"Home Alone": Potential Implications for Adolescents

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146 COMMENTARIES

dren during treatment with prednisolone. Br Med J.1990301:145-148 5. Philip M, Aviram M, Leiberman E, et a. Integrated plasma cortisol

concentration in children with asthma receiving long-term inhaled cur-ticosteroids. Pediatr Pu!monol. 1992;12:84-89

6. Bhan GL, Gwynn CM, Smith JM. Growth and adrenal function of chil-dren on prolonged beclomethasone dipropionate treatment. Lancet. 1980;i96-97

7. Kerrebijn KF. Beclomethasone dipropionate in long-term treatment of asthma in children. IPediatr. 197689:821-826

8. Goldstein DE, Konig P. Effect of inhaled beclomethasone dipropionate on the hypothalamic-pituitary-adrenal axis function in children with asthma. Pediatrics. 1983;72:60-64

9. Shapiro GG, Sharpe M, DeRouen TA, et al. Cromolyn versus triamcin-olone acetonide for youngsters with moderate asthma. JAllergy Clin Immuno!. 1991;88:742-748

10. Ernst P, Spitzer WO, Suissa 5, et al. Risk of fatal and near-fatal asthma in relation to inhaled corticosteroid use. JAMA. 1992;268:3462-3464 11. Bel EH, Timmers MC, Hermans J, Dijkman JH, Sterk PJ. The long-term

effects of nedocromil sodium and beclomethasone dipropionate on

bronchial responsiveness to methacholine in nonatopic asthmatic sub-jects. Am Rev Respir Dis. 1990;141:21-28

12. Special Report. Asthma: a follow-up statement from an international pediatric asthma consensus group. Arch Dis Child. 1992;67:240-248 13. American Academy of Pediatrics, Committee on Drugs. Precautions

concerning the use of theophylline. Pediatrics. 1992;89:781-783 14. Brown PH, Blundell G, Greening A1 Crompton GK Do large volume

spacer devices reduce the systemic effects of high dose inhaled corti-costeroids? Thorax. 1990;45:736-739.

“Home

Alone”:

Potential

Implications

for Adolescents

Considerable attention has been given in the liter-ature to the clustering of adolescent “problem behav-iors” (premature sexual activity, substance abuse,

cigarette smoking, marijuana use, school

under-achievement).3 The resultant potential of these be-haviors for morbidity and mortality has prompted further investigation into the clustering of problem behaviors as a concept. Moreover, if one theory or condition could be shown to underlie such high-risk behaviors, it might be possible to target interventions specifically toward that one etiology rather than to-ward the several elements of the combination of per-sonal, social, and environmental etiologies that are thought to lead to risk-taking. The earlier the

inter-vention, the potentially more effective it would be,

because young people, their families, and society would be spared untoward outcomes.

Because reports of several recent studies have af-firmed the earlier finding of Jessor and Jessor1 that “problem behaviors may cluster,” it is particularly appropriate that several articles in this issue of

Pedi-atrics address topics related to high-risk behaviors among adolescents. In reviewing and considering these articles-and to move further toward testable

theories-perhaps it would be most appropriate to

determine whether there are ways to “lump,” rather than to “split,” the findings of each article.

Let us first, then, take the findings from two of these studies4’- and explore whether a theory evolves. Richardson et al4 hypothesized that young

Received for publication Mar 22, 1993; accepted Apr 2, 1993.

people who are unsupervised after school may be at risk of being lonely (depressed) and/or may be at

risk of having peers influence their behavior. In ad-dition, one might theorize that adolescents who are

either “home alone” or with peers may have more

time for watching television shows and reading

mag-azines that might suggest problem behaviors and

thus lead to such behaviors.

Data from the article by Richardson et al indicate

that adolescents who are not supervised by adults

after school have significantly more problem

behav-ior (more substance abuse, risk-taking, depression, and poor grades) than do those who are supervised by an adult; however, there were no significant

dif-ferences in the risk-taking behavior of those adoles-cents who had adult supervision and those who were

unsupervised, but whose parents always knew

where they were. The investigators defined adult su-pervision as one or both parents (1) actually being in the home, or (2) keeping in close contact with their adolescents. Those young people whose parents

never knew their whereabouts had more problem

behaviors than did those whose parents usually or always knew their whereabouts. When the setting of after-school care was analyzed, adolescents who

were at school, at a job, or unsupervised at a

neigh-bor’s house-and especially those who hung out with Mends-were most likely to engage in problem behaviors. Thus, the possibility of strong peer influ-ences affecting any young person’s behavior nega-lively became even greater in those exposed to out-of-home interactions after school. Adolescents who were unsupervised at home were more likely to watch television, to read or do homework, and/or to cook than were those in other settings.

The study by Klein et a!5 gives us further insight

into the relationship between the use of the popular media and high-risk behaviors. Adolescents who re-ported having engaged in more high-risk behaviors listened to the radio, watched music videos, and watched movies on television more often than did adolescents who engaged in fewer high-risk

behav-iors. Of great interest is the type of television viewing that adolescents reported. Youngsters who reported engaging in few high-risk behaviors watched more action or adventure shows and more game shows than did youngsters reporting more high-risk

behav-iors. Adolescents who reported engaging in more

high-risk behaviors were more likely to read sports magazines and music magazines and less likely to read entertainment magazines, eg, People, than were adolescents who reported less participation in high-risk behaviors.

We know that there are relationships among

clus-ters of high-risk behaviors in adolescents and that there also may be clusters of circumstances placing teenagers at particularly high risk. Without implying any direct cause and effect, but only the potential for

relationships, one way of consolidating the findings

from these two papers might be to say that we have

learned that it is important for parents to be engaged in the supervision or planning of adolescent after-school activities and use of after-school time to

re-duce at least partially the incidence of high-risk

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COMMENTARIES 147

haviors. If parents are unable to do this due to extenuating circumstances, such as poor health or the

need to be at work, they need to find ways to provide

meaningful adult supervision for their adolescents. Such a simple solution could be seen as (1) trivial and obvious, or (2) regressive and/or illogical, because

some would argue that adolescents should be given

increasing responsibility and independence so that they can learn how to cope with challenges in today’s world. To imply that adult supervision of after-school time is important might diminish the

theoret-ical importance of the development of independence.

Perhaps this counterargument is persuasive, but in

truth many of our young people are undersuper-vised, many are in trouble, and many need adult supervision. As caring adults worried about the youth of our society, we need to develop solutions

that are theoretically sound, that make sense, and that can be implemented.

Having made these sweeping theoretical generali-zations, however, we must realize how difficult it is for us to thoroughly understand the complex etiolo-gies, the meanings of problem behaviors, and the relationships among them. For example, we find that

there are ethnic differences, gender differences,

com-bined ethnic and gender differences, and geographic differences in what a behavior means to an

adoles-cent.

Stanton and colleagues,6 who studied two samples of urban, young adolescents who were primarily Af-rican-American, reported that 40% of their subjects reported having had nonmarital coitus and that rates for school truancy fflicit drug use, or drug trafficking were substantially lower than the incidence of coitus. Analysis of reported feelings, behaviors, and per-ceived peer norms showed that sexual activity was consistently noted to be in a different domain from other behaviors commonly recognized as problems.

For example, when feelings about engaging in

high-risk behavior were scored, the mean score for sexual

activity was 2.9 (neither good nor bad), whereas

mean scores for other activities ranged from I .6 to I .2 (bad to very bad). Both boys and girls expressed more positive feelings about sexual activity than they did about the other behaviors assessed. Thus, it is important to understand the personal and cultural meaning of behaviors to target interventions in a meaningful fashion. Among these young people, sex-ual activity was not perceived as a problem behavior, nor was it necessarily related to other behaviors that are perceived as problems by these young people

and by others.

Klein et al reported that white youth were more likely to have engaged in most of the riskier

behav-iors than were black youth, with two exceptions;

more black teenagers reported having had sexual

in-tercourse, and there were no racial differences re-garding stealing. Data from the study of Richardson et a! confirmed that white youth were more likely to smoke cigarettes, drink alcohol, and experience de-pression than were black and/or Hispanic youth.

Gender differences can also be seen in the results of these studies. Boys consistently reported having engaged in more risky behaviors than did girls in the

study by Klein et al; when adolescents were

catego-rized by level of risk, fewer girls than boys fell into

the high-risk category. Richardson et al reported that

girls were more likely to get better grades and that

boys were more likely to be risk-takers. Supervised

girls were less likely than boys to participate in

high-risk behaviors, but they were more likely than boys to engage in problem behaviors when they were un-supervised by an adult or when their whereabouts were unknown to their parents. In addition to ethnic and gender differences, there may be ethnic/gender/ age interactions with regard to high-risk behavior. For example, in the Klein study older white boys were most likely to be classified as high-risk when

adolescents were classified by race, gender, and age

into low-, moderate-, and high-risk groups.

Geographic differences may affect the definition of

and the risk of problem behaviors. Each study

con-centrated on groups of teens from

defined,

different

geographic locations. Adolescents in the study by Stanton et al were from an urban, impoverished area; those in the study by Klein et a! were randomly selected adolescents in the southeastern United States; and those in the study by Richardson et a!

were ninth grade students in six school districts in

southern California. Thus, for us to advance in our

understanding of problem behaviors, we must

at-tend not only to the subtle effects of ethnicity, gender, and age, but also to the possible effects of geographic location on the definition of problem behaviors.

These three papers taken individually, as well as collectively, have extended our knowledge about the high-risk behaviors of adolescents and the potential

conditions that place teenagers at risk of engaging in

such behaviors, but a model such as the one pro-posed earlier on the basis of these three papers fails to acknowledge the vulnerability of the individual

adolescent in given circumstances. That is, a resilient

adolescent who is unsupervised at home may attend to homework and responsibilities at home and may not be vulnerable to outside influences. Another youngster in the same circumstance may not be able to tolerate being home alone, may become depressed, and may either consciously or unconsciously seek

risky means of assuaging the painful effects of being

alone.

Although there are no simple solutions to society’s

most complex problems, the authors of these three studies have helped us to move forward in our con-ceptual thinking as we seek to understand and to ameliorate some of these problems. We should con-gratulate them for executing studies that aid us im-measurably in gaining insights into the problem be-haviors of today’s adolescents.

ELIZABFJH R. MCANARNEY, MD

University of Rochester Medical Center

Rochester, NY 14642

REFERENCES

1. Jessor R, Jessor SL Pmb!em &havior and Psychosocial Development. New

York: Academic Press; 1977

2. Irwin CE, Millstein 5G. Biopsychosocial correlates of risk-taking behav-iors during adolescence. JAdolesc Health Care. 1986;7:82S-96S.

3. Ensminger M. Sexual activity and problem behaviors among black,

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148 COMMENTARIES

urban adolescents. Child Dcv. 1990;61:2032-2046.

4. Richardson JL, Radziszewska B, Dent CW. Relationship between after-school care of adolescents and substance use, risk-taking, depressed mood, and academic achievement. Pediatrics. 199392:32-38

5. Klein JD, Brown JD, Childers KW, Oliver J, Porter C, Dykers C. Ado-lescents’ risky behavior and mass media use. Pediatrics. 1993;92:24-31

6. Stanton B, Romer D, Ricardo I, Black M, Feigelman 5, GalbraithJ. Early initiation of sex and its lack of association with risk behaviors among adolescent African-Americans. Pediatrics. 199392:13-19

Surfactant

Replacement

Therapy:

Prophylaxis

or Treatment?

ABBREVIATIONS. RDS, respiratory distress syndrome; RCT, ran-domi.zed clinical trial.

After extensive preclinical and clinical testing,

sur-factant replacement therapy for premature neonates

has become routine in modern neonatal intensive care units. Even though “everyone’s doing it,” there is nevertheless wide variation in how this therapy is applied. Future studies will be needed to help sort out some of the unresolved issues such as the best preparation, optimal delivery method, how best to ventilate the surfactant-treated neonate, when to re-treat with surfactant, and the role of adjunctive ther-apies such as indomethacin or corticosteroids.

Considerable controversy also exists over when surfactant should be administered. This issue has been studied in some depth, both in animals and premature neonates. Laboratory studies have docu-mented improved outcome when surfactant is given to premature animals at birth rather than after the onset of respiratory failure.13 Prophylaxis, or treat-ment at birth of neonates at high risk of developing respiratory distress syndrome (RDS) regardless of clinical status, has been compared to treatment only

of neonates who have developed RDS of a certain severity in several prospective randomized clinical trials.7 These studies yield divergent results, al-though the largest of the four trials reported a sig-nificant reduction in mortality with prophylaxis, es-pecially in neonates born at less than 27 weeks’

gestation.4 A meta-analysis of all four trials revealed

a marginal reduction in pneumothorax and mortality

with prophylaxis, but no other statistically signifi-cant differences.8 Differences in sample size, study design, and local population characteristics likely ac-count for the different results and conclusions drawn from the various trials. Until more definitive data become available, either approach to surfactant re-placement therapy must be considered valid, and the decision as to which to use should be based on local conditions and practices. While it can be stated that there are theoretical advantages to prophylactic ad-ministration of surfactant, there are also practical

dis-advantages to this approach and many clinicians

have been reluctant to routinely intubate and

admin-Received for publication Apr 15, 1993; accepted Apr 16, 1993.

ister surfactant to all neonates of a certain size or maturity (Tables I and 2).

The study reported by Kattwinkel et al9 in this

issue examines the timing of surfactant

administra-tion in relatively mature preterm neonates of 29 through 32 weeks’ gestation. The study was well designed and executed. Expecting that there might be no advantage to prophylaxis in this group of ne-onates in whom the incidence of RDS is low, the

investigators enrolled sufficiently large numbers to be comfortable with the null hypothesis if no statis-tically significant differences were shown. The find-ing of fewer deaths and decreased oxygen depen-dence with prophylaxis may have been unexpected

in this low-risk population but is consistent with the

findings of animal studies and the study of Kendig et a!4 in smaller neonates.

The authors suggest that we strongly consider ad-ministration of surfactant at birth to all neonates born at less than 31 weeks’ gestation. Before accepting this recommendation, however, the trial methodology and results must be carefully examined for possible alternative explanations for the differences observed. It can be readily appreciated that the criteria for re-treatment with surfactant used in this trial are much more stringent than those generally used in clinical practice. It was necessary for a neonate to require a mean airway pressure of 10 cm H2O and fraction of inspired oxygen of 0.60 before an extra dose of sur-factant could be given. It is possible that, by forbid-ding retreatment until babies had deteriorated to a significant degree, the investigators might have cre-ated the differences in mortality and chronic lung

disease that were eventually detected. That the

neo-nates in the treatment group reached “study failure” and retreatment levels more commonly than those in the prophylactic group is not surprising in that the

lung injury sustained within only a couple of hours

of assisted ventilation in the surfactant-deficient lung may have been sufficient to lead to an increase in surfactant-inhibiting proteins in the airways and the

resultant clinical deterioration.10’” If more liberal

re-treatment of these neonates had been allowed, the

clinical significance of this phenomenon may have

been minimized.

In the design of a large randomized clinical trial, consistency is achieved through adoption of some very specific, often artificial guidelines for clinical management. This is necessary, but can be the Achil-les’ heel of the multicenter randomized clinical trial

(RCT), limiting the generalizations that can be drawn from the results. Even large, fully sponsored and well thought-out trials have their limitations and often end up testing a very restricted hypothesis. It has been suggested that the National Institutes of Health-funded “HIFI Trial” may have failed to show any advantage to high-frequency oscillatory ventilation

TABLE 1. Potential Advantages of Prophylactic

Surfac-tant Replacement Therapy

1. Facilitation of initial lung aeration and resorption of lung liquid

2. Decreased barotrauma/leakage of inhibitor proteins

3. Improved distribution of administered surfactant

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1993;92;146

Pediatrics

ELIZABETH R. MCANARNEY