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Objective: Empathy is a foundational therapeutic skill and a key contributor to client outcome, yet the best combination of instructional components for its training is unclear. We sought to address this by investigating the most effective instructional components (didactic, rehearsal, reflection, observation, feedback, mindfulness) and their combinations for teaching empathy to practitioners. Method: Studies included were randomized controlled trials targeted to mental health practitioners and trainees, included a quantitative measure of empathic skill, and were available in English. A total of 36 studies (37 samples) were included (N = 1,616). Two reviewers independently extracted data. Data were pooled by using random-effects pairwise meta-analysis and network meta-analysis (NMA). Results: Overall, empathy interventions demonstrated a medium-to-large effect (d = .78, 95% CI [.58, .99]). Pairwise meta-analysis showed that one of the six instructional components was effective: didactic (d = .91 vs. d = .39, p = .02). None of the program characteristics significantly impacted intervention effectiveness (group vs. individual format, facilitator type, number of sessions). No publication bias, risk of bias, or outliers were detected. NMA, which allows for an examination of instructional component combinations, revealed didactic, observation, and rehearsal were included among the most effective components to operate in combination. Conclusions: We have identified instructional component, singly (didactic) and in combination (didactic, rehearsal, observation), that provides an efficient way to train empathy in mental health practitioners.What is the public health significance of this article? Empathy in mental health practitioners is a core skill associated with positive client outcomes, with evidence that it can be trained. This article provides an aggregation of evidence showing that didactic teaching, as well as trainees observing and practicing the skill, are the elements of training that are most important.

Although peer victimization is widely considered to be detrimental to children's well-being, knowing what it feels like to be harmed is also thought to contribute to children's sense of concern for others. However, research has yet to establish a clear link between peer victimization and sympathy during childhood. Across two samples of Canadian 4-and 8-year-olds (total N = 504), we examined whether children's emotion regulation capacities (ER) moderated the victimization-sympathy link. Study 1 (n = 300; 33% European origin; 73% of caregivers held bachelor's degree or higher) examined the interactive effects of victimization and child-and caregiver-reported ER on children's self-reported sympathy assessed concurrently and 1 year later. Concurrently, victimization was positively associated with sympathy for children higher in self-reported ER and for boys higher in caregiver-reported ER. Longitudinally, victimization positively predicted changes in sympathy from 4 to 5 years of age for children higher in self-reported ER. No longitudinal interaction effects emerged for caregiver-reported ER or in older children. Using the same caregiver-reported ER measure, Study 2 (n = 204; 30% European origin; 65% of caregiv-

Background/Aims: Gender incongruent (GI) youth experience high rates of mental health comorbidities. While gender-affirming medical care (GAMC) provides psychological benefit, GI youth often present to care at older ages. The goals of this study were to 1) assess the relationship between age at presentation to GAMC and rates of mental health comorbidities, 2) identify factors influencing when youth present to GAMC, and 3) determine whether older presenting youth face more barriers to care. Methods: We performed a cross-sectional chart review of patients presenting to GAMC. Subjects were classified a priori as younger presenting youth (YPY): <15 years of age at presentation or older presenting youth (OPY): > 15 years of age. Self-reported rates of mental health comorbidities and medication use were compared between groups. Binary logistic regression analysis was used to identify determinants of mental health comorbidities. Covariates included pubertal stage at presentation, social transition status, and assigned sex. Next, we performed a sequential exploratory mixed-methods study. Factors influencing age at presentation to GAMC were explored through 24 semi-structured interviews with OPY, YPY, and their caregivers (OPY-C and YPY-C). Thematic analysis identified themes with differential representation between OPY/OPY-C and YPY/YPY-C. From these themes, a questionnaire was designed and distributed to youth and caregivers presenting for follow-up. Responses were compared between OPY and YPY and between OPY-C and YPY-C. Results: Of 300 youth, there were184 OPY and 116 YPY. Upon presentation, more OPY than YPY reported a diagnosis of depression (46% vs. 30%), had self-harmed (40% vs. 28%), had considered suicide (52% vs. 40%), had attempted suicide (17% vs. 9%), and required psychoactive medications (36% vs. 23%), all p < .05. After controlling for covariates, late puberty (Tanner stage 4 or 5) was associated with depressive disorders (OR 5.49 [95% CI: 1.14, 26.32]) and anxiety disorders (OR 4.18 [95% CI: 1.22, 14.49]) while older age remained associated only with psychoactive medication use (OR 1.31 [95% CI: 1.05, 1.63]). Six themes were identified from interviews that influenced age at first clinic visit, including individual, environmental, and healthcare system factors. 101/152 youth and 102/147 caregivers completed questionnaires. While OPY/OPY-C did not endorse more barriers to care than YPY/YPY-C, more OPY than YPY had religious families (54% vs 28%, p=.01) while more YPY than OPY had LGBTQ+ family members (46% vs. 20%, p=.006). Conclusions: Older age and late pubertal stage are associated with worse mental health among GI youth presenting to GAMC. Our findings emphasize the importance of timely access to GAMC for GI youth and highlight familial environment as a factor that influences when youth present to gender-affirmative care.