Culturally tailored digital therapeutic for substance use disorders with urban Indigenous people in the United States: A randomized controlled study.

INTRODUCTION: Indigenous people experience health disparities, including higher rates of substance use disorders (SUDs). Digital therapeutics are a growing platform for treatment services and have the potential to expand access to culturally responsive interventions for Indigenous people. As one of the first randomized controlled trials for SUDs for American Indian and Alaska Native (AI/AN) adults, the aim of this study was to pilot test the efficacy of a culturally tailored intervention among urban Indigenous adults. METHODS: The study used a randomized controlled parallel design of 12 weeks of treatment-as-usual (TAU) (n = 26) versus TAU + Therapeutic Education System-Native Version (TES-NAV) (n = 27) with follow-up assessments at end of treatment and week 24 in an urban outpatient addiction treatment program for Native American adults. TAU consisted of individual/group counseling and cultural activities. The TES-NAV arm comprised TAU + 26 self-directed culturally tailored digital skills-based modules grounded in the community reinforcement approach with contingency management for abstinence and module completion. Primary outcome was longest consecutive weeks of abstinence from drugs and heavy drinking measured using self-report (Timeline Followback) and urine alcohol and drug toxicology screen during 12 weeks of treatment. Secondary outcomes were percent days abstinence during and posttreatment, coping strategies, social connectedness, and substance use and sexual risk behaviors. RESULTS: The study enrolled fifty-three (52.8 % male) AI/AN adults seeking treatment for a SUD. Although the study did not detect a benefit of TAU+TES-NAV over TAU on the primary outcome (Median = 2 consecutive weeks of abstinence for both arms) at end of treatment (treatment effect: Z = -0.78, p = 0.437), TAU+TES-NAV participants did demonstrate significantly greater percent days of abstinence at the week 24 follow-up (69.3 % versus 49.0 % for TAU; t = 2.08, p = 0.045) and significantly greater change in social connectedness mean score, baseline to week 12 (Z = -2.66, p = 0.011), compared to TAU. The study detected no differences between treatment arms for coping strategies or risk behaviors. CONCLUSION: The addition of TES-NAV to TAU did not significantly improve consecutive weeks of abstinence from drugs or heavy drinking; however, several secondary findings suggest promise for a culturally tailored digital therapeutic SUD intervention among urban Indigenous people. CLINICAL TRIALS: GOV REGISTRATION: #NCT03363256.

Acculturative Stress and Self-rated Health among Hispanic Emerging Adults: Examining the Moderating Effects of the Social Environment and Social Support.

Little is known about the impact of sociocultural stressors such as acculturative stress on self-rated health among Hispanics. We aimed to examine (a) associations between acculturative stress and self-rated health, and (b) the moderating effects of the community of settlement (i.e., Maricopa County, AZ and Miami-Dade County, FL) and social support on the association between acculturative stress and self-rated health. A hierarchical multiple regression model and moderation analyses were conducted using a cross-sectional sample of 200 Hispanic emerging adults from Arizona and Florida. Findings indicate that higher levels of pressure to acculturate are associated with lower levels of self-rated health. Community of settlement functioned as a moderator whereby pressure to acculturate was only associated with lower levels of self-rated health in Maricopa County. Lastly, a three-way interaction indicated that emotional social support mitigated the association between pressure to acculturate and self-rated health in Maricopa County. This study highlights the importance of accounting for community of settlement when examining associations between acculturative stress and health-related outcomes. A finding that may have implications for interventions is that social support may help to counteract the effects of acculturative stress.

Dismantling Structural Racism in Child and Adolescent Psychology: A Call to Action to Transform Healthcare, Education, Child Welfare, and the Psychology Workforce to Effectively Promote BIPOC Youth Health and Development.

The field of clinical child and adolescent psychology is in critical need of transformation to effectively meet the mental health needs of marginalized and minoritized youth. As a field, we must acknowledge and grapple with the racist and colonial structures that support the scientific foundation, education and training of psychologists, and the service systems currently in place to support youth mental health in this country. We argue that to effectuate change toward a discipline that centers inclusivity, intersectionality, anti-racism, and social justice, there are four interrelated systems, structures, or processes that currently support racial inequity and would need to be thoroughly examined, dismantled, and re-imagined: (1) the experience of mental health problems and corresponding access to quality care; (2) the school-to-mental healthcare pathway; (3) the child welfare and carceral systems; and (4) the psychology workforce. A "call to action" is issued to address structural racism in these systems and recommendations are provided to guide clinicians, health care systems, educators, welfare and carceral systems, and those involved in training and retaining psychologists in the field in actions they can take to contribute to transformation. We assert that change will only occur when we individually and collectively take responsibility for the roles we have as agents for radical change within the personal and professional contexts in which we live and work. Only then will the field of clinical child and adolescent psychology be able to address the youth mental health crisis and effectively promote the health and well-being of all children.

Pediatric subspecialty healthcare providers' views of recruitment during a randomized controlled trial of a mobile health intervention.

Background: Randomized clinical trials (RCTs) enrolling pediatric populations often struggle with recruitment. Engaging healthcare providers in the recruitment process may increase patients' and caregivers' willingness to participate in research. The purpose of this study was to understand the perspectives of pediatric subspecialty healthcare providers considering recruiting patients to participate in an mobile health (mHealth) RCT. Methods: We conducted 9 semi-structured interviews and 1 focus group with a total of N = 11 providers from various disciplines before the initiation of an mHealth RCT addressing medication nonadherence. Then, we conducted 5 follow-up interviews and 1 follow-up focus group with a total of 8 of these providers several months later. We used thematic analysis to generate themes describing providers' views of the RCT and patient recruitment. Results: Providers indicated that they were willing to recruit for this study because they believed that the intervention sought to address a significant problem. They also thought it made sense to intervene using technology for this age group. However, many providers thought that certain patients (e.g., those with mild, shorter-lasting adherence difficulties) were the most appropriate to recruit. They described how keeping the trial front of mind facilitated recruitment, and they advised researchers to use strategies to promote their ongoing awareness of the study if conducting similar research in the future. Conclusion: Pediatric healthcare providers are important stakeholders in mHealth intervention research. Engaging them in participant recruitment is a complex endeavor that might promote patient enrollment, but their views of research and demanding clinical roles are important to understand when designing study procedures.

Conceptualizing Indigenous strengths-based health and wellness research using group concept mapping.

BACKGROUND: In recent years public health research has shifted to more strengths or asset-based approaches to health research but there is little understanding of what this concept means to Indigenous researchers. Therefore our purpose was to define an Indigenous strengths-based approach to health and well-being research. METHODS: Using Group Concept Mapping, Indigenous health researchers (N = 27) participated in three-phases. Phase 1: Participants provided 218 unique responses to the focus prompt "Indigenous Strengths-Based Health and Wellness Research…" Redundancies and irrelevant statements were removed using content analysis, resulting in a final set of 94 statements. Phase 2: Participants sorted statements into groupings and named these groupings. Participants rated each statement based on importance using a 4-point scale. Hierarchical cluster analysis was used to create clusters based on how statements were grouped by participants. Phase 3: Two virtual meetings were held to share and invite researchers to collaboratively interpret results. RESULTS: A six-cluster map representing the meaning of Indigenous strengths-based health and wellness research was created. Results of mean rating analysis showed all six clusters were rated on average as moderately important. CONCLUSIONS: The definition of Indigenous strengths-based health research, created through collaboration with leading AI/AN health researchers, centers Indigenous knowledges and cultures while shifting the research narrative from one of illness to one of flourishing and relationality. This framework offers actionable steps to researchers, public health practitioners, funders, and institutions to promote relational, strengths-based research that has the potential to promote Indigenous health and wellness at individual, family, community, and population levels.

What Do My (Online) Friends Think? A Topic Modeling Approach to Identifying Patterns of Response to Self-Injurious Behaviors on Reddit.

OBJECTIVE: Approximately 17% of adolescents and young adults will engage in non-suicidal self-injury (NSSI) at least once in their lifetime, leading the World Health Organization to identify self-injury as one of the top five public health concerns for adolescents. Despite the widespread prevalence of this behavior, NSSI continues to be heavily stigmatized in both medical and community settings, deterring many engaged in NSSI from seeking informal support from friends and family as well as formal psychological or psychiatric treatment. In contrast to the low rates of in-person help-seeking for NSSI, online support groups are highly utilized by those engaged in NSSI. Thus, an empirical study of responses to frequent, voluntary disclosure of NSSI on social media is needed to better understand how these communities meet the needs of those who self-injure. METHOD: The current project used latent Dirichlet allocation to identify frequent and favored themes in response to self-injury content in the largest self-injury group on Reddit (over 100,000 members). Reddit, the 9th most visited website in the world, is a chat-based social media platform that has 430+ million active users and billions of site visits, with current estimates suggesting that ∼63% of the U.S. population are Reddit users. RESULTS: Identified themes included: (1) recovery encouragement; (2) provision of social and instrumental support; and (3) daily realities of living with NSSI. Responses that encouraged recovery received more upvotes on Reddit than any other type of comment. CONCLUSION: These results can inform evidence-based, person-centered, dimensional treatments for NSSI.HIGHLIGHTSResponses to NSSI that encourage recovery resonated most with members of the group.Group members provided many social and instrumental NSSI supports to each other.Results provide insight into the real-time needs of those engaged in NSSI.

Crisis Migration Adverse Childhood Events: A New Category of Youth Adversity for Crisis Migrant Children and Adolescents.

The present article proposes an extension of the concept of adverse childhood experiences (ACEs) to apply to crisis migration - where youth and families are fleeing armed conflicts, natural disasters, community violence, government repression, and other large-scale emergencies. We propose that adverse events occurring prior to, during, and following migration can be classified as crisis-migration-related ACEs, and that the developmental logic underlying ACEs can be extended to the new class of crisis-migration-related ACEs. Specifically, greater numbers, severity, and chronicity of crisis-migration-related ACEs would be expected to predict greater impairments in mental and physical health, poorer interpersonal relationships, and less job stability later on. We propose a research agenda centered around definitional clarity, rigorous measurement development, prospective longitudinal studies to establish predictive validity, and collaborations among researchers, practitioners, and policymakers.

Exploring Culturally Based Treatment Options for Opioid Use Disorders Among American Indian and Alaska Native Adults in California.

OBJECTIVE: American Indian and Alaska Native (AIAN) communities have been severely affected by the opioid epidemic, resulting in high opioid overdose death rates and disrupted community life. An added complexity is the diversity of AIAN communities throughout California, with regional differences, resources, infrastructure, and economic opportunities. This study examined the perspective of 163 AIANs in California to assess culturally based or traditional healing treatment modalities to treat opioid/substance use disorder. METHOD: A total of 21 adult focus groups were conducted throughout 10 counties in California reaching 20 urban and tribal communities. Eight of these focus groups were conducted in recovery centers and 13 focus groups were conducted in tribal and urban organizations. Interviews were transcribed and coded using NVivo software utilizing an iterative coding approach with a priori domains. RESULTS: Participants emphasized building a sense of belonging, connecting with their culture, and having awareness of substance use disorder and treatment as protective factors. CONCLUSIONS: Findings indicate that medications for opioid use disorder programs serving AIAN communities should include cultural components that resonate with urban and tribal communities.

Substance and Behavioral Addictions among American Indian and Alaska Native Populations.

OBJECTIVE: This paper examines substance and behavioral addictions among American Indian and Alaska Natives (AIAN) to identify the structural and psychosocial risk and cultural protective factors that are associated with substance use and behavioral addictions. METHODS: Five databases were used to search for peer reviewed articles through December 2021 that examined substance and behavioral addictions among AIANs. RESULTS: The literature search identified 69 articles. Numerous risk factors (i.e., life stressors, severe trauma, family history of alcohol use) and protective factors (i.e., ethnic identity, family support) influence multiple substance (i.e., commercial tobacco, alcohol, opioid, stimulants) and behavioral (e.g., gambling) addictions. CONCLUSIONS: There is a dearth of research on behavioral addictions among AIANs. Unique risk factors in AIAN communities such as historical trauma and socioeconomic challenges have interfered with traditional cultural resilience factors and have increased the risk of behavioral addictions. Future research on resilience factors and effective prevention and treatment interventions could help AIANs avoid behavioral addictions.

An opioid and substance use disorder needs assessment study for American Indian and Alaska Native youth in California.

Objective: American Indian and Alaska Native (AIAN) youth demonstrate significant substance use and mental health disparities and represent a highly underserved population with regard to effective services. A community-based needs assessment study of urban and rural AIAN youth throughout California was conducted to inform the development of community-based, culturally relevant opioid and substance use services. This study examined AIAN youth experiences with opioid and other substance use disorders (OUD/SUD) in their communities, utilization of existing programs, and service system recommendations. Method: Fifteen focus groups were conducted in partnership with urban and rural/reservation health programs, and AIAN serving community-based organizations throughout California with youth ranging from 13 to 18 years of age. Focus groups were recorded and professionally transcribed, then coded using NVivo qualitative data analysis software. An a priori coding structure was refined through a data-informed, iterative process until a final coding structure was agreed upon to characterize data. Results: Findings demonstrate the need for OUD/SUD services that integrate cultural beliefs and practices, incorporate attention to family and community risk and resiliency factors, provide effective outreach and education, and focus on the development of holistic wellness and positive development for AIAN youth. This study also provides a model for conducting a needs assessment using community-based participatory methods to inform effective service development that more directly responds to community-identified needs. Conclusion: Findings indicate that future services and interventions should incorporate a focus on promoting overall wellness and positive youth development in order to prevent or promote recovery from opioid or other substance abuse. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Inflammation, depressive symptoms, and emotion perception in adolescence.

BACKGROUND: Individuals with depression often demonstrate an altered peripheral inflammatory profile, as well as emotion perception difficulties. However, correlations of inflammation with overall depression severity are inconsistent and inflammation may only contribute to specific symptoms. Moreover, measurement of the association between inflammation and emotion perception is sparse in adolescence, despite representing a formative window of emotional development and high-risk period for depression onset. METHODS: Serum interleukin (IL)-6, tumor necrosis factor (TNF)-α, and IL-1ß were measured in 34 adolescents aged 12-17 with DSM-IV depressive disorders (DEP) and 29 healthy controls (HC). Participants were evaluated using the Children's Depression Rating Scale-Revised (CDRS-R) and symptom subscales were extracted based on factor analysis. Participants also completed a performance-based measure of emotion perception, the Facial Emotion Perception Test (FEPT), which assesses the accuracy of categorizing angry, fearful, sad, happy, and neutral facial emotions. RESULTS: IL-6 and TNF-α correlated with reported depressed mood and somatic symptoms, respectively, but not total CDRS-R score, anhedonia or observed mood, across both DEP and HC. DEP demonstrated lower accuracy for identifying angry facial expressions. Higher IL-6 was inversely related to accuracy and discrimination of angry and neutral faces across all participants. IL-1ß was associated with reduced discrimination of fearful faces. CONCLUSIONS: Inflammatory markers were sensitive to affective and somatic symptoms of depression and processing of emotional threat in adolescents. In particular, IL-6 was elevated in depressed adolescents and therefore may represent a specific target for modulating depressive symptoms and emotion processing.

A Sequential Multiple Assignment Randomized Trial (SMART) study of medication and CBT sequencing in the treatment of pediatric anxiety disorders.

BACKGROUND: Treatment of a child who has an anxiety disorder usually begins with the question of which treatment to start first, medication or psychotherapy. Both have strong empirical support, but few studies have compared their effectiveness head-to-head, and none has investigated what to do if the treatment tried first isn't working well-whether to optimize the treatment already begun or to add the other treatment. METHODS: This is a single-blind Sequential Multiple Assignment Randomized Trial (SMART) of 24 weeks duration with two levels of randomization, one in each of two 12-week stages. In Stage 1, children will be randomized to fluoxetine or Coping Cat Cognitive Behavioral Therapy (CBT). In Stage 2, remitters will continue maintenance-level therapy with the single-modality treatment received in Stage 1. Non-remitters during the first 12 weeks of treatment will be randomized to either [1] optimization of their Stage 1 treatment, or [2] optimization of Stage 1 treatment and addition of the other intervention. After the 24-week trial, we will follow participants during open, naturalistic treatment to assess the durability of study treatment effects. Patients, 8-17 years of age who are diagnosed with an anxiety disorder, will be recruited and treated within 9 large clinical sites throughout greater Los Angeles. They will be predominantly underserved, ethnic minorities. The primary outcome measure will be the self-report score on the 41-item youth SCARED (Screen for Child Anxiety Related Disorders). An intent-to-treat analysis will compare youth randomized to fluoxetine first versus those randomized to CBT first ("Main Effect 1"). Then, among Stage 1 non-remitters, we will compare non-remitters randomized to optimization of their Stage 1 monotherapy versus non-remitters randomized to combination treatment ("Main Effect 2"). The interaction of these main effects will assess whether one of the 4 treatment sequences (CBT➔CBT; CBT➔med; med➔med; med➔CBT) in non-remitters is significantly better or worse than predicted from main effects alone. DISCUSSION: Findings from this SMART study will identify treatment sequences that optimize outcomes in ethnically diverse pediatric patients from underserved low- and middle-income households who have anxiety disorders. TRIAL REGISTRATION: This protocol, version 1.0, was registered in ClinicalTrials.gov on February 17, 2021 with Identifier: NCT04760275 .

Assessing change in suicidal ideation intensity for youth in treatment for pediatric bipolar disorder.

OBJECTIVE: Suicidal ideation (SI) is significantly higher for youth with pediatric bipolar disorder (PBD), yet clinical correlates of suicidality remain poorly understood in this population. The current study investigates how change in risk factors for SI relate to change in SI intensity over a 6-month period of treatment. METHOD: Children ages 9 to 13 (N = 71; 41% female; 54% Caucasian; Mean age = 9.17) engaged in one of two psychotherapy treatment conditions and completed assessments of SI risk factors and psychopathology symptoms at baseline (pre-treatment), 4 and 8 weeks (during treatment), 12 weeks (post-treatment), and 39 weeks (follow-up assessment at 6 months post-treatment). Children also completed assessments of SI intensity at baseline, post-treatment (12 weeks), and 6 months post-treatment. RESULTS: Mixed-effects regression models indicate that increases in health-related quality of life in the family, mobilization of the family to acquire/accept help for PBD, and child self-concept were associated with decreased SI intensity over time. CONCLUSIONS: Findings highlight the importance of family and child level factors in influencing longitudinal change in SI intensity in youth with PBD. Clinical implications and future directions are discussed.

Statewide collaborative partnerships among American Indian and Alaska Native (AI/AN) communities in California to target the opioid epidemic: Preliminary results of the Tribal Medication Assisted Treatment (MAT) key informant needs assessment.

American Indian and Alaska Native (AI/AN) communities have disproportionately been impacted by the opioid epidemic with the second highest opioid-related overdose death rates compared to other ethnic groups. The diversity among California AI/AN tribes, including regional differences in economic opportunities, tribal affiliation and organization, resources and infrastructure, requires a strong community-based partnership approach to assess global statewide patterns in service availability, acceptability, and utilization, as well as capturing the unique challenges and service needs within each region. This article describes a statewide community-based needs assessment of strengths and weakness among key informants in CA to identify facilitators and barriers to treatment of substance use disorders (SUD) and opioid use disorders (OUD). We conducted structured interviews of 21 healthcare professionals from Urban Indian Health Programs, Tribal clinics and community-based organizations throughout California. The interview assessed (1) barriers to accessing services; (2) risk factors; (3) protective factors; (4) community substance use description; (5) SUD and OUD services available; and (6) service system needs. Findings indicate an overall increase in SUD and OUD in AI/AN communities. Key informants discussed the importance of comprehensive and culturally centered care, wrap-around services, such as treatment of mental health issues alongside substance abuse, and the need for AI/AN-specific treatment facilities that integrate traditional and cultural activities into western health services.

Immune response to stress induction as a predictor of cognitive-behavioral therapy outcomes in adolescent mood disorders: A pilot study.

Cognitive-behavioral therapy (CBT) alleviates symptoms of depression in youth with bipolar disorder (BD) and major depressive disorder (MDD). Empirical research has linked inflammatory markers to depressive symptoms and acute psychosocial stress; however, a gap remains as to whether immune response to stress may serve as a putative mechanism of treatment. This preliminary pilot study determined the modest feasibility of assessing psychobiological response to stress as a predictor of CBT outcomes for youth with mood disorders. We evaluated whether participation in a 10-session group-CBT intervention for mood disorders altered inflammatory response to a laboratory psychosocial stress induction and if this alteration in immune stress responsivity was related to a decrease in depressive symptoms. Thirty-four youth (age M = 15.03, SD = 1.91) diagnosed with BD or MDD participated in a 10-session CBT group and pre- and post-group assessments; twenty-eight participants who completed the group had usable cytokine data. Pre- and post-group assessments included stress induction with the Trier Social Stress Test (TSST) during which inflammatory cytokines were measured at baseline (time 0) and after the TSST at 30, 60, and 90 min. Results suggest it is modestly feasible to measure immune response to stress alongside CBT treatment for adolescent mood disorders. Our findings were mixed; across seven cytokines, hierarchical linear models indicated two cytokines, IL6 and IL12, were sensitive to acute laboratory stress. We also found significant correlations between life stress, inflammation, and depression both pre- and post- CBT group. Inflammation pre-group, as measured by IL12 and IL1 ß predicted depressive symptoms following treatment. Although we did not find significant within-subject reductions in inflammation, chronic stress predicted changes in IL ß, signaling the central role of chronic stress. This study offers preliminary evidence that immune responsivity to stress induction could serve as a mechanism of treatment for mood disorders in youth, indicating a potential marker for more personalized model of healthcare.

American Indian Researcher Perspectives on Qualitative Inquiry About and Within American Indian Communities.

It is presumed that Indigenous researchers are optimally positioned to conduct research about or within their own or other Indigenous communities. However, these researchers may still experience challenges, barriers, and distressing events that are important to identify. Qualitative inquiry may be a particularly vulnerable context for Indigenous researchers given the nature of data collection methods and an emphasis on researcher-participant relationships. This paper details the personal reflections of two American Indian (AI) researchers who carried out qualitative research focused on AI issues and/or communities. The first project examined undergraduate students' opinions of the use of AI imagery in the form of a race-based university mascot. The second was a study of the mental health needs of AI youth and families in an urban community. Several themes characterized both of their experiences and might be generalizable to others working in these contexts: (a) coping with racism and microaggressions; (b) the role and impact of identity politics; (c) community insider/outsider tension; and (d) managing personal distress associated with the research topics and process. These themes are discussed to illuminate ways that Indigenous researchers, engaged in research on Indigenous topics and/or with Indigenous communities, are challenged and affected by their work.

Editorial: The Impact of Parental Psychopathology on Family Functioning: Prioritizing Transdiagnostic Interventions With Parents and Families.

Bipolar disorder (BD) in children and adolescents is a severe, refractory illness linked with poor mental and physical health and functional outcomes that confers significant risk over the course of development.1 To date, pharmacotherapy and psychosocial treatment studies have focused largely on symptom reduction and remission as primary outcomes. However, researchers and clinicians who study and treat youth with bipolar spectrum disorders are familiar with a host of functional impairments that often persist even after symptoms have been stabilized.

Interplay between pro-inflammatory cytokines, childhood trauma, and executive function in depressed adolescents.

BACKGROUND: Pro-inflammatory cytokines have been linked to depression, early childhood trauma, and impairment in executive function in adults. Whether these links are present during adolescence, a time when vulnerability to depression is heightened, a point more proximal to childhood trauma, and a critical period of brain development, is not well understood. METHOD: Serum levels of interleukin (IL)-6, IL-1ß, and tumor necrosis factor alpha (TNF-α) were measured in 70 adolescents aged 12-17, including 40 with a DSM-IV depressive disorder (DEP), a sub-set (n = 22) of whom reported a history of childhood trauma (DEP-T), and 30 healthy controls (HCs). Participants completed performance-based (Parametric Go/No-Go Task) and observer-rated (Behavior Rating Inventory of Executive Function) measures of executive function. Procedures were conducted at a subspecialty clinic (Dec 2015-June 2017). RESULTS: IL-6 was elevated in DEP and DEP-T adolescents compared to controls (p = .014) and TNF-α was elevated in DEP participants only (p = .040) compared to controls, whereas no group differences were found in IL-1ß (p = .829). Additionally, DEP-T participants demonstrated relative deficits in performance-based (p = .044) and observer-rated inhibitory control (p = .049) compared to controls. Across the whole sample, TNF-α was associated with performance-based (r = -0.25, p = .039) and observer-rated (r = 0.32, p = .009) inhibitory control deficits. In subgroup analyses, TNF-α was associated with increased observer-rated inhibitory deficits in DEP, and at the trend level, with reduced inhibitory control performance in DEP-T. CONCLUSIONS: The current results suggest that inflammation may be a marker of disease processes in adolescent depression. Though longitudinal studies are needed, depressed adolescents with childhood trauma exposure appear to constitute a uniquely vulnerable group in terms of objective risk for executive dysfunction. Immune dysregulation may partly contribute to this risk.