Mapping Cumulative Risk in Delaware: Approach and Implications for Health Equity

BACKGROUND

Addressing health equity requires attention to upstream determinants of health, including environmental and social factors that act in tandem to increase communities' exposure to and vulnerability to toxicants. Cumulative risk assessment, which evaluates combined risks from environmental and social factors, is a useful approach for estimating potential drivers of health disparities. We developed a cumulative risk score of multiple indices of environmental and social conditions and assessed block group-level differences in New Castle County, Delaware.

METHODS

This cross-sectional study used choropleth maps to visualize the distribution of environmental, social, and cumulative risks and Moran's I statistics to assess spatial clustering of cumulative risk across the county and among individual block groups.

RESULTS

Findings indicate that environmental risk rarely occurs without social risk and that environmental and social risks co-occur in distinct areas, resulting in large-scale clustering of cumulative risk. Areas of higher cumulative risk had more Black residents and people of lower socioeconomic status.

CONCLUSIONS

Replicable measures of cumulative risk can show how environmental and social risks are inequitably distributed by race and socioeconomic status, as seen here in New Castle County. Such measures can support upstream approaches to reduce health disparities resulting from histories of environmental racism.

The role of cumulative risk and armed conflict exposure in adolescent psychological symptoms in Turkey

Exposure to risk factors and adversity may cause immediate, and sometimes prolonged, psychological symptoms in adolescents. Identifying universal and specific risk factors in a particular context and examining their cumulative effects is crucial for understanding the mechanisms underlying psychological symptoms and informing about strategies for intervention. Using concurrent measures, the current study aimed to examine the role of armed conflict experiences and cumulation of other risk factors (e.g., maternal psychological symptoms, socioeconomic indicators) in predicting adolescent psychological symptoms in an underresearched community. The sample included 161 adolescents (54.7% female) aged 11-14 years (M = 12.36, SD = 1.27) and their mothers living in the east of Turkey. The cumulative risk index was calculated by summing the standardized scores of the corresponding factors. Hierarchical multiple regression analyses were conducted to predict internalizing and externalizing symptoms among adolescents by introducing demographic variables (age, gender) in the first step, armed conflict experiences and cumulative risk in the second step, and their interaction in the final step. Results showed that the levels of internalizing and externalizing symptoms were predicted by gender, armed conflict experience and cumulative risk. Being a girl was associated with higher levels of internalizing symptoms and lower levels of externalizing symptoms. Higher levels of internalizing and externalizing symptoms were predicted by exposure to armed and cumulative risk. After controlling for other factors, the interaction of armed conflict experience and cumulative risk significantly predicted externalizing, but not internalizing symptoms. These findings suggested that cumulative risk was a stronger predictor of psychological symptoms, and further amplified the strength of the association between armed conflict experiences and externalizing symptoms. These findings can be used in the formulation of intervention strategies and policies to promote psychological well-being in adolescents living in armed conflict zones under multiple risks.

Cumulative contextual risk, mothers' and fathers' parenting, and adolescents' psychosocial problems in Ghana

Limited research exists on the association between cumulative risk factors and the psychosocial well-being of adolescents in low-income, culturally distinct settings. This study aimed to fill this gap by examining the impact of cumulative risk exposure on Ghanaian adolescents' psychosocial problems and exploring the mediating role of parenting. The study involved 212 adolescents (61% girls; average age = 13.38) who completed measures on cumulative risk, maternal and paternal warmth, behavioral control, anxiety, depression, overt aggression, and relational aggression. The results indicated that cumulative risk indirectly influenced adolescents' depression and overt aggression through paternal warmth. Furthermore, paternal behavioral control mediated the relationship between cumulative risk and adolescents' overt aggression. Findings highlight the importance of fathers' parenting in mediating cumulative risk effects.

Variation in global network properties across risk factors for adolescent internalizing symptoms: evidence of cumulative effects on structure and connectivity

BACKGROUND

Identifying adolescents at risk of internalizing problems is a key priority. However, studies have tended to consider such problems in simple ways using diagnoses, or item summaries. Network theory and methods instead allow for more complex interaction between symptoms. Two key hypotheses predict differences in global network properties for those at risk: altered structure and increased connectivity.

METHODS

The current study evaluated these hypotheses for nine risk factors (e.g. income deprivation and low parent/carer support) individually and cumulatively in a large sample of 12-15 year-olds (N = 34 564). Recursive partitioning and bootstrapped networks were used to evaluate structural and connectivity differences.

RESULTS

The pattern of network interactions was shown to be significantly different via recursive partitioning for all comparisons across risk-present/absent groups and levels of cumulative risk, except for income deprivation. However, the magnitude of differences appeared small. Most individual risk factors also showed relatively small effects for connectivity. Exceptions were noted for gender and sexual minority risk groups, as well as low parent/carer support, where larger effects were evident. A strong linear trend was observed between increasing cumulative risk exposure and connectivity.

CONCLUSIONS

A robust approach to considering the effect of risk exposure on global network properties was demonstrated. Results are consistent with the ideas that pathological states are associated with higher connectivity, and that the number of risks, regardless of their nature, is important. Gender/sexual minority status and low parent/carer support had the biggest individual impacts on connectivity, suggesting these are particularly important for identification and prevention.

Parenting Practices May Buffer the Impact of Adversity on Epigenetic Age Acceleration Among Young Children With Developmental Delays

This study examined whether children exposed to adversity would exhibit lower epigenetic age acceleration in the context of improved parenting. Children with developmental delays and externalizing behavior problems (N = 62; Mage = 36.26 months; 70.97% boys, 29.03% girls; 71% Latinx, 22.6% Black) were drawn from a larger randomized controlled trial (RCT), which randomized them to receive Internet-delivered parent-child interaction therapy (iPCIT; n = 30) or community referrals as usual (RAU; n = 32). Epigenetic age acceleration was estimated with the pediatric buccal epigenetic clock, using saliva. Adversity was assessed using parent, family, and neighborhood-level cumulative-risk indicators. Adversity interacted with Time 2 (T2) observations of positive and negative-parenting practices to predict epigenetic age acceleration 1.5 years later, regardless of treatment assignment. Children exposed to more adversity displayed lower epigenetic age acceleration when parents evidenced increased positive (b = -0.15, p = .001) and decreased negative (b = -0.12, p = .01) parenting practices.

Cumulative Risk Evaluation of Phthalates Under TSCA

The U.S. Environmental Protection Agency (EPA) is currently conducting separate Toxic Substances Control Act (TSCA) risk evaluations for seven phthalates: dibutyl phthalate (DBP), butyl benzyl phthalate (BBP), di(2-ethylhexyl) phthalate (DEHP), diisobutyl phthalate (DIBP), dicyclohexyl phthalate (DCHP), di-isodecyl phthalate (DIDP), and diisononyl phthalate (DINP). Phthalates are highly abundant plastic additives used primarily to soften materials and make them flexible, and biomonitoring shows widespread human exposure to a mixture of phthalates. Evidence supports biological additivity of phthalate mixture exposures, including the enhancement of toxicity affecting common biological targets. Risk estimates based on individual phthalate exposure may not be protective of public health. Thus, a cumulative risk approach is warranted. While EPA initially did not signal that it would incorporate cumulative risk assessment (CRA) as part of its current risk evaluation for the seven phthalates, the agency recently announced that it is reconsidering if CRA for phthalates would be appropriate. Based on our review of existing chemical mixtures risk assessment guidance, current TSCA scoping documents for the seven phthalates, and pertinent peer-reviewed literature, we delineate a CRA approach that EPA can easily implement for phthalates. The strategy for using CRA to inform TSCA risk evaluation for existing chemicals is based upon integrative physiology and a common adverse health outcome algorithm for identifying and grouping relevant nonchemical and chemical stressors. We recommend adjustments for how hazard indices (HIs) or margins of exposure (MOEs) based on CRA are interpreted for determining "unreasonable risk" under TSCA.

Priorities and Challenges in Methodology for Human Health Risk Assessment from Combined Exposure to Multiple Chemicals

This paper reviews key elements in the assessment of human health effects from combined exposure to multiple chemicals taking into consideration current knowledge and challenges to identify areas where scientific advancement is mostly needed and proposes a decision-making scheme on the basis of existing methods and tools. The assumption of dose addition and estimation of the hazard index (HI) is considered as a starting point in component-based risk assessments. When, based on the generic HI approach, an unacceptable risk is identified, more specific risk assessment options may be implemented sequentially or in parallel depending on problem formulation, characteristics of the chemical group under assessment, exposure levels, data availability and resources. For prospective risk assessments, the reference point index/margin of exposure (RPI/MOET) (Option 1) or modified RPI/normalized MOET (mRPI/nMOET) (Option 2) approaches may be implemented focusing on the specific mixture effect. Relative potency factors (RPFs) may also be used in the RPI approach since a common uncertainty factor for each mixture component is introduced in the assessment. Increased specificity in the risk assessment may also be achieved when exposure of selected population groups is considered (Option 3/exposure). For retrospective risk assessments, human biomonitoring data available for vulnerable population groups (Option 3/susceptibility) may present more focused scenarios for consideration in human health risk management decisions. In data-poor situations, the option of using the mixture assessment factor (MAF) is proposed (Option 4), where an additional uncertainty factor is applied on each mixture component prior to estimating the HI. The magnitude of the MAF may be determined by the number of mixture components, their individual potencies and their proportions in the mixture, as previously reported. It is acknowledged that implementation of currently available methods and tools for human health risk assessment from combined exposure to multiple chemicals by risk assessors will be enhanced by ongoing scientific developments on new approach methodologies (NAMs), integrated approaches to testing and assessment (IATA), uncertainty analysis tools, data sharing platforms, risk assessment software as well as guideline development to meet legislative requirements.

Depression, Alcohol Misuse, and Suicide Attempt Among North Korean Refugee Women Exposed to Gender-Based Violence

North Korean (NK) refugee women report a disproportionately high rate of suicide compared to the general South Korean (SK) population. NK refugee women's exposure to gender-based violence (GBV) is a risk factor for adverse mental health symptoms. However, the association between GBV exposure and mental health has received less scholarly attention. This study examined NK refugee women's exposure to GBV (i.e., sexual violence, human trafficking, and forced sex work) and explored whether it is associated with an increased risk of depression, alcohol misuse, and suicide attempts. A three-way interaction between depression, alcohol misuse, and suicide attempts among GBV-exposed NK refugee women was examined. Data from a snowball sample of 180NK refugee women were analyzed for this study. Findings show that 47.8% experienced GBV in either NK or intermediary countries. Multivariate analyses revealed that depression (OR = 1.13, p < .05) and alcohol misuse (OR = 3.01, p < .01) was significantly associated with suicide attempts in GBV-exposed groups. Results from the three-way interaction (GBV victimization × Depression × Alcohol misuse) suggest that GBV exposure and higher levels of depression were significantly associated with suicide attempts among NK refugee women with greater severity of alcohol misuse (OR = 1.75, p < .05). The findings indicate that NK refugee women with GBV exposure, depression, and alcohol misuse are at increased risk for suicide attempts. Study limitations included the use of snowball sampling and cross-sectional data. This study discusses implications for future research and targeted, trauma-informed treatments focused on GBV and mental health symptoms among NK refugee women.

Quantitative Measurement of Phthalate Exposure Biomarker Levels in Diaper-Extracted Urine of Japanese Toddlers and Cumulative Risk Assessment: An Adjunct Study of JECS Birth Cohort

Phthalate exposure monitoring and risk assessment in non-toilet-trained children are rarely reported. This adjunct study of the Japan Environment and Children's Study assessed cumulative health risks in 1.5-year-old toddlers in the Aichi regional subcohort by biomonitoring 16 urinary metabolites of eight phthalate plasticizers. Overnight urine was extracted from toddlers' diapers (n = 1077), and metabolites were quantified using ultraperformance liquid chromatography coupled with tandem mass spectrometry. The analyses' quality was assured by running quality control samples. The highest geometric mean concentration was found for mono-(2-ethyl-5-carboxypentyl) phthalate, followed by mono-isobutyl phthalate (23 and 21 μg/L, respectively). Di-2-ethylhexyl phthalate (DEHP) and di-butyl phthalate exhibited higher risks [hazard quotient (HQ) > 1] than the cutoff level in a small proportion of toddlers; 8 and 14% of toddlers were at cumulative risk of multiple phthalates beyond the cutoff level [hazard index, (HI) > 1], based on the tolerable daily intake of the European Food Safety Authority and the United States Environmental Protection Agency Reference Dose. HI > 1 for antiandrogenicity in creatinine-unadjusted and -adjusted estimations were exhibited by 36 and 23% of the children, respectively. Thus, identifying exposure sources and mitigating exposure are necessary for risk management. Additionally, continuous exposure assessment and evaluation of health outcomes, especially antiandrogenic effects, are warranted.

Cumulative Risk and Mental Health of Left-behind Children in China: A Moderated Mediation Model

Based on the dual-factor model of mental health (DFM) and the cumulative risk (CR) model, this study aimed to investigate the impact of CR on left-behind children's mental health and the underlying mechanism involved, specifically the mediating role of coping style and the moderating role of gratitude in the relationship between CR and mental health. The random cluster sampling method was applied to collect data on CR, coping style, gratitude, life satisfaction, and depression from 705 left-behind children (374 boys, Mage = 12.20 ± 1.25). The moderated mediation analyses indicated that: (1) the moderated mediation model of CR and depression was significant: coping style mediated the relationship between CR and depression, and gratitude moderated this mediating effect with gratitude strengthening the negative association between CR and coping style; and (2) gratitude moderated the relationship between CR and life satisfaction and it also strengthened the negative association between CR and life satisfaction. The findings suggest that the mechanisms of coping style may differ in the relationships between CR and positive and negative indicators of mental health in left-behind children and that gratitude as a protective factor has limited capacity to buffer the negative effect of accumulated risk. These findings provide evidence for differentiated intervention approaches to promote disadvantaged children's life satisfaction and depression.

Empirically-derived dimensions of childhood adversity and cumulative risk: associations with measures of depression, anxiety, and psychosis-spectrum psychopathology

Background: Investigating different approaches to operationalizing childhood adversity and how they relate to transdiagnostic psychopathology is relevant to advance research on mechanistic processes and to inform intervention efforts. To our knowledge, previous studies have not used questionnaire and interview measures of childhood adversity to examine factor-analytic and cumulative-risk approaches in a complementary manner.Objective: The first aim of this study was to identify the dimensions underlying multiple subscales from three well-established childhood adversity measures (the Childhood Trauma Questionnaire, the Childhood Experience of Care and Abuse Interview, and the Interview for Traumatic Events in Childhood) and to create a cumulative risk index based on the resulting dimensions. The second aim of the study was to examine the childhood adversity dimensions and the cumulative risk index as predictors of measures of depression, anxiety, and psychosis-spectrum psychopathology.Method: Participants were 214 nonclinically ascertained young adults who were administered questionnaire and interview measures of depression, anxiety, psychosis-spectrum phenomena, and childhood adversity.Results: Four childhood adversity dimensions were identified that captured experiences in the domains of Intrafamilial Adversity, Deprivation, Threat, and Sexual Abuse. As hypothesized, the adversity dimensions demonstrated some specificity in their associations with psychopathology symptoms. Deprivation was uniquely associated with the negative symptom dimension of psychosis (negative schizotypy and schizoid symptoms), Intrafamilial Adversity with schizotypal symptoms, and Threat with depression, anxiety, and psychosis-spectrum symptoms. No associations were found with the Sexual Abuse dimension. Finally, the cumulative risk index was associated with all the outcome measures.Conclusions: The findings support the use of both the empirically-derived adversity dimensions and the cumulative risk index and suggest that these approaches may facilitate different research objectives. This study contributes to our understanding of the complexity of childhood adversity and its links to different expressions of psychopathology.

Individual and cumulative risk factors in developmental language disorder: A case-control study

Many mental disorders (MD) share common etiology, fuelling debates about the specificity of clinical categories and whether the presence of specific risk factors (RF) can distinguish among them. The study of developmental language disorder (DLD), more specifically, has been further hindered by a lack of consensus regarding its definition. These limitations increase the risk of under-detection and lifelong consequences for affected children. This paper aims (1) to document which individual RF allow differentiating DLD from other MD and (2) to compare the cumulative RF between children with DLD versus other MD. This case-control design study used medical records of a psychiatric sample of 795 preschoolers (mean age 4:11, 75% boys). A logistic regression measured the predictive value of potential RF on DLD. Later first sentences, maternal immigration and family history of language delay were identified as significant in explaining 30% of the variance for DLD diagnosis. An ANCOVA revealed that children with DLD were exposed to a significantly higher number of RF than were children with other MD. Public health policies informed with the knowledge of specific RF associated with DLD, and their cumulative impact, could improve early detection and reduce the cascade of negative consequences associated with DLD.

Managing the effects of multiple stressors on wildlife populations in their ecosystems: developing a cumulative risk approach

Assessing cumulative effects of human activities on ecosystems is required by many jurisdictions, but current science cannot meet regulatory demands. Regulations define them as effect(s) of one human action combined with other actions. Here we argue for an approach that evaluates the cumulative risk of multiple stressors for protected wildlife populations within their ecosystems. Monitoring effects of each stressor is necessary but not sufficient to estimate how multiple stressors interact to affect wildlife populations. Examining the mechanistic pathways, from cellular to ecological, by which stressors affect individuals can help prioritize stressors and interpret how they interact. Our approach uses health indicators to accumulate the effects of stressors on individuals and to estimate changes in vital rates, driving population status. We advocate using methods well-established in human health and integrating them into ecosystem-based management to protect the health of commercially and culturally important wildlife populations and to protect against risk of extinction for threatened species. Our approach will improve abilities to conserve and manage ecosystems but will also demand significant increases in research and monitoring effort. We advocate for increased investment proportional to the economic scale of human activities in the Anthropocene and their pervasive effects on ecology and biodiversity.

[Status of Heavy Metal in Organic Fertilizers in Main Tea Growing Regions of China]

To provide guidance for the safe use of organic fertilizers and improve soil quality and tea safety, it is necessary to conduct systematic analyses of the heavy metal content of organic fertilizers applied in the main tea producing areas of China. In this study, we analyzed the heavy metal contents in organic fertilizer samples collected from 2017 to 2019. The risks of collected organic fertilizers from different areas and sources were calculated. The results showed that the average concentrations of ω(As), ω(Hg), ω(Pb), ω(Cd), ω(Cr), ω(Cu), ω(Zn), and ω(Ni) in the collected organic fertilizers were 4.60, 0.22, 27.1, 0.78, 27.9, 58.3, 250.1, and 16.3 mg·kg^-1, respectively. According to the assessment standard in NY/T 525- 2021, the over-limit rates of As, Hg, Pb, Cd, and Cr were 6.19%, 1.33%, 4.42%, 4.42%, and 1.33%, respectively. With respect to the area, the qualified rates were 100% in Shaanxi, Jiangsu, Anhui, Fujian, and Guangxi; 80%-90% in Shandong, Zhejiang, Hubei, Sichuan, Yunnan, and Guangdong; and only 54.5% in Jiangxi. The qualified rates of sources were 100% in rapeseed cake, soybean cake, and pig manure; 95.8% in sheep manure; 91.7% in cow manure; 90.7% in chicken manure; 87.2% in manure of other animals; 82.4% in the mixture of plant and animal sources; 65.2% in other plant sources; and 63.6% in other sources. According to the recommended application rate, the accumulation rate of heavy metals in soil with pig manure, cow manure, chicken manure, and sheep manure would be much higher than that with rapeseed cake and soybean cake. The average accumulation rate of organic fertilizer from animal sources was 7-30 times higher than that from plant sources. Therefore, it is recommended to use rapeseed cake or soybean cake fertilizer in tea plantation and to increase the supervision of heavy metal accumulation in soil and tea in those high-risk areas.

Cumulative Risk Meets Inter-Individual Variability: Probabilistic Concentration Addition of Complex Mixture Exposures in a Population-Based Human In Vitro Model

Although humans are continuously exposed to complex chemical mixtures in the environment, it has been extremely challenging to investigate the resulting cumulative risks and impacts. Recent studies proposed the use of “new approach methods,” in particular in vitro assays, for hazard and dose−response evaluation of mixtures. We previously found, using five human cell-based assays, that concentration addition (CA), the usual default approach to calculate cumulative risk, is mostly accurate to within an order of magnitude. Here, we extend these findings to further investigate how cell-based data can be used to quantify inter-individual variability in CA. Utilizing data from testing 42 Superfund priority chemicals separately and in 8 defined mixtures in a human cell-based population-wide in vitro model, we applied CA to predict effective concentrations for cytotoxicity for each individual, for “typical” (median) and “sensitive” (first percentile) members of the population, and for the median-to-sensitive individual ratio (defined as the toxicodynamic variability factor, TDVF). We quantified the accuracy of CA with the Loewe Additivity Index (LAI). We found that LAI varies more between different mixtures than between different individuals, and that predictions of the population median are generally more accurate than predictions for the “sensitive” individual or the TDVF. Moreover, LAI values were generally <1, indicating that the mixtures were more potent than predicted by CA. Together with our previous studies, we posit that new approach methods data from human cell-based in vitro assays, including multiple phenotypes in diverse cell types and studies in a population-wide model, can fill critical data gaps in cumulative risk assessment, but more sophisticated models of in vitro mixture additivity and bioavailability may be needed. In the meantime, because simple CA models may underestimate potency by an order of magnitude or more, either whole-mixture testing in vitro or, alternatively, more stringent benchmarks of cumulative risk indices (e.g., lower hazard index) may be needed to ensure public health protection.

Adverse childhood experiences and premature mortality through mid-adulthood: A five-decade prospective study

Background

Adverse childhood experiences (ACEs) can have lasting effects on adult health and survival. In this study, we aimed to examine how the cumulative number and clustering patterns of ACEs were related to premature mortality.

Methods

Participants (N=46 129; 45% White, 48% Black; 49·5% females) were offspring (born in 1959-1966) of participants enrolled in the Collaborative Perinatal Project (CPP). We conducted latent class analysis to examine the clustering patterns of ACEs assessed between children's birth and age seven. We also calculated the cumulative ACE scores of 13 individual ACEs. Cox regression models were used to examine the associations of ACE clusters and scores with risk of premature mortality from adolescence to mid-adulthood.

Findings

At the start of the follow-up for mortality in 1979, participants were 12-20 years old (Mean=15·99 years), and within the 38-year follow-up through 2016, 3 344 deaths were observed among the 46 129 CPP offspring. Five latent classes of ACEs were identified. Compared to children with Low Adversity (48% of the sample), children in Family Instability (9%, HR=1·28, 95%CI 1·07-1·53), Poverty & Crowded Housing (21%, HR=1·41, 95%CI 1·24-1·62), and Poverty & Parental Separation (19%, HR=1·50, 95%CI 1·33-1·68) classes had higher hazards of premature mortality. In addition, children with 2 (HR=1·27, 95%CI 1·14-1·41), 3 (HR=1·29, 95%CI 1·15-1·45), and 4+ (HR=1·45, 95%CI 1·30-1·61) ACEs had higher hazards of mortality than those with no ACE. The clusters of Poverty & Crowded Housing (HR=1·28, 95%CI 1·10-1·49) and Poverty & Parental Separation (HR=1·23, 95%CI 1·02-1·48) remained associated with higher risk of premature mortality, beyond the cumulative risk of higher number of ACEs (HR=1·05, 95%CI 1·01-1·08).

Interpretation

About half of the CPP cohort experienced early life adversities that clustered into four distinct patterns, which were associated with different risk of premature mortality. It is important to deepen our understanding of how specific clusters of childhood adversities affect health and premature mortality to better inform approaches to prevention and interventions.

Childhood poverty and psychological well-being: The mediating role of cumulative risk exposure

The current study assessed whether the proportion of childhood (age 0-9 years) in poverty altered the developmental trajectories (ages 9-24) of multimethodological indicators of psychological well-being. In addition, we tested whether exposure to cumulative risk over time mediated the association between poverty exposure and psychological well-being. Measures of psychological well-being included internalizing and externalizing symptoms, a behavioral index of learned helplessness (task persistence), and chronic physiological stress (allostatic load). Exposure to poverty during childhood predicted the trajectory of each development outcome: individuals with more poverty exposure during childhood showed (a) relatively high levels of internalizing symptoms that diminished more slowly with maturation, (b) relatively high levels of externalizing symptoms that increased faster over time, (c) less task persistence indicative of greater learned helplessness, and (d) higher levels of chronic physiological stress which increased faster over time relative to persons with less childhood poverty exposure. Trajectories of cumulative risk exposure from physical and psychosocial surroundings from 9-24 years accounted for the association between childhood poverty and the growth curves of internalizing and externalizing symptoms but not for learned helplessness or chronic physiological stress. Additional sensitivity analyses indicate that early childhood disadvantage is particularly problematic for each outcome, except for internalizing symptoms which seem sensitive to the combination of early and lifetime poverty exposure. We also explored whether domains of cumulative risk as well as two alternatives, maternal sensitivity or family cohesion, functioned as mediators. Little evidence emerged for any of these alternative mediating constructs.

Mental health in children of parents being treated by specialised psychiatric services

BACKGROUND

One in ten children have a parent diagnosed with a mental illness by specialised psychiatric services. Severe parental mental illness is a well-established risk factor for children's mental health problems, making the identification and support of these children a public health concern. This study investigated the mental health and family context of children of parents diagnosed with depression, anxiety, or bipolar disorder in this clinical setting.

METHODS

Parental reports on 87 children aged 8-17 years were analysed. The children's mental health was compared with that of a Swedish population-based sample. Multiple linear regression was used to investigate associations between child mental health and child gender, child age, parent symptoms and social status, family functioning, and perceived parental control. Furthermore, a cumulative risk index explored the effect of multiple risk factors on child mental health.

RESULTS

The children reportedly had significantly more mental health problems than did the population-based sample and about one-third had scores above the clinical cut-off. A significant multiple linear regression explained 49% of the variance in child mental health, with lower perceived parental control and younger child age being associated with more child mental health problems. With more reported risk factors, children reportedly had more mental health problems.

CONCLUSIONS

The results underline the importance of identifying a patient's children and assessing multiple relevant risk factors in the child's life. Furthermore, the results indicate that the needs of younger children and of patients in their parenting role are important to address.

Temporal and regional variability of cumulative ecological risks of pesticides in Japanese river waters for 1990-2010

We quantitatively evaluated the cumulative ecological risks from multiple pesticides used in paddy fields in Japan. Moreover, we visualized the temporal and regional variability of those risks for 1990-2010. Considering the region-specific parameters of environmental conditions, region-specific predicted environmental concentrations were estimated at 350 river-flow monitoring sites in Japan. Then the multi-substance potentially affected fraction (msPAF) was calculated as a risk index of multiple pesticides by using the computation tool NIAES-CERAP. The median msPAF values for insecticides and herbicides decreased by 92.4% and 53.1%, respectively, from 1990 to 2010. This substantial reduction in ecological risk was attributed to the development of low-risk pesticides by manufacturers, the efforts of farmers in risk reduction, and tighter regulation by the Japanese government. In particular, the substantial reduction of the ecological risk from insecticides was largely due to the decrease in the use of organophosphorus insecticides.

Specific and cumulative lifetime stressors in the aetiology of major depression: A longitudinal community-based population study

AIMS

Early-life stressful circumstances (i.e. childhood maltreatment) coupled with stressful events later in life increase the likelihood of subsequent depression. However, very few studies have been conducted to examine the specific and cumulative effects of these stressors in the development of depression. There is also a paucity of research that simultaneously considers the role of biological factors combined with psychosocial stressors in the aetiology of depression. Guided by the biopsychosocial model proposed by Engel, the present study aims to examine to what extent the experience of stressors across the lifespan is associated with depression while taking into account the role of genetic predispositions.

METHODS

Data analysed were from the Social and Psychiatric Epidemiology Catchment Area of the Southwest of Montreal (ZEPSOM), a large-scale, longitudinal community-based cohort study. A total of 1351 participants with complete information on the lifetime diagnoses of depression over a 10-year follow-up period were included in the study. Stressful events across the lifespan were operationalised as specific, cumulative and latent profiles of stressful experiences. Latent profile analysis (LPA) was used to explore the clustering of studied stressors including childhood maltreatment, poor parent-child relationship, and stressful life events. A polygenetic risk score was calculated for each participant to provide information on genetic liability. Multivariate logistic regression was used to examine the association between specific, cumulative and latent profiles of stressors and subsequent depression.

RESULTS

We found that different subtypes of childhood maltreatment, child-parent bonding and stressful life events predicted subsequent depression. Furthermore, a significant association between combined effects of cumulative stressful experiences and depression was found [odds ratio (OR) = 1.20, 95% confidence interval (CI): 1.12-1.28]. Three latent profiles of lifetime stressors were identified in the present study and named as 'low-level of stress' (75.1%), 'moderate-level of stress' (6.8%) and 'high-level of stress' (18.1%). Individuals with a 'high-level of stress' had a substantially higher risk of depression (OR = 1.80, 95% CI: 1.08-3.00) than the other two profiles after adjusting for genetic predispositions, socio-demographic characteristics, and health-related factors.

CONCLUSIONS

While controlling for genetic predispositions, the present study provides robust evidence to support the independent and cumulative as well as compositional effects of early- and later-on lifetime psychosocial stressors in the subsequent development of depression. Consequently, mental illness prevention and mental health promotion should target the occurrence of stressful events as well as build resilience in people so they can better cope with stress when it inevitably occurs.

Adverse childhood experiences predict neurite density differences in young children with and without attention deficit hyperactivity disorder

Adverse childhood experiences (ACEs) put millions of children at risk for later health problems. As childhood represents a critical developmental period, it is important to understand how ACEs impact brain development in young children. In addition, children with attention-deficit/hyperactivity disorder (ADHD) are more likely than typically developing (TD) peers to experience ACEs. Therefore, the current study examined the impact of ACEs on early brain development, using a cumulative risk approach, in a large sample of children with and without ADHD. We examined 198 young children (M_age  = 5.45, 82.3% Hispanic/Latino; 52.5% ADHD) across measures of brain volume, cortical thickness, neurite density index (NDI), and orientation dispersion index (ODI). For the NDI measure, there was a significant interaction between group and cumulative risk (ß = .18, p = .048), such that for children with ADHD, but not TD children, greater cumulate risk was associated with increased NDI in corpus callosum. No other interactions were detected. Additionally, when examining across groups, greater cumulative risk was associated with reduced ODI and volume in the cerebellum, although these findings did not survive a correction for multiple comparisons. Our results highlight the role early cumulative ACEs play in brain development across TD and children with ADHD.

Health and Health Care Use Strongly Associated with Cumulative Burden of Social Determinants of Health

Understanding health outcomes and patterns of health care utilization associated with patients' cumulative social determinant of health (SDOH) risk is essential to supporting better health care. This study compared mental and physical health outcomes and health care utilization by increasing number of social needs among a clinical adult population. Surveys were sent to 6000 patients with recent visits to 7 primary care clinics in Portland, Oregon in 2018. The final study sample included respondents who matched to medical claims data, N = 1748. The authors used a modified logistic regression model to estimate risk ratios for the relationship between cumulative SDOH factors and self-reported chronic conditions, and a 2-part model to estimate the effects of cumulative SDOH risk on health care utilization. Increased SDOH need was associated with increasing likelihood of worse self-reported health outcomes, especially mental health. Compared with those with no SDOH need, having 1-2 SDOH need(s) (adjusted risk ratio [aRR] 1.25; 95% confidence interval [CI]: 1.06-1.46) and 3 or more SDOH needs (aRR 1.45; 95% CI: 1.22-1.73) had a greater risk of reporting any behavioral health condition. However, the number of SDOH had a graded but inverse impact on use of mental health care services where fewer visits were observed among those using care. Having SDOH was associated with increased likelihood of having an emergency department visit and increased number of primary care visits. This study demonstrates the compounding impact of SDOH on health and health care use. This highlights the importance of collecting SDOH, including the total number of SDOH needs, when considering a patient's health and health care.

Work-related potential traumatic events and job burnout among operating room nurses: Independent effect, cumulative risk, and latent class approaches

AIMS

The objective of this study is to explore and compare the strength of associations between work-related potential traumatic events and burnout among operating room nurses based on three different approaches.

DESIGN

The study followed a multisite cross-sectional design.

METHODS

A stratified sampling method was conducted. Cities in the Shandong Province were divided into four groups, and two tertiary hospitals were randomly selected from all tertiary hospitals in cities of each group. A total of 361 eligible operating room nurses provided valid questionnaires between June and November 2019. Work-related potential traumatic events questionnaire and the Chinese version of the Maslach Burnout Inventory were conducted. Associations between individual, cumulative potential traumatic events, as well as latent class analysis-derived patterns of potential traumatic experiences with burnout were examined using logistic regression analysis.

RESULTS

Specific traumatic events (e.g., patients' sudden death, bullying and ostracism from colleagues) were independently associated with an increased risk of burnout. Work-related potential traumatic events had a cumulative effect on burnout, whereby operating room nurses exposed to cumulative potential traumatic events carried a higher risk for burnout than others. The "multiple work-related potential traumatic events" pattern derived by latent class analysis was related to an increased risk of high depersonalization.

CONCLUSION

Operating room nurses who reported specific or multiple work-related potential traumatic events were at high risk for burnout. It is of great significance to provide qualified and timely counselling or support.

IMPACT

This study is the first to focus on work-related potential traumatic events among operating room nurses and examine their relationship with burnout based on three perspectives. The findings could help identify those operating room nurses who are at high risk of burnout in clinical practice. Hospital managers should develop targeted interventions to prevent or mitigate the harmful impact of potential traumatic events on occupational health.

Incidence and relative risk of metachronous second primary cancers for 16 cancer sites, Osaka, Japan, 2000-2015: Population-based analysis

Background

An increasing number of cancer survivors have developed multiple primaries. This study aims to describe the incidence and risk patterns of metachronous second primary cancers (SPCs) in Osaka, Japan.

Methods

Data were obtained from the Osaka Cancer Registry, a population‐based database of all cancers diagnosed in Osaka. The study subjects were individuals who were first diagnosed with invasive cancers in 16 major cancer sites during 2000–2014, aged 15–79 years, survived at least 3 months, and were followed up for 10 years. We measured incidence rates, cumulative risks, and standardized incidence ratios (SIRs: with the Osaka general population as the referent) of developing SPCs during 3 months to 10 years after the first diagnosis.

Results

During 2000–2015, among 418,791 cancer survivors, 24,368 (5.8%) developed SPCs within 10 years of first diagnosis. Males had higher incidence rates than females except among young‐onset survivors (aged 15–39 years). 10‐year cumulative risks among survivors aged 70–79 years (the most dominant age group) were 24.0% (male) and 11.8% (female). 10‐year SIRs were 1.38 (95% CI, 1.36–1.40; male) and 1.44 (95% CI, 1.41–1.48; female) with higher estimates among younger survivors in both sexes. Strong bidirectional associations were observed between oral/pharyngeal, esophageal, and laryngeal cancers. Survivors of any smoking‐related cancers had elevated SIRs of developing smoking‐related SPCs. Similar results were observed for alcohol‐related cancers.

Conclusions

Cancer survivors are at excess risk of developing SPCs compared to the general population. Continued surveillance is warranted to inform survivorship care through risk‐based long‐term care planning and lifestyle‐changing efforts to prevent new cancers.

Lifetime Risk of Heart Failure and Trends in Incidence Rates Among Individuals With Type 2 Diabetes Between 1995 and 2018

Background

There are limited data on the lifetime risk of heart failure (HF) in people with type 2 diabetes and how incidence has changed over time. We estimated the cumulative incidence and incidence rates of HF among Danish adults with type 2 diabetes between 1995 and 2018 using nationwide data.

Methods and Results

In total, 398 422 patients (49% women) with type 2 diabetes were identified. During follow‐up, 36 400 (9%) were diagnosed with HF and 121 459 (30%) were censored due to death. Using the Aalen‐Johansen estimators, accounting for the risk of death, the estimated residual lifetime risk of HF at age 50 years was calculated as 24% (95% CI 22%–27%) in women and 27% (25%–28%) in men. During the observational period, the proportion of patients treated with statins, angiotensin‐converting enzyme inhibitors or angiotensin II receptor blockers, and metformin increased from <30% to >60%. Similarly, the annual incidence rates of HF decreased significantly, with declines being greater in older versus younger individuals (5% versus 2% in age >50 versus ≤50 years, respectively; P<0.0001) and in women versus men (5% versus 4%, P=0.02), but similar in patients with and without IHD (4% versus 4%, P=0.53).

Conclusions

The current lifetime risk of HF in type 2 diabetes approximates 1 in 4 for men and women. Paralleled by an increase in use of evidence‐based pharmacotherapy over the past decades, the risk of developing HF has declined across several subgroups and regardless of underlying IHD, suggesting that optimal diabetes treatment can mitigate HF risk.

Cumulative Social Risk and Child Screen Use: The Role of Child Temperament

OBJECTIVES

It is critical to understand what children, and in which context, are at risk for high levels of screen use. This study examines whether child temperament interacts with cumulative social risk to predict young children's screen use and if the results are consistent with differential susceptibility or diathesis-stress models.

METHODS

Data from 1,992 families in Calgary, Alberta (81% White; 47% female; 94% >$40,000 income) from the All Our Families cohort were included. Mothers reported on cumulative social risk (e.g., low income and education, maternal depression) at <25 weeks of gestation, child's temperament at 36 months of age (surgency/extraversion, negative affectivity, effortful control), and child's screen use (hours/day) at 60 months of age. Along with socio-demographic factors, baseline levels of screen use were included as covariates.

RESULTS

Children high in surgency (i.e., high-intensity pleasure, impulsivity) had greater screen use than children low in surgency as social risk exposure increased. In line with differential susceptibility, children high in surgency also had less screen use than children low in surgency in contexts of low social risk. Children with heightened negative affectivity (i.e., frequent expressions of fear/frustration) had greater screen use as social risk increased, supporting a diathesis-stress model.

CONCLUSIONS

Young children predisposed to high-intensity pleasure seeking and negative affectivity in environments characterized as high in social risk may be prone to greater durations of screen use. Findings suggest that an understanding of social risks and individual characteristics of the child should be considered when promoting healthy digital health habits.

Neonatal Abstinence Syndrome in Rural Appalachia

As the United States faces the repercussions of the current opioid epidemic, it is important for social workers to be able to identify risks for poor birth outcomes in infants with neonatal abstinence syndrome (NAS). Although some studies have identified single risk factors, no studies have tested associations between total amount of risk (that is, cumulative risk) and birth outcomes in infants with NAS. Authors examined 318 mothers who used opioids during pregnancy and their infants' birthweight, length, head circumference, and Apgar scores (which measure overall infant health after birth). All infants were admitted to a neonatal intensive care unit in Appalachia and were diagnosed with NAS. Authors found that high cumulative risk during pregnancy was associated with lower birthweight and Apgar scores one and five minutes after birth as well as shorter length and smaller head circumference at birth. Social workers are encouraged to assess for the quantity of prenatal adversity experienced by the mothers they serve and to consider multicomponent, comprehensive community-based interventions to reduce cumulative risk.

Familial Risk and Heritability of Hematologic Malignancies in the Nordic Twin Study of Cancer

Simple Summary

Hematologic malignancies account for 8–9% of all incident cancers. Both genetic and environmental risk factors contribute to cancer development, but it is unclear if there is shared heritability between hematologic malignancies. This study aimed to investigate familial predisposition to hematologic malignancies using the largest twin study of cancer in the world. We compared individual risk in the general population and the risk of cancer in one twin before some age given that the other twin had (another) cancer before that age. Furthermore, by analyzing information about whether the twins were identical or fraternal, we could estimate the relative importance of genetic and environmental influences on the risk for developing hematologic cancers. This study confirmed previous findings of familial predisposition to hematologic malignancies and provides novel evidence that familial predisposition decreases with increasing age. The latter points to the importance of taking age into account in the surveillance of hematological cancers.

Abstract

We aimed to explore the genetic and environmental contributions to variation in the risk of hematologic malignancies and characterize familial dependence within and across hematologic malignancies. The study base included 316,397 individual twins from the Nordic Twin Study of Cancer with a median of 41 years of follow-up: 88,618 (28%) of the twins were monozygotic, and 3459 hematologic malignancies were reported. We estimated the cumulative incidence by age, familial risk, and genetic and environmental variance components of hematologic malignancies accounting for competing risk of death. The lifetime risk of any hematologic malignancy was 2.5% (95% CI 2.4–2.6%), as in the background population. This risk was elevated to 4.5% (95% CI 3.1–6.5%) conditional on hematologic malignancy in a dizygotic co-twin and was even greater at 7.6% (95% CI 4.8–11.8%) if a monozygotic co-twin had a hematologic malignancy. Heritability of the liability to develop any hematologic malignancy was 24% (95% CI 14–33%). This estimate decreased across age, from approximately 55% at age 40 to about 20–25% after age 55, when it seems to stabilize. In this largest ever studied twin cohort with the longest follow-up, we found evidence for familial risk of hematologic malignancies. The discovery of decreasing familial predisposition with increasing age underscores the importance of cancer surveillance in families with hematological malignancies.

A Cumulative Framework for Identifying Overburdened Populations under the Toxic Substances Control Act: Formaldehyde Case Study

Extensive scholarship has demonstrated that communities of color, low-income communities, and Indigenous communities face greater environmental and health hazards compared to communities with more White or affluent people. Low-income, Indigenous, Black, and/or other populations of color are also more likely to lack access to health care facilities, healthy food, and adequate formal education opportunities. Despite the mountains of evidence that demonstrate the existence and significance of the elevated toxic social and environmental exposures experienced by these communities, the inclusion of these factors into chemical evaluations has been scarce. In this paper, we demonstrate a process built with publicly available data and simple geospatial techniques that could be utilized by the U.S. Environmental Protection Agency (USEPA) to incorporate cumulative approaches into risk assessments under the Toxic Substances Control Act. The use of these approaches, particularly as they relate to identifying potentially exposed and susceptible subpopulations, would help USEPA develop appropriate risk estimates and mitigation strategies to protect disproportionately burdened populations from the adverse effects of chemical exposures. By utilizing such approaches to inform risk evaluation and mitigation, USEPA can identify and protect those most burdened and impacted by toxic chemicals, and finally begin to close the gap of environmental health inequities.

Reimagining Racial Trauma as a Barrier to Breastfeeding Versus Childhood Trauma and Depression Among African American Mothers

Objective: Although breastfeeding provides benefits for mothers and infants, multiple factors prevent women from breastfeeding. This article aims to explore the role of mothers' personal and contextual risk factors to breastfeeding rates with a special emphasis on understanding breastfeeding among African American mothers at 6 months postpartum. Design: This secondary analysis was capitalizing on previously collected postpartum data from a longitudinal cohort study on the consequences of maternal childhood trauma on mother and infant outcomes. Postpartum mothers (n = 188) completed questionnaires on demographics, childhood trauma history, postpartum depression, social support, and breastfeeding status at 6 months postpartum. Results: All risk factors (i.e., demographic and social support risk, childhood trauma history, and postpartum depression) were associated with lower breastfeeding at 6 months postpartum. When risk factors were examined in a single comprehensive model, only cumulative demographic risk emerged as significant. When partialing-out by race, being African American was the only variable associated with lower breastfeeding at 6 months postpartum. Conclusions: Our study confirms that African American mothers report lower breastfeeding rates at 6 months postpartum than non-African American mothers. This association held even when controlling for demographic and social support risk, childhood trauma history, and postpartum depression. We discuss our findings from an intergenerational and historical trauma, racism, chronic discrimination perspective that considers the multifactorial nature of past and current impacts on breastfeeding among African American women in the United States.

Risk of cardiovascular disease is driven by different combinations of environmental, medical and behavioral factors: Building a conceptual model for cumulative risk assessment

The U.S. Environmental Protection Agency (EPA) and National Institute of Environmental Health (NIEHS) held a workshop in 2012 to discuss principles and applications of cumulative risk assessment (CRA). The workshop organizers chose cardiovascular disease (CVD) as an example health outcome for which cumulative risk considerations could illuminate environmental and health management strategies. To guide discussions, we developed a series of conceptual models illustrating factors influencing CVD. The CVD conceptual model represents complex processes across varying space and time scales, different causal pathways, and multiple chemical and non-chemical stressors and factors. It includes causal influences of environmental exposures and lifestyle choices, in the context of genetics and medical factors. The representation of cumulative risk as a network of interrelated nodes and arrows helps define and organize the problem and available information, determine the scope and scale, and creates a platform for analysis. It provides an interface for discussing how different entities (e.g., environmental versus health-driven organizations) can work together on different parts of the problem, and facilitates relative risk ranking and management triage. Color coding is used to distinguish categories of stressors and possible oversight responsibility. This work informs guidelines for CRA planning and assessment of factor combinations affecting real-world risk.

Disentangling adversity timing and type: Contrasting theories in the context of maternal prenatal physical and mental health using latent formative models

Research on the effects of adversity has led to mounting interest in examining the differential impact of adversity as a function of its timing and type. The current study examines whether the effects of different types (i.e., physical, sexual, and emotional abuse) and timing (i.e., early, middle childhood, adolescence, or adulthood) of adversity on maternal mental and physical health outcomes in pregnancy, are best accounted for by a cumulative model or independent effects model. Women from a prospective pregnancy cohort (N =3,362) reported retrospectively on their experiences of adversity (i.e., physical, sexual, and emotional abuse) in early childhood (0-5 years], middle childhood (6-12 years], adolescence (13-18 years], and adulthood (19+ years]. Measures of overall health, stress, anxiety, and depression were gathered in pregnancy. Results showed that a cumulative formative latent model was selected as more parsimonious than a direct effects model. Results also supported a model where the strength of the effect of adversity did not vary across abuse timing or type. Thus, cumulative adversity resulted in greater physical and mental health difficulties. In conclusion, cumulative adversity is a more parsimonious predictor of maternal physical and mental health outcomes than adversity at any one specific adversity timing or subtype.

A Population-Based Analysis of BRCA1/2 Genes and Associated Breast and Ovarian Cancer Risk in Korean Patients: A Multicenter Cohort Study

Simple Summary

Although it has been suggested that cancer risk and genetic variation vary by population, there is still a lack of research on non-European populations. In this study, we applied Korean patients as a model to find out the way to conduct BRCA1/2-related clinical studies in non-European populations who do not have as much clinical data as Europeans. The BRCA1/2 variants were classified following the 2015 ACMG standards/guidelines and using a multifactorial probability-based approach. To estimate the additional sample numbers needed to resolve BRCA1/2 unclassified status, we applied a simulation analysis considering population-specific clinical characteristics. In addition, we estimated the risks of breast or ovarian cancer for BRCA1/2 carriers by mutation regions. Data from this study reveal that BRCA1/2 variants in the non-European population are highly specific; therefore, population-specific study is essential for clinical application of treatment or prevention for breast or ovarian cancer.

Abstract

In this study, we performed a comprehensive analysis of BRCA1/2 variants and associated cancer risk in Korean patients considering two aspects: variants of uncertain significance (VUS) and pathogenic or likely pathogenic variants (PLPVs) in BRCA1 and BRCA2. This study included 5433 Korean participants who were tested for BRCA1/2 genes. The BRCA1/2 variants were classified following the standards/guidelines for interpretation of genetic variants and using a multifactorial probability-based approach. In Korea, 15.8% of participants had BRCA1 or BRCA2 PLPVs. To estimate the additional sample numbers needed to resolve unclassified status, we applied a simulation analysis. The simulation study for VUS showed that the smaller the number of samples, the more the posterior probability was affected by the prior probability; in addition, more samples for BRCA2 VUS than those of BRCA1 VUS were required to resolve the unclassified status, and the presence of clinical information associated with their VUS was an important factor. The cumulative lifetime breast cancer risk was 59.1% (95% CI: 44.1–73.6%) for BRCA1 and 58.3% (95% CI: 43.2–73.0%) for BRCA2 carriers. The cumulative lifetime ovarian cancer risk was estimated to be 36.9% (95% CI: 23.4–53.9%) for BRCA1 and 14.9% (95% CI: 7.4–28.5%) for BRCA2 carriers.

Cumulative socio-demographic risk factors and sleep outcomes in early childhood

STUDY OBJECTIVES

To examine associations between cumulative socio-demographic risk factors, sleep health habits, and sleep disorder symptoms in young children.

METHODS

Two hundred five caregiver-child dyads (child mean age ± SD: 3.3 ± 1.1 years; 53.7% girls; 62.9% black, 22.4% non-Hispanic/Latinx white, 4.4% Hispanic/Latinx; 85.4% maternal caregiver reporter) completed caregiver-rated sleep measures (Brief Child Sleep Questionnaire [BCSQ]; Pediatric Sleep Questionnaire [PSQ] snoring subscale), which were used to generate indexes of poor sleep health habits, pediatric insomnia symptoms, and obstructive sleep apnea (OSA) symptoms. A cumulative risk index was created reflecting caregiver, family, and neighborhood risks.

RESULTS

Overall, 84.5% of children had ≥ 1 poor sleep health habit, 62.9% had ≥ 1 insomnia symptom, and 40.0% had ≥ 1 OSA symptom. Poisson regression indicated that each increase in the number of cumulative risk factors was associated with a 10% increase in poor sleep health habits, a 9% increase in insomnia symptoms, and an 18% increase in OSA symptoms. Specific caregiver risks (depressive symptoms, lower educational attainment) and family risks (single caregiver, crowded home) were most predictive of poor sleep outcomes.

CONCLUSIONS

Poor sleep health habits and sleep disorder symptoms are highly prevalent in early childhood, particularly among families experiencing cumulative socio-demographic risks. Findings underscore the need for targeted screening and prevention for modifiable sleep behaviors and efforts to tailor such strategies for at-risk children and families, especially those living in crowded conditions, or with caregivers who are single or have a lower educational attainment or depressive symptoms.

Framing Environmental Health Decision-Making: The Struggle over Cumulative Impacts Policy

Little progress has been made to advance U.S. federal policy responses to growing scientific findings about cumulative environmental health impacts and risks, which also show that many low income and racial and ethnic minority populations bear a disproportionate share of multiple environmental burdens. Recent scholarship points to a “standard narrative” by which policy makers rationalize their slow efforts on environmental justice because of perceived lack of data and analytical tools. Using a social constructivist approach, ethnographic research methods, and content analysis, we examined the social context of policy challenges related to cumulative risks and impacts in the state of Maryland between 2014 and 2016. We identified three frames about cumulative impacts as a health issue through which conflicts over such policy reforms materialize and are sustained: (a) perceptions of evidence, (b) interpretations of social justice, and (c) expectations of authoritative bodies. Our findings illustrate that policy impasse over cumulative impacts is highly dependent on how policy-relevant actors come to frame issues around legislating cumulative impacts, rather than the “standard narrative” of external constraints. Frame analysis may provide us with more robust understandings of policy processes to address cumulative risks and impacts and the social forces that create health policy change.

The dynamics of maternal scaffolding vary by cumulative risk status

Parental scaffolding, or parenting behaviors that support children's independence and competence, can foster children's self-regulation development. Children facing higher cumulative risk may experience less scaffolding and more directives from parents, but it is unclear how cumulative risk affects the dynamics of parent-child interactions in real time. We examined the role of cumulative risk in mothers' moment-to-moment use of scaffolding and directives in response to preschoolers' off- and on-task behaviors (N = 117). Mothers answered questionnaires about cumulative risk at child age 2.5 years and completed a challenging puzzle task with their preschoolers at age 3 years. Continuous-time multilevel survival analyses revealed differences by cumulative risk in the likelihood of mothers' parenting responses following children's off- and on-task behavioral transitions over the course of the interaction. Specifically, when children went off-task, higher cumulative risk was associated with a lower likelihood of maternal scaffolding, but a comparable likelihood of directives, compared to lower risk mothers. When children got on-task, mothers with higher cumulative risk were less likely to respond with scaffolding and more likely to respond with directives than lower risk mothers. These results suggest that parents at higher risk respond with less scaffolding regardless of child behavior and respond with more directive commands when they may be unnecessary. Findings provide novel, real-time descriptive information about how and when parents experiencing cumulative risk use scaffolding and directive strategies, thus informing microlevel targets for intervention. Implications for the development of self-regulation in children at risk are discussed. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Is There a Cumulative Association Between Adverse Childhood Experiences and Intimate Partner Violence in Emerging Adulthood?

Adverse childhood experiences (ACEs) have been shown to cumulatively predict a range of poor physical and mental health outcomes across adulthood. The cumulative effect of ACEs on intimate partner violence (IPV) in emerging adulthood has not been previously explored. The current study examined the individual and cumulative associations between nine ACEs (emotional abuse, physical abuse, sexual abuse, emotional neglect, physical neglect, witnessing domestic violence, living with a mentally ill, substance abusing, or incarcerated household member) and IPV in a diverse sample of college students (N = 284; M_age = 20.05 years old [SD = 2.5], 32% male, 37% Caucasian, 30% Asian, 33% other, and 27% Hispanic) from an urban, public college in the Northeast of the United States. Participants reported ACEs (measured by the Adverse Childhood Experiences Survey) and IPV perpetration and victimization (measured with the Revised Conflict Tactics Scale-2) of physical and psychological aggression in an online study that took place from 2015 to 2016. Bivariate and multivariate associations between ACEs, cumulative ACEs (assessed by the sum of adverse experiences), and IPV outcomes were assessed, while controlling for demographics and socioeconomic status. No cumulative associations were observed between ACEs and any of the IPV subscales in multivariate regressions, while witnessing domestic violence was significantly associated with perpetration and victimization of physical aggression and injury, and household member incarceration and physical abuse were associated with physical aggression perpetration. Adverse childhood events do not seem to associate cumulatively with IPV in emerging adulthood and the contributions of individual childhood experiences appear to be more relevant for IPV outcomes. Clinical and research implications are discussed.

Effects of Probabilistic Risk Situation Awareness Tool (RSAT) on Aeronautical Weather-Hazard Decision Making

We argue that providing cumulative risk as an estimate of the uncertainty in dynamically changing risky environments can help decision-makers meet mission-critical goals. Specifically, we constructed a simplified aviation-like weather decision-making task incorporating Next-Generation Radar (NEXRAD) images of convective weather. NEXRAD radar images provide information about geographically referenced precipitation. NEXRAD radar images are used by both pilots and laypeople to support decision-making about the level of risk posed by future weather-hazard movements. Using NEXRAD, people and professionals have to infer the uncertainty in the meteorological information to understand current hazards and extrapolate future conditions. Recent advancements in meteorology modeling afford the possibility of providing uncertainty information concerning hazardous weather for the current flight. Although there are systematic biases that plague people’s use of uncertainty information, there is evidence that presenting forecast uncertainty can improve weather-related decision-making. The current study augments NEXRAD by providing flight-path risk, referred to as the Risk Situational Awareness Tool (RSAT). RSAT provides the probability that a route will come within 20 NMI radius (FAA recommended safety distance) of hazardous weather within the next 45 min of flight. The study evaluates four NEXRAD displays integrated with RSAT, providing varying levels of support. The “no” support condition has no RSAT (the NEXRAD only condition). The “baseline” support condition employs an RSAT whose accuracy is consistent with current capability in meteorological modeling. The “moderate” support condition applies an RSAT whose accuracy is likely at the top of what is achievable in meteorology in the near future. The “high” support condition provides a level of support that is likely unachievable in an aviation weather decision-making context without considerable technological innovation. The results indicate that the operators relied on the RSAT and improved their performance as a consequence. We discuss the implications of the findings for the safe introduction of probabilistic tools in future general aviation cockpits and other dynamic decision-making contexts. Moreover, we discuss how the results contribute to research in the fields of dynamic risk and uncertainty, risk situation awareness, cumulative risk, and risk communication.

Perceived Healthcare Access among Persons with and without HIV Who Use Illicit Stimulants: The Role of Cumulative Risk

Background: Persons who use stimulant drugs have greater morbidity and mortality relative to non-users. HIV infection has the potential to contribute to even great disparity in health outcomes among persons who use stimulants. These health disparities likely result in part due to poorer access to healthcare. Our study used a cumulative risk model to examine the impact of multiple risk factors on healthcare access in a sample of persons with and without HIV who use stimulants. Method: Our sample included 453 persons who reported recent use of illicit stimulants (102 HIV+, 351 HIV-). Participants completed clinical interviews, questionnaires, and a rapid oral HIV test. We constructed an 8-item cumulative risk index that included factors related to socioeconomic status, homelessness, legal history, and substance use. Results: Participants with HIV (PHW) were older than participants without HIV and more likely to have health insurance. Participants with and without HIV reported similar prior treatment utilization, but PWH reported better healthcare access and lower cumulative risk scores. Regression analyses showed cumulative risk was a significant predictor of healthcare access (β = -0.20, p < 0.001) even after controlling for age, HIV status, and health insurance status. We did not observe an interaction of HIV status by cumulative risk. Conclusions: Access to care among persons who use stimulants, both with and without HIV, is negatively impacted by the accumulation of risk factors from a number of different domains. Understanding the cumulative effects of these factors is critical for developing interventions to facilitate access to care, thus reducing health disparities and improving health outcomes.

Longitudinal Links Between Media Use and Focused Attention Through Toddlerhood: A Cumulative Risk Approach

Previous studies that examined the links between media use and children's attention abilities have yielded inconclusive findings. In the current study, we aimed to move beyond the focus on isolated aspects of media use to a comprehensive assessment of both direct and indirect media use and practices in early childhood. Drawing from the cumulative risk literature, we examined whether cumulative media use is related to children's subsequent attention abilities. Participants were 199 mothers of toddlers (60% male) who completed questionnaires assessing various aspects of children's media use, as well as children's focused attention abilities at three time points: 18 months (T1), 22 months (T2), and 26 months (T3) of age. Cumulative media use scores were computed based on four indicators: (1) child average daily screen time; (2) household background television; (3) maternal use of media to regulate child distress; and (4) maternal use of mobile devices while spending time with the child. An autoregressive cross-lagged (ARCL) path model controlling for child sex, maternal education, and general parenting practices showed that cumulative media use at 18 months negatively predicted children's focused attention at 22 months. Moreover, there was a significant negative indirect effect from cumulative media use at 18 months to focused attention at 26 months via focused attention at 22 months. Finally, the cumulative media index appeared to be a better predictor of focused attention than any of the singular media use indicators. Children's focused attention did not predict subsequent cumulative media use across time, providing no evidence for bidirectional links. Findings suggest that exposure to multiple (rather than single) aspects of media use is related to decreased subsequent focused attention abilities during toddlerhood. Family media plans that designate media-free time and increase parental awareness to media use habits in the household should therefore be encouraged.

Cumulative socio-contextual risk and child abuse potential in parents of young children: Can social support buffer the impact?

Child abuse potential refers to characteristics and practices closely linked to child abuse. Past investigations document that the number of risk factors parents experience is a correlate of child abuse potential. The purpose of this investigation was to test a model with multiple domains of risk including cumulative socio-contextual risk, parenting locus of control, children's externalizing behavior problems, social support, and child abuse potential. Using self-report data from eighty-seven mothers of children between the ages of 1-5 years old, bivariate correlations and linear regression analyses revealed that cumulative socio-contextual risk was positively associated with child abuse potential and that this association remained statistically significant when controlling for parenting locus of control and child externalizing behavior problems. Additionally, social support moderated the association between cumulative risk and child abuse potential.

Respiratory health effects of residential individual and cumulative risk factors in children living in two cities of the Pearl River Delta Region, China

Background

Indoor environment is complex, with many factors potentially interacting with each other to affect health. However, previous studies have usually focused on effect of a single factor. Assessment of the combined effects of multiple factors can help with understanding the overall health risk.

Methods

A cross-sectional study was conducted among 2,306 school children in Guangzhou and Shenzhen. Questionnaire data on respiratory symptoms and diseases were collected along with sociodemographic and residential environmental information. A subset of children (N=987) were measured for their lung function. A random forest algorithm was applied to screen the top-ranked indoor environmental exposure variables and to form a composite index for cumulative risk of indoor pollution (CRIP). Logistic regressions were conducted to analyze the independent effect of single indoor environmental risk factors and the combined effect of CRIP on children’s respiratory health. Multiple linear regressions were used to examine the independent and combined effects of indoor environmental exposure on lung function.

Results

We found that home dampness and molds as well as environmental tobacco smoke (ETS) were significantly and independently associated with increased prevalence of children’s respiratory symptoms and diseases and with reduced lung function. A higher CRIP level was significantly associated with increased risk of cough with cold (OR =1.37, 95% CI: 1.05–1.79) and wheeze (OR =2.71, 95% CI: 1.16–6.34). A higher CRIP level was also associated with reduced lung function measured as FVC, FEV₁, PEF, FEF_25%, FEF_25–75% and VC.

Conclusions

In children living in the subtropical region of the Pearl River Delta, home dampness and the presence of mold as well as ETS were individual risk factors for children’s respiratory health. The composite CRIP index was associated with respiratory symptoms and lung function, suggesting the utility of this index for predicting the combined effects of multiple risk factors.

Adverse caregiving in early life: The trauma and deprivation distinction in young children

Knowledge and understanding about the impact of cumulative adverse experiences on the health and wellbeing of children, adolescents, and adults has rapidly expanded over the past 30 years. Despite the invaluable attention and support this proliferation has drawn to the importance of early childhood experiences, we believe that it is time to move beyond broad indices of risk and toward more specific and individualized understanding of how risk exposures are linked to clinical outcomes in young children. Within infant and early childhood mental health, there is a need for greater specificity in linking adverse caregiving experiences in early life to psychopathology in children. We highlight a framework distinguishing experiences of trauma from experiences of deprivation and use the examples of posttraumatic stress disorder and reactive attachment disorder to demonstrate how greater specificity in our understanding of early adverse caregiving can lead to more accurate and targeted diagnosis and treatment for young children. Both researchers and clinicians benefit from an approach to gain a greater appreciation of the links between specific types of experiences and outcomes in the children that we serve.

A Cumulative Risk Perspective for Occupational Health and Safety (OHS) Professionals

Cumulative risk assessment (CRA) addresses the combined risk associated with chemical and non-chemical exposures. Although CRA approaches are utilized in environmental and ecological contexts, they are rarely applied in workplaces. In this perspectives article, we strive to raise awareness among occupational health and safety (OHS) professionals and foster the greater adoption of a CRA perspective in practice. Specifically, we provide an overview of CRA literature as well as preliminary guidance on when to consider a CRA approach in occupational settings and how to establish reasonable boundaries. Examples of possible workplace co-exposures and voluntary risk management actions are discussed. We also highlight important implications for workplace CRA research and practice. In particular, future needs include simple tools for identifying combinations of chemical and non-chemical exposures, uniform risk management guidelines, and risk communication materials. Further development of practical CRA methods and tools are essential to meet the needs of complex and changing work environments.

Dyadic synchrony and repair processes are related to preschool children's risk exposure and self-control

We examined associations between preschool children's cumulative risk exposure, dyadic interaction patterns, and self-control abilities in 238 mother-child dyads. Positive interactive synchrony, relationship ruptures, and latency to repair were micro-coded during a 3-5 minute joint challenge task. Children's self-control was assessed via two laboratory tasks and by parent report. Structural equation modeling and mediation analyses were utilized to examine the direct and indirect effects of cumulative risk on children's observed and parent-reported self-control abilities. Parent-child interactive processes of dyadic synchrony and latency to repair ruptures in synchrony were examined as mediators. Dyadic synchrony and latency to repair ruptures were found to mediate associations between cumulative risk exposure and children's behavioral and parent-reported self-control. Children exposed to more cumulative risk engaged in less dyadic synchrony and experienced longer latencies to repair ruptures with their caregiver, which in turn was associated with lower child self-control. Though cross-sectional, findings suggest dyadic synchrony and repair processes may represent viable mechanistic pathways linking cumulative risk exposure and deficits in child self-control. However, independent replications using longitudinal and experimental intervention designs are needed to determine causal pathways and inform new approaches for targeting the effects of early risk exposure through a focus on two-generational interventions.

Pathways from early adversity to later adjustment: Tests of the additive and bidirectional effects of executive control and diurnal cortisol in early childhood

Additive and bidirectional effects of executive control and hypothalamic-pituitary-adrenal (HPA) axis regulation on children's adjustment were examined, along with the effects of low income and cumulative risk on executive control and the HPA axis. The study utilized longitudinal data from a community sample of preschool age children (N = 306, 36-39 months at Time 1) whose families were recruited to overrepresent low-income contexts. We tested the effects of low income and cumulative risk on levels and growth of executive control and HPA axis regulation (diurnal cortisol level), the bidirectional effects of executive control and the HPA axis on each other, and their additive effects on children's adjustment problems, social competence and academic readiness. Low income predicted lower Time 4 executive control, and cumulative risk predicted lower Time 4 diurnal cortisol level. There was little evidence of bidirectional effects of executive control and diurnal cortisol. However, both executive control and diurnal cortisol predicted Time 4 adjustment, suggesting additive effects. There were indirect effects of income on all three adjustment outcomes through executive control, and of cumulative risk on adjustment problems and social competence through diurnal cortisol. The results provide evidence that executive control and diurnal cortisol additively predict children's adjustment and partially account for the effects of income and cumulative risk on adjustment.

Stress of Language Brokering and Mexican American Adolescents' Adjustment: The Role of Cumulative Risk

This study focused on early adolescents' stress of language brokering and examined the moderating role of family cumulative risk in the relation of language brokering to adjustment problems. Data came from self-reports of 604 low-income Mexican American adolescent language brokers (54% female; X ¯ age = 12.4 ; SD = 0.97; 75% born in the United States) and their parents (99% foreign-born) in central Texas. Path analyses revealed that brokering stress, but not frequency, was positively associated with adolescents' adjustment problems, including depressive symptoms, anxiety, and delinquency. We also found that the relation between stress of brokering for mothers and adolescents' depressive symptoms was stronger among families with a high cumulative risk. Further, with a high cumulative risk, adolescents exhibited delinquent behaviors regardless of the levels of stress from translating for fathers. Current findings underscore the importance of examining family contexts in assessing the consequences of language brokering for Mexican American early adolescents' well-being.

Cumulative Sociodemographic Risk Indicators for Difficult Child Temperament

Cumulative risk models provide a convenient, parsimonious way to identify outcomes associated with multiple, highly correlated risk factors. In this paper, we explored linkages between a cumulative sociodemographic risk index, which included rurality status, and aspects of temperamental difficulty in an early school age sample of 53 school-aged children from Southcentral Appalachia. Cumulative risk was significantly predictive of temperamental difficulty, as defined by high negative affectivity and low effortful control, but post-hoc analyses revealed this association to be driven primarily by two of the eight risk indicators: rural status and income-to-needs risk. Although rurality status was highly correlated with income-to-needs risk, rurality predicted negative affectivity over and above income-to-needs risk and income-to-needs risk predicted effortful control over and above rurality status. Future models of cumulative risk may benefit from including rurality status as a risk indicator, despite high collinearity with income-to-needs risk.