Clinician and Staff Perspectives on Implementing Adverse Childhood Experience (ACE) Screening in Los Angeles County Pediatric Clinics.

PURPOSE: To understand clinician and clinical staff perspectives on the implementation of routine Adverse Childhood Experience (ACE) screening in pediatric primary care. METHODS: We conducted a qualitative evaluation in 5 clinics in Los Angeles County, California, using 2 rounds of focus group discussions: during an early phase of the initiative, and 7 months later. In the first round, we conducted 14 focus group discussions with 67 participants. In the second round, we conducted 12 focus group discussions with 58 participants. Participants comprised clinic staff involved in ACE screening, including frontline staff that administer the screening, medical clinicians that use screening to counsel patients and make referrals, and psychosocial support staff who may receive referrals. RESULTS: Themes were grouped into 3 categories: (1) screening acceptability and perceived utility, (2) implementation and quality improvement, and (3) effects of screening on patients and clinicians. Regarding screening acceptability and perceived utility, clinicians generally considered ACE screening to be acceptable and useful. In terms of implementation and quality improvement, significant barriers included: insufficient time for screening and response, insufficient training, and lack of clarity about referral networks and resources that could be offered to patients. Lastly, regarding effects of screening, clinicians expressed that ACE screening helped elicit important patient information and build trust with patients. Further, no adverse events were reported from screening. CONCLUSIONS: Clinic staff felt ACE screening was feasible, acceptable, and beneficial within pediatric care settings to improve trauma-informed care and that ACE screening could be strengthened by addressing time constraints and limited referral resources.

Patient and Caregiver Perspectives on Implementation of ACE Screening in Pediatric Care Settings: A Qualitative Evaluation.

INTRODUCTION: This qualitative research study explored the perspectives of adolescents, 12 to 19-years-old, and caregivers of children under 12-years-old on the acceptibility of adverse childhood experiences (ACEs) screenings in five pediatric clinics. METHOD: A constructivist grounded theory approach was utilized. One-on-one semistructured phone interviews were conducted with 44 adolescents and 95 caregivers of children less than 12 years old. Interviews were analyzed using thematic analysis. RESULTS: Most participants reported feeling comfortable discussing ACEs with their providers. Some reported that screening helped build trust. Others expressed privacy concerns and did not receive information about the reason for screening. Adolescent patients shared conflicting feelings-of both comfort and discomfort. Caregivers attending to multiple children, foster parents, and monolingual Spanish speakers disclosed unique challenges to ACEs screening. We found no evidence of lasting adverse effects. DISCUSSION: Participants generally found ACEs screenings acceptable. Some adolescents identified benefits from the experience. However, clinics planning to adopt routine ACEs screening should ensure clear messaging on why screening is occurring, anticipate and address privacy concerns, and adopt workflows to discuss screening results.

A three-dimensional taxonomy of achievement emotions.

We present a three-dimensional taxonomy of achievement emotions that considers valence, arousal, and object focus as core features of these emotions. By distinguishing between positive and negative emotions (valence), activating and deactivating emotions (arousal), and activity emotions, prospective outcome emotions, and retrospective outcome emotions (object focus), the taxonomy has a 2 × 2 × 3 structure representing 12 groups of achievement emotions. In four studies across different countries (N = 330, 235, 323, and 269 participants in Canada, the United States, Germany, and the U.K., respectively), we investigated the empirical robustness of the taxonomy in educational (Studies 1-3) and work settings (Study 4). An expanded version of the Achievement Emotions Questionnaire was used to assess 12 key emotions representing the taxonomy. Consistently across the four studies, findings from multilevel facet analysis and structural equation modeling documented the importance of the three dimensions for explaining achievement emotions. In addition, based on hypotheses about relations with external variables, the findings show clear links of the emotions with important antecedents and outcomes. The Big Five personality traits, appraisals of control and value, and context perceptions were predictors of the emotions. The 12 emotions, in turn, were related to participants' use of strategies, cognitive performance, and self-reported health problems. Taken together, the findings provide robust evidence for the unique positions of different achievement emotions in the proposed taxonomy, as well as unique patterns of relations with external variables. Directions for future research and implications for policy and practice are discussed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Attributional retraining: Promoting psychological wellbeing in older adults with compromised health.

Older adults make up the largest portion of the population of physically inactive individuals. Health challenges, and psychological barriers (e.g., maladaptive causal attributions), contribute to reduced activity engagement and low perceived control. This pilot study tested an attributional retraining (AR) intervention designed to increase control-related outcomes in a physical activity context for older adults with compromised health. Using a randomized treatment design, we examined treatment effects on a sample of older adults attending a day hospital (N = 37, M age = 80). We employed ANCOVAs, controlling for age, sex, and morbidity, to assess differences in post-treatment outcomes between AR and No-AR conditions. AR recipients (vs. No-AR) reported lower post-treatment helplessness and more perceived control over their health. Our study offers evidence for AR to increase control-related outcomes and lays the groundwork for further research into supporting older adult populations with compromised health.

Adjustment and acceptance beliefs in achievement settings: Implications for student wellbeing.

Research suggests that when dealing with personal setbacks, secondary control (SC) adjustment and acceptance beliefs can foster psychological wellbeing. However, little research has examined these beliefs, in combination, and how they impact students in their academic development. We conducted secondary analysis using an eight-month longitudinal study design over a two-semester introductory course on a sample of university students (n = 237; 64% female; M age = 19 years old). Multiple regression analyses assessed whether the students' Semester 1 adjustment and acceptance SC beliefs influenced Semester 2 learning-related emotions, perceived stress, and perceived course success, and whether Adjustment x Acceptance interactions emerged involving these outcomes. Adjustment beliefs promoted learning-related positive emotions (hope, pride), perceived course success, and reduced perceived stress; acceptance predicted higher shame and perceived stress. Students' adjustment predicted lower helplessness for students with high acceptance beliefs. These findings are discussed in light of the role that SC beliefs might play in curbing psychological distress reported by students on postsecondary campuses.

Reframing Achievement Setbacks: A Motivation Intervention to Improve 8-Year Graduation Rates for Students in Science, Technology, Engineering, and Mathematics (STEM) Fields.

Despite increased emphasis on educating students in science, technology, engineering, and mathematics (STEM) disciplines, nearly half of U.S. college students who enroll in these programs fail to graduate with STEM degrees. Using archival data from the Motivation and Academic Achievement Database, we tested whether a motivation intervention to reframe causal attributions for academic setbacks improved graduation rates for college students in STEM disciplines (N = 496). Results showed that the intervention increased the odds of 8-year graduation for students who were at risk of college dropout. Findings highlight the potential of theory-informed psychological interventions to increase persistence to graduation for at-risk students in STEM fields.

Attributions for physical activity in very old adults: predicting everyday physical activity and mortality risk.

OBJECTIVES: Although physical activity is recognised as a health-promoting behaviour for older adults, notable barriers exist that may reduce physical activity in this age group. Limited research has explored causal beliefs (attributions) as a barrier to physical activity. Our study assessed associations between older adults' attributions about physical activity and objective health outcomes. METHODS: We examined the role of attributions as a predictor of everyday physical activity (EPA) and subsequent mortality risk over a 10-year period (2006-2016) in a sample of older adults (Mage = 87, N = 261). RESULTS: OLS and Cox proportional hazard regression analyses revealed older adults who endorsed more internal and uncontrollable attributions for limited activity (physical incapacity) when feeling unwell had lower subsequent EPA (ß = -0.18), and higher 10-year mortality risk (HR = 1.46). Other attributions with different dimensional properties (e.g. internal and controllable) were not associated with EPA or mortality. DISCUSSION: Findings suggest that causal beliefs older adults have about their physical activity can influence their future behaviour and longevity. Psychological treatments designed to discourage maladaptive attributional thinking for older populations who face barriers to physical activity may be an important avenue for future research.

The Detrimental Consequences of Overestimating Future Health in Late Life.

OBJECTIVES: Although forecasting a positive future can be adaptive, it may not be when expectations are unmet. Our study examined whether such inaccurate expectations about future health status (overestimation) were maladaptive for older adults who commonly experience late life declines in physical functioning. METHOD: We analyzed data from the nationally representative German Aging Survey (DEAS; 1996-2011; n = 2,539; age range 60-85 years) using multilevel growth models that assessed the influence of inaccurate health expectations on older adults' physical functioning over a 9-year period. RESULTS: Overestimating future health status predicted reduced day-to-day physical functioning when age, gender, and self-rated health were controlled. A Time × Overestimation interaction indicated that the negative effects of overestimation on physical functioning became more pronounced over the 9-year period. DISCUSSION: Results suggest that repeatedly unmet health expectations may undermine motivational resources and accelerate late life declines in physical functioning.

A healthy dose of realism: The role of optimistic and pessimistic expectations when facing a downward spiral in health.

RATIONALE AND OBJECTIVES: Whether expectations about future health are adaptive or maladaptive in late life likely depends on the extent to which they conform to or defy a future reality of declining health. Our premise was that, when adults face a downward spiral in health, it can be adaptive to realistically expect poorer future health and maladaptive to unrealistically expect good health. METHOD: This 18-year-long study of community-dwelling older Canadians (n = 132, 72-98 years) involved a baseline interview to identify those who anticipated heath would decline (pessimistic expectation) or improve/remain stable (optimistic expectation). We determined initial (baseline) health status by assessing the severity of chronic conditions. An objective within-person measure of actual health change was derived by documenting hospital admissions (HAs) over time to capture a continuum that ranged from no declines (HAs remained stable) to greater declines in health (increasing numbers of HAs). Our a priori hypotheses examined the effects of health expectations (pessimistic, optimistic) and actual health change on the outcomes of depressive symptoms and mortality. RESULTS: Support was found for our premise that it is adaptive to be realistic when forecasting future health, at least at low levels of initial chronic condition severity. Regression analyses showed that realistically pessimistic (vs. unrealistically optimistic) expectations predicted significantly fewer depressive symptoms and a lower risk of death. The results also supported our premise that it is maladaptive to be unrealistically optimistic when health subsequently declines in reality: The risk of death was 313% higher for those with optimistic expectations that were unrealistic (vs. realistic). CONCLUSION: These findings provide insights for health care professionals regarding the messages they communicate to their patients. Together, they imply that, when good health is slipping away, it seems optimal to encourage a healthy dose of realism.

Paradoxical Effects of Perceived Control on Survival.

Objectives: Appraising health as controllable is typically thought to be adaptive, but recent evidence suggests the paradoxical possibility that perceived control (PC) can be detrimental. We considered the premise that high PC should have a survival benefit when it is part of an adaptive mindset involving high value (importance) for health, but it might be detrimental when it is part of a mindset comprised of low health value (HV). In addition, we examined whether the survival consequences of PC and HV vary with advancing age. Method: Interviews were conducted with a heterogeneous sample of community-dwelling adults (n = 341; 72-99 years) to assess appraisals of control and value in the domain of health. Mortality data were obtained over 12 years from a provincial health registry. Results: Both age and HV moderated the PC effect on mortality. The predicted beneficial and detrimental PC effects emerged at younger ages: higher PC predicted longer survival times when health was highly valued but shorter survival times when health was less highly valued. Discussion: These findings deepen the knowledge regarding the conditions under which PC is or is not adaptive, suggesting the consequences depend on age and the extent to which health is valued.

Tenacious self-reliance in health maintenance may jeopardize late life survival.

Although an active pursuit of health goals is typically adaptive, there may be circumstances in very late life when it is not. Our 10-year study of community-dwelling individuals (n = 220, 79-98 years-old) examined whether investing substantial effort into personal health (high selective primary control) in the absence of help-seeking strategies (low compensatory primary control) jeopardized survival for very old adults who varied in functional independence (low, high). Cox proportional hazard models showed selective primary control (SPC) predicted 10-year mortality risk for only those with low compensatory primary control (CPC) and high initial functional independence. For these individuals, each standard deviation increase in SPC predicted a 101% higher risk of death. Results are consistent with the lines-of-defense model (Heckhausen et al., 2013) and suggest that, for very old adults with little previous need for help-seeking strategies, tenacious self-reliance (high SPC, low CPC) may have life-shortening consequences. (PsycINFO Database Record

The Paradoxical Role of Perceived Control in Late Life Health Behavior.

Research has established the health benefits of psychological factors, including the way individuals appraise outcomes. Although many studies confirm that appraising outcomes as controllable is adaptive for health, a paradoxical possibility is largely ignored: Perceived control may be detrimental under some conditions. Our premise was that appraising health as controllable but at the same time ascribing little value to it might signal a dysfunctional psychological mindset that fosters a mistaken sense of invincibility. During face-to-face interviews with a representative sample of older adults (age range = 72-99), we identified individuals with such a potentially maladaptive "invincible" mindset (high perceived control and low health value) and compared them to their counterparts on several outcomes. The findings were consistent with our hypotheses. The invincibles denied future risks, they lacked the activating emotion of fear, and they visited their physicians less often over a subsequent five-year period. Moreover, in contrast to their counterparts, the invincibles did not appear strategic in their approach to seeking care: Even poor health did not prompt them to seek the counsel of a physician. The recognition that psychological appraisals are modifiable highlights the promise of remedial methods to alter maladaptive mindsets, potentially improving quality of life.

Attributing heart attack and stroke to "Old Age": Implications for subsequent health outcomes among older adults.

This study assessed the extent to which older adults attribute a recent heart attack/stroke to "old age," and examined consequences for subsequent lifestyle behavior and health-care service utilization. Community-dwelling adults (N = 57, ages 73-98 years) were interviewed about their heart attack/stroke, and an objective health registry provided data on health-care utilization over a 3-year period. Endorsement of "old age" as a cause of heart attack/stroke negatively predicted lifestyle behavior change, and positively predicted frequency of physician visits and likelihood of hospitalization over the subsequent 3 years. Findings suggest the importance of considering "old age" attributions in the context of cardiovascular health events.

Juvenile Incarceration and Health.

Addressing the health status and needs of incarcerated youth represents an issue at the nexus of juvenile justice reform and health care reform. Incarcerated youth face disproportionately higher morbidity and higher mortality compared to the general adolescent population. Dental health, reproductive health, and mental health needs are particularly high, likely as a result of lower access to care, engagement in high-risk behaviors, and underlying health disparities. Violence exposure and injury also contribute to the health disparities seen in this population. Further, juvenile incarceration itself is an important determinant of health. Juvenile incarceration likely correlates with worse health and social functioning across the life course. Correctional health care facilities allow time for providers to address the unmet physical and mental health needs seen in this population. Yet substantial challenges to care delivery in detention facilities exist and quality of care in detention facilities varies widely. Community-based pediatricians can serve a vital role in ensuring continuity of care in the postdetention period and linking youth to services that can potentially prevent juvenile offending. Pediatricians who succeed in understanding and addressing the underlying social contexts of their patients' lives can have tremendous impact in improving the life trajectories of these vulnerable youth. Opportunities exist in clinical care, research, medical education, policy, and advocacy for pediatricians to lead change and improve the health status of youth involved in the juvenile justice system.

Azithromycin versus Doxycycline for Urogenital Chlamydia trachomatis Infection.

BACKGROUND: Urogenital Chlamydia trachomatis infection remains prevalent and causes substantial reproductive morbidity. Recent studies have raised concern about the efficacy of azithromycin for the treatment of chlamydia infection. METHODS: We conducted a randomized trial comparing oral azithromycin with doxycycline for the treatment of urogenital chlamydia infection among adolescents in youth correctional facilities, to evaluate the noninferiority of azithromycin (1 g in one dose) to doxycycline (100 mg twice daily for 7 days). The treatment was directly observed. The primary end point was treatment failure at 28 days after treatment initiation, with treatment failure determined on the basis of nucleic acid amplification testing, sexual history, and outer membrane protein A (OmpA) genotyping of C. trachomatis strains. RESULTS: Among the 567 participants enrolled, 284 were randomly assigned to receive azithromycin, and 283 were randomly assigned to receive doxycycline. A total of 155 participants in each treatment group (65% male) made up the per-protocol population. There were no treatment failures in the doxycycline group. In the azithromycin group, treatment failure occurred in 5 participants (3.2%; 95% confidence interval, 0.4 to 7.4%). The observed difference in failure rates between the treatment groups was 3.2 percentage points, with an upper boundary of the 90% confidence interval of 5.9 percentage points, which exceeded the prespecified absolute 5-percentage-point cutoff for establishing the noninferiority of azithromycin. CONCLUSIONS: In the context of a closed population receiving directly observed treatment for urogenital chlamydia infection, the efficacy of azithromycin was 97%, and the efficacy of doxycycline was 100%. The noninferiority of azithromycin was not established in this setting. (Funded by the National Institute of Allergy and Infectious Diseases; ClinicalTrials.gov number, NCT00980148.).

Motivation-focused thinking: Buffering against stress-related physical symptoms and depressive symptomology.

Developmental transitions are experienced throughout the life course and necessitate adapting to consequential and unpredictable changes that can undermine health. Our six-month study (n = 239) explored whether selective secondary control striving (motivation-focused thinking) protects against the elevated levels of stress and depressive symptoms increasingly common to young adults navigating the challenging school-to-university transition. Path analyses supplemented with tests of moderated mediation revealed that, for young adults who face challenging obstacles to goal attainment, selective secondary control indirectly reduced long-term stress-related physical and depressive symptoms through selective primary control and previously unexamined measures of discrete emotions. Results advance the existing literature by demonstrating that (a) selective secondary control has health benefits for vulnerable young adults and (b) these benefits are largely a consequence of the process variables proposed in Heckhausen et al.'s (2010) theory.

Incarcerated Youths' Perspectives on Protective Factors and Risk Factors for Juvenile Offending: A Qualitative Analysis.

OBJECTIVES: We sought to understand incarcerated youths' perspectives on the role of protective factors and risk factors for juvenile offending. METHODS: We performed an in-depth qualitative analysis of interviews (conducted October-December 2013) with 20 incarcerated youths detained in the largest juvenile hall in Los Angeles. RESULTS: The adolescent participants described their homes, schools, and neighborhoods as chaotic and unsafe. They expressed a need for love and attention, discipline and control, and role models and perspective. Youths perceived that when home or school failed to meet these needs, they spent more time on the streets, leading to incarceration. They contrasted the path through school with the path to jail, reporting that the path to jail felt easier. All of them expressed the insight that they had made bad decisions and that the more difficult path was not only better but also still potentially achievable. CONCLUSIONS: Breaking cycles of juvenile incarceration will require that the public health community partner with legislators, educators, community leaders, and youths to determine how to make success, rather than incarceration, the easier path for disadvantaged adolescents.

Health care for youth involved with the correctional system.

Adolescents with involvement in the correctional system have significant health risks and needs. Professional guidelines and policies related to health services in correctional settings can help health care providers who work in youth detention facilities and those who see youth for follow-up care after incarceration. Several challenges exist to providing care in detention facilities, but overcoming these barriers to optimally serve youth is critical. When youth are released to their homes, community providers must understand the extent of care offered in detention facilities, the unique considerations for youth on probation, and the aspects of follow-up care that should be addressed.

Conflicted goal engagement: undermining physical activity and health in late life.

OBJECTIVES: Pursuing health goals in very old age is a challenging task that may be undermined by conflicted goal engagement involving mismatched primary (behavior-focused) and secondary (motivation-focused) control striving. Our study explored whether one potentially detrimental combination of control strategies (low primary control/high secondary control) compromised 3-year indicators of everyday physical activity and blood oxygen saturation. METHOD: We analyzed data from a representative sample of very old adults (n = 107) using simple slope regression analyses that tested the conditional effects of control striving on everyday physical activity and blood oxygen saturation. RESULTS: We found a conflicted engagement effect wherein primary control predicted our outcomes only when secondary control was high. The lowest levels of everyday physical activity and blood oxygen saturation were found for older adults high in secondary control but low in primary control. A supplemental mediation analysis suggested everyday physical activity was the mechanism through which conflicted engagement undermined blood oxygen saturation. DISCUSSION: Employing health maintenance strategies that promote motivation-focused thinking but discourage goal-directed behaviors (conflicted engagement) may compromise physical activity and health among very old adults. Further research is needed to determine whether control-enhancing interventions promote harmonious goal engagement and better health among these high-risk individuals.