| | Racial/Ethnic Differences in Teen and Parent Perspectives toward Depression TreatmentReceived 2 June 2008; accepted 30 October 2008. published online 12 January 2009. Abstract PurposeThere are significant racial/ethnic disparities in youth access to and use of appropriate depression treatment. Although there is a growing literature on racial/ethnic differences in treatment preference among adults, we know very little about whether these differences persist for adolescents and whether parents have an influence on their teens’ treatment perspectives. MethodsTeens and parents from a sample of primary care settings were interviewed at baseline and 6 months. We used bivarate and regression analyses to describe racial/ethnic differences in teen and parent depression knowledge and treatment preference and to assess the impact of parental views on teen perspectives. ResultsLatino and African American teens had lower average scores on antidepressant knowledge (p < .01) and counseling knowledge than white teens (p < .01). These racial/ethnic differences were greater among parents (p < .001). Parent antidepressant knowledge had an impact on teen knowledge when teens reported turning to them for advice (β = 0.20, p < .05). Teen knowledge about medication (odds ratio [OR] = 1.16, p < .01) and counseling (OR = 1.26, p < .001) were associated with a willingness to seek active treatment. ConclusionsRacial/ethnic differences in depression treatment knowledge persist, but are more pronounced for parents than teens. Talking to parents who have more knowledge about depression treatment is associated with more teen knowledge and that knowledge is associated with greater willingness to seek depression treatment. Research is needed on the content and type of conversations that parents and teens have about depression treatment, and if there are differences by race/ethnicity. Depression is a major adolescent health issue, yet unmet mental health need in this population continues to be a serious problem. Nearly 80% of adolescents who suffer from a mental health disorder do not receive adequate or appropriate care [1], [2], [3], with disparities apparent for ethnic minority groups. For instance, despite the fact that Latina teens have the highest rates of depression [4] and the rates of suicide are increasing among African American teens faster than ever before [5], these two groups of teens are less likely to receive necessary mental health services than their Caucasian counterparts [6], [7]. Wu [8] found that African American adolescents were less likely to receive care from a mental health professional, and Latino and African American teens were less likely to receive antidepressants compared with white teens. Traditional access barriers to health care, such as insurance, do not fully account for these differences in mental health service utilization for adults [9], [10]. For example, among adult patients with insurance and a usual source of medical care, Latinos are still less likely than whites to receive appropriate, evidence-based treatment consistent with practice guidelines [11]. Researchers have argued that patient factors, including varying perspectives on the mental health system and ideas about treatment modalities, may help to explain these disparities [10], [11]. Although adults overall are reluctant to use psychopharmacological treatment [12], [13], African Americans are more reluctant to seek active treatment and have higher rates of stigma associated with mental health service use [14], [15] In a study of depressed primary care adult patients, Dwight-Johnson [16] found that African Americans preferred counseling over medication, although patients with more knowledge about antidepressants were more likely to opt for active treatment (e.g., some type of therapy including counseling and/or medication). Among Latino adults, findings are similar. In studies among Latino immigrants, counseling is often preferred over antidepressants, and counseling is perceived to be more effective than medication in treating depression. In addition, antidepressants are viewed as addictive, causing states of “druggedness” [17], [18]. Whereas there is an emerging body of adult research on racial/ethnic differences in depression treatment perspectives, comparable studies among adolescents are limited. However, early findings indicate a similar profile. In studies of child mental health service use, ethnic minority parents are less likely than white parents to choose formal mental health providers, opting instead for informal providers, such as members of the clergy, for their children. These families report less confidence in the utility of psychotherapy and fear that contact with a formal mental health provider will result in institutionalization of the child [19], [20], [21]. The factors may explain the underlying factors that drive parental treatment preferences. These few studies are beginning to elucidate factors related to mental health service use, but have focused on younger children, where the parent is deciding on treatment on behalf of the child. This is contrast to the situation involved with older children and adolescents, where the child may play a more active role in decision making about mental health care. There have been very few studies that have addressed ethnic differences in treatment preference when seeking mental health services among adolescents [22], [23]. Jaycox and colleagues [22] found that African American teens are less likely to choose medication over counseling than their Caucasian counterparts, and Sen noted that African American and Asian males in particular were less likely to ask for help for a mental health issue [23]. Conceptually, it seems important to study adolescent treatment seeking in its own right, because parent perspectives may affect adolescent willingness to seek active treatment (as for younger children), but teens are also more active in the decision to seek care. In other fields, parent–teen communication about health can have a positive impact on adolescent health behaviors and help seeking. For example, teens who communicate with parents about sex have a greater understanding about sexual risk and a higher likelihood of condom use [24], [25]. In addition, interventions that address parent–adolescent communication about diabetes can improve compliance with diabetes regimens among teens [26]. To date, we know very little about the relationship between depression knowledge and mental health treatment preference, and in particular, whether parents and teens have similar perspectives on mental health treatment, and whether these factors differ by racial/ethnic group. Thus, the two aims of this paper are to: (1) describe racial/ethnic differences in teen and parent depression knowledge and treatment preference, and (2) assess whether parent perspectives on treatment are associated with teen knowledge and treatment preference and if this differs by race/ethnicity. Methods  Study design Study enrollment occurred between January 2005 and March 2006. We recruited our sample from seven healthcare organizations in Los Angeles and Washington, DC (three of these sites each had more than one participating clinic, for a total of 11 clinics; two clinics contributed no patients, yielding data from nine clinics). We selected sites purposively to maximize diversity by patient race/ethnicity and whether the clinics were free, public, private managed care, or private insurance. We also selected Los Angeles and Washington, DC, because these locations provided a wide range of public and private settings, and because the study staff are located in these two offices. Youth were approached at the clinic and invited to participate in the study. Youth assent and parent/guardian consent were required. Youth were eligible for the study if they were currently attending school within 2 years of expected grade level, currently living with a parent/guardian who could also speak English or Spanish, not currently pregnant, and did not have a sibling in the study. Once enrolled, eligible teens were assessed via telephone for participation in the project via the Diagnostic Interview Schedule for Children depression module [27], [28], [29]. Teens who were designated as “depressed” were invited to participate further in the study. After a depressed teen was enrolled, the next teen who screened as “nondepressed” from that same clinic, and of the same gender, was invited to participate as well. Thus, nondepressed teens were matched to depressed teens by clinic and gender. Teens and parents who participated in the study were interviewed at two points in time: shortly after the diagnostic interview, and again approximately 6 months later. One parent, generally the consenting parent, was invited to participate in the study. All measures were administered via Computer Assisted Telephone Interview (CATI). The survey was highly structured. Interviewers were trained to not deviate from the interview questions and script, and interviews were monitored for fidelity to this structure. During the period between baseline and follow-up interviews, teens, parents, and physicians received feedback on the teen's depression status, and the teen and parent received educational materials about depression. A random half of the depressed teens completed a motivational interview by telephone with study staff. All participants were free to seek care for depression at any time. All teens and parents who participated in the initial screener interview received feedback via mail on their screening assessment, as well as an educational brochure about depression and an incentive payment. This study was approved by the RAND Human Subjects Protection Committee and relevant clinic institutional review boards where appropriate. We included detailed protocols for teens at risk in this study. Study population A total of 5687 teens expressed interest in the study, and 5084 assented to participate and received parent consent. Of these, 4856 completed a full screening assessment, and 4710 of these teens were eligible for the study. This resulted in equal numbers of depressed and nondepressed teens from each clinic (roughly matching on many demographic, insurance, and socioeconomic factors) and in a similar gender ratio in the two groups (n = 368, response rate 368/375 eligible = 98%). We limited our analyses for this paper to those teens whose parents completed the baseline interview (n = 324). Measures Demographic variables Our key demographic characteristics of interest were teen age, teen gender, teen race/ethnicity (white, black/African American, Latino), parent educational attainment (less than high school, high school, at least some college), and whether the parent interview was conducted in Spanish (a proxy of language comfort/acculturation). We used teen race as our indicator of race given that nearly all of the parents were of the same race (95.4%). In addition, depression status (none, minor, major) was assessed, derived from the scoring algorithm used for this measure (a count of eight items). Depression treatment experience We included depression treatment experience as a predictor in models that examined depression treatment knowledge, given that it may relate to greater knowledge. Teens were queried about whether they had received treatment for depression in the past 6 months (yes/no), whether they had sought counseling for depression (yes/no), and whether they had used antidepressant medication (yes/no). We created indicator variables for each of these items. Parent depression advice Because the relationship between parent and teen knowledge and treatment preferences was likely to depend on the nature of the relationship and communication with parents, we included two measures that describe this relationship. First, we included an item that assessed how much teens agreed with the following statement if they had depression and needed care: “I would get advice from my parents about depression.” Teens who said they strongly agreed or agreed with this statement were classified as teens who looked to their parents for depression advice. This variable served as one indicator of possible parent to teen depression treatment knowledge transmission. Family support or closeness We also included a measure that assessed the general closeness with a parent, as an indication of comfort in discussing mental health issues. Teens were asked about their closeness to parents via three items (amount of togetherness, level of understanding and support from parents, and amount teen talks to parents about issues) (mean = 9.3, SD = 3.4, min = 3, max = 15) Dependent variables Knowledge about depression treatment One of our main outcomes of interest was teen and parent knowledge about depression treatment. We analyzed this two ways. First, we constructed two measures to operationalize knowledge about depression treatment by counting the number of items answered correctly and dividing by the number of items so that a higher score indicates a higher percent of correct items. The first score assessed knowledge about antidepressant medication with ratings of four statements (teen: mean = 12.7, SD = 2.7, min = 4, max = 19; parent: mean = 13.1, SD = 3.0, min = 4, max = 20). One item was not included in the scales based on factor analysis, and thus was analyzed separately—antidepressant medications are safe for most teenagers. The second score assessed knowledge about counseling using ratings of four statements. We also summed items in each knowledge score (1–5) and reverse coded toward correctness, with a higher value indicating more knowledge (see Table 3, Table 4) (teen: mean = 14.6, SD = 2.6, min = 5, max = 20; parent: mean = 15.9, SD = 2.3, min = 8, max = 20). Treatment preference Our second outcome of interest was teen and parent preference for types of depression treatment (antidepressants only, counseling only, combination therapy, watchful waiting, or no treatment at all). We created a preference for seeking active treatment variable by combining any form of treatment (medication only, counseling only, or combination treatment) and comparing against either watchful waiting or no treatment. The depression knowledge, treatment preference, and family support items were adapted from RAND's prior studies on depression in primary care, Partners in Care [30] and Youth Partners in Care (YPIC) [22]. Data analysis Univariate descriptives were run using only the first imputation. However, bivariate and multivariate cross-sectional analyses were repeated on five imputed datasets and results were combined using standard multiple imputation rules [31], [32] to obtain parameter estimates and their adjusted standard errors. Although teens were clustered in sites, the intraclass correlations in our models predicting medication knowledge, counseling knowledge, and treatment preference were close to or equal to zero. Consequently, we decided not to cluster any outcomes by site. Our first step was to examine differences in gender, age, depression status, past experience with medication and counseling, parent education, and closeness to parents, by teen race. We then looked for differences by race in knowledge about depression treatment and treatment preference separately for teens and parents (Aim 1). We utilized bivariate analyses to test for associations between the independent variables of interest and our outcome variables (Aim 2). Our second step was to understand what factors may predict teen knowledge of medication and counseling, and whether parent knowledge played a role in knowledge differences. We ran ordinary least squares regressions (OLS), using parent knowledge, teens’ willingness to turn to their parents for depression advice, and an interaction of the two to predict the our dependent variables while controlling for teen race, age, gender, previous use of medication or counseling, parental educational attainment, and parents’ preference for Spanish-language materials (our acculturation proxy of household linguistic isolation). We did not adjust for socioeconomic status because this factor is often highly confounded with race [33]. Finally, we ran logistic regressions to predict teen preference for active depression treatment. We tested for relationships between teen knowledge about medication and counseling and their treatment preference while controlling for teen race, age, gender, previous use of medication or counseling, parental educational attainment, parents’ preference for Spanish-language materials, and level of teen-reported parental support. Results Sample characteristics Table 1describes the sample sociodemographic characteristics by teen race. This sample was 76% female, 34% black/African American, 50% Latino, and 16% white. Overall, 45% of parents in this sample had completed at least some college, but fewer African Americans and Latino parents compared with white parents had completed at least some college (p < .01). Fifty-nine percent of the Latino parents conducted their interviews in Spanish. | | |  | | Teen race | Probability | |
|---|
| | African American | Latino | White | chi-square | |
|---|
| | (n = 110) | (n = 163) | (n = 51) | | |
|---|
| Gender | | | | | | |  Male | 23.64 | 20.86 | 21.57 | .87 | | | Female | 76.36 | 79.14 | 78.43 | | | | Age | | | | | | | 13–15 | 60.91 | 52.76 | 56.86 | .40 | | | 16–18 | 39.09 | 47.24 | 43.14 | | | | In the past 6 months, | | | | | | | Any treatment for personal/emotional problems | 26.36 | 31.29 | 33.33 | .58 | | | Any medication | 8.18 | 10.43 | 23.53 | .02 | | | Any counseling | 34.55 | 35.58 | 39.22 | .82 | | | Would get advice from parents about depression | | | | | | | No | 43.64 | 41.10 | 37.25 | .76 | | | Yes | 56.36 | 58.90 | 62.75 | | | | Parent education | | | | | | | Did not finish HS | 10.00 | 49.69 | | .00 | | | HS graduate/GED | 33.64 | 26.38 | 11.76 | | | | Some college/AA degree | 37.27 | 14.11 | 23.53 | | | | 4-year college degree | 12.73 | 6.75 | 27.45 | | | | Graduate/professional degree | 6.36 | 3.07 | 37.25 | | | | Depression status | | | | | | | Not depressed | 76.36 | 77.91 | 78.43 | .94 | | | Minor depression | 14.55 | 14.72 | 9.80 | | | | Major depression | 9.09 | 7.36 | 11.76 | | | | | |
| | | | Parameter | Odds ratio | Confidence interval | |
|---|
| Teen knowledge of counseling | 1.26 | (1.12, 1.42)∗∗∗ | | | Teen knowledge of medication | 1.16 | (1.04, 1.29)∗∗ | | | Any treatment for personal/emotional problems in the last 6 months | 1.16 | (0.64, 2.10) | | | Spanish parent survey instrument | 0.75 | (0.32, 1.76) | | | Teen race | | | | | African American | 1.28 | (0.52, 3.14) | | | Latino | 1.12 | (0.42, 2.99) | | | White | 1.00 | | | | Level of parental support | 1.08 | (1.00, 1.17) | | | Parent education | | | | | Did not finish HS | 2.07 | (0.63, 6.82) | | | HS graduate/GED | 1.68 | (0.57, 4.99) | | | Some college/AA degree | 1.17 | (0.41, 3.38) | | | 4-year college degree | 1.40 | (0.44, 4.46) | | | Graduate/professional degree 1.00 | | | | Age | | | | | 13–15 | 0.91 | (0.53, 1.57) | | | 16–18 | 1.00 | | | | Gender | | | | | Male | 0.36 | (0.19, 0.66)∗∗∗ | | | Female | 1.00 | | | | | |
African American, Latino, and white teens have similar rates of (levels of) depression (minor vs. moderate), although more white teens were classified with major depression (data not shown). African Americans reported less experience with any treatment for an emotional problem (counseling and/or medication) compared to their Latino and white peers. African American and Latino teens had significantly less experience with antidepressant use compared with white teens (p = .02), but there was no difference in counseling experience. There was no difference by race/ethnicity in level of family closeness or in willingness to seek advice about depression treatment from a parent. Treatment knowledge As described in our analysis section, we examined racial/ethnic differences in teen and parent knowledge about antidepressants and counseling (Table 2). Latino and African American teens had lower average scores on antidepressant knowledge (p < .01) and counseling knowledge than white teens (p < .01). Although the overall knowledge level was greater for parents, these racial/ethnic differences persisted (p < .001) and were somewhat greater. For example, only 52% of Latino and African American parents thought that antidepressants could help treat people's depression by helping improve sleep, energy, and appetite compared with 90% of white parents. On the other hand, teens did not differ on this item (data not shown). Pairwise t-tests indicated that the difference between black and Latino teen knowledge was not statistically significant, but the difference between black and white, and Latino and white teens is different (p < .01). Parental knowledge about medication followed similar patterns; however, differences regarding counseling knowledge persisted between all racial/ethnic group dyads. To determine which factors were related to teen knowledge, we conducted a series of bivariate analyses with our independent variables of interest (data not shown). In addition to being white, older age and female gender were associated with greater medication and counseling knowledge (p < .05). Interestingly, prior experience with medication was associated with more medication knowledge (p < .001), yet this relationship did not hold for counseling experience. There also was an association between teen and parent depression knowledge, particularly with respect to medication knowledge (p < .001). In addition, turning to a parent for advice was associated with greater teen counseling knowledge for all groups and associated with greater medication knowledge among Latino teens in particular (p < .01). Given our study aims and these findings, we wanted to further explore how parent knowledge influences teen treatment knowledge (Table 3). In multivariate analyses, parent knowledge of antidepressants had an even greater effect on teen knowledge when teens reported turning to them for advice (β = 0.20, p < .05). Female gender was no longer a predictor of greater knowledge of antidepressants; however, the relationship of prior experience with treatment and older age persisted. Even when adjusting for parent knowledge, African American teens reported less medication knowledge than their peers. Latino teens did not have less knowledge unless their parents requested the survey in Spanish (our proxy for language comfort/acculturation level). In terms of counseling, Latinos had lower levels of knowledge as did younger teens. No other predictors were significantly associated with counseling knowledge. Treatment preference Our next objective was to examine if there were racial/ethnic differences in teen and parent preferences for depression treatment. There were no statistically significant differences in treatment preference among teens, with the majority of all teens preferring some form of active treatment (71% of African American, 67% of Latino, 73% white) (Table 2). Fewer Latino and African American parents preferred active treatment compared to white parents (p < .05) (Table 2). In terms of treatment type, Latino and African American parents preferred watchful waiting (22% and 24%, respectively) or counseling (66% and 62%, respectively), whereas white parents opted for combination treatment (45%) or counseling (48%) (p < .001). There was greater disagreement about treatment preference (active vs. passive) between Latino parents and teens (p < .01) and white parents and teens (p < .05), but this level of disagreement was not found among African American parent–teen pairs. Given the findings from the first set of analyses relating teen and parent treatment knowledge, we wanted to examine if knowledge ultimately affects preference. In multivariate analyses (Table 4), we examined predictors of treatment preference with the same variables from the knowledge analyses, with two exceptions. We did not include the item about teens requesting advice on depression from their parents, because it was not associated with preference in bivariate analyses, and did include teen reports of closeness with the parent, because it was associated with preference. Teen knowledge about medication (OR = 1.16, p < .01) and counseling (OR = 1.26, p < .001) were strongly associated with a willingness to seek active treatment. Boys were also less likely to prefer active treatment. We did not find an interaction between gender and race/ethnicity. Although race/ethnicity was a factor in predicting teen treatment knowledge, it was not a predictor of treatment preference. Discussion This study provides key information about racial/ethnic differences in perspectives on depression treatment. In addition, this research adds to our current understanding of adolescent knowledge and viewpoints by analyzing the role of parents in influencing those preferences. Although prior research has revealed that there are racial/ethnic distinctions in treatment views, we really know very little about whether these perspectives are shared by teens and parents for treatment of teens. This information is important, given the increase in public information campaigns and media messages regarding depression. The findings of this study indicate a potential generational difference in depression treatment perspectives, suggesting a slight increase in positive attitudes towards active treatment among ethnic minority teens while the racial/ethnic distinctions among adults remain pronounced. Despite this attitudinal shift among teens with relatively little racial/ethnic difference in general willingness to seek active treatment, there are still meaningful disparities in ethnic minority teens’ comfort with antidepressants. Further, treatment knowledge differences by race/ethnicity exist, and these differences are key predictors of willingness to seek treatment. This study also affords new insight into the role of parents in shaping teen perspectives regarding depression treatment. We identified an association between teen and parental knowledge about medication, and noted that turning to parents for advice about treatment may confer more accurate depression information. Although not statistically significant, we did note a potential relationship between teens who reported more closeness with parents about emotional issues and a willingness to seek active treatment, a finding worthy of continued exploration. The study underscores new directions for research and mental health education. First, our research highlighted continued differences in treatment knowledge and preference by race/ethnicity, and an association between the two. However, it is unclear if this knowledge difference is a function of limited interest in or negative attitudes toward particular treatments. Further, we do not know whether the availability of certain treatment options (varied by insurance status, provider preference) affects teen and parent treatment perspectives. Additional research should examine how adolescents from different racial/ethnic subgroups obtain and process information about depression and treatment options. Second, we found an association between prior exposure to medication and experience, but not between counseling experience and knowledge. This raises new questions regarding how accurate and comprehensive information about counseling can be effectively shared with youth. In addition, we do not know whether this inaccurate counseling knowledge may reflect youth experiences with poorer quality counseling (e.g., supportive counseling rather than cognitive–behavioral therapy). Third, although increasing knowledge about medication in particular may help to change perspectives toward this option among youth and families of color, the preference for counseling may persist. However, we know from prior research that unmet mental health need continues to be a problem among African American and Latino youth, and that counseling is difficult to obtain through primary care [34], [35]. Thus, we should consider examining provider perspectives on dispensing antidepressants and testing interventions to facilitate linkages with counseling specifically for these populations. Fourth, given the findings about the role of parent–teen communication and depression treatment perspectives, more research is needed on the content and type of conversations that parents and teens have about depression and how knowledge and attitudes are conveyed. Finally, the finding that African American teens have greater agreement on treatment preference than their white or Latino counterparts suggests a potentially meaningful difference in parent–teen communication that merits further examination. In addition to these critical areas of research, this study has a few programmatic implications. Given the persistent knowledge differences among parents and the potential role of parents in influencing teen willingness to seek active care, depression education strategies should consider actively engaging both parents and teens. In addition, we know from this work that Latino teens from more linguistically isolated households (as determined by our interview language preference proxy) had more limited knowledge of medication. This suggests that this group in particular may benefit from more targeted, culturally tailored education about the use of medication. Although not a primary focus of this research, we also noted differential perspectives about depression treatment by age and gender, with older teens reporting more counseling and medication knowledge and females reporting greater willingness to seek care. Intervention strategies (e.g., educational materials, clinician sessions) should consider communication methods that may be more effective with younger and male teens. This research provides important findings about racial/ethnic differences in depression treatment perspectives and the influence of parental views, but results should be interpreted with a few caveats. First, our analyses examining variation on depression knowledge are based on a primary care sample. One could argue that families that are less connected with routine primary care may have different knowledge or less favorable perspectives regarding depression treatment. Second, a focus of this research was to examine the influence of parent attitudes, yet we only had two measures of parent–child communication that may not comprehensively characterize the nature of these discussions. Third, our analyses focused on the relationship between race/ethnicity, knowledge, and willingness to seek active treatment. However, we do not know whether this treatment preference links to actual service use. Despite these limitations, this study is one of few to examine adolescent perspectives on depression and to frame a discussion on how information about depression treatment is contextualized by youth from varied racial/ethnic backgrounds. The challenge of unmet mental health need, particularly for youth of color, necessitates continued examination of factors that may help to explain some of these barriers to care. Acknowledgments This research was supported by an unrestricted grant to the RAND Corporation from Pfizer Inc. We wish to acknowledge the following sites for their participation in this study: Capitol Medical Group—Richard Jones, M.D.; Kathy McCue, C.R.N.P; Kaiser Permanente Mid-Atlantic—Mark Snyder, Tami Collins, M.D., Sima Bakalian, M.D.; Children's National Medical Center—Larry D'Angelo, M.D.; Children's Pediatricians and Associates—Ellie Hamburger, M.D.; Northeast Valley Health Corporation and San Fernando High School, Los Angeles Unified School District—Jan Marquard; White Memorial Medical Center, Family Care Specialists, and the WMMC Family Medicine Residency Program—Rosina Franco, M.D.; and Kaiser Permanente Southern California—Virginia Quinn, Ph.D. We also thank Scot Hickey, M.S., for programming and data management, Mayde Rosen, R.N., B.S.N., for project management, Michael Seid, Ph.D., and Stephanie Taylor, Ph.D., for their contributions with instrument development, Daniela Gollnelli, Ph.D., for the study design, Judy Perlman, M.A., from the RAND Survey Research Group for recruitment and data collection support, Sarah Gaillot, M.Phil., and Jane McClure, J.D., for research assistance, and Toni Florence for help with manuscript preparation. 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a RAND Corporation, Arlington, Virginia b RAND Corporation, Santa Monica, California  Address correspondence to: Anita Chandra, Dr.PH., RAND Corp., Health, 1200 South Hayes Street, Arlington, VA 22202-5050.
PII: S1054-139X(08)00590-9 doi:10.1016/j.jadohealth.2008.10.137 © 2009 Society for Adolescent Medicine. Published by Elsevier Inc. All rights reserved. | |
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