In vivo CRISPR base editing of PCSK9 durably lowers cholesterol in primates.

Gene-editing technologies, which include the CRISPR-Cas nucleases1-3 and CRISPR base editors4,5, have the potential to permanently modify disease-causing genes in patients6. The demonstration of durable editing in target organs of nonhuman primates is a key step before in vivo administration of gene editors to patients in clinical trials. Here we demonstrate that CRISPR base editors that are delivered in vivo using lipid nanoparticles can efficiently and precisely modify disease-related genes in living cynomolgus monkeys (Macaca fascicularis). We observed a near-complete knockdown of PCSK9 in the liver after a single infusion of lipid nanoparticles, with concomitant reductions in blood levels of PCSK9 and low-density lipoprotein cholesterol of approximately 90% and about 60%, respectively; all of these changes remained stable for at least 8 months after a single-dose treatment. In addition to supporting a 'once-and-done' approach to the reduction of low-density lipoprotein cholesterol and the treatment of atherosclerotic cardiovascular disease (the leading cause of death worldwide7), our results provide a proof-of-concept for how CRISPR base editors can be productively applied to make precise single-nucleotide changes in therapeutic target genes in the liver, and potentially in other organs.

A Cluster Randomized Trial of Primary Care Practice Redesign to Integrate Behavioral Health for Those Who Need It Most: Patients With Multiple Chronic Conditions.

PURPOSE: Patient outcomes can improve when primary care and behavioral health providers use a collaborative system of care, but integrating these services is difficult. We tested the effectiveness of a practice intervention for improving patient outcomes by enhancing integrated behavioral health (IBH) activities. METHODS: We conducted a pragmatic, cluster randomized controlled trial. The intervention combined practice redesign, quality improvement coaching, provider and staff education, and collaborative learning. At baseline and 2 years, staff at 42 primary care practices completed the Practice Integration Profile (PIP) as a measure of IBH. Adult patients with multiple chronic medical and behavioral conditions completed the Patient-Reported Outcomes Measurement Information System (PROMIS-29) survey. Primary outcomes were the change in 8 PROMIS-29 domain scores. Secondary outcomes included change in level of integration. RESULTS: Intervention assignment had no effect on change in outcomes reported by 2,426 patients who completed both baseline and 2-year surveys. Practices assigned to the intervention improved PIP workflow scores but not PIP total scores. Baseline PIP total score was significantly associated with patient-reported function, independent of intervention. Active practices that completed intervention workbooks (n = 13) improved patient-reported outcomes and practice integration (P ≤ .05) compared with other active practices (n = 7). CONCLUSION: Intervention assignment had no effect on change in patient outcomes; however, we did observe improved patient outcomes among practices that entered the study with greater IBH. We also observed more improvement of integration and patient outcomes among active practices that completed the intervention compared to active practices that did not. Additional research is needed to understand how implementation efforts to enhance IBH can best reach patients.

Co-creating the Patient Partner Guide by a Multiple Chronic Conditions Team of Patients, Clinicians, and Researchers: Observational Report.

BACKGROUND: Engaging patients as partners can influence research, with rewards and deterrents. The authors are researchers and patient co-investigators who collaborated on a comparative effectiveness, randomized controlled study of a structured quality improvement (QI) process to improve behavioral health and primary care integration for people managing multiple chronic conditions (MCC). Patient co-investigators responded to a gap in available resources to support study clinics in partnering with their own patients in QI and co-created the Patient Partner Guide (PPG). OBJECTIVE: Describe the development of the PPG, its use by clinics undertaking the QI project, and research team partnerships. DESIGN: Observational report of study intervention component. PARTICIPANTS: Diverse patients and family members managing MCC and members of their primary care clinics. INTERVENTION: The PPG component of the study intervention is a five-step workbook providing practical tools and resources to sustain partnerships across clinic QI team members, including patient partners. The process of developing the PPG relied on relationship-building tools that were iteratively assessed, practiced, improved, and incorporated into the PPG under the leadership of patient co-investigators. MAIN MEASURES: Observations related to PPG use and patient partner inclusion in clinic QI; impact on the research team. KEY RESULTS: Of 20 clinics, 6 engaged patients as full partners on QI teams. Clinics found resistance in partnering and challenges in using the PPG but valued the material and their partners' contributions. Similarly, engagement of patient co-investigators in research brought a shift in perspective to team members. The PPG is available and was adapted for use by research teams. CONCLUSIONS: Engagement of patients and other stakeholders in research can be transformative and productive. Building relationships through meaningful work benefits others, and in turn, the research process. This approach can enhance clinical care QI and may result in substantial contributions to the conduct of research. CLINICAL TRIAL REGISTRATION: https://clinicaltrials.gov/ct2/show/NCT02868983.

Integrating behavioral health & primary care for multiple chronic diseases: Clinical trial of a practice redesign toolkit.

Context: Most patients in need of behavioral health (BH) care are seen in primary care, which often has difficulty responding. Some practices integrate behavioral health care (IBH), with medical and BH providers at the same location, working as a team. However, it is difficult to achieve high levels of integration. Objective: Test the effectiveness of a practice intervention designed to increase BH integration. Study Design: Pragmatic, cluster-randomized controlled trial. Setting: 43 primary care practices with on-site BH services in 13 states. Population: 2,460 adults with multiple chronic medical and behavioral conditions. Intervention: 24-month practice change process including an online curriculum, a practice redesign and implementation workbook, remote quality improvement coaching services, and an online learning community. Outcomes: Primary outcomes were changes in the 8 Patient-Reported Outcomes Measurement Information System (PROMIS-29) domain scores. Secondary outcomes were changes in medication adherence, self-reported healthcare utilization, time lost due to disability, cardiovascular capacity, patient centeredness, provider empathy, and several condition-specific measures. A sample of practice staff completed the Practice Integration Profile at each time point to estimate the degree of BH integration in that site. Practice-level case studies estimated the typical costs of implementing the intervention. Results: The intervention had no significant effect on any of the primary or secondary outcomes. Subgroup analyses showed no convincing patterns of effect in any populations. COVID-19 was apparently not a moderating influence of the effect of the intervention on outcomes. The intervention had a modest effect on the degree of practice integration, reaching statistical significance in the Workflow domain. The median cost of the intervention was $18,204 per practice. In post-hoc analysis, level of BH integration was associated with improved patient outcomes independent of the intervention, both at baseline and longitudinally. Conclusions: The specific intervention tested in this study was inexpensive, but had only a small impact on the degree of BH integration, and none on patient outcomes. However, practices that had more integration at baseline had better patient outcomes, independent of the intervention. Although this particular intervention was ineffective, IBH remains an attractive strategy for improving patient outcomes.

Lie-telling for personal gain in children with and without externalizing behavior problems.

Few studies have examined the lie-telling behavior of children who have externalizing problems using experimental procedures. In the current study, children's lie-telling for personal gain (N = 110 boys aged 6-11 years) was examined using an experimental paradigm in relation to their theory-of-mind abilities and inhibitory control as well as their moral evaluations of truths and lies. Children with externalizing behavior problems (n = 53) were significantly more likely to lie and to be less skilled at lying than a typical comparison group (n = 57). Children who had lower theory-of-mind scores were significantly more likely to tell a lie for personal gain compared with those who had higher theory-of-mind scores. Children with externalizing problems who told personal gain lies were also more likely to rate tattle truths more positively than other children. For a subsample of children (n = 55), parent-reported diaries of the frequency of children's lies over 2 weeks revealed a higher frequency of lies by children with externalizing problems compared with the typical comparison group. Children whose parents reported a high frequency of lies for their children were also more likely to lie in the experimental personal gain lie paradigm. Results suggest that children with externalizing behavior may have a different pattern of lie-telling than has been previously reported for normative lie development.

Development and validation of the patient centeredness index for primary care.

AIMS AND OBJECTIVES: To describe the development of the Patient Centeredness Index (PCI), evaluate its psychometric characteristics and evaluate the relationships between scores on the PCI and an established measure of empathy. BACKGROUND: Patient centeredness helps patients manage multiple chronic conditions with their providers, nurses and other team members. However, no instrument exists for evaluating patient centeredness within primary care practices treating this population. DESIGN: Multi-site instrument development and validation. STROBE reporting guidelines were followed. METHODS: To identify themes, we consulted literature on patient centeredness and engaged stakeholders who had or were caring for people with multiple chronic conditions (n = 7). We composed and refined items to represent those themes with input from clinicians and researchers. To evaluate reliability and convergent validity, we administered surveys to participants (n = 3622) with chronic conditions recruited from 44 primary care practices for a large-scale cluster randomised clinical trial of the effects of a practice-level intervention on patient and practice-level outcomes. Participants chose to complete the 16-item survey online, on paper or by phone. Surveys assessed demographics, number of chronic conditions and ratings of provider empathy. We conducted exploratory factor analysis to model the interrelationships among items. RESULTS: A single factor explained 93% of total variance. Factor loadings ranged from 0.55-0.85, and item-test correlations were ≥.67. Cronbach's alpha was .93. A moderate, linear correlation with ratings of provider's empathy (r = .65) supports convergent validity. CONCLUSIONS: The PCI is a new tool for obtaining patient perceptions of the patient centeredness of their primary care practice. The PCI shows acceptable reliability and evidence of convergent validity among patients managing chronic conditions. RELEVANCE TO CLINICAL PRACTICE: The PCI rapidly identifies patients' perspectives on patient centeredness of their practice, making it ideal for administration in busy primary care settings that aim to efficiently address patient-identified needs. TRIAL REGISTRATION: Clinicaltrials.org Protocol ID: WLPS-1409-24372. TITLE: Integrating Behavioural Health and Primary Care for Comorbid Behavioural and Medical Problems (IBHPC).

The COVID-19 pandemic and lay perceptions of poverty and neglect.

OBJECTIVES: In cases of child neglect, intervention depends on accurate identification and reporting. Prior work has shown that individuals, especially those of high socioeconomic status (SES), conflate poverty and neglect when making identification and reporting decisions. The COVID-19 pandemic led to changes in people's experiences with poverty, likely influencing their ability to distinguish poverty in families and neglectful parenting. HYPOTHESES: Two studies tested the impact of COVID-19 on laypersons' perceptions of neglect, likelihood of reporting neglect, and attributions of blame for neglect. We hypothesized that laypersons would conflate poverty with neglect, that COVID-19 would be associated with a decreased likelihood of doing so, and that attributions of blame would mediate the latter tendency. METHOD: Adults read vignettes about a mother's care of her daughter and responded to questions about the mother's neglectfulness and their reporting likelihood. Study 1 (N = 676, Mage = 38.80, 48.08% women) compared responses collected before COVID-19 (August 2018) to responses from a separate set of adults collected during COVID-19 (November-December 2020). Study 2 (N = 704, Mage = 43.88, 63.49% women) manipulated mention of COVID-19 to assess whether cuing the pandemic affected identification and reporting, and measured attributions of blame to assess whether they explained the relation between COVID-19 and perceptions of neglect. RESULTS: Whereas most laypersons distinguished situations with versus without neglect, some conflated poverty with neglect when making identification and reporting decisions. However, COVID-19 did not have a direct impact on identification or reporting decisions. Attributions of blame partially explained laypersons' perceptions of situations as neglectful and as warranting reporting. Laypersons' current SES and perceptions of COVID-19 in 2020 were positively associated with identification and reporting. CONCLUSIONS: Laypersons in part mistake poverty for neglect, and COVID-19 had indirect effects on perceptions of neglect and reporting decisions. Public education efforts may help improve identification of vulnerable children by laypersons. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Do laypersons conflate poverty and neglect?

OBJECTIVE: Child neglect is often initially identified via adults who come into contact with children and report their suspicions to the authorities. Little is known about what behaviors laypersons view as constituting neglect and hence worth reporting. We examined laypersons' perceptions of neglect and poverty, particularly how these factors independently and jointly shaped laypersons' decisions about what warrants official reporting of neglect, and how laypersons' socioeconomic background related to their decisions. HYPOTHESES: We anticipated that neglect would be correctly perceived as such, but that extreme poverty would also be perceived as neglect, with these latter perceptions being most pronounced among laypersons of higher socioeconomic background. METHOD: In 2 studies, adults read vignettes about a mother's care of her daughter and rendered decisions about whether the mother's behavior met the legal standard of neglect and should be reported. In Study 1 (N = 365, 55% female, mean age = 37.12 years), indicators of poverty and neglect were manipulated. In Study 2 (N = 474, 53% female, mean age = 38.25 years), only poverty (housing instability: homelessness vs. not) was manipulated. RESULTS: Laypersons often conflated poverty and neglect, especially in circumstances of homelessness. Laypersons of lower socioeconomic background were less likely to perceive neglect in general and to report an obligation to make a referral (R2s ranged from 17-26%, odds ratios ranged from 2.24-3.08). CONCLUSIONS: Laypersons may overreport neglect in circumstances of poverty. Increasing public awareness of how to recognize and separate neglect from poverty may enhance identification of vulnerable children and families. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Carving Pinocchio: Longitudinal examination of children's lying for different goals.

The current study examined children's lie-telling behavior across four motivational contexts at two time points: Time 1 (T1) and Time 2 (T2). There were 127 children (MT1 = 4.65 years old, SD = 0.66; MT2 = 6.93 years old, SD = 0.80) who participated twice in four experimental paradigms to examine antisocial and prosocial lie-telling behavior approximately 2 years apart. Children also completed cognitive measures, and parents completed questionnaires on parenting styles and their children's behavior. Results revealed that children's lie-telling was not uniform across motivational contexts within one time point but that children were fairly consistent in telling antisocial and prosocial lies over time. These findings advance our understanding of the development of lying and how children's decisions to lie may change over time and across motivational contexts.

Overcoming Disclosure Reluctance in Youth Victims of Sex Trafficking: New Directions for Research, Policy, and Practice.

An alarming number of youth worldwide are victims of commercial sexual exploitation, particularly sex trafficking. Normative developmental processes and motivations across the adolescent period-the age when youth are at greatest risk for trafficking-combined with their history, make them highly likely to be reluctant to disclose their exploitation to police, who often encounter victims because they are suspected of delinquency and crime and who interrogate the victims as suspects. Little scientific and policy attention has been devoted to understanding how to question these victims in a way that reduces their disclosure reluctance and increases their provision of legally relevant information. In the current review, we describe research concerning trafficking victims' histories and exploitative experiences, juvenile suspects' and victims' encounters with the legal system, and best-practice forensic interviewing approaches to elicit disclosures from child victims. We highlight the implications of these areas for understanding the dynamics between how police encounter and interact with adolescent trafficking victims and whether and how the victims disclose trafficking details during these interactions. We close with an agenda for research to test interviewing methods for suspected victims of sex trafficking and with policy and practice recommendations for interviewers.

Outcome Trajectories among Homeless Individuals with Mental Disorders in a Multisite Randomised Controlled Trial of Housing First.

PURPOSE: Housing First (HF) has been shown to improve housing stability, on average, for formerly homeless adults with mental illness. However, little is known about patterns of change and characteristics that predict different outcome trajectories over time. This article reports on latent trajectories of housing stability among 2140 participants (84% followed 24 months) of a multisite randomised controlled trial of HF. METHODS: Data were analyzed using generalised growth mixture modeling for the total cohort. Predictor variables were chosen based on the original program logic model and detailed reviews of other qualitative and quantitative findings. Treatment group assignment and level of need at baseline were included in the model. RESULTS: In total, 73% of HF participants and 43% of treatment-as-usual (TAU) participants were in stable housing after 24 months of follow-up. Six trajectories of housing stability were identified for each of the HF and TAU groups. Variables that distinguished different trajectories included gender, age, prior month income, Aboriginal status, total time homeless, previous hospitalizations, overall health, psychiatric symptoms, and comorbidity, while others such as education, diagnosis, and substance use problems did not. CONCLUSION: While the observed patterns and their predictors are of interest for further research and general service planning, no set of variables is yet known that can accurately predict the likelihood of particular individuals benefiting from HF programs at the outset.

Influence of social factors on the relation between lie-telling and children's cognitive abilities.

Lie-telling may be part of a normative developmental process for children. However, little is known about the complex interaction of social and cognitive factors related to this developmental behavior. The current study examined parenting style, maternal exposure to stressors, and children's cognitive abilities in relation to children's antisocial lie-telling behavior in an experimental setting. Children (3-6years, N=157) participated in a modified temptation resistance paradigm to elicit spontaneous lies. Results indicate that high authoritative parenting and high inhibitory control interact to predict a lower propensity to lie, but those who did lie had better semantic leakage control. This suggests that although children's lie-telling may be normative during early development, the relation to children's cognitive abilities can be moderated by responsive parenting behaviors that discourage lying.

Housing Quality in a Randomized Controlled Trial of Housing First for Homeless Individuals with Mental Illness: Correlates and Associations with Outcomes.

Housing quality (HQ) is associated with mental health, and may mediate outcomes in housing interventions. However, studies of housing interventions rarely report HQ. The purpose of this study was to describe HQ in a multi-site randomized controlled trial of Housing First (HF) in five Canadian cities and to examine possible differences by treatment group (HF recipients and treatment-as-usual (TAU) participants who were able to find housing through other programs or on their own). We also examined the association between HQ and the primary trial outcome: housing stability. The performance of a new multi-dimensional standardized observer-rated housing quality scale (the OHQS) in a relatively large cross-site sample was also of interest. HQ was rated by trained research assistants for 204 HF participants and 228 TAU participants using the OHQS. General linear regression models were used to examine unit/building quality scores by group and site adjusting for other group differences, and as a predictor of housing stability outcomes after 24 months of follow-up. The OHQS was found to have good reliability and validity, but because most of the neighborhood subscale items were negatively correlated with the overall scale, only unit and building items were included in the total HQ score (possible scores ranging from 13.5 to 135). Unit/building HQ was significantly better for the HF group overall (91.2 (95 % CI = 89.6-92.9) vs. 88.3 (95 % CI = 86.1-90.5); p = .036), and in one site. HQ in the TAU group was much more variable than the HF group overall (W (mean) = 24.7; p < .001) and in four of five sites. Unit/building HQ scores were positively associated with housing stability: (73.4 (95 % CI 68.3-78.5) for those housed none of the time; 91.1 (95 % CI 89.2-93.0) for those housed some of the time; and 93.1 (95 % CI 91.4-94.9)) for those housed all of the time (F = 43.9 p < .001). This association held after adjusting for site, housing characteristics, participant ethnocultural status, community functioning, and social support. This study demonstrates that HQ can be as good or better, and less variable, in HF programs in Canada that systematically and predominantly source housing stock from the private sector compared to housing procured outside of an HF program. HQ is also an important predictor of housing stability outcomes.

Children's Physical Resilience Outcomes: Meta-Analysis of Vulnerability and Protective Factors.

Resilience has generally been understood as positive coping and adaptation despite stress and adversity and as a buffer against stress. Researchers examining resilience have typically focused on children's psychological resilience because of the well-established impact of stress on children's mental health. However, although it has also been well-established that high levels of stress can impact children's physical health, their physical health has received little attention in resilience research. ELIGIBILITY CRITERIA: Articles were selected for review if they (1) had a variable that was in some way a measure of physical health in response to a psychosocial stressor; (2) had participants who were children or adolescents within the age range of 4-18years; and (3) were a peer-reviewed, empirical study. SAMPLE: Two random-effect meta-analyses were conducted with a sample of 12,772 participants across 14 studies to determine the influence of protective and vulnerability factors on children's physical health in adverse experiences. RESULTS: Protective factors had a moderate effect and vulnerability factors had a small-moderate effect on health measures across domains of physiological, sleep behavior, and overall health. The type of health measure moderated the effect size for vulnerability factors, but not for protective factors. CONCLUSIONS: These findings suggest that protective factors may be associated with an environment that encourages children to thrive, as apparent by their physical health. IMPLICATIONS: The results of this review and meta-analysis can be used to guide the methodological design of future studies on childhood resilience and to inform clinical practice with children and adolescents.

Development and initial validation of the Observer-Rated Housing Quality Scale (OHQS) in a multisite trial of housing first.

Quality of housing has been shown to be related to health outcomes, including mental health and well-being, yet "objective" or observer-rated housing quality is rarely measured in housing intervention research. This may be due to a lack of standardized, reliable, and valid housing quality instruments. The objective of this research was to develop and validate the Observer-Rated Housing Quality Scale (OHQS) for use in a multisite trial of a "housing first" intervention for homeless individuals with mental illness. A list of 79 housing unit, building, and neighborhood characteristics was generated from a review of the relevant literature and three focus groups with consumers and housing service providers. The characteristics were then ranked by 47 researchers, consumers, and service providers on perceived importance, generalizability, universality of value, and evidence base. Items were then drafted, scaled (five points, half values allowed), and pretested in seven housing units and with seven raters using cognitive interviewing techniques. The draft scale was piloted in 55 housing units in Toronto and Winnipeg, Canada. Items were rated independently in each unit by two trained research assistants and a housing expert. Data were analyzed using classical psychometric approaches and intraclass correlation coefficients (ICC) for inter-rater reliability. The draft scale consisted of 34 items assessing three domains: the unit, the building, and the neighborhood. Five of 18 unit items and 3 of 7 building items displayed ceiling or floor effects and were adjusted accordingly. Internal consistency was very good (Cronbach's alpha = 0.90 for the unit items, 0.80 for the building items, and 0.92 total (unit and building)). Percent agreement ranged from 89 to 100 % within one response scale value and 67 to 91 % within one half scale value. Inter-rater reliability was also good (ICCs were 0.87 for the unit, 0.85 for the building, and 0.93 for the total scale). Three neighborhood items (e.g., distance to transit) were found to be most efficiently rated using publicly available information. The physical quality of housing can be reliably rated by trained but nonexpert raters using the OHQS. The tool has potential for improved measurement in housing-related health research, including addressing the limitations of self-report, and may also enable documenting the quality of housing that is provided by publicly funded housing programs.

Eye of the beholder: perceived stress, coping style, and coping effectiveness among discharged psychiatric patients.

Sources of perceived stress, coping style and coping efficacy were investigated among psychiatric patients being discharged to the community. The study's purpose was to (i) qualitatively characterize sources of perceived stress; (ii) identify preferred coping styles, and (iii) test the effectiveness of coping styles. Thematic coding of participants' narratives revealed that dominant stressors were family relationships, mental health symptoms, and employment issues. Consistent with previous findings among non-clinical samples, problem-focused coping styles were predictive of decreased perceived stress and increased perceived efficacy, whereas emotion-oriented coping styles were negatively associated with these outcomes. Contrary to hypotheses, avoidance coping styles was unrelated to outcomes.

Theory of Mind and Concealing vs. Forthcoming Communication in Adolescence.

Concealing information requires that adolescents manage the information that they share, which requires cognitive skills, for example, theory of mind (ToM). This study explored motivations for concealment that early adolescents (N = 90, M = 12.81 years, SD = 5.10 months, range 12-14 years, and 58% female) endorsed concealing or disclosing to friends and parents, in relation to their theory of mind. We found that adolescents broadly endorsed disclosure to both parents and friends, even when it might mean they would face consequences, be impolite (by not protecting another's feelings), or face negative identity-related emotions. We found that ToM ability was associated with a tendency to endorse being forthcoming and sharing information with both friends and parents. These findings provide new insight into how the relation between ToM and concealment may change with age, specifically how in early adolescence it may foster open communication rather than concealment as is the case in early and middle childhood.

Developing Community Co-designed Scenario-Based Training for Police Mental Health Crisis Response: a Relational Policing Approach to De-escalation.

Using the current empirical landscape of police responses to people in mental health crisis as a backdrop, this methods paper makes an argument for the central role of collaborative co-design and production by diverse community experts and stakeholders to build transformative specialized training for frontline officers. Subject matter experts (SMEs) from across key domains participated in focus groups and curriculum creation, with outputs being the co-development of a conceptual approach and an innovative experiential learning training program. Part 1 unpacks the team's conceptual development of a relational policing approach. This humanized method is shaped by procedural justice, trauma-informed, person-centred, and cultural safety frameworks. Part 2 details the co-production of a novel problem-based training method for a police service in Southern Ontario, Canada. The program centres on the acquisition of core competencies related to relational policing, de-escalation, and mental health crisis response. The training was designed to bring learners through a spectrum of authentic crisis scenarios: from observer-participant scenarios informed by Forum Theatre methods and targeted SME feedback to a range of high-fidelity assessment simulations that test officers' abilities to effectively communicate, de-escalate, and make decisions under stress. This program offers repeated opportunities for officers to practice alternative crisis management strategies in scenarios that might otherwise result in the use of force.

Do children unintentionally report maltreatment? Comparison of disclosures of neglect versus sexual abuse.

BACKGROUND AND AIMS: Children's initial reports often play a key role in the identification of maltreatment, and a sizeable amount of scientific research has examined how children disclose sexual and physical abuse. Although neglect constitutes a large proportion of maltreatment experiences, relatively little attention has been directed toward understanding whether and how children disclose neglect. The overarching aim of the present study was to document this process by comparing disclosure patterns in cases of neglect to those in cases of sexual abuse. METHOD: Redacted jurisdiction reports (N = 136) of substantiated dependency cases of neglect (n = 71) and sexual abuse (n = 65) in 4- to 17-year-olds were coded for why maltreatment was suspected, and for children's perceived awareness and disclosure of the maltreatment. RESULTS: Neglect was most often initially suspected via contact with emergency services (e.g., police, emergency medical services), whereas sexual abuse was most often initially suspected as a result of children's statements. Children evidenced greater perceived awareness of sexual abuse than neglect and were more likely to disclose the former in their first investigative interview. Perceived awareness was further associated with a higher likelihood of children's statements initiating discovery of maltreatment and disclosing in the first investigative interview. CONCLUSIONS: Children may benefit from greater knowledge about their needs for safety, supervision, and provision in the home, which could increase the likelihood they would disclose neglect. Such, in turn, could lead to earlier interventions for children and families.

Outcomes of Delay of Care After the Onset of COVID-19 for Patients Managing Multiple Chronic Conditions.

PURPOSE: Many patients delayed health care during COVID-19. We assessed the extent to which patients managing multiple chronic conditions (MCC) delayed care in the first months of the pandemic, reasons for delay, and impact of delay on patient-reported physical and behavioral health (BH) outcomes. METHODS: As part of a large clinical trial conducted April 2016-June, 2021, primary care patients managing MCC were surveyed about physical and behavioral symptoms and functioning. Surveys administered between September 3, 2020, and March 16, 2021, included questions about the extent of and reasons for any delayed medical and BH care since COVID-19. Multivariable linear regression was used to assess health outcomes as a function of delay of care status. RESULTS: Among patients who delayed medical care, 58% delayed more than once. Among those who delayed behavioral health care, 63% delayed more than once. Participants who delayed multiple times tended to be younger, female, unmarried, and reported food, financial, and housing insecurities and worse health. The primary reasons for delaying care were lack of availability of in-person visits and perceived lack of urgency. Participants who delayed care multiple times had significantly worse outcomes on nearly every measure of physical and mental health, compared with participants who delayed care once or did not delay. CONCLUSIONS: Delay of care was substantial. Patients who delayed care multiple times were in poorer health and thus in need of more care. Effective strategies for reengaging patients in deferred care should be identified and implemented on multiple levels. TRIAL REGISTRATION: ClinicalTrials.gov NCT02868983. Registered on August 16, 2016.