Evidence Digest

Evidence to Guide Clinical Practice and FutureResearch with Adolescents

Bernadette Mazurek Melnyk, PhD, RN, CPNP/NPP, FAAN, FNAP

The purpose of Evidence Digest, a recurring columnin Worldviews, is to provide concise summaries of

well-designed/clinically important recent studies alongwith implications for practice, research, administration,and/or health policy. Articles highlighted in this columnmay include quantitative and qualitative studies, system-atic and integrative reviews, as well as consensus state-ments by expert panels. Along with relevant implications,the level of evidence generated by the studies or reportshighlighted in this column (see Figure 1) is included atthe end of each summary so that readers can integrate thestrength of evidence into their healthcare decisions.

Troy, H., Hoyt, D., Coimbra, R., Potenza, B., Sise, M.& Anderson, J. (2005). High rates of acute stress disor-der impact quality-of-life outcomes in injured adolescents:Mechanisms and gender predict acute stress disorder risk.The Journal of Trauma, Injury, Infection and Critical Care,59(5), 1126–1130.

Purpose. The purpose of this study was to identify ratesof acute stress disorder and its relationship to quality of lifefollowing trauma in adolescents.

Sample. The sample was comprised of 401 trauma pa-tients, aged 12–19 years who were triaged to five traumacenter hospitals in a regionalized trauma system in South-ern California, United States. Inclusion criteria includedan injury diagnosis, but excluded teens with severe trau-matic brain injury or spinal cord injury. The mean age ofthe sample was 15 years (Standard Deviation = 2.3 years).The most common injuries were sustained by motor vehi-cle accidents and recreational and bike injuries, followedby intentional injuries (e.g., assaults and gunshot wounds),falls, and pedestrian injuries.

Design. Prospective descriptive cohort study.Measures/Outcomes. Acute stress disorder as measured

by the impact of event scale and Quality of Life as measuredby the quality of well-being (QWB) scale. Perceived threatto life was assessed with the question, “Did you feel duringthis event that your life was in danger?”

Copyright ©2006 Sigma Theta Tau International1545-102X1/06

Methods/Procedure. Subjects were interviewed prior todischarge from the hospital, and then followed at 3, 6, 12,18, and 24 months after discharge from the hospital.

Findings. The overall prevalence rate of acute stress dis-order was 40%. Adolescents who had acute stress disorderin comparison with those who did not before dischargefrom the hospital, had significantly lower quality of lifescores on follow-up, through 24 months. Rates of acutestress disorder were higher in females than males (47%versus 36%). Intentional or violence related injuries alsowere significantly associated with acute stress disorder. Onequestion, which required a yes or no answer, “Did you feelduring this event that your life was in danger?” predictedthose teens who developed acute stress disorder from thosewho did not.

Commentary with Implications for Clinical Practice andFuture Research. The highest cause of death and func-tional disability in adolescents is injuries. Because thereis a large knowledge gap in the literature regarding theoutcomes of traumatically injured adolescents, this studyextended the science in the area by identifying the rate ofacute stress disorder and the relationship between it andquality of life in injured teens. Despite the limitations ofthis study (i.e., whether the teens had preexisting mentalhealth problems or whether they had been admitted tothe intensive care unit), this is the first study to assessquality of life in adolescents up to 24 months followingtrauma. Future research should consider other factorsthat may predict acute distress disorder and lower qual-ity of life (e.g., parental stress and going; parent and peerrelationships, cultural influences).

The fact that one question predicted those teens whodeveloped acute stress disorder from those who didnot is clinically significant as this question could beroutinely asked of all injured adolescents prior to dis-charge from hospital. A more complete mental healthassessment could then be conducted on those whohave an affirmative answer to the question, and closefollow-up could be conducted by their primary careproviders.

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Evidence Digest

• Level I: Evidence from a systematic review or meta-analysis of all relevant randomized controlled trials (RCTs), or evidence-based clinical

practice guidelines based on systematic reviews of RCTs

• Level II: Evidence obtained from at least one well-designed RCT

• Level III: Evidence obtained from well-designed controlled trials without randomization

• Level IV: Evidence from well-designed case-control and cohort studies

• Level V: Evidence from systematic reviews of descriptive and qualitative studies

• Level VI: Evidence from a single descriptive or qualitative study

• Level VII: Evidence from the opinion of authorities and/or reports of expert committees

Modified from Guyatt & Rennie (2002) Harris et al. (2001)

Figure 1. Rating System for the Hierarchy of Evidence (fromMelnyk & Fineout-Overholt, 2005).

As a result of the escalation of mental health problemsin children and teens over the recent years, the lack ofneeded mental health providers for pediatric and adoles-cent care (Melnyk & Moldenhauer 2006), as well as thehigh incidence of acute stress disorder in injured teens,there is an urgent need for the development and test-ing of early interventions to decrease stress and enhancecoping outcomes in injured adolescents, especially thosewho perceive their life as threatened during the courseof trauma. Primary care providers need to be especiallysensitive to screening and early intervention with thishigh-risk population as they follow these adolescentslongitudinally for their healthcare.

Level of Evidence: IV.

Ogilvie, D., Gruer, L. & Haw, S. (2005). Young people’saccess to tobacco, alcohol, and other drugs. British MedicalJournal, 331(7513), 393–396.

Purpose. The purposes of this systematic review wereto: (a) determine the availability of tobacco, alcohol, andother drugs to youth in the United Kingdom, and (b) eval-uate whether measures to control availability affect youngindividuals’ patterns of use.

Sample. Data were gathered from nine population sur-veys of youths under 25 years of age in the United Kingdomas well as from 30 reviews that included systematic reviewsthat assessed the effects of measures to control availabilityon patterns of use and health outcomes.

Design. Systematic review.Findings. Tobacco and alcohol is widely and readily

available. As price for tobacco increases, there is a reduc-tion in use. Most regular smokers aged 12–15 years buycigarettes from shops and from relatives. Peers also providecigarettes to one another.Young people’s early drinking isoften done at home with parents. Approximately 80% of15-year old youth in the United Kingdom believe that al-

cohol is easy to obtain. By age 15 years, many youth obtainalcohol from pubs, off licenses or shops, and it is easier forgirls to acquire. Demand for alcohol also is sensitive to itsprice, as was tobacco. Approximately one third of 13-yearolds and two thirds of 15-year olds perceive illicit drugs,especially cannabis, to be easy to obtain. Between 10% and20% of 10- to 12-year olds report being offered elicit drugs.Two thirds of 15-year olds report knowing where they caneasily purchase cannabis, with a quarter stating that it canbe easily bought at school.

Commentary with Implications for Clinical Practice, Re-search, and Health Policy. One major limitation to thisreport was the lack of inclusion of the process by whichthis systematic review was conducted (e.g., no detail onhow the studies were selected, the explicit methods usedfor the review, the number of total subjects). However,the results have major implications for practice, research,and policy. The ease to access of tobacco, alcohol, anddrugs in youth, especially young adolescents is alarm-ing and prevalent in many countries across the globe.Healthcare providers who routinely care for adolescentsneed to be diligent in screening for substance use andabuse, and institute preventive measures to deter youthfrom beginning to engage in these high-risk behaviors.Research on the development and outcomes of theory-based preventive interventions is needed. Stricter lawson the use of substances need to be enforced and legisla-tion needs to be implemented to impose rigorous stan-dards for the sale (e.g., higher ages to purchase alcohol)and price of these substances since cost is related to usein adolescence.

Level of Evidence: I

Kean, E.M., Kelsay, K., Wamboldt, F. & Wamboldt, M.(2006). Posttraumatic stress in adolescents with asthmaand their parents. Journal of the American Academy of Childand Adolescent Psychiatry, 45(1), 78–86.

Purpose. The purpose of this study was to assess thelevel of posttraumatic stress (PTS) symptoms in ado-lescents, with and without asthma, and their parentsand the relationship between PTS symptoms and asthmamorbidity.

Sample. The convenience sample was comprised of 200adolescents, who were divided into one of three groups:(a) those who had experienced a life-threatening asthma-related event after 5 years of age, including an intensive careunit (ICU) admission, intubation, intravenous terbutalineor continuous albuteral nebulizer treatment for greaterthan 12 hours, seizure or loss of consciousness, or hypoxia(n = 49); (b) those with asthma and on daily controller

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Evidence Digest

asthma medication, but who had not had experienced alife-threatening event (n = 71) (i.e., asthma control); and(c) normal controls (n = 30). One hundred and fifty-eightparents of these adolescents also completed psychologicalmeasures. The first group of subjects was recruited fromhospital ICUs, emergency departments, and physician re-ferrals. The other two groups were recruited through pre-existing databases of adolescents who were interested inresearch, as well as from referrals from groups two andthree, and posted flyers. Attempts were made to matchthe three groups on age, gender, race, and socioeconomicstatus.

Design. Case-Control.Methods/Procedure. One meeting to interview the sub-

jects and for them to complete the study measures wasconducted.

Measures/Outcomes. The teens were asked to thinkabout questions on a life events scale that was first com-pleted or any other frightening or highly stressful expe-riences that they ever had and what made them scared,upset, or distressed about the event? They then de-scribed the incident and responded to the UCLA post-traumatic stress disorder reaction index (PTSD-RI). Ado-lescents with asthma who did not report that an asthma-related event was their most distressing event were givena second questionnaire that addressed their worst asthmaepisode. Adolescents also completed the Reynolds Depres-sion Inventory and the Multidimensional Anxiety Scale forChildren.

Parents completed the Impact of Events Scale-Revisedto assess PTS symptoms in regard to them thinking aboutone of their child’s worst asthma events, the Brief Symp-tom Inventory to assess general levels of psychological dis-tress, and the Rosier Functional Asthma Severity Scale.Nonasthma control parents were asked to think abouta serious accident or injury that their child had experi-enced and answer the Impact of Events Scale accordingly.Asthma severity was classified as mild-intermittent, mild-persistent, moderate, or severe asthma.

Findings. More than 90% of the adolescents who ex-perienced a life-threatening event and 69% of the asthmacontrol group met the criteria for a traumatic event versus33% in the normal control group. Twenty percent of the life-threatening asthma group met the criteria for PTSD in com-parison to 11% for the asthma control group, and 8% for thenormal control group. Adolescents with a life-threateningasthma event were more than twice as likely to meet PTSDcriteria than normal controls. Twenty-nine percent of theparents of adolescents with a life-threatening asthma eventmet criteria for PTSD, versus 14% of the asthma controlparents, and 2% of the non-asthma control parents. Fur-thermore, asthma functional morbidity was significantly

related to adolescent PTS symptoms, depression, and anx-iety, but was not correlated with parent PTS symptoms orgeneral parent psychological distress.

Commentary with Implications for Clinical Practiceand Future Research. Despite the limitations in thisstudy (e.g., variations in length of time since the life-threatening event, snowball sampling, cross-sectionaldata), this is the first study to identify the prevalence ofPTS symptoms in adolescents with asthma and their re-lationship to asthma morbidity. Screening for PTS, anxi-ety, and depression should be routine in adolescents withasthma, but especially for those who have experienceda life-threatening event as a result of their condition.This screening should be completed prior to hospitaldischarge. Close follow-up by primary care providers af-ter hospital discharge is warranted. Parents of these teensalso should be screened for these symptoms as their rateof PTS was even higher than the adolescents. Research todevelop and test theory-based interventions to decreasePTS, anxiety, and depression in these adolescents andtheir families is urgently needed.

Level of Evidence: IV

Carnethon, M., Gulati, M. & Greenland, P. (2005).Prevalence and cardiovascular disease correlates of lowcardiorespiratory fitness in adolescents and adults. JAMA,294(23), 2981–2988.

Purpose. The purpose of this study was to describe theprevalence of low fitness in the United States population,in individuals 12–19 years and 20–49 years of age, and torelate low fitness to cardiovascular disease risk factors inthis population.

Sample. The sample was comprised of 3,110 adoles-cents who were free from diagnosed cardio vascular disease(CVD) who participated in the cardiovascular fitness com-ponent of the National Health and Nutrition ExaminationSurvey (NHANES), 1999–2002.

Design. Cohort study.Methods/Procedure. The adolescents underwent sub-

maximal graded exercise treadmill testing to reach 75–90% of their age-predicted maximum heart rate. Max-imum oxygen consumption was calculated by measur-ing heart rate response to reference levels of submaximalwork.

Measures/Outcomes. Low fitness was defined usingpercentile cut points of estimated oxygen consumptionfrom external referent populations. Anthropometric andother CVD risk factors were measured according to stan-dard methods (e.g., hypertension was defined as the 90th

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percentile of systolic or diastolic blood pressure based onage, sex, and height.

Findings. Thirty-three percent of the adolescents wereidentified as low fitness, which equates to 7.5 million ado-lescents in the United States. The prevalence was similarfor males and females. Non-Hispanic blacks and MexicanAmericans were less fit than non-Hispanic whites. Bodymass index and waist circumference were inversely relatedto fitness. Total cholesterol level and systolic blood pressurewere higher and levels of high-density lipoprotein choles-terol were lower among adolescents with low versus highfitness. Adolescents with low fitness were 2–4 times morelikely to be overweight or obese than participants in themoderate or high fitness categories. Adolescents who wereless fit were more likely to have hypercholesterolemia andmetabolic syndrome.

Commentary with Implications for Clinical Practice, Fu-ture Research, and Health Policy. Although approxi-mately 16% of U.S. children and teens are overweightas defined by gender and weight-specific body massindex (BMI) at or above the 95th percentile as plot-ted on the Centers for Disease Control (2005) growthcharts, being overweight is a global issue. Overweightteens tend to become overweight adults and are morelikely to experience risks related to cardiovascular dis-ease than adolescents who are not overweight. Recent re-search indicates that an adolescent’s beliefs about healthylifestyles affect their lifestyle choices/behaviors as well astheir emotions (Melnyk et al. in press). In addition, de-pressive symptoms in teens are related to their healthylifestyle beliefs and behaviors. Therefore, in future inter-ventions with adolescents, it will be important to include

a strong cognitive-behavioral skills building component(Melnyk et al. in press) in order to positively influencehealthy lifestyles beliefs and behaviors. In comparisonto other age groups, there has been less intervention re-search focused on enhancing healthy lifestyle behaviorsin teens. Thus, these types of studies are urgently needed.Changes in health policy to positively impact the pub-lic’s activity levels also are greatly needed (e.g., makingenvironments more activity friendly).

Level of Evidence: IV.

ReferencesGuyatt, G. & Rennie, D. (2002). Users’ guides to the medical

literature, Washington, DC: American Medical Associa-tion Press.

Harris, R.P., Hefland, M., Woolf, S.H., Lohr, K.N., Mulrow,C.D., Teutsch, S.M. et al (2001). Current methods ofthe U.S. Preventive Services Task Force: A review of theprocess. American Journal of Preventive Medicine, 20 (3Suppl), 21–35.

Melnyk, B.M. & Fineout-Overholt, E. (2005). Evidence-based practice in nursing & healthcare. A guide to bestpractice, Philadelphia: Lippincott, Williams & Wilkins.

Melnyk, B.M. & Moldenhauer, Z. (2006). The KySS guideto child and adolescent mental health screening, early inter-vention, and health promotion, Cherry Hill, New Jersey:NAPNAP.

Melnyk, B.M., Small, L., Morrison-Beedy, D., Strasser,A., Spath, L., Kreipe, R., Crean, H., Jacobson, D.& Van Blankenstein, S. (in press). Mental healthcorrelates of healthy lifestyle attitudes, choices andbehaviors in overweight adolescents. Journal of PediatricHealth Care. WorldviewsEvidenceDigestforMarchof2006FocusonAdolescents

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