Wait-list Condition Research Articles

A randomized controlled feasibility trial of a single-session metacognitive training intervention for reducing eating disorder risk factors

ABSTRACT This study investigates the feasibility and preliminary evidence for the efficacy of a single-session online metacognitive training (MCT-ED) among a population considered to be at-risk of developing an eating disorder. A total of N = 95 participants with high weight concerns were randomised to an MCT-ED condition (n = 43) or a waitlist control condition (n = 52). Participants completed measures of body image flexibility, perfectionism, weight and shape concerns and mood at baseline, post-treatment (one-week post-baseline), and 3-months post-treatment. The MCT-ED intervention consisted of content targeting cognitive flexibility and perfectionism. Treatment completion for MCT-ED was 93.62%, indicating that the intervention was feasible and acceptable. Participants also provided positive ratings on a feedback questionnaire indicating preliminary feasibility. At 1-week post-treatment, relative to the waitlist condition, the MCT-ED group had significantly lower personal standards (d = 0.64) and experienced a significantly greater decrease in concern over mistakes (d = 0.57). These improvements were not sustained at 3-month follow-up. Findings suggested that MCT-ED is a feasible brief intervention format for those with elevated weight concerns, but more research is required to produce longer, more meaningful effects that may impact weight and shape concerns.

Cognitive Training for Emotion-Related Impulsivity and Rumination: Protocol for a Pilot Randomized Waitlist-Controlled Trial.

Inhibitory deficits are common in psychopathology. Emotion-related impulsivity (ERI) and rumination are general risk factors for psychiatric distress that are similarly associated with dysfunctional inhibition-particularly in affective contexts. A number of cognitive remediation procedures have been developed to improve inhibitory control; however, most remediation programs focus on "cold" cognition independent of affective processing. This pilot trial will gather preliminary evidence for a new cognitive training intervention targeting "hot" affective control (ie, inhibitory functions during elevated emotional arousal) in a transdiagnostic sample of adults who report heightened emotion dysregulation. This manuscript describes a protocol for a pilot randomized waitlist-controlled trial to assess changes in ERI and rumination after neurobehavioral affective control training (N-ACT), an 8-week cognitive training intervention designed to improve emotional response inhibition and emotional working memory. Our primary aim is to evaluate the efficacy, feasibility, and acceptability of N-ACT in reducing rumination and ERI, which we respectively conceptualize as complementary cognitive and behavioral consequences of emotion dysregulation. Secondarily, we will examine whether N-ACT leads to improvements in inhibitory control and, more distally, psychopathology symptoms. The final sample will comprise 80 adults who report high ERI or rumination. Participants will be randomized to (1) begin the N-ACT program without delay or (2) join a waitlist condition and then complete N-ACT. Exclusion criteria include active alcohol or substance use disorders, psychosis, and suicide risk. At the baseline and postintervention time points, participants will complete measures of emotion dysregulation and psychiatric symptoms, as well as a neuropsychological assessment of inhibitory control. Individuals assigned to the control group will undergo an identical assessment before joining the waitlist, followed by parallel assessments before and after N-ACT. This trial is funded by support from the University of California Board of Regents and the Peder Sather Foundation (funding period: October 2022-September 2025). Recruitment is scheduled to begin in spring 2025. We will begin data analysis once data collection is complete, which is planned to occur in fall 2025. This pilot randomized waitlist-controlled trial is designed to assess the initial efficacy, feasibility, and acceptability of N-ACT, a novel cognitive remediation approach developed to address 2 key contributors to psychopathology: ERI and rumination. The N-ACT program uses computerized adaptive behavioral tasks to strengthen the affective control processes theoretically and empirically linked to ERI and rumination. We hope this work will help inform future studies with sufficient statistical power to ascertain whether enhancing affective control through cognitive training (N-ACT) produces downstream reductions in psychiatric symptoms via improved emotion regulation. ClinicalTrials.gov NCT06226467; https://www.clinicaltrials.gov/study/NCT06226467; Open Science Framework Registry rak5z; https://osf.io/rak5z. PRR1-10.2196/54221.

A Meaning-Centered Intervention for Undergraduate Women With High Weight and Shape Concerns-Replication of a Randomized Controlled Trial.

Recent studies underscore the relevance of life meaning to the maintenance of eating disorders. A previously conducted randomized controlled trial tested a meaning-centered intervention for female university students with high weight and shape concerns. After a 6-week online intervention led by a trainer, participants in the intervention condition scored higher on life meaning and lower on eating disorder symptoms and general distress compared to a waitlist group. Given that the original study took place during COVID-19, this study replicated the design to test the findings' robustness. Compared to the waitlist condition (n=68), participants in the intervention condition (n=63) again scored higher on the presence of life meaning at post-assessment and follow-up. Participants in the intervention condition also showed moderately lower internalizing symptoms at both timepoints, whereas eating disorder symptoms were only reduced in those with relatively high baseline symptom severity. Thus, also without social distancing measures, the intervention increased life meaning and reduced eating disorder symptoms and comorbid internalizing symptoms in women with weight and shape concerns.

A Pilot Randomized Controlled Trial of a Single-Session Digital Acceptance and Commitment Therapy Intervention.

Adherence challenges are common among digital mental health interventions (DMHIs). Single-session DMHIs may help by providing a low-intensity intervention that takes less time to complete. This pilot randomized controlled trial sought to evaluate the acceptability and preliminary efficacy of a single-session DMHI based on acceptance and commitment therapy (ACT) in a non-clinical sample of college students. The trial was pre-registered (NCT06139718). A total of 61 students were recruited, which was below the target of 100 participants. The participants were randomized to the single-session ACT DMHI or to a waitlist condition, with assessments completed at 1-week and 1-month follow-ups. The vast majority of participants (87%) completed the single-session ACT program. The participants provided high program satisfaction ratings. There were no differences between conditions on psychological flexibility, distress, or mental health help seeking. However, the participants assigned to ACT improved significantly more than the waitlist on well-being from baseline to 1-month follow-up (d = 0.29). Overall, the results were mixed, with some support for the acceptability and potential efficacy of a single-session ACT DMHI but also a lack of effect, most notably on psychological flexibility as the process of change in ACT.

Digital Meditation to Target Employee Stress

Mindfulness meditation may improve well-being among employees; however, effects of digital meditation programs are poorly understood. To evaluate the effects of digital meditation vs a waiting list condition on general and work-specific stress and whether greater engagement in the intervention moderates these effects. This randomized clinical trial included a volunteer sample of adults (aged ≥18 years) employed at a large academic medical center who reported mild to moderate stress, had regular access to a web-connected device, and were fluent in English. Exclusion criteria included being a regular meditator. Participants were recruited from May 16, 2018, through September 28, 2019, and completed baseline, 8-week, and 4-month measures assessing stress, job strain, burnout, work engagement, mindfulness, depression, and anxiety. Data were analyzed from March 2023 to October 2024. Participants were randomized 1:1 to a digital meditation program or the waiting list control condition. Participants in the intervention group were instructed to complete 10 minutes of meditation per day for 8 weeks. The control group was instructed to continue their normal activities and not add any meditation during the study period. The primary outcome measure was change in Perceived Stress Scale (PSS) score at 8 weeks. Secondary outcome measures included changes in job strain, measured as work effort-reward imbalance. A total of 1458 participants (mean [SD] age, 35.54 [10.30] years; 1178 [80.80%] female) were included. Those randomized to meditation (n = 728) vs waiting list (n = 730) showed improvements in PSS (Cohen d, 0.85; 95% CI, 0.73-0.96) and in all secondary outcome measures (eg, job strain: Cohen d, 0.34; 95% CI, 0.23-0.46) at 8 weeks. These improvements were maintained at 4 months after randomization (PSS: Cohen d, 0.71; 95% CI, 0.59-0.84; job strain: Cohen d, 0.37; 95% CI, 0.25-0.50). Those using the app from 5 to 9.9 min/d vs less than 5 min/d showed greater reduction in stress (mean PSS score difference, -6.58; 95% CI, -7.44 to -5.73). The findings suggest that a brief, digital mindfulness-based program is an easily accessible and scalable method for reducing perceptions of stress. Future work should seek to clarify mechanisms by which such interventions contribute to improvements in work-specific well-being. ClinicalTrials.gov Identifier: NCT03527303.

Increasing stress resilience in older adults through a 6-week prevention program: effects on coping strategies, anxiety symptoms, and cortisol levels.

As people age, chronic stress, resulting in prolonged or repeated activation of the hypothalamic-pituitary-adrenal (HPA) axis, has been associated with long-term adverse health outcomes. Coping strategies and social support have been recognized as contributing to resilience to stress in older adults. Few studies have evaluated stress management training (SMT) interventions based on psychoneuroendocrinology that were designed to be delivered to healthy older adults in community settings. In this study, a total of 170 older adults (mean age = 76.07, SD = 7.67) participated in a cluster-randomized trial designed to compare the delivery of an SMT intervention with a waitlist condition. The effect of SMT on coping strategies, stress, anxiety, and depression was measured 3 weeks and 3 months after the intervention. In addition, we tested the effect on basal cortisol secretion over 2 days from saliva samples upon awakening and the total diurnal cortisol output [area under the curve with respect to ground (AUCg)]. Results from repeated measures analyses of variance showed that participants who received the intervention demonstrated a significant increase in problem-solving coping strategies and a decrease in anxiety scores 3 weeks after the intervention compared to the waitlist group. STM participants also demonstrated lower cortisol levels on the AUCg index. At the 3-month follow-up, gains were maintained only on the AUCg index. This type of brief preventive program could reduce basal cortisol levels in older adults, which may be an important protective factor against health outcomes associated with chronic HPA activation. Our results provide sufficient evidence to warrant further research to improve the effectiveness of O'stress in different settings.

INTENTIONAL EVALUATION OF DYADIC BENEFITS OF EARLY-PHASE INTERVENTIONS: ROLES OF PRETEST RISK AND RELATIONAL IMPACT

Abstract The evaluation of early-phase (i.e., Stage I, NIH Stage Model), small sample dyadic interventions is still primarily focused on testing separate effects for each member of the older adult-care partner dyad, rather than the benefits for dyads as a whole. Moreover, there is little attention to assessing pre-test risk status within dyads (especially in quasi-experimental or single-arm designs) or the relational impact of interventions. We first examined pre-test risk status across several outcomes (e.g., depressive symptoms, self-efficacy, communication) in 39 dyads and found 37-68% of older adults with chronic illness were at-risk at baseline; 40-79% of care partners; and 15-53% of dyads. Second, we examined dyadic benefits of a health behavior intervention, using two approaches, and found above zero approaches may deflate dyadic benefits compared to pre-test risk approaches. We used a pattern analysis to examine benefits across outcomes and within dyads and found 40% of dyads who received the intervention had expected positive outcomes for depressive symptoms and self-efficacy; 20% had expected positive scores for depressive symptoms, self-efficacy and aerobic exercise; and 13% had expected positive scores for all five target outcomes. Dyads where both members had highest pre-test risk level did not experience expected dyadic benefits. Finally, although we did not find strong evidence the intervention improved communication compared to a wait-list condition, there was no evidence it resulted in worse communication. Implications of using each approach and selecting different benchmarks for defining success are discussed. Results provide rationale for more intentional evaluation of small-sample, early-phase dyadic interventions.

Efficacy of the Eat Breathe Thrive Recovery Protocol Delivered Virtually to Adults Recovering From Eating Disorders: A Randomized Controlled Trial.

Current treatments for eating disorders have limited effectiveness, leaving over half of patients unremitted. The evaluation of emerging interventions to support recovery is therefore critical. This study evaluated the efficacy and acceptability of an innovative, virtual intervention for eating disorders (Eat Breathe Thrive; EBT-R). Participants recovering from eating disorders from 27 different countries (N = 277) were randomly allocated to EBT-R or waitlist conditions. Assessments were completed at baseline, postintervention, and three-month follow-up. Primary outcomes were eating disorders and co-occurring psychopathology; secondary outcomes included measures of positive embodiment. Compared with controls, participants in EBT-R demonstrated significant improvements in eating disorders and associated psychopathology (i.e., depression, anxiety) than controls. Participants also reported increased appreciation for the body, interoception, interoceptive attunement, intuitive eating, emotion regulation, mindful self-care, and integrity. This study evaluated the efficacy of a brief, virtual, embodiment-focused intervention for eating disorders. The findings suggest that EBT-R may be an effective intervention to support recovery from eating disorders and development of positive embodiment.

The effectiveness and usability of online, group-based interventions for people with severe obesity: a systematic review and meta-analysis.

Long wait times, limited resources, and a lack of local options mean that many people with severe obesity cannot access treatment. Face-to-face group-based interventions have been found effective and can treat multiple people simultaneously, but are limited by service capacity. Digital group interventions could reduce wait times, but research on their effectiveness is limited. This systematic review aimed to examine the literature about online group-based interventions for adults with severe obesity (BMI ≥ 35 kg/m2). The review followed the PRISMA and PICOS frameworks. MEDLINE, Embase, CINAHL, Web of Science, and Cochrane Central Register of Controlled Trials were searched. Two authors independently screened articles. Data extraction, analysis, and quality assessment (using RoB2 and MMAT) was shared between two authors. A meta-analysis was conducted on eligible studies; other results were descriptively analysed. 20 papers reporting on 15 studies were included. Most studies reported some evidence of weight loss, but evidence of weight-related behaviour change was mixed. A meta-analysis on four studies indicated that online, group-based interventions had a statistically significant impact on weight loss (p = 0.001; 95% CI -0.69 to -0.17) with a small-to-moderate effect size, compared to waitlist or standard care conditions. Online interventions were considered more convenient but lack of familiarity with the group or counsellor, accessibility issues, and time constraints hindered engagement. Technical support, incentives, and interactive forums to improve group cohesion could mitigate these barriers. The findings suggested that online, group-based interventions are feasible and potentially beneficial, but barriers such as internet accessibility, digital literacy, and unfamiliarity with group members need to be mitigated. Key recommendations to improve experience and impact include providing instructions and run-throughs, building group cohesion, and providing session and additional content throughout the intervention. Future studies should focus on the influence of specific intervention characteristics and investigate the effect of these interventions compared to face-to-face interventions. Registration: National Institute for Health Research, PROSPERO CRD42021227101; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021227101 .

RCT testing Sources of Strength impact on suicide attempts and moderation by sexual violence

RCT testing Sources of Strength impact on suicide attempts and moderation by sexual violence

Behavioural and neuronal substrates of serious game-based computerised cognitive training in cognitive decline: randomised controlled trial.

Investigations of computerised cognitive training (CCT) show heterogeneous results in slowing age-related cognitive decline. To comprehensively evaluate the effectiveness of serious games-based CCT, integrating control conditions, neurophysiological and blood-based biomarkers, and subjective measures. In this bi-centric randomised controlled trial with parallel groups, 160 participants (mean age 71.3 years) with cognitive impairment ranging from subjective decline to mild cognitive impairment, were pseudo-randomised to three arms: an intervention group receiving CCT immediately, an active control (watching documentaries) and a waitlist condition, which both started the CCT intervention after the control period. Both active arms entailed a 3-month intervention period comprising a total of 60 at-home sessions (five per week) and weekly on-site group meetings. In the intervention group, this was followed by additional 6 months of CCT, with monthly booster sessions to assess long-term training effects. Behavioural and subjective changes were assessed in 3-month intervals. Biological effects were measured by amyloid blood markers and magnetic resonance imaging obtained before and after training. Adherence to the training protocol was consistently high across groups and time points (4.87 sessions per week). Domain-specific cognitive scores showed no significant interaction between groups and time points. Significant cognitive and subjective improvements were observed after long-term training. Voxel-based morphometry revealed no significant changes in grey matter volume following CCT, nor did amyloid levels moderate its effectiveness. Our study demonstrates no benefits of 3 months of CCT on cognitive or biological outcomes. However, positive effects were observed subjectively and after long-term CCT, warranting the inclusion of CCT in multicomponent interventions.

Evaluating a mobile application based intervention for insomnia in college students: a preliminary study

Objective: This study examined the feasibility, acceptability, and efficacy of a self-guided, mobile application for Cognitive Behavioral Therapy for Insomnia (CBT-I Coach) in a sample of college students. Participants: Data was collected from 55 students, who mostly identified as women (82%) and white (84%) and reported at least moderate insomnia symptoms based on the Insomnia Severity Index. Methods: Participants were randomized to either an intervention condition (i.e., 4 wk of CBT-I Coach) or a wait-list condition and completed self-report measures biweekly across the 8-week study period. Results: Nearly 70% of participants found the app moderately to extremely effective. The intervention group experienced a larger reduction in insomnia symptoms from baseline to post-treatment compared to the control group (g = 0.88). Conclusions: These findings provide preliminary evidence that utilizing a self-guided mobile intervention for insomnia among college students is feasible and components of the app were perceived to be moderately to highly effective.

Implementation of a Technology-Enabled Diabetes Self-Management Peer Coaching Intervention for Patients With Poorly Controlled Diabetes: Quasi-Experimental Case Study.

Patients with diabetes experience worse health outcomes and greater health care expenditure. Improving diabetes outcomes requires involved self-management. Peer coaching programs can help patients engage in self-management while addressing individual and structural barriers. These peer coaching programs can be scaled with digital platforms to efficiently connect patients with peer supporters who can help with diabetes self-management. This study aimed to evaluate the implementation of a technology-enabled peer coaching intervention to support diabetes self-management among patients with uncontrolled diabetes. MetroPlusHealth, a predominant Medicaid health maintenance organization based in New York City, partnered with Pyx Health to enroll 300 Medicaid patients with uncontrolled diabetes into its 6-month peer coaching intervention. Pyx Health peer coaches conduct at least 2 evidence-based and goal-oriented coaching sessions per month with their assigned patients. These sessions are focused on addressing both behavioral and social determinants of health (SDoH) with the goal of helping patients increase their diabetes self-management literacy, implement self-management behaviors, and reduce barriers to ongoing self-care. Data analyzed in this study included patient demographic data, clinical data (patient's hemoglobin A1c [HbA1c]), and program implementation data including types of behavioral determinants of health and SDoH reported by patients and types of interventions used by peer coaches. A total of 330 patients enrolled in the peer mentoring program and 2118 patients were considered to be on a waitlist group and used as a comparator. Patients who enrolled in the peer coaching program were older; more likely to be English speakers, female, and African American; and less likely to be White or Asian American or Pacific Islander than those in the waitlist condition, and had similar HbA1c laboratory results at baseline (intervention group 10.59 vs waitlist condition 10.62) Patients in the enrolled group had on average a -1.37 point reduction in the HbA1c score (n=70; pre: 10.99, post 9.62; P<.001), whereas patients in the waitlist group had a -0.16 reduction in the HbA1c score (n=207; pre 9.75, post 9.49; P<.001). Among a subsample of participants enrolled in the program with at least 2 HbA1c scores, we found that endorsement of emotional health issues (β=1.344; P=.04) and medication issues (β=1.36; P=.04) were significantly related to increases in HbA1c. This analysis of a technology-enabled 1-on-1 peer coaching program showed improved HbA1c levels for program participants relative to nonprogram participants. Results suggested participants with emotional stressors and medication management issues had worse outcomes and many preferred to connect through phone calls versus an app. These findings support the effectiveness of digital programs with multimodal approaches that include human support for improving diabetes self-management in a typically marginalized population with significant SDoH barriers.

Parent Training for Disruptive Behaviors in Referred Children with Autism Spectrum Disorder: A Randomized Controlled Trial.

The purpose of this study was to investigate whether face-to-face and therapist-assisted online (i.e., blended) behavioral parent training are effective on reducing disruptive behaviors in children with autism spectrum disorder (ASD) in routine mental health care. Ninety-seven children with ASD (4-13years; 76 boys) were randomized to face-to-face parent training, blended parent training, or a waitlist control condition. We assessed treatment effects on parent-rated child noncompliance (primary outcome) and irritability (secondary outcome). This involved comparing both formats separately to the control condition using linear regression models. Child behaviors at 6months follow-up were also examined. Children in the face-to-face parent training condition improved significantly more on noncompliance and irritability than children in the waitlist condition and improvements sustained to 6months follow-up. Children in the blended condition did not improve more than children in the waitlist condition and attrition was high. Our results extend findings from efficacy studies to routine mental health care and advocate the use of face-to-face parent training for disruptive behaviors in children with ASD. More research into blended parent training programs for children with ASD and disruptive behaviors in routine mental health care should be conducted to draw more definite conclusions about the value of blended parent training for these children. Trial registration number NL4712; date of registration 22-10-2014.

Amelioration of suicidal ideation in routine care psychotherapy: Preliminary findings from a large multicenter assessment

Amelioration of suicidal ideation in routine care psychotherapy: Preliminary findings from a large multicenter assessment

The reROOT Coaching Program: A Pilot Randomized Controlled Trial Evaluating Its Impact on Coaching Style and Athlete Sports Development

The reROOT program teaches coaches 40 behaviors belonging to a need-supportive coaching style (including structure, involvement, and autonomy support), as defined by self-determination theory. This pilot randomized controlled trial, conducted during the COVID-19-related lockdown, evaluated the impact of this 18-hr program on coaching style (e.g., Problems in Sports Questionnaire) and on athlete motivation (Motivation Underlying Achievement Goals Questionnaire), performance (tactical, technical, physical, and psychological skills), and well-being (Satisfaction with Life Scale; Positive and Negative Affect Schedule). Twenty-three sports teams from two universities were randomized in the experimental or the wait-list control condition. Coaches in the experimental condition evaluated autonomy-supportive coaching styles more favorably than those in the control condition at the 1-year follow-up, but not 2 months after the end of the program. Athletes whose coaches participated in the program did not rate them as having a higher need-supportive coaching style, but experienced greater autonomous motivation and (potentially) performance, and under certain circumstances greater well-being and less controlled motivation 2 months after the end of the program compared with the wait-list condition. These findings suggest that the reROOT program could potentially improve readiness to rely on more autonomy-supportive skills and promote some aspects of sports development in athletes.

Preliminary trial of a well-being diary with Japanese primary school students

Preliminary trial of a well-being diary with Japanese primary school students

Can I improve my personal goal level through executive coaching over time? A randomised control trial study

ABSTRACT While existing literature strongly supports the effectiveness of executive coaching, there is a scarcity of empirical studies that assess how coaching facilitates change over time and its potential conditions. This study, conducted in a corporate setting using an experimental design with two measurement points, explores the potential of executive coaching to enhance the perceived coaching client’s personal goal level over time and the possible moderators. Two hundred and two managers from 13 organisations were randomly assigned to a coaching or waiting list condition. Managers in the coaching condition received four weekly coaching sessions from 33 external coaches. The results indicate that managers who received coaching significantly improved their goal level compared with those who did not, suggesting that executive coaching is an effective learning intervention for improving goal measurement for individuals with different backgrounds. The general self-efficacy was not a condition for increased goal level for those who received coaching, highlighting that coaching is an effective tool regardless of the participant’s level of general self-efficacy. However, low general self-efficacy predicted the decision to withdraw from the study, emphasising the importance of the general self-efficacy trait in assessing the readiness of those involved in coaching.

Truce: Outcomes and mechanisms of change of a seven-week acceptance and commitment therapy program for young people whose parent has cancer

Truce: Outcomes and mechanisms of change of a seven-week acceptance and commitment therapy program for young people whose parent has cancer

Positive family connections for families of children with a developmental disability: Cluster randomized controlled trial.

Positive Family Connections is a coproduced, positively oriented, family-systems program for families of children with a developmental disability aged 8-13 years. The study was a feasibility cluster randomized-controlled trial which was registered prospectively (International Standard Randomised Controlled Trial Number 14809884). Families (clusters) were randomized 1:1 to take part in Positive Family Connections immediately or to a waitlist condition and were followed up 4 months and 9 months after randomization. Feasibility outcomes included participant and facilitator recruitment rates, retention, intervention adherence, and fidelity. The proposed primary outcome measure was the family APGAR, a measure of family functioning. Quantitative data were analyzed using multilevel modeling. Sixty families (60 primary parental carers and 13 second carers) were randomized. 73.33% of primary parental carers and 71.43% of second carers in the intervention group attended ≥ 4 intervention sessions, and fidelity of delivery was high (M = 94.02% intervention components delivered). Retention for the proposed primary outcome was 97.26% at 4-month follow-up and 98.63% at 9-month follow-up. Intervention condition was not associated with family APGAR scores at 9-month follow-up (estimate = 0.06, 95% CI [-0.49, 0.61], p = .86, Hedges' g = 0.03, 95% CI [-0.43, 0.49]). However, meaningful improvements were observed for other secondary outcomes related to parental well-being and family relationships. A definitive randomized-controlled trial of Positive Family Connections is feasible. Preliminary evaluation of outcomes shows that Positive Family Connections may be beneficial for parental psychological well-being and family relationships. (PsycInfo Database Record (c) 2024 APA, all rights reserved).