Externalizing and internalizing pathways to Mexican American adolescents' risk taking

US Immigration Policy Stressors and Latinx Youth Mental Health

Importance

The youth mental health crisis is exacerbated for Latinx adolescents, a group whose families are targets of anti-immigrant rhetoric and policy.

Objective

To investigate how immigration-related stressors are associated with disruptions in parent-child relationships and, in turn, the mental health symptoms of Latinx adolescents.

Design, Setting, and Participants

Data for this prospective cohort study of adolescent-mother dyads were derived from surveys completed at 3 time points spanning 4 years (time 1 [T1] in 2018, time 2 [T2] in 2020, and time 3 [T3] in 2022). Mediation analyses estimated paths from immigration-related stressors to parent-child relationship qualities to mental health symptoms from early to late adolescence. Multivariable and multivariate linear models within a structural equation modeling framework regressed mediators and outcome variables on their own T1 values, offering a scientifically rigorous test of mediation. The setting was a school district in suburban Atlanta, Georgia, and included Latinx adolescents (ages 11-16 years) randomly selected from grade and gender strata. Data were analyzed from June 2023 to March 2024.

Exposures

The primary independent variables were T1 mother reports of anti-immigrant worry and behavioral modification and adolescent reports of family member detention or deportation. Mediating variables were the reports of parental support and parent-child conflict of T2 adolescents.

Main Outcomes and Measures

T3 adolescent reports of past 6-month internalizing and externalizing symptoms.

Results

A total of 547 Latinx adolescents (mean [SD] age, 13.3 [1.0] years; 303 female [55.4%]; 244 male [44.6%]) were included in this study. Response rates were 65.2% (547 of 839) among contacted parents and 95.3% (547 of 574) among contacted adolescents with parental permission. Four-year retention rates were 67% (366 of 547 adolescents) and 65% (177 of 271 mothers). Structural model results showed that T1 anti-immigrant worry and behavioral modification was associated with T3 increases in externalizing symptoms indirectly through T1 to T2 increases in parent-child conflict (β = 0.03; SE = 0.02; 95% CI, 0-0.08). For girls, T1 family member deportation or detention was associated with T1 to T3 increases in internalizing and externalizing symptoms indirectly through T1 to T2 declines in parental support (internalizing: β = 0.04; SE = 0.02; 95% CI, 0-0.08; externalizing: β = 0.03; SE = 0.02; 95% CI, 0-0.07). Sensitivity analyses supported structural model findings.

Conclusion and Relevance

Results of this cohort study suggest that legislative bodies, the health care system, and educational institutions should implement safeguards to mitigate potential harm conferred by anti-immigrant environments for parent-child relationships and, in turn, Latinx adolescents' mental health.

Peer Discrimination, Deviant Peer Affiliation, and Latino/a Adolescent Internalizing and Externalizing Symptoms: A Prospective Study

OBJECTIVE

U.S. Latino/a adolescents experience high levels of ethnic discrimination, particularly in new immigrant destinations. Due to the salience of peers during adolescence, this study examined how peer discrimination related directly and indirectly, through deviant peer affiliation, to changes in Latino/a adolescents' internalizing and externalizing symptoms. Culture-specific moderators hypothesized to buffer discrimination impacts on adolescent symptomology included Spanish language enculturation and adolescents' social ties to relatives in the family's country-of-origin.

METHOD

The sample of 547 Latino/a adolescent participants from the Caminos al Bienestar study (55.4% female; age M = 12.8, range = 11-16) was selected at random from middle schools in a large, suburban school district in Atlanta, Georgia. Three time points of survey data spaced roughly 6 months apart were collected during 2018 and 2019.

RESULTS

Results from longitudinal structural equation models revealed that peer discrimination was associated indirectly with increased externalizing symptoms, through increases in affiliation with deviant peers (β = 0.05; SE = 0.02; B = 0.02; 95% CI = 0.01, 0.09). We did not observe direct or indirect effects of peer discrimination on changes in internalizing symptoms, and we found no significant protective effects of either Spanish language enculturation or social ties with the country-of-origin.

CONCLUSIONS

Ethnic discrimination by peers may lead to deviant peer affiliation and, in turn, increased externalizing behaviors. Future research identifying protective factors that buffer discrimination impacts on deviant peer affiliation is needed to inform the development of interventions that can prevent Latino/a adolescents' externalizing symptoms.

The development of personality-From metatraits to facets-Across adolescence and into adulthood in a sample of Mexican-origin youth

The time between adolescence and adulthood is a transformative period of development. During these years, youth are exploring work, relationships, and worldviews while gaining the capacities needed to take on adult roles. These social and psychological processes are reflected in how personality develops across this period. Most youth personality development research has focused on the Big Five domains, ignoring the hierarchical structure of personality and missing broader, higher order processes and more specific, lower order processes. Toward a more comprehensive account, this study examines how personality develops from adolescence into the early years of adulthood at the metatrait (stability, plasticity), domain (Big Five), and facet levels. Data come from a longitudinal study of Mexican-origin youth (N = 645) with few socioeconomic resources who were assessed 5 times from Ages 14 to 23. We used latent growth curve models to investigate mean-level change, rank-order consistency, and the maintenance of trajectories for self-reported personality metatraits, domains, and facets. We found distinct developmental processes unfolding at each level of the hierarchy, including (a) mean-level changes in the metatraits and domains indicating increases in exploratory tendencies (i.e., plasticity) and maturity (i.e., increases in agreeableness and conscientiousness, decreases in neuroticism), and divergent change patterns between facets within each domain indicating nuanced maturational processes; (b) comparable levels of rank-order consistency for metatraits, domains, and facets; and (c) evidence that deviations from youth's developmental trajectories did not persist over time. Our findings offer insights into personality development that would be impossible to glean from the domain-level alone and adds needed sociocultural diversity to the literature. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Associations of externalizing polygenic scores with externalizing disorders among Mexican youth

Several studies have examined the association of externalizing polygenic scores (PGS) with externalizing symptoms in samples of European ancestry. However, less is known about the associations of externalizing polygenic vulnerability in relation to phenotypic externalizing disorders among individuals of different ancestries, such as Mexican youth. Here, we leveraged the largest genome-wide association study on externalizing behaviors that included over 1 million individuals of European ancestry to examine associations of externalizing PGS with a range of externalizing disorders in Mexican adolescents, and investigated whether adversity exposure in childhood moderated these associations. Participants (N = 1064; age range 12-17 years old; 58.8% female) were adolescents recruited for a general population survey on adolescent mental health in the Mexico City Metropolitan region and were genotyped. Childhood adversity exposure and externalizing disorders, specifically attention-deficit hyperactivity disorder (ADHD), conduct disorder, oppositional defiant disorder, and substance use disorder, were assessed via the computer-assisted World Mental Health Composite International Diagnostic Interview for adolescents. A greater externalizing PGS was associated with a greater odds of any externalizing disorder (OR = 1.29 [1.12, 1.48]; p < 0.01) and ADHD (OR = 1.40 [1.15, 1.70]; p < 0.01) in the whole sample, and in females in particular. There were no main effects of the externalizing PGS on conduct disorder, oppositional defiant disorder, or substance use disorder, nor did adversity exposure moderate these associations. Our results suggest that greater genetic propensity for externalizing disorders is associated with increased odds of any externalizing disorders and ADHD among Mexican adolescents, furthering our understanding of externalizing disorder manifestation in this population.

The mediating roles of mental health problems and racial differences in the linkage between social media use and E-cigarette use among American youth

OBJECTIVE

Social media use is shown to be linked to youth's e-cigarette use. However, less is known about the underlying mechanisms. This study examined the mediating roles of internalizing and externalizing problems in the association between youth's social media use and e-cigarette use, and the racial differences in the mediation association.

METHODS

The study sample included 4913 U.S. youth from the Population Assessment of Tobacco and Health Study Waves 3-5 (2015-2019). Two weighted generalized structural equation models were conducted to examine the mediation pathways between youth's social media use (Wave 3) and past-30-day e-cigarette use (Wave 5) through internalizing and externalizing problems (Wave 4), respectively. Invariance tests were conducted to examine racial group differences.

RESULTS

Youth with high social media use frequency were more likely to use e-cigarettes (total effect: OR = 1.20, p < 0.001 in both internalizing and externalizing models). Internalizing and externalizing problems mediated the aforementioned associations (mediation proportions: 5.05% and 5.66%, respectively). The invariance tests indicated a significant difference between White and non-White groups (both ps < 0.001), where a larger proportion of mediation was found in the non-White group (12.22% for internalizing and 11.99% for externalizing) compared to their White counterparts (2.46% for internalizing and 3.17% for externalizing).

CONCLUSIONS

Mental health problems following social media use served as a risk factor for e-cigarette use among youth. Interventions aiming to improve youth's mental health could in turn temper e-cigarette use among youth social media users, and implementing tailored interventions in response to racial differences is warranted.

Maternal Adverse Childhood Experiences and Young Adult Latino Children's Mental Health

INTRODUCTION

Maternal adverse childhood experiences have been linked to a variety of negative health outcomes in young children; however, young adults and, specifically, young adult Latinos have been vastly understudied. This study investigates the intergenerational pathway between maternal adverse childhood experiences and behavioral health outcomes of their young adult children, as mediated through young adults' own adverse childhood experiences and maternal depression.

METHODS

Structural equation modeling was used to analyze data (in 2023) from mothers and their young adult children (n=398 dyads) enrolled in the Center for the Health Assessment of Mothers and Children of Salinas cohort, a primarily Latino agricultural sample. Maternal and young adult adverse childhood experiences were self-reported retrospectively during a visit at the age of 18 years (2018-2020). Young adult- and maternal-reported internalizing and maternal-reported externalizing behaviors were assessed at the age of 18 years with the Behavior Assessment for Children, second edition. Maternal depression was assessed during a visit at the age of 9 years (2010-2012) using the Center for Epidemiologic Studies Depression Scale.

RESULTS

Maternal and young adult adverse childhood experiences were weakly but statistically significantly correlated (r=0.22). Maternal adverse childhood experiences were statistically significantly associated with maternal-reported youth internalizing symptoms (β=0.29; 95% CI=0.19, 0.38; p<0.001) and externalizing symptoms (β=0.24; 95% CI=0.14, 0.33; p<0.001) and marginally associated with youth-reported internalizing symptoms (β=0.08; 95% CI= -0.02, 0.18; p=0.13). Youth adverse childhood experiences and maternal depressive symptomatology mediated the associations between maternal adverse childhood experiences and young adult outcomes.

CONCLUSIONS

Findings demonstrate the potential impacts of adversity across generations in Latino immigrant families, an understudied population. Understanding the mechanisms and factors associated with these pathways may lead to strategies that prevent poor mental health outcomes in young adults.

Are Discrepancies Between Father and Adolescent Perceptions of Harsh Parenting and Conflict Associated with Adolescent Mental Health Symptoms?

Though differences in informant perceptions of family processes are associated with poorer health, few studies have examined discrepancies between father- and adolescent-report of family phenomena and their impact on adolescent mental health. This study examined how father and adolescent-reported parenting and the differences in their perceptions is related to adolescent mental health. Participants were 326 father-adolescent dyads (Fathers: Mage = 41.2; Adolescents: 7th grade students, Mage = 12.0, 48.5% female). Overall, analyses revealed significant main effects of father and/or adolescent report of father-adolescent conflict and harsh parenting on adolescent internalizing and externalizing symptoms. Analyses revealed two instances in which discrepancies between father- and adolescent-report of family phenomena was related to adolescent mental health. Given the mixed nature of the findings based on the outcome reporter, the current study discusses implications for discrepancy research and future directions to better understand discrepant perceptions as useful information on their own. The parent clinical trial is registered at ClinicalTrials.gov (Identifier: NCT03125291, Registration date: 4/13/2017).

Perceived Negative Political Climate Among Hispanic/Latino Adolescents Before and After the 2020 U.S. Presidential Election: Associations with Internalizing Symptoms and Substance Use

The political climate often changes following the installment of a new president. This volatility presents opportunities for examining how elections might affect vulnerable subgroups such as Hispanic/Latino (HL) adolescents. The present study explored the perception of negative political climate among HL adolescents before and after the 2020 U.S. presidential election and its association with internalizing symptoms and substance use. We conducted the study in Los Angeles and Miami between 2020-2021, with a sample of 304 HL adolescents (Females = 60.8%), aged 15.3 years on average. Participants completed measures of negative political climate (pre- post-election) and measures of depressive symptoms, anxiety, substance misuse, and substance use intentions after the election. We used paired tests and linear mixed-effects modeling to explore changes in perceived negative climate before and after the election. Structural equation modeling was used to determine predictors of negative political climate and its associations with internalizing symptoms and substance use. Results indicated that following the election negative political climate increased significantly in Miami and among Cuban-origin adolescents but not in Los Angeles or among Mexican-origin adolescents. Pre-election perceived negative political climate was significantly predicted by gender, study site, and mother's nativity. Pre-election negative political climate predicted post-election internalizing symptoms and substance use intentions indirectly through post-election negative political climate. HL youth's perceived political climate is a complex construct that might vary across different sociopolitical contexts and populational sub-groups. Exploring variations in politically-based cultural stressors and their role as mental health and substance use risk factors is crucial to addressing HL disparities. KEY WORDS: Adolescence, Hispanic/Latino, political climate, presidential election, internalizing symptoms, substance use.

A developmental cascade model of adolescent peer relationships, substance use, and psychopathological symptoms from child maltreatment

INTRODUCTION

Although previous studies have demonstrated high intercorrelations among deviant peer affiliation, substance use, externalizing and internalizing symptoms in adolescence, these studies have been limited because they did not examine 1) the associations over time by assuming one particular sequence; and 2) child maltreatment effects.

METHODS

This study included 617 adolescents (54.3 % girls, 55.6 % Black) at-risk of maltreatment living in the U.S and primarily low-income. Deviant peer affiliation was assessed at ages 12, 14, and 16 using 13 items from the modified version of the Youth Risk Behavior and Monitoring the Future Survey. Externalizing and internalizing symptoms were measured at ages 12, 14, and 16 using the Child Behavior Checklist. The number of substances used (ages 12, 14, 16, and 18) were created by summing the self-reported alcohol, tobacco, and marijuana use. Each type of maltreatment (birth to age 12) was assessed using the self-report.

RESULTS

Autoregressive cross-lagged structural equation modeling explained the stability effects within each domain, as well as how different maltreatment types affect diverse developmental processes. Cross-lagged results showed the socialization effects of peers on substance use, whereas the peer selection effects on externalizing symptoms. Physical abuse was only associated with externalizing symptoms, while sexual abuse was associated with both externalizing and internalizing symptoms. Additionally, emotional abuse was associated with deviant peer affiliation and substance use.

CONCLUSIONS

Identifying the underlying reciprocal processes offers a deeper understanding of peer relationships in the substance use and externalizing symptoms among at-risk of maltreatment sample.

Dampened autonomic nervous system responses to stress and substance use in adolescence

We investigated whether parasympathetic and sympathetic nervous system (SNS) responses to social-evaluative threat at age 14 were related to the number of substances used between ages 14 and 16 among Mexican-origin adolescents (N = 243; 70.4% had never used substances by 14). Participants completed the Trier Social Stress Test, while cardiac measures of parasympathetic and SNS activity were measured continuously using respiratory sinus arrhythmia (RSA) and pre-ejection period (PEP), respectively. Participants reported whether they had ever used alcohol, marijuana, and cigarettes, and had ever vaped nicotine in their lifetime at ages 14 and 16. Multilevel models were used to test associations between RSA and PEP responses at age 14 and substance use at 16. Among youth who had not used substances by 14, dampened RSA and PEP responses, and profiles of greater coinhibition and lower reciprocal SNS activation between RSA and PEP, at age 14 were associated with using substances by 16. Among youth who used by 14, exaggerated PEP responses were associated with using more substances by age 16. Taken together, dampened autonomic responses to social-evaluative threat predicted initiation of substance use over two years, and difficulties with coordination of physiological responses may confer risk for substance use in adolescence.

The joint development of externalizing and internalizing behaviors in black and Hispanic youth and the link to late adolescent substance use

There is a need to understand how the joint development of externalizing and internalizing behaviors is related to substance use, particularly among historically understudied and often disadvantaged populations. Latent class models were used to estimate patterns of externalizing behaviors and internalizing behaviors in the form of depressive and anxious symptoms from age 6 to 14 among 390 Black and Hispanic youth. Then, growth curve models of substance use between the ages of 15 and 19 were estimated as a function of joint latent class membership. Only elevated levels of externalizing behaviors were associated with higher levels of substance use through age 18. Internalizing behaviors appeared to serve as a protective factor among those with moderate displays of externalizing behavior only. Additionally, growth in substance use from ages 15 to 19 was slower among those who displayed the highest level of externalizing behaviors, and internalizing behaviors appeared to moderate growth (and serve as protective factor) among those who displayed moderate levels of externalizing behaviors. The findings underscore the importance of pattern profiles based on observations of the joint development of problem behaviors to assess risk for substance use, particularly in understudied populations where risk/protective factors may operate in a unique manner.

Neural Response to Social Exclusion Moderates the Link Between Adolescent Anxiety Symptoms and Substance Use

BACKGROUND

Substance use (SU) typically increases from middle to late adolescence. Anxiety is one factor associated with greater SU, although variability in who uses substances remains. Some models suggest that brain-based susceptibility markers could reveal which adolescents are at a higher risk for psychopathology, but it is unknown whether these individual differences attenuate or accentuate the association between anxiety and elevated SU even if normative. This study addressed this gap by testing whether neural response to social exclusion moderates the association between anxiety symptoms and increased SU from middle to late adolescence.

METHODS

Participants were 181 Mexican-origin adolescents (48% female; 16-17 years old) who completed a social exclusion task during a functional magnetic resonance imaging scan and filled out questionnaires about their SU and anxiety symptoms. Analyses focused on neural response to social exclusion versus inclusion within 3 regions of interest and change in SU across 2 years.

RESULTS

Dorsal anterior cingulate cortex response to social exclusion, but not subgenual anterior cingulate cortex or anterior insula, moderated the relation between anxiety symptoms and SU, such that higher anxiety symptoms predicted a greater relative increase in SU only for those youth with a lower dorsal anterior cingulate cortex response to exclusion.

CONCLUSIONS

Blunted dorsal anterior cingulate cortex response to social exclusion may serve as a neural susceptibility marker of altered conflict monitoring or emotion regulation in middle adolescence that, in combination with high levels of anxious feelings, elevates the risk for onset of and/or increased SU by late adolescence. These findings have implications for designing targeted interventions to mitigate SU among adolescents.

A Culturally Adapted Parenting Intervention for Mexican-Origin Immigrant Families with Adolescents: Integrating Science, Culture, and a Focus on Immigration-Related Adversity

Low-income Latina/o immigrants are very likely to experience intense contextual challenges in the USA, such as limited exposure to culturally relevant parent training (PT) prevention interventions. This prevention study consisted of an exploratory randomized controlled trial, aimed at empirically testing the implementation feasibility and initial efficacy of a culturally adapted version of the evidence-based PT intervention known as GenerationPMTO^©. The parenting intervention was adapted to overtly address immigration-related stressors, discrimination, and challenges associated with biculturalism. Seventy-one Mexican-origin immigrant mothers participated in this study and were allocated to one of two conditions: (a) culturally adapted GenerationPMTO (i.e., CAPAS-Youth) or (b) wait-list control. Measurements were completed at baseline (T1) and intervention completion (T2). When compared to mothers in the control condition at T2, CAPAS-Youth participants reported significant improvements on four of the core parenting practices delivered in the CAPAS-Youth intervention. As hypothesized, no significant differences in limit-setting skills were identified at T2. With regards to adolescents' outcomes, mothers exposed to CAPAS-Youth reported significant improvements in youth internalizing and externalizing behaviors at T2 when compared to a wait-list control condition. Mothers in both conditions also reported significant reductions in levels of immigration-related stress. Current findings indicate the feasibility of implementing CAPAS-Youth within a context of considerable adversity, as well as the beneficial impacts of the parent-based intervention on salient parenting and youth outcomes.

The Vicious Cycle: Problematic Family Relations, Substance Abuse, and Crime in Adolescence: A Narrative Review

Despite the copiousness of studies on the risky behaviors of adolescents, we cannot establish with certainty the leading aspects involved in teens' substance abuse and criminal actions. This review aims to explore the interplay among the family system, substance abuse, and criminal behavior. An analysis of the main results of the 61 articles published between 2010 and 2020 shows that adolescents whose parents are justice-involved and often absent from home are more likely to perceive lower cohesion, support, and poor family communication. These factors can involve them in criminal acts and substance abuse. Moreover, these conducts are often linked to a form of uneasiness and a search of autonomy. Indeed, risky behaviors could have more than one meaning. Our findings also suggest that the most diffused drug-related crimes in adolescence are economic crimes, weapon carrying, robberies, dealing, and drug possession. Considering these results, future clinical implications might be based on multidimensional approaches, focusing more on the family context to promote interventions for at-risk adolescents.

Motor Vehicle Collisions during Adolescence: The Role of Alexithymic Traits and Defense Strategies

International literature has shown that adolescents represent the population most at risk of fatal and nonfatal motor vehicle collisions (MVCs). Adolescents’ alexithymic traits and significant use of immature defense strategies have been seen to play a key role. This study aimed to investigate the possible mediation role played by defense strategies use in the relationship between alexithymia and MVCs. Our sample consisted of 297 adolescents divided into four subgroups, based on the number of visits to the emergency department due to an MVC. We assessed adolescents’ alexithymic traits and defense strategies use through self-report instruments. Results showed that males reported a higher rate of MVCs than females. Higher rates of MVCs are associated with more alexithymic traits and maladaptive defense strategies use. Adolescents’ Acting Out and Omnipotence use significantly mediated the relationship between alexithymia and MVCs. Our findings suggest the recidivism of MVCs as an attempt to cope with emotional difficulties, with important clinical implications.

Social Support Versus Emotion Regulation: Mediators of Attachment and Psychological Problems After Social Exclusion

Introduction: Secure parental attachment improves the perception of available social support and the socialization of emotion regulation strategies. Research has suggested that both perceived social support and emotion regulation help individuals reappraise stressful situations as less stressful. Individuals under stress are at an increased risk for psychological problems.

Method: The current study examined whether social support, emotion regulation, and psychological inflexibility mediated the relation between parental attachment and psychological problems after a social exclusion task.

Results: Results indicated that secure parental attachment was associated with an increased ability to up-regulate emotions and with an increase in the perception of available social support. Secure attachment to either parent was indirectly associated with psychological problems reported after social exclusion.

Discussion: Indirect effects were found only for pathways from attachment through emotion regulation strategies, which suggests that emotion regulation may be a driving factor between attachment to parental figures and stress induced psychological problems. Further results, limitations, and implications were discussed.

Polygenic risk, family cohesion, and adolescent aggression in Mexican American and European American families: Developmental pathways to alcohol use

Poor family cohesion and elevated adolescent aggression are associated with greater alcohol use in adolescence and early adulthood. In addition, evocative gene-environment correlations (rGEs) can underlie the interplay between offspring characteristics and negative family functioning, contributing to substance use. Gene-environment interplay has rarely been examined in racial/ethnic minority populations. The current study examined adolescents' polygenic risk scores for aggression in evocative rGEs underlying aggression and family cohesion during adolescence, their contributions to alcohol use in early adulthood (n = 479), and differences between Mexican American and European American subsamples. Results suggest an evocative rGE between polygenic risk scores, aggression, and low family cohesion, with aggression contributing to low family cohesion over time. Greater family cohesion was associated with lower levels of alcohol use in early adulthood and this association was stronger for Mexican American adolescents compared to European American adolescents. Results are discussed with respect to integration of culture and racial/ethnic minority samples into genetic research and implications for alcohol use.

Biological and Psychosocial Processes in the Development of Children's Appetitive Traits: Insights from Developmental Theory and Research

There has been increasing concern expressed about children's food intakes and dietary patterns. These are closely linked to children's appetitive traits (such as disinhibited eating and food fussiness/neophobia). Research has examined both biological and psychosocial correlates or predictors of these traits. There has been less focus on possible processes or mechanisms associated with children's development of these traits and research that links biological and psychosocial factors. There is an absence of research that links biological and psychosocial factors. In the present article, we outline a model intended to facilitate theory and research on the development of appetitive traits. It is based on scholarship from developmental theory and research and incorporates biological factors such as genetic predispositions and temperament as well as psychosocial factors in terms of parent cognitions, feeding styles and feeding practices. Particular attention is directed to aspects such as emotional eating and feeding, self-regulation of energy intake, and non-shared family environments. We highlight the opportunity for longitudinal research that examines bidirectional, transactional and cascade processes and uses a developmental framework. The model provides a basis for connecting the biological foundations of appetitive traits to system-level analysis in the family. Knowledge generated through the application of the model should lead to more effective prevention and intervention initiatives.