Chadi N, Weitzman ER, Levy S. Understanding the Impact of National and State Medical Marijuana Policies on Adolescents. Current Addiction Reports. 2018. LinkAbstract

Purpose of Review This article provides an overview of current federal, state, and relevant international “medical marijuana” policies. We also describe the impacts of “medical marijuana” policy on adolescents’ use of marijuana and other substances.

Recent Findings Evidence on the medical benefits of marijuana in adolescents is limited in the context of risks for marijuana-related harm. The legalization of marijuana for medical purposes is associated with a decrease in marijuana risk perception in older adolescents. Marijuana-related harms have increased in states that have legalized marijuana for medical purposes or adult use.

Summary The long-term impacts on adolescents of marijuana policies for medical purposes or adult use remain poorly understood. Marijuana policy changes that liberalize access may increase rates of youth marijuana use. There is an important need for high quality research and open sharing of best practices regarding marijuana policies.

Levy S, Breen L, Lunstead J, Weitzman ER. Facing Addiction: A Laudable, but Incomplete Effort. American Journal of Public Health. 2018;108 (2) :153-155. Link pdf.pdf
Weitzman ER, Wisk LE, Salimian PK, et al. Adding patient-reported outcomes to a multisite registry to quantify quality of life and experiences of disease and treatment for youth with juvenile idiopathic arthritis. Journal of Patient Reported Outcomes. 2017;2 (1). LinkAbstract

Background: Children with Juvenile Idiopathic Arthritis (JIA) often have poor health-related quality of life (HRQOL) despite advances in treatment. Patient-centered research may shed light on how patient experiences of treatment and disease contribute to HRQOL, pinpointing directions for improving care and enhancing outcomes.

Methods: Parent proxies of youth enrolled in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry shared patient-reported outcomes about their child’s HRQOL and experiences of disease and treatment burden (pain interference, morning stiffness, history of medication side effects and methotrexate intolerance). Contributions of these measures to HRQOL were estimated using generalized estimating equations accounting for site and patient demographics.

Results: Patients (N = 180) were 81.1% white non-Hispanic and 76.7% female. Mean age was 11.8 (SD = 3.6) years, mean disease duration was 7.7 years (SD = 3.5). Mean Total Pediatric Quality of Life was 76.7 (SD = 18.2). Mean pain interference score was 50.1 (SD = 11.1). Nearly one-in-five (17.8%) youth experienced >15 min of morning stiffness on a typical day, more than one quarter (26.7%) reported ≥1 serious medication side effect and among 90 methotrexate users, 42.2% met criteria for methotrexate intolerance. Measures of disease and treatment burden were independently negatively associated with HRQOL (all p-values <0.01). Negative associations among measures of treatment burden and HRQOL were attenuated after controlling for disease burden and clinical characteristics but remained significant.

Conclusions: For youth with JIA, HRQOL is multidimensional, reflecting disease as well as treatment factors. Adverse treatment experiences undermine HRQOL even after accounting for disease symptoms and disease activity and should be assessed routinely to improve wellbeing.

Wisk LE, Weitzman ER. Expectancy and Achievement Gaps in Educational Attainment and Subsequent Adverse Health Effects Among Adolescents With and Without Chronic Medical Conditions. J Adolesc Health. 2017;61 (4) :461-470. LinkAbstract


While education-based disparities in health are common, the extent to which chronic conditions contribute to education gaps and to consequent health disparities is not fully understood. As such, we sought to investigate educational aspirations, expectations, and attainment among youth with and without chronic conditions and to determine if these relationships mediated subsequent disparities in health and well-being.


Longitudinal data on 3,518 youths are from the 1997-2013 Panel Study of Income Dynamics, a population-based survey. Multivariate regression was used to assess disparities in educational aspirations, expectations, and attainment by chronic conditionsand the subsequent effects on health and well-being, adjusting for important potential confounders.


Youth with chronic medical conditions (YCMCs) did not report significantly lower educational aspirations than their healthy peers; however, YCMC reported lower expectations for their educational attainment and fewer YCMC had earned their desired degree by the end of follow-up (e.g., ≥bachelor's degree: 19.9% for YCMC vs. 26.0% for peers, p < .05). YCMC reported significantly worse general health, lower life satisfaction, and lower psychological well-being in young adulthood than did their healthy peers. These disparities persisted after adjustment for confounders; the association between chronic disease and health was partially, but significantly, mediated by actual educational attainment.


Findings suggest an important risk mechanism through which YCMC may acquire socioeconomic disadvantage as they develop and progress through educational settings. Disproportionate lags in education, from expectation to attainment, may in turn increase YCMC's susceptibility to poor health and well-being in the future.

Chunara R, Wisk LE, Weitzman ER. Denominator Issues for Personally-Generated Data in Population Health Monitoring. Am J Prev Med. 2017;52 (4) :549-553. Link PDF.pdf
Harris SK, Aalsma MC, Weitzman ER, et al. Research on clinical preventive services for adolescents and young adults: where are we and where do we need to go?. J Adolesc Health. 2017;60 (3) :249-260. LinkAbstract

We reviewed research regarding system- and visit-level strategies to enhance clinical preventive service delivery and quality for adolescents and young adults. Despite professional consensus on recommended services for adolescents, a strong evidence base for services for young adults, and improved financial access to services with the Affordable Care Act's provisions, receipt of preventive services remains suboptimal. Further research that builds off successful models of linking traditional and community clinics is needed to improve access to care for all youth. To optimize the clinical encounter, promising clinician-focused strategies to improve delivery of preventive services include screening and decision support tools, particularly when integrated into electronic medical record systems and supported by training and feedback. Although results have been mixed, interventions have moved beyond increasing service delivery to demonstrating behavior change. Research on emerging technology—such as gaming platforms, mobile phone applications, and wearable devices—suggests opportunities to expand clinicians' reach; however, existing research is based on limited clinical settings and populations. Improved monitoring systems and further research are needed to examine preventive services facilitators and ensure that interventions are effective across the range of clinical settings where youth receive preventive care, across multiple populations, including young adults, and for more vulnerable populations with less access to quality care.

Harstad E, Wisk L, Ziemnik R, et al. Substance Use among Adolescents with ADHD: Reasons for Use, Knowledge of Risks, and Provider Messaging/Education. J Dev Behav Pediatr. 2017;38 (6) :417-423. LinkAbstract


Adolescents with attention-deficit/hyperactivity disorder (ADHD) are at increased risk for alcohol and marijuana use. This study's objective is to describe adolescents' ADHD-specific reasons for marijuana use, knowledge of ADHD-specific alcohol risks, and reported subspecialty provider messaging/education regarding alcohol use among adolescents with ADHD.


Youths with ADHD aged 12 to 18 years completed a survey about alcohol and marijuana use, ADHD-specific reasons for marijuana use, knowledge of ADHD-specific alcohol risks, and reported provider messaging/education regarding alcohol use. We assessed knowledge toward substance use using descriptive statistics. We used χ and t tests to determine whether knowledge or provider messaging/education differed by sociodemographic characteristics.


Of the 96 participants, 61.5% were male, average age was 15.7 years; 31.3% reported past-year alcohol use and 20.8% reported past-year marijuana use. The majority (65.2%) said "no/don't know" to both "Can alcohol make ADHD symptoms worse?" and "Can alcohol interfere or get in the way of the medications you take?" Older participants were more likely to correctly answer the medication question "yes." Despite most (74%) participants reporting that their provider asked about alcohol use, few youth reported that their providers gave specific messages/education that alcohol could make ADHD symptoms worse (9.4%) or interfere with ADHDmedications (14.6%); older participants and past-year alcohol users were more likely to have received these alcohol-specific messages.


Many youth with ADHD are unaware of the risks of alcohol use in relation to ADHD and providers are not consistently discussing these risks in the context of clinical ADHD care.

Christensen KD, Savage SK, Huntington NL, et al. Preferences for the return of individual results from research on pediatric biobank samples. J Empir Res Hum Res Ethics. 2017;12 (2) :97-106. LinkAbstract

Discussions about disclosing individual genetic research results include calls to consider participants’ preferences. In this study, parents of Boston Children’s Hospital patients set preferences for disclosure based on disease preventability and severity, and could exclude mental health, developmental, childhood degenerative, and adult-onset disorders. Participants reviewed hypothetical reports and reset preferences, if desired. Among 661 participants who initially wanted all results (64%), 1% reset preferences. Among 336 participants who initially excluded at least one category (36%), 38% reset preferences. Participants who reset preferences added 0.9 categories, on average; and their mean satisfaction on 0 to 10 scales increased from 4.7 to 7.2 (p < .001). Only 2% reduced the number of categories they wanted disclosed. Findings demonstrate the benefits of providing examples of preference options and the tendency of participants to want results disclosed. Findings also suggest that preference-setting models that do not provide specific examples of results could underestimate participants’ desires for information.

Liu J, Weitzman ER, Chunara R. Assessing Behavioral Stages from Social Media Data. Proceedings of the 2017 ACM Conference on Computer Supported Cooperative Work and Social Computing. 2017 :1320-1333. LinkAbstract

Important work rooted in psychological theory posits that health behavior change occurs through a series of discrete stages. Our work builds on the field of social computing by identifying how social media data can be used to resolve behavior stages at high resolution (e.g. hourly/daily) for key population subgroups and times. In essence this approach opens new opportunities to advance psychological theories and better understand how our health is shaped based on the real, dynamic, and rapid actions we make every day. To do so, we bring together domain knowledge and machine learning methods to form a hierarchical classification of Twitter data that resolves different stages of behavior. We identify and examine temporal patterns of the identified stages, with alcohol as a use case (planning or looking to drink, currently drinking, and reflecting on drinking). Known seasonal trends are compared with findings from our methods. We discuss the potential health policy implications of detecting high frequency behavior stages.

Lunstead J, Weitzman ER, Kaye D, Levy S. Screening and Brief Intervention in High Schools: School Nurse Practices and Attitudes in Massachusetts. Substance Abuse. 2017;38 (3) :257-260. LinkAbstract

BACKGROUND: Screening, brief intervention, and referral to treatment (SBIRT) is recommended as a strategy to prevent or reduce adolescent substance use. Offering SBIRT in schools may provide an opportunity to reach adolescents not accessing primary care. The objective is to assess school nurses' attitudes and practices regarding adolescent SBIRT. METHODS: The authors administered electronically and in person a questionnaire including 29 items on SBIRT attitudes and practices to school nurses registered for the Northeastern University's School Health Institute Summer Program in Massachusetts (N = 168). Survey questions were adapted from a questionnaire originally developed by the American Academy of Pediatrics. RESULTS: One hundred and forty-four nurses completed the survey for a response rate of 85.7%. More than three quarters of the respondents (77.0%) were in favor of universal alcohol screening in schools. None of the respondents reported screening their students on a regular basis. More than half (64.4%) of nurses reported screening students; however, they did so only when they suspected alcohol use. During these instances, only 17.9% used a validated screening tool and almost all (98.2%) used face-to-face clinical interviews. When addressing alcohol use by a student, the large majority of respondents reported including the following recommended clinical strategies: asking about problems related to alcohol use (56.3%), explaining the harms of alcohol use (70.1%), and advising abstinence (73.6%). On average, respondents spend 5 to 10 minutes discussing alcohol use with their students. CONCLUSION: Survey respondents were supportive of universal alcohol screening in school, although few were doing so at the time. When respondents identified students using alcohol, their interventions were closely aligned with clinical recommendations for brief intervention. Implementation of SBIRT that focuses on standardized, annual screening has the potential to deliver high-quality care in this setting.

Conway-Pearson LS, Christensen KD, Savage SK, et al. Family Health History Reporting is Sensitive to Small Changes in Wording. Genet Med. 2016;18 (12) :1308-1311. LinkAbstract

PURPOSE: Family health history is often collected through single-item queries that ask patients whether their family members are affected by certain conditions. The specific wording of these queries may influence what individuals report. METHODS: Parents of Boston Children's Hospital patients were invited to participate in a Web-based survey about the return of individual genomic research results regarding their children. Participants reported whether 11 types of medical conditions affected them or their family. Randomization determined whether participants were specifically instructed to consider their extended family. RESULTS: Family health history was reported by 2,901 participants. Those asked to consider their extended family were more likely to report a positive family history for 8 of 11 medical conditions. The largest differences were observed for cancer (65.1 vs. 45.7%; P < 0.001), cardiovascular conditions (72.5 vs. 56.0%; P < 0.001), and endocrine/hormonal conditions (50.9 vs. 36.7%; P < 0.001). CONCLUSIONS: Small alterations to the way family health history queries are worded can substantially change patient responses. Clinicians and researchers need to be sensitive about patients' tendencies to omit extended family from health history reporting unless specifically asked to consider them.

Himes BE, Weitzman ER. Innovations in health information technologies for chronic pulmonary diseases. Respiratory Research. 2016;17 (1) :1–7. LinkAbstract

Asthma and chronic obstructive pulmonary disease (COPD) are common chronic obstructive lung disorders in the US that affect over 49 million people. There is no cure for asthma or COPD, but clinical guidelines exist for controlling symptoms that are successful in most patients that adhere to their treatment plan. Health information technologies (HITs) are revolutionizing healthcare by becoming mainstream tools to assist patients in self-monitoring and decision-making, and subsequently, driving a shift toward a care model increasingly centered on personal adoption and use of digital and web-based tools. While the number of chronic pulmonary disease HITs is rapidly increasing, most have not been validated as clinically effective tools for the management of disease. Online communities for asthma and COPD patients are becoming sources of empowerment and support, as well as facilitators of patient-centered research efforts. In addition to empowering patients and facilitating disease self-management, HITs offer promise to aid researchers in identifying chronic pulmonary disease endotypes and personalized treatments based on patient-specific profiles that integrate symptom occurrence and medication usage with environmental and genomic data.

Levy S, Dedeoglu F, Gaffin JM, et al. A Screening Tool for Assessing Alcohol Use Risk Among Medically Vulnerable Youth. PLOS One. 2016;11 (5) :e0156240. LinkAbstract

BACKGROUND: In an effort to reduce barriers to screening for alcohol use in pediatric primary care, the National Institute on Alcoholism and Alcohol Abuse (NIAAA) developed a two-question Youth Alcohol Screening Tool derived from population-based survey data. It is unknown whether this screening tool, designed for use with general populations, accurately identifies risk among youth with chronic medical conditions (YCMC). This growing population, which comprises nearly one in four youth in the US, faces a unique constellation of drinking-related risks. METHOD: To validate the NIAAA Youth Alcohol Screening Tool in a population of YCMC, we performed a cross-sectional validation study with a sample of 388 youth ages 9-18 years presenting for routine subspecialty care at a large children's hospital for type 1 diabetes, persistent asthma, cystic fibrosis, inflammatory bowel disease, or juvenile idiopathic arthritis. Participants self-administered the NIAAA Youth Alcohol Screening Tool and the Diagnostic Interview Schedule for Children as a criterion standard measure of alcohol use disorders (AUD). Receiver operating curve analysis was used to determine cut points for identifying youth at moderate and highest risk for an AUD. RESULTS: Nearly one third of participants (n = 118; 30.4%) reported alcohol use in the past year; 86.4% (106) of past year drinkers did not endorse any AUD criteria, 6.8% (n = 8) of drinkers endorsed a single criterion, and 6.8% of drinkers met criteria for an AUD. Using the NIAAA tool, optimal cut points found to identify youth at moderate and highest risk for an AUD were ≥ 6 and ≥12 drinking days in the past year, respectively. CONCLUSIONS: The NIAAA Youth Alcohol Screening Tool is highly efficient for detecting alcohol use and discriminating disordered use among YCMC. This brief screen appears feasible for use in specialty care to ascertain alcohol-related risk that may impact adversely on health status and disease management.

Wisk LE, Weitzman ER. Substance Use Patterns Through Early Adulthood: Results for Youth With and Without Chronic Conditions. Am J Prev Med. 2016;51 (1) :33-45. LinkAbstract

INTRODUCTION: Adolescence and emergent adulthood are periods of peak prevalence for substance use that pose risks for short- and long-term health harm, particularly for youth with chronic medical conditions (YCMC) who are transitioning from adolescence to adulthood. As there have been no nationally representative studies of substance use during this period for these medically vulnerable youth, the authors sought to examine onset and intensification of these behaviors for a national sample of youth with and without chronic conditions. METHODS: Longitudinal data are from 2,719 youth between the ages of 12 and 26 years interviewed from 2002 to 2011 for the Panel Study of Income Dynamics, Child Development and Transition to Adulthood Supplements, a nationally representative, population-based survey. Multivariate generalized linear mixed models were used to estimate patterns of alcohol, tobacco, and marijuana use during adolescence and emergent adulthood for youth with and without chronic conditions, adjusting for potential confounders. RESULTS: Overall, 68.8%, 44.3%, and 47.8% of youth reported ever trying alcohol, tobacco, and marijuana, respectively. Among users, 42.2%, 73.4%, and 50.3% of youth reported binge drinking, regular cigarette use, and recent marijuana use, respectively. YCMC were more likely to engage in any and heavier substance use; transition years and early adulthood were periods of peak risk for YCMC compared with their healthy peers. CONCLUSIONS: Substance use among YCMC during adolescence and emergent adulthood is a substantial concern. Increased prevention and case detection are in order to address these behaviors and promote optimal health outcomes for medically vulnerable youth.

Hersh AO, Salimian PK, Weitzman ER. Using Patient-Reported Outcome Measures to Capture the Patient's Voice in Research and Care of Juvenile Idiopathic Arthritis. Rheumatic Disease Clinics of North America. 2016;42 (2) :333-346. LinkAbstract

Patient-reported outcome (PRO) measures provide a valuable window into how patients with juvenile idiopathic arthritis and their parents perceive their functioning, quality of life, and medication side effects in the context of their disease and treatment. Momentum behind adoption of PRO measures is increasing as these patient-relevant tools capture information pertinent to taking a patient-centered approach to health care and research. This article reviews the clinical and research utility of obtaining PROs across domains applicable to the experience of juvenile idiopathic arthritis and summarizes available self-report and parent-proxy PRO measures. Current challenges and limitations of PRO usage are discussed.

Levy S, Weitzman ER. Building a Learning Marijuana Surveillance System. JAMA Pediatrics. 2016. Link pdf
Pitts S, Borus J, Harris S, et al. Benefiting Brad: An interpersonal case of Adolescent substance use and ADHD. MedEdPORTAL Publications. 2015. LinkAbstract

Adolescents with attention deficit-hyperactivity disorder (ADHD) are more likely to try alcohol and other drugs earlier than their peers, and they are also more likely to develop a substance use disorder. Additionally, medications used to treat ADHD have abuse potential and may be diverted. Given that adolescents with ADHD will present to different providers for care (mental health, nutrition, medical), all providers in an interprofessional team should consider screening patients for substance use in addition to the nutritional, physical, and cognitive issues associated with ADHD and its treatment.

This case evolves over each session to facilitate learners’ development of skills in the screening, assessment, management, and treatment of substance use and ADHD, highlighting the strengths of different specialties of the interprofessional team. We developed this case to provide an opportunity for learners to explore challenges common to the clinical management of substance use and ADHD while also providing exposure to current trends and evidence in ADHD and adolescent substance use. The case introduces learners to aspects of program development and allows them to identify opportunities for advocacy and leadership.

Included herein is the case presentation in four sessions, a resource list of assigned readings, modules to be assigned and/or utilized during case sessions, a motivational interviewing exercise to be used during case session four, and an instructor’s guide.

Gooding H, O'Reilly C, Weitzman E, et al. Transitioning Bryan: The transition to adulthood and the medical home. MedEdPORTAL Publications. 2015. LinkAbstract

This evolving case allows learners to develop skills in the assessment, treatment, and management of youth transitioning from the pediatric to the adult medical home with an emphasis on the role of the multidisciplinary team. This case provides an opportunity for learners to explore challenges common to the clinical management of patients during this transitional time while also providing exposure to current trends and evidence in transition and the medical home. The case introduces learners to aspects of program development and allows learners to identify opportunities for advocacy and leadership.

While this case was written for learners in a multidisciplinary adolescent health fellowship program, the case can be used with residents, fellows, interns, or students from a variety of backgrounds (nursing, social work, psychology, nutrition, and medicine) who will be involved in the assessment or management of adolescents who are transitioning into adulthood. A case-based approach was taken to highlight the need for multidisciplinary care for adolescents through a rich case-based discussion.

Bacon PL, Harris ED, Ziniel SI, et al. The development of a preference-setting model for the return of individual genomic research results. J Empir Res Hum Res Ethics. 2015;10 (2) :107-20. LinkAbstract

Understanding participants' preferences for the return of individual research results (IRR) in genomic research may allow for the implementation of more beneficial result disclosure methods. We tested four preference-setting models through cognitive interviews of parents to explore how parents conceptualize the process of setting preferences and which disease characteristics they believe to be most important when deciding what results to receive on their child. Severity and preventability of a condition were highly influential in decision making and certain groups of research results were anticipated by participants to have negative psychological effects. These findings informed the development of an educational tool and preference-setting model that can be scaled for use in the return of IRR from large biobank studies.

Weitzman ER, Ziemnik RE, Huang Q, Levy S. Alcohol and Marijuana Use and Treatment Nonadherence Among Medically Vulnerable Youth. Pediatrics. 2015;136 (3) :450-7. LinkAbstract

BACKGROUND AND OBJECTIVE: Adolescents face peak risks for onset and intensification of alcohol and marijuana use. However, we know little about these behaviors and their associations with knowledge or treatment adherence among chronically ill youth, a medically vulnerable group. METHODS: Cross-sectional assessment of consented youth ages 9 to 18 years receiving care for asthma/cystic fibrosis, type 1 diabetes, arthritis, or inflammatory bowel disease (IBD) by using a self-administered online tool. Prevalence and correlates of risk behaviors and associations with knowledge and treatment adherence were estimated using descriptive statistics and logistic regression, controlling for demographics, mental health, and the multiclinic sampling frame. RESULTS: Of 403 consented youth (75.8% response), 51.6% were girls, 75.1% were white, and average age was 15.6 years. Of high school youth, 36.5% and 12.7% reported past-year alcohol use and binge drinking, respectively; 20% reported past-year marijuana use. Among high school youth, 53.1% and 37.2% answered correctly that alcohol can interfere with their medications and laboratory tests; youth answering incorrectly were 8.53 and 4.46 times more likely to drink and binge drink, respectively (P values < .001). Thirty-two percent and 8.3% of high school youth reported regularly forgetting or skipping their medications in the past 30 days; compared with past-year nondrinking youth, drinkers were 1.79 and 1.61 times as likely to report regularly missing or skipping medications (P values < .05). CONCLUSIONS: Alcohol and marijuana use are common among youth with chronic medical conditions. Alcohol use is associated with treatment nonadherence. Education and preventive interventions are warranted to ameliorate risk.