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Sifaki M, Flouri E, Midouhas E. Paternal and maternal psychological distress and adolescent health risk behaviors: The role of sensitive periods. J Adolesc 2024. [PMID: 39072763 DOI: 10.1002/jad.12385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 04/09/2024] [Accepted: 07/17/2024] [Indexed: 07/30/2024]
Abstract
INTRODUCTION Adolescent health risk behaviors are linked to poor physical and mental health outcomes. While past research shows that maternal psychological distress predicts those behaviors, we know less about the role of paternal psychological distress and the role of sensitive periods. METHODS Using 11,128 data from families (50.5% female children) from the UK's Millennium Cohort Study, we examined the role of timing of exposure to paternal and maternal psychological distress in engagement in health risk behaviors (smoking, alcohol use, binge drinking, and sexual activity) at age 14. Paternal and maternal psychological distress, measured with the Kessler-6 scale, were assessed at child ages 3, 7, and 11. We performed path analysis, adjusting for key covariates, modeling maternal distress parallel to paternal, and allowing for autoregressive paths. RESULTS Paternal distress experienced at age 11 predicted a higher likelihood of smoking at age 14. Maternal distress at age 7 also predicted a higher likelihood of smoking, alcohol use, and binge drinking, but only for boys. Moreover, maternal distress at age 3 was associated with a lower risk for alcohol use. Effects were not replicated in the sensitivity analysis we performed, including only families with resident biological fathers across the study period. Instead, maternal and paternal distress at age 11 raised girls' risk for binge drinking and sexual activity, respectively. CONCLUSIONS Parental distress in early childhood does not predict adolescent health risk behaviors. In late childhood, however, both paternal and maternal distress seem to influence the likelihood of engagement in such behaviors.
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Affiliation(s)
- Maria Sifaki
- Research Department of Epidemiology and Public Health, UCL Institute of Epidemiology and Health Care, London, UK
| | - Eirini Flouri
- Department on Psychology and Human Development, UCL Institute of Education, London, UK
| | - Emily Midouhas
- Department on Psychology and Human Development, UCL Institute of Education, London, UK
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Guo Y, Swaim RC, Mason WA. Protective factors in the relationship between perceived discrimination and risky drinking among American Indian adolescents. Drug Alcohol Depend 2023; 250:109936. [PMID: 37418800 PMCID: PMC11081532 DOI: 10.1016/j.drugalcdep.2023.109936] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 04/22/2023] [Accepted: 05/15/2023] [Indexed: 07/09/2023]
Abstract
INTRODUCTION The relationship between perceived discrimination and risky drinking among American Indian (AI) youth is understudied, and the potential protective factors that may buffer this association are unknown. Therefore, the objective of this study was to examine protective factors across individual, family, school, peer, and cultural domains of the social ecology that might attenuate the relationship between perceived discrimination and risky drinking among AI adolescents. METHOD Data were from the Substance Use Among American Indian Youth Study (Swaim and Stanley, 2018, 2021). AI youth who have used alcohol in their lifetime (n = 2516 within 62 schools) had an average age of 15.16 years (SD = 1.75) and 55.5% were female. Five sets of linear regressions were conducted. Risky drinking was regressed on demographic variables, alcohol use frequency, perceived discrimination, one protective factor (religiosity, parental monitoring, peer disapproval of alcohol use, school engagement, and ethnic identity), and one two-way interaction between perceived discrimination and the protective factor. RESULTS Prevalence of risky drinking among lifetime drinkers was 40.1%. There were positive associations between perceived discrimination and risky drinking in all models (Bs range from.20 to.23; p <.001). Parental monitoring had a negative association with risky drinking (B = -0.255, p <.001). Religiosity was the only statistically significant moderator (B = -0.08, p = 0.01), indicating that religiosity weakened the relation between perceived discrimination and risky drinking. CONCLUSIONS Religiosity may represent an important protective factor that could help guide efforts to prevent risky drinking in the face of discrimination among AI adolescents.
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Affiliation(s)
- Ying Guo
- University of Nevada-Las Vegas, School of Public Health, 4700 S. Maryland Parkway, Suite #335, Las Vegas89119, United States.
| | - Randall C Swaim
- Department of Psychology, Colorado State University, Fort Collins, CO80523, United States
| | - W Alex Mason
- Department of Child, Youth and Family Studies and Nebraska Center for Research on Children, Youth, Families and Schools, University of Nebraska-Lincoln, 36 Carolyn Pope Edwards Hall, Lincoln, NE68588, United States
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Haruyama D, Prince MA, Swaim RC, Chavez EL. The relationship between depressed affect, parental monitoring, and sex on cannabis use among American Indian youth. Am J Addict 2023; 32:402-409. [PMID: 36959723 PMCID: PMC10330835 DOI: 10.1111/ajad.13416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 03/09/2023] [Accepted: 03/22/2023] [Indexed: 03/25/2023] Open
Abstract
BACKGROUND AND OBJECTIVES American Indian (AI) adolescents report higher rates of cannabis use than national US adolescents. Previous study examined interactive relationships between depressed affect and family factors on AI adolescent alcohol use. These factors have not been investigated for cannabis use. We examined whether parental monitoring dampened risk for cannabis use due to depressed affect, and potential moderation by sex. METHODS We measured cannabis use, depressed affect, parental monitoring, and sex among reservation area AI youth among students in grades 7-12 attending 45 schools. We used censor-inflated regression models to identify parental monitoring as a moderator of the relationship between depressed affect and cannabis use. RESULTS In the logistic portion of censor-inflated models, level of depressed affect and parental monitoring significantly related to last 30-day cannabis use. Higher levels of parental monitoring at lower levels of depressed affect related to lower likelihood of cannabis use. Female students had greater likelihood of endorsing cannabis use at higher levels of depressed affect. In the linear portion of the censor-inflated regression models, sex and level of parental monitoring significantly related to cannabis use frequency. Male students endorsed more frequent cannabis use while higher levels of parental monitoring related to lower frequency of use. DISCUSSION AND CONCLUSIONS Parental monitoring may dampen the effect of depressed affect on cannabis use among AI youth on reservations. SCIENTIFIC SIGNIFICANCE Future interventions should foster skill-building prevention efforts directed at coping with depression, along with parental training for effective monitoring. Special attention to AI female adolescents may be indicated.
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Kelly LM, Correia N, Kearns MD, Lang SG, Yermash J, Guigayoma J, Helseth SA, Becker SJ. From parenting skills to adolescent treatment needs: Questions elicited by parents of adolescents discharged from residential treatment. DRUG AND ALCOHOL DEPENDENCE REPORTS 2022; 5:100110. [PMID: 36844169 PMCID: PMC9949345 DOI: 10.1016/j.dadr.2022.100110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 10/21/2022] [Accepted: 10/25/2022] [Indexed: 11/05/2022]
Abstract
Background Despite the utility of parent involvement in continuing care following adolescent residential treatment, parent engagement in traditional office-based treatment is low. In our prior work, we found that parents who had access to a continuing care forum directed questions to a clinical expert and to other parents around five topics: parenting skills; parent support; managing the post-discharge transition; adolescent substance use; family functioning. The current qualitative study elicited questions from parents without access to a continuing care support forum to explore overlapping and new themes. Methods This study was embedded within the pilot trial of a technology-assisted intervention for parents of adolescents in residential treatment for substance use. Thirty-one parents randomized to residential treatment as usual were asked two prompts at follow-up assessments: what questions they would like to ask a clinical expert and what questions they would like to ask other parents of adolescents discharged from residential care. Thematic analysis identified major themes and subthemes. Results Twenty-nine parents generated 208 questions. Analyses revealed three themes identified in prior work: parenting skills; parent support; adolescent substance use. Three new themes emerged: adolescent mental health; treatment needs; socialization. Conclusions The current study identified several distinct needs among parents who did not receive access to a continuing care support forum. Needs identified in this study can inform resources to support parents of adolescents during the post-discharge period. Parents may benefit from convenient access to an experienced clinician for advice on skills and adolescent symptoms, paired with access to parental peer support.
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Schluter PJ, Kokaua J, Tautolo ES, Iusitini L, Richards R, Ruhe T. Parental education related to their children's health in late childhood and early adolescence for Pacific families within New Zealand. Sci Rep 2022; 12:5313. [PMID: 35351955 PMCID: PMC8964731 DOI: 10.1038/s41598-022-09282-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 03/16/2022] [Indexed: 11/09/2022] Open
Abstract
Pacific people continue to carry a disproportionately heavy social and health burden relative to their non-Pacific peers in New Zealand, and those with less formal education are experiencing social and health declines. Improving education and educational needs is seen as being central to decreasing these health inequities. While expansive, the empirical evidence-base supporting this stance is relatively weak and increasingly conflicting. Using a large birth cohort of 1,368 eligible Pacific children, together with their mothers and fathers, this study longitudinally investigates the relationship between paternal education levels and sentinel measures of their children's physical health, mental health and health risk taking behaviours during late childhood and early adolescence. In adjusted analyses, it was found that mothers and fathers who undertook further schooling over the 0-6 years postpartum period had children with significantly lower logarithmically transformed body mass index increases at 11-years and 14-years measurement waves compared to 9-years levels than those who did not study (p = 0.017 and p = 0.022, respectively). Furthermore, fathers who undertook further schooling over this 0-6 years postpartum period also had children with significantly lower odds of risk taking behaviours (p = 0.013). These results support policy aimed at increasing educational opportunities for Pacific people in New Zealand.
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Affiliation(s)
- Philip J Schluter
- School of Health Sciences - Te Kura Mātai Hauora, and Child Well-being Research Institute - Te Kāhui Pā Harakeke, University of Canterbury - Te Whare Wānanga o Waitaha, Private Bag 4800, Christchurch, 8140, New Zealand. .,School of Clinical Medicine, Primary Care Clinical Unit, The University of Queensland, Brisbane, Australia.
| | - Jesse Kokaua
- Division of Health Sciences, Va'a O Tautai, University of Otago, Dunedin, New Zealand
| | - El-Shadan Tautolo
- Centre for Pacific Health and Development Research, Auckland University of Technology, Auckland, New Zealand
| | - Leon Iusitini
- Centre for Pacific Health and Development Research, Auckland University of Technology, Auckland, New Zealand
| | - Rosalina Richards
- Division of Health Sciences, Va'a O Tautai, University of Otago, Dunedin, New Zealand
| | - Troy Ruhe
- Division of Health Sciences, Va'a O Tautai, University of Otago, Dunedin, New Zealand
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Becker SJ, Helseth SA, Janssen T, Kelly LM, Escobar K, Spirito A. Parent Smart: Effects of a Technology-Assisted Intervention for Parents of Adolescents in Residential Substance Use Treatment on Parental Monitoring and Communication. EVIDENCE-BASED PRACTICE IN CHILD AND ADOLESCENT MENTAL HEALTH 2021; 6:459-472. [PMID: 35087933 PMCID: PMC8791644 DOI: 10.1080/23794925.2021.1961644] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Promoting parent involvement in adolescent residential substance use treatment is an evidence-based principle, yet engaging parents is challenging. Parent SMART (Substance Misuse among Adolescents in Residential Treatment) is a technology-assisted intervention that was designed to engage parents of adolescents in residential SU treatment during the post-discharge transition period. A prior pilot randomized controlled trial (n=61 parent-adolescent dyads) established Parent SMART's feasibility, acceptability, and preliminary effectiveness in reducing adolescent substance use and substance-related problems across both a short- (i.e., acute stay) and long- (i.e., residential) term care facility. The current secondary analysis extends this prior work by examining whether Parent SMART was associated with improvements in putative mediators of change: parental monitoring and parent-adolescent communication. Multi-modal assessment consisting of participant-report questionnaires and a behavioral interaction task evaluated parenting processes over the 24 weeks following discharge. Generalized linear mixed models showed no significant time by condition interactions on the participant-report questionnaires, but found significant interactions on all five scales of the behavioral interaction task. Supplemental analyses by residential facility detected additional interaction effects favoring Parent SMART on the participant-report questionnaires. Plotting of the interaction effects indicated that Parent SMART was associated with improvements in parenting processes, whereas TAU was associated with relatively stable or worsening parenting scores. Parent SMART demonstrated preliminary effectiveness in improving key parenting processes among adolescents discharged from residential substance use treatment. Parent SMART warrants further testing in a fully-powered trial that evaluates parental monitoring and parent-adolescent communication as mediators of change.
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Affiliation(s)
- Sara J Becker
- Center for Alcohol and Addictions Studies, Brown University School of Public Health
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University
| | - Sarah A Helseth
- Center for Alcohol and Addictions Studies, Brown University School of Public Health
| | - Tim Janssen
- Center for Alcohol and Addictions Studies, Brown University School of Public Health
| | - Lourah M Kelly
- Center for Alcohol and Addictions Studies, Brown University School of Public Health
| | | | - Anthony Spirito
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University
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Jovičić Burić D, Muslić L, Krašić S, Markelić M, Pejnović Franelić I, Musić Milanović S. Gender Differences in the Prediction of Alcohol Intoxication among Adolescents. Subst Use Misuse 2021; 56:1024-1034. [PMID: 33792493 DOI: 10.1080/10826084.2021.1906278] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Alcohol is one of the most commonly consumed substances in adolescence and can lead to many (mental) health problems. This study aimed to examine social determinants related to family, peers and school achievement as risk factors for alcohol intoxication (AI) among adolescents and to examine whether these risk factors differ in their prediction of AI concerning potential gender differences. METHODS The data used in this study were obtained from the cross-sectional "European School Survey Project on Alcohol and Other Drugs" and involved 2558 participants who were turning 16 in the year of the research. Multinomial and binary logistic regressions were performed for each AI indicator (lifetime, in the last 12 months, in the last 30 days and heavy episodic drinking (HED) in the last 30 days) in relation to gender. RESULTS School achievement, parental knowledge, peer pressure (for alcohol consumption and for AI) were found to be consistent predictors for varying AI among adolescents. High school achievement was found to be a protective factor for all AI indicators explored in our study, regardless of gender. Peer pressure made a more pronounced contribution to AI experience among boys, while parental knowledge demonstrated a more protective nature with regards to AI among girls. CONCLUSION Overall, results indicate that social determinants as predictors of AI among adolescents are consistent across various AI indicators and confirm gender specific predictors for AI. These findings indicate the possible benefit of involving parents in preventive programs and of using a gender perspective regarding observed differences.
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Affiliation(s)
- Diana Jovičić Burić
- Health Promotion Division, Croatian Institute of Public Health, Zagreb, Croatia
| | - Ljiljana Muslić
- Health Promotion Division, Croatian Institute of Public Health, Zagreb, Croatia
| | - Sandro Krašić
- Department of Psychology, Faculty of Philosophy, University of Zagreb, Zagreb, Croatia
| | - Martina Markelić
- Health Promotion Division, Croatian Institute of Public Health, Zagreb, Croatia
| | - Iva Pejnović Franelić
- Department for International Cooperation, Croatian Institute of Public Health, Zagreb, Croatia
| | - Sanja Musić Milanović
- Health Promotion Division, Croatian Institute of Public Health, Zagreb, Croatia.,The "Andrija Štampar" School of Public Health, The University of Zagreb, School of Medicine, Zagreb, Croatia
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Protective and Risk Factors for Adolescent Substance Use in Spain: Self-Esteem and Other Indicators of Personal Well-Being and Ill-Being. SUSTAINABILITY 2020. [DOI: 10.3390/su12155962] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Although self-esteem has traditionally been considered as an important correlate of psychosocial adjustment, some empirical studies have found a positive relationship between some domains of self-esteem and drug use among adolescents. The present study analyzes self-esteem and other adjustment personal indicators as protective or risk factors for substance use. Participants were 644 Spanish adolescents aged 12–17 years. Substance use (cigarettes, alcohol, marijuana, and other illicit drugs), multidimensional self-esteem (academic, social, emotional, family, and physical), and other indicators of adolescents’ well-being and ill-being (psychological problems, behavior problems, and parenting) were measured. We observed, on the one hand, that substance use had a significant negative relationship with academic, family, and physical self-esteem. On the other hand, we also observed a significant positive relationship between drug use and social self-esteem. However, this significant relationship disappeared after statistically controlling for sex and age, using both partial correlation analyses and covariance analysis. Interestingly, beyond the importance of each factor related to drugs, prevention science should first of all be able to identify whether the main psychological variables (e.g., social or physical self-esteem) are risk or protective factors for drug use.
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Hurley E, Dietrich T, Rundle-Thiele S. A systematic review of parent based programs to prevent or reduce alcohol consumption in adolescents. BMC Public Health 2019; 19:1451. [PMID: 31684909 PMCID: PMC6829962 DOI: 10.1186/s12889-019-7733-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 10/09/2019] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Adolescent alcohol consumption is an issue of ongoing concern and programs targeting parents have been identified as an important component in minimizing and preventing alcohol related harm in adolescents. This paper aims to evaluate existing parent based alcohol education programs with a focus on understanding parent specific outcomes including parental attitudes, parent-child communication, alcohol specific rule setting and parental monitoring; study quality, the extent of stakeholder engagement in program design and the level of theory application. METHOD A systematic review of electronic databases EBSCO, Emerald, ProQuest, PubMed, Ovid, ScienceDirect, Taylor and Francis and Web of Science was conducted from database inception to August 2019. A total of 4288 unique records were retrieved from the eight databases. Studies were included if they evaluated school based alcohol education programs that included a parent component and detailed outcome measures associated with parent data. The methodological quality of the included studies was assessed using the Effective Public Health Practice Project (EPHPP) quality assessment tool. RESULTS In total 17 studies qualified for assessment, detailing 13 individual parent programs. Of these, ten programs demonstrated positive effects in at least one parent reported outcome measure. Stakeholder engagement during the design of programs was lacking with the majority of programs. One third of the programs did not report theory use and when theory was used reporting was weak with three programs applying theory, five testing theory and none building theory. According to the EPHPP tool, overall ten programs were rated as weak, three as moderate and none as strong. CONCLUSION Future studies are recommended to further enhance the effectiveness of parental programs by improving study quality, increasing stakeholder engagement and increasing the level of theory application and reporting.
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Affiliation(s)
- Erin Hurley
- Social Marketing @ Griffith, Griffith University, 170 Kessels Road, Nathan, Qld 4111, Australia.
| | - Timo Dietrich
- Social Marketing @ Griffith, Griffith University, 170 Kessels Road, Nathan, Qld 4111, Australia
| | - Sharyn Rundle-Thiele
- Social Marketing @ Griffith, Griffith University, 170 Kessels Road, Nathan, Qld 4111, Australia
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Inguglia C, Costa S, Iannello NM, Liga F. Parental Monitoring and Youth's Binge Behaviors: The Role of Sensation Seeking and Life Satisfaction. ACTA ACUST UNITED AC 2019. [DOI: 10.1080/13575279.2019.1626803] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Cristiano Inguglia
- Dipartimento di Scienze Psicologiche, Pedagogiche, Dell’esercizio Fisico e Della Formazione, Università Degli Studi Di Palermo, Palermo, Italy
| | - Sebastiano Costa
- Dipartimento di Psicologia, Università Degli Studi Della Campania, Napoli, Italy
| | - Nicolò Maria Iannello
- Dipartimento di Cultura, Educazione e Società, Università Della Calabria, Rende, Italy
| | - Francesca Liga
- Dipartimento di Medicina Clinica e Sperimentale, Università Degli Studi Di Messina, Messina, Italy
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The future and me: Imagining the future and the future self in adolescent decision making. COGNITIVE DEVELOPMENT 2019. [DOI: 10.1016/j.cogdev.2019.04.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Understanding Mechanisms of Genetic Risk for Adolescent Internalizing and Externalizing Problems: The Mediating Role of Parenting and Personality. Twin Res Hum Genet 2018; 21:310-321. [PMID: 30027866 DOI: 10.1017/thg.2018.36] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Genetic predispositions play an important role in the development of internalizing and externalizing behaviors. Understanding the mechanisms through which genetic risk unfolds to influence these developmental outcomes is critical for developing prevention and intervention efforts, capturing key elements of Irv's research agenda and scientific legacy. In this study, we examined the role of parenting and personality in mediating the effect of genetic risk on adolescents' major depressive disorder and conduct disorder symptoms. Longitudinal data were drawn from a sample of 709 European American adolescents and their mothers from the Collaborative Studies on Genetics of Alcoholism. Results from multivariate path analysis indicated that adolescents' depressive symptoms genome-wide polygenic scores (DS_GPS) predicted lower parental knowledge, which in turn was associated with more subsequent major depressive disorder and conduct disorder symptoms. Adolescents' DS_GPS also had indirect effects on these outcomes via personality, with a mediating effect via agreeableness but not via other dimensions of personality. Findings revealed that the pattern of associations was similar across adolescent gender. Our findings emphasize the important role of evocative gene-environment correlation processes and intermediate phenotypes in the pathways of risk from genetic predispositions to complex adolescent outcomes.
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Moñino-García M, Adoamnei E, Gadea-Nicolás A, Arense-Gonzalo JJ, López-Espín JJ, Torres-Cantero AM. Family environmental factors associated with underage drinking. JOURNAL OF SUBSTANCE USE 2018. [DOI: 10.1080/14659891.2018.1523965] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Miriam Moñino-García
- Division of Preventive Medicine and Public Health, Department of Public Health Sciences, University of Murcia School of Medicine, Espinardo (Murcia), Spain
- Institute for Biomedical Research of Murcia, IMIB-Arrixaca, El Palmar (Murcia), Spain
| | - Evdochia Adoamnei
- Division of Preventive Medicine and Public Health, Department of Public Health Sciences, University of Murcia School of Medicine, Espinardo (Murcia), Spain
- Institute for Biomedical Research of Murcia, IMIB-Arrixaca, El Palmar (Murcia), Spain
| | - Alicia Gadea-Nicolás
- Division of Preventive Medicine and Public Health, Department of Public Health Sciences, University of Murcia School of Medicine, Espinardo (Murcia), Spain
| | - Julián J. Arense-Gonzalo
- Division of Preventive Medicine and Public Health, Department of Public Health Sciences, University of Murcia School of Medicine, Espinardo (Murcia), Spain
- Institute for Biomedical Research of Murcia, IMIB-Arrixaca, El Palmar (Murcia), Spain
| | - José J. López-Espín
- Institute for Biomedical Research of Murcia, IMIB-Arrixaca, El Palmar (Murcia), Spain
- Center of Operation Research, Miguel Hernández University of Elche, Elche, Spain
| | - Alberto M. Torres-Cantero
- Division of Preventive Medicine and Public Health, Department of Public Health Sciences, University of Murcia School of Medicine, Espinardo (Murcia), Spain
- Institute for Biomedical Research of Murcia, IMIB-Arrixaca, El Palmar (Murcia), Spain
- CIBER Epidemiology and Public Health (CIBERESP), Carlos III Health Institute, Madrid, Spain
- Department of Preventive Medicine, “Virgen de la Arrixaca” University Clinical Hospital, El Palmar (Murcia), Spain
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