Patient Characteristics Associated With Self-Reported Adherence to Chiropractic Treatment Recommendations: A Feasibility Study.

OBJECTIVE: The purpose of this study was to examine the feasibility of developing and administering a patient adherence survey to assess self-reported adherence to treatment recommendations from a chiropractic doctor within an academic health center. METHODS: The survey items were developed by the authors and vetted by the university's students and faculty, who serve as health care practitioners at an academic health center. Adult patients with spine pain who were seen by a doctor of chiropractic at an academic health center were included in this survey study. A 32-item survey was administered between October 2019 and March 2020. RESULTS: A total of 62 respondents completed the anonymous survey. We found that 89% of respondents adhered to their clinic appointments. Although 82% of respondents said that their doctor's recommendation made sense, only 44% reported completely following treatment recommendations for at-home stretching and exercise. CONCLUSION: This study determined that it is feasible to assess patient self-reported adherence to chiropractic treatment within an academic health center setting. In our sample we found that although patient adherence to clinic appointments was high, adherence to treatments was not.

Long-Term Medicare Costs Associated With Opioid Analgesic Therapy vs Spinal Manipulative Therapy for Chronic Low Back Pain in a Cohort of Older Adults.

OBJECTIVES: The purpose of this study was to compare Medicare healthcare expenditures for patients who received long-term treatment of chronic low back pain (cLBP) with either opioid analgesic therapy (OAT) or spinal manipulative therapy (SMT). METHODS: We conducted a retrospective observational study using a cohort design for analysis of Medicare claims data. The study population included Medicare beneficiaries enrolled under Medicare Parts A, B, and D from 2012 through 2016. We assembled cohorts of patients who received long-term management of cLBP with OAT or SMT (such as delivered by chiropractic or osteopathic practitioners) and evaluated the comparative effect of OAT vs SMT upon expenditures, using multivariable regression to control for beneficiary characteristics and measures of health status, and propensity score weighting and binning to account for selection bias. RESULTS: The study sample totaled 28,160 participants, of whom 77% initiated long-term care of cLBP with OAT, and 23% initiated care with SMT. For care of low back pain specifically, average long-term costs for patients who initiated care with OAT were 58% lower than those who initiated care with SMT. However, overall long-term healthcare expenditures under Medicare were 1.87 times higher for patients who initiated care via OAT compared with those initiated care with SMT (95% CI 1.65-2.11; P < .0001). CONCLUSIONS: Adults aged 65 to 84 who initiated long-term treatment for cLBP via OAT incurred lower long-term costs for low back pain but higher long-term total healthcare costs under Medicare compared with patients who initiated long-term treatment with SMT.

Spinal Manipulation vs Prescription Drug Therapy for Chronic Low Back Pain: Beliefs, Satisfaction With Care, and Qualify of Life Among Older Medicare Beneficiaries.

OBJECTIVE: The objective of this study was to compare patients' perspectives on the use of spinal manipulative therapy (SMT) compared to prescription drug therapy (PDT) with regard to health-related quality of life (HRQoL), patient beliefs, and satisfaction with treatment. METHODS: Four cohorts of Medicare beneficiaries were assembled according to previous treatment received as evidenced in claims data: SMT, PDT, and 2 crossover cohorts (where participants experienced both types of treatments). A total of 195 Medicare beneficiaries responded to the survey. Outcome measures used were a 0-to-10 numeric rating scale to measure satisfaction, the Low Back Pain Treatment Beliefs Questionnaire to measure patient beliefs, and the 12-item Short Form Health Survey to measure HRQoL. RESULTS: Recipients of SMT were more likely to be very satisfied with their care (84%) than recipients of PDT (50%; P = .002). The SMT cohort self-reported significantly higher HRQoL compared to the PDT cohort; mean differences in physical and mental health scores on the 12-item Short Form Health Survey were 12.85 and 9.92, respectively. The SMT cohort had a lower degree of concern regarding chiropractic care for their back pain compared to the PDT cohort's reported concern about PDT (P = .03). CONCLUSION: Among older Medicare beneficiaries with chronic low back pain, long-term recipients of SMT had higher self-reported rates of HRQoL and greater satisfaction with their modality of care than long-term recipients of PDT. Participants who had longer-term management of care were more likely to have positive attitudes and beliefs toward the mode of care they received.

Impact of Chiropractic Care on Use of Prescription Opioids in Patients with Spinal Pain.

OBJECTIVE: Utilization of nonpharmacological pain management may prevent unnecessary use of opioids. Our objective was to evaluate the impact of chiropractic utilization upon use of prescription opioids among patients with spinal pain. DESIGN AND SETTING: We employed a retrospective cohort design for analysis of health claims data from three contiguous states for the years 2012-2017. SUBJECTS: We included adults aged 18-84 years enrolled in a health plan and with office visits to a primary care physician or chiropractor for spinal pain. We identified two cohorts of subjects: Recipients received both primary care and chiropractic care, and nonrecipients received primary care but not chiropractic care. METHODS: We performed adjusted time-to-event analyses to compare recipients and nonrecipients with regard to the risk of filling an opioid prescription. We stratified the recipient populations as: acute (first chiropractic encounter within 30 days of diagnosis) and nonacute (all other patients). RESULTS: The total number of subjects was 101,221. Overall, between 1.55 and 2.03 times more nonrecipients filled an opioid prescription, as compared with recipients (in Connecticut: hazard ratio [HR] = 1.55, 95% confidence interval [CI] = 1.11-2.17, P = 0.010; in New Hampshire: HR = 2.03, 95% CI = 1.92-2.14, P < 0.0001). Similar differences were observed for the acute groups. CONCLUSIONS: Patients with spinal pain who saw a chiropractor had half the risk of filling an opioid prescription. Among those who saw a chiropractor within 30 days of diagnosis, the reduction in risk was greater as compared with those with their first visit after the acute phase.

Implementation of the Primary Spine Care Model in a Multi-Clinician Primary Care Setting: An Observational Cohort Study.

OBJECTIVE: The objective of this investigation was to compare the value of primary spine care (PSC) with usual care for management of patients with spine-related disorders (SRDs) within a primary care setting. METHODS: We retrospectively examined existing patient encounter data at 3 primary care sites within a multi-clinic health system. Designated clinicians serve in the role as PSC as the initial point of contact for spine patients, coordinate, and follow up for the duration of the episode of care. A PSC may be a chiropractor, physical therapist, or medical or osteopathic physician who has been trained to provide primary care for patients with SRDs. The PSC model of care had been introduced at site I (Lebanon, New Hampshire); sites II (Bedford, New Hampshire) and III (Nashua, New Hampshire) served as control sites where patients received usual care. To evaluate cost outcomes, we employed a controlled quasi-experimental design for analysis of health claims data. For analysis of clinical outcomes, we compared clinical records for PSC at site I and usual care at sites II and III, all with reference to usual care at site I. We examined clinical encounters occurring over a 24-month period, from February 1, 2016 through January 31, 2018. RESULTS: Primary spine care was associated with reduced total expenditures compared with usual care for SRDs. At site I, average per-patient expenditure was $162 in year 1 and $186 in year 2, compared with site II ($332 in year 1; $306 in year 2) and site III ($467 in year 1; $323 in year 2). CONCLUSION: Among patients with SRDs included in this study, implementation of the PSC model within a conventional primary care setting was associated with a trend toward reduced total expenditures for spine care compared with usual primary care. Implementation of PSC may lead to reduced costs and resource utilization, but may be no more effective than usual care regarding clinical outcomes.

Unmasking the Association between Psychopathic Traits and Adaptive Functioning in Children.

The appearance of positive adjustment is a theoretically relevant element of psychopathy, and is valuable for demonstrating its incremental validity over a broader antisocial orientation. We examined associations between psychopathic-like features and two measures of adaptive functioning: psychometric intelligence and (immunity to) internalizing problems. Ratings of psychopathy and behavioral problems were obtained in a community sample of children (N=1210). A bifactor model was fit to the psychopathic personality items to capture the underlying variance common to all traits (i.e., general factor) and to isolate a unique cluster of interpersonal traits. We hypothesized that the general psychopathy factor and specific interpersonal factor would exhibit opposing patterns of associations with external criteria. As expected, the general psychopathy factor was associated with greater anxiety/depression and lower cognitive ability. Contrary to hypothesis, the interpersonal factor was not associated with adaptive functioning (i.e., reduced internal distress or superior cognitive ability), although the predicted relations emerged after controlling for antisocial behavior. Hence, in a large representative sample of children, there is limited support for the premise that psychopathic traits are associated with positive adjustment and enhanced intelligence. Implications regarding the construct validity of psychopathy are discussed, including the role of heterogeneity in sample characteristics and instrument.

Psychopathic personality development from ages 9 to 18: Genes and environment.

The genetic and environmental etiology of individual differences was examined in initial level and change in psychopathic personality from ages 9 to 18 years. A piecewise growth curve model, in which the first change score (G1) influenced all ages (9-10, 11-13, 14-15, and 16-18 years) and the second change score (G2) only influenced ages 14-15 and 16-18 years, fit the data better did than the standard single slope model, suggesting a turning point from childhood to adolescence. The results indicated that variations in levels and both change scores were mainly due to genetic (A) and nonshared environmental (E) influences (i.e., AE structure for G0, G1, and G2). No sex differences were found except on the mean values of level and change scores. Based on caregiver ratings, about 81% of variance in G0, 89% of variance in G1, and 94% of variance in G2 were explained by genetic factors, whereas for youth self-reports, these three proportions were 94%, 71%, and 66%, respectively. The larger contribution of genetic variance and covariance in caregiver ratings than in youth self-reports may suggest that caregivers considered the changes in their children to be more similar as compared to how the children viewed themselves.

The Southern California Twin Register at the University of Southern California: III.

The Southern California Twin Register at the University of Southern California (USC) was initiated in 1984 and continues to provide an important resource for studies investigating genetic and environmental influences on human behavior. This article provides an update on the current register and its potential for future twin studies using recruitment through school district databases and voter records. An overview is also provided for an ongoing longitudinal twin study investigating the development of externalizing psychopathology from childhood to young adulthood, the USC Study of Risk Factors for Antisocial Behavior. Characteristics of the twins and their families are presented, including recruitment and participation rates, as well as attrition analyses and a summary of key findings to date.

Psychopathic Personality and Negative Parent-to-Child Affect: A Longitudinal Cross-lag Twin Study.

PURPOSE: Previous studies that have explored the relationship between parenting style and children's antisocial behavior have generally found significant bidirectional effects, whereby parenting behaviors influence their child's antisocial outcomes, but a child's behaviors also lead to changes in parenting style. METHODS: The present study investigated the genetic and environmental underpinnings of the longitudinal relationship between negative parent-to-child affect and psychopathic personality in a sample of 1,562 twins. Using a biometrical cross-lag analysis, bidirectional effects were investigated across two waves of assessment when the twins were ages 9-10 and 14-15, utilizing both caregiver and youth self-reports. RESULTS: Results demonstrated that negative parental affects observed at ages 9-10 influenced the child's later psychopathic personality at ages 14-15, based on both caregiver and youth self-reports. For these 'parent-driven effects', both genetic and non-shared environmental factors were important in the development of later psychopathic personality during adolescence. There were additional 'child-driven effects' such that children's psychopathic personality at ages 9-10 influenced negative parent-to-child affect at ages 14-15, but only within caregiver reports. CONCLUSIONS: Thus, children's genetically influenced psychopathic personality seemed to evoke parental negativity at ages 14-15, highlighting the importance of investigating bidirectional effects in parent-child relationships to understand the development of these traits.

Efficiency of primary spine care as compared to conventional primary care: a retrospective observational study at an Academic Medical Center.

BACKGROUND: Primary Spine Care (PSC) is an innovative model for the primary management of patients with spine-related disorders (SRDs), with a focus on the use of non-pharmacological therapies which now constitute the recommended first-line approach to back pain. PSC clinicians serve as the initial or early point of contact for spine patients and utilize evidence-based spine care pathways to improve outcomes and reduce escalation of care (EoC; e.g., spinal injections, diagnostic imaging, hospitalizations, referrals to a specialist). The present study examined 6-month outcomes to evaluate the efficiency of care for patients who received PSC as compared to conventional primary care. We hypothesized that patients seen by a PSC clinician would have lower rates of EoC compared to patients who received usual care by a primary care (PC) clinician. METHODS: This was a retrospective observational study. We evaluated 6-month outcomes for two groups seen and treated for an SRD between February 01, 2017 and January 31, 2020. Patient groups were comprised of N = 1363 PSC patients (Group A) and N = 1329 PC patients (Group B). We conducted Pearson chi-square and logistic regression (adjusting for patient characteristics that were unbalanced between the two groups) to determine associations between the two groups and 6-month outcomes. RESULTS: Within six months of an initial visit for an SRD, a statistically significantly smaller proportion of PSC patients utilized healthcare resources for spine care as compared to the PC patients. When adjusting for patient characteristics, those who received care from the PSC clinician were less likely within 6 months of an initial visit to be hospitalized (OR = .47, 95% CI .23-.97), fill a prescription for an opioid analgesic (OR = .43; 95% CI .29-.65), receive a spinal injection (OR = .56, 95% CI .33-.95), or have a visit with a specialist (OR = .48, 95% CI .35-.67) as compared to those who received usual primary care. CONCLUSIONS: Patients who received PSC in an academic primary care clinic experienced significantly less escalation of their spine care within 6 months of their initial visit. The PSC model may offer a more efficient approach to the primary care of spine problems for patients with SRDs, as compared to usual primary care.

Association between chiropractic care and use of prescription opioids among older medicare beneficiaries with spinal pain: a retrospective observational study.

BACKGROUND: The burden of spinal pain can be aggravated by the hazards of opioid analgesics, which are still widely prescribed for spinal pain despite evidence-based clinical guidelines that identify non-pharmacological therapies as the preferred first-line approach. Previous studies have found that chiropractic care is associated with decreased use of opioids, but have not focused on older Medicare beneficiaries, a vulnerable population with high rates of co-morbidity and polypharmacy. The purpose of this investigation was to evaluate the association between chiropractic utilization and use of prescription opioids among older adults with spinal pain. METHODS: We conducted a retrospective observational study in which we examined a nationally representative multi-year sample of Medicare claims data, 2012-2016. The study sample included 55,949 Medicare beneficiaries diagnosed with spinal pain, of whom 9,356 were recipients of chiropractic care and 46,593 were non-recipients. We measured the adjusted risk of filling a prescription for an opioid analgesic for up to 365 days following diagnosis of spinal pain. Using Cox proportional hazards modeling and inverse weighted propensity scoring to account for selection bias, we compared recipients of both primary care and chiropractic to recipients of primary care alone regarding the risk of filling a prescription. RESULTS: The adjusted risk of filling an opioid prescription within 365 days of initial visit was 56% lower among recipients of chiropractic care as compared to non-recipients (hazard ratio 0.44; 95% confidence interval 0.40-0.49). CONCLUSIONS: Among older Medicare beneficiaries with spinal pain, use of chiropractic care is associated with significantly lower risk of filling an opioid prescription.

Initial Choice of Spinal Manipulation Reduces Escalation of Care for Chronic Low Back Pain Among Older Medicare Beneficiaries.

STUDY DESIGN: We combined elements of cohort and crossover-cohort design. OBJECTIVE: The objective of this study was to compare longterm outcomes for spinal manipulative therapy (SMT) and opioid analgesic therapy (OAT) regarding escalation of care for patients with chronic low back pain (cLBP). SUMMARY OF BACKGROUND DATA: Current evidence-based guidelines for clinical management of cLBP include both OAT and SMT. For long-term care of older adults, the efficiency and value of continuing either OAT or SMT are uncertain. METHODS: We examined Medicare claims data spanning a five-year period. We included older Medicare beneficiaries with an episode of cLBP beginning in 2013. All patients were continuously enrolled under Medicare Parts A, B, and D. We analyzed the cumulative frequency of encounters indicative of an escalation of care for cLBP, including hospitalizations, emergency department visits, advanced diagnostic imaging, specialist visits, lumbosacral surgery, interventional pain medicine techniques, and encounters for potential complications of cLBP. RESULTS: SMT was associated with lower rates of escalation of care as compared to OAT. The adjusted rate of escalated care encounters was approximately 2.5 times higher for initial choice of OAT vs. initial choice of SMT (with weighted propensity scoring: rate ratio 2.67, 95% confidence interval 2.64-2.69, P < .0001). CONCLUSION: Among older Medicare beneficiaries who initiated long-term care for cLBP with opioid analgesic therapy, the adjusted rate of escalated care encounters was significantly higher as compared to those who initiated care with spinal manipulative therapy.Level of Evidence: 3.

The structure of DSM-IV ADHD, ODD, and CD criteria in adolescent boys: a hierarchical approach.

Numerous studies have examined the structure of the childhood externalizing disorder symptoms of Attention Deficit Hyperactivity Disorder (ADHD), Oppositional Defiant Disorder (ODD), and Conduct Disorder (CD), both separately as well as simultaneously. The present study expanded on previous findings by implementing a multi-level hierarchical approach to investigating the component structure of ADHD, ODD, and CD criteria in 487 14-year-old boys from the Minnesota Twin Family Study (MTFS). We found support for a hierarchical conceptualization of externalizing behavior criteria in early adolescent boys by specifying how one-, two-, three-, four-, five- and six-factor models of externalizing criteria can be integrated. These results suggest that it may be more beneficial to conceptualize different levels of this hierarchy as relevant to different issues in case conceptualization and research design, from the broad level of an overall externalizing spectrum, to the level of finer-grained subtypes within specific disorders.

The genetic and environmental covariation among psychopathic personality traits, and reactive and proactive aggression in childhood.

The present study investigated the genetic and environmental covariance between psychopathic personality traits with reactive and proactive aggression in 9- to 10-year-old twins (N = 1,219). Psychopathic personality traits were assessed with the Child Psychopathy Scale (D. R. Lynam, 1997), while aggressive behaviors were assessed using the Reactive Proactive Questionnaire (A. Raine et al., 2006). Significant common genetic influences were found to be shared by psychopathic personality traits and aggressive behaviors using both caregiver (mainly mother) and child self-reports. Significant genetic and nonshared environmental influences specific to psychopathic personality traits and reactive and proactive aggression were also found, suggesting etiological independence among these phenotypes. Additionally, the genetic relation between psychopathic personality traits and aggression was significantly stronger for proactive than reactive aggression when using child self-reports.

Experiences and Attitudes About Chiropractic Care and Prescription Drug Therapy Among Patients With Back Pain: A Cross-Sectional Survey.

OBJECTIVE: The purpose of this study was to examine experiences and attitudes toward care offered by chiropractors and prescription drug therapy offered by medical physicians for patients who have back pain. METHODS: A cross-sectional survey measured patients with back pain (n = 150) seeking care within an academic primary care setting. A survey assessed patient experiences, beliefs, and attitudes regarding chiropractic care and prescription drug therapy. Two samples of patients in the New Hampshire region included 75 patients treated by a doctor of chiropractic (DC) and 75 treated by a medical primary care physician (PCP). The 30-item survey was sent to existing and new patients between February 2019 and January 2020. Between-group comparisons were examined to test rates of reporting and to determine the mean difference in the total number of office visits between the 2 samples. RESULTS: Patients treated by both DCs and PCPs reported high overall satisfaction with chiropractic care received for low back pain with no significant differences between groups. The majority in both groups reported that seeing a DC for back pain made sense to them (95% of patients treated by a DC and 75% of patients treated by a PCP) whereas the minority reported that taking prescription drugs for back pain made sense (25% of patients treated by a DC and 41% of patients treated by a PCP). There was no statistical difference between groups when patients were asked if seeing a chiropractor changed their beliefs or behaviors about taking pain medication. Significant differences were found between groups for agreement that chiropractic care would be a suitable treatment for back pain (79% of patients treated by a DC and 45% of patients treated by a PCP). There were 7% of patients treated by PCP and 23% of the patients treated by DC who agreed that a DC would be the first health care provider they would like to see for their general health needs. CONCLUSIONS: In this sample of patients, patient satisfaction regarding chiropractic care received for back pain was high. There were differences between patient groups about preferences for treatment for back pain. Our results indicate that patients reported that seeing a DC for back pain did not change their beliefs or behaviors regarding prescription drug therapy provided by their medical PCP.

Initial Choice of Spinal Manipulative Therapy for Treatment of Chronic Low Back Pain Leads to Reduced Long-term Risk of Adverse Drug Events Among Older Medicare Beneficiaries.

STUDY DESIGN: Retrospective observational study. OBJECTIVE: Opioid Analgesic Therapy (OAT) and Spinal Manipulative Therapy (SMT) are evidence-based strategies for treatment of chronic low back pain (cLBP), but the long-term safety of these therapies is uncertain. The objective of this study was to compare OAT versus SMT with regard to risk of adverse drug events (ADEs) among older adults with cLBP. SUMMARY OF BACKGROUND DATA: We examined Medicare claims data spanning a 5-year period on fee-for-service beneficiaries aged 65 to 84 years, continuously enrolled under Medicare Parts A, B, and D for a 60-month study period, and with an episode of cLBP in 2013. We excluded patients with a diagnosis of cancer or use of hospice care. METHODS: All included patients received long-term management of cLBP with SMT or OAT. We assembled cohorts of patients who received SMT or OAT only, and cohorts of patients who crossed over from OAT to SMT or from SMT to OAT. We used Poisson regression to estimate the adjusted incidence rate ratio for outpatient ADE among patients who initially chose OAT as compared with SMT. RESULTS: With controlling for patient characteristics, health status, and propensity score, the adjusted rate of ADE was more than 42 times higher for initial choice of OAT versus initial choice of SMT (rate ratio 42.85, 95% CI 34.16-53.76, P < 0.0001). CONCLUSION: Among older Medicare beneficiaries who received long-term care for cLBP the adjusted rate of ADE for patients who initially chose OAT was substantially higher than those who initially chose SMT.Level of Evidence: 2.

Cost comparison of two approaches to chiropractic care for patients with acute and sub-acute low Back pain care episodes: a cohort study.

BACKGROUND: Low back pain (LBP) imposes a costly burden upon patients, healthcare insurers, and society overall. Spinal manipulation as practiced by chiropractors has been found be cost-effective for treatment of LBP, but there is wide variation among chiropractors in their approach to clinical care, and the most cost-effective approach to chiropractic care is uncertain. To date, little has been published regarding the cost effectiveness of different approaches to chiropractic care. Thus, the current study presents a cost comparison between chiropractic approaches for patients with acute or subacute care episodes for low back pain. METHODS: We employed a retrospective cohort design to examine costs of chiropractic care among patients diagnosed with acute or subacute low back pain. The study time period ranged between 07/01/2016 and 12/22/2017. We compared cost outcomes for patients of two cohorts of chiropractors within health care system: Cohort 1) a general network of providers, and Cohort 2) a network providing conservative evidence-based care for rapid resolution of pain. We used generalized linear regression modeling to estimate the comparative influence of demographic and clinical factors on expenditures. RESULTS: A total of 25,621 unique patients were included in the analyses. The average cost per patient for Cohort 2 (mean allowed amount $252) was lower compared to Cohort 1 (mean allowed amount $326; 0.77, 95% CI 0.75-0.79, p < .001). Patient and clinician related factors such as health plan, provider region, and sex also significantly influenced costs. CONCLUSIONS: This study comprehensively analyzed cost data associated with the chiropractic care of adults with acute or sub-acute low back pain cared by two cohorts of chiropractic physicians. In general, providers in Cohort 2 were found to be significantly associated with lower costs for patient care as compared to Cohort 1. Utilization of a clinical model characterized by a patient-centered clinic approach and standardized, best-practice clinical protocols may offer lower cost when compared to non-standardized clinical approaches to chiropractic care.

Trends in Insurance Coverage for Complementary Health Care Services.

Introduction: Complementary health care professionals deliver a substantial component of clinical services in the United States, but insurance coverage for many such services may be inadequate. The objective of this project was to follow up on an earlier single-year study with an evaluation of trends in reimbursement for complementary health care services over a 7-year period. Methods: The authors employed a retrospective serial cross-sectional design to analyze health insurance claims for services provided by licensed acupuncturists, chiropractors, and naturopaths in New Hampshire (NH) from 2011 to 2017. They restricted the analyses to claims in nonemergent outpatient settings for Current Procedural Terminology code 99213, which is one of the most commonly used clinical procedure codes across all specialties. They evaluated by year the likelihood of reimbursement, as compared with primary care physicians as the gold standard. A generalized estimating equation model was used to account for within-person correlations among the separate claim reimbursement indicators for individuals used in the analysis, using an exchangeable working covariance structure among claims for the same individual. Reimbursement was defined as payment >0 dollars. Results: The total number of clinical services claimed was 26,725 for acupuncture, 8317 for naturopathic medicine, 2,539,144 for chiropractic, and 1,860,271 for primary care. Initially, likelihood of reimbursement for naturopathic physicians was higher relative to primary care physicians, but was lower from 2014 onward. Odds of reimbursement for both acupuncture and chiropractic claims remained lower throughout the study period. In 2017, as compared with primary care the likelihood of reimbursement was 77% lower for acupuncturists, 72% lower for chiropractors, and 64% lower for naturopaths. Conclusion: The likelihood of reimbursement for complementary health care services is significantly lower than that for primary care physicians in NH. Lack of insurance coverage may result in reduced patient access to such services.

Genetic and environmental influences on the junior temperament and character inventory in a preadolescent twin sample.

This study evaluated the genetic and environmental structure of personality variables from the Junior Temperament and Character Inventory (JTCI), in 605 pairs of 9- and 10-year old twins. There is a paucity of information on the biometric structure of temperament and character traits in preadolescent children. Latent factor models were fit to the subscales/items of each trait as a method of estimating genetic and environmental effects on true score variance, especially since internal consistency and reliability were moderate or low for some scales (particularly Reward Dependence and Persistence). Shared environmental influences on Cooperativeness were substantial. Significant heritability estimates were obtained for Self-directedness and Harm Avoidance, but not Novelty Seeking, Reward Dependence or Persistence. With the exception of Harm Avoidance, each of the scales failed to show measurement invariance with respect to sex, suggesting these scales may differ in meaning for boys and girls at this age.

Brief Report: Interaction between social class and risky decision-making in children with psychopathic tendencies.

OBJECTIVE: Adult psychopaths are thought to have risky decision-making and behavioral disinhibition, but little is known about the moderating effects of psychosocial factors and whether these associations can be observed in children with psychopathic tendencies. This study tests the biosocial hypothesis that social class will moderate psychopathy-neurocognition relationships, with these effects being stronger in children from high social classes. METHOD: Preadolescent community twins (N=298) were assessed on decision-making (Iowa Gambling) and behavior inhibition (Porteus Maze) tasks, while psychopathic tendencies and socioeconomic status were assessed by the child's caregiver. RESULTS: A significant interaction was observed whereby risky decision-making was associated with psychopathic tendencies only in children from benign home environments. CONCLUSIONS: Findings support a biosocial interaction perspective on child psychopathy, suggesting that risky decision-making may particularly predispose to psychopathic traits in children from benign home backgrounds.