Publications by authors named "Elizabeth Mayfield Arnold"

37 Publications

Using Machine Learning to Predict Young People's Internet Health and Social Service Information Seeking.

Prev Sci 2021 May 11. Epub 2021 May 11.

University of California, UCLA Center for Community Health, 10920 Wilshire Blvd Suite 350, Los AngelesLos Angeles, CA, 90024, USA.

Machine learning creates new opportunities to design digital health interventions for youth at risk for acquiring HIV (YARH), capitalizing on YARH's health information seeking on the internet. To date, researchers have focused on descriptive analyses that associate individual factors with health-seeking behaviors, without estimating of the strength of these predictive models. We developed predictive models by applying machine learning methods (i.e., elastic net and lasso regression models) to YARH's self-reports of internet use. The YARH were aged 14-24 years old (N = 1287) from Los Angeles and New Orleans. Models were fit to three binary indicators of YARH's lifetime internet searches for general health, sexual and reproductive health (SRH), and social service information. YARH responses regarding internet health information seeking were fed into machine learning models with potential predictor variables based on findings from previous research, including sociodemographic characteristics, sexual and gender minority identity, healthcare access and engagement, sexual behavior, substance use, and mental health. About half of the YARH reported seeking general health and SRH information and 26% sought social service information. Areas under the ROC curve (≥ .75) indicated strong predictive models and results were consistent with the existing literature. For example, higher education and sexual minority identification was associated with seeking general health, SRH, and social service information. New findings also emerged. Cisgender identity versus transgender and non-binary identities was associated with lower odds of general health, SRH, and social service information seeking. Experiencing intimate partner violence was associated with higher odds of seeking general health, SRH, and social service information. Findings demonstrate the ability to develop predictive models to inform targeted health information dissemination strategies but underscore the need to better understand health disparities that can be operationalized as predictors in machine learning algorithms.
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http://dx.doi.org/10.1007/s11121-021-01255-2DOI Listing
May 2021

Exercise and antiretroviral adherence in adults living with HIV: A systematic review.

J Health Psychol 2020 Oct 26:1359105320967421. Epub 2020 Oct 26.

University of California, Los Angeles, USA.

This systematic review assessed the relationship between exercise and ART adherence in adults living with HIV. A comprehensive search through June 2020 for relevant studies was conducted, and PRISMA guidelines were followed. To be included, studies had to meet the following criteria: (a) published in a peer-reviewed journal; and (b) examined the relationship between exercise and ART adherence. A total of 4310 studies were identified, and nine were included. The majority (five out of nine) of studies found a significant and positive relationship between exercise and ART adherence. Strengths, limitations, and future directions are discussed.
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http://dx.doi.org/10.1177/1359105320967421DOI Listing
October 2020

Medical Comorbidities and Medication Use Among Homeless Adults Seeking Mental Health Treatment.

Community Ment Health J 2020 07 18;56(5):885-893. Epub 2020 Jan 18.

Department of Psychiatry and Behavioral Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA.

Little is known about the medical conditions and medication use of individuals who are homeless and have mental health problems. This study used secondary data (N = 933) from a mental health clinic serving homeless adults. Primary outcomes were the number and types of self-reported medical conditions and medications. About half (52.60%) of participants were taking one or more medications (mean = 1.67; SD = 2.30), most commonly antidepressants, antipsychotics, and anticonvulsants. Most frequently reported medical conditions were headaches/migraines, hypertension, and arthritis with a mean of 3.09 (SD = 2.74) conditions. Age and sex were significant predictors of the number of medical conditions. Age and the length of time homeless were significant predictors of the number of medications taken. Results suggest that those who are older and have been homeless longer appear to be increased risk for health problems and may need more medications to manage these conditions.
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http://dx.doi.org/10.1007/s10597-020-00552-4DOI Listing
July 2020

Text-Messaging, Online Peer Support Group, and Coaching Strategies to Optimize the HIV Prevention Continuum for Youth: Protocol for a Randomized Controlled Trial.

JMIR Res Protoc 2019 08 9;8(8):e11165. Epub 2019 Aug 9.

University of California, Los Angeles, Department of Psychiatry & Biobehavioral Sciences, Los Angeles, CA, United States.

Background: America's increasing HIV epidemic among youth suggests the need to identify novel strategies to leverage services and settings where youth at high risk (YAHR) for HIV can be engaged in prevention. Scalable, efficacious, and cost-effective strategies are needed, which support youth during developmental transitions when risks arise. Evidence-based behavioral interventions (EBIs) have typically relied on time-limited, scripted, and manualized protocols that were often delivered with low fidelity and lacked evidence for effectiveness.

Objective: This study aims to examine efficacy, implementation, and cost-effectiveness of easily mountable and adaptable, technology-based behavioral interventions in the context of an enhanced standard of care and study assessments that implement the guidelines of Centers for Disease Control and Prevention (CDC) for routine, repeat HIV, and sexually transmitted infection (STI) testing for high-risk youth.

Methods: Youth aged between 12 and 24 years (n=1500) are being recruited from community-based organizations and clinics serving gay, bisexual, and transgender youth, homeless youth, and postincarcerated youth, with eligibility algorithms weighting African American and Latino youth to reflect disparities in HIV incidence. At baseline and 4-month intervals over 24 months (12 months for lower-risk youth), interviewers monitor uptake of HIV prevention continuum steps (linkage to health care, use of pre- or postexposure prophylaxis, condoms, and prevention services) and secondary outcomes of substance use, mental health, and housing security. Assessments include rapid diagnostic tests for HIV, STIs, drugs, and alcohol. The study is powered to detect modest intervention effects among gay or bisexual male and transgender youth with 70% retention. Youth are randomized to 4 conditions: (1) enhanced standard of care of automated text-messaging and monitoring (AMM) and repeat HIV/STI testing assessment procedures (n=690); (2) online group peer support via private social media plus AMM (n=270); (3) coaching that is strengths-based, youth-centered, unscripted, based on common practice elements of EBI, available over 24 months, and delivered by near-peer paraprofessionals via text, phone, and in-person, plus AMM (n=270); and (4) online group peer support plus coaching and AMM (n=270).

Results: The project was funded in September 2016 and enrollment began in May 2017. Enrollment will be completed between June and August 2019. Data analysis is currently underway, and the first results are expected to be submitted for publication in 2019.

Conclusions: This hybrid implementation-effectiveness study examines alternative models for implementing the CDC guidelines for routine HIV/STI testing for YAHR of acquiring HIV and for delivering evidence-based behavioral intervention content in modular elements instead of scripted manuals and available over 24 months of follow-up, while also monitoring implementation, costs, and effectiveness. The greatest impacts are expected for coaching, whereas online group peer support is expected to have lower impact but may be more cost-effective.

Trial Registration: ClinicalTrials.gov NCT03134833; https://clinicaltrials.gov/ct2/show/NCT03134833 (Archived by WebCite at http://www.webcitation.org/76el0Viw9).

International Registered Report Identifier (irrid): DERR1-10.2196/11165.
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http://dx.doi.org/10.2196/11165DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6707028PMC
August 2019

Excess Cancer Cases and Medical Costs Due to Suboptimal Human Papillomavirus Vaccination Coverage in California.

Sex Transm Dis 2019 08;46(8):527-531

University of California, Division of Infectious Diseases, Los Angeles, CA.

Background: Human papillomavirus (HPV) vaccination coverage continues to be at low to moderate levels throughout the United States. HPV infection is linked to multiple types of cancers resulting in high economic and health burden. We aimed to estimate the excess number of cancer cases and associated medical costs due to current HPV vaccination coverage for a 20-year-old birth cohort in California.

Methods: We estimated the lifetime number of cancer cases caused by vaccine-preventable strains of HPV for a cohort of 20 year-olds in California. We then estimated the excess number of cancer cases in that cohort which would occur due to 2017 HPV vaccination coverage compared with an optimal coverage of 99.5%. By multiplying those excess cases by the average cost of treatment, we determined the excess cost due to current HPV vaccination coverage.

Results: With current vaccination coverage in California, the 20-year-old cohort is at risk for an excess 1352 cancer cases that could be prevented with a projected optimal vaccination coverage of 99.5%. The excess cost of treatment for those cancer cases would be US $52.2 million. Male oropharyngeal cancer accounts for the greatest projected cost burden US $21.3 million followed by cervical cancer US $16.1 million.

Conclusions: Increased HPV vaccination coverage in California is needed to reduce economic and health burdens associated with cancers caused by HPV infection.
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http://dx.doi.org/10.1097/OLQ.0000000000001016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6748638PMC
August 2019

Degree of Correspondence Between Retrospective and Proximal Reports of Borderline Personality Disorder Symptoms, Symptom Triggers, and Emotions.

J Pers Disord 2019 Mar 28:1-20. Epub 2019 Mar 28.

Department of Psychology, Wake Forest University, Winston-Salem, North Carolina.

This study investigated the degree of correspondence of retrospective reports of personality disorder symptoms, triggers, and emotions with reports closer in time to the actual experiences. Retrospective reports of symptoms, triggers, and emotions are heavily used in both clinical and research settings, yet no study has investigated the correspondence for symptoms or triggers of personality disorders. A total of 257 participants, including 75 with BPD, completed overlapping daily, weekly, monthly, and semi-annual questionnaires. Retrospective reports showed: (1) systematic biases, reporting fewer symptom and situational trigger occurrences, and greater emotion intensities; but (2) little unsystematic error, largely reproducing bias-adjusted individual levels of symptoms, situational triggers, and emotions (rs generally .70-.80). People with BPD did not retrospectively misremember their symptoms, triggers, or emotions much more than others. Thus, retrospective reports of symptoms, triggers, and emotions should be adjusted for systematic bias, but after such adjustment can be taken as relatively faithful accounts of individuals' experiences.
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http://dx.doi.org/10.1521/pedi_2019_33_418DOI Listing
March 2019

The Stepped Care Intervention to Suppress Viral Load in Youth Living With HIV: Protocol for a Randomized Controlled Trial.

JMIR Res Protoc 2019 02 27;8(2):e10791. Epub 2019 Feb 27.

Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, Los Angeles, CA, United States.

Background: Among youth living with HIV (YLH) aged 12-24 years who have health care in the United States, only 30% to 40% are virally suppressed. YLH must achieve viral suppression in order to reduce the probability of infecting others as well as increasing the length and quality of their own life.

Objective: This randomized controlled trial aimed to evaluate the efficacy of an Enhanced Standard Care condition (n=110) compared to an Enhanced Stepped Care intervention condition (n=110) to increase viral suppression among YLH aged 12-24 years with established infection (not acutely infected).

Methods: YLH (N=220) who are not virally suppressed will be identified at homeless shelters, health clinics, and gay-identified community-based organizations in Los Angeles, CA, and New Orleans, LA. Informed consent will be obtained from all participants. YLH will be randomly assigned to one of two study conditions: Enhanced Standard Care, which includes standard clinical care plus an automated messaging and monitoring intervention (AMMI), or an Enhanced Stepped Care, which includes three levels of intervention (AMMI, Peer Support via social media plus AMMI, or Coaching plus Peer Support and AMMI). The primary outcome is viral suppression of HIV, and YLH will be assessed at 4-month intervals for 24 months. For the Enhanced Stepped Care intervention group, those who do not achieve viral suppression (via blood draw, viral load<200 copies/mL) at any 4-month assessment will "step up" to the next level of intervention. Secondary outcomes will be retention in care, antiretroviral therapy adherence, alcohol use, substance use, sexual behavior, and mental health symptoms.

Results: Recruitment for this study began in June 2017 and is ongoing. We estimate data collection to be completed by the end of 2020.

Conclusions: This is the first known application of an Enhanced Stepped Care intervention model for YLH. By providing the lowest level of intervention needed to achieve viral suppression, this model has the potential to be a cost-effective method of helping YLH achieve viral suppression and improve their quality of life.

Trial Registration: ClinicalTrials.gov NCT03109431; https://clinicaltrials.gov/ct2/show/NCT03109431.

International Registered Report Identifier (irrid): DERR1-10.2196/10791.
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http://dx.doi.org/10.2196/10791DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6414817PMC
February 2019

Strategies to Treat and Prevent HIV in the United States for Adolescents and Young Adults: Protocol for a Mixed-Methods Study.

JMIR Res Protoc 2019 Jan 21;8(1):e10759. Epub 2019 Jan 21.

Department of Pediatrics, School of Medicine, Tulane University, New Orleans, LA, United States.

Background: Over 20% of HIV diagnoses in the United States are among youth aged 12-24 years. Furthermore, youth have the lowest rates of uptake and adherence to antiretroviral (ARV) medications and are least aware of their HIV status.

Objective: Our objective was to design a set of interrelated studies to promote completion of each step of the HIV Prevention Continuum by uninfected youth at high risk (YHR), as well as completion of steps in the Treatment Continuum by youth living with HIV (YLH).

Methods: Gay, bisexual, and transgender youth; homeless youth; substance-abusing youth; youth with criminal justice contact; and youth with significant mental health challenges, particularly black and Latino individuals, are being recruited from 13 community-based organizations, clinics, drop-in centers, and shelters in Los Angeles and New Orleans. Youth are screened on the basis of self-reports and rapid diagnostic tests for HIV, drug use, and sexually transmitted infections and, then, triaged into one of 3 studies: (1) an observational cohort of YLH who have never received ARV medications and are then treated-half initially are in the acute infection period (n=36) and half with established HIV infection (n=36); (2) a randomized controlled trial (RCT) for YLH (N=220); and (3) an RCT for YHR (N=1340). Each study contrasts efficacy and costs of 3 interventions: an automated messaging and weekly monitoring program delivered via text messages (short message service, SMS); a peer support intervention delivered via social media forums; and coaching, delivered via text message (SMS), phone, and in-person or telehealth contacts. The primary outcomes are assessing youths' uptake and retention of and adherence to the HIV Prevention or Treatment Continua. Repeat assessments are conducted every 4 months over 24 months to engage and retain youth and to monitor their status.

Results: The project is funded from September 2016 through May 2021. Recruitment began in May 2017 and is expected to be completed by June 2019. We expect to submit the first results for publication by fall 2019.

Conclusions: Using similar, flexible, and adaptable intervention approaches for YLH and YHR, this set of studies may provide a roadmap for communities to broadly address HIV risk among youth. We will evaluate whether the interventions are cost-efficient strategies that can be leveraged to help youth adhere to the actions in the HIV Prevention and Treatment Continua.

International Registered Report Identifier (irrid): DERR1-10.2196/10759.
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http://dx.doi.org/10.2196/10759DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6360384PMC
January 2019

Trauma, Family Factors and the Mental Health of Homeless Adolescents.

J Child Adolesc Trauma 2019 Mar 22;12(1):37-47. Epub 2017 Jun 22.

1Department of Psychiatry and Biobehavioral Sciences, University of California at Los Angeles, Los Angeles, CA USA.

Family factors, such as poor family functioning and trauma, have been associated with negative outcomes for homeless adolescents. Further study is needed to better understand how family factors and trauma jointly relate to mental health problems and externalizing behaviors among homeless adolescents. Structural equation modeling was used to examine the influence of trauma (encompassing traumatic events experienced prior to, and after, becoming homeless) and family factors (poor family functioning and family conflict) on mental health problems and externalizing behaviors (substance use, delinquent behaviors, and sexual risk) among 201 homeless adolescents, ages 12 to 17 years. Trauma, poor family functioning, and family conflict significantly predicted greater mental health problems, delinquent behaviors, high-risk sexual behaviors and substance use. Overall, the findings suggest that family factors appear to be key to understanding mental health problems and externalizing behaviors among homeless adolescents. Implications, limitations and future directions are addressed.
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http://dx.doi.org/10.1007/s40653-017-0157-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7163862PMC
March 2019

Differentiating the everyday emotion dynamics of borderline personality disorder from major depressive disorder and bipolar disorder.

Personal Disord 2018 03 29;9(2):192-196. Epub 2017 May 29.

Department of Psychology, Wake Forest University.

A major barrier to the understanding of emotion dynamics in borderline personality disorder (BPD) lies in its substantial comorbidity with major depressive disorder (MDD) and bipolar disorder (BD). Whereas BPD has often been characterized in terms of dynamic emotional processes, including instability, reactivity, and inertia, its substantial comorbidity with MDD and BD makes it difficult to discern the specificity of these dynamics. To differentiate the emotion dynamics of BPD from those of MDD and BD, an experience sampling study of 38 participants with BPD, 15 participants with MDD, 14 participants with BD, and 62 healthy controls obtained reports of interpersonal challenges and emotions 5 times daily for 2 weeks. Interpersonal challenges included rejection, betrayal, abandonment, offense, disappointment, and self-image challenge; emotions included anger, excitement, guilt, happiness, irritability, and shame. Multilevel analyses revealed that heightened interpersonal reactivity of guilt and shame and heightened inertia of shame were relatively specific to BPD. These findings could not be accounted for by the presence of current MDD or BD. By contrast, heightened instability of anger and irritability and heightened inertia of irritability appeared to be largely transdiagnostic. Implications for clinical assessment, research, and theory are discussed. (PsycINFO Database Record
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http://dx.doi.org/10.1037/per0000255DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5708157PMC
March 2018

Differentiating the everyday emotion dynamics of borderline personality disorder from major depressive disorder and bipolar disorder.

Personal Disord 2018 03 29;9(2):192-196. Epub 2017 May 29.

Department of Psychology, Wake Forest University.

A major barrier to the understanding of emotion dynamics in borderline personality disorder (BPD) lies in its substantial comorbidity with major depressive disorder (MDD) and bipolar disorder (BD). Whereas BPD has often been characterized in terms of dynamic emotional processes, including instability, reactivity, and inertia, its substantial comorbidity with MDD and BD makes it difficult to discern the specificity of these dynamics. To differentiate the emotion dynamics of BPD from those of MDD and BD, an experience sampling study of 38 participants with BPD, 15 participants with MDD, 14 participants with BD, and 62 healthy controls obtained reports of interpersonal challenges and emotions 5 times daily for 2 weeks. Interpersonal challenges included rejection, betrayal, abandonment, offense, disappointment, and self-image challenge; emotions included anger, excitement, guilt, happiness, irritability, and shame. Multilevel analyses revealed that heightened interpersonal reactivity of guilt and shame and heightened inertia of shame were relatively specific to BPD. These findings could not be accounted for by the presence of current MDD or BD. By contrast, heightened instability of anger and irritability and heightened inertia of irritability appeared to be largely transdiagnostic. Implications for clinical assessment, research, and theory are discussed. (PsycINFO Database Record
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http://dx.doi.org/10.1037/per0000255DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5708157PMC
March 2018

Drug use and emotional distress differentiate unstably- versus stably-housed adults living with HIV who engage in unprotected sex.

J Health Psychol 2017 03 10;22(3):302-313. Epub 2016 Jul 10.

4 Medical College of Wisconsin, USA.

Among adults living with HIV, unstable housing is a barrier to health. Stably- and unstably-housed adults living with HIV were assessed for over 25 months. At baseline, unstably-housed adults living with HIV had a more recent HIV diagnosis, higher viral loads, worse physical and mental health, lower rates of antiretroviral therapy use and insurance coverage, and higher rates of hard drug use than stably-housed adults living with HIV. At follow-up, the health of both groups was similar, but unstably-housed adults living with HIV reported significantly more hard drug use and mental health symptoms when compared to the stably-housed adults living with HIV. Drug and mental health risks decreased for both groups, but decreases in unprotected sex were greater among unstably-housed adults living with HIV.
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http://dx.doi.org/10.1177/1359105315603465DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4785098PMC
March 2017

A Contingency-Oriented Approach to Understanding Borderline Personality Disorder: Situational Triggers and Symptoms.

J Pers Disord 2015 Aug;29(4):486-502

Department of Psychology, Wake Forest University.

This article tested a contingency-oriented perspective to examine the dynamic relationships between in-the-moment borderline personality disorder (BPD) symptom events and in-the-moment triggers. An experience sampling study with 282 adults, including 77 participants with BPD, obtained reports of situational triggers and BPD symptom events five times daily for 2 weeks. Triggers included being rejected, betrayed, abandoned, offended, and disappointed; having one's self-concept threatened; being in a boring situation; and being alone. BPD was associated with increased situational triggers. Multilevel models revealed significant within-person associations between situational triggers and BPD symptoms for the average participant in the study, with significant individual variance in the strength and direction of trigger-symptom contingencies. Most trigger-symptom contingencies were stronger for individuals with greater borderline symptomatology, suggesting that triggers are meaningfully related to BPD. These findings highlight possible proximal mechanisms that maintain BPD and help explain the course of a disorder often described as chaotic and unpredictable.
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http://dx.doi.org/10.1521/pedi.2015.29.4.486DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4511961PMC
August 2015

A Contingency-Oriented Approach to Understanding Borderline Personality Disorder: Situational Triggers and Symptoms.

J Pers Disord 2015 Aug;29(4):486-502

Department of Psychology, Wake Forest University.

This article tested a contingency-oriented perspective to examine the dynamic relationships between in-the-moment borderline personality disorder (BPD) symptom events and in-the-moment triggers. An experience sampling study with 282 adults, including 77 participants with BPD, obtained reports of situational triggers and BPD symptom events five times daily for 2 weeks. Triggers included being rejected, betrayed, abandoned, offended, and disappointed; having one's self-concept threatened; being in a boring situation; and being alone. BPD was associated with increased situational triggers. Multilevel models revealed significant within-person associations between situational triggers and BPD symptoms for the average participant in the study, with significant individual variance in the strength and direction of trigger-symptom contingencies. Most trigger-symptom contingencies were stronger for individuals with greater borderline symptomatology, suggesting that triggers are meaningfully related to BPD. These findings highlight possible proximal mechanisms that maintain BPD and help explain the course of a disorder often described as chaotic and unpredictable.
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http://dx.doi.org/10.1521/pedi.2015.29.4.486DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4511961PMC
August 2015

Using Negative Emotions to Trace the Experience of Borderline Personality Pathology: Interconnected Relationships Revealed in an Experience Sampling Study.

J Pers Disord 2016 Feb 24;30(1):52-70. Epub 2015 Feb 24.

Department of Psychology, Wake Forest University, Winston-Salem, North Carolina.

While emotional difficulties are highly implicated in borderline personality disorder (BPD), the dynamic relationships between emotions and BPD symptoms that occur in everyday life are unknown. The current paper examined the function of negative emotions as they relate to BPD symptoms in real time. Experience sampling methodology with 281 participants measured negative emotions and borderline symptoms, expressed as a spectrum of experiences, five times daily for two weeks. Overall, having a BDP diagnosis was associated with experiencing more negative emotions. Multilevel modeling supported positive concurrent relationships between negative emotions and BPD symptoms. Lagged models showed that even after 3 hours negative emotions and several symptoms continued to influence each other. Therefore, results indicated that negative emotions and BPD symptoms are intricately related; some evidenced long-lasting relationships. This research supports emotion-symptom contingencies within BPD and provides insight regarding the reactivity and functionality of negative emotions in borderline pathology.
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http://dx.doi.org/10.1521/pedi_2015_29_180DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4547903PMC
February 2016

What Can We Learn About Family-Based Obesity Treatment From Family Therapists?

Glob Pediatr Health 2015 1;2:2333794X15607316. Epub 2015 Oct 1.

Wake Forest School of Medicine, Winston-Salem, NC, USA; Brenner Children's Hospital, Winston-Salem, NC, USA.

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http://dx.doi.org/10.1177/2333794X15607316DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4784616PMC
June 2016

The structure of borderline personality disorder symptoms: a multi-method, multi-sample examination.

Personal Disord 2014 Oct;5(4):380-9

Department of Psychology, Wake Forest University.

We examined the factor structure of borderline personality disorder (BPD) symptoms by using a multimethod, multisample approach. The factorial structure of BPD has previously been examined through the lens of broad retrospective reports of symptoms without directly contrasting results from different samples of participants, with studies producing inconsistent patterns of results. We go beyond previous work by examining symptoms from multiple timeframes and by examining results across and within 2 diagnostic groups-individuals with and without BPD. Participants (n = 281) completed a structured clinical interview for personality disorders, 2 weekly reports of BPD symptoms, and 2 weeks of in-the-moment "immediate" symptom reports, assessed 5 times daily. Across all participants, results revealed a robust 1-factor structure that replicated across all assessment methods. Moreover, these results replicated within each diagnostic group, with the lone exception of an unclear structure in interview assessment among participants who had a BPD diagnosis. Results have implications regarding the nature, assessment, and treatment of BPD.
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http://dx.doi.org/10.1037/per0000086DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4197810PMC
October 2014

The structure of borderline personality disorder symptoms: a multi-method, multi-sample examination.

Personal Disord 2014 Oct;5(4):380-9

Department of Psychology, Wake Forest University.

We examined the factor structure of borderline personality disorder (BPD) symptoms by using a multimethod, multisample approach. The factorial structure of BPD has previously been examined through the lens of broad retrospective reports of symptoms without directly contrasting results from different samples of participants, with studies producing inconsistent patterns of results. We go beyond previous work by examining symptoms from multiple timeframes and by examining results across and within 2 diagnostic groups-individuals with and without BPD. Participants (n = 281) completed a structured clinical interview for personality disorders, 2 weekly reports of BPD symptoms, and 2 weeks of in-the-moment "immediate" symptom reports, assessed 5 times daily. Across all participants, results revealed a robust 1-factor structure that replicated across all assessment methods. Moreover, these results replicated within each diagnostic group, with the lone exception of an unclear structure in interview assessment among participants who had a BPD diagnosis. Results have implications regarding the nature, assessment, and treatment of BPD.
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http://dx.doi.org/10.1037/per0000086DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4197810PMC
October 2014

Family Systems Theory and Obesity Treatment: Applications for Clinicians.

Infant Child Adolesc Nutr 2014 Feb;6(1):24-29

Department of Psychiatry and Behavioral Medicine (SGK, EMA), the Department of Pediatrics (MBI, JAS), and the Department of Epidemiology and Prevention (JAS), Wake Forest School of Medicine, and Brenner FIT (Families In Training) Program, Brenner Children's Hospital (MBI, KAB, JAS), Winston-Salem, North Carolina.

Family-based approaches are recommended for the treatment of pediatric obesity, although most of the literature describes programs that only include the identified child and one parent in the treatment process. As a result, the clinical application of research protocols in nutrition settings may be inadequate; multiple representations of a "family" will be encountered in the clinical environment. Mental health professionals, particularly those who work with children, often engage families in psychotherapy. Developing an understanding of their methods may be beneficial to Dietitians and other clinicians who wish to follow a more family-based approach and may present new avenues for effective treatment. In our tertiary care pediatric obesity clinic, we routinely involve multiple family members throughout the treatment process. Here we discuss our experiences and introduce Bowen's Family Systems Theory as a model for translating family therapy principles into nutrition-focused treatment settings.
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http://dx.doi.org/10.1177/1941406413516001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3979546PMC
February 2014

When Life is a Drag: Depressive Symptoms Associated with Early Adolescent Smoking.

Vulnerable Child Youth Stud 2014 Jan;9(1):1-9

University of California, Los Angeles, Center for Community Health, 10920 Wilshire Boulevard, Suite 350, Los Angeles, California, 90024, U.S.A. Tel: (310) 794-8278; ;

Adolescent nicotine use continues to be a significant public health problem. We examined the relationship between the age of youth reporting current smoking and concurrent risk and protective factors in a large state-wide sample. We analyzed current smoking, depressive symptoms, and socio-demographic factors among 4,027 adolescents, ages 12-17 years using multivariate logistic regression (see 2005 California Health Interview Survey (CHIS) Public Use File). Consistent with previous work, Latinos, girls, those whose family incomes were below the poverty level, and those with fair-poor health were more likely to display depressive symptoms. Males, whites, older teens and those in fair-poor health were more likely to be current smokers. In a multivariate analysis predicting depressive symptoms, the interaction between age and current smoking was highly significant (Wald Χ=15.8, p<.01). At ages 12-14 years, the probability of depressive symptoms was estimated to be four times greater among adolescents who currently smoked, compared to those who were not current smokers. The likelihood of depressive symptoms associated with current smoking decreases with age and becomes non-significant by 17 years. Interventions to reduce smoking may be most useful among youth prior to age 12 years and must be targeted at multiple risks (e.g. smoking and depression).
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http://dx.doi.org/10.1080/17450128.2013.797129DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3928103PMC
January 2014

On the Contributions of a Network Approach to Personality Theory and Research.

Eur J Pers 2012 Jul;26(4):437-439

Department of Psychiatry& Behavioral Medicine, Wake Forest School of Medicine, USA.

Understanding personality structure and processes is one of the most fundamental goals in personality psychology. The network approach presented by Cramer et al. represents a useful path toward this goal, and we address two facets of their approach. First, we examine the possibility that it solves the problem of breadth, which has inhibited the integration of trait theory with social cognitive theory. Second, we evaluate the value and usability of their proposed method (qgraph), doing so by conducting idiographic analyses of the symptom structure of Borderline Personality Disorder.
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http://dx.doi.org/10.1002/per.1871DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3972620PMC
July 2012

A family intervention to reduce sexual risk behavior, substance use, and delinquency among newly homeless youth.

J Adolesc Health 2012 Apr 26;50(4):358-64. Epub 2011 Oct 26.

Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, Center for Community Health, University of California, Los Angeles, CA, USA.

Purpose: We evaluate the efficacy of a short family intervention in reducing sexual risk behavior, drug use, and delinquent behaviors among homeless youth.

Methods: A randomized controlled trial of 151 families with a homeless adolescent aged 12 to 17 years. Between March 2006 and June 2009, adolescents were recruited from diverse sites in Southern California and were assessed at recruitment (baseline), and at 3, 6, and 12 months later. Families were randomly assigned to an intervention condition with five weekly home-based intervention sessions or a control condition (standard care). Main outcome measures reflect self-reported sexual risk behavior, substance use, and delinquent behaviors over the past 90 days.

Results: Sexual risk behavior (e.g., mean number of partners; p < .001), alcohol use (p = .003), hard drug use (p < .001), and delinquent behaviors (p = .001) decreased significantly more during 12 months in the intervention condition compared with the control condition. Marijuana use, however, significantly increased in the intervention condition compared with the control condition (p < .001).

Conclusions: An intervention to reengage families of homeless youth has significant benefits in reducing risk over 12 months.
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http://dx.doi.org/10.1016/j.jadohealth.2011.08.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3313467PMC
April 2012

Adjustment of trendy, gaming and less assimilated tweens in the United States.

Vulnerable Child Youth Stud 2011 Sep;6(3):263-275

Wake Forest University School of Medicine, Department of Psychiatry and Behavioral Medicine, Medical Center Boulevard, Winston-Salem, NC, USA.

Youth transitioning from childhood to adolescence (tweens) are exposed to increasing amounts of media and advertisement. Tweens have also emerged as a major marketing segment for corporate America with increasing buying power.We examine how tweens relate to popular culture messages and the association of different orientations to popular culture on adjustment. A secondary data analysis was conducted on a marketing survey of 3527 tweens, aged 10-14 years, obtained from 49 schools using stratified sampling methods. A sample of children nationwide described their preferences on popular culture and measures of psychosocial adjustment. Using cluster analysis, we identified three main clusters or adaptation styles of tweens: (1) those who enjoyed gaming, (2) trendy youth and (3) youth less assimilated into popular culture. There were differences in clusters based on adjustment indices. Gaming and trendy tweens reported higher self-perceptions of being smart, caring and confident compared to less assimilated tweens. However, gaming and trendy tweens worried more about fitting in than less assimilated tweens. Gaming and trendy tweens also endorsed future goals and traditional values more strongly than less assimilated tweens. Trendy tweens reported the strongest positive feelings about substance use. Results suggest that for each method of adaptation (gamer, trendy and less assimilated), there are unique differences in adjustment that can impact the child's future. Parents and service providers must recognize the complexity of these decisions and be sensitive to the unique needs of youth as they move from childhood to adolescence.
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http://dx.doi.org/10.1080/17450128.2011.597794DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4288444PMC
September 2011

An agenda for symptom-based research.

Behav Brain Sci 2010 Jun;33(2-3):157

Department of Psychology, Wake Forest University, Winston-Salem, NC 27109, USA.

The network approach proposed by Cramer et al. suggests fascinating new directions of research on mental disorders. Research is needed to find evidence for the causal power of symptoms, to examine symptoms thoroughly, to investigate individual differences in edge strength, to discover etiological processes for each symptom, and to determine whether and why symptoms cohere into distinct mental disorders.
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http://dx.doi.org/10.1017/S0140525X10000750DOI Listing
June 2010

Relationships over time between mental health symptoms and transmission risk among persons living with HIV.

Psychol Addict Behav 2010 Mar;24(1):109-118

Center for Complementary and Alternative Medicine, National Institutes of Health.

Relationships between mental health symptoms (anxiety and depression) or a positive state of mind and behavior associated with HIV transmission (substance use and risky sexual behavior) were explored in a longitudinal study of persons living with HIV (PLH; N = 936) who were participants in a transmission-prevention trial. Bivariate longitudinal regressions were used to estimate the correlations between mental health symptoms and HIV-related transmission acts for 3 time frames: at the baseline interview, over 25 months, and from assessment to assessment. At baseline, mental health symptoms were associated with transmission acts. Elevated levels of mental health symptoms at baseline were associated with decreasing alcohol or marijuana use over 25 months. Over 25 months, an increasingly positive state of mind was associated with decreasing alcohol or marijuana use; an increasingly positive state of mind in the immediate intervention condition and increasing depressive symptoms in the lagged condition were related to increasing risky sexual behavior. Our findings suggest that mental health symptoms precede a decrease in substance use and challenge self-medication theories. Changes in mental health symptoms and sexual behavior occur more in tandem.
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http://dx.doi.org/10.1037/a0018190DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2845324PMC
March 2010

Differential disclosure across social network ties among women living with HIV.

AIDS Behav 2009 Dec 9;13(6):1253-61. Epub 2009 Apr 9.

UCLA Semel Institute for Neuroscience and Human Behavior and Center for Community Health, University of California-Los Angeles, Los Angeles, CA, USA.

Women's disclosure of their HIV serostatus across social network ties was examined in a sample of women living in Los Angeles (n = 234), using multivariate random intercept logistic regressions. Women with disclosure-averse attitudes were less likely to disclose, while women with higher CD4+ counts were significantly more likely to disclose, regardless of relationship type. Relative to all other types of relationships, spouses/romantic partners were greater than four times more likely to be the targets of disclosure. Women were more than 2.5 times more likely to disclose to a given network member if that target provided the woman with social support. Social network members whom women believed to be HIV-positive were more than 10 times more likely to be the targets of disclosure. The implications for how social roles and social identities are manifest in these results are discussed, including the implications such an interpretation has for future prevention research.
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http://dx.doi.org/10.1007/s10461-009-9554-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2785899PMC
December 2009

Comparisons of prevention programs for homeless youth.

Prev Sci 2009 Mar;10(1):76-86

Department of Psychiatry and Behavioral Medicine, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC, 27157-1087, USA.

There are six HIV prevention programs for homeless youth whose efficacy has been or is currently being evaluated: STRIVE, the Community Reinforcement Approach, Strengths-Based Case Management, Ecologically-Based Family Therapy, Street Smart, and AESOP (street outreach access to resources). Programs vary in their underlying framework and theoretical models for understanding homelessness. All programs presume that the youths' families lack the ability to support their adolescent child. Some programs deemphasize family involvement while others focus on rebuilding connections among family members. The programs either normalize current family conflicts or, alternatively, provide education about the importance of parental monitoring. All programs aim to reduce HIV-related sexual and drug use acts. A coping skills approach is common across programs: Problem-solving skills are specifically addressed in four of the six programs; alternatively, parents in other programs are encouraged to contingently reward their children. Each program also engineers ongoing social support for the families and the youth, either by providing access to needed resources or by substituting a new, supportive relationship for the existing family caretaker. All of the interventions provide access to health and mental health services as basic program resources. A comparison of HIV prevention programs for homeless youth identifies the robust components of each and suggests which programs providers may choose to replicate.
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http://dx.doi.org/10.1007/s11121-008-0119-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4028969PMC
March 2009

Reducing risky sexual behavior and substance use among currently and formerly homeless adults living with HIV.

Am J Public Health 2009 Jun 17;99(6):1100-7. Epub 2008 Sep 17.

Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, USA.

Objectives: We examined the efficacy of the Healthy Living Program in reducing risky sexual behavior and substance use among adults with HIV infection who were marginally housed (i.e., homeless at some point over a 37-month period).

Methods: We had previously conducted a randomized controlled trial with 936 adults living with HIV infection. In that study, 3 intervention modules of 5 sessions each addressed different goals: reducing risky sexual acts and drug use, improving the quality of life, and adhering to healthful behaviors. Participants were interviewed at baseline and at 5, 10, 15, 20, and 25 months; 746 completed 4 or more assessments. In this study, we analyzed sexual behavior and drug use outcomes for the 35% (n = 270 of 767) of participants who were considered marginally housed.

Results: Among the marginally housed participants, there were significantly greater reductions in unprotected risky sexual acts, the number of sexual partners of HIV negative or unknown serostatus, alcohol or marijuana use, and hard drug use among the intervention group than among the control group.

Conclusions: Intensive, skill-focused intervention programs may improve the lives of marginally housed adults living with HIV infection.
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http://dx.doi.org/10.2105/AJPH.2007.121186DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2679793PMC
June 2009

Attention deficit hyperactivity disorder accommodations for psychiatry residents.

Acad Psychiatry 2007 Jul-Aug;31(4):290-6

Department of Psychiatry and Behavioral Medicine, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA.

Objective: With the increase in diagnosis and treatment of attention deficit hyperactivity disorder (ADHD) in adults, it is expected that more resident physicians will require accommodations so that their academic performance and clinical competency can be measured adequately. The authors provide an overview of the requirements and issues regarding the provision of ADHD accommodations for psychiatry resident physicians as well as recommendations regarding policy development in this area.

Method: The authors review the symptoms of ADHD, proper documentation of ADHD, and the rationale and legal basis for providing accommodations to resident physicians with ADHD.

Results: Executive functioning, attention, and affect regulation are three domains that could negatively affect the functioning of a resident physician with ADHD. Possible accommodations specific to each general competency are described.

Conclusions: In order to comply with existing guidelines, training programs should be proactive and have a procedure in place that 1) requires adequate documentation; 2) ensures confidentiality; 3) grants accommodations which measure core knowledge and not the limits of the disability; and 4) does not alter the core curriculum of the program.
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http://dx.doi.org/10.1176/appi.ap.31.4.290DOI Listing
October 2007

Unmet needs at the end of life: perceptions of hospice social workers.

J Soc Work End Life Palliat Care 2006 ;2(4):61-83

School of Social Work, University of North Carolina at Chapel Hill, USA.

Among persons at the end of life, it is important to understand whether the needs of patients are being adequately addressed. In particular, in hospice settings where the emphasis is on comfort care and quality of life, we know little about the presence of unmet needs. The purpose of this study was to examine the experiences of hospice social workers in working with hospice patients who had unmet needs at the end of life. Surveys were mailed to hospice social workers (N = 212) in two Southeastern states with a response rate of 36%. Results revealed that hospice social workers perceived patients to experience a wide variety of unmet needs-more commonly at the time of admission than during subsequent patient interactions. The most common unmet need reported at both times was a decreased ability to participate in activities that make life enjoyable. In situations where unmet needs exist, social workers reported that the most common perceived reasons were patient- related psychosocial issues and family conflict/issues. Additionally, a variety of interventions were used to address unmet needs, but a large number of barriers appear to impact outcomes in the cases. Results suggest that hospice patients experience a number of unmet needs, many of which are potentially treatable problems and concerns. Hospice professionals must continue to seek ways to assess and intervene effectively with patients who have unmet needs.
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http://dx.doi.org/10.1300/j457v02n04_04DOI Listing
July 2007