Such studies have revealed that substance use disorders are accompanied by either low or unaltered dopamine synthesis capacity , possibly reflecting variability in presynaptic dopamine cell injury due to varying amounts of excessive drug use or differences in drug induced neuroplasticity . We argue that this difference between pathological gambling and substance use disorders might reflect the absence of substance-specific confounds, including toxicity of drugs on the dopamine system, in the case of pathological gambling. This highlights the potential of studying pathological gambling, which does not involve the administration of exogenous substances, for investigating the role of dopamine in addiction. An alternative possibility is that pathological gambling might not be as good a model of addiction as hitherto thought or at least might not be as similar to stimulant addiction as previously hypothesized . Importantly, research has shown that various substance use disorders are associated with varying degrees of dopamine abnormality, suggesting that addiction is likely a multi-pleneuro transmitter disorder . Previous work has shown increased gambling-induced dopamine release in the ventral striatum as a function of gambling severity/excitement level as well as reduced ventral striatal dopamine D2/D3 receptor availability as a function of sensation seeking/impulsivity . In light of the positive relationship between dopamine synthesis capacity and dopamine release , on the one hand, and the negative relationship between dopamine synthesis capacity and D2/D3 receptor availability observed in HCs ,cannabis grow equipment on the other [but see ], the current results raise the hypothesis that increased striatal dopamine release and reduced D2/D3 receptor availability in pathological gambling may reflect increased dopamine synthesis capacity.

However, it is noteworthy that another recent [18F]DOPA PET study did not find evidence of dopamine synthesis abnormality in PGs compared with HCs . The basis of this discrepancy is unclear, but we speculate that differences in drug dependence history might play a role, although this information was not provided in the article by Majuri et al. . The incidence of smoking was higher in their study compared with the current study . Given that nicotine/ drugs of abuse can affect dopamine synthesis capacity , it is possible that differences in nicotine/drug dependence history between the populations of the two studies contributed to the observed differences in dopamine synthesis levels. Another factor that has been suggested to contribute to mixed results in gambling research is the heterogeneity among PGs . In particular, it has been proposed that different subtypes of PGs, who gamble for different motives, might be characterized by different underlying brain mechanisms. For example, PGs who gamble to cope with negative affect might be primarily characterized by abnormal functioning of the amygdala circuit, whereas PGs who gamble to enhance positive affect might be primarily characterized by a hyperactive orbitofron to-striatal circuitry . More research is needed to elucidate the various endophenotypes underlying pathological gambling sub-types and to assess their validity in research and clinical treatment. Future studies will be needed to replicate the current findings and better understand the interplay among dopamine synthesis capacity, dopamine release, and D2/D3 receptor availability. The observation that higher dopamine synthesis capacity in PGs was most consistently found in the dorsal parts of the striatum is striking and overlaps with the location of increased striatal dopamine release previously reported as a result of amphetamine administration in the anterior caudate and putamen . The dorsal striatum is thought to play a crucial role in habitual control of behavior, as evidenced by dorsolateral striatal lesions disrupting habit formation in animals , for instance. Increased dopamine synthesis capacity in the dorsal putamen in PGs also fits with incentive sensitization studies in humans, showing that after repeated exposure to amphetamine the dorsal putamen becomes progressively involved .

Note that such increased dopamine response to rewarding stimuli could also reflect a vulnerability to develop addictive behaviors . Indeed, animals with increased addiction vulnerability show increased dopamine release in the nucleus accumbens and dorsomedial striatum following psychostimulant administration, as assessed using voltammetry . Thus, increased dopamine synthesis capacity, especially in the dorsal putamen, could be a vulnerability and/or consequence of addictive behavior driving excessive reward-seeking behavior. However, our study was not designed to dissect whether alterations in dopamine synthesis capacity are a direct cause or consequence of pathological gambling, and the origin of this alteration is still speculative. One possibility is that genetic factors affecting components of the dopamine synthesis pathway, such as variants in the dopa decarboxylase gene found to be associated with gambling disorder , might play a role there. Our results should be interpreted with the following limitations in mind. First, the study included a small sample of only male subjects. This strategy led to a homogeneous population without psychiatric comorbidities—in particular, without drug dependence—which enabled us to measure dopamine synthesis capacity in pathological gambling without confounding factors. However, one should note that, with the exception of current and past-year drug dependence history, all other clinical assessments were performed away from the PET study on the occasion of a preceding pharmaco-fMRI study. In addition, 5 HCs and 5 PGs scored $8 on the Alcohol UseDisorders Identification Test questionnaire, indicating possible alcohol problems. However, because groups did not differ on Alcohol Use Disorders Identification Test scores, it is unlikely that this would have influenced our main finding of enhanced dopamine synthesis capacity in PGs relative to HCs. Interestingly, at the time of the PET scan, only 4 of the 13 gamblers were experiencing acute problems with gambling . It is unclear how this might have affected our results, but because dopamine synthesis capacity is thought to be a stable measure over long periods of time , the increased dopamine synthesis capacity found in our PGs might reflect a vulnerability in the dopamine system rather than a consequence of current gambling problems.

Preclinical and longitudinal studies are needed to address whether heightened dopamine synthesis capacity in pathological gambling existed before the onset of problematic gambling or developed as a consequence of the disorder. Another caveat is that although we observed a clearly enhanced dopamine synthesis capacity in PGs compared with HCs in the non PVC ROIs—specifically in the dorsal putamen, caudate body, and ventral striatum—this group difference was less striking in the PVC ROIs and significant only in the dorsal putamen ROI . These differences between non-PVC and PVC results are explained by the incorporation of the size and shape of the ROIs, as well as their proximity to white matter and cerebral spinal fluid, in the latter method. Using PVC ROIs is not always the most sensitive method because PVC methods can amplify the existing noise such as increasing the variance in the time–activity curves . Given the scarcity of reports examining [18F]DOPA differences in pathological gambling, we included different analysis methods to comprehensively test the reproducibility of the results. We believe that our analyses reveal robust findings of higher dopamine synthesis capacity in the dorsal putamen in PGs. At the clinical level, our results suggest that it could be beneficial to reduce dopamine levels in pathological gambling. However, two double-blind, placebo-controlled trials of the atypical antipsychotic olanzapine,mobile grow system a dopamine and serotonin antagonist, have shown no benefit over placebo , similar to what was found with bupropion, a dopamine and norepinephrine transporter inhibitor . Multiple psychopharmacological studies using the dopamine D2/D3 receptor antagonists sulpiride and haloperidol have also yielded inconclusive results regarding the ability of these drugs to normalize reward processing in pathological gambling . However, a small single-blind study using the D1 receptor antagonist ecopipam in PGs did lead to significant reductions in gambling severity measures . Clearly, more research is needed to assess whether and how striatal dopamine receptor blockade would be effective in treating pathological gambling. Finally, addiction is a complex mixture of behaviors and cognitions that is reflected in the heterogeneity of the patients and also varies from drug to drug, game to game, and drug to game. As emphasized by Nutt et al. , “it is unlikely that a single neurotransmitter could explain every aspect of addiction.”Disparate rates of felony drug arrests and convictions across race and geography have implications for inequalities in health and social outcomes linked to criminal justice exposure. California Proposition 47 , passed in 2014, reduced drug possession offenses classified as felonies or wobblers unintended consequences with regards to drug-related hospital visits. For objective 1: using data on all drug arrests made in California from 2011-2016, we compared the immediate and one year post-policy changes in racial disparities in drug arrests between Whites, Blacks, and Latinos, controlling for secular and seasonal trends. For objective 2: after propensity score matching arrests made in the year after the implementation of Prop 47 to similar arrests in the year prior to Prop 47, we used mixed models to estimate the change in county variance in the probability of felony conviction. For objective 3: Incorporating data on all drug-related hospital visits in California from 2011-2015 with drug arrests data, we use county fixed effects models to estimate expected rates in the 10- months post-policy, and calculate the difference compared to observed rates.

We use linear regression to test whether county-level changes in drug arrest rates were associated with changes in drug-related hospital visit rates. In the month following passage, absolute Black-White disparities in monthly felony drug arrests decreased from 81 to 44 per 100,000 and continued to decrease over time. The probability of a felony conviction among those arrested for Prop 47 drug offenses declined by 14 percentage points , from 0.21 to 0.07 . Counties with higher felony conviction probabilities pre-Prop 47 declined most, reducing cross-county variance, with no evidence of increases in felony convictions for concurrent offenses. Declines in arrests were not associated with increases in drug-related hospital visits.Over seven million Americans had an illicit substance use disorder in 2014 , and substance-related disorders excluding alcohol were the primary diagnosis in over 700,000 emergency department visits that year . The U.S. has taken an increasingly punitive approach to substance use in recent decades, which has disproportionately affected people of color. Twenty years after the war on drugs was launched in 1986, arrests for drug possession had grown by 150%, and Black-White disparities widened from 3:1 to 5:1 . The collateral consequences of felony drug convictions are severe. Impacts on parental custody rights, immigration status, and access to professional licensing, employment, health and social benefits, housing, and financial support for higher education may exacerbate racial/ethnic disparities in health and social outcomes . Felony convictions also increase the likelihood and length of incarceration for future convictions, exposure to which has negative health effects. Of the 1.5 million jail and prison inmates with substance use disorders, just 11% have received any type of treatment since admission , and few jails and prisons offer evidence-based strategies like medication-assisted treatment . Ultimately, incarceration may increase injecting, infectious diseases, and mortality post-release, while disrupting access to health services . The mental and physical health of partners and children is also affected – incarceration can lead to family break-up and economic strain – with family income declining by 22% during a father’s incarceration and 15% following release . Taken together, criminal justice involvement has been identified as a significant social determinant of health for an already vulnerable population . Exposure to felony convictions is both profoundly unequal across race/ethnicity, and strikingly prevalent for some: an estimated 8% of all adults and 33% of Black men have a felony conviction . Rates of felony disenfranchisement are three to four times higher in predominantly Black communities than predominantly White communities, disadvantaging low-income communities of color and obstructing their impact on public policies that could reduce inequalities.Research conducted in 2010 in California found the proportion of arrests for possession of a controlled substance that were charged as felonies varied across California counties from 25 to 100 percent . Even after controlling for case characteristics and criminal history, county of residence was a strong predictor of felony filings following arrest . Many states are beginning to reduce criminal penalties for drug possession. While many drug law reforms have focused on marijuana, California passed Proposition 47: The Safe Neighborhoods and Schools Act in 2014, which made more expansive changes by reducing possession of narcotics , possession of a controlled substance and possession of concentrated cannabis (H&S 11357 to misdemeanors, as well as several property offenses.

Resilience was included in this study to assess whether social support was a buffer between schizoid personality traits and substance use. Strengths of youths with a criminal record were included in this study in order to shift the focus from risks and deficits of the youths toward maintaining the complexity of youth offending behaviors. Juveniles with a criminal history reported a number of strengths, especially in the domains of family support. This has implications for treatment interventions that would ideally leverage on those strengths and include families more regularly. The important role of family in treatment of adolescents has been demonstrated in effectiveness studies of interventions like the A-CRA . Yet, caution is warranted when formulating social support as a universal protective factor against substance problems. Social support as measured in this study by the number of different types of support was not found to be a protective factor against substance problems for individuals with schizoid personality traits. This could also imply that for individuals with schizoid traits social relationships and support are not as protective as are other, unstudied factors. It may be that for this personality type it is less about having access but more about how to access different support networks. These individuals may benefit from interventions that provide corrective emotional experiences of relatedness in a therapeutic setting lowering fear and distrust by the client in regard to his own needs. Since the measure did not specify the nature of the social support, it could be that youths who committed crimes seek support from peers who are gang members or involved in delinquent activities themselves. Also, cultural factors may have influenced participants’ responses to the social support measure so that for Latino males,growing indoor cannabis for instance, affirmative responses to having social support may reflect their value of loyalty but not necessarily the presence of networks that help lower their personal distress.

Social support is a multifaceted construct; it may be that it is a particular form of social support that is more effective than another for this population. Since the measure employed in the study grouped different types of social support together I was not able to test such a differential effect. The finding that schizoid personality traits had a negative relation with social support suggests that individuals with this personality type were, first of all, less likely to have different types of social support, and, second of all, may not benefit from treatment interventions emphasizing prosocial peer support in the same way other personality types do. This should be determined by future effectiveness studies that include personality type as a study variable. To my knowledge this study is one of the first empirical approaches to the developmental trajectory between trauma, schizoid personality, and antisocial behaviors, i.e., substance problems, among youths on probation. Even though the distinction resilience researchers draw between internal and external factors is helpful, it appears that risks like trauma and maladaptive personality traits carry both, internal and external implications for the individual simultaneously. For example, an individual high on schizoid traits is likely to experience interpersonal difficulties even though personality is an internal resilience factor. Similarly, when reviewing psychoanalytic concepts of object relations it becomes evident that a trauma history affects the individual on an internal and external level. In other words, a youth with a trauma history is more likely to experience internalizing disorders, such as depression and anxiety, and higher levels of mistrust and affect dysregulation which hinder interpersonal connections. As a result, the distinction between internal and external resilience factors is artificial when conceiving of the deeper-rooted processes involved. This study argues that its findings corroborate an alternate conceptualization of internal and external resilience factors not as distinct categories but as dualistic entities that represent both intra- and extrapsychic processes at once.

As expected, substance use was reported by a high proportion of youths. Over 80% had reported using AOD weekly or more often at some point in their lives, and 71% had received complaints from parents about their AOD use. While AOD use is normative during adolescence, a high number of youths in the sample reported experiencing problems related to their use. It was found that trauma had a detrimental effect on substance use behaviors in a youth offender’s life. Moreover, the study provided evidence for the relations between pasttrauma, schizoid personality traits, and substance problems, indicating the importance of context whereby for one individual using substances recreationally may be normative, and for another it may be maladaptive. For example, when using drugs is motivated by an attempt at coping with previous trauma, intervention would be indicated. Additionally, if substance use, even if infrequent, is causing interpersonal difficulties in the youth’s life, such as conflicts with family and friends, therapeutic intervention is recommended. marijuana daily to cope with feelings of loneliness and emotional disconnect, someone with impulsive personality traits may use cocaine for a thrill. Substance problems are an “equifinal” outcome which means that there are different trajectories from early trauma to later substance use.For example, anxiety sensitivity and introversion motivated cannabis use as a way for coping with sad emotions and to help with socializing . For individuals high on anxiety, cannabis was a means for an escape . Thus, substance use may look the same across individuals; however, it is likely to be motivated by different needs. Where one person uses cannabis to forget, another may use it to feel more alive. Unless research addresses the complexity of substance use behaviors in individuals with different personalities treatment efforts are likely to be generic and ineffective. When not correctly identified by clinicians and criminal justice personnel, individuals with schizoid personality traits may not have their treatment needs met. Hence, assessing for personality types is critical for treatment process and outcome because it allows for anticipating challenges and resistances. Moreover, the study showed that including personality as a factor when assessing youths who struggle with substance-related issues provides insight into their unique way of interacting with the world, which in turn has implications for treatment and recovery. Having a better understanding of the individual client will improve diagnostics and treatment planning.

Hopefully, this in turn will create long-term benefits for the client.Future research is needed to compare different personality types and their relationship to trauma and substance use. Are impulsive personalities more likely to benefit from social support as an intervention for substance use reduction? Since adolescence is a developmental construct that implies significant changes in personality and interpersonal behaviors, it will be important to consider grouping participants in different age clusters corresponding to early-, mid-, and late-adolescence or early adulthood, for example. Since social support did not mediate the relation between schizoid personality and substance problems,indoor cannabis growing research is needed to determine whether there are other protective factors that work for this specific personality type. Based on the characterological description of the schizoid personality type in the DSM-IV-TR, individuals on this personality dimension prefer solitary activities and have little interest in relationships . Thus, they may respond more favorably to interventions that suggest legal hobbies that do not involve large-group interactions. Females who engage in illegal activities have been underrepresented in the empirical literature and differ from males who offend . Future research should include female youths to explore their specific risk and protective factors and trajectories to antisocial behaviors. Likewise, differences of antisocial trajectories between ethnic or cultural groups should be examined. Research on ethnic identity and well being found that there is an association of ethnic regard, which is defined as the degree to which one perceives one’s ethnic group as positive, to overall happiness and lower anxiety levels . Research needs to be conducted on whether trajectories from trauma to antisocial behaviors differ for youths who hold their ethnicity in high regard. Another line of research that would add to the current understanding of substance use behaviors will be fulfilled through qualitative methods. Asking participants about what feelings they are trying to either avoid or have when using can provide critical nuances for understanding substance use. Learning about the motivation behind using is critical for developing healthier alternatives for those youths. Similarly, research is needed to help learn about the specific patterns of use related to cannabis versus other drugs. A lot of the research on drug use and treatment is based on adults using alcohol, heroin, or cocaine; current approaches would benefit from specific research efforts on youths and their cannabis use . Analyzing whether trajectories differ by drug type across personality types will help adapt substance abuse interventions and foster greater flexibility in treatment. Additionally, qualitative approaches will be able to access the nature of different types of support, what kinds of needs they fulfill, and what they mean to the individual. Previous research found teachers to provide informational support, whereas peers provided informational and emotional support . Semi-structured interviews will be able to address whether a caregiver or family member is fulfilling a different need than a gang member. Is the former addressing a practical or informational need, and the latter an emotional one during adolescence? What needs do different types of support fulfill? What needs are there that may not yet have been assessed or studied? And what differential effects do different types of support have on rehabilitation for youths on probation? This study has several limitations. First, I did not control for some potentially confounding variables.

Indeed, genetic predispositions and the presence of neighborhood and domestic violence have been linked to trauma and the development of antisocial behaviors , so that statistical conclusion validity may have been compromised. Moreover, the trauma measure did not exclude recent traumatic experiences that occurred during adolescence. If traumatic experiences occurred close to when measured in the adolescent sample they were unlikely to have shaped personality traits. Another limitation refers to the measure of schizoid personality that did not prevent nonschizoid traits from being included. For example, the CPI measure consisted of traits that are shared with paranoid, antisocial, and borderline personality types potentially limiting statistical conclusion validity. However, the idea of shared traits across different categorizations of personality is state-of-the art in current personality research, and has informed revisions of diagnostic instruments like the DSM-V . Therefore, dimensional constructs of personality may provide a more accurate representation of personality, so that the CPI measure, by being inclusive of overlapping traits across categories, may have been an enhancement of construct validity instead of a detriment. Because all measures relied on self-report increasing mono-method bias, a potential threat for construct validity exists. In futures studies parental or friend reports on youths may help alleviate this problem. Potentially, observational data on interpersonal behaviors can augment creation of personality profiles in the future. This study did not implement an experimental design that manipulates the independent variable, which may have compromised internal validity . Similarly, participants were not sampled randomly but were part of a youth offender reentry grant. This makes it likely that the participants shared some preexisting differences causing selection bias. Therefore, findings should not be generalized to youths in the community who were not arrested for illegal behaviors and do not share some of the main characteristics of the sample. Another limitation is due to the lack of covariates in the study. In order to best recreate the complexity of individual AOD users, it would be helpful to account for concurrent existing levels of depression and anxiety, for example. Finally, since the social support variable measured different types of social support that could include talking with a peer while high on drugs, it may have confounded prosocial aspects of support with antisocial ones. This would have had an impact on the validity of that measure for assessing positive social support. Moreover, since the measure captured quantity and not quality of social supports, I was unable to differentiate effects between different peer and adult support, for example. The design and engineering for the project is funded; however, the construction will require additional funding. More amenity-based planning for and implementation of active transportation infrastructure is ongoing in a handful of cities. San Leandro is looking into street scaping and bicycle work in industrial areas “to support place making and next generation work places.” South San Francisco is working on improving the Bay trail in Oyster Point; Hayward staff also emphasized connections on the Bay Trail.

Since diagnostic definitions and criteria of schizoid personality disorder have changed over the years, it is difficult to determine population prevalence. In an effort to represent national prevalence rates in the general population Grant et al. took data from the National Epidemiologic Survey on Alcohol and Related Conditionsand found that 3.13% met diagnostic criteria of the DSM-IV for schizoid personality disorder. The most common personality disorder was obsessive-compulsive personality disorder . Overall, approximately 15% of adult Americans met criteria for at least one personality disorder. The researchers concluded that personality disorders are prevalent in the general population and are highly associated with disability . Guntrip argues that individuals who develop schizoid tendencies have come to believe that wanting love is in itself potentially destructive, which is why they prefer staying aloof. A cluster A personality is therefore different from a cluster B, e.g., antisocial personality, in terms of the defenses employed against a negative object. An individual with schizoid tendencies disengages instead of becoming angry and appears to choose being emotionless instead of confronting an intolerable feeling of rejection from a negative object. Schizoid personalities can be characterized as splitting themselves from the world but without a loss of reality as found in the psychotic states of schizophrenia, for example . McWilliams argues that individuals with schizoid tendencies tend to feel overwhelmed by emotions and therefore choose disengagement as a defensive mechanism from this threatening state. Individuals with schizoid traits experience a fear that their need for love is destructive and exaggerated so that they “cancel object-relationships” .

Expressing love is considered dangerous and therefore replaced with indifference . Importantly,hydroponics system for cannabis the withdrawal into the internal world is a reaction to unmet needs or frustrations with the self object. Thus, individuals with schizoid traits secretly desire the object, whereas individuals with autism do not. There are significant overlaps of a depressive and a schizoid state because they both ascertain a sense of loss of hope and loneliness. Yet, schizoid tendencies are less concerned with a loss of object than with a loss of self . Guntrip views the schizoid problem to be the polarization of relatedness with rejection and identification of objects at either extreme, and at the expense of continuity of the ego and individuation. The desire for identification with the object is ultimately regressive because it reflects a state of complete dependence and merger with the object similar to the prenatal period in the womb. Benjamin conceptualizes individuals with schizoid personalities as having grown up in functioning families that socialized the child for taking on societal roles and jobs, yet that created a formal home life in which solitary activities were fostered and emotional interactions were scarce. From her perspective on personality, she states that, when growing up in such households, individuals who develop schizoid tendencies lack interest in social connections and are indifferent to praise or criticism from others . They present with emotional coldness and do not report sexual activity . Characteristic of schizoid personalities are introversion and withdrawal, narcissism, self-sufficiency, a sense of superiority, loss of affect, loneliness, depersonalization, and regression . Introversion is the result of emotionally detaching from the outer world and finding refuge in fantasy. The narcissism of schizoid personalities is based on a “disguised internalized object-relation” whereby the individual creates objects within himself that he becomes identified with. To an outsider, a person with a schizoid personality may appear therefore completely self-sufficient and primarily concerned with himself.

The preoccupation with one’s internal life serves to veil painful feelings of emptiness and loss of self. This is similar to narcissistic personality types who develop defenses that serve to hide a grandiose, infantile self as a means to fill an inner emptiness. Narcissism is a symptom that has significant overlaps across personality clusters since it is prevalent in antisocial and borderline personalities as well. Hence, excessive narcissism is a core construct for the development of maladaptation. The schizoid personality communicates self-sufficiency because interactions with the external world are limited and are carried out intrapsychically instead. According to Guntrip this is a defense against the anxiety of interactions with others. The paradoxical effect of individuals with schizoid traits is that they display self-sufficiency and a sense of superiority albeit feeling entirely dependent and psychologically incorporated by others. Guntrip calls this “overcompensation” because it is an attempt to lower feelings of inferiority and weakness resulting from feeling dependent on others. This is accompanied by a flat affect presentation whereby those individuals show little concern for others and their feelings, which makes them appear callous. Emotional callousness is a character trait observed in antisocial personality as well and a commonly reported characteristic of youths engaging in criminal behaviors. Another characteristic of schizoid personality is loneliness. Individuals who report feeling separated from others and the social world around them describe an affective split that is typical for schizoid personalities. Finally, depersonalization and regression are probably the two most debilitating traits of a schizoid personality. The former creates sensations of un-reality and loss of self, and the latter evokes infantile urges of merger and dependency. Individuals with schizoid traits are prone to avoid human closeness because of their emotional fragility and the fear of regression into primitive states of self . They often display “devitalization” and a lack of enthusiasm about goals for their own lives. They tend to not feel passionate about their interests and are unable to give their lives direction .

Treatment efforts that are heavily reliant on group-based interventions may not be effective with this group. Similarly, skills-based interventions that foster clients’ motivations for pursuing their interests and legal hobbies may not resonate with schizoid individuals based on the preceding description. Since schizoid symptoms are the outcome of parental emotional unresponsiveness and neglect, therapeutic interventions targeting a corrective experience of the early, central object relationship are important for recovery . Seinfeld argues that borderline personalities are the outcome of abuse, whereas schizoid personality types are the result of neglect. Schizoid features are a form of regression where the individual considers any attempts to relate to others and the world as futile . When children come to believe that they are a burden to their parents they internalize that they are worthless and not loved; moreover, they may come to think that their need for love is overwhelming to their environment . This can be particularly relevant for children from homes where a parent struggles with mental illness, such as depression, and is emotionally unavailable to the child. In order to help those clients psychoanalytic case studies point to the role of empathic attunement and confrontation of the client’s self-destructiveness . By establishing a symbolic child-parent relationship the therapist can come to represent a caring, attuned parent fostering the integration of self in the client. In conclusion, personality types are integral for understanding adaptation as well as maladaptation. Schizoid personality traits have a significant overlap with the impulsive and antisocial personality type, and both types depend on immature defenses. Moreover, schizoid personalities share intrapsychic experiences of “…falseness, split experiences, difficulty with affect tolerance, and internalization of toxic others” with dissociative, narcissistic,indoor hydroponics cannabis and borderline disorders . The schizoid self is diagnostically differentiated from other disorders by the symptoms of eccentricity and lack of concern with others’ approval . Traditionally, personality-based explanations of delinquency considered an overactive id, the part of the self that is demanding, primitive, and “prerational” , and a weak superego, also described as instance of self-evaluation and morality, as predictors of delinquency . Applying a similar model to the schizoid type may indicate that a split ego explains some of the person’s self-destructive behaviors, such as substance abuse, that occur in the context of disintegration of personality functions and a loss of reality.The resilience literature has pointed to the role of personality for the development of risky and antisocial behaviors in children and adolescents. Personal attributes are incremental to resilience because they can increase an individual’s proneness to “sensation seeking, emotion regulation deficits, and novelty seeking” , all of which have been related to maladaptive, antisocial behavior. A longitudinal study by Oshri et al. assessed the effects of ego control and ego resiliency on externalizing behaviors along mediation models for children at three time points: between the ages of 7 to 9, 10 to 12, and 13 to 15. The authors were interested in how personality characteristics affected the relationship between childhood maltreatment and cannabis abuse. They implemented the California Child Q-Set Instrument developed by Block and Block in 1969, which contains 100 items referring to the children’s personality, cognitive and social characteristics . They found that the severity of early childhood abuse was related to more ego undercontrol and less ego resiliency. Ego undercontrol indicates impulsive behavior that for low levels of ego resiliency tends to occur in socially inappropriate ways and contexts. The two maladaptive personality attributes preceded externalizing problems in preadolescents and cannabis abuse symptoms in adolescence . Findings from a study in 2005 indicated that for physically, emotionally, or sexually abused Latino children higher ego resiliency and moderate ego overcontrol were related to resilience .

Furthermore, having an outside, positive source of social support, i.e., a camp counselor, was beneficial for both maltreated and nonmaltreated children. Future research is needed to study the effects of protective factors in the face of abuse. Related resilience research looking at the role of ego strengths was conducted by Cicchetti and Rogosch comparing maltreated and nonmaltreated children’s functioning over three years. This longitudinal study measured functioning by self-report and caretaker-report on social competence, school performance, internalizing and externalizing behaviors . Results showed that for nonmaltreated children positive and close relationships to the mother and other caretakers mattered, whereas for abused children and adolescents it was personality characteristics and levels of self-control that yielded adaptive outcomes . Specifically, maltreated children benefited more from ego overcontrol, ego resilience, and self-esteem.In certain contexts a more inhibited personality style may be beneficial because high levels of emotionality may interfere with functioning. This study points to the usefulness of ego strengths for maltreated children whereby having a trauma history may result in greater difficulty with forming meaningful interpersonal connections with adults, so that building up intrapersonal strengths of self-control and adaptability may compensate for trauma-related vulnerabilities. In summary, ego strength is an important factor for well being and psychological adaptation. The development of ego strength is threatened by abuse and inadequate parenting, which can lead to behavioral problems. Mental health problems as the result of trauma or genetic predispositions are another internal risk factor. Two-thirds of male youths in the juvenile justice system are estimated to have one or more psychiatric disorders . Male detainees report most frequently three types of trauma: witnessing violence, having been threatened with a weapon, and thinking that someone close to them was going to be badly hurt or die . A lot of research has been dedicated to examining the subsequent development of post traumatic stress disorder that is often comorbid with other psychiatric disorders . A study by Abram and colleagues found that in a sample of youth detainees from a Chicago-based detention center 11% of the males and 15% of the females endorsed PTSD. Critics have questioned the universality of the construct of PTSD. They suggest conceptualizing PTSD along a dimensionality of behavioral propensities and personality types. That is, among individuals with a trauma history, the antisocial personality type is more likely to externalize distress, whereas an anxious personality is turning inward. Research on the veteran population identified personality-based differences on how traumatized individuals express their distress . Hyer, Davis, Albrecht, Boudewyns, and Woods found that there are subtypes of PTSD that fall on the two extremes of behavioral reactions to distress: internalization and externalization. Individuals who fell in the anxious and inhibited personality type cluster had lower levels of substance abuse and narcissism than individuals in the impulsive and antisocial cluster . Another study employing the Multidimensional Personality Questionnaire on 221 male combat veterans found that there are three distinct clusters of post traumatic responses, which were low pathology, internalizing, and externalizing behaviors . Externalizing propensities were associated with substance abuse and internalizing ones with depression .

Figure 1 shows clearly that imports account for almost all the growing consumption of olive oil in the United States. Figure 1 also shows that virgin olive oils account for most of the growth of U.S. imports. The U.S. imported 200,000 tons of virgin olive oil in 2012—two-thirds of total imports. While the EU remains the dominant supplier of olive oil to the United States, shares from non-EU countries have grown.As part of an ongoing study requested by Congress, the United States International Trade Commission held a public hearing in December 2012 to assess the U.S. competitiveness in olive oil in the context of market trends and policies, especially in Europe. At the USITC hearing U.S. olive oil industry representatives expressed concerns about European olive oil policies as well as global quality standards and compliance. The European Commission has provided substantial support for its olive industry for decades. Until the mid 2000’s, the European Union tied financial support directly to production of olive oil. Support to the industry continues, but is less direct; now, the EU ties payments to recent capacity to produce an aggregate of commodities and as an incentive to meet environmental standards. For olive oil specifically, the EU also offers “Private Storage Aid” that pays whenever market prices of olive oil are lower than government-set minimums. Such aid was provided in 2011 and 2012. Subsidies for olive oil vary by country within the EU and aggregate figures are difficult to assemble. In a 2012 statement,cannabis equipment the Spanish Minister for Agriculture, Food and Environmental Affairs said that subsidies were equal to about 40% of the value of Spanish olive oil, with aid of about $1.3 billion. Lack of quality control and standards also raises concerns among U.S. industry representatives. The retail grades and quality standards developed by the International Olive Council are not binding in the United States, and the U.S. Department of Agriculture quality monitoring program that was launched in late 2010 is only voluntary.

Olive oil producers in Europe and U.S. importers of olive oil from Europe have expressed concerns about the U.S. government investigations. European producers asked the European Commission to be ready to act on the potential threats of U.S. trade barriers.Data on olive oil imports into the United States are available by point of entry, country of export, container size , and “quality”—as indicated by the “virgin” designation. No publicly available data provide information on country of production of the oil and import data do not record “extra virgin” or other more-specific quality characteristics. Olive oil is sold into three broad channels in the United States: retail packages of olive oil sold to consumers, olive oil sold to food service establishments for cooking and table use, and olive oil used in food processing and sold as an ingredient in other foods such as sauces. Olive oil imported in bulk containers may be delivered to food processing firms, but most bulk oil is packaged in the United States for food service or retail sales. Bulk shipments have been increasing because of improved technology and the cost savings inherent in not shipping fragile and heavy retail containers. Because the consumers and market channels are mostly the same for bulk and bottled imports, we aggregate oil imported in different containers. We estimated demand equations for three categories of olive oil at the wholesale/import stage of the market. We use the quantity of per capita imports each month to measure quantity demanded. For the relevant prices, we use average unit values computed as the ratios of import values to quantities. We treat the United States as a price-taker in the world market for olive oil because the United States accounts for less than 10% of the world consumption, so we would not expect changes in import prices to be caused by changes in U.S. demand. In fact, import prices have fluctuated widely—driven by exporting country production and demand.

One concern is that given how we measure price simply as the import value divided by the import quantity, errors in the measurement of quantities would exaggerate the measured price responses in the estimation by creating an additional negative correlation between measured quantity and measured price. However, after reviewing the variations in import series by port of entry and using standard statistical tests for potential bias caused by measurement error in import prices, we conclude that any remaining bias is small in magnitude. To complete the demand model, we use per capita U.S. personal income, the number of articles published in U.S. newspapers and magazines that report either the health benefits or the Mediterranean diet attributes associated with olive oil to account for consumer awareness, imports of Italian-style cheese and the price of canola oil—a potential substitute. Finally, we include monthly indicators to reflect seasonality and deflate all prices and income by the CPI. For most of the discussion here, we group olive oil into three categories: virgin oils imported from the EU, virgin oils imported from elsewhere, and non-virgin oils. The classification accounts for the quality difference in olive oils and is supported by the price relations in Figure 2.Our set of estimated demand equations includes the impacts by type of olive oil. We also use our estimates by type of oil to calculate effects for all olive oil considered as an aggregate. We evaluate the estimated elasticities of demand at recent average prices and quantities . The U.S. quantity demanded for all olive oil falls when the average price of olive oil increases, but the percentage effect is small. A 10% increase in the price of all olive oil would reduce U.S. total consumption of olive oil by about 2%. Because of substitution among olive oils, the price elasticity of demand for each individual olive oil type is larger. We find that the quantity demanded of EU virgin oil would increase significantly with a 10% increase in the price of virgin oil imported from non-EU countries, but U.S. consumption of both types of virgin oils is insensitive to changes in the price of non-virgin oils.

That is, virgin oils imported from EU and non-EU countries tend to substitute for each other, but non-virgin oils do not seem to compete significantly with virgin oils. We find that canola oil is a slight substitute for olive oil as a group, but the substitution effect applies mostly to non-EU virgin oil. We also find that U.S. consumption of olive oil would grow by about 10% if U.S. personal income grows by 10%. Most of the income effect applies to EU virgin olive oil, which would rise by more than 20% with an increase in income of 10%. In contrast, the consumption of non-virgin oil has no statistically significant response to an increase in personal income. Finally, we find that accumulated information about the healthiness and trendiness of olive oil and the ongoing globalization of the American diet both stimulate more olive oil consumption in the United States. Alternative aggregations, specifications, and methods used to check robustness of our estimated impacts, yield results that are consistent with those reported here. Olive oil consumption has been growing rapidly in the United States, but U.S. production remains a tiny part of the total supply in the U.S. market. Virgin oil imports have been gaining,vertical grow shelf as have imports of olive oil directly from North Africa—both at the expense of non-virgin oil from the EU. These trends have generated controversy as the U.S. industry seeks to evaluate how EU policies and lack of consistent mandatory quality standards affect demand and market shares for olive oil. We find that attention to the health benefits of olive oil and its place in a flavorful and healthful Mediterranean diet has contributed to growth in consumption. Olive oil consumption also responds to income growth and to relative price changes. The currently available data have not allowed us to estimate impacts of prices, income, or market trends on the consumption of olive oil produced in the United States. Nonetheless, the growing market provides opportunities and U.S. industry can gain insights from analysis of market relationships and estimates of effects of prices and other factors on olive oil imports. Much more work is needed to understand olive oil demand more fully and to place the demand analysis reported here in a context that allows one to evaluate impacts of policy. We are engaged in such a project and expect to report results later this year.Two competing legends dominate the telling of California’s agricultural history. According to the first legend, California farmers are progressive, highly educated, early adopters of modern machinery, and unusually well organized. Through irrigation, they made a “desert” bloom. Through cooperation, they prospered as their high-quality products captured markets around the globe. This farmers-do-no-wrong legend is the mainstay of the state’s powerful marketing cooperatives, government agencies, and agricultural research establishment. According to the opposing legend, the California agricultural system was founded by land-grabbers who continue to this day to exploit impoverished migrant workers and abuse the Golden State’s natural environment. Although the contest between these competing interpretations of the nature of California’s farm system has raged for the past one and-a-half centuries, neither account has engaged in a systematic accumulation and dispassionate analysis of the available data, and both have generally lacked the comparative perspective needed to assess why California agriculture developed as it did.This chapter analyzes major developments in California’s agricultural history to provide a better understanding of how and why the state’s current agricultural structure and institutions emerged.

We will focus on major structural transformations: the growth and demise of the extensive wheat economy of the nineteenth century; the shift to intensive orchard, vine, and row crops; and the emergence of modern livestock operations. Intertwined with our discussion of sectional shifts will be an analysis of some of the special institutional and structural features of California’s agricultural development. Here we offer a brief look at the subjects of farm power and mechanization, irrigation, the labor market, and farmer co-operatives. In all of these areas, California’s farmers responded aggressively to their particular economic and environmental constraints to create their own institutional settings. The results have been remarkable. In recent years, this one state alone has accounted for one-tenth of the value of the nation’s agricultural output. What distinguishes California from other regions more than the volume of output, however, is the wide diversity of crops, the capital intensity, the high yields, and the special nature of the state’s agricultural institutions.When disgruntled miners left the gold fields, they found an ideal environment for raising wheat: great expanses of fertile soil and flat terrain combined with a climate of rainy winters and hot, dry summers. By the mid-1850s, the state’s wheat output exceeded local consumption, and California’s grain operations began to evolve into a form of agriculture quite different from the family farms of the American North. The image of lore is of vast tracts of grain, nothing but grain, grown on huge bonanza ranches in a countryside virtually uninhabited except at harvest and plowing time. While this picture is clearly overdrawn, it contains many elements of truth. California grain operations were quite large by contemporary standards and extensively employed labor-saving, scale-intensive technologies. As examples, they pioneered the adoption of labor-saving gang plows, large headers, and combined harvesters.1 Most of the wheat and barley was shipped to European markets, setting a pattern of integration into world markets that has characterized California agriculture to the present. Large-scale operations, mechanization, and a reliance on hired labor would also become hallmarks of the state’s farm sector. Not only were California wheat farms typically larger and more reliant on laborsaving machinery and animal power than mid-western and eastern wheat farms, Californians grew fundamentally different varieties of wheat and employed different cultural techniques than their eastern brethren. These biological differences, although not generally appreciated, were critical to the success of the early California wheat industry. In fact, when eastern farmers migrated to California they had to relearn how to grow the crop. In the eastern U.S. , grain growers planted either winter-habit varieties in the fall to allow the seedlings to emerge before winter or spring-habit varieties in the spring shortly before the last freeze. The difference was that winter-habit wheat required prolonged exposure to cold temperatures and an accompanying period of dormancy to shift into its reproductive stage.

Consistent with our hypothesis, HIV infection was observed to have both direct and indirect effects via inflammation on complex motor performance, such that inflammation burden accounted for 15.1% of the effect of HIV infection on motor performance when controlling for relevant covariates. These results indicate that inflammatory processes may contribute to worse complex motor skills in the context of cART-treated HIV. Our sample consisted of virally suppressed, chronic HIV-positive patients; however, impairment in complex motor skills was still observed among 20% of the HIV-positive sample. This observed impairment rate is consistent with motor impairment rates reported in previous literature e.g.,.Some evidence indicates a higher impairment rate in complex motor performance among persons with chronic HIV compared to persons with acute or early HIV infection, which may reflect a history of immunosuppression and/or greater inflammation burden. For example, persons with AIDS performed significantly worse on a fine motor speed test than those without AIDS. Deficits in motor skills may indicate injury to the basal ganglia, which are part of the motor control pathways. The basal ganglia appears to be particularly vulnerable to alterations in BBB permeability,immune cellular infiltration, and accumulation of HIV viral RNA. Neuropathological studies have observed higher concentrations of macrophages, microglia, and viral proteins in the basal ganglia. Our path analyses indicate that inflammation burden may play a role in the association between HIV infection and worse complex motor performance. This finding is consistent with previous research demonstrating the detrimental impact of HIV and its proteins on the brain through peripheral and CNS pathways. Monocytes and macrophages are observed to infiltrate the CNS in HIV infection. 10 Elevations in soluble markers of monocyte and cytokine activation, including sCD14, MCP-1/CCL2 and IL-6, have been observed among HIV-positive adults with neurocognitive impairment.

Expression of MCP-1/CCL2 may contribute to upregulation of HIV-1 replication, thereby contributing to an increased risk of neurocognitive impairment.In addition to inflammation,led grow lights coagulation imbalance, which includes upregulation of D-dimer, is associated with global neurocognitive functioning among HIV-positive adults. 15 In the current analysis, D-dimer was included in the inflammation burden composite given the bidirectional relationship between inflammation and coagulation . Multiple factors likely contribute to activation of inflammatory and coagulation pathways observed among HIV-positive persons on cART, such as viral replication, excess levels of translocated microbial products and other chronic pathogens , and loss of immunoregulatory responses. HIV was observed to have both direct and indirect effects via inflammation burden on complex motor performance; however, inflammation burden only accounted for 15.1% of the effect of HIV on complex motor performance. These results suggest there are additional mechanisms by which HIV may have deleterious effects on complex motor performance. Other factors contributing to neurocognitive impairment may include vascular remodeling ,metabolic disorders ,and co-infections.The present study evaluated a model that identified one plausible indirect pathway between HIV and worse complex motor performance; future research may build upon this work by evaluating models with multiple pathways in order to estimate the relative contribution of various plausible mediators. A better understanding of the interplay of factors contributing to neurologic dysfunction in HIV may lead to more accurate prognosis and and/or risk stratification of HIV-positive adults in regard to neurologic dysfunction. Although some brain metabolite abnormalities may improve after initiating cART, some abnormalities persist, including ongoing inflammatory processes. A long-term prospective cohort study found interacting effects of aging and HIV disease stage, such that the magnitude of motor performance impairment was greater than the sum of the independent effects of age and HIV disease stage.The interaction between aging and HIV disease stage suggest that complex motor skills may be particularly susceptible to aging-related progression of neurocognitive impairment among HIV-positive adults. The Grooved Pegboard Test appears to be particularly sensitive to detecting neurocognitive decline among HIV-positive persons.

Our study findings should be considered in light of its limitations. First, although we used path analysis, this study was cross-sectional in nature, which precludes us from making inferences in regard to causation or mediation. Our results are also consistent with the alternative hypothesis that both inflammatory processes and complex motor skills may be mediated by an unobserved third variable. Given that the parent study involves repeated assessment of neurocognitive functioning and inflammation over five years, future analyses will examine whether changes in inflammation are associated with changes in complex motor functioning. Second, our study could not rule out other pathology underlying complex motor performance deficits . Third, it is unclear how to best conceptualize inflammation burden as normative standards regarding biomarker measurement and conceptualization have not been established. However, our calculation of a composite inflammation burden score may be a viable method compared to reliance on a single biomarker given our analysis indicated that complex motor performance was significantly associated with the composite but not any individual biomarker. Furthermore, conceptualization of an inflammation burden composite adds to the body of research aimed at developing clinically relevant risk indices . Fourth, our HIV-negative comparison group was relatively healthy and differed from the HIV-positive group on multiple characteristics. Fifth, our HIV-positive group consisted of mostly non-Hispanic white males with some college education, which is not fully representative of HIV-positive persons in the United States. Sixth, prior research indicates multitasks may better detect motor impairment compared to a single motor task; the Grooved Pegboard Test, however, involves the use of many complex operations and is correlated with a range of cognitive functions.In summary, HIV has a deleterious impact on complex motor skills, which may be partially explained by inflammatory processes. Future studies of strategies for managing chronic inflammation in HIV may consider using an inflammation burden composite and examining how changes in inflammation burden affect complex motor performance given this neurocognitive domain appears to be more strongly associated with inflammation relative to other domains.

Much research has focused on externalizing symptoms of juvenile males with a criminal record, and little is known about introverted personality types. Schizoid personality traits lie on the introversion personality dimension and have specific characteristics that represent potentially maladaptive intra- and interpersonal styles. A latent variable approach explored pathways between childhood trauma, schizoid personality traits, and substance problems among 1,029 juvenile males who committed an offense. Trauma, schizoid personality traits, and social support were specified as predictors, and substance problems represented the outcome of a structural equation model. The model tested whether or not social support was a mediator for the association between schizoid personality and substance problems. Moreover, I was interested in the association between trauma, schizoid personality, and substance problems. I found that childhood trauma was significantly and positively related to schizoid personality traits, and that it had an indirect, positive effect on substance problems. Specifically, schizoid personality mediated the relationship between trauma and substance problems. Trauma appeared to increase substance problems through the pathway it shared with schizoid personality traits, yet not through the pathway of social support. Results show that schizoid personality had a positive, significant association with substance problems,vertical grow system while social support was not significantly related to the outcome. There was no evidence that social support mediated the relation of schizoid personality and substance problems. Hence, a lack of social support did not explain why individuals higher on schizoid traits used alcohol or drugs in problematic ways. The study calls for intervention models that incorporate personality assessments for enhancing services to fit with interpersonal styles of clients. Screening for substance use behaviors is not sufficient when treating youths who committed crimes; assessing trauma history and personality style are important elements for treatment planning. Social support as a strength may not buffer the effects of trauma and schizoid personality traits, so that alternative or additional strengths should be assessed and incorporated into the treatment of adolescents who struggle with antisocial behaviors such as criminal activity and substance use. Juvenile crime challenges societal beliefs about children and their innocence. Juveniles who engage in criminal activity tend to disturb not only social order but existing concepts of how to address deviance among the very young and vulnerable, that is, among children. Policy makers struggle with how best to address this issue. Over the past decades criminal justice has moved into an interdisciplinary field that acknowledges the roles of psychology, sociology, economy, culture, and politics in the treatment of juveniles who commit crimes.

This study addresses the complex phenomenon of youth offending by enhancing the understanding of different intra- and extrapsychic variables that are associated with such behaviors. By helping develop a more intimate and nuanced understanding of youths who commit illegal acts, policymakers can be supported in making informed decisions and develop efficient interventions. The recidivism rate of juveniles as reported by the Division of Juvenile Justice was at 81% in terms of new arrests after release for the fiscal year of 2004-2005 in the state of California . Clearly, the processes and mechanisms of juvenile offending are not entirely understood and therefore not sufficiently addressed with current rehabilitation efforts. While this study is not aimed at replacing current, evidence-based treatment efforts, it strives to add to those treatments by contributing research on understudied personality types and traumagenic factors correlated with antisocial behavior.Youths in the juvenile justice system have high rates of victimization, emotional, and behavioral problems compared to youths who are not incarcerated . Abram et al. found that approximately one-third of juvenile detainees were suffering from post traumatic stress disorder. Past and ongoing traumatic experiences such as physical, sexual, and emotional abuse among individuals who abuse substances have been associated with avoidant, dependent, impulsive, sadistic, paranoid, schizoid, borderline, and narcissistic personality traits . Frequently reported high-risk personality characteristics for offending are impulsivity, sensation-seeking, irritability, and low empathy . The U.S. Department of Health and Human Services reports that adolescents who have been victimized or exposed to violence are more likely to aggress against others. Given the high rate of trauma among the offender population, more research is needed to explore the various pathways on which it operates . For example, more research is needed to explore how traumatic experiences influence substance problems, and whether there are developmental trajectories that increase the risk for problematic substance use. Similarly, research is needed to investigate how trauma affects personality development. Traumatic experiences have been associated with the development of personality disorders . A study by Johnson et al. on verbal abuse and PD found that verbal abuse was related to increased risks for developing borderline, narcissistic, obsessive-compulsive, and paranoid PDs during adolescence and early adulthood. Remarkably, verbal abuse was also associated with elevated schizoid and schizotypal PD symptom levels during adolescence and early adulthood . Before studying the effects of trauma on personality traits it is critical to define what personality is. Personality traits are defined as “enduring patterns of perceiving, relating to, and thinking about the environment and oneself that are exhibited in a wide range of social and personal contexts” . Therefore, personality carries intra- and extrapsychic qualities. For this study on adolescents personality is conceptualized as a fluid, dimensional construct consisting of propensities that undergo developmental changes and that are affected by stressors in the environment such as poverty and poor family relations . Personality emerges over time as a result of a combination of early caregiver relationships, biological manifestations, and social interactions. There are different approaches to studying personality that include categorical and dimensional ones. The DSM-IV-TRrelies on categorical classifications of personality that according to critics creates the illusion of an exclusive division between related personality constructs . In clinical reality patients present with many co-occurring and overlapping symptoms, which is why a dimensional approach is favored in this study. The five-factor model is a widely recognized dimensional model capturing five central personality dimensions that have been corroborated across many cultures . Because this study is concerned with personality traits and not disorders, the five-factor model is particularly suitable; it provides a dimensional model of normal personality traits that are grouped into neuroticism, extraversion, openness to experience, agreeableness, and conscientiousness . The introversion dimension includes individuals with schizoid traits; it lies at the other end of the extraversion dimension that encompasses antisocial personality types. Individuals with schizoid traits prefer introspection and solitary activities .

Additionally, the studies differed in the type of data they collected, especially individual level data, which do not provide the necessary statistical measures that would make a meta-analysis meaningful.The use of self-report methods, which can be susceptible to recall bias, a method utilized in the majority of the reviews included, poses another limitation. Future studies that integrate objective methods of measurement would be useful for confirming the presented results thereby enhancing comparability. Additionally, all 8 included studies were retrospective cross-sectional type studies; these types of study designs limit the ability of establishing causality and directionality of relationships as well as any inferred associations. As a trauma clinician, my theoretical orientation focuses on injury prevention and favorable outcomes in the context of severe trauma, especially TBI. Epidemiological observation shows that the landscape of TBI prevalence and outcome is changing, but there is not a good understanding of how, which would make visible actionable areas for beneficial intermediation. Therefore, this study orients to the phenomenon of TBI epidemiologically. The definition of epidemiology is the study of the distribution and determinants of diseases and injuries in human populations . Epidemiological data includes data gathered via interviews, archival research,indoor garden table and record review as well as via direct observation. The unit of analysis in epidemiology is the individual, yet focuses on identifying factors that are deleterious to the public . For the phenomenon of marijuana use, there are many reasons why individuals choose to use marijuana, either for recreational purposes or medicinal purposes.

While the social aspects and context for marijuana exposure and use are important in and of themselves, potentially adverse clinical outcomes are equally as important and valid. Findings of this epidemiological study may uncover important demographic characteristics and health effects that warrant further study to help better understand the positive and negative effects of marijuana exposure in the context of traumatic brain injury. In summary, while the individual and social characteristics of marijuana use may be diverse and in need of study, findings from the literature review in Chapter 2 identified that these individuals as a collective group are potentially at more at risk for incurring an injury that could eventually lead to a TBI. Determining this risk and identifying characteristics of the population that are potentially at greater risk than others is an appropriate focus for study.A correlate is defined in this study as a characteristic of the marijuana-positive patient. Correlates were identified through the literature review , other observational research, and clinical practice expertise. Identified correlates include age, gender, race, ethnicity, other substances, alcohol, alcohol use disorder, chemotherapy for cancer, disseminated cancer and mental/personality disorders. Age will be included because research has shown that certain age groups comprise of a larger percentage of current marijuana users . While no research has associated gender and ethnicity with marijuana use, they are both variables commonly studied in most observational research, therefore, it will be included in this study. Alcohol and other drug use at time of injury will be included in this study because research has shown that 1 in 8 individuals had both alcohol and an drug use disorder in the past year . Cancer dissemination and cancer treatment are included as correlates because studies show that smoked marijuana may be helpful in the treatment of nausea and vomiting because of chemotherapy . Other studies have found that smoked marijuana may be beneficial in the treatment of neuropathic pain related to chemotherapy treatment .

Finally, mental illness will be included as a variable as Cannabis Use Disorder is much higher in individuals with schizophrenia, personality disorders, post-traumatic stress disorder, mood and anxiety disorders, and other types of mental illnesses when compared to the general population . Identified correlates were both identified and confirmed as extractable in the NTDB. There were no identified correlates that were NOT present in the NTDB. See Chapter 4 Table 6 for details about how each variable will be operationalized. Confounding is a type of bias where a variable is associated with both the exposure and a given outcome resulting in a misrepresentation of the true relationship . Confounding variables may conceal a true association, or they may falsely demonstrate an existent association between an intervention or exposure and an outcome when no association actually exists . For this study, a confounder is defined as a variable that is associated with both the independent and dependent variable. Confounders were identified through the literature review , other observational research, and clinical practice expertise. Identified confounders include age, gender, alcohol exposure at time of TBI, and alcohol use disorder, which is defined by the DSM-V as medical diagnosis indicating that the problem of drinking has become severe and chronic for the patient . Physicians typically diagnosis this disorder through their history and physical assessment, which is documented in the patient’s medical record and extracted into the NTDB by trained trauma program registrars. Participants’ age as well as gender may be potential confounders, with males being at higher risk of sustaining a TBI . Another potential confounder in this study is alcohol, or alcohol use disorder. There have been extensive studies conducted on the relationship between alcohol and TBI related outcomes, with alcohol identified in 35-50% of individuals who sustain a TBI . Another confounding variable that will be examined is the use of other drugs.

Evidence suggests that there is an increase in the presence of other drugs, aside from alcohol, in injured and fatally injured drivers . Furthermore, findings from the literature review showed that the presence of other drugs in combination with marijuana was a common occurrence.The first phase of the data cleaning process will be data screening. When screening data, four types of abnormalities will be assessed: missing data, in consistences and outliers,microgreens grow rack odd patterns of distributions, and unexpected analysis results, inferences or abstractions . Descriptive tools, such as Statistical Package for the Social Sciences will be utilized to facilitate the screening process and ensure the process is objective and systematic. A potential source of problem in this study that may be encountered during data collection is missing data, outliers, and inconsistencies due to the use of a database that includes existing data that was not specifically collected for the purposes of this study. Errors such as blank fields, unintentional deletions or duplications during data entry, blank data fields, or values incorrectly entered must be accounted for . Screening methods involving graphical exploration of distributions and statistical outlier detection will be utilized. The second phase in the data cleaning process is the diagnostic phase. In this phase, a diagnosis regarding the nature of concerning data points or patterns will be attempted. Potential diagnoses for each data point include the following: erroneous, true normal, true extreme, or idiopathic . The correct value or data point for certain fields can be obvious and easily noticed . For such erroneous or missing data points, processes regarding dealing with missing data will be implemented and corrected prior to analysis. The treatment phase of identified erroneous data involves correcting, deleting or leaving the error unchanged . For purposes of this study, if impossible or missing values are observed, they will have to be deleted, as there would be no way of correcting that value related to the retrospective and secondary nature of the data. For data points that are true extremes, further examination on the influence of these data points, individually and collectively, on analysis will be made prior to determining whether or not that data point will be deleted or left unchanged .First, an exploratory analysis will be performed to look at frequencies or percentages of missing data, and to help identify how much data is missing. Next, an analysis of the mechanisms, or types, of missingness will be performed to identify whether the missing data is missing completely at random , missing at random , or not missing at random using statistical tests, such as Little’s test for MCAR. Following this, an analysis for patterns of missingness will be performed using a missing pattern value chart. There are two patterns that may be potentially observed: 1) a monotone pattern where data is missing systematically, or 2) an arbitrary pattern where data are missing at random . While the analyses are not definitive, they can bring attention to blatant anomalies in the missingness of data and help to make decisions on the missing data handling procedures.

There are a variety of methods that can be utilized to deal with missing data. The type of method utilized will depend on the percentage of missing data present and cannot be specified beforehand. Simple methods, such as list wise or pairwise deletion are helpful when the percentage of missing data is less than 5%. List wise deletion, also known as complete-case analysis, removes all data for a case with one or more missing values. In other words, that case is omitted completely. A disadvantage when using list wise deletion is that it can reduce the sample size. On the other hand, pairwise deletion, also known as available-case analysis, aims at minimizing the loss of other potential data incurred with list wise deletion. Pairwise deletion still uses that case when analyzing other variables with non-missing values; it just excludes that one value with a missing data. An advantage to pairwise deletion over list wise is that it can help increase statistical power. However, pairwise deletion does have its disadvantages in that most software packages use the average sample size across analyses which can create over or underestimation. If the percentage of missing data is greater than 5%, then more advanced methods of dealing with missing data can be utilized, such as imputation. Imputation methods will depend on the pattern of missingness identified and the type of variable requiring imputation . In patterns where missing data is systematic or monotone, methods such as regression, predicted mean matching or propensity scoring are helpful. In patterns where missing data is arbitrary or at random, methods such as multiple imputation using maximum likelihood regression methods to predict missing values based on observed values and sensitivity analyses that simulate the results based on a range of plausible values can be used. Observational studies offer valuable methods for studying various problems within healthcare where other study design methods, such as randomized controlled designs , may not be feasible or even unethical. High quality observational studies can render invaluable and credible results that positively impact healthcare when studying clinically relevant topics in patient populations of interest to practicing clinicians. Despite this, observational studies can be subject to a few potential problems within the design and analytical phases rendering results highly compromised. Potential problems that will be encountered in this study design are selection bias, information bias and confounding. Possible countermeasures to address these problems will be discussed in this section.A potential problem regarding selection bias is present in the current study. The target study population is comprised of a purposive sample of patients registered in the NTDB. The NTDB is a centralized national trauma registry developed by the American College of Surgeons with the largest repository of trauma related data and metrics reported by 65% of trauma centers across the U.S. and Canada. The main advantage to utilizing such a registry for this study is that it constitutes the largest trauma database in the U.S. Furthermore, the NTDB allows for risk-adjusted analyses which can be important when evaluating outcomes in trauma . Despite its incredible potential in informing trauma related research, the selection of participants from the NTDB is not without its own biases. The reporting of data into the NTDB is done on a voluntary basis by participating trauma centers, rendering a convenience sample that may not be representative of all trauma patients, and may also not be representative of all trauma centers across the U.S. . This creates the problem of selection bias. Furthermore, the NTDB is subject to the limitations of selection bias is that it includes a larger number of trauma centers with typically more severely injured patients potentially under representing patients with milder traumatic injuries and injury scores .

If SRET was removed from the equation, approximately equal contributions were seen from use of tobacco products and the number of SUD items.These analyses evaluated whether a long-term prospective study of the development of AUDs and/or SUDs in men corroborated several findings from prior cross-sectional and retrospective studies. The rates of alcohol-related conditions in the current sample reflect the fact that half of the men had an alcoholic parent. Over the 30 years, 41% of these probands developed an AUD, compared with an estimated 12 month or lifetime risk of 15 to 20% in the general population . However, considering the fact that these high-functioning probands had not been selected for an FH of SUDs, the 21% rate of drug-related conditions found in these analyses, compared with general population lifetime estimates of about 10% , might have been less expected.As predicted by Hypothesis 1 and several reports in the literature , the presence of either an AUD or an SUD was associated with an increased rate of the other diagnosis. This increase for SUDs among subjects with AUDs was in the range of individuals with alcohol abuse who developed an SUD as reported in an earlier study , although not as great an increase in SUDs evidenced in subjects with alcohol dependence in that investigation. The less robust increase in this study compared with some prior reports may reflect the exclusion from the protocol of subjects with severe antisocial problems, the few subjects with an FH of SUDs,greenhouse tables and the overall high functioning of these probands. The general similarity among the probands regarding baseline demography and psychiatric histories facilitated our ability to focus on the impact of several genetically influenced intermediate phenotypes that relate to the risk of SUDs and/or AUDs . Regarding Hypothesis 2 , in Tables 1 and 2, while the 4 outcome groups did not diffffer greatly on internalizing problems, higher scores on externalizing traits were related to SUDs, AUDs, and combined diagnoses.

The fact that the externalizing questionnaires had not been measured at T1, but were evaluated at T10 or T15, means that we can only describe associations of these scores with the 4 outcomes, although the trait nature of the measures implies a possible causal relationship. Regarding Hypothesis 3 , the first 2 tables also demonstrated a consistent relationship between a baseline low LR with the risk of AUDs, but LR was not related to the vulnerability toward SUDs. These findings underscore the heterogeneity among genetically influenced characteristics that impact on the risk of AUDs and/or SUDs. The results are consistent with the literature indicating that some intermediate phenotypes relate to both AUD and SUD development,while other characteristics, such as the low LR to alcohol and the skin flush associated with drinking, have been reported to be associated with the risk of AUDs alone . Regarding Hypothesis 4 , there were few unique earlier life correlates of combined diagnoses, and the predictors of Group 1 reflected items that related to AUDs alone and SUDs alone. One important caveat regarding this conclusion, however, relates to the differences across Groups 1, 2, and 3 regarding the performance of novelty seeking, sensation seeking, and impulsivity, as these externalizing characteristics are not homogenous . Additional study is needed to explore the possibility that the different scores on these questionnaires across Groups 1 to 3 may have clinically relevant implications. The data in Table 3 support Hypothesis 5 . Even in this prospective study of men at high risk of AUDs, the development of combined AUDs and SUDs was associated with heavier substance use and more alcohol and drug problems over the 30 years for men in Group 1 compared with Groups 2 or 3. This result was observed despite similar ages, racial distributions, education, religious involvement, as well as alcohol and drug histories at T1 for Groups 1 and 3. The course of combined diagnoses might reflect the impact of concomitant substance use itself, perhaps through greater impaired judgment, poor executive functioning, and problems in mood regulation associated with the exposure to multiple types of substances . Table 3 also offers information regarding the outcomes at T30 for SUDs and AUDs in these high-functioning men from a nonclinical population. As described in a recent article , 42% of these probands with AUDs no longer met criteria for alcohol abuse or dependence in the approximate 5 years prior to T30.

It is interesting to note that those results were seen for members of both Group 1 and Group 3. Remissions at T30 were even more striking for SUDs where >70% of Group 1 and 2 men no longer fulfilled criteria for these diagnoses, with similar rates for the combined diagnosis Group 1 and the SUD only Group 2. These impressive rates of recovery may reflect the combination of indicators of a good prognosis in these subjects regarding their nonclinical status at T1, the high proportion who were married during the follow-up, their high education level, and the general absence of premorbid conduct or antisocial problems, as well as the high rates of spontaneous recovery associated with substance-related conditions over time . Results might be different in less educated or more antisocial groups recruited from clinical populations . Several caveats must be kept in mind when viewing these findings. On the positive side, the SDPS is a large study with intensive follow-up interviews carried out about every 5 years over 30 years. The project was structured to allow for evaluation of the development of AUDs and related problems over time in individuals for whom the impact of several additional factors that affect the risk of alcoholism was partially controlled. Thus, the probands did not have severe conduct problems or prior histories of bipolar disorder or schizophrenia, each of which enhance the risk of all substance-related disorders . Those steps were taken to optimize the ability to evaluate the relationship between the low LR to alcohol and the future development of AUDs. These deliberate exclusions were also likely to have contributed to selecting probands with future high levels of functioning despite their elevated risk of AUDs. However, those steps and the relative homogeneity of the sample regarding sex, education, and race potentially limited the generalizability of the findings. An additional caveat is that, while the population was relatively large for a long-term intensive follow-up, the number of individuals developing SUDs was relatively small with resulting limited statistical power in some analyses. This contributed to the decision to combine abuse and dependence into a single category and to consider amphetamines and cocaine as stimulants.

It is also important to emphasize that while the results regarding externalizing personality test scores were consistent with the predicted direction of such values, only 3 questionnaires were used and those were measured at least 10 years after subjects entered the protocol. In addition, earlier life internalizing phenomena were evaluated by only baseline histories of depressions or mental health treatment. Finally, the approach to regressions used here may have optimized statistical power by minimizing standard errors and producing relatively narrow confidence intervals, although an alternate method, hierarchical logistic regression, produced similar results but has the limitation of not requiring that every item in the block add significantly to the prediction.Recreational marijuana commercialization is gaining momentum in the US. Among the 11 states and Washington DC that have legalized recreational marijuana since 2012, retail markets have been opened or anticipated in 10 states, where over a quarter of the US population live. Children are at a high risk of initiating marijuana use and developing adverse consequences related to marijuana. The rapidly evolving environment poses considerable concerns about children’s exposure to marijuana and related marketing and creates significant challenges for pediatricians preventing, treating,vertical farming and educating about marijuana related harms among children. As stated in its most recent policy statement about marijuana commercialization, the American Academy of Pediatrics “strongly recommends strict enforcement of rules and regulations that limit access and marketing and advertising to youth”. The presence of RMDs in neighborhoods and point-of-sale marketing such as advertising and promotional activities in RMDs might increase the visibility and awareness of marijuana products among children, whose perceptions and behaviors may be influenced. A study in Oregon found that dispensary storefront was the most common source of advertising seen after commercialization. Self-reported exposure to medical marijuana advertising was found to be related to higher levels of use and intentions of future use among children in California schools. Products, packages, and advertisements that are designed to be appealing to children are particularly concerning. Tobacco and alcohol literature repeatedly suggested that children are common targets of marketing. Despite the fact that all the states with marijuana commercialization have some form of prohibitions on child-appealing products and marketing, it remains undocumented as to what extent the marijuana industry is complying. This study is the first to comprehensively assess point-of-sale marketing practices in RMDs with a focus on those relevant to children. Unlike previous marijuana research relying on individual self-reported exposure measures, we adopted the direct and objective observation approach that has been commonly used in tobacco and alcohol studies on retail outlets. We audited RMDs near a representative and large sample of schools in California, the largest legal retail market in the US where over 10 million children can be potentially influenced. We identified product and packaging characteristics, advertising and promotional activities, and access restrictions in these dispensaries. This was a cross-sectional and observational study conducted in June-September in 2018.

We obtained a list of public schools in California that participated in the 2017-18 California Student Tobacco Survey . The CSTS schools were drawn using a two-stage stratified random sampling approach. California was first stratified into 22 regions. Schools within each region were then randomly selected, proportional to the number of students enrolled within the region. A total of 623 schools across California were sampled and invited, with 403 schools agreeing to participate. Among these 403 schools, 44 schools opted out before the survey was conducted, and 26 schools participated in the survey but were excluded from CSTS data due to low response rate. The final effective school sample size was 333, among which 256 were high schools and 77 were middle schools. The total number of students participating in the survey was 151,404, making it the largest school-based surveys in California. Our study focused on RMDs near these 333 schools. Six trained field workers audited retail environments in RMDs in closest proximity to the 333 schools . We first identified dispensaries using crowd sourced online websites, including Weedmaps, Wheres weed, Leafly, and Yelp. State licensing records were not used because they could not provide a complete list of dispensaries at the time of data collection. Specifically, 1) Marijuana commercialization in California took effect in January 2018. During the study period, California was in a transition stage when annual licenses were just issued, and most were not approved. 2) The licensing policy in California was not enforced, with a large portion of dispensaries operating without licenses. 3) For licensed dispensaries, the registered and actual business name and address often mismatched. Alternatively, we utilized crowd sourced databases, which were considered as reliable, up-todate, and comprehensive sources of dispensary directories. To identify the dispensary closest to a school, field workers entered school zip code in the online searchable databases. The street addresses of all the dispensaries with the school zip code were geocoded and mapped in ArcGIS to compute their distances to the school. Field workers then called the dispensary with the shortest distance to verify its address and operational status. These procedures were repeated if a dispensary was permanently closed or not verifiable via multiple calls until an active dispensary was identified. The primary focus was RMDs. Yet, medical marijuana dispensaries that require a doctors’ recommendation or state patient ID cards coexisted in California in 2018. During call verifications, if dispensary staff indicated that a doctors’ recommendation or a patient ID was required to enter the dispensary and make purchase, the dispensary was categorized as a MMD.i Fieldworkers also verified dispensary classification during the subsequent auditing. For those verified as MMDs, we repeated the aforementioned procedures until an active RMD was identified.

Evaluations asked about their interval drinking status and problems, including each of what became the 11 DSM-IV AUD criteria using questions derived from the Semi-Structured Assessment for the Genetics of Alcoholism instrument . Subsequently, over 90% of probands were evaluated every 5 years where data were gathered regarding their own drinking practices and problems, and where the probands and their spouses offered information regarding the proband’s biological offspring. Note that the proband’s AUD diagnoses used in the current analysis were based on personal interviews with that proband father. For the current data, beginning at offspring age 18, an interview was carried out with these second-generation sons and daughters using a set of questions similar those asked during proband followups. Offspring were also followed with personal interviews about every 5 years regarding changes in demography, substance use and problems, and development of major psychiatric disorders. Followup evaluations also included filling out the Impulsiveness Sub-scale of the Karolinska Scales of Personality and the Zuckerman Sensation Seeking Scale . The offspring interviews contained items extracted from the Family History Assessment Module used in conjunction with the SSAGA in Collaborative Study of the Genetics of Alcoholism research . As part of the FH section of their interview, offspring were asked: “Have any of your parents or siblings had any of the these [following] experiences because of their own drinking?”. The items included the 11 DSM-IV AUD criteria plus a question about craving. In our offspring protocol,cannabis growing supplies before exiting the FH section interviewers also asked about alcohol quantities and frequencies for each first degree relative along with a re-review of the alcohol problems.

For these analyses, if the son or daughter endorsed 2 or more of the alcohol problem items for their father, the report was considered a positive indication of the proband’s alcohol problem. This relatively liberal FH interpretation of alcohol problems was used considering the advice against invoking excessively restrictive criteria when identifying a FH of AUDs , as described in the Introduction. At the time the current analyses were carried out, there were 447 probands’ sons and daughters age 18+, of whom 352 had been interviewed. Of these 352, 135 were offspring who were eligible for the analyses because they were drinking offspring of the 73 probands who had developed DSM-IV AUDs in the interval since entering the study. The major analyses focus on whether the offspring recognized the presence of their father’s DSM-IV alcohol problems that had been identified from the father’s own semi-structured interview. The proband’s AUD FH listed in Table 1 was based on the proband’s report of his mother’s and father’s alcohol problem history, but, using the FHM approach at study entry, the proband’s parents were not directly interviewed. Among those AUD probands, 21 had only one relevant offspring, 44 had 2 offspring, and 8 reported 3 or more drinking offspring age 18+. The Design Effect related to the possible skew of results caused by the number of children per family ranged from 0.08 to 1.37 across the FH alcohol questions, where 2.0 or higher would indicate a potential meaningful effect of multiple off- spring per family . In addition to SSAGA interviews and personality questionnaires, all probands and drinking offspring also reported their usual intensity of response to alcohol using the retrospective Self-Report of the Effects of Alcohol questionnaire , which is the only LR to alcohol measure available in both generations. This 12-item instrument records the average number of standard drinks required for up to 4 effects during the approximate first 5 times of drinking , their period of heaviest alcohol intake, and the 3 most recent drinking months.

The 4 possible effects included drinks required to: actually experience first alcohol effects, slurring speech, develop unsteadiness of walking, and unwanted falling asleep, with the greater the number of drinks for effects the lower the level of response, or sensitivity, per drink .The data were based on personal interviews with 135 SDPS drinking offspring who were age 18 or older and whose fathers developed DSM-IV alcohol abuse or dependence since entering the study as non-AUD drinkers at about age 20. To be included in analyses, the probands had to have at least one drinking biological offspring who was at least age 18 at the time of their most recent follow-up in 2018 or 2019 . While not the focus of this report, additional data indicated that 97.2% of the offspring of non-AUD probands correctly identified their father’s status . As shown in the first data column of Table 1, the average father in the proband–offspring pairs was 55 years old, European American, had ever been married, 25% ever divorced, and reported 18 years of education. Reflecting the criteria used to select the original SDPS probands, 64% had a parent with an AUD. During the 35 years of their followups, 61% of these AUD probands met criteria for alcohol dependence and 39% for alcohol abuse. During the followup, these men reported a lifetime average maximum of 17 standard drinks per occasion and endorsed an average of 5.5of the 11 DSM-IV criterion items. The lifetime rate of endorsement for each AUD criterion ranged from 87% for often using alcohol in higher quantities or for longer periods than intended to 21% for recurrent alcohol-related legal problems. During the 35 years of follow-up, about half of these probands had used tobacco products, over 90% had used cannabis, 73% had used other illegal drugs, 16% ever met criteria for a cannabis use disorder, and 21% met criteria for a SUD on another illicit drug. Although the numbers for variables in Table 1 were generated by considering all 135 proband–offspring pairs, no values were significantly different from those in Table 1 if data were limited to the 73 individual AUD probands involved in these analyses.

Data columns 2 through 4 in Table 1 indicate 11 signififi- cant differences across the 22% of probands for whom at least 1 offspring reported knowing about their father’s alcohol problems and the 78% of probands for whom no son or daughter recognized their father’s condition . Two of these 11 differences did not survive the Holm–Bonferroni procedure . The 9 differences that did survive included a slight but significantly lower ages for Group 1 probands, but there were no other significant demographic differences, including similarities for the proportions who were divorced from the off- spring’s mothers. Group 1 also reported higher values for the proband having a parent with an AUD, a proband diagnosis of alcohol dependence, the need for more drinks for effects the first 5 times of drinking, and reporting a higher number of the 11 lifetime DSM-IV AUD items. The latter included noting higher proportions of probands who endorsed spending a great deal of time involved with alcohol, decreasing other important activities in order to drink, continuing to use alcohol despite medical or psychological problems caused by alcohol, and drinking despite social or interpersonal problems related to alcohol. Although not shown in Table 1, if the analyses were limited to counting each proband only once and selecting only the oldest son or daughter when data from multiple offspring were available, significant differences remained for criterion items of a great deal of time spent regarding alcohol,cannabis indoor growing giving up important activities to drink, continuing to drink despite medical and psychological problems caused by alcohol and continuing despite interpersonal or social problems. In that smaller sample, group differences similar to those in Table 1 remained at a trend for a proband’s AUD FH, his alcohol dependence diagnosis and for his maximum drinks. Table 2 focuses on data from the 135 interviewed offspring of the probands who had developed an AUD during the 35 years of follow-up. Overall, these sons and daughters were 25 years old, European American, and had 15 years of education, with about 20% having ever been married and a third who identified with a religion. Two thirds of these offspring ever met criteria for an AUD , their average lifetime maximum drinks per occasion was 11, and they reported experiencing an average of 3 of the 11 AUD criteria in their lives, ranging from 60% for spending a great deal of time involved with alcohol to 3% who ever fulfilled criteria for alcohol withdrawal. About 32% had used tobacco products, 71% had ever used cannabis , and 6% ever met criteria for a SUD related to another illegal drug. Among these 135 sons and daughters, 8 variables were significantly different across Group 1 offspring who correctly identified their proband father as having an alcohol problem and those who did not . Four of these variables did not survive the Holm–Bonferroni procedure . Focusing on the 4 variables that survived the Bonferroni step, Group 1 offspring were more likely to have ever fulfilled criteria for an AUD, including higher rates than Group 2 for alcohol dependence.

Overall, offspring in Group 1 reported experiencing a higher number of alcohol criterion items, including higher proportions who endorsed spending a great deal of time centered on alcohol. In Table 2, however, the 2 groups were similar on demography , use of tobacco products or illicit drugs, and had similar scores on impulsivity. The major findings in this report relate to Table 3, and data from Tables 1 and 2 are offered to describe the populations overall and characterize how the group differences in Table 3 relate to the original data. Table 1 had 11 significant effects, and Table 2 had 8, for a total of 19 such effects across the 2 tables. Using the Lowry VassarStats binomial program , the exact binomial likelihood for 19 significant out of 60 tests is <0.0001, indicating that that number of significant findings would only occur by chance one in less than 10,000 times. Also, the Holm–Bonferroni sequential correction was conducted to take into account multiple testing effects and adjusting for family-wise error in Tables 1 and 2, using the Gaetano EXCEL calculator. This yielded 13 variables that remained significant with adjusted p-values from 0.0143 to 0.044. These included 9 proband variables as well as total number of DSM items, alcohol dependence, parent AUD, SRE-T, and age. Also included were 4 offspring items . It is important to note that of the 6 variables that remained in the backward elimination logistic regression , 5 are among those that were still significant after correcting for multiple testing. Only the item “identify with religion” that remained in the final regression model was not on the list of those that were significant after the Holm–Bonferroni sequential correction. The key step in these analyses, as shown in Table 3, simultaneously evaluated both fathers and offspring characteristics that related to Group 1 membership. Recognizing that many of the variables in Tables 1 and 2 were likely to correlate with each other, regression analyses were constructed to determine which characteristics remained robust when considered in the context of all other characteristics used in relevant analyses. To ensure that all father–offspring pairs were considered, the analyses used a bootstrap approach. In Table 3, all variables from Tables 1 and 2 were evaluated except for items that overlapped greatly with another variable or when the item was endorsed similarly by the large majority of participants in both groups.Table 3 presents the results from this bootstrapping approach for variables that added significantly to at least 200 iterations of the 1,000 bootstrap analyses. Here, for each relevant variable data column 1 presents the number of bootstrap regression analyses to which the variable added significantly, data column 2 presents the average odds ratio regarding correct identification that the AUD proband father had problems with alcohol, and the average significance level of that OR is presented in data column 3. With a mean McFadden pseudo R2 of 0.36, 5 variables from the probands and one from the offspring significantly entered at least 200 bootstrap analyses. Significant items for probands that related to the offspring correctly indicating their father had alcohol problems included the father’s self-report of spending a lot of time using alcohol or recovering from its effects, being more likely to identify with a religion , the proband was more likely to report that he continued to drink despite social/interpersonal problems or despite physical/ psychological problems and that the proband had a parent who met criteria for an AUD.

Participants missing flavor preference data were excluded from the LCA analysis. Given the small number of missing observations, we do not expect their exclusion to impact results. The latent class model is a finite mixture model to identify and characterize clusters of similar participants. To identify distinct subgroups based on participants’ discrete responses to the 8 flavors, where each flavor question included 5 options, we started with fitting marginal latent class models for multiple polytomous outcomes . Starting with a one-class model, we fitted models with increasing numbers of classes up to 10 classes. Each model was run multiple times in the R package poLCA to have relatively good certainty in obtaining global maximum log-likelihood . Models from 2-class to 10-class were compared based on considerations statistically and for ease of interpretation . A five-class model was considered most adequate to describe the data based on statistical and interpretability considerations. Participant sociodemographic characteristics and e-cigarette and/or other tobacco use behaviors were compared between the retained latent classes using pair-wise hypothesis tests and then a multi-variable multi-nomial logistic regression model. Additionally, past 30-day e-cigarette users were asked to endorse their reasons for using e-cigarettes from a list of 21 potential reasons compiled from literature . Reasons were examined across flavor preference classes. Responses were unweighted. Results were considered statistically significant if P<0.05, cannabis growing supplies unless otherwise noted . A five-class LCA solution was chosen based on model fit and interpretability . One class of “straight line” responses was considered potentially indicative of inattentive survey taking and not included in association analyses.

The remaining four classes were subjectively labeled as mint ; no preference ; fruit/sweet ; and dislikes one or more . Consistent with preferences, past 30-day e-cigarette users who were members of the fruit/ sweet class were most likely to report using any fruit and any sweet flavored e-cigarette. However, the mint and no preference classes also reported substantial use of fruit and sweet flavors. Past 30-day e-cigarette users who were members of the mint class were most likely to report use of mint and menthol e-cigarettes. Mint use was less common in the fruit/sweet class and no preference class , but due to use of fruit-ice flavors, menthol use was common . More than one year following FDA enforcement prioritization against certain flavors and types of e-cigarettes , adolescent and young adult e-cigarette users in the present study near universally reported use of flavored products, most often sweet, fruit, or menthol. Use of cartridge/pod systems and disposable e-cigarettes was widespread. It was uncommon to report difficulty finding e-cigarettes in desirable flavors or to report more difficulty finding sweet/fruit flavors compared with prior to enforcement prioritization. Together, the results suggest ample access to and prevalent use of flavored and pod-based e-cigarettes, despite recent policy. Menthol and disposable e-cigarettes were not prioritized for enforcement, citing evidence at the time that youth preference for menthol was “much lower” than for mint and fruit . In a national online survey of adolescents and young adults conducted three months after the policy took effect, a combined category of mint, wintergreen, or menthol flavors was the most used flavor, matching or exceeding use of fruit flavors in all age groups and device types . Disposable devices, which offer convenience and conceal ability at a lower initial cost than reusable devices with interchangeable cartridges/pods, gained substantial market share in the year before the enforcement prioritization policy . Use of disposable devices was widespread in the present work, the other national online study , and 2020 NYTS findings .

These results suggest that flavors and device types not prioritized for enforcement had already or would soon rank among those most used by young people. However, not only were non-prioritized flavors and devices popular with youth, but flavors and devices that were prioritized also persisted as readily accessible and commonly used in the present data and other recent work . The emergence of fruit-ice combination flavors potentially contributes to increasing youth use of mentholated e-cigarettes. Fruit-ice e-cigarette flavors gained substantial popularity around the time of the 2020 FDA enforcement prioritization announcement and, among young adults, have been associated with more frequent vaping and dual- use of combustible tobacco . Participants in our study, when asked to endorse e-cigarette flavors they used from a list, selected menthol less often than fruit ; however, considering fruit-ice flavors as a form of both menthol and fruit greatly narrowed the popularity gap . A survey of high school students in Connecticut emphasized the cooling sensation produced by freeze, ice, or chill vape flavors over the word “menthol” and found 52% prevalence of cooling flavor use among e-cigarette users . Rather than rely on respondents to recognize menthol as a flavor, survey instruments should include ice, fruit-ice, and cooling terminology to capture menthol product use fully. “Ice” flavors not explicitly characterized as menthol in their marketing also have implications for tobacco control and regulation. In April 2021, the FDA announced a commitment to work toward a proposed product standard to eliminate menthol as a characterizing flavor in cigarettes and to ban all characterizing flavors in cigars, aimed in part at reducing youth initiation . Restricting the additives that produce the cooling sensation rather than relying on a characterizing flavor definition would be a more direct and enforceable approach to eliminate cooling flavors . In the present study, strong preference for mint or menthol comprised the largest class and was associated with more lifetime and past 30-day e-cigarette use. While greater lifetime use was also associated with fruit/sweet preference , unlike mint/menthol, fruit/sweet preference was associated with less dual-use of other tobacco.

The cross-sectional nature of the present study requires cautious interpretation, but it is possible that sweet/fruit flavors are more attractive than mint/menthol flavors to youth at lower risk for combustible tobacco use. Notably, female participants were more likely than males to prefer sweet/fruit flavors, reminiscent of tobacco industry research showing that flavored cigarettes would appeal to women and younger smokers . A previous latent class analysis of young adult e-cigarette users found that participants who used multiple devices and flavors tended to vape more . Similarly, a study of high school students reported an association between greater e-cigarette use and liking a larger number of flavors . Likewise, among middle school students in Mexico, liking fruit flavors was associated with greater lifetime e-cigarette use . Together, these results suggest that young people with more experience using e-cigarettes tend also to have stronger flavor opinions. Prospective findings have shown that youth who use sweet, fruit, or buttery e-cigarette flavors are more likely than users of mint/menthol, unflavored, or tobacco flavors to sustain their e-cigarette use over time . While prior research has focused on the most appealing e-cigarette flavors, our study revealed a novel class of individuals who strongly disliked certain flavors. Most participants in this class had weak affinity for some flavors, strongly disliked one or two flavors, cannabis indoor growing and were not unified in which flavor they disliked. Notably, participants in this class differed from all other e-cigarette users in their endorsed reasons for vaping: addiction-related reasons were much more prominent. For youth in this class, for whom nicotine dependence is a potentially stronger driver than flavors of e-cigarette use, flavor restriction policies alone may be insufficient to reduce their use. This suggests a need for multi-pronged policies, including effective youth e-cigarette cessation treatments. In August 2021, the FDA began announcing e-cigarette authorization decisions under the Premarket Tobacco Product Application pathway . The FDA denied marketing orders to many flavored products, granted authorization to a single tobacco-flavored product, Vuse Solo, but as of this writing, had yet to decide on some of the largest e-cigarette brands, including JUUL. In announcing its decision, the FDA cited relatively low youth use of the Vuse brand and tobacco flavors in the 2021 NYTS . In the present study, use of tobacco flavor was indeed relatively uncommon. However, the no preference latent class was the second largest and the group most amendable to tobacco and unflavored e-cigarettes. In its pending PMTA decisions, the FDA should consider both youth affinity for menthol e-cigarettes and the potential for authorized tobacco flavored or unflavored e-cigarettes to become viable alternatives for the many youth without strong flavor preferences. Several study limitations should be considered. While this sample was diverse in its sociodemographic characteristics, commercially administered panel survey respondents are not necessarily representative of the general population . Online survey panels may differ from the general population in their demographic and attitudinal composition. This study was cross-sectional.Only included were e-cigarette repeated ever-users; thus, perceptions of e-cigarette never-users and overall population e-cigarette use prevalence could not be estimated.

It is possible that the FDA enforcement prioritization policy deterred some youth from ever initiating e-cigarette use, and these individuals would not be eligible for this study. Included e-cigarette non-users largely did not perceive difficulty accessing flavored e-cigarettes. Recent evidence indicates that people with schizophrenia or schizoaffective disorder experience deficits in anticipatory pleasure, or pleasure related to future activities, but not in consummatory pleasure, or pleasure experienced in-the-moment . The Temporal Experience of Pleasure Scale is a self-report measure of the general propensity to experience anticipatory and consummatory pleasure . Studies in the U.S., China, Switzerland, and France have found that people with schizophrenia or schizoaffective disorder reported lower anticipatory pleasure but comparable consummatory pleasure on the TEPS compared to healthy controls . Prior studies have also found that TEPS anticipatory and consummatory pleasure scores are positively correlated with functional outcome and negatively correlated with negative symptoms . TEPS anticipatory, but not consummatory, pleasure is negatively correlated with subclinical negative symptoms and is lower in people who score higher on social anhedonia measures compared to those who do not . Studies that utilize the TEPS have thus far almost exclusively included chronically ill people with schizophrenia. However, studies using other self-report measures of anhedonia, such as the Chapman scales of physical and social anhedonia, have found that people early in the course of schizophrenia report more physical anhedonia than the controls and people experiencing their first lifetime episode of psychosis report more social anhedonia compared to the controls . To date, two studies have administered the TEPS to people early in the course of a schizophrenia spectrum disorder . Cassidy et al. found no differences in TEPS anticipatory pleasure between people with and without a psychotic disorder. However, most participants in the study had used cannabis throughout the lifetime, thus making conclusions about the contributions of psychosis versus cannabis use on TEPS scores difficult to disentangle. Schlosser et al. found that people with recent-onset schizophrenia reported less anticipatory than consummatory pleasure on the TEPS but did not differ on either scale compared to a younger, healthy control group. However, people at clinical high risk for schizophrenia reported less anticipatory pleasure than a demographically matched healthy control group. In the current study, we examined people with a recent-onset SSD to determine if and when deficits in reported anticipatory pleasure emerge in the course of the illness. We defined “recent-onset” in our study as experiencing a first episode of psychosis within one year of study participation. Based on previous studies with more chronically ill samples, we hypothesized that people with an SSD would show deficits in anticipatory pleasure but not in consummatory pleasure compared to people without an SSD. We also included measures of symptom severity, occupational functioning, and social functioning in order to examine the correlates of anticipatory pleasure.People with schizophrenia , schizophreniform disorder , or schizo affective disorder who had their first episode of psychosis within one year of study participation were invited to participate . All SSD participants were clinically stable, defined as no inpatient hospitalization within three months of study participation. People who had never experienced a psychotic episode and did not meet the criteria for a current Axis I diagnosis were included as the control group. All but eight participants with an SSD were taking at least one psychiatric medication: 72 were taking a second generation antipsychotic medication, four were taking both first and second generation antipsychotic medications, and four were taking non-antipsychotic psychiatric medication.

Covariates were included into multi-variable models, if univariable analyses showed that they were associated with the outcome variable at the .Significance level. Backward model selection process was applied and the final models kept only those covariates that had P values <.05. For reported models, effects of predictors are described by regression coefficients and their standard errors . A third set of analyses was performed in the subgroup of participants who did not show NCI at baseline. We used Cox proportional hazard models to assess time to NCI. Two models were run: a baseline model, which used values of the VACS Index and baseline covariates; and a time-dependent model, which included time-dependent measures of the VACS Index and covariates. Covariate selection followed the same process as described above. Hazard ratio was used as a measure of effect size for these analyses. Given that the VACS Index was initially developed in HIV-infected persons initiating therapy, we investigated interactions between the VACS Index and ART status for all 3 types of analyses. Based on prior cross-sectional findings showing that HIV infected persons with particularly elevated VACS Index scores might be at highest risk for NCI, we categorized VACS Index scores at each time point based on cutoff scores. These cutoff scores were based on the distribution of the VACS Index at baseline of the current sample . We then performed again the main analyses described above using these categories of the VACS Index . P values for pairwise comparisons of the groups were adjusted for multiple testing using Tukey and false discovery rate methods, and Cohen’s d was computed to measure effect sizes of group differences. All analyses were carried with the statistical software R and used 2-sided tests and a significance level of .05, unless stated otherwise. Sample sizes vary by model, because complete data were not available for some of the covariates .

For a subset of participants ,growing cannabis outdoors the baseline visit for current analyses was their first time to complete neurocognitive assessments. This allowed us to investigate neurocognitive change based on published summary regression-based change scores in this subset of participants. Following methods outlined elsewhere, we determined overall neurocognitive change and performed again core analyses presented above. Results were comparable to previous findings; that is, the VACS Index was significantly associated with neurocognitive decline in time-dependent models after adjustment for significant covariates.We also investigated whether lifetime history of intravenous drug use affected the association of the VACS Index with neurocognitive change in the subset of participants for whom data were available, as well as whether CNS penetration effectiveness affected this association among persons on ART. Findings from all core models showed that the association between the VACS Index and neurocognitive change was substantially similar to that of prior analyses.The present longitudinal study adds to the evolving scientific literature on the VACS Index and NCI by showing that changes in VACS Index scores correspond to changes in neurocognitive function over time in a large, well-characterized HIV-infected cohort. Baseline VACS Index scores were not significantly associated with change in global neurocognitive function during the overall follow-up period of up to 6 years . This suggests that the VACS Index might not be a good predictor of subsequent neurocognitive change over the span of a number of years. However, we found statistically significant associations in time-dependent analyses, indicating that changes in the VACS Index correspond to concurrent changes in global neurocognitive function. These significant associations, albeit relatively small, were found across multiple neurocognitive domains, and remained significant after adjusting for the effect of potential covariates, suggesting an independent effect of the VACS Index. Analyses of a subset of participants who were neurocognitively normal at baseline yielded a similar pattern of results. Baseline VACS Index scores were not significantly associated with incident NCI in adjusted analyses.

However, time-dependent analyses showed that increases in VACS Index scores significantly increased the probability of becoming neurocognitively impaired. Because the VACS Index was initially developed in samples of HIV-infected persons initiating ART, we investigated whether ART status modified the association between the VACS Index and neurocognitive change. We found that this was the case for the memory domain in time-dependent analyses, where there was a significant association between VACS Index scores and memory decline among untreated participants but not among participants receiving ART. Other biomarkers not included in the VACS Index might be important for memory decline in participants on ART. In line with this, effect sizes of analyses by VACS Index group tended to be smaller for learning and memory. Memory problems are the hallmark of neurocognitive conditions of aging, such as Alzheimer’s disease. Considering biomarkers of these other age-related conditions might assist in developing an index that fully encompasses the neurocognitive changes observed among persons aging with HIV infection. We have also found that the association of learning and memory to NCI was not significant among Hispanics. Unfortunately, we did not have enough Hispanic participants with longitudinal data to examine ethnic/racial differences in the current study. Prior findings had indicated that it is valuable to categorize the VACS Index to better understand its association with NCI. In the current study, we found that participants who scored high on the VACS Index were significantly more likely to experience global neurocognitive decline, with effect sizes indicating a relatively strong effect. Among participants who were neurocognitively normal at baseline, those who scored within the high VACS Index range were twice as likely to develop incident NCI as those in the low VACS Index group, and 76% more likely than those in the middle group. Overall, results from these analyses on categorized VACS Index scores support the notion that those with particularly higher VACS Index values are indeed at risk for worse neurocognitive outcomes. Our study had several limitations. Our group of participants was relatively young. Including older participants with higher rates of medical comorbid conditions might strengthen the association between the VACS Index and neurocognitive change.

Most baseline assessments in the present study were completed in the early 2000s and the median duration of HIV infection was 9 years. Thus, many of the participants were diagnosed with HIV infection in the era before combination ART era, and findings might differ in more recently infected cohorts. A relatively small proportion of participants in our sample were of Hispanic origin. Given recent findings, future studies including more Hispanic subjects would better address whether longitudinal associations between the VACS Index and neurocognitive change differ by ethnic group. It has also yet to be established whether other biomarkers not included in the VACS Index might increase its predictive utility for detecting NCI. Some covariates examined in present analyses were unexpectedly associated with neurocognitive change; for example, cannabis use and being off ART were associated with better neurocognitive performance in some models. Although these potentially interesting associations warrant further investigation,microgreens shelving our models were not constructed to investigate their impact on neurocognitive change, and thus caution is warranted in interpreting these findings. Most relevant for the purpose of the current study, the VACS Index was significantly associated with neurocognitive change, even after adjustment for multiple covariates. Another future direction is to investigate whether the combination of the VACS Index and NCI might help improve predictive power for mortality risk among HIV infected persons. Some of the strengths of the study include the use of a comprehensive neurocognitive battery that has been validated in persons with HIV infection and enabled the examination of domains based on composite scores. Overall, baseline VACS Index scores may not be a good predictor of neurocognitive change in the longer term. Changes in VACS Index scores, however, correspond to changes in neurocognition. Although the strength of this association is relatively weak in analyses using continuous scores of the VACS Index, results from categorized VACS Index scores indicate that having very high VACS Index scores might indicate a notable increased risk for neurocognitive decline and for incident NCI. These findings support the VACS Index as a simple tool for identifying HIV-infected patients who are at high risk for NCI and might warrant further neurocognitive follow-up.One -fifth of new HIV diagnoses in the United States are in young people aged 13 to 24 years. Youth are more likely than other age groups to engage in behaviors, such as unprotected sex, substance use, and having multiple sexual partners that place them at higher risk for infection with HIV; however, youth are less likely than older Americans to receive HIV testing.

After infection, adolescents and young adults are also less likely than other age groups to be connected with HIV-related health care, and have low rates of viral suppression. Risk of HIV transmission is greatly elevated for the many young people involved in the U.S. justice system. In 2016, over 850,000 youth under age 18 were arrested. At any given time, nearly 50,000 youth are incarcerated or detained in residential settings. Prevalence of other sexually transmitted infections among youth with justice involvement is significantly higher than what is observed in the general adolescent population,ranging from 9% and 13% chlamydia diagnosis among newly arrested males and females, respectively to 20 to 42% infection rates in studies of detained females. Yet prevalence rates of HIV among the juvenile justice population remain largely unknown and challenging to accurately measure, particularly since many youth are not screened for HIV when entering the juvenile justice system. However, behavioral risk data are clear. Nearly 90% of youth in juvenile detention are sexually active. Thirty -five percent of boys and over 40% of girls report unprotected sex in the past month prior to detention, and 20% of boys and 10% of girls report ever having sex with a high-risk partner. Substance use is often a catalyst for risky behavior: approximately a third of detained youth report having had unprotected sex while drunk or high. As formerly detained youth age into young adulthood, HIV/STI risk behaviors and substance use remain substantially higher than those experienced by youth in the general population, pointing to the enduring influence of incarceration and criminal justice involvement in long-term public health outcomes. Young adults ages 20–-29 years had the highest rates of new HIV infection in the US in 2014, accounting for 36% of new HIV diagnoses, with the vast majority occurring among racial/ethnic minorities. The vast majority of juveniles involved in the justice system return to their communities following arrest, typically within 2 weeks, where they have opportunities to engage in risky substance use and sexual behaviors that increase HIV vulnerability. Individuals supervised by the justice system living in the community may be at higher risk of HIV acquisition and have more difficulty accessing treatment than those incarcerated. These populations often struggle with lack of health insurance, increased rates of sexually transmitted infections, and housing instability, all factors associated with increased risk of HIV acquisition. This is critical to consider for youth involved in the justice system, as legal policies over the past decade have increasingly emphasized diverting justice-involved youth from detention to the community. Diversion programs are an effective way to reduce recidivism. However, fewer youth may receive STI/HIV screening and treatment when not in supervised settings. Congruent with juvenile justice policy changes , recent research examining the interrelationships among HIV/STI risk and substance use has expanded from focusing on detained youth to communitysupervised . For example, in 2010, when our group published a comprehensive rigorous review of any published HIV -prevention interventions for justice involved youth, 16 studies were identified and of these, four were conducted with non-detained or community-supervised justice-involved populations. Five years later, Hong and colleagues published a comprehensive review of HIV/STI -prevention interventions among detained and delinquent youth, of which only 1 of 15 identified studies focused on non-detained youth. To advance public health priorities in line with shifting juvenile justice policy changes, clinicians, researchers, and policymakers must gain a better understanding of justice-involved youths’ intersecting HIV and substance use risks, particularly in their natural environments. We summarize recent main themes of this area of research using data from published reports and provide future directions to guide the field as to requisite next clinical, research, and policy steps regarding HIV prevention and substance use for justice-involved youth. In order to capture all relevant, published studies addressing this broad topic, a comprehensive search strategy was employed, using multiple online search tools.