Trauma-Informed Undergraduate Medical Education: A Pathway to Flourishing with Adversity by Enhancing Psychological Safety.

We describe the Life Experiences Curriculum (LEC), which attempts to integrate medical student well-being with trauma-informed medical education. The long-term goal of LEC is to help medical students flourish with adversity and trauma, where flourishing refers to having a sense of purpose that arises from awareness of one's strengths and limitations, shaped by life experiences. The short-term goal of LEC is to develop students' relational capacities, such as acceptance and awareness of self and others, while building and maintaining students' psychological safety. We describe the conceptual rationale for these goals and the curriculum's development, implementation, evaluation, and limitations. The curriculum extends over four years and involves a preclinical seminar and students' individual and group reflection sessions with LEC faculty. The seminar addresses the coexistence of trauma and flourishing across life experiences, as well as how safety in relationships is impaired by traumatic experiences and must be restored for healing and growth. The physician faculty have no role in student evaluation and co-lead all LEC activities. LEC is intended to provide students with new language for understanding the process of trauma and flourishing in both individuals and systems and to build and sustain students' relational capacities. There are ongoing efforts to re-imagine self-care as communal-care in which care and support are given and received in a community of students and faculty. Such a model may help build the relational capacities needed to deliver trauma-informed care and also promote flourishing with adversity in healers and in those seeking to be healed.

The Association of Childhood Parental Connection With Adult Flourishing and Depressive Symptoms.

OBJECTIVES: To determine whether a common measure of childhood emotional neglect, scored instead as a continuous measure of increasing parental connection, is associated with adult flourishing and depressive symptoms, and to compare the magnitude of these 2 associations. METHODS: We pooled cross-sectional survey data from the Midlife in the United States study, collected from 2 national cohorts (2004-2006 and 2011-2014) of English-speaking, US adults, aged 25 to 74 years. Using the 5-item emotional neglect subscale of the Childhood Trauma Questionnaire, a score of increasing childhood parental connection was created by not reverse-scoring responses. The adult outcomes were standardized scores of flourishing, from Ryff's Psychological Well-Being Scale, and depressive symptoms, from the Center for Epidemiologic Studies Depression Scale. RESULTS: Data were available for 2079 of 2118 participants (98.2%). The mean (SD) age was 53.1 (12.6) years and 54.6% were female. After adjusting for covariates (age, gender, race and ethnicity, marital status, chronic disease, socioeconomic disadvantage), the adult flourishing score was 0.74 (95% confidence interval 0.63-0.86) SD units higher in those in the highest quartile of childhood parental connection compared with the lowest, whereas the depressive symptoms score was lower by a similar magnitude (-0.65 [95% confidence interval -0.77 to -0.54] SD units). CONCLUSIONS: When emotional neglect is reframed as parental connection, it has associations with adult flourishing and depressive symptoms that are of similar magnitude but opposite direction. Clinicians and researchers should consider the more positive and aspirational frame of parental connection and its potential contribution to life course flourishing.

The Association Between Early Childhood Education Professionals' Perception of Workplace Spirituality and Their Intention to Stay in Their Current Program.

Turnover in the US early childhood education (ECE) workforce is associated with worse outcomes for children. Greater workplace spirituality, or the perception of meaningful work, sense of community, and alignment with organizational values, is associated with reduced turnover. However, this association has not been examined in ECE professionals. We administered an online survey to 265 ECE professionals in Pennsylvania (US) in the spring of 2021. Respondents were asked about their intention to stay in their current program, if given the option to leave. Workplace spirituality was measured with a 21-item scale assessing the dimensions of meaningful work, sense of community, and alignment with organizational values. The survey was completed by 246 (92.8%), and data were analyzed for 232 respondents. Of these, 94.8% were female, 54.4% were non-Hispanic White, and 70.7% had a bachelor's or graduate degree. The prevalence of intention to stay was 33.2%. After adjusting for all covariates, including gender, age, race/ethnicity, education, job position, workplace stress, and economic hardships, the prevalence (95% confidence interval [CI]) of intention to stay increased across tertiles of workplace spirituality from low to medium to high: 16.4% (7.9%, 24.9%) to 38.6% (28.4%, 48.8%) to 43.7% (32.1%, 55.3%), respectively. ECE professionals who perceived greater workplace spirituality were more likely to report they intended to stay in their current program. Turnover in the ECE workforce could potentially be reduced through efforts to increase a sense of meaning and community at work and to align the values of ECE programs with those who work in them. Supplementary Information: The online version contains supplementary material available at 10.1007/s10643-023-01506-7.

The Association Between Work as a Calling and Turnover Among Early Childhood Education Professionals.

Turnover of early childhood education (ECE) professionals negatively impacts program costs, staff morale, and relationships with children. We determined whether the presence of work as a calling was associated with less intention to leave the ECE field. From an online survey administered to 265 ECE professionals in Pennsylvania, a calling score based on the Calling and Vocation Questionnaire was used to create sample-defined tertiles of low (< 38), medium (38-44), and high (> 44) presence of calling. Those intending to leave the ECE field reported that, given the option, they would most likely "find a position or get training in a completely different field," or "stop work, stay home, or retire." Analysis was restricted to 194 respondents currently employed in ECE and under age 60, of whom 94.8% were female and 53.9% were non-Hispanic White. After adjusting for race/ethnicity and workplace stress, the prevalence (95% CI) of intention to leave decreased as calling increased, from low (28.6% [17.8%, 38.4%]) to medium (12.2% [4.3%, 20.1%]) to high (9.1% [1.5%, 16.6%]). The presence of call was associated with less intention to leave the ECE field. Identifying, building, and sustaining call among ECE professionals may decrease turnover.

Relational Health as a Pathway from Trauma to Flourishing in School Communities.

BACKGROUND: Because traumatic life experiences are common, teaching and learning can be difficult without recognizing how trauma can make people feel psychologically unsafe. Safety can be restored through healthy relationships. CONTRIBUTIONS TO THEORY: We present a framework for how relational health-the capacity to develop and maintain safe, stable, and nurturing relationships with others-may allow flourishing in school communities, even amidst past and ongoing adversity. We propose four key assets for relational health-awareness of self, acceptance of self, awareness of others, and acceptance of others. To support this framework, we developed a relational asset score using data from a survey of 214 early childhood education professionals and examined its association with meaningful work, purpose in life, work satisfaction, and intention to stay in one's program. IMPLICATIONS FOR SCHOOL HEALTH: School health requires relational health. Research should evaluate the associations between relational assets and the perceptions of safety and connection in school communities. Leadership can prioritize relational health by supporting staff in building and using their relational assets. CONCLUSIONS: School communities may be more likely to flourish, even amidst adversity, if all adults in the community prioritize relational health, which provides the psychological safety required for teaching and learning.

Family Connection and Flourishing Among Adolescents in 26 Countries.

OBJECTIVES: To determine whether higher levels of family connection are associated with a greater prevalence of flourishing in adolescence. METHODS: We analyzed cross-sectional data from the International Survey of Children's Well-Being collected in 26 countries between 2016 and 2019 from 11- to 13-year-olds. Family connection was based on a mean score of 5 items that asked about care, support, safety, respect, and participation using a Likert-type scale (range 0-4). Flourishing was based on a mean score of 6 items that asked about self-acceptance, purpose in life, positive relations with others, personal growth, environmental mastery, and autonomy using a Likert-type scale (range 0-10). A mean score of >8 was considered flourishing. RESULTS: The analysis involved 37 025 of 39 286 (94.2%) adolescents, after excluding those with missing data. The mean (SD) age was 11.9 (0.6) years and 51.4% were girls. The prevalence (95% confidence interval) of flourishing was 65.8% (65.3-66.3). Adolescents were distributed across 5 increasing levels of the family connection score: <2.5 (11.2%), 2.5 to <3.0 (8.8%), 3.0 to <3.5 (24.2%), 3.5 to <4.0 (25.1%), and 4.0 (30.7%). After controlling for covariates, including material resources and food sufficiency, the prevalence (95% confidence interval) of flourishing increased across the 5 levels of increasing family connection: 34.9% (33.3-36.5), 45.0% (43.2-46.8), 58.2% (57.2-59.3), 72.6% (71.6-73.5), and 84.3% (83.6-85.1), respectively. CONCLUSIONS: Among adolescents from 26 countries, greater family connection was associated with a higher prevalence of flourishing. Family connection may contribute to flourishing, not just the avoidance of negative outcomes.

The interaction of adverse childhood experiences and gender as risk factors for depression and anxiety disorders in US adults: a cross-sectional study.

BACKGROUND: Exposure to adverse childhood experiences (ACEs) and being female are distinct risk factors for having a major depressive episode (MDE) or an anxiety disorder (AD) in adulthood, but it is unclear whether these two risk factors are synergistic. The purpose of this study was to determine whether exposure to ACEs and being female are more than additive (synergistic) in their association with MDE and AD in US adults. METHODS: We pooled cross-sectional survey data in the Midlife in the United States study from two nationally-representative cohorts of English-speaking US adults. Data from the first cohort were collected in 2004-2006 and from the second in 2011-2014. Data from both cohorts included the 12-month prevalence of MDE and AD (generalized anxiety disorder or panic disorder) assessed with the Composite International Diagnostic Interview Short Form, gender (here termed female and male), and the count of five categories of exposure to ACEs: physical, sexual, or emotional abuse; household alcohol or substance abuse; and parental separation or divorce. RESULTS: Of the 5834 survey respondents, 4344 (74.5%) with complete data on ACEs were included in the analysis. Mean (SD) age was 54.1 (13.8) years and 53.9% were female. The prevalences of MDE, AD, and exposure to 3-5 categories of ACEs were 13.7, 10.0, and 12.5%, respectively. After adjusting for covariates (age, race, and current and childhood socioeconomic disadvantage), for those with both risk factors (female and 3-5 ACEs) the prevalence of MDE was 26.9%. This was 10.2% (95% CI: 1.8, 18.5%) higher than the expected prevalence based on the additive associations of the two risk factors. The adjusted prevalence of AD among females with 3-5 ACEs was 21.9%, which was 11.4% (95% CI: 4.0, 18.9%) higher than the expected prevalence. CONCLUSIONS: For both MDE and AD, there was synergy between the two risk factors of exposure to ACEs and being female. Identification and treatment of MDE and AD may benefit from understanding the mechanisms involved in the synergistic interaction of gender with ACEs.

Diabetes distress and glycaemic control in young adults with type 1 diabetes: Associations by use of insulin pumps and continuous glucose monitors.

AIMS: We determined whether high diabetes distress (DD) in young adults with type 1 diabetes was associated with higher glycated haemoglobin (HbA1c ) levels and whether this association was similar among those who were and were not using diabetes devices (insulin pumps and/or continuous glucose monitors [CGMs]). METHODS: In 2017, an online survey was completed by 423 of 743 (57%) young adults (19-31 years) with type 1 diabetes receiving care at a specialty clinic in New York City. HbA1c level was the primary outcome measure, and high DD (Diabetes Distress Scale score ≥3) was the primary exposure. Associations were adjusted for sociodemographic covariates. RESULTS: Of the 419 respondents with complete DD data, 59% were female and 69% were non-Hispanic white. Both devices (pump and CGM) were used by 35%, either device by 42% and neither device by 24%. The mean (SD) HbA1c was 64 (19) mmol/mol (8.0 [1.7] %) and 24% had high DD. The adjusted mean (95% confidence interval) HbA1c was 10 (6, 14) mmol/mol (0.9 [0.5, 1.2] %) greater in those with high DD than in those without it. This HbA1c difference associated with high DD was similar regardless of device use: 9 (3, 15) mmol/mol (0.8 [0.3, 1.4] %) greater among those using both devices; and 9 (-0.9, 18) mmol/mol (0.8 [-0.1, 1.7] %) greater among those using neither device. CONCLUSIONS: High DD in young adults requires more attention because it is associated with higher HbA1c levels, even among those using insulin pumps and CGMs.

Childhood Family Connection and Adult Flourishing: Associations Across Levels of Childhood Adversity.

OBJECTIVE: To investigate whether higher levels of childhood family connection were associated with greater adult flourishing and if this association was present across levels of adverse childhood experiences (ACEs) and childhood socioeconomic disadvantage (SED). METHODS: We pooled cross-sectional data from telephone and mailed surveys in the Midlife in the United States study that were collected from 2 nationally representative cohorts (2004-06 and 2011-14) of English-speaking, US adults, aged 25 to 74 years. Adult flourishing z score, standardized to the study population, was created from Ryff's 42-item Psychological Well-being Scale and quartiles of childhood family connection from a 7-item scale assessing parental attention, affection, and communication during childhood. RESULTS: Data were analyzed for the 4199 (72.0% of 5834) participants with complete data. The mean age of participants was 53.9 years and 85.4% were White. After adjusting for covariates, including adult chronic disease, ACEs, and childhood and current SED, mean (95% CI) flourishing z scores increased from the lowest to highest quartiles of family connection: -0.41 (-0.49, -0.33), -0.18 (-0.25, -0.12), -0.01 (-0.07, 0.06), and 0.25 (0.18, 0.32), respectively. For each 1 SD increase in the family connection score, there was a 0.25 (95% CI, 0.20, 0.29) unit increase in the adjusted flourishing z score. This positive association was also present across levels of ACEs and childhood SED. CONCLUSIONS: Greater childhood family connection was associated with greater flourishing in US adults across levels of childhood adversity. Supporting family connection in childhood may influence flourishing decades later, even with early adversity.

Association of Childhood Family Connection With Flourishing in Young Adulthood Among Those With Type 1 Diabetes.

Importance: Higher levels of childhood family connection have been associated with measures of adult flourishing or eudaimonic well-being, such as purpose, self-acceptance, positive relationships, and growth. However, this association has not been examined among those with childhood-onset chronic disease. Objectives: To investigate whether higher levels of childhood family connection were associated with greater flourishing in young adulthood among those with type 1 diabetes and, secondarily, whether this association was present across levels of adverse childhood experiences and childhood social position. Design, Setting, and Participants: In 2017, the cross-sectional Type 1 Flourish survey was administered to all 743 young adults, aged 18 to 29 years, with type 1 diabetes who had received outpatient care in 2016 at a diabetes specialty clinic in New York, New York. Eligible participants completed the survey online or during clinic visits. Data analyses were conducted in September and October 2019. Exposures: The main exposure was childhood family connection (sample-defined tertiles), based on scores from a 7-item scale assessing parental attention, affection, and communication during childhood. Adverse childhood experiences, childhood social position, and other sociodemographic characteristics were also reported. Recent hemoglobin A1c levels were abstracted from medical records. Main Outcomes and Measures: Flourishing score calculated from the 42-item Psychological Well-being Scale developed by Ryff. Results: The survey was completed by 423 of 743 patients (56.9%), and the analysis included 415 participants (98.1%) with complete data on family connection and flourishing. The mean (SD) age of the sample was 25.0 (3.2) years, with 246 (59.3%) female respondents and 288 (69.6%) non-Hispanic white respondents. The mean (SD) flourishing score was 221.8 (37.7). After adjusting for age, sex, race/ethnicity, education, income, age at type 1 diabetes diagnosis, and hemoglobin A1c level, mean flourishing scores increased from the lowest (201.0; 95% CI, 195.0-207.0) to medium (225.2; 95% CI, 219.4-231.0) to highest (240.4; 95% CI, 234.4-246.4) tertiles of family connection; compared with those in the lowest tertile of family connection, the flourishing scores were 1.04 (95% CI, 0.81-1.27) SD units higher among those in the highest tertile and 0.64 (95% CI, 0.42-0.86) SD units higher among those in the middle tertile. This association was also present across levels of childhood adversity. In the subgroup of respondents with 2 or more adverse childhood experiences, those in the highest tertile of family connection had adjusted flourishing scores 0.76 (95% CI, 0.14-1.38) SD units higher than those in the lowest tertile. In the subgroup with low childhood social position, those in the highest tertile of family connection had flourishing scores 1.08 (95% CI, 0.63-1.52) SD units higher than those in the lowest tertile. Conclusions and Relevance: In this cross-sectional study of young adults with type 1 diabetes, higher levels of childhood family connection were associated with greater flourishing in young adulthood across levels of childhood adversity. Beyond disease management, clinician support of family connection may help children with type 1 diabetes flourish in adulthood.

The association between dispositional mindfulness and glycemic control in type 1 diabetes during early adulthood: Differences by age and adverse childhood experiences.

BACKGROUND: The study objective was to determine whether higher levels of dispositional mindfulness were associated with lower HbA1c levels among young adults with type 1 diabetes (T1D) and whether this association differed by age or exposure to adverse childhood experiences (ACEs). METHODS: An online cross-sectional survey, called T1 Flourish, was completed in 2017 by 423 of 743 (56.9%) young adults (19-31 years) with T1D receiving outpatient care at a diabetes specialty clinic in New York City. HbA1c levels were abstracted from medical records. Respondents were categorized by age, high and low dispositional mindfulness (median split on Cognitive and Affective Mindfulness Scale-Revised), and exposure to any of 10 ACEs. RESULTS: Respondents had a mean (SD) HbA1c of 64 (18) mmol/mol [8.0 (1.7)%]; 59.3% were female and 69.4% were non-Hispanic white. The covariate-adjusted association between dispositional mindfulness and HbA1c differed by age group and ACEs. Among 27- to 31-year-olds, those with high mindfulness had HbA1c levels that were 8 mmol/mol [0.7%] lower (95% confidence interval, 2-13 mmol/mol [0.2-1.2%]) than those with low mindfulness, and this association tended to be stronger in those with ≥1 ACEs. Weaker, non-significant associations in the same direction occurred in 23- to 26-year-olds. Among 19- to 22-year-olds, those with high mindfulness and no ACEs tended to have higher HbA1c levels. CONCLUSIONS: In young adults with T1D, higher mindfulness was significantly associated with lower HbA1c only among 27- to 31-year-olds. In early adulthood, the impact of mindfulness-based interventions on glycemic control may vary by age and childhood trauma history.

Reconciling mixed messages from mixed methods: A randomized trial of a professional development course to increase trauma-informed care.

In a previously reported randomized trial, we used both quantitative and qualitative methods to assess the impact of a professional development course, Enhancing Trauma Awareness, to increase trauma-informed care among preschool teachers in a large, urban, US school district. Although quantitative data from surveys showed no impacts of the course, the qualitative data from focus groups suggested that the course had positive, meaningful impacts on the teachers. These contrasting results are reconciled here by describing our experience of conducting and analyzing the focus group data. We explain how the course impacted the teachers and the implications of these mechanisms for implementing and evaluating approaches to increasing trauma-informed care. The course combined content about the effects of trauma with a key ingredient-a group-based relational process carried out over 12 weeks by two trainers. Through their engaged presence, the trainers allowed the course participants to feel emotionally safe. This safety allowed the participants to develop awareness and acceptance of trauma in their own lives and those of others. Teachers described the course as healing. They developed relational capacities manifested in their own engaged presence, characterized as a compassionate approach to addressing trauma experienced by children and families.

The association of fatigue with dispositional mindfulness: relationships by levels of depressive symptoms, sleep quality, childhood adversity, and chronic medical conditions.

Although mindfulness-based interventions may be effective in addressing the common symptom of fatigue, no population-based studies have examined the relationship between mindfulness and fatigue. We determined whether higher levels of dispositional mindfulness were associated with lower levels of fatigue. Cross-sectional data were obtained through the Pennsylvania Head Start Staff Wellness Survey, a 2012 web-based survey in which 2199 of 3375 (65%) eligible staff participated. The analytic sample was restricted to the 2083 female respondents with complete data on dispositional mindfulness (Cognitive and Affective Mindfulness Scale-Revised) and fatigue (Fatigue Severity Scale). We determined the mean covariate-adjusted fatigue scores in each quartile of dispositional mindfulness. This relationship was examined in the overall sample and within subgroups defined by levels of four variables: depressive symptoms, poor sleep quality, childhood adversity, and chronic medical conditions. The sample was 86% non-Hispanic White, and 61% had a bachelor's or more advanced degree. The mean (SD) Fatigue Severity Scale score was 3.3 (1.3). The adjusted mean fatigue score decreased significantly and in a graded manner across higher quartiles of mindfulness, with the adjusted fatigue score 1.4 points lower (95% confidence interval: -1.5, -1.2) among those in the highest quartile of dispositional mindfulness compared to the lowest. This significant graded relationship was present within each subgroup examined, and there was not a statistically significant interaction between dispositional mindfulness and any subgroup variable. Future trials of mindfulness-based interventions should consider assessing the outcome of fatigue in both clinical and non-clinical populations.

A quasi-experimental study of the impact of school start time changes on adolescents' mood, self-regulation, safety, and health.

OBJECTIVE: To determine whether school start time changes impact adolescents' mood, self-regulation, safety, and health. METHODS: In September 2015, two school start time changes were implemented in Fairfax County (VA) Public Schools: a 50-minute delay (to 8:10 am) for high schools and secondary schools and a 30-minute advance (to 7:30 am) for middle schools. We conducted cross-sectional surveys of students' sleep, mood, self-regulation, health, and safety before (2017 students) and after (1180 students) these changes. RESULTS: Adjusted for confounders, a 50-minute delay was associated with a decreased prevalence of low mood (-4.7%; 95% confidence interval [CI]: -8.2%, -1.2%), drowsy driving, (-8.4%; 95% CI: -15.9%, -0.9%), and skipping breakfast (-4.2%; 95% CI: -8.1%, -0.2%) but no other significant changes. There were no significant changes associated with a 30-minute advance. CONCLUSIONS: A 50-minute delay in school start time in high schools and secondary schools was associated with a decreased prevalence of low mood, drowsy driving, and skipping breakfast. A 30-minute advance in start time in middle schools was not associated with any appreciable changes.

Family Resilience And Connection Promote Flourishing Among US Children, Even Amid Adversity.

The outcome of flourishing and its predictors have not been well documented among US children, especially those who face adversity. Using data for 2016 and 2017 from the National Survey of Children's Health, we determined the prevalence and predictors of flourishing among US children ages 6-17. A three-item index included indicators of flourishing: children's interest and curiosity in learning new things, persistence in completing tasks, and capacity to regulate emotions. The national prevalence of flourishing was 40.3 percent (29.9-45.0 percent across states). At each level of adverse childhood experiences, household income, and special health care needs, the prevalence of flourishing increased in a graded fashion with increasing levels of family resilience and connection. Across the sectors of health care, education, and human services, evidence-based programs and policies to increase family resilience and connection could increase flourishing in US children, even as society addresses remediable causes of childhood adversity.

Effect of a Trauma-Awareness Course on Teachers' Perceptions of Conflict With Preschool-Aged Children From Low-Income Urban Households: A Cluster Randomized Clinical Trial.

Importance: Adverse childhood experiences are common and are associated with changes in early development and learning, but training early childhood educators in trauma-informed approaches to care has not been evaluated with randomized clinical trials. Objective: To determine whether a 6-session (12-week) professional development course, "Enhancing Trauma Awareness," improved the quality of teachers' relationships with the children in their classrooms. Design, Setting, and Participants: This cluster randomized clinical trial conducted from September 2017 to May 2018 allocated classrooms by a computer-generated random sequence to intervention (attend Enhancing Trauma Awareness course) and control (no course) groups. Outcomes were reported by participants via survey and analyzed by group allocation. Classrooms under the auspice of the School District of Philadelphia, Pennsylvania, serving 3- and 4-year-old children living in low-income households were invited to participate. Lead and/or assistant teachers from 63 of 348 eligible classrooms (18.1%) agreed to participate, and none were excluded. Of 96 enrolled teachers, 93 (96.9%) were assessed at follow-up (61 of 63 classrooms [96.8%]). Exposures: In September 2017, 32 classrooms (48 teachers) were assigned to receive a professional development course that taught about the effects of trauma using a group-based relational process, and 31 classrooms (48 teachers) received no intervention. Teachers completed online surveys immediately before and after the course. Exploratory focus groups with intervention teachers (n = 15) were conducted 5 months after the course ended. Main Outcomes and Measures: The primary outcome was teacher-children relationship quality, with a hypothesized decrease in teacher-children conflict scores. Secondary outcomes included relational capacities (eg, empathy, emotion regulation, and dispositional mindfulness). Focus group themes described teachers' experience of the course. Results: Of 96 teachers enrolled, 93 (96.9%) were women, and 58 (60.4%) were 40 years and older. Follow-up surveys were completed by 46 teachers (95.8%) in the control group and 47 (97.9%) in the intervention group, of whom 38 (79.2%) attended 4 or more course sessions. Adjusting for baseline values, mean (SE) conflict scores after the course were not significantly different between course participants (15.8 [0.6]) and controls (15.0 [0.6]) (effect size = 0.16; 95% CI, -0.19 to 0.52). There were no significant between-group differences in secondary outcomes. However, in focus groups, the teachers reported improvements in teacher-children relationship quality and several related relational capacities. Conclusions and Relevance: A course to enhance trauma awareness among preschool teachers did not reduce teacher-children conflict scores, yet qualitative assessments suggested the potential for improved teacher-children relationship quality. Trial Registration: ClinicalTrials.gov identifier: NCT03303482.

Drowsy Driving, Sleep Duration, and Chronotype in Adolescents.

OBJECTIVE: To determine whether self-reported drowsy driving was associated with an evening chronotype, a biologically-based difference in circadian sleep-wake timing, and shorter school-night sleep duration in a sample of high school drivers. STUDY DESIGN: Cross-sectional observational data were obtained from an online survey in spring 2015 of 431 drivers, age 15.5-18.7 years, attending Fairfax County (Virginia) Public schools. Drowsy driving was defined as having ever "driven a car or motor vehicle while feeling drowsy" in the last year. School-night sleep duration was calculated from school-night bedtime and wake time. Those with scores in the lower and upper tertiles of the Morningness-Eveningness Scale for Children were designated as having an evening or morning chronotype, respectively. RESULTS: Among survey respondents, 63.1% drove at least several times a week and 47.6% reported drowsy driving. The covariate-adjusted prevalence of drowsy driving was 13.9% (95% CI 3.0%-24.9%) higher in students who slept <7 hours on school-nights than in those who slept 8 or more hours. Compared with those with a morning chronotype, the adjusted prevalence of drowsy driving was 15.2% (95% CI 4.5%-25.9%) higher among those with an evening chronotype. CONCLUSION: Among adolescent drivers, both an evening chronotype and shorter school-night sleep duration were associated with more frequent reports of drowsy driving. Interventions to improve the timing and duration of nighttime sleep in adolescents may reduce the occurrence of drowsy driving.

Association of Self-regulation With Obesity in Boys vs Girls in a US National Sample.

Importance: Poor self-regulation in childhood is associated with increased risk of obesity. However, studies have assumed that greater self-regulation is associated with a lower obesity risk and have rarely examined differences in the association by sex. Objectives: To examine how different levels of toddler self-regulation are associated with the prevalence of obesity at kindergarten age and whether the pattern of association is different between boys and girls. Design, Setting, and Participants: This was a prospective cohort study using data from the Early Childhood Longitudinal Study, Birth Cohort, a nationally representative sample of 10 700 US children born in 2001 and followed up through kindergarten entry (2006-2007). The analytic sample included 6400 children with observed toddler self-regulation. Data collection occurred in children's homes and consisted of a parent interview and direct assessment of the child. Data analysis took place between May 2016 and March 2018. Exposures: During a standardized, in-home, developmental assessment at 24 months of age, observers scored 4 dimensions of children's self-regulation: adaptability, attention, persistence, and frustration tolerance. Self-regulation scores ranging from a low of 4 to a high of 20 were grouped into quartiles. Main Outcomes and Measures: With use of measured heights and weights at 5.5 years, obesity was defined as a body mass index for age in the 95th percentile or greater. Results: The analytic sample consisted of 6400 children (3250 boys [50.6%, weighted]), with a median age of 24.1 months (interquartile range, 23.4-24.7 months) and 64.5 months (interquartile range, 61.7-67.6 months) at the self-regulation and body mass index assessments, respectively. Self-regulation scores were lower for boys than for girls (mean, 13.7 [95% CI, 13.4-13.9] vs 14.9 [95% CI, 14.7-15.1]), and the lowest self-regulation quartile comprised more boys than girls (weighted percentages, 66.5% vs 33.5%). The prevalence of obesity at 5.5 years was 19.2% among boys and 16.5% among girls. The pattern of association between toddler self-regulation and obesity at 5.5 years was different for boys and girls (P = .008 for interaction). Among boys, the adjusted prevalence of obesity was 19.7%, 18.3%, 20.3%, and 15.9% from lowest to highest quartile of self-regulation. In contrast, among girls, there was a U-shaped association (adjusted prevalence of obesity from lowest to highest self-regulation quartile, 17.0%, 10.3%, 10.7%, and 15.0%). Conclusions and Relevance: In a large national cohort of US children, there were differences between boys and girls in the pattern of the association between self-regulation at 24 months and obesity at 5.5 years of age. Obesity prevention efforts aimed at improving self-regulation may have different results for girls and boys.