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Prevalence and Patterns of Intimate Partner Violence Among Adolescent Mothers During the Postpartum Period
Samantha D. Harrykissoon, MPH;
Vaughn I. Rickert, PsyD;
Constance M. Wiemann, PhD
Arch Pediatr Adolesc Med. 2002;156:325-330.
ABSTRACT
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Objective To examine prevalence, frequency, severity, and patterns of intimate
partner violence (IPV) during the first 24 months' post partum within a multiethnic
cohort of adolescents.
Design A prospective study of adolescent girls followed up for 24 months into
the postpartum period. Follow-up surveys were completed at 3, 6, 12, 18, and
24 months' post partum. Overall, 74% completed at least 4 of the 5 follow-up
surveys.
Setting Postpartum unit at a university teaching hospital in Galveston, Tex.
Participants A total of 570 adolescents (18 years or younger; 219 Mexican Americans,
182 African Americans, and 169 European Americans) completed face-to-face
interviews within 48 hours of delivery and returned at least 4 of 5 follow-up
surveys.
Main Outcome Measures Prevalence of IPV and frequent and severe IPV.
Results Prevalence of IPV was highest at 3 months' post partum (21%) and lowest
at 24 months (13%). The percentage of assaulted mothers who experienced severe
IPV increased from 40% to 62% across this period. Seventy-five percent of
mothers reporting IPV during pregnancy also reported IPV within 24 months
following delivery. Of importance, 78% who experienced IPV during the first
3 postpartum months had not reported IPV before delivery. Ethnic differences
in IPV were observed at 3, 6, and 18 months' post partum.
Conclusions Adolescents are at high risk for experiencing IPV during the postpartum
period. Frequent screening for IPV by health care practitioners is critical
to maximize detection.
INTRODUCTION
PHYSICAL VIOLENCE during pregnancy is now recognized as a serious public
health concern, with females aged 16 to 24 years at highest risk.1-5
Despite the observation that many battered women endure a pattern of progressively
escalating intimate partner violence (IPV) over time6
and a recent study7 reporting increased risk
of homicide among postpartum females aged 15 to 19 years, few studies8-10 have systematically
examined abuse of young mothers in the months following delivery. In one small
study8 of females aged 14 to 40 years who were
physically abused during pregnancy, the mean number of incidents of physical
assaults per abused woman was significantly higher 3 months' post partum than
during the 3 months before conception or at any trimester of pregnancy. In
another study9 of women of mixed ages, physical
violence was more common at 6 months' post partum than during the prenatal
period, with younger mothers at greatest risk. Gessner and Perham-Hester10 compared the risk of experiencing violence following
delivery among women older than 20 years to the risk among women aged 18 to
19 years and to those younger than 18 years. At 3.9 months' post partum, the
youngest mothers were 2 to 3 times more likely to report IPV. Yet, how far
into the postpartum period high rates of IPV are maintained and what proportion
of young mothers experience repeated episodes of assault have not been systematically
examined.
The purpose of this investigation was to extend our prior study on IPV
during pregnancy11 among a large, multiethnic
cohort of young mothers who began childbearing as adolescents. The objective
was to examine IPV during specific intervals (3, 6, 12, 18, and 24 months)
across the postpartum period. Although studies12-14
have shown that experiencing IPV during pregnancy may differ by ethnicity,
to date no studies have examined differences among African American, Mexican
American, and European American young mothers during the postpartum period.
A first step in eliminating ethnic disparity in the occurrence of IPV among
pregnant or parenting adolescents is to evaluate whether it exists, independent
of socioeconomic level. Therefore, ethnic differences in the prevalence of
IPV during the first 24 months following delivery also were examined. Patterns
of IPV were evaluated, with particular attention to cumulative IPV across
the postpartum period and the relationship between IPV experienced post partum
and IPV reported before delivery.
SUBJECTS AND METHODS
SAMPLE SELECTION
All girls 18 years or younger who were delivered of neonates at The
University of Texas Medical Branch–Galveston (UTMB) between March 16,
1994, and February 28, 1996, and who met the following criteria were eligible
to participate in this study: self-reported African American, Mexican American,
or European American ethnicity; plan to retain custody of their newborns;
ability to read and write at a fifth grade level; absence of major psychiatric
disorders; and delivery of a healthy infant with a birth weight of more than
1500 g. A total of 847 mothers between ages 12 and 18 years were eligible
to participate, with 77 (9%) refusing, yielding an overall response rate of
91%.
PROCEDURES
Data were collected as part of a larger study of substance use among
pregnant and parenting adolescents. The larger project was presented to potential
subjects as a study of the transition into adolescent motherhood. Written
consent to participate was obtained from each subject. In addition, written
consent from a parent or legal guardian was obtained for women younger than
18 years who were currently living with their parents or guardians and were
not legally married. All protocols were approved by institutional review boards
of UTMB, Baylor College of Medicine, and/or The University of Texas Health
Science Center School of Public Health.
As previously described,15 each subject
was interviewed within 48 hours of delivery. To evaluate IPV during the postpartum
period, surveys were mailed to participants 3, 6, 12, 18, and 24 months following
delivery. When surveys were not returned within 2 weeks, subjects were contacted
by telephone to encourage completion. Compensation of $10 was given to each
subject who returned a completed survey. Each returned survey was reviewed
for incomplete or inconsistent responses, and subjects were contacted for
clarification, as needed. Overall, 570 (74%) completed at least 4 of 5 follow-up
surveys.
Baseline demographic characteristics and rates of IPV for the 570 subjects
who completed 4 or 5 of 5 possible surveys were compared with the original
sample of 770 young mothers. No significant differences were observed in age,
education level, parity, gravidity, abortions, ethnicity, language, religion,
school enrollment, employment during last 3 months of pregnancy, maternal
education, whether the head of the household worked more than 35 hours per
week, or whether IPV was experienced during the 12 months preceding delivery.
MEASUREMENT OF STUDY VARIABLES
A modified version of the Abuse Assessment Screen, designed by the Nursing
Research Consortium on Violence and used in previous studies with pregnant
women of all ages,4, 16-17
was used to identify physical assault committed by an intimate partner. The
modification included an inadvertent insertion of the clause "to cause bruising
or bleeding." The IPV was confirmed if the subject answered yes to a series
of 3 questions. The first question was, "Have you been hit, slapped, kicked,
or physically hurt enough to cause bruising or bleeding?" If the answer was
yes, the subject was then asked about her relationship with the perpetrator
and the frequency (1, 2-5, 6-10,  10 times) of IPV episodes experienced.
To maximize detection of assault, 2 additional questions were used to assess
the adolescents' exposure to IPV. These questions also were pilot tested on
adolescents who had recently given birth and reviewed by experts for content
validity. Each subject was asked to indicate the number of times (0, 1-2,
3-5, 6-9, 10-19, and 20) "your boyfriend or husband hit you during an
argument" or "your boyfriend or husband hit you while he was drunk or high."
Spearman correlations among the 3 questions evaluating IPV at each point of
contact ranged from 0.44 to 0.84 (P<.001).
For the purposes of this study, IPV was defined as having answered yes
to having been hit by a boyfriend or husband during an argument or while he
was drunk or high or having been hit, slapped, kicked, or physically hurt
enough by a current or ex-boyfriend or ex-husband to cause bruising or bleeding.
At each of the 3- and 6-month follow-up surveys, the period of recall was
3 months, whereas at the 12-, 18-, and 24-month surveys, IPV was evaluated
for each of the preceding 6-month spans. As reported previously,11
IPV during the baseline interview included the 12 months before delivery.
Frequent IPV was defined as IPV that occurred 6 or more times in a given interval.
This cutoff was chosen because it captured the upper 20% of the sample. Severe
IPV was calculated as the proportion of subjects experiencing IPV who reported
violence severe enough to cause bruising or bleeding per sampling interval.18
Additional questions at the baseline interview assessed demographic
variables, such as age of the mother, ethnicity (self-report as European American,
African American, Mexican American), marital status, gravity, parity, school
enrollment, highest education level completed, and socioeconomic status measured
by having enough money to live on, education level of adolescent's mother,
and whether the head of the household worked more than 35 hours per week.
At each point of data collection, adolescent mothers were also asked about
their relationship with the father of their newborn and whether they were
romantically involved with someone else. This was used to assess change in
the intimate partner status across the 24-month postpartum period. Social
support from family members, relatives, or others important to the young mother
was also assessed at each point of contact. Adolescent mothers were asked
to indicate, on a 5-point scale, the amount of emotional, financial, informational,
transportation, and child care support received from "anywhere." The resulting
variable, termed social support (Cronbach coefficient 
ranged from .89 to .91 across data collection periods), was calculated by
summing each item and dividing by 5 (the total number of items). Higher mean
scores indicated greater amounts of support received. Face and content validity
for this variable were established by experts in the fields of nursing and
social work.
STATISTICAL ANALYSIS
Prevalence of IPV and frequent and severe IPV was calculated at each
point of follow-up. Prevalence of IPV was computed as the proportion of subjects
who affirmed that IPV had occurred. We used  2 tests and 95%
confidence intervals (CIs) to compare differences among ethnic groups in prevalence
of IPV and frequent and severe IPV at each follow-up point. Logistic regression
was used to calculate the relative odds of experiencing IPV adjusted for the
covariates of social support,19 age, education,
and socioeconomic level.2 These covariates
were related to violence and ethnicity empirically or through prior studies.
Next, the association between IPV experienced during pregnancy and IPV
experienced during the postpartum period was explored. The total number of
follow-up surveys on which IPV was reported was compared between those who
had experienced IPV during the 12 months before delivery and those who had
not. To provide a basis for comparison to prior studies on IPV in the early
postpartum period and to provide important information on the prevalence of
assault over time, the associations between IPV experienced during the 12
months before delivery and IPV reported at 3 or 6 months' post partum were
explored. These analyses allowed us to determine whether young mothers who
had experienced IPV during the first 6 months post partum were more likely
to experience IPV during pregnancy. Logistic regression was used to determine
risk of IPV in the postpartum period, and ethnic differences were examined
using 2 tests.
Cumulative IPV was calculated by taking the percentage of young mothers
who experienced IPV at 3 months' post partum and adding to it the proportion
of subjects who experienced IPV for the first time at each subsequent follow-up.
For purposes of these analyses, subjects with one missing survey were assumed
not to have experienced IPV at this data collection point. The net effect
of this strategy for handling missing data most likely resulted in a slight
underestimation of the prevalence of IPV across the postpartum period. All
analyses were performed using the Statistical Package for Social Sciences
(version 10.0 for Windows; SPSS Inc, Chicago, Ill).
RESULTS
The sample was fairly evenly divided among ethnic groups, with 219 Mexican
Americans (38%), 182 African Americans (32%), and 169 European Americans (30%).
Approximately 52 (9%) spoke Spanish only and 200 (35%) reported being in a
legal or common law marriage. Participants averaged 16.8 (SD, 1.2) years of
age, with 83 (15%) having graduated from high school or obtained a graduate
equivalency diploma. Approximately 84 (15%) had experienced childbirth previously
and 81 (14%) were employed during the last 3 months of pregnancy.
Denominator terms for prevalence of IPV varied across follow-up surveys
because of missing data, with no more than 10% of surveys missing for the
entire sample or any one ethnic group at any point of follow-up. The number
and percentage of young mothers reporting IPV on the 3 separate screening
questions at each point of follow-up are provided in Table 1. On each survey the highest percentage of IPV was determined
by the question, "Have you been hit by a boyfriend or husband during an argument?"
Most subjects who experienced IPV were identified with only 2 questions, "Have
you been hit, slapped, kicked, or physically hurt by a current or ex husband
or boyfriend enough to cause bruising or bleeding?" and "Have you been hit
by a boyfriend or husband during an argument?"
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Table 1. Young Mothers Reporting Intimate Partner Violence on 3 Separate
Screening Questions at Each Point of Follow-up*
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The reported prevalence of IPV was highest at 3 months' post partum
(21%, n = 116) and lowest at 24 months' post partum (13%, n = 68), despite
the fact that IPV at 3 months represented the 3 months following delivery,
whereas IPV at 24 months covered the preceding 6 months (Table 2). Among Mexican Americans and African Americans, the highest
rates of IPV were reported at 3 months' post partum (23%, n = 48, and 24%,
n = 42, respectively). In contrast, the highest rate for European Americans
was observed at 18 months' post partum, with 34 (22%) reporting IPV. Comparisons
among ethnic groups using 2 analysis and 95% CIs found no
significant differences in reported prevalence of IPV among the 3 ethnic groups
at any point during the 24-month postpartum period. Logistic regression was
then used to control for covariates at each point of follow-up. At 3 months
after delivery, African Americans were 1.8 (95% CI, 1.03-3.17; P = .04) times as likely to report IPV compared with European Americans.
Likewise, at 6 months' post partum, Mexican Americans were 1.9 (95% CI, 1.05-3.58; P = .04) times as likely to have experienced IPV compared
with European Americans. At 18 months, European Americans were 2.0 (95% CI,
1.11-3.79; P = .02) times as likely to report IPV
compared with African Americans. These findings indicate that young minority
mothers are at an increased risk, relative to European Americans, for reporting
IPV during the first 6 months after delivery but that European Americans are
at risk at 18 months following delivery. At 12 and 24 months' post partum,
there were no statistically significant differences found among the ethnic
groups when controlling for age, education, socioeconomic level, or social
support.
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Table 2. Prevalence of Intimate Partner Violence Experienced by Adolescent
Mothers During the First 24 Months Post Partum by Ethnicity and Month of Follow-up*
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The overall prevalence of frequent IPV was fairly constant across the
postpartum period, with between 16% and 22% of those experiencing IPV reporting
frequent assault at each survey point (Table 3). The percentage of those assaulted who experienced severe
IPV increased during the postpartum period from 40% at 3 months to 62% at
24 months (Table 3). Of importance,
the overall prevalence of IPV decreased during the postpartum period (Table 2), whereas the percentage of those
assaulted experiencing severe abuse increased across this same time (Table 3). Significant differences of reported
severe IPV were seen between 3 and 18 months after delivery. Because of the
small number of women reporting assault within each ethnic group, ethnic differences
in the prevalence of frequent or severe IPV could not be examined statistically.
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Table 3. Reported Prevalence of Frequent and Severe Intimate Partner
Violence (IPV) Among Adolescent Mothers Who Experienced IPV at Each Follow-up
Period
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A subsequent series of analyses was conducted to estimate cumulative
IPV experienced by the sample of young mothers. Analysis of IPV in this manner
revealed a steady increase in the cumulative experience of IPV during the
postpartum period. Specifically, 3% to 7% of the sample reported IPV for the
first time at each of the follow-up surveys conducted at 6, 12, 18, and 24
months after delivery. Thus, 26% of the sample had experienced IPV by 6 months,
33% by 12 months, 38% by 18 months, and 41% by 24 months following delivery.
Similar patterns were observed for each ethnic group.
Analyses were conducted to determine whether young mothers who had experienced
IPV during pregnancy were more likely to experience IPV during the first 6
months post partum. Two of 5 (26/60 [43%]) of those reporting IPV during pregnancy
also reported IPV took place during the first 3 months following delivery,
whereas only 90 (19%) of the 485 not experiencing IPV during pregnancy reported
IPV during this time (odds ratio, 3.4; 95% CI, 1.92-5.87; P<.001). One in 2 (32/61 [52%]) young mothers who reported IPV during
pregnancy also reported IPV at the 6-month survey. In comparison, 117 (23%)
of 507 (odds ratio, 3.8; 95% CI, 2.12-6.87; P<.001)
young mothers not reporting IPV during pregnancy experienced IPV at 6 months.
Comparable findings were observed across ethnic groups. Of interest, 3 of
every 4 (46/61 [75%]) young mothers who had experienced IPV during pregnancy
reported IPV on at least 1 follow-up survey, with 1 of every 4 (16/61 [26%])
reporting IPV on 3 or more surveys. In contrast, 190 (37%) of the 509 (P<.001) young mothers not experiencing IPV during pregnancy
reported IPV on 1 or more surveys, with less than 10% (45/509; P<.001) reporting IPV on 3 or more surveys.
To determine whether young mothers who had experienced IPV during the
first 3 months post partum were more likely to have experienced IPV during
pregnancy, IPV at the baseline interview was compared between those who had
reported IPV at 3 months and those who had not. Twenty-six (22%) of the 116
who reported IPV at 3 months' post partum also had experienced IPV in the
12 months before delivery. Of importance, 3 of every 4 young mothers (90/116
[78%]) who reported IPV at the 3-month survey had not experienced IPV during
the 12 months before delivery.
To better understand the increased rates of severe IPV reported across
the postpartum period, rates of severe abuse at 12 and 24 months were evaluated
relative to the number of surveys (1 vs 2 or 3 at 12 months and 1 vs 2, 3,
4, or 5 at 24 months) on which IPV had been reported. Those who experienced
IPV on more than one survey were significantly more likely to report severe
abuse at 12 and 24 months' post partum than those who reported IPV on only
one follow-up survey (41% vs 24%, P<.009 at 12
months; 26% vs 12%, P<.008 at 24 months).
We did not query subjects as to the perpetrator of each act of IPV reported
and were therefore unable to determine whether the perpetrator was the father
of their newborn delivered at baseline or a new intimate partner. However,
information on the romantic involvement with the father of their newborn and
other persons was available from each follow-up survey. At 3 months' post
partum, 73 (63%) of 116 young mothers experiencing IPV were romantically involved
with the father of their newborn compared with 19 (16%) of 116 who were seeing
someone other than the father. At 6 months, 59 (68%) of 87 assaulted women
were romantically involved with the father of their newborn vs 12 (14%) of
87 who reported romantic involvement with another partner. At 12, 18, and
24 months, these numbers shifted to 60 (63%) of 95 vs 25 (26%) of 95, 42 (45%)
of 94 vs 34 (36%) of 94, and 35 (51%) of 68 vs 29 (43%) of 68, respectively.
Thus, these data suggest that perpetrators of IPV toward young mothers may
shift from being the father of the newborn during the early postpartum period
to a different intimate partner over time.
COMMENT
To our knowledge, this is the first prospective study to examine IPV
within a cohort of adolescent girls followed up for 24 months into the postpartum
period and the only published study to examine ethnic differences in the prevalence
of IPV and patterns of frequent and severe IPV following delivery. Overall,
41% of our young mothers reported IPV at some point within these first 24
months of delivery, with the highest prevalence (21%) observed during the
first 3 months' post partum. This 3-month prevalence was higher than the 6%
to 10% prevalence among women 19 years and younger previously reported by
Gessner and Perham-Hester10 at an average of
3.9 months after delivery, despite the fact that their definition of perpetrator
included anyone close to the subject who had inflicted physical harm. Only
66% of adolescents to whom surveys were sent in the Gessner and Perham-Hestner10 study returned surveys in contrast to the 74% who
completed 4 of 5 follow-up surveys in our study. It is possible that sample
attrition in the Gessner and Perham-Hester study favored those who experienced
violence.
Similarly, at 6 months' post partum, 16% of the young women in our sample
reported IPV, a smaller percentage than the 25% reported previously by Gielen
et al.9 This discrepancy may be explained by
differences in study methods. For instance, Gielen and colleagues surveyed
violence taking place within the first 6 months after delivery; in our study,
violence surveyed at 6 months' post partum included assault during the prior
3 months only. Also, Gielen et al9 defined
violent incidents as acts perpetrated by both intimate and nonintimate persons.
Previous studies12-13 of
adolescents and adult women indicated that European Americans are at greatest
risk of severe and frequent abuse during pregnancy, whereas another study14 found African Americans are most at risk. We found
statistically significant ethnic differences in the prevalence of IPV at 3,
6, and 18 months after delivery, with African Americans and Mexican Americans
at elevated risk in the early postpartum period and European Americans at
greatest risk by 18 months. In addition, there were small differences observed
in the prevalence of IPV across the 24-month period. Both African Americans
and Mexican Americans experienced the highest prevalence at 3 months' post
partum, with the relative percentage of young mothers in both groups experiencing
a decline in violence during the remaining 21 months. In contrast, European
Americans reported the highest prevalence of IPV at 18 months following delivery.
This study presents compelling evidence that all young women need to be screened
for IPV across the postpartum period.
Although the prevalence of IPV generally declined during the 24-month
postpartum period (21% at 3 months vs 13% at 24 months), the prevalence of
severe IPV increased across this same period. About 41% of the young women
reporting IPV at the 3-month survey experienced assault severe enough to cause
bruising or bleeding. In contrast, nearly 60% of those reporting IPV at 12,
18, or 24 months reported experiencing severe violence. Severe IPV at 12 and
24 months was more common among young mothers who reported IPV on more than
one follow-up survey. Thus, the increased prevalence of severe IPV in the
later months observed in our study may be caused by an escalation in the severity
of IPV among those young mothers who reported IPV on earlier surveys. Since
we do not have detailed data on the perpetrator in each episode of violence
and the nature of his relationship to the young mother at the time of each
assault, it is not possible to evaluate whether IPV becomes more severe over
time. Further research that systematically examines perpetrators in repeated
episodes of IPV across the postpartum period is needed.
Young women in our study who experienced IPV during the 12 months before
delivery were at increased risk of reporting IPV during the first 6 months
following delivery. This trend is consistent with Gielen et al,9
who observed that 41% of women who experienced IPV during pregnancy reported
IPV during the first 6 months post partum. Of importance, 3 of 4 subjects
who experienced IPV by the 3-month follow-up had not reported IPV during the
12 months before delivery. Moreover, we observed a 3% to 7% increase in new
cases of IPV at each follow-up beyond the 3-month survey. Thus, many adolescent
mothers experience IPV for the first time in the months following delivery.
These results suggest that screening for IPV should occur during each contact
with medical professionals and should not be confined to any one particular
point or to only those who report prior assault. This stance is concordant
with the American College of Obstetricians and Gynecologists, which recommends
screening for IPV at each gynecologic visit.20
We were unable to determine the perpetrator of each act of IPV. Although
the father of the newborn was the most likely perpetrator in most assault
episodes reported during the first 12 months following delivery, observed
shifts toward romantic relationships with other males by 18 months' post partum
suggest IPV may be perpetrated by males other than or in addition to the infants'
fathers. In one prior study of adult women, Hillard2
reported that 14% of subjects had been in more than one relationship where
physical violence was frequent. It is reasonable to assume that at least some
young mothers in our study experienced violence at the hands of more than
one intimate partner.
This study has several limitations. First, only 3 questions were used
to evaluate IPV. Although this is accepted practice in many studies of IPV
among pregnant women,13 at least one prior
study21 on adolescents has demonstrated that
comprehensive assessments with specific and direct questions yield higher
rates of violence. Thus, additional questions on the occurrence of IPV under
circumstances other than during an argument or while a partner was drunk or
high may have revealed an even higher prevalence than observed herein. Moreover,
we used a modified version of the Abuse Assessment Screen and therefore our
results are not easily compared with prior studies that used this measure
to assess IPV. Second, only one question was used to evaluate severe IPV;
additional questions assessing severity might have led to a higher observed
prevalence. Third, subjects in this study were primarily of low socioeconomic
level and confined to those living in the Southeastern region of Texas; the
prevalence of IPV may differ among young mothers from higher socioeconomic
levels or those living in different regions of the United States. Fourth,
information on whether perpetrators changed over time and the role subjects
played in episodes of IPV was not available. Previous research among adolescents
showed that victimization and perpetration are often concurrent22;
thus, knowledge of the young mother's role in IPV and information about whether
IPV was experienced from multiple perpetrators may have helped explain some
of our findings. Finally, we did not have sufficient power to adequately examine
ethnic differences in the prevalence of frequent or severe IPV.
Healthy People 201023 has set as one
of its primary goals to eliminate health disparities by ethnicity and to reduce
the rate of physical assault by current or former intimate partners (objective
15-34). This study demonstrates that IPV is not restricted to any specific
ethnicity or to any particular period within the first 24 months following
delivery. Therefore, systematic screening for IPV in multiple practice settings,
such as obstetrics and gynecology, family and emergency medicine, and pediatrics,
should be conducted at each point of contact with young mothers.20, 24
As health care practitioners become more familiar with the risk of IPV during
the postpartum period, it is likely that screening for abuse will become an
important aspect of each visit to a physician's office. Future research needs
to identify strategies to implement and sustain routine screening at different
segments of the postpartum period and to examine the long-term impact of screening
on the health and quality of life of young mothers and their children.
| What This Study Adds
Intimate partner violence is a significant public health concern, especially
among young mothers. Although many studies have examined IPV during pregnancy,
few have looked at the prevalence of experiencing IPV during the postpartum
period. This study demonstrated that IPV is not restricted to any specific
ethnicity or to any particular period within the first 24 months following
delivery. Therefore, systemic screening in multiple practice settings should
be conducted at each point of contact with young mothers.
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AUTHOR INFORMATION
Accepted for publication December 17, 2001.
This research was supported by grants DA09636 and DA08404 from the National
Institutes of Health, Bethesda, Md, and grant 3777 from the Hogg Foundation
for Mental Health, Austin, Tex.
Corresponding author and reprints: Constance M. Wiemann, PhD, Department
of Pediatrics, Section of Adolescent and Sports Medicine, Baylor College of
Medicine, 6621 Fannin St, CC610.01, Houston, TX 77030-2399 (e-mail: cwiemann{at}bcm.tmc.edu).
From the Department of Pediatrics, Baylor College of Medicine, Houston,
Tex (Ms Harrykissoon and Dr Wiemann); and Heilbrunn Department of Population
and Family Health, Mailman School of Public Health, Columbia University, New
York, NY (Dr Rickert).
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