Epidemiology and clinical significance of persistent bacteremia in severely burned patients.

BACKGROUND: The utility of follow-up blood cultures (FUBC) for gram-negative bloodstream infections (BSIs) are controversial due to low rates of positivity. However, recent studies suggest higher rates of positivity in critically ill patients. The utility of FUBC in gram-negative BSI in patients with severe burn injuries is unknown. METHODS: Patients ≥ 18 years old admitted to the US Army Institute of Surgical Research Burn Center for combat-related thermal burns from 1/2003-6/2014 with a monomicrobial BSI were included. FUBC were defined as repeat cultures 1-5 days from index BSI. Persistent BSI (pBSI) was defined as isolation of the same organism from initial and FUBC. The primary endpoint was all-cause in-hospital mortality in patients with gram-negative pBSI. RESULTS: Of 126 patients meeting inclusion criteria with BSI, 53 (42%) had pBSI. Compared to patients without persistence, patients with pBSI had more severe burns with median total body surface area (TBSA) burns of 47% ([IQR 34-63] vs. 35.3% [IQR 23.3-56.6], p = 0.02), increased mortality (38 vs. 11%, p = 0.001) compared to those with non-persistent BSI. On multivariate analysis, pBSI was associated with an odds ratio for mortality of 5.3 [95% CI 1.8-15.8, p = 0.003). Amongst gram-negative pathogens, persistence rates were high and associated with increased mortality (41% vs. 11%, p = 0.001) compared to patients without pBSI. CONCLUSION: In this cohort of military patients with combat-related severe burns, pBSI was more common than in other hospitalized populations and associated with increased mortality. Given this high frequency of persistence in patients with burn injuries and associated mortality, FUBC are an important diagnostic and prognostic study in this population.

"Dogs on Call": A Community-Engaged Human Subjects Training with Hospital Based Therapy Dog Teams.

Problem: As community-engaged research (CER) methods evolve, Institutional Review Boards (IRBs) must adapt policies to facilitate CER research. This paper describes a novel collaboration between hospital-based therapy dog volunteer teams (CERs), academic faculty, and an IRB. Subjects: CER volunteers delivered a canine-assisted intervention to hospitalized adults in a clinical trial. Methods: IRB members and faculty developed a human subjects protections training tailored to the volunteer handlers' role as study interventionists including an interactive video- and discussion-based training with a knowledge assessment. Findings: Fourteen volunteer handlers were trained. The expedited IRB review period was similar to national average rates (18 days.) Volunteer handlers have conducted 107 research visits with little patient attrition. Conclusion: Tailored human subjects trainings facilitate research with interventions delivered by people who are not typically involved in research. Bespoke CER human subjects training requires collaboration between researchers and IRBs and flexibility in IRB policy regarding CER.

Evaluation of a Culturally Adapted Online Basic Psychosocial Skills Training Program for International Frontline Workers in Under-Resourced Contexts During the COVID-19 Pandemic.

OBJECTIVE: Frontline workers report negative mental health impacts of being exposed to the risk of COVID-19, and of supporting people struggling with the effects of the virus. Uptake of psychological first-aid resources is inconsistent, and they may not meet the needs of frontline workers in under-resourced contexts. This study evaluates a culturally adapted basic psychosocial skills (BPS) training program that aimed to meet the needs of frontline workers in under-resourced settings. METHODS: A cross-sectional survey administered to frontline workers who completed the program between 2020 and 2022, investigated their perceived confidence, satisfaction, and skill development, as well as their views on relevance to context and accessibility of the program. RESULTS: Out of the 1000 people who had undertaken the BPS program, 118 (11.8%) completed the survey. Participants reported high levels of satisfaction and improved confidence in, and knowledge of, psychosocial skills. Participants reported that the BPS program was culturally and contextually relevant, and some requested expansion of the program, including more interactivity, opportunities for anonymous participation, and adaption to other cultural contexts, including translation into languages other than English. CONCLUSION: Findings indicate a need for free, online, and culturally adapted psychosocial skills training program that is designed with key stakeholders to ensure relevance to social and cultural contexts.

Reimagining Healthcare: Human-Animal Bond Support as a Primary, Secondary, and Tertiary Public Health Intervention.

The emergence of human-animal support services (HASS)-services provided to help keep people and their companion animals together-in the United States has been driven by two global public health crises. Despite such impetuses and an increasing recognition of One Health approaches, HASS are generally not recognized as public health interventions. The Ottawa Charter, defining health as well-being and resources for living and calling for cross-sector action to advance such, provides a clear rationale for locating HASS within a public health framework. Drawing from Ottawa Charter tenets and using the United States as a case study, we: (1) recognize and explicate HASS as public health resources for human and animal well-being and (2) delineate examples of HASS within the three-tiered public health intervention framework. HASS examples situated in the three-tier framework reveal a public health continuum for symbiotic well-being and health. Humans and their respective companion animals may need different levels of intervention to optimize mutual well-being. Tenets of the Ottawa Charter provide a clear rationale for recognizing and promoting HASS as One Health public health interventions; doing so enables cross-sector leveraging of resources and offers a symbiotic strategy for human and animal well-being.

Reactivation of a Hospital-Based Therapy Dog Visitation Program during the COVID-19 Pandemic.

This study examined human−animal interactions during the reactivation of a hospital-based therapy dog program during the COVID-19 pandemic. Data were collected from human−dog interactions at an academic medical center in Virginia. Interaction length, participant role, age group (pediatric or adult), and observed gender were recorded. Handler adherence to human and animal safety protocols (donning personal protective equipment (PPE), using hand sanitizer, and limiting visit length) was measured. Observations from 1016 interactions were collected. t-tests and analysis of variance were conducted. Most visit recipients were healthcare workers (71.69%). Patients received longer visits than other participants (F(4880) = 72.90, p = <0.001); post hoc Bonferroni analyses (p = 0.05/4) showed that patients, both adult (M = 2.58 min, SD = 2.24) (95% C.I = 0.35−1.68) and pediatric (M = 5.81, SD = 4.38) (95% C.I. 3.56−4.97), had longer interaction times than healthcare workers (M = 1.56, SD = 1.92) but not visitors (p = 1.00). Gender differences were not statistically significant (t(552) = −0.736), p = 0.462). Hand sanitizer protocols were followed for 80% of interactions. PPE guidelines were followed for 100% of visits. Most interactions occurred with healthcare workers, suggesting that therapy dog visits are needed for this population. High adherence to COVID-19 safety protocols supports the decision to reactivate therapy animal visitation programs in hospitals. Challenges to safety protocol adherence included ultra-brief interactions and crowds of people surrounding the dog/handler teams. Program staff developed a "buddy system" mitigation strategy to minimize departures from safety protocols and reduce canine stress.

Development and implementation of the Bachelor of Nursing (Conversion) course in Vanuatu.

CONTEXT: Vanuatu, a Pacific Island nation in the Western Pacific region, has to date educated its nurses by diploma program. Research evidence in developed countries has consistently shown that nurses educated by bachelor degree improve patient health outcomes and reduce hospital length of stay. In seeking to improve health outcomes, the Vanuatu Ministry of Health decided to introduce a new Bachelor of Nursing degree to provide a skilled, safe nursing workforce for the provision of health care to its peoples{1-3}. The curriculum for this degree was to be developed by Ni-Vanuatu nurse educators with the collaboration of educators from the WHO Collaborating Centre, University of Technology Sydney. However, it was first necessary to upgrade (from diploma to bachelor level) the qualifications of teachers and senior nursing practitioners who would lead the new degree course by introducing a Bachelor of Nursing (Conversion) course. ISSUES: In order to design and implement a Bachelor of Nursing (Conversion) course that would be relevant for the educational and healthcare context in Vanuatu and that would meet qualification requirements of the local regulatory bodies, it was essential to build collaborative relationships with key stakeholders in Vanuatu. A second key concern was to design a program that would cater for participants who were working full time, who were not all living in the same physical location, and who had limited access to internet technology and resources. The course also needed to take into account that participants were multilingual, and that English was not their first language. LESSONS LEARNED: Lessons learned included the importance of coming to understand the sociocultural nexus within which this course was developed and implemented, as well as appreciating the constraints that affect nursing education within the Pacific.

Recognizing and Mitigating Canine Stress during Animal Assisted Interventions.

Animal-assisted Interventions (AAI) proliferated rapidly since clinicians and researchers first noted the positive effects animals have on people struggling with physical and mental health concerns. The intersection of AAI with the field of animal welfare evolved from considering animals' basic needs, such as freedom from pain, to recognition that animals experience nuanced emotions. Current conceptualizations of the various roles of companion animals as an adjunct to treatments for humans emphasize not only the animals' physical comfort and autonomy, but also their mental well-being and enjoyment of AAI activities. However, numerous challenges to effective monitoring of animals involved in AAI exist. This article focuses specifically on dogs, highlighting factors that may lead handlers and therapists to miss or ignore canine stress signals during human-animal interactions and offers strategies to recognize and ameliorate dogs' distress more consistently. The primary goals of this discussion are to summarize the current thinking on canine well-being and to highlight practical applications of animal welfare principles in real-world AAI settings. The paper highlights contextual factors (e.g., physical setting, patient demand), human influences (e.g., desire to help), and intervention characteristics (e.g., presence or absence of a dog-specific advocate) that may promote or inhibit humans' ability to advocate for therapy dogs during AAI activities. Deidentified examples of each of these factors are discussed, and recommendations are provided to mitigate factors that interfere with timely recognition and amelioration of canine distress.

Reporting the Presence of Coronary Artery Calcium in the Final Impression of Non-gated CT Chest Scans Increases the Appropriate Utilization of Statins.

Background Coronary artery calcium (CAC) scoring based on gated non-contrast cardiac computed tomography (CT) is a validated risk marker of major adverse cardiovascular events (MACE). Reporting of CAC on non-gated CT chest (NGCT) scans and the impact on medical therapy is not well studied. Methods A retrospective cohort of 5,043 NGCT scans was reviewed for the presence of CAC. The radiology report was reviewed to determine whether CAC was mentioned in either the body of the report or the final impression. Electronic medical records (EMR) were abstracted for baseline demographics, cardiovascular (CV) risk factors, lipid-lowering agents, and aspirin (ASA) prior to and after NGCT. Results CAC was present in 63.0% of NGCT scans. Of these scans, CAC was mentioned in the body of the report in 81.6% of studies. Conversely, CAC was mentioned in the final impressions in only 15.1% of these scans. Amongst patients with CAC, initiation of a statin in treatment-naive patients was more common when CAC was mentioned in the final impression versus the body only (12.3% vs. 4.9%, p=0.001) despite the fact that baseline utilization of statins in this cohort was higher (71.1% vs. 64.1%, p=0.005). Initiation of a statin in treatment-naive patients had a trend towards significance when CAC was mentioned in the body of the report versus not reported (4.9% vs. 2.62%, p=0.142). Reporting of CAC in the final impression significantly increased the initiation of ASA in treatment-naive patients (9.52% vs. 4.33%, p=0.033). Reporting of CAC in either the final impression or the body of the report did not affect the initiation of non-statin lipid-lowering therapies in patients with CAC. Conclusion The inclusion of CAC in the final impression of NGCT radiology reports positively impacts the appropriate initiation of statin and aspirin therapy in treatment-naive patients. Universal adherence to a standardized reporting system for the presence of CAC on NGCT should be considered to improve the initiation of guideline-directed medical therapy.

Computer-Assisted Psychiatric Diagnosis.

Accurate psychiatric diagnosis is critical for both sound clinical interventions and valid research methodology. Over the years, attempts to improve diagnostic reliability and accuracy led to the development of more explicit operationalized diagnostic criteria, starting with DSM-III, and subsequently fully structured and semistructured diagnostic interviews.1 As diagnostic assessment changed and with advances in technology, the use of computers soon developed in parallel to improve the reliability and validity of psychiatric diagnosis. As far back as 1968, computers were used to help clinicians formulate psychiatric diagnoses, by helping them process clinical information according to diagnostic algorithms.2 Since that time, there has been an exponential rise in the use of technology in clinical research and practice. Indeed, computers have been used both to transition diagnostic interviews from paper-and-pencil format to instruments that are clinician-administered via an electronic platform and to create self-report versions of clinician-administered diagnostic interviews. We will discuss each of these in turn.

Development of Three Web-Based Computerized Versions of the Kiddie Schedule for Affective Disorders and Schizophrenia Child Psychiatric Diagnostic Interview: Preliminary Validity Data.

OBJECTIVE: To present initial validity data on three web-based computerized versions of the Kiddie Schedule for Affective Disorders and Schizophrenia (KSADS-COMP). METHOD: The sample for evaluating the validity of the clinician-administered KSADS-COMP included 511 youths 6-18 years of age who were participants in the Child Mind Institute Healthy Brain Network. The sample for evaluating the parent and youth self-administered versions of the KSADS-COMP included 158 youths 11-17 years of age recruited from three academic institutions. RESULTS: Average administration time for completing the combined parent and youth clinician-administered KSADS-COMP was less time than previously reported for completing the paper-and-pencil K-SADS with only one informant (91.9 ± 50.1 minutes). Average administration times for the youth and parent self-administered KSADS-COMP were 50.9 ± 28.0 minutes and 63.2 ± 38.3 minutes, respectively, and youths and parents rated their experience using the web-based self-administered KSADS-COMP versions very positively. Diagnoses generated with all three KSADS-COMP versions demonstrated good convergent validity against established clinical rating scales and dimensional diagnostic-specific ratings derived from the KSADS-COMP. When parent and youth self-administered KSADS-COMP data were integrated, good to excellent concordance was also achieved between diagnoses derived using the self-administered and clinician-administered KSADS-COMP versions (area under the curve = 0.89-1.00). CONCLUSION: The three versions of the KSADS-COMP demonstrate promising psychometric properties, while offering efficiency in administration and scoring. The clinician-administered KSADS-COMP shows utility not only for research, but also for implementation in clinical practice, with self-report preinterview ratings that streamline administration. The self-administered KSADS-COMP versions have numerous potential research and clinical applications, including in large-scale epidemiological studies, in schools, in emergency departments, and in telehealth to address the critical shortage of child and adolescent mental health specialists. CLINICAL TRIAL REGISTRATION INFORMATION: Computerized Screening for Comorbidity in Adolescents With Substance or Psychiatric Disorders; https://clinicaltrials.gov/; NCT01866956.

Rapid response to acute stress reaction: Pilot test of iCOVER training for military units.

OBJECTIVE: The purpose of this study was to pilot the iCOVER curriculum-a training product designed to teach service members how to recognize and respond to acute stress reactions (ASRs) using a simple, 6-step procedure, iCOVER. Three goals guided the pilot: (a) assess training acceptability, (b) assess impact of training on knowledge and performance of the iCOVER procedure, and (c) explore the effects of in-person and computer-simulated practical exercises. METHOD: Six military squads (N = 66) were randomly assigned to 3 conditions: iCOVER Standard (iCOVER instruction with an in-person practical exercise), iCOVER Tech (iCOVER instruction with a computer-simulated practical exercise), or Control (no iCOVER instruction). Squads in the iCOVER conditions received iCOVER instruction, completed a knowledge test and practical exercise to which they were assigned (i.e., Standard or Tech), demonstrated their iCOVER skills in live-action scenarios, and reported their perceptions of the training. RESULTS: iCOVER training was acceptable to most participants and associated with improved knowledge about iCOVER (Mpre = 3.33 vs. Mpost = 5.15; t[42] = -7.61, p < .001, d = 1.41); iCOVER Standard resulted in more iCOVER behaviors during a live-action scenario compared with the other conditions, F(2, 35) = 13.36, p < .001, η2 = 0.43. Compared with iCOVER Tech, iCOVER Standard had greater acceptability and resulted in better performance of iCOVER. CONCLUSIONS: This is the first U.S. demonstration of a training program designed to address ASRs during high-risk operations and offers a potential way ahead for preparing military teams to manage ASRs. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Prevalence and Correlates of Bullying Victimization in Four Low-Resource Countries.

Bullying is one of the most common forms of aggression experienced by school-aged youth, yet research is sparse in low- and middle-income countries (LMIC) where cultural and contextual factors may influence victimization dynamics. We aimed to examine correlates of victimization and the prevalence of specific victimizing behaviors among youth in four LMIC. Data were included from 3,536 youth collected as part of the ongoing Young Lives Study cohorts in Ethiopia, India (Andhra Pradesh), Peru, and Vietnam who reported frequency of past-year exposure to nine bullying behaviors at age 15. We calculated both total victimization scores and subtype victimization scores (physical, verbal, relational, and property) by summing the frequencies of experiencing each behavior and used hurdle modeling to examine, separately by country, associations between three demographic correlates (sex, urban/rural setting, and school enrollment) and both total and subtype victimization scores, adjusting for clustered sampling. Mean past-year victimization scores were 11.1 in Ethiopia, 13.4 in India, 14.9 in Peru, and 12.0 in Vietnam, indicating that the average youth in Ethiopia reported two victimization experiences in the past year, up to nearly six in Peru. With the exception of Peru, direct victimization was higher among boys compared with girls, whereas relational victimization was not associated with sex. Physical bullying was less common than other forms of bullying in Ethiopia, Peru, and Vietnam but had a similar frequency as other forms in India. The different patterns in victimization experiences across the samples suggest that culture and/or context may influence victimization dynamics and highlights the need to better understand patterns and variation of bullying victimization in LMIC.

A Team Training Field Research Study: Extending a Theory of Team Development.

Recent advances in the science of teams have provided much insight into the important attitudes (e.g., team cohesion and efficacy), cognitions (e.g., shared team cognition), and behaviors (e.g., teamwork communications) of high performing teams and how these competencies emerge as team members interact, and appropriate measurement methods for tracking development. Numerous training interventions have been found to effectively improve these competencies, and more recently have begun addressing the problem of team dynamics. Team science researchers have increasingly called for more field studies to better understand training and team development processes in the wild and to advance the theory of team development. In addition to the difficulty of gaining access to teams that operate in isolated, confined, and extreme environments (ICE), a major practical challenge for trainers of ICE teams whose schedules are already strained is the need to prioritize the most effective strategies to optimize the time available for implementation. To address these challenges, we describe an applied research experiment that developed and evaluated an integrated team training approach to improve Tactical Combat Casualty (TC3) skills in U.S. Army squads. Findings showed that employing effective team training best practices improved learning, team cognition, emergent team processes, and performance. We recommend future research should focus on understanding the types of training strategies needed to enable teams and team leaders to develop from novices to experts. Effectively modifying training to scale it to team expertise requires more research. More laboratory and field research is needed to further develop measures of team knowledge emergence for complex task domains, and include other potential emergent factors such as team leadership and resilience. Practical implications for research include developing automated tools and technologies needed to implement training and collect team data, and employ more sensitive indicators (e.g., behavioral markers) of team attitudes, cognitions and behaviors to model the dynamics of how they naturally change over time. These tools are critical to understanding the dynamics of team development and to implement interventions that more effectively support teams as they develop over time.

Professional development for teachers of nursing students for whom English is an additional language: A reflection on practices.

The increasing linguistically and culturally diverse cohort of university students in nursing degree programmes has resulted in a plethora of approaches to address issues related to English language, academic writing and professional communication. Approaches that integrate language development within core nursing subjects are usually regarded as effective, as they offer students opportunities to be socialised into the language of their specific discipline areas. However, developing and implementing an integrated model can be challenging and many discipline academics feel unprepared to address language issues within the curriculum. This paper discusses a pilot project where we, a language academic and a group of nursing academics, adopted a clinical supervision model to problematise subject content and pedagogic practices. The aim was to enable English as additional language students better transition to Australian university studies by integrating an explicit focus on language development within the subject content. The paper outlines the model and draws on our reflections to discuss outcomes. These included changes to subject content and pedagogic practices, as well as increased confidence of nursing academics to teach in ways that have been found to be effective for English as additional language students.

Gender Differences in Depression Literacy and Stigma After a Randomized Controlled Evaluation of a Universal Depression Education Program.

PURPOSE: Depression is a debilitating illness with frequent onset during adolescence. Depression affects women more often than men; men are more likely to complete suicide and less likely to seek treatment. The Adolescent Depression Awareness Program (ADAP) is a school-based depression intervention that educates adolescents about depression symptoms and addresses accompanying stigma. The study aims examined gender differences in the ADAP's impact on depression literacy and stigma. METHODS: Data came from a randomized trial (2012-2015). Six thousand six hundred seventy-nine students from 54 schools in several states were matched into pairs and randomized to the intervention or wait-list control. Teachers delivered the ADAP as part of the health curriculum. Depression literacy and stigma outcomes were measured before intervention, 6 weeks later, and at 4 months. Multilevel models evaluated whether gender moderated the effect of ADAP on depression literacy and stigma. RESULTS: At 4 months, there was a main effect of the ADAP on depression literacy (odds ratio [OR] = 3.3, p = .001) with intervention students achieving depression literacy at higher rates than controls. Gender exhibited a main effect, with women showing greater rates of depression literacy than men (OR = 1.51, p = .001). There was no significant intervention × gender interaction. The ADAP did not exhibit a significant main effect on stigma. There was a main effect for gender, with women demonstrating less stigma than men (OR = .65, p = .001). There was no significant interaction between the intervention and gender on stigma. CONCLUSIONS: The ADAP demonstrates effectiveness for increasing rates of depression literacy among high school students. In this study, gender was not associated with ADAP's effectiveness.

Incidence and Implication of Coronary Artery Calcium on Non-gated Chest Computed Tomography Scans: A Large Observational Cohort.

Introduction  Coronary artery calcification (CAC) scoring is typically performed utilizing non-contrast, electrocardiogram- (ECG) gated CT and offers an estimation of cardiovascular (CV) prognosis and risk stratification beyond previously established cardiac risk factors. Coronary calcification can also be assessed during non-gated chest CT, which is significant given the recent recommendations for lung cancer screening by low-dose CT. Methods We retrospectively reviewed 4,953 non-contrast chest CT scans in a single, closed referral tertiary military treatment facility over an 18-month period. Baseline CV outcomes to include myocardial infarction (MI), cerebral vascular accidents (CVA), revascularization with percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG), death, or a composite of all major adverse cardiac events (MACE), and baseline CV risk factors were abstracted from an electronic medical record (EMR) review. Results CAC was seen in 3,119 (63%) patients while 1,834 (27%) were without CAC. All traditional CV risk factors were more commonly observed in patients with CAC. Unadjusted odds of composite MACE, death, MI, coronary revascularization, and CVA between presence and absence of CAC were as follows: 3.55 [95% confidence interval (CI): 2.60-4.86, p: <0.0001]; 2.98 (95% CI: 2.02-4.40, p: <0.0001); 24.42 (95% CI: 3.36-177.6, p: <0.0001); 5.64 (95% CI: 2.58-12.32, p: <0.0001); and 2.32 (95% CI: 1.19-4.50, p: 0.0104), respectively. However, after adjusting for baseline risk factors, CAC on non-gated CT was associated only with an increased observed rate of MI (aOR: 38.1, 95% CI: 4.57-318.2, p: <0.0001) and revascularization (aOR: 5.58, 95% CI: 2.22-14.0, p; 0.0003). Conclusions Findings of CAC on non-gated chest CT may help to recognize patients who are at increased risk of MI and revascularization. Given the expected increase in chest CT utilization among former smokers for lung cancer screening, observed CAC should be reported to ordering providers in order to identify patients at increased risk of these important outcomes.

It Gets Better: Attenuated Associations Between Latent Classes of Peer Victimization and Longitudinal Psychosocial Outcomes in Four Low-Resource Countries.

Very few studies of peer victimization have been conducted in low-resource countries, where cultural and contextual differences are likely to influence the dynamics of these experiences in ways that may reduce the generalizability of findings of the larger body of literature. Most studies in these settings are also subject to multiple design limitations that restrict our ability to understand the dynamics of peer victimization experiences. Person-centered approaches such as latent class analysis are an improvement on more traditional modeling approaches as they allow exploration of patterns of victimization experiences. The goal of the current study was to examine associations between patterns of peer victimization in adolescence and both concurrent and longitudinal psychosocial adjustment. Data were included for 3536 youth (49.6% female) in Ethiopia, India, Peru, and Vietnam to examine associations between adolescent peer victimization and indicators of poor psychosocial adjustment. Previously derived latent classes of peer victimization based on youth self-report of past-year exposure to nine forms of peer victimization at age 15 were used to predict self-reported emotional difficulties, self-rated health, and subjective wellbeing at ages 15 and 19 while controlling for sex. The findings show that at age 15, victimization was associated with higher emotional difficulties in all settings, lower subjective wellbeing in all except Peru, and lower self-rated health in Vietnam. At follow-up, all associations had attenuated and were largely non-significant. Sensitivity analyses confirmed the robustness of these results. These findings illustrate the multifinality of outcomes of peer victimization, suggesting social and developmental influences for potential pathways of resilience that hold promise for informing interventions and supports in both low and high resource settings.

Clinical Implications From the Treatment of Severe Childhood Aggression (TOSCA) Study: A Re-Analysis and Integration of Findings.

OBJECTIVE: The Treatment of Severe Childhood Aggression (TOSCA) project examined augmentation of stimulant treatment and parent training (PT) with risperidone for severe physical aggression. This article summarizes the clinical implications; reanalyzes the data to examine the utility of 4 criteria for deciding to augment; and presents a treatment algorithm. METHOD: The newly analyzed 4 criteria for augmenting after 3 weeks of stimulant and PT treatment consisted of not meeting a Clinical Global Impressions-Improvement (CGI-I) score of 1 and a normal score (≤15) on the Nisonger Child Behavior Rating Form Disruptive-Total (D-Total); a CGI-I score of 1 or 2 plus 25% improvement in D-Total score; a D-Total score no higher than 15; and a CGI-Severity score of 3 (mild) or better. Effect sizes were calculated. Prior TOSCA publications were reviewed for clinically relevant findings. RESULTS: All 4 criteria resulted in medium or better effect sizes (d = 0.59-0.72) when comparing risperidone with placebo. Providing risperidone to children who did not reach a CGI-I score of 1 plus a D-Total score no higher than 15 resulted in the greatest benefit. In addition, a review of clinically relevant data suggests that stimulant plus PT shows further improvement after 3 weeks even without augmentation. CONCLUSION: For those children who did not attain a CGI-I score of 1 and a D-total score no higher than 15, adding risperidone maximized the number of children benefitting from treatment and the average amount of benefit. Unless clinical circumstances dictate otherwise, practitioners should delay an antipsychotic drug for at least 1 month after the optimal stimulant dose is achieved and PT has commenced. Clinical trial registration information-Treatment of Severe Childhood Aggression (The TOSCA Study); http://clinicaltrials.gov; NCT00796302.

School-Based Curriculum to Improve Depression Literacy Among US Secondary School Students: A Randomized Effectiveness Trial.

OBJECTIVES: To determine the effectiveness of a universal school-based depression education program. METHODS: In 2012-2015, we matched 6679 students from 66 secondary schools into pairs by state (Maryland, Delaware, Pennsylvania, Michigan, and Oklahoma) and randomized to the Adolescent Depression Awareness Program (ADAP; n = 3681) or to a waitlist control condition (n = 2998). Trained teachers delivered ADAP as part of the health education curriculum to students aged 14 to 15 years. The primary outcome was depression literacy. Secondary outcomes included mental health stigma and, in a subset of the sample, the receipt of mental health services. Follow-up was at 4 months. RESULTS: ADAP resulted in significantly higher levels of depression literacy among participating students than did waitlist controls, after adjusting for pretest assessment depression literacy (P < .001). Overall, ADAP did not significantly affect stigma (P = .1). After ADAP, students approached 46% of teachers with concerns about themselves or others. Of students who reported the need for depression treatment, 44% received treatment within 4 months of ADAP implementation. CONCLUSIONS: ADAP is an effective public health intervention for improving depression literacy among students. TRIAL REGISTRATION: Clinicaltrials.gov NCT02099305.

The Association of School Climate, Depression Literacy, and Mental Health Stigma Among High School Students.

BACKGROUND: Although school climate is linked with youth educational, socioemotional, behavioral, and health outcomes, there has been limited research on the association between school climate and mental health education efforts. We explored whether school climate was associated with students' depression literacy and mental health stigma beliefs. METHODS: Data were combined from 2 studies: the Maryland Safe Supportive Schools Project and a randomized controlled trial of the Adolescent Depression Awareness Program. Five high schools participated in both studies, allowing examination of depression literacy and stigma measures from 500 9th and 10th graders. Multilevel models examined the relationship between school-level school climate characteristics and student-level depression literacy and mental health stigma scores. RESULTS: Overall school climate was positively associated with depression literacy (odds ratio [OR] = 2.78, p < .001) and negatively associated with stigma (Est. = -3.822, p = .001). Subscales of engagement (OR = 5.30, p < .001) and environment were positively associated with depression literacy (OR = 2.01, p < .001) and negatively associated with stigma (Est. = -6.610, p < .001), (Est. = -2.742, p < .001). CONCLUSIONS: Positive school climate was associated with greater odds of depression literacy and endorsement of fewer stigmatizing beliefs among students. Our findings raise awareness regarding aspects of the school environment that may facilitate or inhibit students' recognition of depression and subsequent treatment-seeking.