The longitudinal mediating role of sleep in associations between COVID-19 stressors predicting mental and physical health outcomes among emerging adult college students.

The current study tested a longitudinal mediation model throughout the COVID-19 pandemic focused on whether students' housing instability stress and food/financial instability stress at the beginning of the pandemic in spring 2020 (T1) informed sleep dissatisfaction and duration in fall 2020 (T2) and, in turn, physical and mental health in spring 2021 (T3). Further, we tested whether relations varied based on students' ethnic-racial backgrounds. Participants included 879 Asian, Black, Latine, Multiracial, and White emerging adult college students (Mage = 19.95, SD = 0.33) from a large public university in the mid-Atlantic region of the United States who attended college during the COVID-19 pandemic and completed surveys about their experiences. Findings indicated a significant mediation process, such that T1 housing instability stress predicted greater T2 sleep dissatisfaction and, in turn, less physical health, greater depressive symptoms, and greater anxiety symptoms at T3. Additionally, T1 food/financial instability stress was significantly associated with less T2 sleep duration but was not, in turn, associated with any T3 outcomes. Findings did not vary by students' ethnicity/race. Results highlight that sleep dissatisfaction is an important factor that accounts for relations between COVID-19 stressors predicting mental and physical health outcomes throughout the pandemic.

When a parent dies: A scoping review of protective and risk processes for childhood bereavement.

The death of a parent can have profound effects on child development. Yet, little is known about the individual and environmental processes that contribute to heterogeneity in child bereavement outcomes. A scoping review was conducted in samples of parentally bereaved children to identify key processes, synthesize results, and determine research gaps. This scoping review identified 23 studies (mainly from the United States), published between 1990 and 2023, that reported child (ages 3-22 years) individual and/or environmental protective and/or risk processes that contributed to bereavement outcomes. Individual processes (i.e., how children manage stressors and think about themselves/their environment) included child coping and perception of themselves and/or their environment. Environmental processes (i.e., contextual resources) included family, mentorship, and stress exposure. Findings can be used to apprise clinicians, families, and policymakers of the unique nature of childhood bereavement and to identify malleable processes to target in interventions designed to prevent problematic outcomes in bereaved children.

Interpersonal ethnic-racial discrimination and tobacco products: The moderating role of critical action.

OBJECTIVE: The present study aimed to understand the role of critical action, sociopolitical participation, an essential form of consciousness in the relationship between interpersonal discrimination and the use of tobacco products. METHOD: The present study was part of a more extensive longitudinal study on students' genetic and environmental experiences. To examine these associations, 164 racially minoritized college students (Mage = 19.86, SD = 0.28) were surveyed for this study. RESULTS: Findings indicated that the relation between interpersonal ethnic-racial discrimination (IERD) and tobacco products was moderated by critical action. Specifically, IERD was associated with greater use of tobacco products when students had low critical consciousness-critical action. The relation between IERD and the use of tobacco products became nonsignificant when students had high critical action. CONCLUSIONS: Critical action was protective in mitigating increased tobacco use in the context of discrimination experiences. Research, clinical, and policy implications are discussed in efforts to reduce tobacco-related disparities among racially minoritized college students. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Profiles of Latinx cultural orientation among adolescents: Associations with internalizing symptoms and moderation by ethnic-racial discrimination.

INTRODUCTION: The objectives of the current study were the following: (1) to explore multidimensional profiles of Latinx cultural orientation using Spanish language use, familismo, and ethnic-racial identity (ERI) affirmation among Latinx adolescents, (2) to test how Latinx cultural orientation profiles were associated with adolescents' internalizing symptoms (i.e., depressive symptoms and anxiety symptoms), and (3) to test whether associations between profiles and internalizing symptoms were moderated by adolescents' ethnic-racial discrimination experiences. METHODS: The study was conducted among a sample of 204 Latinx adolescents (52.4% female; Mage = 14.35, SDage = 1.75). RESULTS: Latent profile analysis indicated four profiles of Latinx cultural orientation: higher affirmation and lower Spanish (HALS), higher Spanish (HS), lower familismo and affirmation (LFA), and higher familismo/lower Spanish and affirmation (HFLSA). Latinx adolescents who reported lower levels on more than one Latinx cultural orientation dimension (e.g. LFA or HFSLA) also reported worse health when compared to adolescents who reported higher levels of more than one Latinx cultural orientation dimension (e.g., HSA). The associations between Latinx cultural orientation profiles and internalizing symptoms were not moderated by adolescents' ethnic-racial discrimination. CONCLUSION: Findings provide researchers and practitioners with an understanding of the various ways in which Latinx adolescents remain connected to their Latinx culture and implications for their outcomes.

Protective factors for adverse childhood experiences: Scoping review and evidence gap map.

OBJECTIVE: Adverse childhood experiences (ACES) negatively impact mental, physical, and behavioral health of adults. To develop empirically supported interventions to reduce the impact of ACES, we need to have a strong empirical base of research on modifiable protective factors that reduce the link between ACES and health outcomes. The current review is focused on assessing the state of the literature on modifiable protective factors on the ACE-health outcome relationship in adults. METHOD: We conducted a scoping review in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. A systematic search for peer-reviewed literature published in English was conducted in Medline, Embase, PsycINFO, CINAHL, and Web of Science from inception of the databases to January 5, 2023. We then constructed an evidence gap map to provide an innovative, visual approach to guide research prioritization. RESULTS: Seventy-seven articles met inclusion criteria. Findings indicated that the majority focused on mental health outcomes (59%), and investigated individual (52%) and general social support (23%) protective factors. Also, the majority of the work was done in North America (65%) with predominantly female samples. CONCLUSIONS: Future studies should focus on addressing gaps in our understanding of what factors may buffer the influence of ACES on physical health outcomes and risky health behaviors and our understanding of family and nonfamily relationships and community and cultural protective factors on the ACE-health outcome relationship in adults. Additionally, research is needed that focuses on samples that are more gender diverse and from countries outside of North America. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Family-based and external discrimination experienced by multiracial individuals: Links to internalizing symptoms and familial support.

Multiracial individuals are exposed to many forms of interpersonal racial discrimination, including general discrimination against their monoracial groups and discrimination against being multiracial. Because their families include members of different racial groups, multiracial people may also be exposed to various forms of discrimination from within the family. In the present study, we leverage recent advances in latent profile analysis to identify distinct patterns of family-based and external (i.e., from outside the family unit) discrimination experienced by multiracial college students, the differential impacts of these discrimination patterns on depressive and anxiety symptoms, and whether parental support of participants' multiracial experiences and identity impacts their exposure to different forms of discrimination. In a sample of 635 diverse multiracial college students (Mage = 21.2, SD = 5.3, range = 18-57, 74.0% female) from three U.S. universities, we identified three distinct discrimination profiles: High External and Familial Discrimination (43.2%), Average External Low Familial Discrimination (32.1%), and Low External and Familial Discrimination (24.7%). Profiles differed in depressive and anxiety symptomatology, with those in the High External and Familial Discrimination profile displaying the worst outcomes. Parental support of multiracial experiences was associated with lower levels of family-based discrimination. The complex relations between parental support, family-based discrimination, and multiracial participants' internalizing symptomology are discussed. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Children's ethnic-racial identity and mothers' cultural socialization as protective in relations between sociocultural risk factors and children's internalizing behaviors.

OBJECTIVES: The present study examined whether sociocultural risk factors (i.e., mothers' risky behaviors, mothers' and grandmothers' ethnic discrimination, and family economic hardship) predicted children's internalizing behaviors. We also tested whether sociocultural protective factors, including children's positive ethnic-racial identity (ERI) attitudes and mothers' cultural socialization, moderated relations. METHOD: Participants were 182 5-year-old Mexican-origin children, their mothers, and grandmothers. RESULTS: Findings indicated that children's positive ERI attitudes were protective, such that grandmothers' discrimination predicted children's greater internalizing at low levels of children's positive ERI attitudes, but this relation was not significant at high levels of children's positive ERI attitudes. Mothers' cultural socialization was also protective, such that mothers' risky behaviors predicted children's greater internalizing at low levels of mothers' cultural socialization, but this relation was not significant at high levels of mothers' cultural socialization. Economic hardship predicted children's greater internalizing and no variables moderated this relation. CONCLUSIONS: Findings highlight that mothers' engagement in risky behaviors, grandmothers' ethnic discrimination experiences, and family economic hardship contribute to children's greater internalizing behaviors. However, in some of these relations, children's positive ERI attitudes and mothers' cultural socialization are protective. In future research and programming, a consideration of the role of individual, family, and cultural factors will be important for addressing and reducing children's internalizing behaviors. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Black adolescents' racial discrimination and suicide behaviors: Testing perceived school safety as a protective moderator.

The current study examined associations between Black adolescents' (Mage = 15.55, SD = 1.23) racial discrimination and suicide behaviors (i.e., suicide ideation, suicide plan, and suicide attempts), and whether perceived school safety was a protective moderator. Furthermore, we tested gender differences in relations, which were not significant. Racial discrimination predicted greater suicide behaviors, and school safety informed less suicide behaviors. School safety moderated the relation between discrimination and suicide plan, such that at low school safety, discrimination predicted having a suicide plan but was not significant at high school safety. Furthermore, school safety moderated the relation between discrimination and suicide attempts. At low school safety, discrimination predicted more suicide attempts, but was not significant at high school safety.

A longitudinal test of Mexican-origin teen mothers' cultural characteristics and children's Spanish vocabulary via mothers' Spanish language use.

OBJECTIVES: The present study examined whether teen mothers' adaptive cultural characteristics (i.e., familism values, language competency pressures, and involvement in Mexican culture and U.S. mainstream culture) when children were 3 years old (i.e., Wave 4; W4) informed mothers' Spanish language use with their children when children were 4 years old (W5) and, in turn, children's subsequent Spanish receptive vocabulary when children were 5 years old (W6). METHOD: The present study included 204 Mexican-origin children (58% male) and their mothers who entered parenthood during adolescence (M = 16.24, SD = .99 at W1). RESULTS: Five mediational processes were significant, such that mothers' higher familism values (i.e., emphasizing family support and obligations), Spanish competency pressure (i.e., stress associated with Spanish language competency), and involvement in U.S. mainstream culture at W4 were associated with mothers' lower Spanish language use with children at W5 and, in turn, children's lower levels of Spanish receptive vocabulary at W6. Mothers' greater involvement in Mexican culture and English competency pressure (i.e., stress associated with English language competency) at W4 were associated with mothers' greater Spanish language use with children at W5 and, in turn, children's greater Spanish receptive vocabulary at W6. Additionally, mothers' greater involvement in U.S. mainstream culture at W4 was directly associated with children's lower Spanish language abilities at W6. CONCLUSIONS: Findings highlight the importance of the family context in Mexican-origin children's Spanish language skills over time. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Interactions between COVID-19 family home disruptions and relationships predicting college students' mental health over time.

The present study tested whether family home disruptions during the COVID-19 pandemic in the Spring 2020 (Time 1; T1) informed mental health (i.e., posttraumatic stress disorder [PTSD], depressive, and anxiety symptoms) 7 months later in Fall 2020 at T2 and whether family relationship quality moderated relations. Multigroup path analysis models were used to test whether there were significant differences in relations by emerging adults' ethnic-racial backgrounds. Participants were 811 Black, Asian American, Latine, and White emerging adult college students (Mage = 19.95, SD = .33), and the majority (79.6%) who reported their gender identified as cisgender women. Results indicated that across all individuals, T1 family relationship quality moderated relations between T1 family home disruptions and T2 anxiety and depressive symptoms. At lower levels of T1 family relationship quality, family home disruptions predicted greater T2 depressive and anxiety symptoms. At higher levels of T1 family relationship quality, these relations were not significant. Findings highlight that family relationship quality is an important protective factor for diverse emerging adult college students. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Public safety redefined: Mitigating trauma by centering the community in community mental health.

The summer of 2020 marked a shift in public perception of police brutality and racism in the United States. Following the police murder of George Floyd and ensuing social unrest, the appropriate role and function of the police in communities have been a frequent topic of debate. Of particular concern is the intersection of policing and mental health where we see a pattern of police using excessive force disproportionately against persons with disabilities, especially mental health disabilities (Autistic Self Advocacy Network, 2017). The introduction of race only exacerbates this disparity (Saleh et al., 2018). Given the realities of these mental health inequities, the aim of this scoping review is to explore first response models/programs that emphasize a therapeutic intervention as an alternative to policing. Seventeen articles were selected for inclusion in the review, six exploratory or experimental studies and 11 review or discussion articles. Using findings from the review, we offer recommendations to help reimagine this country's approach to emergency response. We urge psychologists and other health care providers to step out of the clinic and engage the community in the development of crisis responses for mental health emergencies that are therapeutic rather than inflammatory, healing rather than harming. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Processes underlying Mexican adolescents' sexual behaviors and intentions: Examining the roles of familial cultural values and parental monitoring.

OBJECTIVES: The study examined the associations between familial cultural values of familismo (familism) and respeto (respect), parental monitoring, and Mexican adolescents' sexual behaviors. METHOD: The sample consisted of 1,024 Mexican adolescents (12-18 years) from two urban schools in Puebla, Mexico. RESULTS: Findings indicated that respeto was associated with paternal and maternal monitoring, sexual responsibility, sexual intention, and sexual behavior. Further, through indirect effects, among males, respeto was associated with paternal monitoring, which was, in turn, associated with sexual intentions. CONCLUSIONS: Findings highlight the relevance of caregivers and cultural values in Mexican adolescents' sexual health. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Racial discrimination and depressive symptoms mediated by conversations about race among students of color.

Racial discrimination is associated with adverse mental health outcomes among Students of Color. In order to address racial tensions, it is important to consider students' dialogues about race. The current study tested whether having positive and negative conversations about one's ethnic-racial group mediated the relation between racial discrimination at T1 and depressive symptoms 5 months later at T2 among 94 college Students of Color. Findings indicated that greater racial discrimination at T1 was associated with more frequent negative conversations about race at T2 (b = .38, p = .00), which was, in turn, associated with greater depressive symptoms at T2 (b = 2.73, p = .04); this pathway demonstrated significant mediation. However, positive conversations about race was not a significant mediator in this association. The current study highlights the importance of focusing on racial conversations after racial discrimination in order to minimize adverse effects on mental health among Students of Color.

Sex differences in how ethnic-racial identity informs first coital affect and virginity beliefs among Black college students.

Objective: The present study examined whether ethnic-racial identity (ERI) exploration, resolution, and affirmation informed individuals' beliefs about virginity (ie, virginity as a gift, stigma, process) and first coital affective reactions (FCAR; ie, positive and negative), and whether these relations varied by biological sex. Participants and method: The sample consisted of 184 Black college students (Mage = 19.79, SD = 2.08) enrolled in a large Southern university. Participants completed a virginity beliefs measure, first coital affective reaction measure, and an ethnic-racial identity measure. Results: Findings indicated that for Black females, greater ERI exploration was associated with decreased virginity as a gift beliefs; and ERI resolution was associated with increased virginity as a gift beliefs. Additionally, for Black males and females, ERI affirmation resulted in more positive FCAR, less negative FCAR, and less views of virginity as a stigma. Conclusion: Finding implications are presented in the context of future research.

COVID-19-Induced Inequalities and Mental Health: Testing the Moderating Roles of Self-rated Health and Race/Ethnicity.

This study examines the relationship among COVID-19-induced social, economic, and educational inequalities on mental health (i.e., anxiety and depression). This study also examines if levels of self-rated health (SRH) moderate the relationship (i.e., COVID-induced inequalities [CII] and mental health), as well as examines the racial/ethnic group differences among 567 young adults in the mid-Atlantic region. Using a moderation model, results indicate that CII were significantly related to depression (b = .221, t(554) = 4.59, p = .000) and anxiety (b = .140, t(555) = 3.23, p = .001). SRH and race/ethnicity also moderated both relationships. At above-average SRH (i.e., moderator), higher CII were also significantly related to lower anxiety (Asian young adults only) and lower depression (Asian and White young adults only). Overall, SRH and race/ethnicity are important factors in the mental health impact of COVID-19 on young adults.

Cultural Socialization and Ethnic-Racial Identity Mediated by Positive and Negative Conversations about Race: Exploring Differences among Asian American, African American, Latinx, Multiracial, and White Students.

The current study examined associations between cultural socialization and ethnic-racial identity via positive and negative conversations about one's ethnicity/race. Ethnic-racial differences between Asian American, African American, Latinx, Multiracial, and White students were explored. College students 18-22 (M age = 18.46) participating in a university-wide study provided self-reports of childhood cultural socialization, engagement in conversations about ethnicity/race during college, and ethnic-racial identity. Cultural socialization was associated with more positive conversations about race, and, in turn, greater ethnic-racial identity exploration, resolution, and affirmation among all students. Additionally, among Multiracial and African American students, cultural socialization was associated with greater negative conversations about race and, in turn, less ethnic-racial identity affirmation. Although cultural socialization was not associated with negative conversations about race for Asian American, Latinx, or White students, the relation between greater negative conversations about race and less ethnic-racial identity affirmation was significant. Negative conversations about race also informed greater ethnic-racial identity exploration among all students, but was not associated with ethnic-racial identity resolution. The current study highlights the nuanced ways that childhood cultural socialization and conversations about one's ethnicity/race influence college students' ethnic-racial identity, both similarly and differently among Asian American, African American, Latinx, Multiracial, and White students. Two items created for the current study were used to assess positive and negative conversations about one's ethnicity/race in the past month. Response options for the positive conversation item ("In the past month, I had conversations with someone about something positive about my ethnic-racial group.") and negative conversation item ("In the past month, I had conversations with someone about something negative about my ethnic-racial group.") were scored using a 5-point Likert scale ranging from (1) Not at all to (5) Extremely or almost always. Higher scores indicated more frequent positive conversations and more frequent negative conversations, respectively. Initial support for the validity of the two items for positive and negative conversations about race has been provided by research with emerging adults (Delaney et al., in press).

Moderating Influence of Social Support on the Relations between Discrimination and Health via Depression in Latinx Immigrants.

The purpose of this study was to examine the relations among discrimination, depression, and health among a sample of diverse Latinx immigrants. A secondary aim was to examine whether direct and indirect effects among these variables were moderated by social support. A sample of 204 Latinx immigrants completed questionnaires in community centers, health clinics, and retail establishments. Depression was found to mediate the effect of discrimination on physical health. Social support was found to moderate this indirect effect, wherein higher levels of social support weakened the effect. Results from this study indicate that through depression, health can be impacted by minority stressors, and these relationships can be buffered by links to cultural strengths including social support.

El propósito de este estudio fue examinar las relaciones entre la discriminación, la depresión y la salud entre una muestra de diversos inmigrantes Latinxs. Un segundo objetivo fue examinar si los efectos directos e indirectos entre estas variables fueron moderados por el apoyo social. Una muestra de 204 inmigrantes Latinxs completaron cuestionarios en centros comunitarios, clínicas de salud y establecimientos minoristas. Se descubrió que la depresión media la relación entre la discriminación y la salud física. Se encontró que el apoyo social moderó esta relación indirecta y que los niveles más altos de apoyo social la debilitaron. Los resultados de este estudio indican que, a través de la depresión, la salud puede verse afectada por factores estresantes de las minorías, y estas relaciones se pueden amortiguar a través de fortalezas culturales, incluyendo el apoyo social.

Prevalence and surgical management of cholesteatoma in Down Syndrome children.

OBJECTIVE: The objective was to report the outcomes of surgical management of cholesteatoma in Down Syndrome (DS) children and to determine the prevalence of cholesteatoma in DS children at three academic tertiary care centers. METHODS: A retrospective chart review was performed of all DS children diagnosed with cholesteatoma from three tertiary care academic centers. Demographic data, comorbidities, imaging findings, surgical management, and pre- and postoperative pure tone averages were collected. RESULTS: The prevalence of cholesteatoma in DS patients at these three institutions was calculated to be 8/802 (0.998%), 4/448 (0.893%), and 4/1016 (0.394%), with an average prevalence of 0.762%. Of the 16 patients with cholesteatoma identified, the average age of diagnosis was 10.8 years, and 5/16 (31%) had at least three sets of pressure equalizing tubes (PETs) placed. Of the 13 patients with preoperative CTs, 4/13 (30.8%) had blunting of the scutum, 4/13 (30.8%) had tegmen involvement, 1/13 (7.7%) had erosion of the semicircular canal, 2/13 had facial nerve dehiscence, and 7/13 (53.8%) had ossicular chain erosion. For surgical management, disease control was attained in 4/16 children with tympanoplasty only and canal wall up (CWU) tympanomastoidectomy in 11/16 patients. Available pre- and postoperative audiograms were evaluated; however, there was insufficient audiological data to contribute to outcomes. CONCLUSION: Cholesteatoma occurs in nearly 1% of DS patients, and the disease tends to be advanced with tegmen involvement in nearly a third of patients, and ossicular erosion seen in more than half the patients. A CWU procedure can be successful in managing DS patients with cholesteatoma when consistent long term follow-up is planned. Close monitoring and a high index of suspicion for cholesteatoma are essential to prevent delays in diagnosis and treatment of DS patients with a history of multiple sets of PET placement.

Racial Discrimination and Alcohol Problems: Examining Interactions with Genetic Risk and Impulsivity among African American Young Adults.

Experiences of racial discrimination have been shown to increase risk for alcohol problems. Some individuals may be particularly vulnerable to the negative effects of racial discrimination. However, little research has examined interaction effects between racial discrimination and individual characteristics, such as genetic predispositions and personality, in relation to alcohol outcomes. This study examined whether genetic risk and dimensions of impulsivity moderate the association between racial discrimination and alcohol problems among African American young adults (n = 383, Mage = 20.65, SD = 2.28; 81% female). Participants completed online surveys and provided a saliva sample for genotyping. Results from multiple regression analyses indicated that both blatant and subtle forms of racial discrimination (i.e., experience of racist events and racial microaggressions) were associated with more alcohol problems. Racial microaggressions interacted with dimensions of impulsivity in relation to alcohol problems, such that racial microaggressions were associated with more alcohol problems when negative urgency was high or when sensation seeking was low. There was no significant interaction between alcohol use disorder genome-wide polygenic score and experience of racist events or racial microaggression in relation to alcohol problems, which may partly reflect low power due in part to limited representation of African-Americans in genetic research. The findings highlight the need to increase the representation of African Americans in genetically-informed research in order to better characterize genetic risk and understand gene-environment interaction in this understudied population, as well as the importance of examining impulsivity as a multidimensional construct that interacts with racial discrimination in relation to alcohol outcomes.

Incidence of Emergency Department Visits for Electric Rental Scooters Using Detailed Ridership Data.

INTRODUCTION: Electric scooter (e-scooter) rental usage has increased exponentially around the country, expanding to more than 120 cities by the end of 2018. Early attempts to capture the safety effects of widespread adoption of this technology have been hampered by lack of accurate ridership data. Here we describe a 17-month evolution of ridership characteristics in St. Louis, Missouri, and the frequency of e-scooter rental-related injuries serious enough to require an emergency department (ED) visit over this time frame; we also provide estimates of incidence rates of injuries based on company ridership data. METHODS: We performed a combination retrospective chart review and prospective questionnaire-based analysis of adult e-scooter rental-related ED visits in both downtown St. Louis Level 1 trauma centers during the first 17 months of e-scooter rental usage (August 2018-December 2019). The retrospective portion focused on demographics, alcohol use, helmet use, disposition, operative repair, and temporal and severity markers. The prospective portion focused on more detailed crash and rider data. Finally, we used ridership data from both e-scooter rental companies in St. Louis to estimate incidence and temporal trends. RESULTS: A total of 221 patients had e-scooter rental-related ED visits. The median age of our population was 31 years with 58.8% male and 53.8% White. There were no deaths. Ninety-two patients were found to have fractures with 38% requiring surgery. Of the 21 patients diagnosed with head injury, five had an intracranial bleed. Overall incidence of ED visits related to e-scooters was 2.1 per 10,000 trips and 2.2 per 10,000 miles with the number of ED visits by month closely correlated with the number of rides per month (Pearson correlation coefficient = 0.95). CONCLUSION: The number of e-scooter rental-related injuries seen in St. Louis trauma centers was relatively low and correlated closely with overall number of rides. The number of injuries decreased and were less severe from 2018 to 2019 with infrequent intracranial injuries and a large percentage of fractures requiring operative repair.