Exploring Quality of Primary Care for Patients Who Experience Homelessness and the Clinicians Who Serve Them: What Are Their Aspirations?

To develop and evaluate an effective model of patient-centered, high-quality, homeless-focused primary care, our team explored key domains of primary care that may be important to patients. We anchored our conceptual framework in two reports from the Institute of Medicine (IOM) that defined components of primary care and quality of care. Using questions developed from this framework, we conducted semistructured interviews with 36 homeless-experienced individuals with past-year primary care engagement and 24 health care professionals (clinicians and researchers) who serve homeless-experienced patients in the primary care setting. Template analysis revealed factors important to this population. These included stigma, respect, and perspectives on patient control of medical decision-making in regard to both pain and addiction. For patients experiencing homelessness, the results suggest that quality primary care may have different meanings for patients and professionals, and that services should be tailored to meet homeless-specific needs.

The sleep environment and its association with externalizing behaviors in a sample of low-income adolescents.

This study examined the sleep environment and its association with externalizing problems in adolescents attending an alternative high school. Participants included 114 students (56% female, 91% Black, mean age = 18.03, standard deviation [SD] = 1.49) from an alternative high school in a southeastern city. Most participants reported sleeping in a bed (83%) and at their house (72%) for 7 nights in the past week. Participants reported an average of 2.34 (SD = 1.86) past-week ambient sleep disruptions. Sleeping fewer nights in their own home and experiencing higher levels of ambient sleep disruptions were associated with delinquency engagement. Fewer nights sleeping in a bed and higher levels of ambient sleep disruptions were associated with a significant arrest history. The sleep environment is important to consider when assessing sleep problems, particularly among low-income adolescents living in urban environments. This information may inform comprehensive interventions to address behavioral health concerns.

Do sleep problems mediate the link between adverse childhood experiences and delinquency in preadolescent children in foster care?

BACKGROUND: Adverse childhood experiences (ACEs) are associated with multiple mental and physical health problems. Yet, mechanisms by which ACEs confer risk for specific problems are largely unknown. Children in foster care typically have multiple ACEs and high rates of negative sequelae, including delinquent behaviors. Mechanisms explaining this link have not been explored in this population. Impaired sleep has been identified as a potential mechanism by which ACEs lead to delinquency in adolescents, because inadequate sleep may lead to poor executive function and cognitive control - known risk factors for delinquency. METHODS: Interviews were conducted with 516 maltreated children in foster care, ages 9-11 years, and their caregivers regarding child exposure to ACEs, sleep problems, engagement in delinquent acts, symptoms of posttraumatic stress disorder, and current psychotropic medication use. ACEs data were also obtained from child welfare case records. RESULTS: After controlling for age, gender, race/ethnicity, placement type (residential, kin, foster), length of time in placement, posttraumatic stress symptoms, and current psychotropic medication use, sleep partially mediated the association between ACEs and delinquency. CONCLUSIONS: Although delinquency is likely multiply determined in this population, improving sleep may be one important strategy to reduce delinquency.

A Meta-Analysis of the Impact of Natural Disasters on Internalizing and Externalizing Problems in Youth.

Although exposure to natural disasters can lead to diverse mental health (MH) outcomes in youth, most child disaster MH research has focused on posttraumatic stress symptoms (PTSS). To highlight the likelihood of other MH outcomes, we meta-analyzed studies that have examined other (non-PTSS) internalizing and externalizing behavior problems in youth exposed to natural disasters. We used PRISMA guidelines to systematically gather studies that have examined the association between natural disaster exposure and non-PTSS internalizing and/or externalizing problems in samples of children and adolescents. Analyses of random effects models of 62 studies examining non-PTSS internalizing problems and 26 studies examining externalizing problems showed exposure to natural disasters was significantly associated with non-PTSS internalizing, rmean = .18, k = 70, and externalizing problems, rmean = .08; k = 31, in youth. Moderator analyses revealed a stronger association between disaster exposure and non-PTSS internalizing problems in countries with a "medium" Human Development Index (HDI) ranking, r = .56, than in countries with "high," r = .15, and "very high," r = .16, HDI rankings. We also found a stronger association between disaster exposure and externalizing problems in countries with a medium HDI ranking, r = .54, versus high, r = .05, and very high, r = .04, HDI rankings, and based on parent, r = .16, compared to child, r = -.01, report. Results support the need for assessment of multiple postdisaster MH outcomes to inform comprehensive interventions. We also include a discussion of the state of the disaster MH research.

Self-Reported Time in Bed and Sleep Quality in Association with Internalizing and Externalizing Symptoms in School-Age Youth.

This study investigated the relationship between self-reported time in bed and sleep quality in association with self-reported internalizing and externalizing symptoms in a sample of 285 elementary school students (52 % female) recruited from a rural Midwestern elementary school. Path models were used to estimate proposed associations, controlling for grade level and gender. Curvilinear associations were found between time in bed and anxiety, depressive symptoms, and irritability. Marginal curvilinear trends were found between time in bed and emotion dysregulation, reactive aggression, and proactive aggression. Sleep quality was negatively associated with anxiety, depressive symptoms, irritability, reactive aggression, and delinquency engagement. Gender and grade differences were found across models. Findings suggest that examining self-reported time in bed (both linear and quadratic) and sleep quality is important for understanding internalizing and externalizing symptoms associated with sleep in school-age youth. Incorporating self-reported sleep assessments into clinical practice and school-based evaluations may have implications for a child's adjustment.

Associations Between Physical and Relational Forms of Peer Aggression and Victimization and Risk for Substance Use Among Elementary School-Age Youth.

This study examined associations between physical and relational forms of aggression and victimization and risk for willingness to engage in substance use and actual use in a sample of 231 (50% Male) 2nd thru 4th grade students (Mean age = 8.3 years). Physical aggression was more strongly associated with risk for substance use outcomes than physical victimization. Neither relational aggression nor victimization were linked to risk for substance use. Specifically targeting physical aggression for the prevention of early substance use among elementary school-age youth appears to be warranted.

The Role of Reactive Aggression in the Link Between Hyperactive-Impulsive Behaviors and Peer Rejection in Adolescents.

Attention-deficit/hyperactivity disorder (ADHD) symptoms and aggressive behaviors are both associated with peer rejection, but little is known the nature of this association with respect to the two symptom dimensions of hyperactivity-impulsivity and inattention and different types of aggression. The present study examines the relations between dimensions of ADHD symptomatology, proactive and reactive aggression, and peer rejection in adolescence. Teacher-reported data were obtained for 200 high school students (grades 9-12; 48% female; predominately Latino). In structural equation modeling path analyses, the indirect effects of reactive aggression accounted for the link between hyperactivity-impulsivity and peer rejection. Within the same model, neither inattention nor proactive aggression were associated with peer rejection. These findings suggest that reactive aggression may be a key mechanism through which hyperactive-impulsive behavior is associated with peer rejection. Future research and intervention efforts should address the role of reactive aggression among youth with ADHD symptomatology.

Reactive/proactive aggression and the development of internalizing problems in males: the moderating effect of parent and peer relationships.

The current study examined whether reactive and/or proactive aggression in adolescent males prospectively predicted increased levels of internalizing symptoms (depression and anxiety) in late adolescence. It was postulated that reactive aggression would be robustly related to later internalizing problems, but only among adolescent males who had problematic family or peer social relationships. Participants were a racially diverse group of 289 adolescent males (Mean age = 16). Measures of reactive and proactive aggression, peer rejection, and poor parent-adolescent communication were examined as predictors of both depression and anxiety symptoms assessed approximately 3 years later. The interactive effects between the two facets of aggression and measures of peer rejection and poor parent-adolescent communication in predicting internalizing problems was also examined. Adolescents with high levels of reactive aggression were more likely to exhibit elevated internalizing problems during late adolescence, even when controlling for pre-existing levels of anxiety/depression. However, this association only emerged for adolescents who had high levels of peer rejection and/or poor communication with their parent. Consistent with expectations, proactive aggression was unrelated to internalizing symptoms regardless of social relationship quality. Adolescent reactive, but not proactive, aggression is a risk factor for the development of internalizing problems. However, the findings suggest that interventions designed to foster positive social relationships among reactively aggressive youth may help protect them from developing significant internalizing problems over time.

Further evaluation of associations between attention-deficit/hyperactivity and oppositional defiant disorder symptoms and bullying-victimization in adolescence.

Relations between symptoms of attention-deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD) and bullying-victimization in adolescence are not yet clear. Accordingly, the current study evaluated these associations, with attention to gender differences, in a sample of predominantly Latino 9th-12th grade students (52.6 % male; mean grade level = 10.35, SD = 1.11). Further, the role of peer delinquency in these associations was evaluated. Findings indicated that ODD symptoms were more strongly associated with both bullying and victimization than ADHD symptoms, and the effects of ODD symptoms on physical forms of both bullying and victimization were stronger for males than females. The association between ODD symptoms and physical bullying was stronger at high levels of peer delinquency when compared to low levels of peer delinquency for both males and females. The role of peer delinquency in the link between ADHD symptoms and bullying and victimization appears to be gender specific and in need of further evaluation. Implications for the need to focus primarily on ODD symptoms for both bullying and victimization prevention and intervention are discussed.

Trauma exposure and associated sleep problems in Black adolescent and young adult students attending an alternative high school.

OBJECTIVE: Given the dearth of literature examining the link between trauma exposure and sleep among youth and young adults of color, the current study examined the association between individual types of trauma exposure, accumulation within subtypes of trauma exposure, and overall cumulative trauma exposure with sleep problems in a sample of Black students attending an alternative high school. METHOD: Participants were recruited from an alternative high school in a large, southeastern city in the United States, of which all students qualify for free/reduced lunch. The sample included 101 students (53% female) ages 16-24 (M = 17.86 years, SD = 1.36) who identified as Black. RESULTS: Participants reported a high rate of trauma exposure (M = 6.03 unique traumatic experiences, SD = 2.63). Linear regression models showed that exposure to more overall cumulative trauma and to interpersonal loss was significantly associated with higher levels of insomnia symptoms. Threats to health were significantly related to daytime sleepiness. Other threats to safety were associated with restless legs syndrome symptoms. CONCLUSIONS: Adolescence and young adulthood are a time of complex sleep-related issues. Black youth and young adults have elevated risk of trauma exposure and sleep problems; therefore, targeted assessment and intervention are warranted. Clinicians and researchers addressing sleep in youth and young adults, and those working within alternative school settings, should also consider a trauma-informed lens to optimize outcomes. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Socioemotional health, trauma exposure, and internalizing symptoms in students attending an alternative high school.

Students attending alternative schools often present with internalizing symptoms, likely related to high rates of trauma. Little is known about factors that buffer the relationship between trauma exposure and internalizing symptoms in this population. The present study examined the role of internal (i.e., self-efficacy, self-awareness, persistence) and external resources (i.e., peer support, family coherence, school support) as buffers in the association between trauma exposure and symptoms of depression and anxiety in 113 students (55% female, 91% Black, 8% Hispanic or Latinx, Mage = 18.0, SD = 1.5) attending an alternative school in a large, southeastern city. Results showed that trauma exposure was positively associated with depression and anxiety symptoms, while self-awareness and family coherence were negatively associated with depression and anxiety symptoms. Additionally, significant interactions revealed that trauma exposure was associated with depression symptoms at low but not high levels of self-awareness, and at low but not high levels of family coherence. Understanding strengths to support alternative high school students exposed to trauma is a valuable component of mental health intervention. Future research should investigate ways to cultivate self-awareness and enhance family coherence to address the complex needs of alternative school students. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Aberrant drug-related behaviors: unsystematic documentation does not identify prescription drug use disorder.

OBJECTIVE: No evidence-based methods exist to identify prescription drug use disorder (PDUD) in primary care (PC) patients prescribed controlled substances. Aberrant drug-related behaviors (ADRBs) are suggested as a proxy. Our objective was to determine whether ADRBs documented in electronic medical records (EMRs) of patients prescribed opioids and benzodiazepines could serve as a proxy for identifying PDUD. DESIGN: A cross-sectional study of PC patients at an urban, academic medical center. SUBJECTS: Two hundred sixty-four English-speaking patients (ages 18-60) with chronic pain (≥3 months), receiving ≥1 opioid analgesic or benzodiazepine prescription in the past year, were recruited during outpatient PC visits. OUTCOME MEASURES: Composite International Diagnostic Interview defined Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnoses of past year PDUD and no disorder. EMRs were reviewed for 15 prespecified ADRBs (e.g., early refill, stolen medications) in the year before and after study entry. Fisher's exact test compared frequencies of each ADRB between participants with and without PDUD. RESULTS: Sixty-one participants (23%) met DSM-IV PDUD criteria and 203 (77%) had no disorder; 85% had one or more ADRB documented. Few differences in frequencies of individual behaviors were noted between groups, with only "appearing intoxicated or high" documented more frequently among participants with PDUD (N = 10, 16%) vs no disorder (N = 8, 4%), P = 0.002. The only common ADRB, "emergency visit for pain," did not discriminate between those with and without the disorder (82% PDUD vs 78% no disorder, P = 0.6). CONCLUSIONS: EMR documentation of ADRBs is common among PC patients prescribed opioids or benzodiazepines, but unsystematic clinician documentation does not identify PDUDs. Evidence-based approaches are needed.

Adolescent sleep health and school start times: Setting the research agenda for California and beyond. A research summit summary.

In fall 2019, California passed and signed into law SB328, the first US statewide legislation explicitly designed to protect adolescent sleep health by requiring most California public school districts to start no earlier than 8:00 AM for middle schools and 8:30 AM for high schools. Recognizing the unique opportunity presented by the bill's 3-year implementation period, a group of experts in adolescent sleep and school start times held a virtual summit on January 22-23, 2021 to (1) summarize the research on adolescent sleep and school start time change; (2) develop recommendations for relevant, refined, and innovative research areas and research questions; (3) provide input regarding research design, methodology, and implementation; and (4) offer a forum for networking, exchanging ideas, and establishing interdisciplinary research collaborations. Participants represented a multidisciplinary range of academic backgrounds including sleep and circadian biology, neuroscience, education, medicine, public health, mental health, safety, public policy, economics, implementation science, criminology, diversity studies, and science communication. This paper summarizes summit presentations regarding current knowledge on adolescent sleep health and school start times and key research recommendations from small group workshops on topics including research design and tools, methodological issues, sleep health disparities, logistical challenges in conducting school-based research, public-health impact, and novel and expanded approaches to research.

Associations of bullying, victimization, and daytime sleepiness with academic problems in adolescents attending an alternative high school.

Adolescents attending alternative high schools often present with high rates of academic and behavior problems. They are also at increased risk of poor health behaviors and engaging in physical violence compared with students in traditional high school settings. To address the needs of students in these educational settings, examining factors that influence academic problems in this population is essential. Research has established that both bullying/victimization and sleep problems increase adolescents' risk for academic problems. Little is known about how these 2 factors together may exacerbate risk for academic problems among students attending an alternative high school. The current study investigated the interaction between teacher-reported bullying, victimization and daytime sleepiness on academic concerns (attention and learning problems) among a sample of 172 students (56% female; age M = 18.07 years, SD = 1.42) attending an alternative high school in a large, Southeastern U.S. city. Findings from path models indicated that daytime sleepiness, bullying, and victimization were uniquely associated with attention and learning problems. Further, significant interactions indicated that the association between victimization/bullying and attention/learning problems weakened as levels of daytime sleepiness increased. Results suggest the importance of assessing and addressing multiple contextual risk factors in adolescents attending alternative high schools to provide comprehensive intervention for students in these settings. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Individual and neighborhood stressors, sleep problems, and symptoms of anxiety and depression among Latino youth.

Limited research has examined the relation between exposure to stressors and internalizing symptoms among Latino adolescents, including factors that account for this relation. This study examined whether sleep played a role in the relation between exposure to neighborhood- (i.e., neighborhood disadvantage) and individual-level (i.e., negative life events) stressors and symptoms of anxiety and depression among a sample of 144 low-income, Latino adolescents (54% males, mean age = 16.25, SD = 1.46) attending a charter high school in a large, Midwestern city. The bias corrected bootstrap method was used to evaluate indirect effects. Significant findings indicated an indirect effect via sleep problems in the link between negative life events and anxiety. Alternative models were also explored. Results suggest that sleep problems are important to consider for interventions among Latino youth, particularly those exposed to neighborhood and individual stressors, as this may also have implications for reducing internalizing symptoms among this population. (PsycINFO Database Record

Differences in Sleep Patterns and Problems by Race in a Clinical Sample of Black and White Preschoolers.

STUDY OBJECTIVES: Community-based research indicates that Black preschoolers tend to have more bedtime difficulties and are at higher risk for obstructive sleep apnea (OSA) compared to White preschoolers. This study examined differences in sleep patterns and problems by race among a clinical sample of Black and White preschoolers at an outpatient sleep clinic. METHODS: Data were collected from electronic medical records for 125 children ages 2-5 years (mean = 3.37 years, 64.0% White, 36.0% Black; 59.2% male) presenting at a pediatric sleep clinic in an academic medical center. Neighborhood income data were based on ZIP codes entered into the United States Census Bureau's American Fact Finder. RESULTS: Black patients (51.1%) were significantly more likely than White patients (20.0%) to bed-share with a caregiver (χ2 = 12.99, P ≤ .001). There were no other significant differences in presenting sleep patterns (bed/wake times, sleep onset latency, naps, night awakenings, or sleep opportunity). Logistic regressions showed that White patients were more likely to present with difficulty falling/staying asleep and receive an insomnia diagnosis, and Black patients were more likely to present with OSA-related concerns and receive a diagnosis of suspected OSA, even when controlling for relevant sociodemographic covariates. CONCLUSIONS: In contrast to community-based research, Black and White children showed similar sleep patterns. However, there were differences by race in referral questions and diagnoses. Findings suggest the need to consider caregiver perceptions and other sociocultural factors that may contribute to differential rates of presentation for sleep services, as well as potential health disparities in this regard.

Individual and socio-demographic factors related to presenting problem and diagnostic impressions at a pediatric sleep clinic.

OBJECTIVE: Individual and socio-demographic factors have been found to be associated with sleep disturbances in children. Few studies have examined these factors among children presenting for care at pediatric sleep clinics. This study examined individual and socio-demographic factors in association with presenting problems and diagnostic impressions for new patients at an interdisciplinary pediatric sleep clinic. METHODS: Data were collected from electronic medical records of 207 consecutive patients (54% male, 59% White, Meanage = 7.73, SD = 5.62). RESULTS: Older age, female gender, and White race were associated with higher likelihood of presenting with difficulty falling asleep; younger age, male gender, and Black race were associated with higher likelihood of presenting with obstructive sleep apnea (OSA)-related concerns. Older age was associated with diagnostic impressions of inadequate sleep hygiene, insufficient sleep, circadian rhythm disorder/delayed sleep phase disorder, periodic limb movement disorder/restless legs syndrome, and insomnia, while younger age was associated with provisional OSA and behavioral insomnia of childhood (BIC) diagnoses. Male gender was associated with provisional OSA. White race was associated with BIC. Age-based analyses were also conducted to further understand the findings within a developmental context. CONCLUSIONS: Age- and gender-related findings converged with prevalence literature on pediatric sleep disorders. Race was only associated with presenting concern and BIC, and one association for neighborhood disadvantage was found within the age-based analysis. Results suggest a potential service delivery gap, with racial/ethnic minority youth being less likely to present for sleep services, despite prevalence data on the increased likelihood of sleep disturbances among these youth.

The Role of Peers in the Relation between Hurricane Exposure and Ataques de Nervios among Puerto Rican Adolescents.

Although a relation between disaster exposure and ataques de nervios (ataques) has been established in adult samples, little is known about this among youth, including factors that may moderate this relation. This study examined the role of the peer context in the relation between exposure to Hurricane Georges and experiencing a past year and lifetime ataques among a representative community sample of 905 youth (N = 476 boys and 429 girls; ages 11-18) residing in Puerto Rico. Data were gathered from 1999-2000 in Puerto Rico, 12-27 months following Hurricane Georges. Logistic regression analyses found that peer violence significantly predicted experiencing an ataque in the past year. Hurricane exposure and peer violence were both significant predictors of a lifetime experience of an ataque. An interaction was found between hurricane exposure and peer violence, indicating that hurricane exposure was significantly related to a lifetime experience of an ataque among adolescents who do not report associating with violent peers. For participants reporting high levels of peer violence, hurricane exposure did not add additional risk for a lifetime experience of an ataque. Understanding the influence of peers in the relation between hurricane exposure and experiencing an ataque may assist in planning developmentally and culturally sensitive response plans.

Towards successful Dissemination of Psychological First Aid: a study of provider training preferences.

Dissemination of Psychological First Aid (PFA) is challenging considering the complex nature of disaster response and the various disaster mental health (DMH) trainings available. To understand challenges to dissemination in community mental health centers (CMHCs), interviews were conducted with nine DMH providers associated with CMHCs. Consensual qualitative analysis was used to analyze data. Interviews were targeted toward understanding organizational infrastructure, DMH training requirements, and training needs. Results clarified challenges to DMH training in CMHCs and factors that may promote buy-in for trainings. For example, resources are limited and thus allocated for state and federal training requirements. Therefore, including PFA in these requirements could promote adoption. Additionally, a variety of training approaches that differ in content, style, and length would be useful. To conclude, a conceptual model for ways to promote buy-in for the PFA Guide is proposed.

Hope as a Moderator of the Associations between Common Risk Factors and Frequency of Substance Use among Latino Adolescents.

Ample research suggests that delinquency, depressive symptoms, and peer substance use are common risk factors associated with adolescent substance use. However, the factors that may help to buffer the deleterious effects of these risk factors on adolescent substance use, such as hope, have yet to be examined. The current study evaluated hope as a moderator of the associations between these common risk factors and frequency of substance use (alcohol, tobacco, and marijuana) in a sample of Latino high school students (Mage = 16.14years, SD = 1.30; 55% female). Findings indicated that the influence of delinquency on frequency of tobacco and marijuana use depended on levels of hope, with delinquency only positively associated with frequency of use when levels of hope were low. Additionally, hope moderated the association between depressive symptoms and alcohol use, such that depressive symptoms were only positively associated with frequency of alcohol use when levels of hope were low. Results and their implications for intervention are reviewed.