Neighborhood crime, socioeconomic status, and suspiciousness in adolescents and young adults at Clinical High Risk (CHR) for psychosis

Exposure profiles of social-environmental neighborhood factors and psychotic-like experiences

Importance

Recent research has demonstrated that domains of social determinants of health (SDOH) (e.g., air pollution and social context) are associated with psychosis. However, SDOHs have often been studied in isolation.

Objective

To identify distinct exposure profiles, estimate their associations with persistent distressing psychotic-like experiences (PLE), and evaluate whether involvement with physical activities partially explains this association.

Design Setting and Participants

This population-based study used data from the Adolescent Brain and Cognitive Development (ABCD) Study. Participants were recruited from 22 US sites between September 2016 and January 2022. Data from baseline and three follow-ups were included.

Exposures

Area-level geocoded variables spanning various domains of SDOH, including socioeconomic status (SES), education, crime, built environment, social context, and crime, were clustered using a self-organizing map method to identify exposure profiles.

Main Outcomes and Measures

Persistent distressing PLE was derived from the Prodromal Questionnaire-Brief Child Version across four years. Generalized linear mixed modeling tested the association between exposure profiles and persistent distressing PLE as well as physical activities (i.e., team and individual sports), adjusting for individual-level covariates including age, sex, race/ethnicity, highest level of parent education, family-relatedness, and study sites.

Results

Among 8,145 participants (baseline mean [SD] age, 9.92 [0.63] years; 3,868 (47.5%) females; 5,566 (68.3%) White, 956 (11.7%) Black, 159 (2.0%) Asian, and 1,480 (18.4%) Hispanic participants), five exposure profiles were identified. Compared to the reference Profile 1 (suburban affluent areas, 2521 children, 30.9%), Profile 3 (rural areas with low walkability and high ozone; 1459 children, 17.9%; adjusted OR: 1.34, 95% CI: 1.09-1.64) and Profile 4 (urban areas with high SES deprivation, high crime, and high pollution; 715 children, 8.8%; adjusted OR: 1.40, 95% CI: 1.08-1.81), were associated with persistent distressing PLE. Team sports mediated 6.14% of the association for Profile 3.

Conclusion and Relevance

This study found that neighborhoods characterized by rural areas with low walkability and urban areas with high socioeconomic deprivation, air pollutants, and crime were associated with persistent distressing PLE. Further research is needed to explore the pathways through which different environmental factors may impact the development of psychosis.

Multidimensional Approach to Exploring Neighborhood Determinants and Symptom Severity Among Individuals With Psychosis

Importance

The impact of cumulative exposure to neighborhood factors on psychosis, depression, and anxiety symptom severity prior to specialized services for psychosis is unknown.

Objective

To identify latent neighborhood profiles based on unique combinations of social, economic, and environmental factors, and validate profiles by examining differences in symptom severity among individuals with first episode psychosis (FEP).

Design, Setting, and Participants

This cohort study used neighborhood demographic data and health outcome data for US individuals with FEP receiving services between January 2017 and August 2022. Eligible participants were between ages 14 and 40 years and enrolled in a state-level coordinated specialty care network. A 2-step approach was used to characterize neighborhood profiles using census-tract data and link profiles to mental health outcomes. Data were analyzed March 2023 through October 2023.

Exposures

Economic and social determinants of health; housing conditions; land use; urbanization; walkability; access to transportation, outdoor space, groceries, and health care; health outcomes; and environmental exposure.

Main Outcomes and Measures

Outcomes were Community Assessment of Psychic Experiences 15-item, Patient Health Questionnaire 9-item, and Generalized Anxiety Disorder 7-item scale.

Results

The total sample included 225 individuals aged 14 to 36 years (mean [SD] age, 20.7 [4.0] years; 152 men [69.1%]; 9 American Indian or Alaska Native [4.2%], 13 Asian or Pacific Islander [6.0%], 19 Black [8.9%], 118 White [55.1%]; 55 Hispanic ethnicity [26.2%]). Of the 3 distinct profiles identified, nearly half of participants (112 residents [49.8%]) lived in urban high-risk neighborhoods, 56 (24.9%) in urban low-risk neighborhoods, and 57 (25.3%) in rural neighborhoods. After controlling for individual characteristics, compared with individuals residing in rural neighborhoods, individuals residing in urban high-risk (mean estimate [SE], 0.17 [0.07]; P = .01) and urban low-risk neighborhoods (mean estimate [SE], 0.25 [0.12]; P = .04) presented with more severe psychotic symptoms. Individuals in urban high-risk neighborhoods reported more severe depression (mean estimate [SE], 1.97 [0.79]; P = .01) and anxiety (mean estimate [SE], 1.12 [0.53]; P = .04) than those in rural neighborhoods.

Conclusions and Relevance

This study found that in a cohort of individuals with FEP, baseline psychosis, depression, and anxiety symptom severity differed by distinct multidimensional neighborhood profiles that were associated with where individuals reside. Exploring the cumulative effect of neighborhood factors improves our understanding of social, economic, and environmental impacts on symptoms and psychosis risk which could potentially impact treatment outcomes.

Review of factors resulting in systemic biases in the screening, assessment, and treatment of individuals at clinical high-risk for psychosis in the United States

Background

Since its inception, research in the clinical high-risk (CHR) phase of psychosis has included identifying and exploring the impact of relevant socio-demographic factors. Employing a narrative review approach and highlighting work from the United States, sociocultural and contextual factors potentially affecting the screening, assessment, and service utilization of youth at CHR were reviewed from the current literature.

Results

Existing literature suggests that contextual factors impact the predictive performance of widely used psychosis-risk screening tools and may introduce systemic bias and challenges to differential diagnosis in clinical assessment. Factors reviewed include racialized identity, discrimination, neighborhood context, trauma, immigration status, gender identity, sexual orientation, and age. Furthermore, racialized identity and traumatic experiences appear related to symptom severity and service utilization among this population.

Conclusions

Collectively, a growing body of research from the United States and beyond suggests that considering context in psychosis-risk assessment can provide a more accurate appraisal of the nature of risk for psychosis, render more accurate results improving the field's prediction of conversion to psychosis, and enhance our understanding of psychosis-risk trajectories. More work is needed in the U.S. and across the globe to uncover how structural racism and systemic biases impact screening, assessment, treatment, and clinical and functional outcomes for those at CHR.

Psychosis-like experiences and resilience: A systematic and critical review of the literature

Resilience research has documented the ability to cope with traumatic and stressful situations and/or retain functioning given certain risk factors in the context of psychosis. In this study, we conducted the first systematic review of the literature on psychosis-like experiences (PLEs) and resilience. Fifteen articles (from 11 unique study samples) from 10 countries were included in this systematic review, with a total of 11,937 unique study participants. Inclusion criteria were broad, capturing a wide range of individuals with PLEs who have not yet experienced threshold psychosis, such as individuals in the general population with elevated self-reports of PLEs, as well as clinical groups diagnosed by clinician interviews (i.e., clinical- or ultra-high-risk for psychosis [CHR or UHR]). For this review, studies needed to include research aims and empirical research related to resilience, and use an established or author-defined measure of psychological and/or social resilience. Data reporting quality was assessed with the Strengthening the Reporting of Observational Studies in Epidemiology and place of residence, race/ethnicity/culture/language, occupation, gender/sex, religion, education, socioeconomic status, social capital (PROGRESS) guidelines. Study aims and measurement of key variables varied widely, and all studies were cross-sectional. In 73% of the studies, resilience was inversely associated with PLEs or psychosis risk status (e.g., CHR or UHR). Results related to specific resilience subscales were mixed. Author-defined resilience was typically related to internal/psychological resources. Future research, particularly longitudinal research involving multidimensional measurement of resilience (e.g., internal and external factors), along with well-defined theoretical models, are necessary before drawing firm conclusions on resilience and PLEs. We propose a dynamic, multifaceted, developmentally appropriate, and culturally sensitive model of resilience for future research. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Equity in Mental Health Services for Youth at Clinical High Risk for Psychosis: Considering Marginalized Identities and Stressors

Prevention and early intervention programs have been initiated worldwide to serve youth at Clinical High Risk for Psychosis (CHR-P), who are adolescents and young adults experiencing subclinical psychosis and functional impairment. The primary goals of these efforts are to prevent or mitigate the onset of clinical psychosis, while also treating comorbid issues. It is important to consider issues of diversity, equity, and inclusion in CHR-P work, especially as these programs continue to proliferate around the world. Further, there is a long history in psychiatry of misdiagnosing and mistreating psychosis in individuals from racial and ethnic minority groups. Although there have been significant developments in early intervention psychosis work, there is evidence that marginalized groups are underserved by current CHR-P screening and intervention efforts. These issues are compounded by the contexts of continued social marginalization and significant mental health disparities in general child/adolescent services. Within this narrative review and call to action, we use an intersectional and minority stress lens to review and discuss current issues related to equity in CHR-P services, offer evidence-based recommendations, and propose next steps. In particular, our intersectional and minority stress lenses incorporate perspectives for a range of marginalized and underserved identities related to race, ethnicity, and culture; faith; immigration status; geography/residence; gender identity; sexual orientation; socioeconomic status/class; and ability status.

Family's Subjective Economic Status and Children's Matrix Reasoning: Blacks' Diminished Returns

BACKGROUND

Due to a pattern known as Marginalization-related Diminished Returns (MDRs), historically oppressed non-Hispanic Black Americans show weaker effects of economic status on health and development, when compared to socially privileged non-Hispanic White Americans. Such MDRs are also documented for the effects of economic status on the school performance of non-Hispanic Black children. However, the existing knowledge is minimal on similar diminished returns on children's intelligence.

AIM

To compare racial and ethnic groups for the effect of subjective economic status on children's cognitive performance, we compared non-Hispanic White and non-Hispanic Black children for the effects of subjective economic status on children's matrix reasoning.

METHODS

This cross-sectional study included 7898 children from the Adolescent Brain Cognitive Development (ABCD) study. The predictor variable was subjective economic status, which was treated as a continuous measure. The primary outcome was children's matrix reasoning, a domain of cognitive performance, measured by the Wechsler Intelligence Scales for Children-IV (WISC-V) matrix reasoning total score.

RESULTS

Overall, high subjective economic status was associated with higher matrix reasoning score. Race showed a statistically significant interaction with subjective economic status on children's matrix reasoning score. This interaction suggested that high subjective economic status has a smaller boosting effect on increasing matrix reasoning score for non-Hispanic Black children relative to non-Hispanic White children.

CONCLUSION

The degree by which subjective economic status correlates with matrix reasoning score, an important domain of cognitive performance, depends on race and racialization. Non-Hispanic Black children may show weaker gains in matrix reasoning from their subjective economic status than their non-Hispanic White counterparts. To minimize the racial gap in cognitive performance, we need to address diminished returns that occur as a result of the racialization of racial and ethnic minority children. Not only should we equalize economic status, but also increase the marginal returns of economic status for racial minorities, particularly non-Hispanic Black families. Such efforts require public policies that go beyond access and also consider how we can empower non-Hispanic Black communities and families so they can more effectively leverage and utilize their economic resources to secure measurable and tangible outcomes. Structural and societal barriers such as residential and school segregation may hinder non-Hispanic Black children from receiving the full effects of their family-level economic status on a variety of outcomes, including their cognitive performance.

Parents' Perceived Neighborhood Safety and Children's Cognitive Performance: Complexities by Race, Ethnicity, and Cognitive Domain

BACKGROUND AIM

To examine racial/ethnic variations in the effect of parents' subjective neighborhood safety on children's cognitive performance.

METHODS

This cross-sectional study included 10,027 children from the Adolescent Brain Cognitive Development (ABCD) study. The exposure variable was parents' subjective neighborhood safety. The outcomes were three domains of children's cognitive performance: general cognitive performance, executive functioning, and learning/memory. We used mixed-effects regression models for data analysis.

RESULTS

Overall, parents' subjective neighborhood safety was positively associated with children's executive functioning, but not general cognitive performance or learning/memory. Higher parents' subjective neighborhood safety had a more positive influence on the executive functioning of non-Hispanic White than Asian American children. Higher parents' subjective neighborhood safety was associated with higher general cognitive performance and learning/memory for non-White children relative to non-Hispanic White children.

CONCLUSION

The race/ethnicity of children moderates the association between neighborhood safety and cognitive performance. This becomes more complicated, as the patterns seem to differ across race/ethnicity and cognitive domains. It is unknown whether the observed racial/ethnic variations in the effect of neighborhood safety on cognitive performance are due to neighborhood characteristics such as residential segregation. Addressing neighborhood inequalities is needed if we wish to reduce racial/ethnic inequities in the cognitive development of children.

Household Income and Children's Depressive Symptoms: Immigrants' Diminished Returns

Introduction

Relative to socially privileged groups, socially marginalized people experience weaker health effects of household income and other economic resources, a pattern known as Minorities' Diminished Returns (MDRs). These MDRs are frequently seen in racial and ethnic minorities, but less is known about the relevance of such MDRs in immigrant families. To investigate the MDRs of household income on children's depression as a function of immigration, we compared non-immigrant and immigrant children for the effect of household income on children's depressive symptoms.

Methods

This cross-sectional study was conducted across multiple cities in the United States. Baseline data from the Adolescent Brain Cognitive Development (ABCD) study collected in 2018 was used. A total of 6,412 children between the ages of 9-10-year-old were included. The predictor variable was household income. The primary outcome was children's depression measured by the Child Behavior Checklist (CBCL). Race, ethnicity, age, sex, parental marital status, parental employment, and financial difficulties were the covariates. Immigration status was the effect modifier.

Results

Overall, high household income was associated with lower children's depressive symptoms. Immigration status showed a statistically significant interaction with household income on children's depression. This interaction term suggested that high household income has a smaller protective effect against depression for immigrant children than non-immigrant children.

Conclusion

The protective effect of household income against children's depression is diminished for immigrant than non-immigrant children.

Parental Human Capital and Adolescents' Executive Function: Immigrants' Diminished Returns

Racial minorities, particularly non-Hispanic Blacks in the US, experience weaker effects of family socioeconomic position (SEP) on tangible outcomes, a pattern called Minorities' Diminished Returns (MDRs). These MDRs are frequently shown for the effects of family SEP on immigrant adolescents' school performance. As a result of these MDRs, immigrant adolescents from high SEP families show worse than expected cognitive outcomes, including but not limited to poor school performance. However, the existing knowledge is minimal about the role of executive function in explaining diminished returns of family SEP on adolescents' outcomes. To investigate racial differences in the effects of parental human capital on adolescents' executive function, we compared non-Hispanic White non-immigrant and immigrant adolescents for the effect of parental human capital on adolescents' executive function. This was a cross-sectional analysis that included 2,723 non-twin non-Hispanic White adolescents from the Adolescent Brain Cognitive Development (ABCD) study. The independent variable was parental human capital (parental educational attainment), treated as a continuous measure with a higher score reflecting higher subjective socioeconomic status. The primary outcome was adolescents' executive function measured by the stop-signal task (SST). Age, sex, parental marital status, parental employment, family income, and financial difficulties. Immigration status was the effect modifier. Overall, high parental human capital was associated with higher task-based executive function. Immigration status showed statistically significant interactions with parental human capital on adolescents' executive function outcomes. This interaction term suggested that high parental human capital has a smaller effect on increasing immigrants' executive function compared to non-immigrant adolescents. The boosting effect of parental human capital on executive function is diminished for immigrants compared to non-immigrant adolescents. To minimize the inequalities in executive function-related outcomes such as school performance, we need to address the diminishing returns of existing resources for immigrants. Not only should we equalize groups based on their SEP but also equalize the marginal returns of their existing SEP. Such efforts require public policies that aim for equal processes. As such, social policies should address structural and societal barriers such as xenophobia, segregation, racism, and discrimination that hinder immigrant families' ability to effectively utilize their resources. In a fair society, immigrant and non-immigrant families should be equally able to leverage their SEP resources and turn them into tangible outcomes.

Subjective Family Socioeconomic Status and Adolescents' Attention: Blacks' Diminished Returns

Background: Racial minorities, particularly non-Hispanic blacks (NHBs) in the US, experience weaker effects from their families' socioeconomic status on tangible outcomes, a pattern called the Minorities' Diminished Returns (MDRs) theory. These MDRs are frequently shown in the effects of the families' socioeconomic status (SES) on NHB adolescents' school performance. As a result of these MDRs, NHB adolescents from high SES families show a worse than expected school performance. The existing knowledge is, however, minimal about the role of attention in explaining the diminished returns of the families' SES with regard to the adolescents' outcomes. Aim: To investigate the racial differences in the effects of the subjective family SES on adolescents' attention, we compared non-Hispanic white (NHW) and NHB adolescents to assess the effect of the subjective family SES on adolescents' attention. Methods: This was a cross-sectional analysis that included 4188 adolescents from the Adolescent Brain Cognitive Development (ABCD) Study. The independent variable was the subjective family SES. The primary outcome was the adolescents' attention to be measured by the stop-signal task (SST). The attention domain of the Child Behavior Checklist (CBCL) was also measured. Results: Overall, a high subjective family SES was associated with a higher task-based and CBCL-based attention. Race showed statistically significant interactions with subjective family SES in terms of adolescents' attention outcomes. These interactions suggested that a high subjective family SES has smaller tangible effects on increasing the attention of NHB than NHW adolescents. Conclusion: The boosting effect of subjective family SES on attention is diminished for NHB rather than NHW adolescents. To minimize the racial gap in attention-related behaviors, such as school performance, we need to address the diminished returns of resources in the lives of NHB families. Not only should we equalize SES, but also increase the marginal returns of SES for racial minorities, particularly NHB families. Such efforts require public policies that empower NHB families to better leverage their SES resources and turn them into tangible outcomes. In addition, social policies should directly aim to alter the societal barriers that limit NHB families' ability to effectively utilize their resources. Discrimination, segregation, and racism should be targets of our policy solutions.

Telepsychotherapy with Youth at Clinical High Risk for Psychosis: Clinical Issues and Best Practices during the COVID-19 Pandemic

Early detection and prevention of psychosis has become an international priority. Much of this work has focused on youth presenting with attenuated symptoms of psychosis-those at Clinical High Risk for psychosis (CHR)-given their elevated probability of developing the full disorder in subsequent years. Individuals at CHR may be prone to exacerbated psychological distress during the COVID-19 pandemic and its subsequent physical isolation measures, due to heightened stress sensitivity and comorbid mental health problems. Telepsychotherapy holds promise for reaching this population, especially during the current COVID-19 outbreak. However, there are limited evidence-based guidelines or interventions for use of telepsychotherapy with this population. In this paper, we review common clinical issues for individuals at CHR and how they might be exacerbated by the COVID-19 pandemic; best practices for treatment and adaptations for telepsychotherapy for individuals at CHR; and highlight real clinical issues that we are currently experiencing in a United States-based specialized CHR clinic as we conduct telepsychotherapy via videoconferencing. We conclude with questions for those in the field to contemplate, as well as potential challenges and benefits in using telepsychotherapy with individuals at CHR and their families.