The Association of Military Sexual Harassment/Assault With Suicide Ideation, Plans, Attempts, and Mortality Among US Service Members/Veterans: A Meta-Analysis.

Suicide rates continue to increase among service members/veterans. Military sexual harassment/assault (MSH/A) may increase risk of suicide, but little is known about the collective magnitude of associations between MSH/A and suicide outcomes, including ideation, plan, attempt, and mortality. The current meta-analysis addressed this literature gap while testing potential moderators of gender, marital status, discharge status, and military branch. PsycINFO, PubMed, Dissertations/Theses, relevant citation lists, and conference brochures were reviewed for papers that included quantitative analyses in English, U.S. military samples, and measures of MSH/A and suicide ideation/plan/attempt/mortality. The search resulted in 22 studies (N = 10,898,875) measuring the association of MSH/A with suicide ideation (k = 15), plans (k = 1), attempts (k = 14), and mortality (k = 2), with papers published from 2007-2021. MSH/A was associated with suicide ideation (r ¯ = .14) and attempts (r ¯ = .11, ps < .05). The association of MSH/A and suicide ideation and attempts was higher among women relative to men, those identifying as married versus not married, those actively serving compared to discharged, and those reporting service in the Air Force relative to all other branches. The association of MSH/A with suicide plans and mortality was not calculated due to the small number of studies reporting those effect sizes (ks = 1-2). The effect sizes observed suggest MSH/A is part of a larger network of risk factors for suicide. Moderators indicate that suicide risk is higher among specific groups, and prevention strategies would be most effective if they targeted these individuals. This research area would be strengthened by additional studies of plans and mortality.

Symptom phenotypes in pulmonary arterial hypertension: The PAH "symptome".

Women with pulmonary arterial hypertension (PAH) experience multiple symptoms, including dyspnea, fatigue, and sleep disturbance, that impair their health-related quality of life (HRQOL). However, we know little about phenotypic subgroups of patients with PAH with similar, concurrent, multiple symptoms. The objectives of this study were to define the "symptome" by symptom cluster phenotypes and compare characteristics such as biomarkers, cardiac structure and function (echocardiography), functional capacity (6-min walk distance), and HRQOL between the groups. This cross-sectional study included 60 women with PAH. Subjects completed an assessment battery: Pulmonary Arterial Hypertension Symptom Scale, Pittsburgh Sleep Quality Index, Multidimensional Dyspnea Profile, Patient-Reported Outcomes Measurement Information System (PROMIS®) Physical Function, PROMIS® Sleep-Related Impairment, and the emPHasis-10. Subjects also underwent transthoracic echocardiography, phlebotomy, 6-min walk distance, and actigraphy. The three symptoms of dyspnea, fatigue, and sleep disturbance were used to define the symptom clusters. Other PAH symptoms, plasma and serum biomarkers, cardiac structure and function (echocardiography), exercise capacity (6-min walk distance), sleep (actigraphy), and HRQOL were compared across phenotypes. The mean age was 50 ± 18 years, 51% were non-Hispanic white, 32% were non-Hispanic Black and 40% had idiopathic PAH. Cluster analysis identified Mild (n = 28, 47%), Moderate (n = 20, 33%), and Severe Symptom Cluster Phenotypes (n = 12, 20%). There were no differences for age, race, or PAH etiology between the phenotypes. WHO functional class (p < 0.001), norepinephrine levels (p = 0.029), right atrial pressure (p = 0.001), physical function (p < 0.001), sleep onset latency (p = 0.040), and HRQOL (p < 0.001) all differed significantly across phenotypes. We identified three distinctive symptom cluster phenotypes (Mild, Moderate, and Severe) for women with PAH that also differed by PAH-related symptoms, physical function, right atrial pressure, norepinephrine levels, and HRQOL. These phenotypes could suggest targeted interventions to improve symptoms and HRQOL in those most severely affected.

Depression symptoms as a potential mediator of the association between disordered eating symptoms and sexual function in women service members and veterans.

Sexual dysfunction is associated with disorders commonly diagnosed in service members/veterans (SM/Vs; e.g., depression, posttraumatic stress disorder) and increased risk for suicide in service women. Theory indicates depression may play an important role in predicting sexual dysfunction in the presence of certain mental health challenges, such as disordered eating symptoms. Given the risk for depression and incidence of eating disorders in women SM/Vs, the current study examined whether depressive symptoms mediated the association of disordered eating symptoms and sexual dysfunction in women SM/Vs. Participants (n = 494) were recruited via social media and completed measures of sexual function, disordered eating symptoms, depressive symptom severity, a demographic inventory, and measures of relationship satisfaction and trauma exposure (covariates). Based on self-report measures, probable sexual dysfunction, eating disorder, and depressive disorders were found among 58.70%, 38.5%, and 44.13% of participants, respectively. The relationship of higher disordered eating symptoms and lower sexual function was indirect, through higher depressive symptoms (indirect effect: -0.57, 95% confidence interval: -0.82, -0.34). Findings underscore the importance of screening for sexual function, particularly when disordered eating behavior or depression is present. Integrating treatment for sexual function into existing treatments for women SM/Vs with disordered eating and depression symptoms may be valuable.

Gender as a moderator of the association of military sexual trauma and posttraumatic stress symptoms.

OBJECTIVE: The current study examined the moderating role of gender on the association of military sexual trauma (MST) type (harassment-only vs. assault) and posttraumatic stress symptoms (PTSS) using the 6-factor Anhedonia Model. METHODS: Participants were 1321 service members/veterans. Two-part hurdle models assessed the moderating role of gender on the association of MST type with the presence (at least "moderate" symptoms endorsed within each cluster) or severity of PTSS and symptom clusters. RESULTS: Among those who experienced assault MST, women were at higher risk for the presence of intrusive, avoidance, negative affect, and anhedonia symptoms, and higher risk for more severe negative affect symptoms. Among those who experienced harassment-only MST, men were at higher risk of more severe PTSS symptoms overall and in the intrusive and dysphoric arousal symptom clusters. No other significant differences were observed. CONCLUSIONS: Gathering information on MST type may be helpful in treatment planning.

Discriminating between consensual intercourse and sexual assault: Genital-anal injury pattern in females.

BACKGROUND: Assessment of genital-anal (GA) injuries following sexual assault promotes health and assists prosecutors to build a case. The pattern of injuries may help differentiate between consensual and non-consensual intercourse, bolster the survivors' credibility, and increase prosecutions in sexual assault cases. OBJECTIVES: To identify the constellation of G-A injury-related characteristics that most effectively discriminated between consensual sexual intercourse and sexual assault in females when controlling for intercourse-related variables. METHODS: We employed a comparative study with two groups: a prospective cohort group with consensual participants and a group derived from an existing sexual assault registry. In the prospective cohort, we performed a sexual assault forensic examination at baseline and following consensual sexual intercourse with females ≥21 years. We compared their injury patterns to the injury records of females ≥21 years who were sexual assaulted. RESULTS: We enrolled a sample of 834 females: 528 consensual (63.3%) participants and 306 non-consensual (36.7%) registry cases. After controlling for race/ethnicity, age, and time between intercourse and examination, logistic regression analyses showed that the presence of an external genital tear increased the odds of non-consensual intercourse more than two times (adjusted odds ratio [AOR] = 2.70, 95% CI = 1.28-5.56). Logistic regression analyses also showed that the odds of non-consensual sexual intercourse were significantly greater with a lower prevalence and frequency of external and internal genital redness, lack of condom use and lubrication, and presence of anal penetration. Latent class analysis identified high and low G-A injury prevalence subgroups among both consensual and non-consensual samples. One subset of results emerged that may be indicative of non-consensual as compared to consensual intercourse: a higher prevalence of external genital and anal tears. CONCLUSION: External genital tears occurred more frequently in the non-consensual sample and increased the odds of non-consensual intercourse more than two times. Anal tears, swelling, and ecchymosis and anal penetration were markers for non-consensual intercourse and should increase suspicion for lack of consent.

Initial Testing of a Web-Based Intervention to Reduce Adolescent Driver Inattention: A Randomized Controlled Trial.

INTRODUCTION: Motor vehicle crashes are the leading cause of adolescent death. Inattention to the roadway contributes to crash risk. The objective of this study was to deploy an initial study of a web-based intervention (Let's Choose Ourselves) designed to improve adolescent driver attention to the roadway. METHODS: We used a randomized controlled trial design in a sample of adolescent drivers to test if a web-based intervention decreased cell phone engagement in driving simulation at 3 months as compared with controls. As secondary hypotheses, we tested if the intervention increased the use of peer passengers to manage distractions and decreased eyes off the forward roadway in driving simulation and decreased self-reported risky driving behaviors. Adolescents, aged 16-17 years, licensed for ≤90 days were randomized to Let's Choose Ourselves with distractions in the simulator protocol at baseline, Let's Choose Ourselves with no distractions, an attention control intervention on healthy eating with distractions, or attention control with no distractions. We used Poisson regression modeling to test the primary and secondary hypotheses. RESULTS: The trial included 60 adolescents (66.7% female, 78.3% non-Hispanic white subjects, mean age 16.8 years, licensed 50.8 days). In Poisson regression, controlling for sex, we found no significant effects of Let's Choose Ourselves on primary or secondary outcomes. However, there was a significant effect of visit on self-report outcomes, with self-reported distracted driving behaviors increasing over time. DISCUSSION: Although there were no significant effects of Let's Choose Ourselves, self-reported risky driving behaviors increased over time. Further investigation of the relationship between driving experience and increasing inattention to the road in adolescents is warranted.

Comorbid PTSD and Depression Diagnoses Mediate the Association of Military Sexual Trauma and Suicide and Intentional Self-Inflicted Injury in VHA-Enrolled Iraq/Afghanistan Veterans, 2004-2014.

BACKGROUND: Exposure to military sexual trauma (MST) in veterans is associated with suicidal ideation. Previous research suggests there are mechanisms of this association, including posttraumatic stress disorder (PTSD) and depression. Research has yet to examine whether comorbid PTSD and depression mediate the association of MST and suicide and intentional self-inflicted injury, and whether this comorbidity confers a greater risk for suicide relative to PTSD-only and depression-only. The current study addressed this gap in our knowledge. METHODS: Screening results identifying MST exposure, PTSD and depression diagnoses, suicide and intentional self-inflicted injury, and demographic covariates in 435,690 Iraq/Afghanistan veterans were extracted from Veterans Health Administration (VHA) medical records. Veterans were included if they attended VHA from 2004-2014. Mediation was tested with path analyses. RESULTS: Suicide and intentional self-inflicted injury was observed in 16,149 (3.71%) veterans. The indirect effect of suicide and intentional self-inflicted injury, given a positive screen for MST, was highest among veterans with comorbid PTSD and depression diagnoses (indirect effect=3.18%, 95% confidence interval [CI] [3.01%, 3.32%]), with smaller probabilities observed for both PTSD-only (indirect effect=-0.18%, 95% CI [-0.20%, -0.14%]) and depression-only (indirect effect=0.56%, 95% CI [0.51%, 0.62%]; ps<.05). LIMITATIONS: Data were limited to VHA-enrolled Iraq/Afghanistan veterans. CONCLUSIONS: To reduce suicide risk among veterans with a history of MST, treatments may be most effective if they target comorbid PTSD and depression. Future research should examine the mechanisms through which comorbid PTSD and depression result in heightened risk for suicide and intentional self-inflicted injury.

Gender moderates the association of military sexual trauma and risk for psychological distress among VA-enrolled veterans.

BACKGROUND: Military sexual trauma (MST) is associated with increased risk for posttraumatic stress disorder (PTSD) and depression diagnoses, as well as suicidal ideation/behavior (SI/B). Little is known about the differential effect of gender on the association of MST and the aforementioned mental health outcomes. As females are the fastest growing subpopulation of the Veterans Health Administration (VHA), it is imperative to assess possible between-gender differences in the association of MST with PTSD, depression, and SI/B. METHODS: Participants were 435,690 (n = 382,021, 87.7% men) 9/11 era veterans seen for care at the VHA between 2004 and 2014. Demographics, gender, PTSD and depression diagnoses, SI/B, and MST screen status were extracted from medical records. Adjusted logistic regression models assessed the moderating effect of gender on the association of MST with PTSD and depression diagnoses, as well as SI/B. RESULTS: Women with MST had a larger increased risk for a PTSD diagnosis (predicted probability =0.56, 95% confidence interval [CI] [0.56, 0.56]) and comparable risk for a depression diagnosis (predicted probability = 0.63, 95% CI [0.63, 0.64]) compared to men with MST. Men were more likely to have evidence of SI/B (predicted probability = 1.07, 95% CI [0.10, 0.11]) relative to women, but the interaction between gender and MST was nonsignificant. LIMITATIONS: Data were limited to veterans seeking care through VHA and the MST screen did not account for MST severity. CONCLUSIONS: Non-VHA settings may consider screening for MST in both men and women, given that risk for PTSD and depression is heightened among female survivors of MST.

Higher depression severity mediates the association of assault military sexual trauma and sexual function in partnered female service members/veterans.

BACKGROUND: Military sexual trauma (MST), and assault as opposed to harassment-only MST in particular, is associated with lower sexual function among female service members/veterans (SM/Vs). Recent research revealed that higher posttraumatic stress disorder (PTSD) symptom clusters of anhedonia and dysphoric arousal mediated the association of assault MST and sexual function. Such clusters represent the depressive symptoms of PTSD, and theories of sexual function suggest that depression worsens sexual function. The impact of depression on the association of MST and sexual function has yet to be tested. METHOD: Using path analysis, the study examined whether depression severity mediated the association of MST and sexual function after accounting for demographics and mediators of PTSD-related anhedonia and dysphoric arousal. Female SM/Vs (N = 697) completed measures of MST (history, severity), depression, PTSD-related anhedonia and dysphoric arousal, sexual function, and a demographic inventory. RESULTS: One hundred twenty-two (17.50%) indicated that they did not experience MST, 336 (48.21%) reported that they experienced harassment-only MST, and 239 (34.29%) reported assault MST. Fit indices evidenced strong model fit, χ2(12, N = 697)=18.85, p=.09, CFI=1.00, TLI=0.99, SRMR=0.02, and RMSEA=0.03. The indirect effect of depression severity was significant (p<.001). LIMITATIONS: Use of cross-sectional data in a convenience sample of female SM/Vs. CONCLUSIONS: Even after accounting for established covariates and mediators of assault MST and sexual function, depression accounted for a significant amount of variance in this association. Treatment of poor sexual function must address depressive symptoms. As medications for depression can exacerbate sexual issues, psychotherapy may be the most effective treatment strategy.

A Comparison of the Storage-Only Deficit and Joint Mechanism Deficit Hypotheses of the Verbal Working Memory Storage Capacity Limitation of Children With Developmental Language Disorder.

Purpose The storage-only deficit and joint mechanism deficit hypotheses are 2 possible explanations of the verbal working memory (vWM) storage capacity limitation of school-age children with developmental language disorder (DLD). We assessed the merits of each hypothesis in a large group of children with DLD and a group of same-age typically developing (TD) children. Method Participants were 117 children with DLD and 117 propensity-matched TD children 7-11 years of age. Children completed tasks indexing vWM capacity, verbal short-term storage, sustained attention, attention switching, and lexical long-term memory (LTM). Results For the DLD group, all of the mechanisms jointly explained 26.5% of total variance. Storage accounted for the greatest portion (13.7%), followed by controlled attention (primarily sustained attention; 6.5%) and then lexical LTM (5.6%). For the TD group, all 3 mechanisms together explained 43.9% of total variance. Storage accounted for the most variance (19.6%), followed by lexical LTM (16.0%), sustained attention (5.4%), and attention switching (3.0%). There was a significant LTM × Group interaction, in which stronger LTM scores were associated with significantly higher vWM capacity scores for the TD group as compared to the DLD group. Conclusions Results support a joint mechanism deficit account of the vWM capacity limitation of children with DLD. Results provide substantively new insights into the underlying factors of the vWM capacity limitation in DLD. Supplemental Material https://doi.org/10.23641/asha.9932312.

Comparison of Skin Biomechanics and Skin Color in Puerto Rican and Non-Puerto Rican Women.

OBJECTIVE: Skin biomechanics are physical properties that protect the body from injury. Little is known about differences in skin biomechanics in racial/ethnic groups and the role of skin color in these differences. The purpose of this study was to determine the relationship between skin biomechanics (viscoelasticity, hydration) and skin color, when controlling for demographic and health-related variables in a sample of Puerto Rican and non-Puerto Rican women. METHODS: We performed a secondary analysis of data from 545 women in a longitudinal, observational study of skin injury in Puerto Rico and the United States. Data included measures of skin viscoelasticity, skin hydration, skin color, demographic, and health related variables. Skin color was measured by spectrophotometry (L* - lightness/darkness, a*- redness/greenness, b* - yellowness/blueness). The sample was 12.5% Puerto Rican, 27.3% non-Puerto Rican Latina, 28.8% Black, 28.6% White, and 2.8% Other. RESULTS: Regression analyses showed that: 1) higher levels of skin viscoelasticity were associated with lower age, higher BMI, and identifying as non-Puerto Rican Latina as compared to Puerto Rican; (all p < .001); and 2) higher levels of hydration were associated with lower L* values, higher health status, lower BMI, and identifying as non-Puerto Rican Latina, White, or Other as compared to Puerto Rican (all p < .05). CONCLUSION: When adjusting for skin color, Puerto Rican women had lower viscoelasticity and hydration as compared to other groups. Puerto Rican women may be at long-term risk for skin alterations, including pressure injury, as they age or become chronically ill.

Are the Fitzpatrick Skin Phototypes Valid for Cancer Risk Assessment in a Racially and Ethnically Diverse Sample of Women?

The Fitzpatrick Skin Phototypes (FSP) were developed to classify skin color and response to ultraviolet radiation. FSP are used clinically to assess risk for sunburn and skin cancer. Our aim was to determine the criterion-related validity of self-reported FSP when compared with skin color and sunburn history, controlling for age, race/ethnicity, and seasonality/geography. We performed a secondary analysis of data (N=466) from an observational study. The racial/ethnic composition of the sample was 45% White/White Hispanic (WWH), 40% Black/Black Hispanic (BBH), and 15% Other Identities. Outcome measures were self-reported FSP and sunburn history, as well as physiological measures of skin color (L* lightness/darkness, a* redness/greenness, b* yellowness/blueness). Correlation between FSP and L* was -.77 (95% CI -.81, -.73; P<.001). Although 60% of the variance in FSP was accounted for by L* values for the entire sample, only 5% of the variance was accounted for among BBH participants (r=-.23), and up to 30% for WWH/Other Identity participants (r=-.48 and -.52). Multiple regression analysis indicated L* and b* values, sunburn history, and race/ethnicity, but not geography/seasonality or a* values significantly and collectively accounted for 72% of the variance in FSP. While the criterion validity of FSP was established by the strong relationship between L* values and FSP for the entire sample, when examined at the level of individual racial/ethnic subgroups, criterion validity of FSP was not demonstrated. When self-reported FSP are used for clinical skin assessment and sun cancer screening, they provide a restricted range of options for people with darker skin that does not capture variations in their skin color. Inaccuracy of clinical data may lead to unequal treatment or inadequate cancer risk assessment.

Understanding rates of genital-anal injury: Role of skin color and skin biomechanics.

PURPOSE: A series of studies suggest that non-Hispanic White women have significantly more injuries than non-Hispanic Black women after sexual assault and consensual sexual intercourse. One explanation for this difference is that the degree of skin protection may vary as skin mechanics and skin pigmentation vary. The aim of the study was to determine the association among genital-anal injury, skin color, skin viscoelasticity and skin hydration in women following consensual sexual intercourse when controlling for age, smoking history, body mass index (BMI), sun exposure, and health status. PROCEDURES: We employed a prospective cohort study design to enroll women 21 years of age or older at two study sites. They underwent two data collection sessions, baseline and follow-up after consensual sexual intercourse. Baseline genital-anal injury identification occurred with a standard forensic examination (direct visualization, nuclear staining with toluidine blue contrast, and colposcopy examination) and measurements of other variables (skin color, skin viscoelasticity, skin hydration, age, smoking history, body mass index [BMI], sun exposure, and health status). Participants were then asked to have consensual sexual intercourse with a male partner of their choice and to return for a second forensic examination for injury detection. Genital-anal injury was regressed on skin color, skin viscoelasticity, skin hydration, age, smoking history, BMI, sun exposure, and health status. FINDINGS: We enrolled 341 participants, 88 non-Hispanic White (25.8%), 54 non-Hispanic Black (15.8%), 190 Hispanic/Latina (55.7), and 9 Other Identities (2.6%). At baseline the genital-anal injury prevalence was 57.77% and at follow-up after consensual sexual intercourse, injury prevalence was 72.73%. External genital injury prevalence was associated with increased L* (lightness) values (Adjusted Odds Ratio [AOR] = 1.98, 95% Confidence Interval [CI] = 1.03, 4.04) and decreased skin elasticity (AOR = 0.96, 95% CI = 0.93, 0.99) at baseline. Increased skin hydration was associated with a significantly higher frequency of external, internal, anal, and total genital-anal injuries (Adjusted Rate Ratio [ARR] > 1.27) at follow-up. Also at the follow-up examination, Hispanic/Latina participants had significantly lower external genital and total genital-anal injury prevalence and frequency as compared to non-Hispanic White participants (AOR < 0.40). CONCLUSIONS: Our findings provide qualified support for the importance of skin color during the forensic examination. Women with lighter skin tones may have skin that is more easily injured than women with darker tones. In contrast, external genital injuries may be more easily identified in women with light as compared to dark skin, a situation that is important in both the health care and criminal justice systems. Additionally, women with decreased viscoelasticity and increased hydration may be more easily injured. These findings support the need to develop forensic procedures that are effective in people across the range of skin colors and to interpret forensic findings considering the innate properties of the skin.

Combining Natural Language Processing of Electronic Medical Notes With Administrative Data to Determine Racial/Ethnic Differences in the Disclosure and Documentation of Military Sexual Trauma in Veterans.

BACKGROUND: Despite national screening efforts, military sexual trauma (MST) is underreported. Little is known of racial/ethnic differences in MST reporting in the Veterans Health Administration (VHA). OBJECTIVE: This study aimed to compare patterns of MST disclosure in VHA by race/ethnicity. RESEARCH DESIGN: Retrospective cohort study of MST disclosures in a national, random sample of Veterans who served in Afghanistan and Iraq and completed MST screens from October 2009 to 2014. We used natural language processing (NLP) to extract MST concepts from electronic medical notes in the year following Veterans' first MST screen. MEASURE(S): Any evidence of MST (positive MST screen or NLP concepts) and late MST disclosure (NLP concepts following a negative MST screen). Multivariable logistic regressions, stratified by sex, tested racial/ethnic differences in any MST evidence, and late disclosure. RESULTS: Of 6618 male and 6716 female Veterans with MST screen results, 1473 had a positive screen (68 male, 1%; 1405 female, 21%). Of those with a negative screen, 257 evidenced late MST disclosure by NLP (44 male, 39%; 213 female, 13%). Late MST disclosure was usually documented during mental health visits. There were no significant racial/ethnic differences in MST disclosure among men. Among women, blacks were less likely than whites to have any MST evidence (adjusted odds ratio=0.75). In the subsample with any MST evidence, black and Hispanic women were more likely than whites to disclose MST late (adjusted odds ratio=1.89 and 1.59, respectively). CONCLUSIONS: Combining NLP results with MST screen data facilitated the identification of under-reported sexual trauma experiences among men and racial/ethnic minority women.

VHA-Enrolled Homeless Veterans Are at Increased Risk for Eating Disorder Diagnoses.

Introduction: Veterans are overrepresented in the U.S. homeless population, comprising 8.6% of the general U.S. population, but 14% of the homeless population. Homeless veterans have several risk factors for eating disorder diagnoses, but the association of homelessness and eating disorders in this population is understudied. Given limited access to adequate food given their diminished resources, it is critical to better understand risk for eating disorders as a function of homelessness. Materials and Methods: Administrative data on homelessness, eating disorder diagnoses, and related comorbidities occurring within the first 5 years of Veterans Health Administration (VHA) healthcare utilization between 2004 and 2014 in 265,806 Iraq/Afghanistan veterans were extracted from VHA medical records. Logistic regression analysis estimated the risk for eating disorders as a function of homelessness while accounting for demographic, military, and mental health covariates. Results: Homelessness was observed in 11,876 veterans (4.5%), and of these, 71 (0.6%) had an eating disorder diagnosis. Odds of having an eating disorder diagnosis were 59% higher (adjusted odds ratio = 1.59, 95% confidence interval [1.21-2.09]) among homeless veterans relative to domiciled veterans. Conclusions: A diagnosis of eating disorders in veterans is rare at the VHA, however, the current study found that homelessness may increase risk for eating disorders in this population. Unique strategies to provide evidenced-based care while accounting for inadequate daily resources are needed to reduce the risk of eating disorders in this population.

Predictive modeling of housing instability and homelessness in the Veterans Health Administration.

OBJECTIVE: To develop and test predictive models of housing instability and homelessness based on responses to a brief screening instrument administered throughout the Veterans Health Administration (VHA). DATA SOURCES/STUDY SETTING: Electronic medical record data from 5.8 million Veterans who responded to the VHA's Homelessness Screening Clinical Reminder (HSCR) between October 2012 and September 2015. STUDY DESIGN: We randomly selected 80% of Veterans in our sample to develop predictive models. We evaluated the performance of both logistic regression and random forests-a machine learning algorithm-using the remaining 20% of cases. DATA COLLECTION/EXTRACTION METHODS: Data were extracted from two sources: VHA's Corporate Data Warehouse and National Homeless Registry. PRINCIPAL FINDINGS: Performance for all models was acceptable or better. Random forests models were more sensitive in predicting housing instability and homelessness than logistic regression, but less specific in predicting housing instability. Rates of positive screens for both outcomes were highest among Veterans in the top strata of model-predicted risk. CONCLUSIONS: Predictive models based on medical record data can identify Veterans likely to report housing instability and homelessness, making the HSCR screening process more efficient and informing new engagement strategies. Our findings have implications for similar instruments in other health care systems.

Regional Variations in Documentation of Sexual Trauma Concepts in Electronic Medical Records in the United States Veterans Health Administration.

Background: Experiences of sexual trauma are associated with adverse patient and health system outcomes, but are not systematically documented in electronic health records (EHR). Objective: To describe variations in how sexual trauma is documented in the Veterans Health Adminstration's EHR. Methods: Sexual trauma concepts were extracted from from 362,559 clinical notes using a natural language processing pipeline. Results: We observed variations in the presence of sexual trauma in notes across five United States regions: Pacific, Continental, Midwest, North Atlantic, Southeast. We also observed variations in the types of notes used to document sexual trauma (e.g., mental health, primary care) and sources of sexual trauma (e.g., adult, childhood, military) mentioned in the EHR. Our findings illustrate potential differences in cultural norms related to patient disclosure of sensitive information, and provider documentation. Standardized protocol for eliciting and documenting sexual trauma histories are needed to ensure Veteran access to high quality, trauma-informed care.

Structural Relationship Between Cognitive Processing and Syntactic Sentence Comprehension in Children With and Without Developmental Language Disorder.

Purpose: We assessed the potential direct and indirect (mediated) influences of 4 cognitive mechanisms we believe are theoretically relevant to canonical and noncanonical sentence comprehension of school-age children with and without developmental language disorder (DLD). Method: One hundred seventeen children with DLD and 117 propensity-matched typically developing (TD) children participated. Comprehension was indexed by children identifying the agent in implausible sentences. Children completed cognitive tasks indexing the latent predictors of fluid reasoning (FLD-R), controlled attention (CATT), complex working memory (cWM), and long-term memory language knowledge (LTM-LK). Results: Structural equation modeling revealed that the best model fit was an indirect model in which cWM mediated the relationship among FLD-R, CATT, LTM-LK, and sentence comprehension. For TD children, comprehension of both sentence types was indirectly influenced by FLD-R (pattern recognition) and LTM-LK (linguistic chunking). For children with DLD, canonical sentence comprehension was indirectly influenced by LTM-LK and CATT, and noncanonical comprehension was indirectly influenced just by CATT. Conclusions: cWM mediates sentence comprehension in children with DLD and TD children. For TD children, comprehension occurs automatically through pattern recognition and linguistic chunking. For children with DLD, comprehension is cognitively effortful. Whereas canonical comprehension occurs through chunking, noncanonical comprehension develops on a word-by-word basis. Supplemental Material: https://doi.org/10.23641/asha.7178939.

Costs Associated with Health Care Services Accessed through VA and in the Community through Medicare for Veterans Experiencing Homelessness.

OBJECTIVE: To estimate health care utilization and costs incurred by homeless Veterans relative to nonhomeless Veterans and to examine the impact of a VA homelessness program on these outcomes. DATA SOURCES/STUDY SETTING: Combined Department of Veterans Affairs (VA) administrative and Medicare claims data. STUDY DESIGN: Observational study using longitudinal data from Veterans engaged with the VA system and enrolled in Medicare. Veterans with administrative evidence of homelessness at any point during 2006-2010 were matched on period of military service to Veterans with no evidence of homelessness. PRINCIPAL FINDINGS: Experience of homelessness was associated with 1.37 (95 percent CI = 1.34-1.40) and 0.16 (95 percent CI = 0.14-0.17) more outpatient encounters per quarter in VA and non-VA settings, respectively, and 1.31 (95 percent CI = 1.30-1.32) and 0.49 (95 percent CI = 0.48-0.49) more inpatient days per quarter in VA and non-VA hospitals, respectively. These were associated with higher costs. Relative to stably housed Veterans less than 65 years of age, those enrolled in a VA homelessness program had 94.4 percent (95 percent CI = 90.7 percent-98.1 percent) more VA outpatient visits but 5.5 percent (95 percent CI = 3.0 percent-7.9 percent) fewer Medicare outpatient visits. CONCLUSIONS: Homelessness was associated with an increase in VA and Medicare utilization and cost. A VA homelessness program decreased use of Medicare outpatient services.

Simulated Driving Performance, Self-Reported Driving Behaviors, and Mental Health Symptoms in Adolescent Novice Drivers.

BACKGROUND: Risky driving behaviors contribute to adolescent injury, disability, and death, yet little is known about how mental health factors are associated with adolescent driving behaviors. OBJECTIVES: The purpose of the research was to determine the association of risky driving behaviors and mental health symptoms in novice adolescent drivers. METHODS: We recruited a convenience sample (n = 60) of adolescents to complete an assessment of driving performance errors in a high-fidelity simulator (Simulated Driving Assessment [SDA] Error Score) and a self-report measure of risky driving (Behavior of Young Novice Drivers Survey [BYNDS]). Participants also completed a mental health assessment of self-reported symptoms of depression (Center for Epidemiologic Studies-Depression Scale) and attention-deficit/hyperactivity disorder (ADHD; inattention and hyperactivity-impulsivity), conduct disorder, and oppositional defiant disorder (Conners-3 self-report and parent report). We evaluated the cross-sectional relationships between SDA Error Score, BYNDS, and mental health survey data with descriptive statistics, bivariate correlations, and linear regression. RESULTS: In linear regression models, higher self-reported inattentive ADHD T-scores were associated with higher SDA Error Score (model adjusted R = .20). Higher self-reported T-scores of hyperactive-impulsive ADHD and conduct disorder were associated with higher BYNDS total scores (model adjusted R = .32). Parent report measures were not associated with adolescent BYNDS total score or SDA Error Score. DISCUSSION: These data highlight the association of risky driving with adolescent symptoms of inattention, hyperactivity, and conduct disorder. The early stage of independent driving is an important time for addressing the relationship between driving performance and mental health conditions.