universities across 10 states, had an average age of 19.4years (SD=1.8), were 67% female and 77% Caucasian. A total of 20 health professionals participated. The seven clusters depicted on the PIU Concept Map include: psychosocial risk factors, physical impairment, emotional impairment, social/functional impairment, risky internet use, impulsive internet use and internet use dependence. The stress value for the fit of the multidimensional solution to the structuring data was 0.28, indicating adequate fit. The concept map may be used towards development of a future comprehensive model of PIU as well as scale development efforts.

Objective To test the hypothesis that salivary cortisol levels respond differently when infants play with blocks compared with watching a digital video disk (DVD). Study design We conducted a randomized experiment in which 8- to 14-month-old infants either watched a DVD or played with blocks for 30 minutes. Serial salivary cortisol measurements were obtained and analyzed, and parental and infant responses and activities were recorded. Results were converted to standardized effect sizes (ESs) for clarity of presentation. Results A total of 49 infants (49% female, mean age 10.6 months) participated in the study. In linear regression analyses, there was a trend toward higher cortisol levels in the block group at the 35-minute collection point (ES = 0.47, P = .08) and significantly higher levels at 45 minutes (ES = 0.56, P = .04); these salivary cortisol levels reflect serum levels approximately 10 and 20 minutes into the activity period, respectively. The results were substantially the same in sensitivity analyses excluding the outliers. Conclusion Viewing by infants of a DVD leads to different neuroendocrine responses than block play in a laboratory setting. The implications of these differences are currently unknown, but may suggest different means of cognitive engagement between interactive play and DVD viewing.

Internet use is challenging for individuals to quantify and describe. Previous internet use studies have relied on self-report measures, which may be subject to recall bias. This studied aimed to assess college student internet use using a real-time methodology, experience sampling method (ESM). Undergraduate students participated in a 7-day ESM campaign using text message surveys sent at 6 random times each day. Survey questions evaluated current internet use time and activities. Analyses included hierarchical clustering analysis, multilevel and probability modeling. Among the 189 participants, mean age was 18.9 (SD=0.9), 58.8% were female and most were Caucasian (90.5%). The modeled average total amount of daily internet time was 56min, 95% CI [51, 62]. The correlation between self-reported internet use time and ESM data was 0.31 (p

Objective To (a) reduce the total amount of television viewing to which preschool children are exposed; and (b) shift the balance of exposure away from commercial television toward educational content. Method Randomized controlled clinical trial. Data collected in 2007; analyzed 2008–2011. Participants were 67 English-speaking families in Seattle with a preschool-aged child exposed to more than 90 min of television viewing on average per day. A case manager for each group used in-person conferences, monthly newsletters, and e-mail contact to motivate behavior change around child television viewing (intervention) or child safety (control). Results Compared to those in the control group, families randomized to the intervention group experienced a significant reduction by 37 minutes/day in total viewing time (95% CI: 5.6–68.7), including a marginally significant reduction by 29 minutes/day in viewing of commercial content (95% CI: − 4.6–63). Compared to those in the control group, those in the intervention group experienced a positive change in outcome expectations. There were no significant changes in self-efficacy or volitional control. An advance in stage-of-change was marginally significant. Conclusions Targeting commercial TV viewing may prove a successful behavioral intervention to achieve public health goals in this population.

Objective To assess preschoolers' cumulative daily screen time, measure the contributions of the home and the child care setting to this total, and characterize children that are most at risk for excessive screen time. Study design We used data from the Early Childhood Longitudinal Study-Birth Cohort, to calculate daily screen time based on reports by preschooler's parents and care providers. Results The sample size of 8950 represented approximately 4 million children. By preschool age, >80% of children were in some child care. On average, children in this study were exposed to 4.1 hours of screen time daily, including 3.6 hours at home and 0.4 hours in child care. Children in centers had the lowest screen time (3.2 hours) compared with children in parental care only (4.4 hours), home-based care (5.5 hours), and Head Start (4.2 hours). Even when adjusted for relevant covariates, these differences remained significant ( P Conclusions Preschoolers' cumulative screen time exceeds recommendations and most previous estimates. Pediatric clinicians are uniquely positioned to encourage families to discuss screen time with their children's caregivers and to advocate for high quality child care. Efforts to decrease screen time in homes and home-based child care settings are needed.

Objective Characterize and compare care in children with hemangiomas, who do or do not undergo airway procedures. Methods National retrospective cohort study of patients aged 0–18 with hemangiomas, from 33 freestanding United States pediatric hospital discharge records, 2001–2005. The main outcome measures were therapy, readmission and mortality. Results Of 2890 patients diagnosed with hemangiomas, 337 (12%) underwent airway procedures. Most airway procedures were for patients between ages 1 and 11 months. Patients with hemangiomas and airway procedures had more steroid use (80%), increased readmission (30%), and increased mortality (2%) compared to hemangioma patients without airway procedures. Procedures (i.e. laser, open surgery, tracheotomy) and age over 4 months in airway procedure patients were associated with decreased readmission. Increased readmissions were associated with systemic steroid administration. Conclusion Hemangioma patients who undergo airway procedures experience increased medical and surgical therapy compared to those who do not. Readmission is increased in patients with hemangiomas and airway procedures, but surgical intervention and age greater than 4 months decreased readmission.

To test the hypothesis that children enrolled in Medicaid managed care health plans that provide asthma-specific communication to providers would be more likely to have adequate asthma medication filling.We conducted a historical cohort study of 4498 children (2-17 years old) with moderate-severe asthma in Washington State and Tennessee Medicaid managed care programs from 2000 to 2002. Interviews with health plans were conducted to identify communication strategies health plans used to improve asthma care by providers in the plan. The main outcome measure was guideline-recommended filling of asthma preventer medications.Children in plans that provided specific feedback to providers about asthma quality and notified providers when children had an asthma-related event had the highest mean days plus or minus SE of filling in the 365-day follow-up period (164.6 +/- 13 days) compared with children in plans with neither (135.3 +/- 10.8 days; P.05). In children with the greatest asthma severity, enrollment in a plan with both features was associated with 27.1 additional days of filling (95% CI, 0.7-53.4 days) during the follow-up period.Health plan communication to providers was associated with increased preventer filling in children with moderate-severe asthma in 2 state Medicaid programs.

Objective To analyze the content of food and drink commercials aired during after-school hours on Spanish-language television. Study design We performed a content analysis of food and drink advertisements, evaluating product type, food category, and message content. All advertisements aired during after-school hours (3 to 9 p.m .) on 2 U.S. Spanish-language television stations were sampled over a 1-week period in the spring of 2006. Results We reviewed 60 hours of programming. Of the non-program content, 47% was for product advertisements, 15% (n = 153) of which was for food/drink. A mean of 2.5 food/drink commercials aired per hour (range 0-8), and the median duration was 30 seconds; 31% of food/drink commercials advertised fast food, and 27% advertised drinks, most (54%) of which were sugared. About one third (31%) of the food/drink commercials targeted children, 12% featured Latino celebrities, and 19% made reference to Latino culture. Only 16% of the food/drink commercials had health-related content. Conclusions Children viewing Spanish-language television in the United States after school are exposed to food and drink commercials, most of which advertise unhealthy foods, including fast food and sugared drinks. Food and beverage advertising on Spanish-language television may play an important role in the high risk of overweight among Latino children.

Objective To determine differences in case fatality rates between children with and without Down syndrome. Study design We used the Pediatric Health Information System (PHIS) database, which includes demographic and diagnostic data from freestanding children's hospitals. Using Poisson regression, we determined the risk of mortality from sepsis for children with Down syndrome, after controlling for potential confounding factors. Results A total of 35,645 patients met our inclusion criteria, of which 3936 (11%) died during hospitalization. Altogether, 620 of the included patients also had a diagnosis of Down syndrome; 106 (17%) of these died during hospitalization. Children with Down syndrome had significantly elevated risk of mortality (mortality rate ratio = 1.30; 95% confidence interval = 1.06 to 1.59) after adjusting for potential confounding factors including demographics, pathogens, and concomitant conditions. Conclusions Children with Down syndrome and sepsis have elevated risk of mortality. These findings have implications for treatment decisions, communications about prognosis, and future research.

To determine pediatricians' routine screening urinalysis practices.This was a survey of a nationally representative sample of pediatricians practicing in the U.S. regarding their screening urinalysis practices in childhood.Of the 1502 pediatricians sampled, 653 eligible subjects participated, for an estimated response rate of 49.5%. The vast majority of participants (78%) routinely screen asymptomatic children with urinalysis in at least 1 age group. Pediatricians' screening urinalysis practice varies based on age group: 9% screen during infancy (1 year), 60% screen during early childhood (1 up to 5 years), 55% screen during late childhood (5 to 12 years), and 58% screen during adolescence (13 to 20 years). The majority of pediatricians (58%) routinely screen more than 1 age group. Some 38% of the pediatricians surveyed believe that the overall health of children is improved by screening all asymptomatic children with urinalysis.Many pediatricians routinely conduct screening urinalysis during childhood, frequently at ages not recommended by the American Academy of Pediatrics.

Background Tobacco use results in 500,000 premature deaths annually. Most smokers begin using tobacco before age 21, so the greatest impact on preventing smoking-related mortality is likely to come from campaigns targeting youths. This study estimates the cost-effectiveness of an anti-smoking media campaign and $1 per pack increase in cigarette taxes on the lifetime decrease in smoking-attributable mortality among the cohort of all 18-year-olds in the United States during the year 2000. Methods Cost-effectiveness analysis conducted from a societal perspective. Results The combined effects of a media campaign and $1 per pack tax increase will result in a societal savings of between $590,000 per life-year saved, at a 3% discount rate and $1.4 million per life year saved, at a 7% discount rate. Conclusions A media campaign and $1 per pack cigarette tax increase will reduce overall smoking prevalence, significantly decrease smoking-attributable mortality, and decrease net societal costs.

Background.—A digital divide with respect to computer and Internet access has been noted in numerous studies and reports. Equally important to ownership is comfort with computers and Internet technology, and concerns about privacy of personal data. Objective.—To measure how households in a pediatric clinic vary in their attitudes toward computers, concerns about Internet confidentiality, and comfort using the Internet and whether these views are associated with household income or education. Design/Methods.—A phone survey was administered to a population-based sample of parents with children aged 0 to 11 years. All children received medical care from a community-based clinic network serving patients in King County, Wash. Results.—Eighty-eight percent of respondents used a computer once a week or more, and 83% of respondents reported favorable feelings toward computers. Although 97% of respondents were willing to share personal information over the Internet, many respondents considered data security important. While household income and parental education were associated with comfort and familiarity with computers, the effect is small. Respondents who already owned a computer and had Internet access did not differ in their perceptions according to socioeconomic or educational attainment. Conclusions.—Most families like using computers and feel comfortable using the Internet regardless of socioeconomic status. Fears about the digital divide's impact on the attitudes of parents toward computers or their comfort using the Internet should not be seen as a barrier to developing Internet-based health interventions for a pediatric clinic population.

Background Several systematic reviews of school-based smoking prevention trials have shown short-term decreases in smoking prevalence but have not examined long-term follow-up evaluation. The purpose of this study was to conduct a systematic review of rigorously evaluated interventions for school-based smoking prevention with long-term follow-up data. Methods We searched online bibliographic databases and reference lists from review articles and selected studies. We included all school-based, randomized, controlled trials of smoking prevention with follow-up evaluation to age 18 or 12th grade and at least 1 year after intervention ended, and that had smoking prevalence as a primary outcome. The primary outcome was current smoking prevalence (defined as at least 1 cigarette in the past month). Results The abstracts or full-text articles of 177 relevant studies were examined, of which 8 met the selection criteria. The 8 articles included studies differing in intervention intensity, presence of booster sessions, follow-up periods, and attrition rates. Only one study showed decreased smoking prevalence in the intervention group. Conclusions Few studies have evaluated the long-term impact of school-based smoking prevention programs rigorously. Among the 8 programs that have follow-up data to age 18 or 12th grade, we found little to no evidence of long-term effectiveness.

To conduct a population-based survey of television and other media usage in young children to determine (1) total media usage; (2) the proportion of children who have televisions in their bedrooms and who eat breakfast or dinner in front of the television; and (3) predictors of parental concern about the amount of television their child watches.Telephone survey administered to 1454 parents of children11 years old derived from a diverse clinic population.The mean age of the index child was 5.05 years. Mean daily reported child media use was as follows: television (1.45 hours; SD, 1.5); videos (1.1 hours; SD, 1.30); and computer games (0.54 hours; SD, 0.96). Thirty percent of parents reported that their child ate breakfast or dinner in front of the television in the past week, and 22% were concerned about the amount of television that their child watched. In multivariate linear regression, eating breakfast or dinner in front of the television in the past week was associated with increased hours of television viewing (0.38 hours [0.21, 0.54]) and video (0.19 hours [0.04, 0.34]). Having a television in a child's bedroom was associated with increased hours of television (0.25 hours [0.07, 0.43]), video viewing (0.31 hours [0.16, 0.47]), and computer games (0.21 hours [0.10, 0.32]). In general, higher parental education was associated with decreased hours of television and video but not computer games. Older children were 2 to 3 times more likely than younger children to have a television in their bedroom and to have eaten a meal in front of it in the past week. More educated parents were less likely to report that their child had a television in their bedroom and more likely to be concerned about the amount of television their child viewed.Combined video and computer game usage exceeded television usage. Both children of low- and high-income parents are at risk for certain behaviors associated with television usage. Parents whose children watched more television were more likely to be concerned about the amount of television their child viewed.

Background Tobacco is the leading cause of death in the United States. The majority of people who smoke begin before age 18. Objective Determine the number of smoking-attributable deaths and years of potential life lost (YPLL) in adults that might be saved through interventions to reduce smoking prevalence among children and adolescents. Methods Calculation of the smoking-attributable mortality and years of potential life lost by age 85 among the cohort of people aged 18 in 2000. Results By age 85, there would be 127,670 smoking-attributable deaths among women and 284,502 deaths among men, for a total 412,172 smoking-attributable deaths in the United States among the cohort of 3,964,704 people aged 18 years alive in 2000. Through large-scale multimedia campaigns and a $1 increase in the price per pack of cigarettes, smoking prevalence could be reduced by 26% and would result in an annual savings of 108,466 lives and 1.6 million YPLL. Conclusions Interventions to decrease smoking prevalence among children and adolescents can have large effects on adult mortality.

Objective To conduct a systematic review of controlled trials for adolescent smoking cessation. Methods Online bibliographic databases were searched as of June 2002, and reference lists from review articles and the selected articles were also reviewed for potential studies. The methodology and findings of all retrieved articles were critically evaluated. Data were extracted from each article regarding study methods, intervention studied, outcomes measured, and results. Results The abstracts or full-text articles of 281 relevant studies were examined, of which six met the selection criteria. Included were three school-based studies, a study in pregnant adolescent girls, a hospital-based study, and a trial of laser acupuncture. All three of the school-based studies reported significant impacts on cessation rates, although only one of these was a randomized trial. None of the studies had follow-up times of >5.2 months. Conclusions There is very limited evidence demonstrating efficacy of smoking-cessation interventions in adolescents, and no evidence on the long-term effectiveness of such interventions. Smoking-cessation interventions that have proven most effective in adults, such as nicotine replacement and antidepressant use, have not been studied in adolescents in a controlled manner.

Objective To conduct a systematic review of randomized controlled trials of smoking prevention interventions for youth delivered via medical or dental providers' offices. Methods Online bibliographic databases were searched as of July 2002, and reference lists from review articles and the selected articles were also reviewed for potential studies. The methodology and findings of all retrieved articles were critically evaluated. Data were extracted from each article regarding study methods, intervention studied, outcomes measured, and results. Results The literature search returned 81 abstracts from MEDLINE and 49 from Cochrane Clinical Trials Registry (CCTR); of these, four articles met the inclusion criteria. Included were two studies conducted in primary care, and one each in dental and orthodontic offices. Only one study demonstrated a significant effect on smoking initiation; in that study, 5.1% of the intervention group and 7.8% of the control group reported smoking at 12-month follow-up (odds ratio= 0.63; 95% confidence interval, 0.44–0.91). None of the studies had follow-up times greater than 3 years. Conclusions There is very limited available evidence demonstrating efficacy of smoking prevention interventions in adolescents conducted in providers' offices and no evidence for long-term effectiveness of such interventions.

Context.—The importance of continuity of care as a means to promote care coordination remains controversial. Objective.—To determine if there is an association between having an objective measure of continuity of care and parental perception that care is well coordinated. Design.—Cross-sectional study. Setting and Population.—Seven hundred fifty-nine patients presenting to a primary care clinic completed surveys that included 5 items from the Components of Primary Care Index (CPCI) that relate to care coordination. Main Predictor Variable.—A continuity of care index (COC) that quantifies the degree of dispersion of care among providers. Main Outcome Measures.—Likelihood of parents reporting high scores on the care coordination domain as well as each of the 5 individual CPCI items related to care coordination. Results.—Greater continuity of care was associated with higher scores on the CPCI care-coordination domain (P Conclusions.—Greater continuity of primary care is associated with better care coordination as perceived by parents. Efforts to improve and maintain continuity may be justified.

Clinicians, health services researchers, and third-party payers, among others, are justifiably interested in the outcomes of pediatric medical care and are, therefore, supportive of research in this area. Pediatric populations pose some unique methodologic challenges for health services researchers. To date, however, many of the approaches, models, and techniques used in pediatric outcomes research have been imported uncritically from experience with adult populations. As a result, some of the most interesting and salient aspects of pediatric outcomes research have yet to be fully developed. These include the following: 1) the problems posed by the dynamics of childhood development, 2) an emphasis on health supervision, 3) the need to see children within the context of a family system and to appreciate the interrelatedness of child health domains, 4) the measurement of the effects of interventions that span sectors, and 5) the paucity of available data sources. This article reviews these problematic areas and argues for a broad conceptual definition of pediatric health, a systems approach to assessing outcomes, and increased interdisciplinary collaboration.

The effect of a journal's prestige on readers' impressions of an article is unknown. Two hypotheses were tested: first, that attribution of a study to a "high" prestige journal would be associated with improved impressions and attribution to a "low" prestige journal would be associated with diminished impressions; and second, that formal training in epidemiology and biostatistics would mitigate the effects of this journal attribution bias. The study was designed as a trial among a random sample of 264 internists. Participants were asked to read an article and an abstract from either the Southern Medical Journal (SMJ) or the New England Journal of Medicine (NEJM). Questionnaires were constructed that either attributed the article or abstract to its source or presented it as unattributed. After each article or abstract, respondents were asked to rate the quality of the study, the appropriateness of the methodology employed, the significance of the findings, and its likely effects on their practice. A 20-point impression score was created based on responses to these statements. The effect of attribution to a specific journal and formal epidemiology training on impression scores were assessed using linear regression. Of the 399 eligible participants, 264 questionnaires were returned (response rate 66%). Differences in impression scores associated with attribution of an article or abstract to the NEJM were.71 [95% C.I. (-.44-1.87)] and.50 [95% C.I. (-.87-1.87)] respectively; differences in impression scores associated with attribution of an article or abstract to the SMJ were -.12 [95% C.I. (-1.53-1.30)] and -.95 [95% C.I. (-2.41-.52)]. A stratified analysis demonstrated that epidemiology training did not meaningfully alter the effect of journal attribution on participants' impression scores. If journal attribution bias exists, it is likely to exert small and clinically insignificant effects when physicians read articles carefully. Formal training in epidemiology and biostatistics does not appear to alter these results.

Objectives To determine parental participation in medical decision-making (MDM) during hospitalization and its association with parental self-efficacy and to explore other factors associated with participation. Study design We surveyed parents of children admitted to a pediatric medical unit to measure parental report of participation in MDM during hospitalization and self-efficacy with physician interactions (categorized into tertiles). We performed multivariate logistic regression to evaluate the association between self-efficacy and parental participation, controlling for potential confounders. Results One hundred thirty of 278 eligible parents completed surveys and 86% reported participating in MDM about their child’s care. After adjusting for covariates, parents with scores in the middle and highest self-efficacy tertiles had higher odds of participating in MDM compared with parents in the lowest tertile. Younger parents and parents of previously hospitalized children were also more likely to participate although parents with a high school education or less were less likely. Conclusions Self-efficacy was significantly associated with parental participation in MDM during hospitalization after adjusting for confounding factors. Interventions to increase self-efficacy may also improve parental participation in MDM.