Insomnia affects 30-45% of the world population, is related to mortality (i.e., auto accidents and job-related accidents), and is related to mood and affect disorders such as anxiety and depression. Better understanding of insomnia via increased research will decrease the burden on insomnia. The neurocognitive model of sleep proposes that conditioned somatic and cognitive hyperarousal develop in response to repeated pairings of sleep-related stimuli with insomnia-related wakefulness. The purpose of this study was to examine the neurocognitive model of sleep using a novel laboratory paradigm, the Sleep Approach Avoidance Task (SAAT). It was hypothesized that individuals who report symptoms of insomnia will display a bias for negative sleep-related images from the SAAT, which is presumably a reflection of cognitive, behavioral and physiological processes associated with hyperarousal. It was also hypothesized that participants who report poor sleep would provide different subjective ratings for negative images (i.e., stronger valence and arousal) than individuals who reported better sleep.

An initial sample of 66 healthy college-aged participants completed the Insomnia Severity Index (ISI), the Pittsburgh Sleep Quality Index (PSQI) the Dysfunctional Attitudes and Beliefs about Sleep (DBAS) scale and the Epworth Sleepiness Scale (ESS). Participants also completed the SAAT. The SAAT was developed to assess sleep-related bias in adults. The SAAT is a visual, joystick controlled reaction time task that measures implicit bias for positive and negative sleep-related images. At the end of the task the participants are also asked to rate each image along three dimensions included valence, arousal and dominance.

There was a positive correlation between the SAAT and the ISI [r(61) = .30, p = .01], indicating that symptoms of insomnia are related to negative approach-related bias for sleep-related images. No other correlations were observed between the SAAT and self-report sleep measures. With regard to rating of images, higher dominance ratings for negative images were correlated with the SAAT [r(62) = .24, p = .03], which indicates that the approach bias for negative images is associated with “being in control.” Multiple linear regression was used to test if ISI scores and dominance ratings for negative images significantly predicted SAAT bias scores. The overall regression was statistically significant [r2 = .13, F(2, 58) = 4.15, p = .02]. ISI scores significantly predicted SAAT scores (ß = .27, p = .04), whereas dominance ratings for negative images did not significantly predict SAAT scores (ß = .20, p = .11). Exploratory correlational analyses were also completed for ratings of images and other sleep self-report measures. Valence ratings for positive sleep-related images were positively correlated with the ESS [r(64) = .36, p = .01], whereas valence ratings for negative sleep-related images were negatively correlated with the ESS [r(64) = -.24, p = .03].

Hypotheses were partially supported with the ISI being the only self-report measure associated with negative bias for sleep-related images. While ratings of dominance are associated with bias for negative sleep-related images, these ratings do not provide unique variance. These findings indicate a cognitive processing bias for sleep-related stimuli among young adult poor sleepers. Limitations, implications for assessment and intervention are discussed.

When neuropsychologists serve as consultants to schools, concussion management programs are associated with fewer referrals, faster cognitive recovery, and reduced incidence of protracted recovery compared to programs with physician consultants. However, accessing neuropsychological services can be challenging due to geographical and financial barriers. Particularly in rural areas, travel associated with post-concussion management can represent as a significant financial and time burden. Increasing accessibility to neuropsychologists has the potential to address these concerns, while also providing quality care to more

individuals. The current study aims to assess the cost-effectiveness and clinical outcomes of a remote, neuropsychologist-led consultation model of concussion management. We hypothesized that this remote model would save patients both money and time, while also improving patient outcomes.

604 high school concussion cases occurring between May 2019 and May 2022 were reviewed; 571 were included in the current analysis. The sample was 51% male with a mean age of 15.8 years (SD=1.32). All students took ImPACT tests following suspected concussions, with tests administered at the school by certified athletic trainers or nurses. Test results were electronically reviewed by the consulting neuropsychologist. Interpretations and recommendations were then sent via email to the school official. Cognitive recovery, defined as the days from the injury to the final ImPACT test, and incidence of repeat concussions, or concussions occurring within 3 months of a previous concussion, were used as indicators of patient outcomes. Financial burden was determined by calculating the round-trip distance in miles from the patient’s school to the neuropsychologist’s medical center, then multiplying this number by the 2022 standard mileage reimbursement rate of $0.63/mile to determine the travel cost for a single consultation.

The sample consisted of 571 individual concussion cases and 1,285 total ImPACT tests. An average of 2.25 tests were administered for each concussion case (SD=0.90), with an average of 18.47 days to the final test (SD=16.59). 8 concussions (1.4% of total concussions) occurred within 3 months of a previous injury. The distance from schools to the closest available neuropsychologist ranged from 2.4 to 102 miles. The remote nature of the consultation model allowed for patients to avoid up to 204 miles, or up to 4.5 hours, of driving for each consultation. Thus, patients saved anywhere from $3.00 to $127.50 in travel costs per consultation.

The remote nature of this consultation model yielded a similar cognitive recovery time to previous literature, indicating that it may be as effective as in-person consultation. Repeat concussions represented less than 1.5% of concussion cases, indicating that care was successful enough to prevent second concussions in the majority of the sample. The remote nature of the model also saved patients time (up to 4.5 hours of driving) and money (up to $127.50 in travel costs). Thus, a remote consultation model has the potential to increase access to first-rate concussion care in rural settings, while also being cost- and time-effective for patients.

Exposure to toxic chemicals during early brain development increases the risk of neurodevelopmental problems in children. Parents' and prospective parents' understanding of the impact of toxic chemicals on brain development and the efficacy of translation tools for children's environmental health literacy are poorly understood. We developed and validated a questionnaire, PRevention of Toxic chemicals in the Environment for Children Tool (PRoTECT) to assess knowledge of toxic chemicals and neurodevelopment, intentions to reduce exposures to toxic chemicals, and preferences for actions by government and industry to prevent neurodevelopmental disorders. Using PRoTECT, we surveyed people of child-bearing age across five countries (Canada, United States (US), United Kingdom (UK), India, and Australia) to identify general patterns of responses on this questionnaire by demographic characteristics, including country, age, gender, parental status, pregnancy status, and education. We also employed a randomized control design to examine the efficacy of a knowledge translation video to instill knowledge and prompt behavioral changes to reduce exposures to toxic chemicals immediately following its presentation and after a six-week follow-up period.

We recruited 15,594 participants, ages 18 to 45, via CloudResearch's Prime Panels between October-December 2021. After completing the PRoTECT survey, participants were randomly assigned to watch the video Little Things Matter: Impact of Toxic Chemicals on Brain Development (i.e., the experimental group) or to serve as the control group. Next, both groups answered a series of questions to assess their knowledge of toxic chemicals, their intentions to reduce exposures to toxic chemicals, and barriers to changing their behaviours. After six-weeks, we recontacted a subset (N=4,842) of participants to repeat PRoTECT and answer the same series of behavioural questions assessing whether they modified any of their behaviours to reduce exposure and why or why not.

Most participants (i.e., 75-85%) agreed that toxic chemicals can impact brain development and endorsed preferences (∼85%) for allocating more resources to prevent neurodevelopmental disorders, especially people with higher education, parents and pregnant women, and people who lived in India. Despite this, a large proportion of participants (∼50%) trusted industry and believed that government effectively regulated toxic chemicals. After the six-week follow-up, experimental participants showed greater changes in scores on PRoTECT (i.e., between 5-15% change), indicating greater knowledge about harms posed by toxic chemicals, more intentions to reduce exposure, and stronger preferences for prevention as compared to the control group. Differences were larger among people from the US, those who were more highly educated, and people in their thirties. However, the differences between groups in making behavioural changes to reduce exposures were attenuated at the six-week follow up as compared to baseline. Significant barriers to reduce exposure to toxic chemicals were reported by both groups and included cost, inconvenience, and not knowing how to determine whether a product is non-toxic or where to purchase non-toxic products.

We observed greater knowledge and concerns about toxic chemicals among more affluent respondents, pregnant women and parents, and people living in India across both groups. While the video enhanced participants' knowledge about toxic chemicals and intentions to reduce exposure, they indicated that barriers hindered them from making behavioral changes.

The apolipoprotein E (APOE) gene has been identified as a major risk factor for the development of Alzheimer’s disease in late life. Research has shown that APOE e4 allele carriers demonstrate poorer memory performance and accelerated cognitive decline relative to non-carriers, and there is a need to identify potential factors of resiliency against the negative effects of e4 on cognition. Social support may represent one potential mechanism given that higher levels of social support have been linked to better cognitive and functional outcomes in older adults. Thus, the current study sought to examine whether social support moderates the relationship between APOE e4 status and subjective and objective memory performance in a large community-based sample of Hispanic/Latino (H/L) and Non-Hispanic White (NHW) older adults residing in Texas.

Participants included 1,564 (H/L = 808, NHW = 756) older adults (mean age = 66.36±8.68) without dementia that had enrolled in the Health and Aging Brain Study-Health Disparities. Participants completed study questionnaires and a comprehensive neuropsychological battery. Apolipoprotein e4 status (e4 carriers vs. non-carriers) was determined by possession of at least one e4 allele. Perceived social support was measured using the total score from the abbreviated 12-item version of the Interpersonal Support Evaluation List. Objective memory performance was assessed using a z-score composite of Story A and B from the Weschler Memory Scale (WMS)-III and immediate and delayed recall trials from the Spanish-English Verbal Learning Test. Subjective memory was assessed using the total score from the Subject Memory Complaints Questionnaire. Race stratified multiple linear regression models, controlling for age, sex, and years of education, examined APOE e4 positivity x social support interactions on subjective and objective memory performance.

There was a significant APOE e4 genotype x social support interaction on objective memory performance (ß = -1.10, p = 0.003) in H/Ls such that higher levels of social support were associated with better memory performance in non-e4 carriers (ß = 0.14, p < .001), but not in e4 carriers (ß = -0.13, p = 0.9). In contrast, no significant APOE e4 status x social support interaction was observed on subjective memory (ß = -0.39, p = 0.35) in H/Ls. Finally, results revealed no significant APOE e4 genotype x social support interactions on subjective memory (ß = 0.14 p = 0.77) or objective memory (ß = 0.67, p = 0.11) performance in NHWs. Conclusions: Findings revealed that social support did not mitigate against the negative effects of e4 on subjective and objective memory performance in H/Ls or NHWs. However, results demonstrate that higher levels of social support are associated with better objective, but not subjective memory performance in H/Ls without the e4 genotype. These findings suggest that social support may protect against cognitive decline and enhance cognitive reserve in non-e4 carriers. Future studies should explore other potential factors of resiliency (e.g., diet, exercise) and examine the association between genetic risk and social support on neural markers (e.g., cortical thinning, hippocampal atrophy).

Children who are HIV-exposed uninfected (CHEU) are at risk of neurodevelopmental impairments due to perinatal HIV and antiretroviral therapy exposure as well as additional health and psychosocial burdens. There is limited understanding of the impact of perinatal risk factors on long-term outcomes of CHEU. The present study investigated the association between perinatal risk factors and the intellectual and language abilities in CHEU and children who are HIV-unexposed uninfected (CHUU).

CHEU and CHUU, 6 to 10 years, of age underwent neurodevelopmental assessments through the Kids Imaging and Neurocognitive Development (KIND) study at the Hospital for Sick Children in Toronto, Canada between January 2020 and August 2022. CHUU were recruited from the community with similar sociodemographic backgrounds based on residential area in Toronto and parental income levels. Measures of Full-Scale IQ (FSIQ), Verbal Comprehension (VCI), Visual Spatial skills (VSI), Fluid Reasoning (FRI), Working Memory (WMI), and Processing Speed (PSI) were evaluated with the Wechsler Intelligence Scale for Children - Fifth Edition. Core Language, Receptive Language, and Expressive Language skills were assessed with the Clinical Evaluation of Language Fundamentals - Fifth Edition. Perinatal risk factors included birthweight, birth complications (e.g., premature rupture of membranes, jaundice, etc.), maternal smoking and alcohol use during pregnancy, and NICU admission. Analyses of variance and chi-square tests were performed to investigate group differences and multiple regression analyses tested the relation between neurodevelopmental measures and birth factors. Significance was held at p <0.05.

36 CHEU (21 female, 8.74 ±1.56 years) and 26 CHUU (12 female, 8.53 ±1.50 years) children were included. For both groups, mean standardized scores of the cognitive abilities assessed were in the average range. CHEU had significantly lower birth weight than CHUU, but there were no differences between these groups with respect to maternal smoking and alcohol use, birth complications or NICU admission. There were no between group differences identified for the intellectual and language abilities. In the CHEU group, birthweight was significantly associated with lower VCI, WMI, and expressive language. In the CHUU group, prenatal alcohol and smoking exposure was associated with lower VCI scores. Birth complications were associated with lower WMI, PSI, and FSIQ scores.

In this interim analysis, perinatal risk factors impacted neurodevelopmental outcomes of CHEU and CHUU differently. While the groups did not differ in frequency of birth complications and maternal smoking and alcohol use, these factors negatively impacted aspects of intellectual ability in the CHUU group. CHEU with lower birthweight are at greater risk of working memory and language difficulties, supporting the need for early interventions and close neuropsychological follow-up of this population throughout childhood.

Children with pediatric brain tumors (PBT) are at increased risk of psychosocial challenges (e.g., emotional distress, social difficulties), which in turn can result in functional impairment, or problems engaging appropriately across settings. These concerns have been shown to be especially pronounced in patients with lower socioeconomic status (SES), which tends to be overrepresented among ethnic minorities, such as Latino populations. On the other hand, resilience (the ability to utilize resources to alleviate stress and overcome adversity) can act as a protective factor against functional impairment. While resilience has been found to be lower among Latino survivors of pediatric cancer, little is known about the potential role of resilience in mitigating functional impairment among Latino patients with PBT. The authors hypothesized poorer resilience and increased functional impairment among Latino patients with PBT compared to normative expectations, in an attempt to explore need for additional support within this population.

42 Latino patients with PBT ages 2-20 (x=11.08 years, SD=5.24) completed neuropsychological evaluation between 2018 and 2022. The sample was split relatively equally in terms of sex (47.6% male, 52.4% female), tumor location (45.2% infratentorial, 54.8% supratentorial), and household language (47.6% predominantly English, 52.4% predominantly Spanish). Outcome variables included Resiliency and Functional Impairment content scales from the Behavior Assessment Scale for Children – Third Edition: Parent Rating Scales (BASC-3: PRS). Standardized T-scores (x=50; SD=10) were derived using age-appropriate normative data, with higher T-scores indicating better resiliency, yet poorer functional impairment. Median household income for specific neighborhoods was used as a proxy for SES.

The sample as a whole did not deviate from age expectations in terms of resiliency [t(41)=-.469, p=.642] or functional impairment [t(38)=.118, p=.907]. However, when separated by household language, participants from English speaking households demonstrated lower resiliency and increased functional impairment as compared to both normative expectations [t(19)=-2.748, p=.006; t(18)=1.882, p=.038, respectively] and participants from Spanish speaking households [t(40)=-3.327, p=.002; t(37)=2.717, p=.010, respectively]. In contrast, participants from Spanish speaking households performed similarly to same-aged peers in terms of both resiliency [t(21)=1.931, p=.067] and functional impairment [t(19)=-1.969, p=.064]. Furthermore, household language predicted both resiliency [F(2, 39)=8.639, p=.0008] and functional impairment [F(2, 36)=6.203, p=.005] above and beyond SES, explaining an additional 29.4% (p=.0002) and 24.3% (p=.002) of the variation in these variables, respectively.

Latino patients with PBT from Spanish speaking households had better reported resiliency and lower functional impairment than their counterparts from English speaking households. Given the subjective nature of parent reported outcomes and the importance of appropriately supporting patients and families from underserved populations, the roles of culturally-ingrained protective factors and cultural/linguistic differences in perceiving or articulating distress need further exploration. Future research, including comparison of parent report with objective measurement of impairment, is needed to better understand relationships between home language and these important variables. Additionally, examination of diagnostic and treatment-related factors will be beneficial to determine the best approaches to interventions and resources within this population.

Youth with spina bifida (SB) are at increased risk of neuropsychological deficits, including executive dysfunction and inattention. While these deficits are well-documented cross-sectionally, little research has considered the development of these difficulties longitudinally. The limited research on executive dysfunction over time in youth with SB has been mixed, with some studies suggesting stable, elevated executive dysfunction (Tarazi et al., 2008) and others demonstrating improvements in inhibition and shifting in particular (Zabel et al., 2011). In contrast, no research has examined inattention over time in SB. Understanding the development of these constructs is critical for early identification of dysfunction and intervention development. This study thus aims to characterize the development of executive dysfunction and inattention in youth with SB.

One hundred forty youth with SB were recruited as part of a larger, longitudinal study. Mothers, fathers, and teachers of participants (Time 1: Myouth age = 11.4 years, 53.6% female) completed questionnaire-based measures of executive dysfunction (Behavior Rating Inventory of Executive Function, BRIEF; inhibit, shift, working memory, plan/organize subscales) and inattention (Swanson, Nolan, and Pehlam Teacher and Parent Rating Scale - Fourth Edition, SNAP-IV). Data were collected over five time points occurring at two-year intervals. Growth curves were estimated using linear mixed effects models to estimate development over time.

Difficulties with inhibition decreased across age in youth with SB according to mother, father, and teacher reports (p=.000-.007). Mother and father reports of shifting problems decreased across age (p=.009), while teacher reports showed no significant change (p=.799). Working memory problems also significantly decreased over time, but only according to fathers and teachers (p=.004-.005). Difficulties with planning/organizing remained stable across age for all reporters (p=.076-.935). With regards to inattention, symptoms decreased across age according to mothers and teachers (p=.000-.017), but not fathers.

Overall, inhibition, shifting, and inattention improved across age in this sample of youth with SB according to at least two reporters. Contrary to existing literature, working memory also improved over time in this sample. Planning/organizing was the only area of executive functioning that remained stable over time across reporters. These results support previous findings of improvements in behavioral regulation (i.e., inhibition, shifting), and stable, elevated planning/organizing difficulties. These findings also highlight the importance of considering different contexts and reporters’ perspectives when examining change over time. Predictors of the development of executive dysfunction and inattention should be considered, as this information may aid with increased understanding of neuropsychological function in SB and identifying which individuals may be most likely to benefit from early intervention. Examining predictors may also help explain differences in working memory development demonstrated in the current study compared to extant literature.

When assessing individuals from diverse backgrounds, APA ethical principles emphasize the consideration of language and culture when selecting appropriate measures. Research among hearing, English-speaking individuals has shown the effects in identifying cognitive deficits when language, culture, and educational background are not considered in the selection and administration of measures (Ardilla, 2007). Among the Deaf community in the US, a minority group with a unique culture and language (American Sign Language: ASL), there have been few attempts to adapt existing English cognitive measures. Factors complicating this include research resources given the limited number of neuropsychologists and researchers who understand both the complexities of the measures as well as the linguistic and cultural factors within the Deaf population. The goal of the current project is to develop a culturally informed interpretation of a cognitive screening tool for appropriate use with older Deaf adults.

Item selection was informed by MMSE data from Dean et al. (2009) and methods utilized by Atkinson et al. (2015). Items selection occurred through consultation with three neuropsychologists and graduate peers with either native signing abilities or demonstrated ASL fluency, as well as Deaf identities, cultural affiliation and or community engagement. Selection considered the potential for translation errors, particularly related to equivalence of translation from a spoken modality to a signed. Items were categorized into the following domains: Orientation, Attention, Memory, Language, Executive Functioning, Visuospatial, and Performance Validity. Two native signers (Deaf interpreters) provided formal translation of the items. The measure was piloted with 20 deaf and hard of hearing (DHH) adult signers (ages M=41.10, SD=5.50, Range=31-48). Items were prerecorded to standardize the administration, which was shown to participants through the screenshare function of Zoom software.

The average performance was 100.80 (SD=3.91)/ 105 possible points. Within the memory domain, some errors, especially for word selection on delayed recall, were noted which may be related to sign choice and dialect. Additionally, with culture-specific episodic memory items, participants 35% of participants were unable to provide a correct answer with qualitative responses indicating this information may be more familiar to a subset of the Deaf community that had attended Gallaudet University in Washington, D.C. There was a significant positive relationship between ASL fluency, determined by the ASL-Comprehension Test, and performance on the cognitive screener (r(18)=.54, p=.01) while age of onset of deafness (r(18)=-.16, p=.51) and age of ASL acquisition (r(18)= .21, p=.37), were not significant.

Results of this preliminary project yielded a measure that benefited from inclusion of content experts in the field during the process of interpretation and translation. It appears appropriate for Deaf signers who are proficient in ASL. The pattern of correlations suggests the measure may be appropriate for use with fluent signers with experience in ASL acquisition. Further development of the measure should focus on appropriate items that address the diversity of the Deaf experience as well as continue to explore inclusive translation approaches.

Cognitive impairment is an often-overlooked issue that non-CNS cancer survivors face. Our current understanding of their issues is lacking, as traditional memory sum scores grant us little insight into the underlying cognitive processes of memory and its impairment. We can improve the informativity of memory impairment studies by isolating which cognitive processes are impaired.

Participants were breast cancer survivors who received chemotherapy (n=68), and women controls (n=157). The participants completed the Amsterdam Cognition Scan (ACS), in which classical neuropsychological tests are digitally recreated for online at-home administration. Online administration reduces the burden on patients and allows for recording measurements with greater precision. The specific test used to illustrate the effectiveness of our computational modeling approach was the ACS equivalent of the Rey Auditory Verbal Learning Test, in which participants are tasked with recalling a list of 15 words five times. We formulated a Hierarchical Bayesian Cognitive Model to replace traditional sum scores and disentangle performance into the more theoretically meaningful concepts of 'memory storage’ and 'memory retrieval'.

A traditional analysis of the sum of trials 1-5 indicated no significant difference between patients and controls (t(223)=-0.99, p = 0.323), with a small effect size (Cohen’s d = -0.14).

For the newly isolated cognitive process “memory storage”, a non-significant difference was found between patients and controls (d=0.10, 95% credible interval on Cohen’s d: [0.25, 0.43]). On the “memory retrieval” process, a medium significant difference was found between patients and controls (d = -0.57, 95% credible interval on Cohen’s d: [-1.00, -0.19]).

The results indicate that the impaired memory processes in cancer patients are not a general impairment across all memory functions, but rather a selective impairment of memory retrieval. Our method of analysis revealed information that would have been left unnoticed had we relied on traditional sum over trials 1-5.

Mayo Test Drive (MTD): Test Development through Rapid Iteration, Validation and Expansion, is a web-based multi-device (smartphone, tablet, personal computer) platform optimized for remote self-administered cognitive assessment that includes a computer-adaptive word list memory test (Stricker Learning Span; SLS; Stricker et al., 2022; Stricker et al., in press) and a measure of processing speed (Symbols Test: Wilks et al., 2021). Study aims were to determine criterion validity of MTD by comparing the ability of the MTD raw composite and in-person administered cognitive measures to differentiate biomarkerdefined groups in cognitively unimpaired (CU) individuals on the Alzheimer’s continuum.

Mayo Clinic Study of Aging CU participants (N=319; mean age=71, SD=11, range=37-94; mean education=16, SD=2, range=6-20; 47% female) completed a brief remote cognitive assessment (∼0.5 months from in-person visit). Brain amyloid and brain tau PET scans were available within 3 years. Overlapping groups were formed for 1) those on the Alzheimer’s disease (AD) continuum (A+, n=110) or not (A-, n=209), and for 2) those with biological AD (A+T+, n=43) or with no evidence of AD pathology (A-T-, n=181). Primary outcome variables were MTD raw composite (SLS sum of trials + an accuracy-weighted Symbols response time measure), Global-z (average of 9 in-person neuropsychological measures) and an in-person screening measure (Kokmen Short Test of Mental Status, STMS; which is like the MMSE). Linear model ANOVAs were used to investigate biomarker subgroup differences and Hedge’s G effect sizes were derived, with and without adjusting for demographic variables (age, education, sex).

Remotely administered MTD raw composite showed comparable to slightly larger effect sizes compared to Global-z. Unadjusted effect sizes for MTD raw composite for differentiating A+ vs. A- and A+T+ vs. A-T- groups, respectively, were -0.57 and -0.84 and effect sizes for Global-z were -0.54 and -0.73 (all p’s<.05). Because biomarker positive groups were significantly older than biomarker negative groups, group differences were attenuated after adjusting for demographic variables, but MTD raw composite remained significant for A+T+ vs A-T- (adjusted effect size -0.35, p=.007); Global-z did not reach significance for A+T+ vs A-T- (adjusted effect size -0.19, p=.08). Neither composite reached significance for adjusted analyses for the A+ vs A- comparison (MTD raw composite adjusted effect size= -.22, p=.06; Global-z adjusted effect size= -.08, p=.47). Results were the same for an alternative MTD composite using traditional z-score averaging methods, but the raw score method is preferred for comparability to other screening measures. The STMS screening measure did not differentiate biomarker groups in any analyses (unadjusted and adjusted p’s>.05; d’s -0.23 to 0.05).

Remotely administered MTD raw composite shows at least similar ability to separate biomarker-defined groups in CU individuals as a Global-z for person-administered measures within a neuropsychological battery, providing evidence of criterion validity. Both the MTD raw composite and Global-z showed greater ability to separate biomarker positive from negative CU groups compared to a typical screening measure (STMS) that was unable to differentiate these groups. MTD may be useful as a screening measure to aid early detection of Alzheimer’s pathological changes.

In the context of primary care, cognitive screenings are brief, non-diagnostic tests that clinicians can administer in order to provide appropriate referrals to neuropsychologists. Annual cognitive screening for adults over age 65 (“older adults”) can help monitor cognitive functioning over time and ensure more patients with cognitive impairments receive neuropsychological assessment and care earlier. Unfortunately, time constraints and lack of training present major barriers to cognitive screening in primary care, and less than half of cognitive impairment cases are identified in these settings. A remote cognitive screening mobile app has the potential to save primary care clinics time, particularly for the majority of older adults who are cognitively healthy. Moreover, a screening app well-validated for remote clinical use can replace the inadequate or nonexistent screening practices currently employed by many primary care clinics. In order to achieve their potential, remote smartphone-enabled cognitive screening paradigms must be acceptable and feasible for both patients and clinical end users. With this goal in mind, we describe the collaborative, human-centered design process and proposed implementation of MyCog Mobile (MCM), a self-administered cognitive screening app based on well-validated NIH Toolbox measures.

We conducted foundational interviews with primary care clinicians (N=5) and clinic administrators (N=3) and created user journey maps of their existing and proposed cognitive screening workflows. We then conducted individual semi-structured interviews with healthy older adults (N=5) as well as participated in a community stakeholder panel of older adults and caregivers (N=11). Based on the data collected, we developed high-fidelity prototypes of the MCM app which we iteratively tested and refined with the older adult interview participants. Older adults rated the usability of the prototypes on the Simplified System Usability Scale (S-SUS) and After Scenario Questionnaire (ASQ).

Clinicians and administrators were eager to use a well-validated remote screening app if it saved them time in their workflows and were fully integrated into their EHR. Clinicians prioritized easily interpretable score reports tied to automated best practice guidelines. Findings from interviews and user journey mapping further informed the details of the proposed implementation and core functionality of MCM. Older adult participants were motivated to complete a remote cognitive screener to ensure they were cognitively healthy, save time during their in-person visit, and for privacy and comfort reasons. Older adults also identified several challenges to remote smartphone screening which informed the user experience design of the MCM app. The average rating across prototype versions was 91 (SD 5.18) on the SSUS and 6.13 (SD 8.40), indicating above average usability.

Through our iterative, humancentered design process, we were able to develop a viable remote cognitive screening app and proposed implementation for primary care settings optimized for multiple stakeholders. Next steps include validating MCM in clinical and healthy populations, collaboratively developing best practice alerts for primary care EHRs with neuropsychologists, and piloting the finalized app in a community clinic. We hope the finalized MCM app will promote broader screening practices within primary care and improve early assessment and diagnosis of cognitive impairment for older adults.

Patients with Parkinson’s disease (PD) commonly show deficits on tests of visuospatial functioning. The Identi-Fi is a new measure of visual organization and recognition composed of two components. The Visual Recognition (VR) subtest asks persons to identify an object that has been broken its pieces and rearranged, akin to the Hooper Visual Organization Test, but using updated and colorful pictures. The Visual Matching (VM) subtest involves showing the same stimuli, but the examinee must select the correct response from among five choices (1 correct and 4 foils), placing greater demand on visuospatial discrimination. Together, the two subtests comprise the Visual Organization Index (VOI), reflecting overall visual processing and organization ability. The present study examined performance on the Identi-Fi in patients with PD and its association with other aspects of cognition.

Participants were 23 patients with PD (95% male; mean age = 69.7 years [SD = 7.8], range = 47-79) and 12 patients with cognitive concerns (CC) who were intact on neuropsychological testing (excluding consideration of Identi-Fi scores; 50% male, mean age = 71.08 [SD = 6.27], range = 60-78) seen for a neuropsychological evaluation at a large Northeastern medical center. As part of a larger battery, patients completed the Identi-Fi, Trail Making Test (TMT), Category Fluency, Test of Premorbid Functioning (TOPF), and Brief Visuospatial Memory Test, Revised (BVMT-R).

The PD group performed significantly worse than the CC group on VR and VM, as well as VOI, of the Identi-Fi (p < .001). Within the PD group, poorer VR, VM, and VOI performance was associated with lower scores on the TOPF (p < .05), BVMT-R learning (p < .05) and delayed recall (p < .05), as well as TMT Parts A and B (p < .05). VR was significantly correlated with Category Fluency (p < .05), while a trend was seen for the association between VOI and Category Fluency (p = .094).

Identi-Fi performance was worse in the PD group than the CC group, which is consistent with prior research indicating that visuospatial processing is often abnormal in patients with PD. Furthermore, findings indicate that poorer performance on the Identi-Fi in the PD group is associated with poorer cognitive functioning in other domains (i.e., visuospatial learning and memory, processing speed, cognitive flexibility, and semantic fluency), as well as lower premorbid intellectual functioning. While these findings suggest that the Identi-Fi is useful in identifying visuospatial dysfunction in PD, findings should be interpreted with caution given the small sample sizes and uneven gender distribution

Executive functions (EFs) refer to a set of top-down cognitive processes that are fundamental for the control of goal directed behaviours (Lezak et al., 2004). Inhibition (the capacity to ignore irrelevant information) and selective attention (the capacity to selectively focus on relevant information) are considered as the core components of EFs (Barkley, 2001; Veer et al., 2017). EFs can be impaired following brain damage (Chung et al., 2013) and they are traditionally assessed individually, using paper-and-pencil tests that have long been criticized for their ecological and sensitivity limitations (Dugbartey et al., 1999; Miyake et al., 2000). Here we developed a serious game in immersive virtual reality to measure inhibition and selective attention based on the go/no-go paradigm and the D2 Test.

Sixty healthy participants were asked to perform a series of tasks, where in each task, the target was a mole wearing a coloured helmet. In task A, either the target or a distractor bomb was presented. The participants had to respond to the target and inhibit a response to the bomb. In task B, the target was presented with distractor moles wearing different coloured helmets. The two tasks could also be combined, task AB, where the target was presented with distractors (as in task B) versus the bomb was presented with distractor moles. All the stimuli appeared from four molehills aligned to sagittal axis (near to far from the participant). Responses were made with the dominant hand in task A and with both tasks in tasks B and AB. The participants were instructed to hit the target with a virtual hammer.

Response time analysis showed that in tasks A, B and AB, participants were slower to respond to the far compared to near targets. In task B and AB, participants were additionally slower to respond to the left compared right targets. Significant interactions between laterality and proximity for tasks B and AB showed that the participants were significantly slower to response to left vs right target in both far and near conditions. All participants were able to inhibit responses to the bomb and distractor stimuli.

In conclusion, we have developed a novel serious game in immersive virtual reality for the assessment of inhibition and selective attention, both as individual tests and as a combined test. Future studies will test patients with executive dysfunction to test the validity of this new serious game.

ADHD and anxiety symptoms are highly comorbid in childhood. While worse functional outcomes are typically expected for children with comorbid ADHD and anxiety symptoms, an emerging body of literature has suggested that anxiety symptoms may actually contribute to compensatory effects for executive functioning (EF) skills in children with ADHD symptoms. However, the results of studies investigating this claim have been quite mixed, possibly due to the use of smaller sample sizes and cross-sectional datasets. The current study extends the previous literature by examining the possible compensatory effects of anxiety symptoms in the context of ADHD symptoms on EF abilities (e.g., working memory [WM] and inhibition) both cross-sectionally and longitudinally in a large, well-validated sample.

547 children and adolescents (8-16 years) were included from a population-based sample of twins (CLDRC sample) with enrichment for reading and attention challenges. Participants were retested at a second time point approximately 5 years later. ADHD symptoms (inattention and hyperactivity-impulsivity) were measured by a DSM-based ADHD rating scale, anxiety symptoms were measured by the RCMAS, inhibition was measured by stop-signal reaction time (SSRT), and working memory was measured by Digit Span Backwards (WISC/WAIS-R/III). Covariates included age and sex assigned at birth. Multiple regression models examined cross-sectional and longitudinal associations between ADHD (inattention and H-I) symptoms, anxiety symptoms, and the interaction between ADHD and anxiety symptoms on WM and inhibition abilities.

As expected, higher anxiety, inattention, and H-I symptoms were generally associated with lower inhibition and WM abilities both cross-sectionally and longitudinally. While no significant interactions between ADHD and anxiety symptoms were identified cross-sectionally at Time 1, significant interactions between Time 1 ADHD and anxiety symptoms predicted Time 2 inhibition scores. An inattention x anxiety interaction (p=.002) and a H-I x anxiety (p=.016) interaction significantly predicted Time 2 inhibition. Simple slopes analysis confirmed a compensatory interaction pattern, where ADHD symptoms showed a stronger association with inhibition weaknesses in children without anxiety symptoms compared to those with anxiety symptoms. This suggests that anxiety symptoms may be serving as a compensatory factor for children with ADHD symptoms as compared to their peers without ADHD symptoms.

These findings help clarify a previously mixed literature. Our findings suggest that the compensatory effect of anxiety symptoms on inhibition abilities in children with ADHD symptoms may be a developmental mechanism that takes time to emerge. The fact that the compensatory effect may take time to emerge may explain conflicting results within prior cross-sectional samples. These findings also have implications for research investigating the link between ADHD symptoms and EF abilities, as anxiety symptoms may be an important moderator to consider when attempting to explain why the correlation between ADHD symptoms and EF abilities is often weaker than expected. Finally, clinical implications for this work help to provide empirical evidence to support anecdotal experiences reported by individuals with ADHD and the clinicians who assess them, who often report that anxiety symptoms help them to improve EF performance.

Executive functioning (EF) and socioeconomic status (SES) are associated with functional outcomes (adaptive functioning and academic achievement) in healthy controls and pediatric populations with executive dysfunction. However, these relationships have yet to be investigated in survivors of childhood acute lymphoblastic leukemia (ALL), a population with EF impairment resulting from disease and treatment characteristics. The objective of this study was to examine the associations of functional outcomes with EF and SES (neighborhood-specific variables and academic support) in survivors of childhood ALL.

Forty-four participants (38.6% female, 72.7% non-Hispanic White, ages 6-17) previously diagnosed with low-risk or standard-risk pre-B cell ALL and treated with chemotherapy-only were included. Participants were evaluated on performance-based measures of EF (cognitive flexibility, verbal fluency, working memory, and processing speed) and academic achievement (word reading and math calculation), and parent-ratings of EF and adaptive functioning. All measures were expressed as T-scores with lower scores indicating better performance. Neighborhood-specific variables were based on participants’ zip codes and census block group, and included area deprivation index (ADI) and child opportunity index (COI). Lower ADI and COI indicate lesser deprivation and greater opportunity. Individualized education plan (IEP) status was used as a proxy of academic support, coded dichotomously as with or without IEP. Percentages of participants showing impairments in functional outcomes were calculated using a cutoff of > 1 SD above the normative mean. Partial correlations were conducted while controlling for age at evaluation, age at diagnosis, sex, and verbal IQ, to examine whether participants with poorer performance-based and parent-rated EF would show reduced functional outcomes. Multiple regression analyses were conducted to evaluate whether neighborhood-specific variables and IEP status would predict functional outcomes while controlling for covariates.

Compared to population norms, survivors of childhood ALL showed worse functional outcomes. Within adaptive functioning, 45.5% of participants showed impairment in activities of daily living and leadership. Adaptive functioning was significantly positively correlated with parent-rated, but not performance-based, EF (r=0.694, p<0.001). Compared to female survivors, male survivors were at increased risk for adaptive functioning difficulties (r=-0.401, p<0.05). Impairments for word reading and math calculation were 25% and 41.7%, respectively. Greater math calculation was associated with better verbal fluency (r=0.378, p<0.05) and processing speed (r=0.439, p<0.05). Older participants at evaluation (/3=-0.580, p<0.001) and those without IEP support (ß=0.465, p<0.05) showed better word reading. Lower ADI predicted better verbal fluency (ß=0.282, p=0.041), however, neighborhood-specific variables were not associated with functional outcomes.

Prior findings indicate that performance-based measures and parent-ratings assess different constructs of EF. Thus, adaptive functioning may relate more to the behavioral construct of EF than its cognitive construct. Current findings also suggest that male survivors are at increased risk for reduced adaptive functioning, consistent with recent reports that male survivors of ALL are at greater risk for specific neurocognitive outcomes. Overall, functional outcomes may be more strongly related to EF than neighborhood-specific variables. Long-term goals include early screening of adaptive and academic difficulties, targeted intervention, and neuropsychological monitoring to support pediatric survivors’ neurocognitive and psychosocial development.

Prospective memory (PM) is the ability to execute a planned action in the future (e.g., remembering to take medication before going to bed). Prior work has suggested that PM failure can account for 50-80% of reported memory problems. Research has also shown that PM becomes increasingly impaired in the Alzheimer's disease (AD) process. To our knowledge, most PM studies use PM accuracy as a measure of PM performance. However, examining the speed of the response as it relates to the AD process remains relatively unexplored. In this study, we examined both PM accuracy and speed in healthy aging, mild cognitive impairment (MCI), and AD.

Participants included healthy older controls (N=65), persons with MCI (N=70), and persons with AD (N=11). The PM task was embedded within a working memory task as PM demands often occur during an ongoing activity in everyday life. For the working memory component of the PM task, participants were shown a series of words and asked to continuously monitor the words while maintaining the last 3 in memory. All words were displayed within 1 of 6 background patterns. For the PM component, participants were asked to press "1" on the keyboard whenever they were shown a particular background pattern on the screen. PM abilities were measured using the median response time and total accuracy.

Age was correlated with PM accuracy. An ANCOVA, controlling for age, and examining the impact of diagnosis on PM accuracy, was significant. Post-hoc tests revealed a trend toward the AD and MCI groups being less accurate than healthy controls. In contrast to accuracy, age was not related to PM speed. An ANOVA examining the impact of diagnosis on PM accuracy found that the AD group responded faster than healthy controls. The MCI group did not show differences in speed from the healthy control and AD groups.

Overall, the pattern of results differed in accuracy and speed of PM performance. There was a trend for the MCI and AD groups being less accurate than the controls, with no difference in performance between the MCI and AD groups. However, the AD group responded more quickly than the controls, which may have impacted their accuracy. These findings indicate that PM performance differences among groups can be detected by examining speed and not just accuracy. As speed appears to be an essential aspect involved in PM performance, future research should consider incorporating speed as a measure of PM performance when examining PM differences in populations.

Late Life Major Depressive Disorder (LLD) and Hoarding Disorder (HD) are common in older adults with prevalence estimates up to 29% and 7%, respectively. Both LLD and HD are characterized by executive dysfunction and disability. There is evidence of overlapping neurobiological dysfunction in LLD and HD suggesting potential for compounded executive dysfunction and disability in the context of comorbid HD and LLD. Yet, prevalence of HD in primary presenting LLD has not been examined and potential compounded impact on executive functioning, disability, and treatment response remains unknown. Thus, the present study aimed to determine the prevalence of co-occurring HD in primary presenting LLD and examine hoarding symptom severity as a contributor to executive dysfunction, disability, and response to treatment for LLD.

Eighty-three adults ages 65-90 participating in a psychotherapy study for LLD completed measures of hoarding symptom severity (Savings Inventory-Revised: SI-R), executive functioning (WAIS-IV Digit Span, Letter-Number Sequencing, Coding; Stroop Interference; Trail Making Test-Part B; Letter Fluency), functional ability (World Health Organization Disability Assessment Schedule-II-Short), and depression severity (Hamilton Depression Rating Scale) at post-treatment. Pearson's Chi-squared tests evaluated group differences in cognitive and functional impairment rates and depression treatment response between participants with (HD+LLD) and without (LLD-only) clinically significant hoarding symptoms. Linear regressions were used to examine the association between hoarding symptom severity and executive function performance and functional ability and included as covariates participant age, years of education, gender, and concurrent depression severity.

At post-treatment, 24.1% (20/83) of participants with LLD met criteria for clinically significant hoarding symptoms (SI-R.41). Relative to LLD-only, the LLD+HD group demonstrated greater impairment rates in Letter-Number Sequencing (χ2(1)=4.0, p=.045) and Stroop Interference (χ2(1)=4.8, p=.028). Greater hoarding symptom severity was associated with poorer executive functioning performance on Digit Span (t(71)=-2.4, β=-0.07, p=.019), Letter-Number Sequencing (t(70)=-2.1, β=-0.05, p=.044), and Letter Fluency (t(71)=-2.8, β=-0.24, p=.006). Rates of functional impairment were significantly higher in the LLD+HD (88.0%) group compared to the LLD-only (62.3%) group, (χ2(1)=5.41, p=.020). Additionally, higher hoarding symptom severity was related to greater disability (t(72)=2.97, β=0.13, p=.004). Furthermore, depression treatment response rates were significantly lower in the LLD+HD group at 24.0% (6/25) compared to 48.3% (28/58) in the LLD-only group, χ2(1)=4.26, p=.039.

The present study is among the first to report prevalence of clinically significant hoarding symptoms in primary presenting LLD. The findings of 24.1% co-occurrence of HD in primary presenting LLD and increased burden on executive functioning, disability, and depression treatment outcomes have important implications for intervention and prevention efforts. Hoarding symptoms are likely under-evaluated, and thus may be overlooked, in clinical settings where LLD is identified as the primary diagnosis. Taken together with results indicating poorer depression treatment response in LLD+HD, these findings underscore the need for increased screening of hoarding behaviors in LLD and tailored interventions for this LLD+HD group. Future work examining the course of hoarding symptomatology in LLD (e.g., onset age of hoarding behaviors) may provide insights into the mechanisms associated with greater executive dysfunction and disability.

Investigate the relationship of chronic neurobehavioral and cognitive symptoms in military personnel with history of blast-related mild TBI and compare to a well-matched group of combat-deployed controls.

274 participants (mean age=34 years; mean education=14.75 years; 91.2% male) enrolled in the EVOLVE longitudinal study of combat-deployed military personnel were subdivided into those with history of blast TBI (n=165) and controls without history of blast exposure and TBI (n=109). As part of a larger study, we conducted a sub-analysis of 5-year follow up data. We focused on group differences (Mann-Whitney U) and correlational relationships between self-report neurobehavioral symptoms via the Frontal Systems Behavior Scale (FrSBE) and cognitive performances on measures of attention, working memory, processing speed, and executive functioning including D-KEFS Color Word Interference (CWI), Trailmaking A and B, and the Conners Continuous Performance Test (CPT).

The Blast TBI group reported higher levels of neurobehavioral symptoms on the FrSBE (p<.001), including domains of apathy (p<.001), disinhibition (p<.001), and executive dysfunction (p<.001), compared to Controls. On cognitive measures, group differences were observed on CWI Inhibition/Switching (p=.008), Trails B time (p=.010), and CPT commission errors (p=.014), such that the Blast TBI group performed worse than Controls. No significant group differences were observed for CPT omission errors or CPT hit rate (p’s>.05). After adjustment for multiple comparisons, greater FrSBE apathy correlated with slower performance on Trails A for Blast TBI (r=0.22, p=.014) but not Controls. Apathy endorsement was not significantly related to CPT omission errors for either group (p’s>.05). Higher endorsement of disinhibition symptoms was associated with worse performance on CWI Inhibition (Blast TBI: r=-0.19, p=.036; Controls: r=-0.28, p=.012) and Inhibition/Switching (Blast TBI: r=-0.23, p=.010; Controls: r=-0.29, p=.010) conditions for both groups, whereas only the Blast TBI group showed significant relationships between disinhibition symptoms and Trails B-A time (r=0.20, p=.025) and CPT commission errors (r=.18, p=.038). Higher endorsement of executive dysfunction correlated with poorer performance for Trails B-A for both groups (Blast TBI: r=.24, p=.009; Controls: r=.24, p=.030).

Our findings reveal that at 5-year follow up, military personnel with history of blast-related mild TBI reported significantly greater neurobehavioral symptoms and performed lower on standardized measures of executive functioning, relative to combat-deployed controls without TBI or blast exposure. Significant relationships between neurobehavioral symptoms and cognitive performance were present in both groups. However, these relationships were more pronounced in the Blast TBI group, including greater apathy associated with slower visual tracking as well as greater endorsement of disinhibition associated with set-switching. Objective measures of response inhibition were related to disinhibition endorsement for both groups, though impulsive errors were more pronounced for the Blast TBI group. Our results suggest chronic cognitive and neurobehavioral symptoms are present in military personnel with history of blast TBI exposure, and also discrepant from a well-matched control group of combat deployed military personnel. Future studies of this population should explore models to predict cognitive performance from neurobehavioral symptoms in military personnel, as this could inform treatment approaches for those at greatest risk of cognitive change.

The field of clinical neuropsychology has increasingly recognized the importance of cultural and identity factors through the development of clinical, research, and educational initiatives. Only within the last 10 years have guidelines for psychological practice with lesbian, gay, bisexual, transgender, and queer (LGBTQ+) people included recommendations for neuropsychological assessment. However, it remains unclear to what extent neuropsychologists have acquired the knowledge and skills necessary to implement these recommendations. It is also unknown whether they engage in LGBTQ+ inclusive neuropsychological assessment. In this study, we surveyed the LGBTQ+ related education, training, and clinical practice of independently licensed neuropsychologists in the United States. We sought to understand the implementation of inclusive guidelines, including factors that predict affirmative neuropsychological assessment. We hypothesized that sexual/gender identities, female identity, recency of training, and LGBTQ+ related education would be associated with use of recommended practices.

A workgroup of clinical psychologists with experience in LGBTQ+ psychology and neuropsychology developed a survey to identify personal and professional factors that predict LGBTQ+ affirmative neuropsychological assessment practices. The survey was distributed through professional organizations and listservs between August and September 2021 with 118 responses meeting inclusionary criteria. We used logistic, multinomial logistic, and ordinal logit regressions to examine unadjusted, univariate effects. Predictors included in the final, adjusted, univariate and multivariate models were those for which we had specific hypotheses and variables that predicted more than two affirming practice behaviors.

The majority of participants identified as heterosexual (70.3%), cisgender (97.5%), and female (66.1%). Participants reported obtaining their highest degree between 1977 and 2019. Most obtained a Ph.D. (73.7%), were not board-certified (69.5%), and worked primarily with adults (54.2%). Generally, participants reported having little experience working with LGBTQ+ patients. However, they reported greater exposure to lesbian, gay, and bisexual identities as compared to transgender and queer identities. Most (48-63%) received LGBTQ+ training post-licensure. Between 19% and 32% of participants reported never completing LGBTQ+ specific education. Participants described using affirmative clinical practice behaviors either “always/often” or “never/rarely.” Factors predicting those practice behaviors were LGBTQ+ education/training, prior experience with LGBTQ+ patients, primary patient population (child vs. adult), and personal background (sexual minority status, female gender, and years since degree). When in need of consultation, the current sample consulted with their colleagues most often (n = 95) followed by academic literature (n = 90) and professional organizations (n = 80). Qualitative responses indicated varying attitudes and knowledge regarding collection of LGBTQ+ information and modification of clinical practice.

Consistent with the broader clinical psychology literature, neuropsychologists have limited education/training on LGBTQ+ concepts. Neuropsychologists underutilize affirming practices as evidenced by low rates of querying pronouns, knowing whether LGBTQ+ health information is available at their institutions, and adjusting evaluation and feedback approaches. Our findings imply a great need to expand continuing education trainings to address providers’ gaps and limitations, including opportunities for inclusive neuropsychological services throughout the assessment process (interview, testing, feedback). We present additional recommendations for future research as well as resources.

Previous research indicates that women tend to struggle with insomnia at higher rates both prior to and during the global COVID-19 pandemic; however, not much research has investigated the extent to which insomnia correlates with comorbid problems, including aggression, depression, anxiety, PTSD severity, and alcohol use between the sexes. On a neurobiological level, insomnia could be associated with those mood disorders due to the effects of sleep disturbance on serotonergic and GABA neurotransmission, and males might experience such associations at a lower frequency due to their increased rates of serotonin synthesis. Consequently, we hypothesized that women would demonstrate higher prevalence of the aforementioned comorbidities during COVID than males due to higher rates of insomnia reported in women during COVID.

We surveyed a total of 13,313 adults, with 5,598 females (Mage=36.4, SD=11.9) and 7,654 males (Mage=37.81, SD=12.7) using Amazon Mechanical Turk between April 2020 and April 2021. Insomnia was measured using the Insomnia Severity Index (ISI), while levels of depression, anxiety, PTSD severity, and alcohol use, and aggression were assessed through Patient Stress Questionnaires (PSQs) and the Buss Perry Aggression Questionnaire (BPAQ).

As expected, there were significant positive correlations between ISI and BPAQ (r(13306)=0.364, p<0.0001), PSQ Depression (r(13300)=0.694, p<0.0001), PSQ Anxiety (r(13211)=0.627, p<0.0001), PSQ PTSD (r(13305)=0.444, p<0.0001), and PSQ Alcohol (r(12915)=0.218, p<0.001). The strength of these associations was significantly higher in males than females in almost all categories: aggression (z=4.27, p<0.0001), depression (z=2.41, p=0.016), anxiety (z=3.16, p=0.0016), and alcohol use (z=5.89, p<0.0001) - not significant for PTSD severity (z=1.48, p=0.14).

We found that insomnia was more strongly correlated with comorbid emotional and behavioral problems among males than females. This stands in contrast to our initial hypothesis, as the findings suggest that men who suffer from greater insomnia are more likely to experience those four comorbidities than females. This suggests that sex may play a role in the association between sleep disturbances and other clinical presentations relevant to neuropsychology. Further work will be necessary to identify the neurobiological mechanisms that drive the sex differences in these associations. While the present findings cannot determine the causal direction of the association, it will be crucial to determine the directionality of these associations and the mechanisms that lead to differences in expression between the sexes.