Childhood maltreatment is a major determinant in physical and mental illnesses, and is associated with increase health risk behaviors. While there are a number of treatment modalities that have been used and shown effective with this population, many of those who have been maltreated do not disclose such abuse and trauma experiences unless they are specifically asked and therefore are not offered these treatment modalities. In fact, the experience of MSAHC providers is that 20-30% of our adolescents questioned have experienced either physical or sexual abuse.

The American Academy of Pediatrics (AAP) recommends pediatricians and other health care providers serving children to routinely screen for child maltreatment and abuse. This is necessary because many patients, especially adolescents, do not willingly or spontaneously report past or current victimization events. In contrast to medical tests that examine the presence or absence of disease where high specificity and sensitivity is desired for diagnosis, the diagnosis of childhood abuse is usually made after extensive investigation interviews have been conducted by designated law enforcement and child protective service agencies. Thus, screening for child maltreatment represents only the first step in a lengthy process to substantiate and validate the occurrence of abuse. Unfortunately, many clinicians are very reluctant to screen trauma backgrounds in the absence of spontaneous patient disclosure, fearing that such lines of inquiry are invasive, irrelevant, needlessly distressing, or overly complicated. Research suggests that a great majority of patients, regardless of their race, gender, socioeconomic status, age, and education level, would welcome physician screening about assault experiences. Clearly, there is a need to develop, evaluate, and employ reliable screening methodologies to meet the AAP's recommendation for primary care pediatricians to do routine screening of abuse.

The "Disclosure Study" examines the ways in which a psychosocial health history is taken. Patients who consent to participate are randomly assigned to one of four survey methods for eliciting information on abuse:

1. Self administered paper and pencil
2. Audio Computer Assisted Interview (ACASI)
3. Structured clinical interview
4. Unstructured clinical history

This work will help pediatricians, adolescent medicine specialists and other providers screen for abuse.

In spring of 2007 we closed the study to recruitment. Six hundred male and female adolescent primary care patients completed the study. Results of the study are forthcoming.

Human papillomavirus (HPV) infection is the central etiologic factor in the development of cervical and anal cancers. Recent data suggest that it is causally involved in 30 percent of oral cancers. Studies by our group and others have shown that 30-60 percent of sexually active college age women have cervical HPV infection. Our inner-city adolescence population, with its many high risk (HR) characteristics, has a prevalence of 63 percent cervical, 58 percent anal and 13 percent oral in our pilot study. The new vaccine contains HPV 6, 11, 16 & 18 virus-like particles and has been shown to have a very high efficacy in HPV-DNA negative and HPV seronegative subjects. Little is know about its efficacy and effectiveness in a HR adolescent population, or in anal and oral mucosa. Despite these uncertainties physicians would find it unacceptable to not vaccinate high-risk adolescents, such as our population. The results of our research may demonstrate the need for a formal clinical trial of high risk adolescents.

We have been funded to study incidence of HPV infection following HPV vaccination in a prospective cohort of 1000 sexually active adolescent girls, ages 14-19 enrolled at the Mount Sinai AHC. We will collect baseline cervical, anal, oral specimens for HPV DNA testing and serum for HPV antibodies, the vaccine naive subjects will complete the 3 necessary vaccinations. They will be followed every 6 months for two years. Blood samples will be collected at baseline and 12 months.

Our aims are to:

1. study the type-specific prevalence of HPV DNA in the cervix, anus, and oral cavity in high risk adolescents prior to vaccination including risk factors and co infection across sites;
2. determine the incidence of persistent HPV infection of the cervix following vaccination and contrast these rates with those expected based on the published vaccine trial results, by assessing incidence of persistent cervical infection in those adolescent women
3. identify risk factors for an incidentally developed persistent cervical infection with HPV, despite vaccination in those who were serologically and DNA negative for those types at baseline including infection in the anus or oral cavity and other risk factors;
4. study the incidence of persistent anal and oral infection with HPV following vaccination in this high risk cohort and the risk factors for infection with these HPV types in the anus, and to determine the incidence and risk factors for infection with phylogenetically- related and -unrelated HPV types in the anal and oral mucosa.

We propose to examine the effectiveness of the vaccine on a high risk population, and on extra cervical sites. This study has been funded for five years by the NIAID and in a joint collaboration for experts from Albert Einstein College of Medicine. The enrollment period is from August 20, 2007 to September 30, 2009.

Since 1994 the MSAHC has participated as a Clinical Trials Unit of NICHD sponsored research with HIV infected adolescents. The Adolescent Medicine HIV/AIDS Research Network (ATN) investigated HIV disease progression and manifestation in adolescents at 16 clinical sites, characterizing immunologic response, establishing normative data, and exploring the influence of co-infections such as STIs. In 2001, the Adolescent Medicine Trials Network for HIV/AIDS Interventions (ATN) initiated therapeutic, behavioral and community intervention research.

Connect-To-Protect ®, the community research arm of ATN, seeks to reduce the incidence of HIV in adolescents and young adults through partnerships with community based organizations that collaborate to implement community intervention research. The ATN is the first to respond to the unique biopsychosocial issues of HIV infected adolescents and the highly challenging prevention issues of at-risk adolescents.

MSAHC offers an Adolescent Medicine fellowship program to physicians who have completed their primary residency training in pediatrics, family medicine, or internal medicine. As part of their Adolescent Medicine training, all fellows participate in research. MSAHC fellows have been actively engaged in research projects and have been presenters at national conferences.

We are in the process of developing a study to examine the anxiety and resilience in trauma exposed adolescents. We will examine psychological and neural correlates.

Details are forthcoming.