Construct validity of the international standards to document remaining autonomic function after spinal cord injury (ISAFSCI) (1st edition).

STUDY DESIGN: Observational study. OBJECTIVES: To assess the construct validity of the International Standards to Document Remaining Autonomic Function after Spinal Cord Injury (ISAFSCI) (2012 1st Edition). SETTING: Two Canadian spinal cord injury (SCI) centers. METHODS: Data were collected between 2011-2014. Assessments included the ISAFSCI, standardized measures of autonomic function and a clinical examination. Construct validity of ISAFSCI was assessed by testing a priori hypotheses on expected ISAFSCI responses to standard measures (convergent hypotheses) and clinical variables (clinical hypotheses). RESULTS: Forty-nine participants with an average age of 45 ± 12 years were included, of which 42 (85.7%) were males, 37 (77.6%) had a neurological level of injury at or above T6, and 23 (46.9%) were assessed as having motor and sensory complete SCI. For the six General Autonomic Function component hypotheses, two hypotheses (1 clinical, 1 convergent) related to autonomic control of blood pressure and one clinical hypothesis for temperature regulation were statistically significant. In terms of the Lower Urinary Tract, Bowel and Sexual Function component of the ISAFSCI, all the hypotheses (5 convergent, 3 clinical) were statistically significant except for the hypotheses on female sexual items (2 convergent, 2 clinical), likely due to small sample size. CONCLUSION: The construct validity of ISAFSCI (2012 1st Edition) for the General Autonomic Function component was considered to be weak while it was much stronger for the Lower Urinary Tract, Bowel and Sexual Function component based on a priori hypotheses. These results can inform future psychometric studies of the ISAFSCI (2021 2nd Edition).

Scaling up behavioral science interventions in online education.

Online education is rapidly expanding in response to rising demand for higher and continuing education, but many online students struggle to achieve their educational goals. Several behavioral science interventions have shown promise in raising student persistence and completion rates in a handful of courses, but evidence of their effectiveness across diverse educational contexts is limited. In this study, we test a set of established interventions over 2.5 y, with one-quarter million students, from nearly every country, across 247 online courses offered by Harvard, the Massachusetts Institute of Technology, and Stanford. We hypothesized that the interventions would produce medium-to-large effects as in prior studies, but this is not supported by our results. Instead, using an iterative scientific process of cyclically preregistering new hypotheses in between waves of data collection, we identified individual, contextual, and temporal conditions under which the interventions benefit students. Self-regulation interventions raised student engagement in the first few weeks but not final completion rates. Value-relevance interventions raised completion rates in developing countries to close the global achievement gap, but only in courses with a global gap. We found minimal evidence that state-of-the-art machine learning methods can forecast the occurrence of a global gap or learn effective individualized intervention policies. Scaling behavioral science interventions across various online learning contexts can reduce their average effectiveness by an order-of-magnitude. However, iterative scientific investigations can uncover what works where for whom.

Ratings and experiences in using a mobile application to increase physical activity among university students: implications for future design.

University students have low levels of physical activity and are at risk of mental health disorders. Mobile apps to encourage physical activity can help students, who are frequent smartphone-users, to improve their physical and mental health. Here we report students' qualitative feedback on a physical activity smartphone app with motivational text messaging. We provide recommendations for the design of future apps. 103 students used the app for 6 weeks in the context of a clinical trial (NCT04440553) and answered open-ended questions before the start of the study and at follow-up. A subsample (n = 39) provided additional feedback via text message, and a phone interview (n = 8). Questions focused on the perceived encouragement and support by the app, text messaging content, and recommendations for future applications. We analyzed all transcripts for emerging themes using qualitative coding in Dedoose. The majority of participants were female (69.9%), Asian or Pacific Islander (53.4%), with a mean age of 20.2 years, and 63% had elevated depressive symptoms. 26% felt encouraged or neutral toward the app motivating them to be more physically active. Participants liked messages on physical activity benefits on (mental) health, encouraging them to complete their goal, and feedback on their activity. Participants disliked messages that did not match their motivations for physical activity and their daily context (e.g., time, weekday, stress). Physical activity apps for students should be adapted to their motivations, changing daily context, and mental health issues. Feedback from this sample suggests a key to effectiveness is finding effective ways to personalize digital interventions.

Nonprofessional Peer Support to Improve Mental Health: Randomized Trial of a Scalable Web-Based Peer Counseling Course.

BACKGROUND: Millions of people worldwide are underserved by the mental health care system. Indeed, most mental health problems go untreated, often because of resource constraints (eg, limited provider availability and cost) or lack of interest or faith in professional help. Furthermore, subclinical symptoms and chronic stress in the absence of a mental illness diagnosis often go unaddressed, despite their substantial health impact. Innovative and scalable treatment delivery methods are needed to supplement traditional therapies to fill these gaps in the mental health care system. OBJECTIVE: This study aims to investigate whether a self-guided web-based course can teach pairs of nonprofessional peers to deliver psychological support to each other. METHODS: In this experimental study, a community sample of 30 dyads (60 participants, mostly friends), many of whom presented with mild to moderate psychological distress, were recruited to complete a web-based counseling skills course. Dyads were randomized to either immediate or delayed access to training. Before and after training, dyads were recorded taking turns discussing stressors. Participants' skills in the helper role were assessed before and after taking the course: the first author and a team of trained research assistants coded recordings for the presence of specific counseling behaviors. When in the client role, participants rated the session on helpfulness in resolving their stressors and supportiveness of their peers. We hypothesized that participants would increase the use of skills taught by the course and decrease the use of skills discouraged by the course, would increase their overall adherence to the guidelines taught in the course, and would perceive posttraining counseling sessions as more helpful and their peers as more supportive. RESULTS: The course had large effects on most helper-role speech behaviors: helpers decreased total speaking time, used more restatements, made fewer efforts to influence the speaker, and decreased self-focused and off-topic utterances (ds=0.8-1.6). When rating the portion of the session in which they served as clients, participants indicated that they made more progress in addressing their stressors during posttraining counseling sessions compared with pretraining sessions (d=1.1), but they did not report substantive changes in feelings of closeness and supportiveness of their peers (d=0.3). CONCLUSIONS: The results provide proof of concept that nonprofessionals can learn basic counseling skills from a scalable web-based course. The course serves as a promising model for the development of web-based counseling skills training, which could provide accessible mental health support to some of those underserved by traditional psychotherapy.

Community Assessments for Public Health Emergency Response (CASPERs)-US Virgin Islands, 2017-2018.

Objectives. To assess preparedness levels of communities to help public health and others plan for disasters or emergencies and tailor messaging to increase community preparedness.Methods. US Virgin Islands Department of Health conducted a Community Assessment for Public Health Emergency Response (CASPER) in June 2017, 2 hurricane response CASPERs in November 2017, and a recovery CASPER in February 2018. CASPER is a 2-stage cluster sampling method designed to provide household-based information about a community's needs in a timely, inexpensive, and representative manner.Results. Roughly the same amount of households reported having a 3-day supply of food and water before and 3 months after the hurricanes. During the response, approximately a third of households resupplied between 3 and 6 days and an additional approximately 40% between days 7 and 14.Conclusions. On the basis of the CASPERs, we were able to track whether households had an emergency preparedness kit, whether they used it during the storms (and what was missing), and if they resupplied their kit in recovery.Public Health Implications. CASPER is a promising tool to measure community preparedness to help state, local, tribal, and territorial jurisdictions plan for disasters or emergencies.

Exploring User Perspectives on Brief Reflective Questioning Activities for Stress Management: Mixed Methods Study.

BACKGROUND: Current online interventions dedicated to assisting individuals in managing stress and negative emotions often necessitate substantial time commitments. This can be burdensome for users, leading to high dropout rates and reducing the effectiveness of these interventions. This highlights an urgent need for concise digital activities that individuals can swiftly access during instances of negative emotions or stress in their daily lives. OBJECTIVE: The primary aim of this study was to investigate the viability of using a brief digital exercise, specifically a reflective questioning activity (RQA), to help people reflect on their thoughts and emotions about a troubling situation. The RQA is designed to be quick, applicable to the general public, and scalable without requiring a significant support structure. METHODS: We conducted 3 simultaneous studies. In the first study, we recruited 48 participants who completed the RQA and provided qualitative feedback on its design through surveys and semistructured interviews. In the second study, which involved 215 participants from Amazon Mechanical Turk, we used a between-participants design to compare the RQA with a single-question activity. Our hypotheses posited that the RQA would yield greater immediate stress relief and higher perceived utility, while not significantly altering the perception of time commitment. To assess these, we measured survey completion times and gathered multiple self-reported scores. In the third study, we assessed the RQA's real-world impact as a periodic intervention, exploring engagement via platforms such as email and SMS text messaging, complemented by follow-up interviews with participants. RESULTS: In our first study, participants appreciated the RQA for facilitating structured reflection, enabling expression through writing, and promoting problem-solving. However, some of the participants experienced confusion and frustration, particularly when they were unable to find solutions or alternative perspectives on their thoughts. In the second study, the RQA condition resulted in significantly higher ratings (P=.003) for the utility of the activity and a statistically significant decrease (P<.001) in perceived stress rating compared with the single-question activity. Although the RQA required significantly more time to be completed (P<.001), there was no statistically significant difference in participants' subjective perceived time commitment (P=.37). Deploying the RQA over 2 weeks in the third study identified some potential challenges to consider for such activities, such as the monotony of doing the same activity several times, the limited affordances of mobile phones, and the importance of having the prompts align with the occurrence of new troubling situations. CONCLUSIONS: This paper describes the design and evaluation of a brief online self-reflection activity based on cognitive behavioral therapy principles. Our findings can inform practitioners and researchers in the design and exploration of formats for brief interventions to help people with everyday struggles.

Understanding the Role of Large Language Models in Personalizing and Scaffolding Strategies to Combat Academic Procrastination.

Traditional interventions for academic procrastination often fail to capture the nuanced, individual-specific factors that underlie them. Large language models (LLMs) hold immense potential for addressing this gap by permitting open-ended inputs, including the ability to customize interventions to individuals' unique needs. However, user expectations and potential limitations of LLMs in this context remain underexplored. To address this, we conducted interviews and focus group discussions with 15 university students and 6 experts, during which a technology probe for generating personalized advice for managing procrastination was presented. Our results highlight the necessity for LLMs to provide structured, deadline-oriented steps and enhanced user support mechanisms. Additionally, our results surface the need for an adaptive approach to questioning based on factors like busyness. These findings offer crucial design implications for the development of LLM-based tools for managing procrastination while cautioning the use of LLMs for therapeutic guidance.

Using Adaptive Bandit Experiments to Increase and Investigate Engagement in Mental Health.

Digital mental health (DMH) interventions, such as text-message-based lessons and activities, offer immense potential for accessible mental health support. While these interventions can be effective, real-world experimental testing can further enhance their design and impact. Adaptive experimentation, utilizing algorithms like Thompson Sampling for (contextual) multi-armed bandit (MAB) problems, can lead to continuous improvement and personalization. However, it remains unclear when these algorithms can simultaneously increase user experience rewards and facilitate appropriate data collection for social-behavioral scientists to analyze with sufficient statistical confidence. Although a growing body of research addresses the practical and statistical aspects of MAB and other adaptive algorithms, further exploration is needed to assess their impact across diverse real-world contexts. This paper presents a software system developed over two years that allows text-messaging intervention components to be adapted using bandit and other algorithms while collecting data for side-by-side comparison with traditional uniform random non-adaptive experiments. We evaluate the system by deploying a text-message-based DMH intervention to 1100 users, recruited through a large mental health non-profit organization, and share the path forward for deploying this system at scale. This system not only enables applications in mental health but could also serve as a model testbed for adaptive experimentation algorithms in other domains.

The 'missing heritability' of common disorders: should health researchers care?

This article critiques the "missing heritability" position, which calls for greater efforts and funding to identify the genetic architecture of common disorders, even if this endeavor has yet to translate into tangible prevention, diagnosis, or treatment interventions. Supporters of the position contend that genetic variants "for" common disorders, which they argue must exist based on heritability estimates (hence their "missing heritability" position), have not been found because the current state of science and technology is not adequate to the task, yet they insist that this search warrants significant societal investments. We argue, instead, that these variants have not been found because they do not exist. The thrust of the problem with the "missing heritability" position, we propose, lies in its proponents' use of faulty concepts and research methods, including reliance on twin studies, plagued with environmental confounds; on the concept of heritability, a breeding statistic and not a measure of the importance of genetic influences on phenotypes; and on the belief that genetic variations are relevant to understanding, preventing, or treating common disorders, a belief that we argue is false. We elaborate on these problems, discuss their public health implications, and suggest future directions for a critical analysis of human genetics.

A flexible micro-randomized trial design and sample size considerations.

Technological advancements have made it possible to deliver mobile health interventions to individuals. A novel framework that has emerged from such advancements is the just-in-time adaptive intervention, which aims to suggest the right support to the individuals when their needs arise. The micro-randomized trial design has been proposed recently to test the proximal effects of the components of these just-in-time adaptive interventions. However, the extant micro-randomized trial framework only considers components with a fixed number of categories added at the beginning of the study. We propose a more flexible micro-randomized trial design which allows addition of more categories to the components during the study. Note that the number and timing of the categories added during the study need to be fixed initially. The proposed design is motivated by collaboration on the Diabetes and Mental Health Adaptive Notification Tracking and Evaluation study, which learns to deliver effective text messages to encourage physical activity among patients with diabetes and depression. We developed a new test statistic and the corresponding sample size calculator for the flexible micro-randomized trial using an approach similar to the generalized estimating equation for longitudinal data. Simulation studies were conducted to evaluate the sample size calculators and an R shiny application for the calculators was developed.

Investigating the Role of Context in the Delivery of Text Messages for Supporting Psychological Wellbeing.

Without a nuanced understanding of users' perspectives and contexts, text messaging tools for supporting psychological wellbeing risk delivering interventions that are mismatched to users' dynamic needs. We investigated the contextual factors that influence young adults' day-to-day experiences when interacting with such tools. Through interviews and focus group discussions with 36 participants, we identified that people's daily schedules and affective states were dominant factors that shape their messaging preferences. We developed two messaging dialogues centered around these factors, which we deployed to 42 participants to test and extend our initial understanding of users' needs. Across both studies, participants provided diverse opinions of how they could be best supported by messages, particularly around when to engage users in more passive versus active ways. They also proposed ways of adjusting message length and content during periods of low mood. Our findings provide design implications and opportunities for context-aware mental health management systems.

"I Kind of Bounce off It": Translating Mental Health Principles into Real Life Through Story-Based Text Messages.

Adopting new psychological strategies to improve mental wellness can be challenging since people are often unable to anticipate how new habits are applicable to their circumstances. Narrative-based interventions have the potential to alleviate this burden by illustrating psychological principles in an applied context. In this work, we explore how stories can be delivered via the ubiquitous and scalable medium of text messaging. Through formative work consisting of interviews and focus group discussions with 15 participants, we identified desirable elements of stories about mental health, including authenticity and relatability. We then deployed story-based text messages to 42 participants to explore challenges regarding both the stories' content (e.g., specific versus generalized) and format (e.g., story length). We observed that our stories helped participants reflect on and identify flaws in their thinking patterns. Our findings highlight design implications and opportunities for mental wellness interventions that utilize stories in text messaging services.

Developing Messaging Content for a Physical Activity Smartphone App Tailored to Low-Income Patients: User-Centered Design and Crowdsourcing Approach.

BACKGROUND: Text messaging interventions can be an effective and efficient way to improve health behavioral changes. However, most texting interventions are neither tested nor designed with diverse end users, which could reduce their impact, and there is limited evidence regarding the optimal design methodology of health text messages tailored to low-income, low-health literacy populations and non-English speakers. OBJECTIVE: This study aims to combine participant feedback, crowdsourced data, and researcher expertise to develop motivational text messages in English and Spanish that will be used in a smartphone app-based texting intervention that seeks to encourage physical activity in low-income minority patients with diabetes diagnoses and depression symptoms. METHODS: The design process consisted of 5 phases and was iterative in nature, given that the findings from each step informed the subsequent steps. First, we designed messages to increase physical activity based on the behavior change theory and knowledge from the available evidence. Second, using user-centered design methods, we refined these messages after a card sorting task and semistructured interviews (N=10) and evaluated their likeability during a usability testing phase of the app prototype (N=8). Third, the messages were tested by English- and Spanish-speaking participants on the Amazon Mechanical Turk (MTurk) crowdsourcing platform (N=134). Participants on MTurk were asked to categorize the messages into overarching theoretical categories based on the capability, opportunity, motivation, and behavior framework. Finally, each coauthor rated the messages for their overall quality from 1 to 5. All messages were written at a sixth-grade or lower reading level and culturally adapted and translated into neutral Spanish by bilingual research staff. RESULTS: A total of 200 messages were iteratively refined according to the feedback from target users gathered through user-centered design methods, crowdsourced results of a categorization test, and an expert review. User feedback was leveraged to discard unappealing messages and edit the thematic aspects of messages that did not resonate well with the target users. Overall, 54 messages were sorted into the correct theoretical categories at least 50% of the time in the MTurk categorization tasks and were rated 3.5 or higher by the research team members. These were included in the final text message bank, resulting in 18 messages per motivational category. CONCLUSIONS: By using an iterative process of expert opinion, feedback from participants that were reflective of our target study population, crowdsourcing, and feedback from the research team, we were able to acquire valuable inputs for the design of motivational text messages developed in English and Spanish with a low literacy level to increase physical activity. We describe the design considerations and lessons learned for the text messaging development process and provide a novel, integrative framework for future developers of health text messaging interventions.

Disaster-Related Surveillance Among US Virgin Islands (USVI) Shelters During the Hurricanes Irma and Maria Response.

OBJECTIVES: Two Category 5 storms, Hurricane Irma and Hurricane Maria, hit the U.S. Virgin Islands (USVI) within 13 days of each other in September 2017. These storms caused catastrophic damage across the territory, including widespread loss of power, destruction of homes, and devastation of critical infrastructure. During large scale disasters such as Hurricanes Irma and Maria, public health surveillance is an important tool to track emerging illnesses and injuries, identify at-risk populations, and assess the effectiveness of response efforts. The USVI Department of Health (DoH) partnered with shelter staff volunteers to monitor the health of the sheltered population and help guide response efforts. METHODS: Shelter volunteers collect data on the American Red Cross Aggregate Morbidity Report form that tallies the number of client visits at a shelter's health services every 24 hours. Morbidity data were collected at all 5 shelters on St. Thomas and St. Croix between September and October 2017. This article describes the health surveillance data collected in response to Hurricanes Irma and Maria. RESULTS: Following Hurricanes Irma and Maria, 1130 health-related client visits were reported, accounting for 1655 reasons for the visits (each client may have more than 1 reason for a single visit). Only 1 shelter reported data daily. Over half of visits (51.2%) were for health care management; 17.7% for acute illnesses, which include respiratory conditions, gastrointestinal symptoms, and pain; 14.6% for exacerbation of chronic disease; 9.8% for mental health; and 6.7% for injury. Shelter volunteers treated many clients within the shelters; however, reporting of the disposition (eg, referred to physician, pharmacist) was often missed (78.1%). CONCLUSION: Shelter surveillance is an efficient means of quickly identifying and characterizing health issues and concerns in sheltered populations following disasters, allowing for the development of evidence-based strategies to address identified needs. When incorporated into broader surveillance strategies using multiple data sources, shelter data can enable disaster epidemiologists to paint a more comprehensive picture of community health, thereby planning and responding to health issues both within and outside of shelters. The findings from this report illustrated that managing chronic conditions presented a more notable resource demand than acute injuries and illnesses. Although there remains room for improvement because reporting was inconsistent throughout the response, the capacity of shelter staff to address the health needs of shelter residents and the ability to monitor the health needs in the sheltered population were critical resources for the USVI DoH overwhelmed by the disaster. (Disaster Med Public Health Preparedness. 2019;13:38-43).

Addressing Community Needs During the Hurricane Response and Recovery Efforts Through Community Assessments for Public Health Emergency Response (CASPER)-United States Virgin Islands, 2017-2018.

OBJECTIVES: Two category 5 storms hit the US Virgin Islands (USVI) within 13 days of each other in September 2017. This caused an almost complete loss of power and devastated critical infrastructure such as the hospitals and airports METHODS: The USVI Department of Health conducted 2 response Community Assessments for Public Health Emergency Response (CASPERs) in November 2017 and a recovery CASPER in February 2018. CASPER is a 2-stage cluster sampling method designed to provide household-based information about a community's needs in a timely, inexpensive, and representative manner. RESULTS: Almost 70% of homes were damaged or destroyed, 81.2% of homes still needed repair, and 10.4% of respondents felt their home was unsafe to live in approximately 5 months after the storms. Eighteen percent of individual respondents indicated that their mental health was "not good" for 14 or more days in the past month, a significant increase from 2016. CONCLUSION: The CASPERs helped characterize the status and needs of residents after the devastating hurricanes and illustrate the evolving needs of the community and the progression of the recovery process. CASPER findings were shared with response and recovery partners to promote data-driven recovery efforts, improve the efficiency of the current response and recovery efforts, and strengthen emergency preparedness in USVI. (Disaster Med Public Health Preparedness. 2019;13:53-62).

Inter-Rater Reliability of the International Standards to Document Remaining Autonomic Function after Spinal Cord Injury.

The autonomic nervous system can be profoundly affected after spinal cord injury (SCI). Despite its importance to quality of life, autonomic function is rarely systematically assessed in the clinical setting. The International Standards to Document Remaining Autonomic Function after Spinal Cord Injury (ISAFSCI) is an assessment designed to determine which autonomic functions are intact, impaired, or lost after SCI. The psychometric properties of the ISAFSCI have not yet been reported. The objective of this study was to describe the inter-rater reliability of the ISAFSCI. Participants with chronic traumatic SCI (greater than 1 year) able to remain on the same medications for the study period and communicate clearly with the assessor were recruited for the study. A standard protocol minimized variation between the sites. During the first assessment, neurologic examination (ISNCSCI) was performed and ISAFSCI completed. After 10-14 days, the ISAFSCI was repeated. Inter-rater reliability was calculated using percentage agreement, kappa, and weighted kappa statistics. Participants (n = 48) had an average age of 45 ± 12 years. Forty-one (85.4%) were male, 38 (79.2%) had a SCI at or above the T6 level, 24 (50.0%) had a complete SCI. Inter-rater reliability within the general autonomic component was moderate with kappa values ranging 0.41-0.6 (p < 0.05). Within the Lower Urinary Tract, Bowel, and Sexual Function component, agreement was good-strong with weighted kappa values 0.62-0.88 (p < 0.05). Given the results, we conclude that the ISAFSCI can be considered to have at least moderate and up to strong inter-rater reliability, especially in the bladder, bowel, and sexual function component of the assessment.

Quality of life of children after repair of transposition of the great arteries.

BACKGROUND: We sought to assess quality of life of children with transposition of the great arteries (TGA) enrolled during transition in management strategy from atrial to arterial switch operation. METHODS AND RESULTS: Neonates enrolled by the Congenital Heart Surgeons Society in a prospective study of TGA between 1985 and 1989 were eligible. A Child Health Questionnaire was sent for completion by the child between February and June 2000. Data were compared with published normative values. Child Health Questionnaires were completed by 306 of 708 survivors at a mean age of 13+/-1 years. Diagnosis included TGA (n=202, 66%), TGA/ventricular septal defect (VSD) (n=84, 27%), and TGA/VSD/pulmonary stenosis (n=20, 7%). Repair type was arterial switch (n=189, 62%), atrial switch (n=105, 34%; Senning=58, Mustard=47), or Rastelli (n=12, 4%). Children with TGA scored significantly higher than published norms in all categories except self-esteem. TGA/VSD/pulmonary stenosis was associated with lower scores than TGA and TGA/VSD in physical functioning (P=0.002), general health perceptions (P=0.012), and mental health (P=0.048). Arterial repair was associated with higher scores than atrial or Rastelli repair in physical functioning (P<0.001), pain (P=0.004), mental health (P=0.019), self-esteem (P=0.004), and general health perceptions (P<0.001). By multivariable analyses, the most common independent factors impacting scores were repair type, perfusion parameters, and gender. CONCLUSIONS: Quality of life and health status as perceived by children 11 to 15 years after TGA repair is excellent when compared with published normative data and is better after arterial switch operation than after atrial repair.

The 1942 'euthanasia' debate in the American Journal of Psychiatry.

This paper discusses and analyses three articles appearing in a 1942 issue of the American Journal of Psychiatry. In the first, neurologist Foster Kennedy argued that 'feebleminded' people should be killed (an act which he referred to as 'euthanasia'). The rebuttal was written by psychiatrist Leo Kanner, who argued against 'euthanasia'. An unsigned editorial discussing these positions clearly sided with Kennedy: that 'euthanasia' would be appropriate in some cases, and that parents' opposition to this procedure should be the subject of psychiatric concern. The arguments are analysed and discussed within the context of eugenics and the murder of mental patients in Germany. Finally, the author points out that currently ascendant genetic theories in psychiatry could be a precursor for future proposals similar to Kennedy's.

A critical assessment of the equal-environment assumption of the twin method for schizophrenia.

The classical twin method (CTM) is central to the view that schizophrenia is ~80% heritable. The CTM rests on the equal-environment assumption (EEA) that identical and fraternal twin pairs experience equivalent trait-relevant environmental exposures. The EEA has not been directly tested for schizophrenia with measures of child social adversity, which is particularly etiologically relevant to the disorder. However, if child social adversity is more similar in identical than fraternal pairs in the general twin population, the EEA is unlikely to be valid for schizophrenia, a question which we tested in this study. Using results from prior twin studies, we tested if intraclass correlations for the following five categories of child social adversity are larger in identical than fraternal twins: bullying, sexual abuse, physical maltreatment, emotional neglect and abuse, and general trauma. Eleven relevant studies that encompassed 9119 twin pairs provided 24 comparisons of intraclass correlations, which we grouped into the five social exposure categories. Fisher's z-test revealed significantly higher correlations in identical than fraternal pairs for each exposure category (z ≥ 3.53, p < 0.001). The difference remained consistent across gender, study site (country), sample size, whether psychometric instruments were used, whether interviewing was proximate or distant to the exposures, and whether informants were twins or third persons. Combined with other evidence that the differential intraclass correlation for child social adversity cannot be explained by evocative gene-environment covariation, our results indicate that the CTM does not provide any valid indication of genomic effects in schizophrenia.

Genetics and antisocial behavior.

This commentary article reviews a recent meta-analysis of genetic influences on antisocial behavior by Rhee and Waldman (2002). The authors combined the results of 51 twin and adoption studies and concluded that antisocial behavior has an important genetic component. However, twin and adoption studies contain several methodological flaws and are subject to the confounding influence of environmental factors. Therefore, Rhee and Waldman's conclusions in favor of genetic influences are not supported by the evidence. Two additional topics are Rhee and Waldman's incorrect description of the heritability concept and their failure to discuss several German criminal twin studies published during the Nazi era.