Sports:

 

Soccer and Brain Injuries

Soccer is a very popular sport for children and youth in the U.S. So when the National Academy of Sciences asks if soccer is bad for children’s heads, we should pay attention to the answer.

Unfortunately, the answer is yes. The Institute of Medicine, which is part of the National Academy of Sciences, brought together researchers at a meeting that is the basis for this report. They concluded that head injuries are more common in soccer than other sports -- neuropsychologist Jill Brooks’ study of high school soccer players found that more than one in four had experienced one or more concussions. Surprisingly, “heading” the ball (intentionally using the head to pass or move the ball in a different direction) is probably a small part of the problem, since the ball is unlikely to be moving fast enough to cause a concussion. However, youth that head the ball are probably at greater risk of knocking their head into a player behind them. And more aggressive players are at more risk of head collisions with other players, goalposts, or when they fall on the ground.

Concussions are defined as a brain injury that causes an alternation in mental status. It’s more than “being dazed” and less than a coma. It does not necessarily cause loss of consciousness, but even if it does, unconsciousness may last only a few seconds and not be noticed. Other symptoms, such as headache, lightheadedness, diminished concentration, poor memory, irritable or depressed mood, difficulty sleeping, or problems with bright light or loud noise may not be noticed, or may not become obvious until a few days later. Many concussions are not reported by the students, who either don’t think they are serious or want to continue playing the game.

Concussions are difficult to diagnose and x-rays and other brain imaging are not always accurate. Magnetic Resonance Imaging (MRI) can detect small amounts of bleeding in the brain, but MRIs are expensive and difficult to do, and so doctors rarely order them for a concussion patients unless they suspect a life-threatening condition.

As a result, many concussions are not diagnosed or not taken seriously. If a second concussion occurs before the brain recovers from the first one (which can take weeks) energy-starved brain cells will be more likely to die. This can cause a swelling of the brain, even if one of the “bangs to the head” seems quite minor. The result can be serious, long-lasting brain damage, disability, or even death. Youth may be more vulnerable than adults because the human brain does not reach maturity until age 20 and the higher concentration of water in a young brain can indirectly cause the death of brain tissue.

What’s the solution for coaches and others that work with youth? Dr. Joseph Crisco, a bioengineer who is director of Research for the National Operating Committee on Standards for Athletic Equipment, questions whether helmets could help protect children. In the report he states that helmets might not prevent concussion and speculates that adults and children might assume that it does, and therefore worry less about safety. Instead, he suggests developing safer soccer balls.

Meanwhile, by being more aware of these potential dangers, youth workers can help soccer players and other athletes who have hurt their heads by asking about symptoms, calling a timeout immediately after a player is injured in order to determine if the player loses consciousness, seeking medical attention after head injuries occur, and taking a more cautious approach to putting players back in the game (or later games) after a head injury.

Reference:
Is Soccer Bad for Children’s Heads?
Institute of Medicine
National Academy Press, DC, 2002
Available free at www.nap.edu or for $ by ordering online or 800-624-6242

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Making Baseball Safer for Kids

It’s no surprise that contact sports can be dangerous, but deaths from chest injuries in youth sports is probably much more common than has been reported.

In a study published in Pediatrics, medical researchers explain that blows to the chest are especially likely to kill if the injury is on the chest wall over the heart. The victims are usually young males, who are more vulnerable to ventricular fibrillation, a potentially fatal result of this injury. Fatal injuries can result from chest blows from a hockey puck, lacrosse ball, softball, fistfights or other incidents, but baseballs are responsible for most of the reported injuries. Making safer baseballs with rubber cores has been suggested as a way to reduce the risk of injury to the head and body, and the purpose of this study was to see whether such safety baseballs would lower the risk of sudden death from a blow to the chest.

How do you study this? It’s not possible to intentionally expose children to potentially fatal injuries, so these researchers used “juvenile swine” as an animal model. The researchers replicated the velocity of a typical pitched baseball for 11- to 12-year-olds, which is 40 mph. Forty animals were anesthetized and placed in an upright position where they were hit a total of 83 times with baseballs of varying hardness.

With the softest balls, three of 26 (11 percent) hits resulted in ventricular fibrillation, which could potentially cause death. (The animals received immediate emergency medical care which prevented death in most cases, but would not be available so quickly in a baseball game.) The medium and hardest safety baseballs resulted in ventricular fibrillation for approximately 20 percent of the hits, which was still much safer than standard baseballs, which caused the potentially fatal problem 69 percent of the time.

The study design is upsetting and it is obviously impossible to say how relevant the results are to children. However, it seems reasonable to assume that the baseballs that were less harmful to young pigs in this research would be less likely to kill a child who is accidentally hit in the chest with a baseball. Even the hardest “safety baseballs” were safer than the standard baseballs in use today.

Why not use safer baseballs and try to save some lives? The authors state that the major obstacle is the opposition of coaches and even some parents, because changing the ball changes the game. Safety baseballs can apparently have an unpredictable and exaggerated bounce, and don’t travel as fast when struck by the bat. However, the safety baseballs of medium hardness are apparently very similar to standard balls, yet still considerably safer. The authors suggest softer balls for young players, and medium balls as a reasonable option for older children.

Reference:
Reduced Risk of Sudden Death from Chest Wall Blows (Commotio Cordis) With Safety Baseballs
Mark Link, M.D., Barry Maron, M.D., Paul Wang, M.D., et al
Pediatrics, Vol. 109, No. 5, May 2002, pp. 873-877
Available from Dr Link at New England Medical Center, Box 197, 750 Washington St, Boston, MA 02111 or mlink@lifespan.org

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Girls and Sports

   With all the concern about couch potatoes, lets start by emphasizing that exercise is good for children and adolescents, and girls are more actively participating in sports than ever before. However, parents, coaches, and others involved in girls' athletic activities need to be aware of research suggesting possible health problems that can arise.

   The American Academy of Pediatrics Committee on Sports Medicine and Fitness recently published a review of the research and information about female athletes. The article summarizes information about eating disorders, menstrual problems, and bone mineral density.

   Eating disorders is a problem for girls in several different sports, especially swimming, diving, gymnastics, dancing, and figure skating. Sometimes, girls are encouraged by their coaches or teammates to lose weight to improve their appearance or their performance. Binge eating followed by intentional vomiting or use of laxatives are two of the commonly used dangerous weight loss strategies, but compulsive exercise is another form of purging. Despite the use of purging strategies to improve performance, they can impair performance and increase the risk of injury.

   When athletic activity results in less body fat, they can also delay puberty in girls, and increase the risk of menstrual problems. If breast development has not begun by age 13, and menstruation has not occurred by age 16, a medical exam should be considered. In addition to how these problems affect a girl's self-esteem, they may have implications for osteoporosis or other health problems.

   The pediatricians' recommendations are intended for other pediatricians, but have implications for parents and coaches as well. Exercise and sports should be encouraged in girls, but adults should encourage a reasonable approach to diet and nutrition, and discourage excessive exercise. Menstrual problems should not be considered "normal" for athletes and efforts should be made to encourage weight gain and modify exercise if menstrual problems persist.

References:
Medical Concerns in the Female Athlete
American Academy of Pediatrics Committee on Sports Medicine and Fitness
Pediatrics
September 2000, Vol 106, 610-613.
Summary at www.aap.org/advocacy/archives/septath.htm

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Jocks, Head Injuries, and Learning Problems

    Team sports can teach valuable lessons about cooperation, perseverance, and discipline, and help keep problem kids out of trouble. Of course, there are costs too - such as less time to spend on schoolwork, and the potential for injuries. Unfortunately, the long-term implications might be worse than most youth workers every imagined: three newly published medical research studies all found potentially serious brain injuries related to popular contact sports such as football, soccer, wrestling, and basketball.

    The three studies, all published in the Sept. 8 issue of the Journal of the American Medical Association, were conducted in different countries and on different types of athletes, but the results were similar.

    A study of athletes at 114 high schools concluded that there are almost 63,000 mild traumatic brain injuries every year among high school varsity athletes. Unlike the other studies, this study did not measure how the injuries affected learning, but was a more comprehensive study of how commonly they occur and what kinds of sports are involved. The results were based on reports made to certified athletic trainers who were at the schools involved. Football accounted for approximately 63 percent, wrestling for 11 percent, girls and boys soccer for 6 percent each, and girls' and boys basketball for approximately 5 percent each. Baseball, softball, field hockey, and volleyball also resulted in brain injuries, although the rates were much lower.

    In most sports, injuries were much more common at games than during practice; wrestling and volleyball were the exception. Collisions with balls or other players (including tackling in football), were the major cause of these injuries.

    A study of 393 college football players, comparing their abilities before and after football season, found that after the season was over, the 20 percent of players who had two or more concussions were slower in processing information and did more poorly on other tests. The researchers concluded that football players with learning disabilities before their concussions suffered even more. The kinds of problems that result from concussions are especially harmful to students who already had learning disabilities.

    A small but detailed study of amateur soccer players indicated their memory and ability to plan was impaired, compared to athletes involved in swimming and track. Approximately one in four of the soccer players reported 2 or more concussions and one in four reported one concussion. The players who had more concussions performed more poorly on the neurological tests. Players with a history of learning disabilities or other medical conditions that could have affected their learning were excluded from the study.

    The researchers conducting the study of high school students concluded that changing playing rules and teaching techniques might be necessary to make the games safer for high school athletes. These three studies clearly indicate the need to make sports safer for other athletes as well.

References:
Traumatic Brain Injury in High School Athletes, by John Powell and Kim Barber-Foss (john@med-sports-systems.com)
Relationship Between Concussion and Neuropsychological Performance in College Football Players, by Michael Collins, et al. (mcollin1@hfhs.org)

Neuropsychological Impairment in Amateur Soccer Players, by Erik Matser et al. (akes@aozg.azm.nl)
Journal of the American Medical Association
September 8, 1999
Vol. 282, No. 10
FREE summary of all 3 at www.ama-assn.org/sci-pubs/sci-news/1999/snr0908.htm

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Girls, Sports, and Soda: A Bad Mix?

    Remember when children, even teenagers, were forced to drink three glasses of milk a day? It may be time to bring those days back.

    A new study of high school girls found that girls who drink carbonated beverages are much more likely to experience a bone fracture. Physically active girls who drink colas are most at risk.

    The 460 girls in the study were mostly in ninth or tenth grade. Almost 80 percent reported that they drink carbonated beverages and half of those drink only cola beverages. One-fifth of the girls had ever had a bone fracture, but for this study only those fractures occurring after age 8 were counted. However, calcium consumption from milk or other foods was not measured.

    The study can’t prove that the soda contributes to the fractures, and the author points out the many shortcomings of this study. Calcium consumption was not measured, and neither was the amount of carbonated beverages. It is therefore impossible to determine whether soda consumption is the real problem, or whether girls who drink more sodas drink less milk and therefore lack calcium. You might be surprised that 20 percent of the girls reported not drinking carbonated beverages at all. In addition, it is unclear why colas seem to create a particular risk of fractures. Overall, the study raises more questions than it answers, but given the increased number of girls participating in sports and the increased availability of soda at schools and the pervasive availability just about everywhere kids are, these are important questions for parents and adults who work with kids to be aware of.

Reference:
Teenaged Girls, Carbonated Beverage Consumption, and Bone Fractures
Grace Wyshak, Ph.D.
Archives of Pediatric Adolescent Medicine
Vol 154, June 2000, p. 610-13.
Available from author, Department of Population and International Health, Harvard School of Public Health, 665 Huntington Ave., Boston, MA 02115 or wyshak@hsph.harvard.edu

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Sports Can Hurt As Well As Help Urban Youth

    Sports can be a great activity for kids, but the injuries they cause can also be serious and expensive, according to a new study of children between 10 and 19 years of age in Washington, DC.

    The study focused on injuries that were serious enough to result in visits to emergency room visits, hospitalization, or death. Injuries included trauma or poisoning. Most (84 percent) of those hurt were boys. The researchers found that six sports caused 17 percent of all injuries: baseball/softball, basketball, biking, football, skating, and soccer. These six sports resulted in an injury rate of 2.5 percent of all adolescents per year (not just those who participated). The most common cause of injuries were falls and being struck by or against objects. Only 2% of those who visited emergency rooms required hospitalization, and there were no deaths in the 2-year study.

    There were a few patterns of injuries. Most (55 percent) of baseball injuries involved a bat or ball, using hitting the eye or another part of the head. Although bicycling injuries were not common, they were disproportionately likely to require hospitalization -- nearly one-third from collisions with motor vehicles.

    There were 51 injuries that appeared to be caused by sports-related assaults during the two-year study, in addition to at least 30 assaults using baseball bats. Assaults included 4 stab wounds (from basketball and football), 2 gunshot wounds (basketball and biking), and 3 assaults with objects.

    Nine percent of the sports injuries involved poor field conditions, such as falls against concrete, glass, or fixed objects. An additional 12 percent of sports injuries were related to equipment, suggesting the need to redesign or pad some equipment; for example, the authors suggest the removal of the center bar in boys bikes and better padding in football helmets.

    The study has important implications for kids and the adults who care for them and about them: make sure that helmets and other safety equipment are used, and make sure that other equipment and recreational areas are as safe as possible.

Reference:
Sports Injuries: An Important Cause of Morbidity in Urban Youth
Tina L. Cheng, M.D, and colleagues
Pediatrics, Vol 105, No. 3, March 2000, p. e32
Available at www.pediatrics.org or from Dr. Cheng at Children’s National Medical Center, 111 Michigan Ave, NW, Washington, DC 20010

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Smoking:

How does smoking start?

Everyone knows that smoking is unhealthy, but thanks to the more than $5 billion spent on tobacco advertising and promotion last year, almost one in four Americans still smoke. Almost all started smoking as children or youth, despite drug prevention efforts in most schools. If youth workers want to help prevent smoking they need to understand how to prevent a nonsmoking child from becoming a smoker.

This study of more than 17,000 students ages 13-19, in grades 9-12 in 1996, set out to provide that information. In addition to the large sample size, the study is impressive because it attempted to delineate the stages by which teens change from nonsmokers to regular smokers. They start with teens who have never smoked, categorizing them as “susceptible” if they didn’t say they “absolutely would not smoke” some time during the next year or ever in the future, even if one of their best friends offered a cigarette. The next stage -- the experimenter -- has never smoked an entire cigarette but has tried at least a few puffs. Those who have ever smoked an entire cigarette are categorized in terms of whether they smoked in the last 30 days. If not, they are categorized as former smokers who either think they would definitely never smoke again, or think they might. “Regular smokers” are defined as those who smoked at least one day during the previous 30 days and smoked at least 100 cigarettes in their lifetime.

Among the youngest (ages 13-14), 41 percent were deemed susceptible to smoking-- which means that they did not vehemently rule out smoking in the future -- compared to only 26 percent of the 17-18 year olds. Approximately one in three of the White and Hispanic youth were susceptible compared to 27 percent of the black youth. Approximately one in three females who had never smoked were susceptible, which was slightly higher than the males

Approximately 9 percent of all adolescents were experimenters, regardless of their age. Blacks were more likely to be experimenters (14 percent) than whites (7 percent) or Hispanics (11 percent) Given the addictive nature of smoking and the cost, it is not surprising that older youth were more likely to be regular smokers -- one in four of 17-18 year olds compared to 13 percent of 13-14 year olds. However, the 26 percent of white adolescents who were regular smokers was more than twice as high as the 12 percent of Hispanics and almost five times as high as the 5 percent of black adolescents who were regular smokers.

In addition to demographics, there were other predictors of whether a youth was likely to smoke. Youth who were exposed to the smoking of friends or family members were more susceptible, more likely to have experimented with a few puffs, and much more likely to be regular smokers. The study did not include questions about the smoking habits of adult role models, but it is expected that they would be similar.

Skipping school and doing poorly in school also predicted being an experimenter or regular smoker. Lack of attendance in religious activities predicted regular smoking but not other behavior. “No smoking” policies at school -- either on paper or enforced -- were not related to whether students smoked or thought about smoking. Students who described themselves as having a favorite advertisement predicted being susceptible to smoking or having experimented by puffing on a cigarette, but did not predict being a regular smoker.

Reference:
Predictors of Change on the Smoking Uptake Continuum Among Adolescents
Nancy J. Kaufman, MS, Brian Castrucci, Paul Mowery, MS, and colleagues
Archives of Pediatrics and Adolescent Medicine, Vol 156, June 2002, pgs 581-7

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Nicotine Patches And Teens

     Smoking is increasing among teens, and the expectation is that teens will get more and more addicted to nicotine the longer they smoke. Nicotine patches have been found to be effective for helping adults to stop smoking, but unfortunately, a recent study found that they are not nearly as effective in helping teens to quit. Fortunately, they can help teens dramatically cut back on cigarettes.

    Dr. Richard Hurt and his colleagues at the Mayo clinic were easily able to recruit 101 Minnesota teenagers who said they wanted to quit. Almost all the teens were white, most were 16 or 17, and 41% were girls. Although 96 were still smoking six months after treatment with the nicotine patch, they were averaging less than 3 cigarettes a day, compared to 18 before treatment.

    Approximately one in four adults who use nicotine patches are able to quit, so these findings were surprisingly low, according to Hurt, director of Mayo Clinic's Nicotine Dependence Center. He points out that studies show that between 0-11 percent of teens stop smoking on their own, without any kind of treatment. That would suggest that the nicotine patches were no more effective than no treatment at all.

    The patch treatment lasted 6 weeks, requiring daily diaries and weekly visits to the clinic. The diaries were surprisingly accurate, perhaps because the teens knew the researchers would compare the diaries to test results based on the amount of carbon monoxide in the teenagers’ breath. Ten of the teens never came back after their first visit. Each of the 71 who finished the entire six weeks received $100 for their participation. Of the 42 days they were supposed to wear patches, the teens wore patches an average of 38 days – surprisingly compliant for teenagers! At the end of the six weeks, 11 had stopped smoking, but six months later, only 5 were still abstinent.

    Almost two-thirds of the teens reported that there were other smokers in their household. When asked what other household members did to help or hurt their efforts to stop smoking, family members who smoked nearby or kept cigarettes in the house were major complaints. Nagging, not surprisingly, was also seen as harmful. Praise, encouragement, and talking about the program were seen as helpful.

    Hurt focused on whether there are biological differences that could account for the failure. For example, he found more nicotine withdrawal symptoms than expected, suggesting that the patch wasn't providing enough nicotine to many of the teens. Hurt was not very encouraged by the drastic reduction in the number of cigarettes smoked, since research on adults has suggested that if smoking doesn’t stop completely, the habit is likely to continue. However, he points out that reducing the habit could make the teen more likely to quit if they subsequently enroll in a behavior-oriented smoking cessation program.

Reference:
Nicotine Patch Therapy in 101 Adolescent Smokers
Richard Hurt, M.D. and colleagues
Archives of Pediatric and Adolescent Medicine
Vol 154, January 2000, Available free online at www.archpediatrics.com

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Anti-smoking Campaigns Can Prevent Teen Smoking

    An unprecedented drop in cigarette use among Florida teenagers seems to be the result of an antismoking campaign. The message of the campaign, devised by the teens themselves, is that kids are being manipulated by tobacco companies.

    The result is an impressive 54 percent decline in middle school cigarette use (from 19 percent to 9 percent) and a 24 percent drop among high school students (from 27 percent to 21 percent) over the past 2 years. The results are based on a survey of more than 23,000 students done by the Florida Health Department. Smoking was defined as using using tobacco at least one day in the past month. The results were similar for cigars and smokeless tobacco, and regardless of gender and ethnicity.

    Florida's campaign, which is called "the truth," involves a counter-marketing campaign, in-school and after-school programs, local partnerships, enforcement campaigns, and evaluation and research. The program started as a pilot project with funding from its 1997 settlement of a lawsuit filed against tobacco companies to reimburse the state for the costs of providing smoking-related health care.

    Florida's antismoking program is unusual because it involved youth relatively extensively at the state and local levels. According to the Florida Department of Health, the teens suggested the main message of manipulation, saying that would work because "teens don't want to be told what to do by anybody." Danny McGoldrick, research director for the national nonprofit advocacy group Campaign for Tobacco-Free Kids, agrees that the message is effective because it reinforces teens desire to rebel. McGoldrick says "They're saying, 'These people have targeted you for years and you should reject that.'"

    For example, one of the TV ads portrays two executives visiting a man in the hospital. They thank the man, who is coughing and struggling for breath, for being such a loyal customer and wonder how they will replace him. When they walk into the hall and see a teenager walking by, the teen looks at them watching him and asks, "What?"

    The results of the study are dramatic because nationwide teen smoking is higher than it was 10 years ago. Since the study is based on self-reported behavior, the accuracy can be questioned, but at the very least it shows a big change in teens' attitudes about whether it is "cool" to say they smoke. Most states have not yet decided whether to fund anti-tobacco programs with their share of money from a national settlement reached in 1998; this study shows that states should be urged to follow the lead of programs that have been successful.

Reference:
Florida Cuts Teen Smoking Big Time
Christine Kilgore
Clinical Psychiatry News 25(5) p. 1, 2000

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Another Reason Not to Smoke

    Does smoking cause anxiety or does anxiety cause smoking? Smokers tell you that smoking calms them down, but a new study finds that adolescents who smoke are more likely to suffer from phobias, panic attacks, and other serious anxiety problems as young adults.

    This study started with interviews of almost 700 young teens (with an average age of 14) in 1983 and followed them for 10 years. They lived in upstate New York, so most were white and Catholic.

    When these teens were about 16 years of age, only 6 percent smoked at least 20 cigarettes per day. At the age of 22, 15 percent smoked at least 20 cigarettes per day and 10 percent had anxiety disorders. Smoking habits changed over time, and so did anxiety: only 3 percent smoked at least 20 cigarettes per day as adolescents and young adults and only 2 percent had anxiety disorders as adolescents and as young adults.

    Since smokers tell us that smoking calms them down, it would be logical to expect that kids who were anxious became adults who smoked. Surprisingly, the opposite was true: it was the kids who smoked who were more likely to have agoraphobia (fear of open places), panic disorder, or general anxiety as young adults.

    In this kind of study, where you can’t control who smokes and who doesn’t, there is always concern that the smokers differed from nonsmokers in some important ways, and that anxiety was really caused by these other factors, rather than the smoking. In this study, the researchers statistically controlled for all the other possible influences they could – age, sex, teen drinking and drug use, depression during adolescence, difficult temperament during childhood, parents’ education and psychiatric problems, and parents’ smoking habits. By eliminating those influences from the statistical analysis, they were able to conclude that smoking was the likely culprit.

    Jeffrey Johnson, the senior author, offers us two possible explanations for their findings. First, smoking can impair respiration, which can contribute to panic attacks (and panic attacks are one symptom of phobias). Second, there is evidence that nicotine itself increases anxiety, despite the claims of smokers. Although anxiety increases when an individual stops smoking, a few weeks later their anxiety level will be lower than it was when they were smoking. This suggests that the nicotine itself causes increased symptoms of anxiety, even though withdrawal initially also increases anxiety.

    Jeffrey Johnson told us that he hopes that adults will use this information to help teens become more motivated to quit smoking, or not to start. He acknowledges that fear of cancer in the distant future does not always help, but predicts that teens may be more motivated to avoid anxiety problems that could start in just a few years.

Reference:
Association Between Cigarette Smoking and Anxiety Disorders During Adolescence and Early Adulthood
Jeffrey Johnson, Ph.D., Patrician Cohen, Ph.D., Daniel Pine, MD and colleagues
Journal of the American Medical Association
November 8, 2000, Vol 284, No. 18, 2348-2351
Available from Dr. Johnson at jjohnso@pi.cpmc.columbia.edu or 212 543-5523.

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Drinking and Drugs:

 

Teen Jobs and Drug Use

About one in six adolescents in the U.S. hold a job while going to school. This is the latest of several major research studies to show that the risks from teenage jobs can outweigh the benefits.

Using data from the U.S. government's National Household Surveys on Drug Abuse, the authors compared a national sample of more than 7,500 students ages 12-17 who did not have jobs with more than 1,000 who worked part-time and 96 who worked full-time.

Youths who worked either part-time or full-time were more likely to smoke, drink or use illegal drugs than those who did not have jobs. For example, 24 percent of students who worked full time had binged on five or more alcoholic drinks at one time in the last month, compared with 12 percent who worked part time and 6 percent who were not employed. Results were similar for heavy drinking, defined as having five or more drinks on each of at least five occasions in the last month - a criterion met by 13 percent of youths working full time, 5 percent of part timers and 2 percent of those who didn't work. The same was true for heavy cigarette use (at least a pack a day), which was reported by 10 percent of full timers, 3 percent of part timers and 1 percent of nonworkers.

The differences were not as great, however, for heavy drug use, which was reported by 5 percent of full time workers, and by 2 percent of part timers and nonworkers. Heavy drug use was defined as daily marijuana use; heroin use at least once; or weekly use of cocaine, inhalants, pain relievers, sedatives, tranquilizers, stimulants, or hallucinogens.

Is there something about work that causes drug use? Not exactly. School dropouts who were unemployed were the most likely to report heavy drug use (8 percent) and were similar to full time workers in rates of binge drinking (21 percent), heavy drinking (12 percent) and heavy smoking (7 percent).

Since older students are more likely to drink, smoke and use drugs, and more likely to have jobs, that could explain the relationship between jobs and drugs. Fortunately, the researchers conducted statistical analyses taking age, race, ethnicity, mental health problems and other factors into account. They found that even when those traits were statistically controlled, youths who worked were more likely to report recent and heavy substance use.

The researchers also found differences for boys and girls.

Boys who work full time are more likely to smoke, smoke heavily, binge on alcohol, drink heavily and use marijuana compared to those who don't work. Boys who work part time are more likely to smoke marijuana but did not differ from nonworking boys in other respects. Unemployed boys who had dropped out of school were more likely to smoke heavily and use illegal drugs other than marijuana, compared to the other boys.

Females who worked full time or part-time were more likely to use alcohol than were other girls, whereas girls who worked part-time were more likely than nonemployed students to smoke, binge drink, drink heavily or use drugs other than marijuana. Unemployed girls who were school dropouts were more likely than the female students to use alcohol, binge drink, or drink heavily.

The reasons for the link between work and substance use is not known, but likely explanations include exposure to co-workers with those habits, the availability of drugs and alcohol through co-workers, and the availability of earnings to buy drugs and alcohol (without parents knowing about it). In addition, research shows that students who work tend to have poorer grades and be less committed to doing well in school or going to college, so they might not be as motivated to avoid behaviors that could interfere with those goals.

The implications for parents or adults who counsel, mentor or supervise teens is clear: Be aware of the risks that jobs can present for teens, and find ways to minimize those risks. If kids need the money or other benefits that work provides, try to help them find jobs that won't expose them to negative influences. Encourage some controls on the earnings so that they won't be spent on alcohol, cigarettes and drugs.

Reference:
The Relationship Between Employment and Substance Abuse Among Students Aged 12 to 17
Li-Tsy Wu, ScD, William Schlednger, PhD, and Deborah Galvin, PhD
Journal of Adolescent Health, Vol 32, No1, January 2003, pp. 5-15.
Available from Dr Wu at liwu@rti.org

 

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Can DARE be Fixed? Is There Reason to Try?

It has long been established that the Drug Abuse Resistance Education (DARE) program, the most widely used drug prevention program in the country, usually does not work. A program called DARE Plus, which combined DARE with components such as peer-led parental involvement classes and youth-led extracurricular activities, was developed and implemented in Minnesota. A new study indicates that these additions "enhanced the effectiveness" of the DARE curriculum. But what does that mean?

It doesn't take much to enhance the effectiveness of a program that doesn't work. Does DARE Plus work because of the "Plus" part, or does the DARE curriculum actually add anything?

The study involved more than 6,000 seventh graders in 24 Minnesota schools during the 1999-2000 academic year. Approximately one-third participated in DARE's 10-session curriculum taught by police officers, one-third in DARE Plus, and one-third in a control group.

DARE Plus started with a classroom-based, peer-led parental involvement program entitled "On the VERGE," implemented by trained teachers once a week for four weeks. The program included classroom activities as well as activities for the students to complete with their parents. Students also participated in a theater production in their classrooms and received three postcards through the mail that focused on the tobacco industry's targeting of youth. Ten more postcards were mailed to the parents every six to eight weeks with "short and relevant behavioral messages."

DARE Plus also included youth action teams led by eight community organizers, helping the students choose extracurricular activities.

Although the "Plus components" are described in the article, it was difficult to understand exactly what they were talking about.

The results showed (again) that DARE did not prevent substance abuse or violence. However, compared to boys who were in the control group, boys in DARE Plus were less likely to use or intend to use alcohol, tobacco and multiple drugs, and - less likely to increase their alcohol use and intentions, tobacco use and intentions, current frequency of smoking, or multidrug use behavior and intentions. They were also less likely to be victimized.

The differences between DARE and DARE Plus were similar but not as consistent. Compared to boys in DARE, boys in DARE Plus were less likely to increase tobacco use and intentions or violent behavior or intentions.

Girls showed almost no benefit. The only difference was that compared to girls in DARE, those in DARE Plus were less likely to report increases in ever having been drunk.

The authors were enthusiastic about DARE Plus for boys. I do not share that enthusiasm about the program results, or the way this study was conducted.

Since DARE is not more effective than no program at all, there is no good reason to enhance it. However, if it is desirable to do so (for political or other reasons) then researchers should include a group of youth who received the "Plus" components without the DARE curriculum. If the results then show that the "Plus" part works just as well as the DARE Plus combination, they could and should save time and resources by eliminating the DARE curriculum.

If, however, the combination is more effective than the Plus components alone, youth workers could consider whether the improvement justifies continuing to spend resources and time on DARE.

But if you don't want to know whether the DARE curriculum has any value, why spend the resources to evaluate it?

Reference:
A Randomized Controlled Trial of the Middle and Junior High School D.A.R.E. and D.A.R.E. Plus Programs,
Cheryl Perry, Ph.D., Keith Komro, Sara Veblen-Mortenson, et al,
Archives in Pediatrics and Adolescent Medicine, Vol. 157, February 2003, pgs. 178-84.
Copies available from perry@epi.umn.edu.

 

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Violence and Substance Abuse in 3 Countries

Drug abuse and exposure to community violence are thought of as American problems, but a new study conducted on youth in Antwerp, Belgium, Arkangelsk, Russia, and New Haven, CT found considerable exposure to drugs and violence and similar dysfunctional responses to it.

The study was based on more than 3,000 inner-city youth (ages 14 through 17). Victimization included being beaten or mugged, threatened with serious physical harm, shot at, attacked with a knife, chased by gangs or individuals or seriously wounded in a violent incident. Exposure to violence was measured as witnessing the same kinds of violence.

The rates of witnessing one or two events and experiencing moderate victimization were similar in the three countries. However, the teens in the United States were more than twice as likely to report witnessing more than two (54 percent, compared to 24 percent in Belgium and 13 percent in Russia). Moderate victimization was similar in all three countries (between 26 and 30 percent), but severe victimization was considerably higher in the United States (18 percent compared with 8 percent in Belgium and 2 percent in Russia).

When age, sex and race are statistically controlled, smoking and alcohol use were higher in Belgium and the United States than in Russia. In all the countries, teens who witnessed more violence or were victims of violence tended to smoke, drink, and use marijuana more often and were more likely to use hard drugs. However, American adolescents who witnessed violence were less likely to use drugs and alcohol than were teens in other countries.

The results suggest that programs aiming to reduce substance abuse need to consider how teens "self-medicate" themselves with alcohol or drugs to cope with fears and anger from witnessing or experiencing violence. Helping teens avoid violent experiences or find other ways to cope could reduce substance abuse.

Reference:
Violence Exposure and Substance Use in Adolescents: Findings from Three Countries,
Robert Vermeiren, M.D., Mary Schwab-Stone, M.D., Dirk Deboutte, M.D., Ph.D. et al,
Pediatrics, Vol. 111, March 2003, pgs. 535-40

 

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Just One Drink Can be Too Many

Teens and young adults like to drink and they like to drive, and everyone knows it's a disastrous combination. This new study shows that even one or two beers can have a bad impact on judgment and driving decisions.

Nineteen Texas men and women of various ages and ethnic backgrounds were trained to perform specific driving behaviors. Six drank no alcohol, while the other 13 were allowed to drink any type and amount of alcohol. When the drinkers' blood alcohol level reached about 0.04 percent (which is half the legal limit for driving in Texas and 20 other states), all of the participants were asked to drive through a closed course, featuring six different exercises of varying difficulty.

The researchers found that even those at the .04 blood alcohol level - half the legal limit -- had trouble controlling a skid, steering to avoid a simulated crash, or dealing with a car that was difficult to steer and break. They were not badly impaired in their efforts to maneuver through stationary cones, making a "T" turn, or dealing with a blocked lane. All driving tests were conducted during daylight.

Researcher Dr. Maurice Dennis points out that most people drink after dark, and they would likely be further impaired by darkness and fatigue. He also points out that a 120-lb woman could reach a .04 blood alcohol level after only one beer, and a 150-lb man could reach that level after only 1-2 beers.

"You don't have to be staggering, fall-down drunk to have driving problems if you're drinking" Dennis warns. "A very small amount can affect your driving ability and especially the decisions you make while driving."

The research has important implications for teens, who are not always aware about how drinking affects them, and who are less experienced drivers and less able to cope with the unexpected while driving. It has important implications for adults, who are aware of the pervasiveness of teen drinking and can inform teens of how even moderate drinking can be deadly when combined with driving. And of course, adults also should avoid drinking before driving.

The researchers taped the results of the study on a VHS tape, which is available in Texas for driver education courses and law enforcement agencies.

Reference:
Analysis and Evaluation of the Effects of Varying Blood Alcohol Concentrations on Driving Abilities
Maurice Dennis
Chronicle of the American Driver and Traffic Safety Education Association, 2003

 

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Does Smoking Marijuana Predict Other Drug Use?

Marijuana has traditionally been considered less worrisome than other illegal drugs, but the costs to our society may be higher than you think. There were 220,000 marijuana-related admissions to publicly-funded substance abuse programs in the United States in 1999, and approximately one-third were youth between 12 and 17. Another one-third were ages 18 to 25.

As marijuana has become a more powerful drug, there have been growing concerns about its short-term dangers as well as its long-term health risks, such as cancer. However, a long-standing concern has been based on the view that marijuana is a gateway drug, leading to the abuse of other, more dangerous illegal drugs.

Research has shown what most youth workers already knew: Teens often progress from marijuana to other drugs. But the studies have not been able to tease out whether marijuana use causes a teen to seek more powerful drugs or merely increases their access to other illegal drugs. Another question is whether personal traits or genetic factors might predispose an individual to seek a way to become high, making marijuana a convenient first drug rather than a necessary first step toward addiction.

A study of 2,765 pairs of twins attempts to examine this progression while controlling for all the factors that twins have in common, such as genes, personality traits, home environment and (for the most part) access to drugs. They found that men and women who used marijuana or hashish before age 17 were more than twice as likely as others to ever become dependent on alcohol or to abuse any illegal drugs. Specifically, they were twice as likely to ever use marijuana/hashish, more than twice as likely to abuse sedatives, four times as likely to abuse stimulants or cocaine, and almost four times as likely to abuse heroin or other opiates. This was true whether the twins were identical or not.

In addition to the fact that twins have so much in common, the study also controlled for certain factors that were already known to predict illegal drug use, such as early alcohol or tobacco use, childhood sexual abuse, depression, social anxiety and parental conflict or separation.

The implications are that using marijuana or hashish before the age of 17 makes it much more likely that teens will abuse other drugs in their lifetimes - regardless of their genes or home life, or whether they have access to drugs through their twins.

The study has some shortcomings. Most importantly, it relied on self-report by adults (ranging in age from 24 to 36) who were asked to remember when they started using marijuana and to honestly report all their illegal drug use.

A second shortcoming for anyone living outside Australia is that the twins were all Australians, and the social pressures might be different in Australia than here. However, the overall findings about the impact of early marijuana use, even compared to twins who did not use marijuana, is likely to be relevant across cultures.

Reference:
Escalation of Drug Use in Early-Onset Cannibis Users vs. Co-twin Controls
Michael Lynskey, PhD, Andrew Heath, DPhil, Kathlleen Bucholz, PhD and others
Journal of the American Medical Association, January 22/29, 2003, Vol. 289, No. 4, pgs. 427-33, Available from mlynskey@matlock.wustl.edu

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Reducing Smoking, Drinking and Drug Use

Drug-abuse prevention programs can help high-risk youth, according to this five-year study by the Center for Substance Abuse Prevention (CSAP). The report found that prevention programs for high-risk youth have been effective in reducing rates of alcohol, tobacco and marijuana use.

The study included more than 10,500 youth in 48 communities with high levels of poverty, crime and substance abuse. The results showed that prevention programs strongly influence boys’ behavior while they are participating in those programs and for a few months afterwards. The impact on girls is initially weaker, but increases over time and is longer-lasting.

The programs varied widely in design, and some were effective while others were not. Unfortunately, the report does not specify the range of effectiveness, or the proportion of programs that were effective. However, it concludes that the programs that were most successful showed a clear purpose and evidence-based strategy, focused on self-examination, maintained intensive participant contact and were offered in after-school settings.

For girls, programs that focused on behavior-related life skills were the most effective. Boys benefited most from programs that emphasized interaction with peers or adults.

Approximately 60 percent of the youths participated in prevention programs. Their reported first-time use of cigarettes, alcohol and marijuana was 12 percent lower when the program was completed, compared to those who were not in a program. Eighteen months later, the participants’ first time use was still 6 percent below that of other youth.

For youths who had already used tobacco, alcohol or marijuana, use of these substances was 10 percent lower for those who completed a prevention program compared to those who did not. Eighteen months later, however, participants’ substance abuse levels were 22 percent below the levels of the other youths.

The programs had a more immediate impact on boys, who were 29 percent less likely to use drugs at the end of the program, and 22 percent less likely six months later. However, this difference disappeared 18 months after a prevention program was completed.

In contrast, substance use was only 3 percent lower for girls who completed a program compared to girls who did not participate, but 18 months later this difference had increased to 9 percent.

The report confirmed a “web of influence” in the lives of these youth, which included school, family, peers and community. For example, in strong families, parents influence their children’s choice of friends and their decisions about whether to smoke, drink or use drugs. Youth who do well in school tend to have friends who do not use these substances, and those youths are also less likely to use them. The report concluded that “family, peers, school, community and society protect against substance abuse.”

Reference:
The National Cross-Site Evaluation of High-Risk Youth Programs, U.S. Center for Substance Abuse Prevention, DHHS Publication No. SMA-25-01.
Available free from National Clearinghouse for Alcohol and Drug Information, P.O. Box 2345, Rockville, MD 20847-2345. (800) 729-6686, TDD (800) 487-4889

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Smoking Marijuana: An Update

Despite its widespread use, there is still much to be learned about the impact of smoking marijuana. In a new review of the research, published 15 years after an earlier review, Richard Schwartz speaks in the voice of an unbiased expert. However, he also reveals that his 34-year old son was under treatment for drug abuse at the time that his first research review was published, and after 10 drug-free years his son has “finally attained some adult goals.”

That kind of personal experience influences objectivity. Nevertheless, the review cites major research studies and makes interesting points about marijuana use in the U.S.

Annual marijuana use among adolescents fell steadily between 1979 and the early half of the 1990s, but started to increase rapidly and peaked among eighth-graders in 1996. At the same time, perceptions of the risk of smoking marijuana changed; as concerns decreased, smoking increased.

A major concern about marijuana has been that it is a gateway drug, opening the door to other substance abuse. According to the latest research, marijuana smoking seems to precede tobacco smoking and alcohol abuse in girls, but not necessarily “hard” drugs such as heroin and cocaine in either boys or girls. However, kids who smoke marijuana at an early age and who use it frequently are more likely to live an unconventional lifestyle: hanging out with delinquent and substance-abusing teens, dropping out of school, leaving home and becoming parents at an early age.

Memory problems are an obvious short-term effect from marijuana. Smokers can’t process newly learned information and store it for later use. Several studies indicate the loss of “executive functions” such as learning lists and doing homework, and that this continues when the individual is no longer high.

Marijuana also has a clearly negative impact on driving. In a road test, for example, reaction time increased 36 percent, which would result in driving an additional 139 feet before stopping if the person was driving 59 miles per hour.

Schwartz points out that marijuana web sites make it easy to purchase marijuana seeds and growing instructions, as well as pipes and water pipes that cool and concentrate the smoke so that even middle school smokers can get a “super high” compared to smoking a cigarette-sized joint. The web sites also convey the view that marijuana use is safe and should be legalized. These web sites, he says, may account for the recent increase in marijuana use and make it more difficult for youth workers and other adults who try to provide more accurate information to youth. Meanwhile, seedless marijuana that is stronger than ever is readily available in towns, suburbs and cities across the country.

Reference:
Marijuana: A Decade and a Half Later, Still a Crude Drug with Underappreciated Toxicity
Richard Schwartz, M.D.
Pediatrics, Vol. 109, No 2, February 2002, pp. 284-289.
Available from Schwartz at 115 Park St., SE, Ste. 203, Vienna, VA 22180, or rhs738@aol.com.

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The Impact of Marijuana