Date Presented 04/03/2025 This study demonstrates that the Somatosensory Test of Grip Force (STOG) is a reliable tool for assessing force control in young children. Tools for assessing force control in early childhood are needed to support early intervention for pediatric OT practice. Primary Author and Speaker: Madison K. Bollinger Additional Authors and Speakers: Virginia W. Chu, Jaela Watkins Contributing Authors: Elsie Baker, Mary Alice Montgomery, Stacey Dusing, James Thomas, Olivier Rolin, Jonathon Jacobs, Robert Perera

PURPOSE/OBJECTIVE:Caregivers of veterans with comorbid traumatic brain injury (TBI) and dementia face many challenges managing their loved ones' neurobehavioral functioning and, importantly, their own well-being. This study developed and tested Resources for Enhancing All Caregivers' Health (REACH) Hope, which provides caregivers with one-on-one telehealth education, support, skills building, and personalized digital information. METHOD:Caregivers (N = 110) of veterans with both TBI and dementia were randomly assigned to either REACH Hope (n = 56) or a waitlist-control group (n = 54) for 3 months; waitlist participants then received REACH Hope. Data collection occurred by telephone at baseline, 3 months (postintervention/waitlist switch), 6 months, and 9 months (for waitlist-control only). The 12-item short-form Zarit Burden Interview (ZBI-12) at 3 months (posttreatment) was the primary outcome. Secondary outcomes included caregiver depression, anxiety, self-efficacy, and number of veteran safety risks. RESULTS:REACH Hope reduced burden and anxiety for caregivers with moderate to high levels of burden and anxiety compared to the waitlist group. Caregivers with ZBI-12 scores ≥ 21 had increasing treatment benefits with higher burden. Caregivers with Generalized Anxiety Disorder-7 scores ≥ 13 showed the same pattern for higher anxiety levels. There were no significant treatment group effects for depression, self-efficacy, or veteran safety. CONCLUSION:This is the first clinical trial to evaluate the efficacy of a telehealth intervention for caregivers of veterans with both TBI and dementia. REACH Hope represents the first evidence-based intervention of its kind and one that warrants further study and implementation. (PsycInfo Database Record (c) 2026 APA, all rights reserved).

Conduct Disorder (CD) and callous-unemotional (CU) traits are associated with persistent antisocial behavior, emotional processing deficits, and poor treatment response. CU traits designate a subgroup of youth with CD who are at greater risk of violence and long-term mental health challenges. It is well-established that CU traits, CD, and aggression are tied to deficits in emotion recognition, social information processing, and interpersonal functioning, yet few interventions directly target these mechanisms. This randomized controlled trial tested the effects of Impact VR, a brief virtual reality program designed to improve emotion recognition and build social-emotional skills in youth with CD. One hundred and ten youth diagnosed with CD were randomly assigned to either Impact VR or a treatment control group. Youth and caregivers completed assessments at baseline, post-intervention, and 3-month follow-up. Youth in the Impact VR group had lower levels of self-reported and caregiver-reported CU traits at follow-up. Caregiver ratings also indicated that youth who received Impact VR had significantly lower conduct problems at both follow-up time points. Youth reported immediate reductions in reactive aggression, which was sustained until the 3-month follow-up. However, the intervention groups did not significantly differ on proactive aggression. These findings suggest that CU traits may be modifiable through brief, engaging interventions like Impact VR.

In response to the replication and confidence crisis across various empirical disciplines, ensuring the validity of research has gained attention. High validity is crucial for obtaining replicable and robust study outcomes when both exploring new questions and replicating previous findings. In this study, we aimed to address this issue by developing a comprehensive checklist to assist researchers in enhancing and monitoring the validity of their research. After systematically analyzing previous findings on validity, a comprehensive list of potential checklist items was compiled. Over the course of three rounds, more than 30 interdisciplinary and psychological-science experts participated in a Delphi study. Experts rated items on their importance and were given the opportunity to propose novel items as well as improve existing ones. This process resulted in a final set of 91 items, organized according to common stages of a research project. The VALID checklist is accessible online ( https://www.validchecklist.com/ ) and provides researchers with an adaptable, versatile tool to monitor and improve the validity of their research and to suit their specific needs. By focusing on adaptiveness during its development, VALID encompasses 331 unique checklist versions, making it a one-stop solution suitable for a wide range of projects, designs, and requirements.

PURPOSE:The Master Adaptive Learner (MAL) is a model describing the collective skills of planning, learning, assessing, and adjusting that may translate into continually improving clinical proficiency. The objective of this study was to develop a MAL assessment instrument to measure these skills. METHOD:1,427 students completed the 36-item candidate MAL instrument. The authors performed exploratory factor analysis (EFA) on half of the dataset. The factors and items were determined by eigenvalues, structure, parsimony, and theoretical considerations. Once an appropriate factor structure was identified, confirmatory factor analysis (CFA) was used on the second dataset to confirm results and the global fit. RESULTS:The final CFA model consisted of four factors: two items in a resilience factor subscale, eight items in a MAL factor subscale, three items in a curiosity/exploration factor subscale, and three items in a motivation/mindset/challenge factor subscale. This model's scaled global fit statistics fit moderately well (CFI = 0.961, RMSEA = 0.041 (0.035, 0.047), SRMR = 0.037), indicating this was an adequate model. DISCUSSION:The resultant MAL instrument demonstrated sufficient internal structure validity evidence. The instrument may be useful for a variety of applications including assessment of practice-based learning competencies, coaching, and remediation activities.

Objective: To examine: (1) the trajectory of caregiver resilience over 2 years after onset of a care-recipient's moderate-to-severe traumatic brain injury (TBI), (2) caregiver-related outcomes associated with resilience, and (3) changes in associations between caregiver resilience, other caregiver characteristics, and care-recipient variables across time. Design: Prospective cohort. Setting: TBI Model System (TBIMS) centers. Participants: TBIMS participants (care-recipients) were approached to enroll in this study and identify a caregiver. Two hundred fifty-eight (N=258) care-recipient and caregiver dyads were enrolled. Interventions: Not applicable. Main Outcome Measures: Caregiver data included demographics, health history, Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7, Zarit Burden Interview (ZBI), Family Needs Questionnaire-Revised, and Connor-Davidson Resilience Scale 10 (CD-RISC-10). All caregiver data were self-reported via phone interview or mailed surveys at 6, 12, and 24 months after injury. At all 3 timepoints, care-recipients with TBI also completed their own CD-RISC-10, PHQ-9, Generalized Anxiety Disorder-7, and Disability Rating Scale. Results: Linear mixed-effects models indicated that the trajectory of resilience was stable within caregivers over 2 years after injury. There were significant, positive associations for all caregiver Family Needs Questionnaire-Revised subscales (all P<.001) with care-recipient and caregiver CD-RISC-10 scores (P=.001), indicating that more caregiving needs endorsed as "met" corresponded with higher resilience. Caregiver PHQ-9 and ZBI scores were found to be negatively associated with resilience (both P<.001). When all covariates were included in the multivariable model, met emotional needs was positively associated with caregiver resilience (P<.0001). Negative associations with caregiver resilience included higher caregiver PHQ-9 scores (P=.001) and perceptions of caregiving burden (P=.003). Conclusions: Caregiver levels of resilience were generally stable over 2 years post-TBI. Caregivers' resilience was positively associated with perceptions of their needs being met and negatively associated with caregiving burden and emotional distress. Further research is needed to develop and evaluate the utility and feasibility of interventions to enhance resilience, meet family needs, and improve long-term outcomes after brain injury.

OBJECTIVE:Auditory event-related potentials (ERP) may reflect chronic effects of repetitive mild traumatic brain injury (mild TBI), but the influence of auditory impairment on these ERP changes is unclear. METHODS:We compared hearing sensitivity, complex auditory processing, and auditory cortical ERPs in combat veterans (N = 270) with and without mild TBI, TBI in combat deployment setting, blast TBI, post-traumatic amnesia (PTA), loss of consciousness, and non-TBI blast exposures. Mediation analysis assessed the hearing, age, and psychological symptom-adjusted effect of number of TBI exposures on P50 and N100 amplitude and latency, and whether ERPs mediated between TBI and complex auditory processing. RESULTS:After adjustment, higher exposures to combat and blast TBI predicted larger P50 amplitudes; mild TBI with PTA was associated with longer P50 latency, which mediated speech in noise perception; combat blast exposures (non-TBI) were associated with reduced N100 amplitude. CONCLUSION:Auditory cortical response changes observed for higher exposure to blast or combat mild TBI and blast exposures were not attributable to auditory dysfunction or current psychological distress. In contrast, mild TBI with PTA predicted auditory cortical responses with behavioral consequences for speech processing in noise. SIGNIFICANCE:Auditory P50 and N100 are promising biomarkers for both the non-auditory and auditory chronic effects of mild TBI on brain function.

Background: Individuals with pre-existing heavy alcohol use, prior traumatic exposures, and psychiatric disorders were considered an at-risk group for increased alcohol use and problems in the context of the COVID-19 pandemic.Objective: This study recruited from a multi-centre longitudinal cohort study of US military service members/veterans with combat exposure to examine the trajectories of alcohol use and problems in the context of a prolonged stressor.Methods: Individuals who endorsed heavy drinking and completed a measure of PTSD symptoms prior to the pandemic were invited to participate in a longitudinal survey study at three time points, three months apart, during the second year of the pandemic. Participants (N = 44) completed surveys assessing alcohol consumption and alcohol-related problems (via the AUDIT), PTSD symptoms (via the PCL-5), and infection mitigation behaviours (via a COVID-19 specific survey). Random intercept models were fitted to the longitudinal data for each of these outcomes, covarying for demographics, pandemic quarantine/physical distancing experience, pre-pandemic baseline alcohol consumption and PTSD symptoms, and time-varying alcohol consumption and alcohol-related problems as well as PTSD symptoms.Results: We did not find an increase in alcohol consumption or problems over time. However, pre-pandemic alcohol consumption predicted alcohol consumption over time (B = 0.52, SE = 0.11, p < .01). Time-varying alcohol consumption and PTSD symptoms predicted alcohol problems over time (B = 0.84, SE = 0.18, p < .01; B = 0.04, SE = 0.02, p < .05, respectively).Conclusions: Findings highlight the relevance of pre-existing hazardous alcohol consumption prior to stressors as well as ongoing consumption and PTSD symptoms as risk factors for alcohol-related problems. Findings captured more chronic impacts of pandemic stressors and demonstrated that heavy drinking and PTSD are notable risk factors for alcohol-related problems even if in the context of stabilizing, albeit still high, alcohol use.

BACKGROUND:The effects of phosphodiesterase 5 (PDE5) inhibitors on the incidence of long-term outcomes in patients with cardiovascular disease are not well understood. OBJECTIVE:We studied the association between PDE5 inhibitor therapy and the incidence of adverse cardiovascular major adverse cardiovascular events (MACE) in patients undergoing coronary angiography and intervention. METHODS:We studied 4582 consecutive patients undergoing coronary angiography and intervention. The incidence of MACE at 1 year, defined as urgent revascularization, myocardial infarction, admission for heart failure or all-cause death, was considered the primary outcome. RESULTS:Of the 4582 patients, 562 (12.3%) had current prescriptions for PDE5 inhibitors before the procedure and 4020 (87.7%) did not. The incidence of MACE was 171 (30.4%) among patients of the PDE5 inhibitor group versus 1482 (36.9%) in the non-PDE5 inhibitor group (p = 0.003). In a propensity score-matched analysis of 1124 of patients, 171 (30.4%) patients in the PDE5i group and 175 (31.1%) patients in the non-PDE5i group had a MACE (p = 0.84). On multivariable analysis, the treatment with PDE5 inhibitors was not significantly associated with the risk of MACE (odds ratio [OR] = 0.99, 95% CI 0.93-1.06; p = 0.86). CONCLUSION:In this cohort of veterans undergoing coronary angiography/cardiac catheterization, chronic PDE5i therapy was not associated with an increased risk of MACE at 1 year.

Research aiming to understand the risk of violence among women is scarce, yet women account for 18-21% of all violent crimes. Once incarcerated, women convicted of a violent crime still pose a high risk of prison violence. Research has found that a history of violence is a strong predictor of prison violence. However, little is known about the relation between the mechanism of prior violence (i.e. firearms) and subsequent prison violence. The goal of this study was to assess if women who had committed violent crimes with or without a firearm were at greater risk of prospectively committing prison violence over a 12-month period. A sample of 206 incarcerated women was used to assess the associations between criminal convictions and violent prison misconducts. Logistic regressions showed that women who committed a firearm-related crime were more likely to engage in prison violence when compared to women convicted of general forms of violence and non-violent crime. Due to the lack of research, future studies should explore firearm-related violence in female offenders to inform gender-specific violence.

Background The responsibility of care for Veterans and Service Members (V/SMs) with traumatic brain injury (TBI) often defaults to informal family caregivers. Caregiving demands considerable knowledge, skill, and support to facilitate the health and well-being of V/SMs and themselves. Persistent and common TBI caregiver issues include strain, depression, and anxiety. While evidence-based, brief interventions have been developed and implemented for family caregivers in Veteran neurodegenerative populations, few interventions have been developed, adapted, or tested to support the unique needs of caregivers of V/SMs with TBI. Objective This study will adapt and test an evidence-based, personalized, 6-session telehealth caregiver intervention, “Resources for Enhancing All Caregivers’ Health” (REACH), to meet the unique needs of caregivers of V/SMs with TBI. If successful, a community-based participatory research team will develop an implementation plan to roll out REACH TBI across the national Veterans Affairs Polytrauma System of Care. Methods This mixed methods, crossover waitlist control clinical trial will use a Type 1 Hybrid Effectiveness-Implementation approach to adapt and then test the effects of REACH TBI on key TBI caregiver outcomes. Results This study was funded by the Department of Defense in September 2023. Participant enrollment and data collection will begin in 2024. Conclusions If effective, REACH TBI will be the first evidence-based intervention for caregivers of V/SMs with TBI that can be scaled to implement across the Veterans Affairs Polytrauma System of Care and fill a notable gap in clinical services. International Registered Report Identifier (IRRID) PRR1-10.2196/57692

BACKGROUND:Recent studies have challenged the reported causal association between acute kidney injury and iodinated contrast administration, ascribing some cases to changes in renal function that are independent of contrast administration. METHODS:We studied 1779 consecutive patients undergoing right heart catheterization (RHC) at a Veterans Administration Medical Center. We compared the incidence of acute kidney injury and of nephropathy at 3 months in veterans undergoing right and left heart catheterization and coronary angiography (R&LHC) to the incidence of acute kidney injury and of nephropathy at 3 months in patients undergoing RHC only. RESULTS:The incidence of acute kidney injury at 3 days was 47 (9.7%) in the R&LHC group and 58 (9.6%) in the RHC group (P = .99). The incidence of nephropathy at 3 months was 115 (17%) in the L&RHC group and 141 (19.2%) in the RHC group (P = 0.31). In a propensity score-paired analysis of 782 patients and after adjustment for baseline characteristics, the odds ratio for acute kidney injury at 3 days among patients undergoing R&LHC was 1.25 (95% confidence interval, 0.65-2.42; P = .50), and the odds ratio for nephropathy at 3 months was 0.69 (95% confidence interval, 0.46-1.04; P = .08). CONCLUSION:The incidence of changes in creatinine consistent with acute kidney injury at 3 days and of nephropathy at 3 months was not significantly different in patients undergoing R&LHC compared with patients undergoing RHC only. This supports the thesis that not all changes in creatinine after procedures involving administration of contrast are caused by the contrast.

Research documents racial disparities in chronic low back pain (CLBP). Few studies have examined racial disparities in movement -related appraisals and no studies have examined anticipatory appraisals prior to or pain behaviors during functional activities among individuals with CLBP. This cross-sectional study examined racial differences in anticipatory appraisals of pain, concerns about harm, and anxiety, appraisals of pain and anxiety during movement, and observed pain behaviors during 3 activities of daily living (supine -to -standing bed task, sitting -to -standing chair task, floor -towaist lifting task) in a sample (N = 126) of non -Hispanic Black (31.0%), Hispanic (30.2%), and nonHispanic White (38.9%) individuals with CLBP. Hispanic participants reported more expected pain, concerns about harm, and pre -movement anxiety prior to the bed and chair tasks compared to nonHispanic White participants. Hispanic participants reported more pain during the bed task and more anxiety during the bed and chair tasks compared to non -Hispanic White participants. Non -Hispanic Black participants reported more expected pain, concerns about harm, and pre -movement anxiety prior to the bed task and more pre -movement anxiety prior to the chair task compared to non -Hispanic White participants. Non -Hispanic Black participants reported more anxiety during the bed and chair tasks compared to non -Hispanic White participants. Non -Hispanic Black participants were observed to have significantly more verbalizations of pain during the bed task compared to non -Hispanic White participants. Current findings identify racial disparities in important cognitive -behavioral and fearavoidance mechanisms of pain. Results indicate a need to revisit traditional theoretical and treatment models in CLBP, ensuring racial disparities in pain cognitions are considered. Perspective: This study examined racial disparities in anticipatory and movement -related appraisals, and pain behaviors during activities of daily living among Non -Hispanic Black, Non -Hispanic White, and Hispanic individuals with CLBP. Racial disparities identified in the current study have potentially important theoretical implications surrounding cognitive -behavioral and fear -avoidance mechanisms of pain. (R) 2024 (R) Published by Elsevier Inc. on behalf of United States Association for the Study of Pain, Inc All rights reserved.

OBJECTIVE:Although headache (HA) is a common sequela of traumatic brain injury (TBI), early predictors of chronic HA after moderate to severe TBI are not well established, and the relationship chronic HA has with psychosocial functioning is understudied. Thus, we sought to (1) determine demographic and injury predictors of chronic HA 1 or more years after moderate to severe TBI and (2) examine associations between chronic HA and psychosocial outcomes.SETTING:Community.PARTICIPANTS:Participants in the TBI Model System (TBIMS) with moderate to severe TBI who consented for additional chronic pain questionnaires at the time of TBIMS follow-up.DESIGN:Multisite, observational cohort study using LASSO (least absolute shrinkage and selection operator) regression for prediction modeling and independent t tests for psychosocial associations.MAIN OUTCOME MEASURES:Chronic HA after TBI at year 1 or 2 postinjury and more remotely (5 or more years).RESULTS:The LASSO model for chronic HA at 1 to 2 years achieved acceptable predictability (cross-validated area under the curve [AUC] = 0.70). At 5 or more years, predictability was nearly acceptable (cross-validated AUC = 0.68), but much more complex, with more than twice as many variables contributing. Injury characteristics had stronger predictive value at postinjury years 1 to 2 versus 5 or more years, especially sustained intracranial pressure elevation (odds ratio [OR] = 3.8) and skull fragments on head computed tomography (CT) (OR = 2.5). Additional TBI(s) was a risk factor at both time frames, as were multiple socioeconomic characteristics, including lower education level, younger age, female gender, and Black race. Lower education level was a particularly strong predictor at 5 or more years (OR up to 3.5). Emotional and participation outcomes were broadly poorer among persons with chronic HA after moderate to severe TBI.CONCLUSIONS:Among people with moderate to severe TBI, chronic HA is associated with significant psychosocial burden. The identified risk factors will enable targeted clinical screening and monitoring strategies to enhance clinical care pathways that could lead to better outcomes. They may also be useful as stratification or covariates in future clinical trial research on treatments.

Date Presented 03/22/24 This study examines force control development in children ages 6 to 72 months, comparing children born preterm and full term. By understanding this topic more, practitioners will be better equipped to address proprioception deficits in young children. Primary Author and Speaker: Elsie Baker Additional Authors and Speakers: Virginia W. Chu, Madison K. Bollinger Contributing Authors: Nicole Botha, Megan G. Pesci, Madison Quesinberry, Marina Nguyen, Meraj Shaikh, Alyssa Tsui, Mary Alice Montgomery, Chloe Eilers, Stacey Dusing, Robert Perera, James Thomas, Olivier Rolin

Insomnia is more frequently reported in stroke survivors but its independent role in mortality in stroke survivors is unknown. The purpose of this study was to investigate the association of insomnia symptoms with all-cause mortality among stroke survivors. The Health and Retirement Study, a survey of Americans older than 50 years and their spouses of any age from 2002 to 2018 was used. Only participants with a history of stroke were included. The exposure variable of interest was insomnia symptoms including difficulty initiating sleep, difficulty maintaining sleep, waking up too early, and nonrestorative sleep. The outcome was all-cause mortality. Cox proportional hazards regression models were employed to investigate the association between insomnia symptoms and all-cause mortality. A total of 3,501 stroke survivors were included of which 55

BACKGROUND:Assessment of the Core Entrustable Professional Activities for Entering Residency requires direct observation through workplace-based assessments (WBAs). Single-institution studies have demonstrated mixed findings regarding the reliability of WBAs developed to measure student progression towards entrustment. Factors such as faculty development, rater engagement and scale selection have been suggested to improve reliability. The purpose of this investigation was to conduct a multi-institutional generalisability study to determine the influence of specific factors on reliability of WBAs. METHODS:The authors analysed WBA data obtained for clerkship-level students across seven institutions from 2018 to 2020. Institutions implemented a variety of strategies including selection of designated assessors, altered scales and different EPAs. Data were aggregated by these factors. Generalisability theory was then used to examine the internal structure validity evidence of the data. An unbalanced cross-classified random-effects model was used to decompose variance components. A phi coefficient of >0.7 was used as threshold for acceptable reliability. RESULTS:Data from 53 565 WBAs were analysed, and a total of 77 generalisability studies were performed. Most data came from EPAs 1 (n = 17 118, 32%) 2 (n = 10 237, 19.1%), and 6 (n = 6000, 18.5%). Low variance attributed to the learner (<10%) was found for most (59/77, 76%) analyses, resulting in a relatively large number of observations required for reasonable reliability (range = 3 to >560, median = 60). Factors such as DA, scale or EPA were not consistently associated with improved reliability. CONCLUSION:The results from this study describe relatively low reliability in the WBAs obtained across seven sites. Generalisability for these instruments may be less dependent on factors such as faculty development, rater engagement or scale selection. When used for formative feedback, data from these instruments may be useful. However, such instruments do not consistently provide reasonable reliability to justify their use in high-stakes summative entrustment decisions.

Background:Burnout is common among residents and negatively impacts patient care and professional development. Residents vary in terms of their experience of burnout. Our objective was to employ cluster analysis, a statistical method of separating participants into discrete groups based on response patterns, to uncover resident burnout profiles using the exhaustion and engagement sub-scales of the Oldenburg Burnout Inventory (OLBI) in a cross-sectional, multispecialty survey of United States medical residents. Methods:The 2017 ACGME resident survey provided residents with an optional, anonymous addendum containing 3 engagement and 3 exhaustion items from the OBLI, a 2-item depression screen (PHQ-2), general queries about health and satisfaction, and whether respondents would still choose medicine as a career. Gaussian finite mixture models were fit to exhaustion and disengagement scores, with the resultant clusters compared across PHQ-2 depression screen results. Other variables were used to demonstrate evidence for the validity and utility of this approach. Results:From 14 088 responses, 4 clusters were identified as statistically and theoretically distinct: Highly Engaged (25.8% of respondents), Engaged (55.2%), Disengaged (9.4%), and Highly Exhausted (9.5%). Only 2% of Highly Engaged respondents screened positive for depression, compared with 8% of Engaged respondents, 29% of Disengaged respondents, and 53% of Highly Exhausted respondents. Similar patterns emerged for the general query about health, satisfaction, and whether respondents would choose medicine as a career again. Conclusion:Clustering based on exhaustion and disengagement scores differentiated residents into 4 meaningful groups. Interventions that mitigate resident burnout should account for differences among clusters.

Date Presented 03/21/24 This study explored the use of a multisensory task to examine object permanence and sensorimotor control in preterm children. Results showed that preterm children reached Stage 6 object permanence later and had challenges with sensorimotor control. Primary Author and Speaker: Virginia W. Chu Additional Authors and Speakers: Jonathon Jacobs Contributing Authors: Stacey Dusing, Robert Perera, Olivier Rolin, James Thomas

The co-occurrence of mental disorder symptoms is common in people who use substances. It is unclear whether patterns of comorbidity in a population-based sample of adults are consistent with prior work. The study goal was to identify this comorbidity structure and evaluate its stability over time. Using Waves 1, 2, and 3 of the Population Assessment of Tobacco and Health Study, this study applied latent class analysis to identify comorbid substance use, internalizing and externalizing mental disorder symptoms, and their stability over time. A four-class solution was identified for Wave 1 as: (1) low symptom (N = 23,571, 72.9%), (2) internalizing (N = 4,098, 12.7%), (3) externalizing (N = 2,691, 8.3%), and (4) comorbid (N = 1,960, 6.1%). Similar latent profiles emerged across the three waves specifically where the low symptom class was largest (65.5% to 72.9%), and the comorbid class was smallest (6.1% to 8.2%). However, the composition of the classes changed in Wave 3 with low comorbid (N = 5,400, 20.6%) and substance use (N = 1,524, 5.8%) classes emerging. Overall, when individuals transitioned from preceding to subsequent wave, they typically transitioned into the low symptom class. The comorbidity structure of substance use behaviors, including cigarette and e-cigarette use, and mental disorder symptoms in a population-based sample of U.S. adults was characterized by four classes. Psychiatric comorbidity may vary in severity within a population and by specific sociodemographic factors. When comparing the latent classes over three years of data, the results suggest that the comorbidity structure may change as participants age.