The influence of positivity and self-efficacy beliefs on family functioning among young adults in Italy and Colombia.

Background: Research suggests that positivity and self-efficacy beliefs may impact adaptive behavior and developmental outcomes, such as social adjustment and subjective wellbeing. The present study explored the effect of positive dimensions (positivity and self-efficacy beliefs) and individual characteristics (gender, type of country, age, and sexual orientation) on family cohesion and flexibility in a group of Colombian and Italian young adults. Method: An online survey was administered to 949 Colombian and 2,073 Italian people aged between 18 and 40 years (M age = 24.3; SDage = 4.5; 67% women). A mediational model was performed to test the influence of positivity on family functioning via the mediational role of self-efficacy beliefs, analyzing the moderated effects of gender, type of country, sexual orientation, and age. Results: Filial self-efficacy mediated the effect of positivity on family functioning, showing stronger paths in men and Colombian participants than in women and Italian counterparts. Regulatory self-efficacy mediated the associations between positivity and family functioning for both genders and types of countries. Conclusion: The results suggest that positivity and self-efficacy beliefs may allow families to engage in more adaptive family functioning across countries and genders. Further research should focus on implications from a cross-national perspective to examine other culture-specific factors that may impact family adjustment.

Positive LGBT+ Identity, Interpersonal Discrimination, and Satisfaction with Life: A Cross-National Comparison Between LGBT+ People in the UK, Italy, and Turkey.

The present study explored how identity authenticity and LGBT+ community connectedness may mediate the effects of interpersonal discrimination on life satisfaction in a sample of LGBT+ participants across three counties. We used a cross-sectional online survey to collect data and paper questionnaires. Participants were 723 LGBT+ people (56.6% females): 308 (42%) of participants were from the UK, 245 (34%) from Italy, and 170 (24%) from Turkey. Participants' age ranged from 18-60 years (M = 33.83, SD = 11.55). Analysis of variance and multigroup mediation models implemented through path analysis were performed. The associations of interpersonal discrimination with identity authenticity and connectedness to the LGBT+ community showed cross-country variations. The association between interpersonal discrimination and identity authenticity was stronger in Italy than in the UK but non-significant in Turkey. Interpersonal discrimination showed a negative association with connectedness to the LGBT+ community in Italy and the UK, with Italy exhibiting the strongest effect. Conversely, this association was positive in Turkey. Irrespective of the country, life satisfaction showed a negative association with interpersonal discrimination and positive associations with identity authenticity and connectedness to the LGBT+ community. This study provides valuable insights into the differences and similarities between the experiences of LGBT+ people in the UK, Italy, and Turkey. The social and policy implications that emerge from the study highlight the relevance of addressing structural stigma in different cultures and emphasize the need for targeted interventions and supportive policies at the supranational level to improve the quality of life of LGBT+ individuals.

Past body shaming experiences and food and alcohol disturbance in young adults: indirect effects via psychological distress.

PURPOSE: This study investigated the associations between retrospective reports of body image victimization (i.e. body shaming) perpetrated by peers and by parents during childhood or adolescence, and food and alcohol disturbance (FAD) in young adulthood, considering the possible mediating role of psychological distress (i.e. subthreshold symptoms of anxiety and depression). METHODS: The study involved 1624 young adults aged between 18 and 30 (69% women), who completed an online survey. RESULTS: Our findings revealed that participants who reported more frequent body image victimization episodes during childhood and adolescence exhibited higher levels of psychological distress and, in turn, higher scores of FAD in young adulthood. CONCLUSIONS: This result represents a novel contribution to understanding the psychological correlates of FAD in youths. Limitations and implications are discussed. Level of evidence Level V, descriptive study.

From One's Heart to the Mind of Others: A Study in School-Aged Children.

Studies have shown a significant association between effective parasympathetic modulation of the heart and processes linked to social cognition. Particularly, Quintana and colleagues documented a relation between vagally-mediated heart rate variability (vmHRV) and performance on a theory of mind (ToM) task, namely, the Reading the Mind in the Eyes Test (RMET), in a sample of university students. The purpose of the present study was to test whether such result would extend to a sample of school-aged children (7-9 years old) using the child version of the RMET. In addition, the Eyes Test Revised was administered as it is more suitable to evaluate ToM during childhood. Results supported the positive association between vmHRV and ToM abilities, replicating and extending previous results obtained in young adults. The current study adds to the existing literature pointing to HRV as a putative biomarker of social cognition abilities.

Aggressive and Withdrawn Behaviour at School through the Lens of Teachers and Peers: A Qualitative Study.

We explored teachers' understanding of children with aggressive or socially withdrawn behaviour in their classes and we associated our findings with a status of rejected, neglected, or popular, as provided by peer nominations. Five kindergarten and elementary school teachers scored their 143 pupils with the Child Behaviour Checklist for Withdrawal and Aggression. Subsequently, only those children whose scores were 1 standard deviation above the mean for withdrawal or for aggression were included in the final sample (n = 46; Mage = 6.5 years, SD = 1.7; age range = 4-9 years). The final sample included 31 children (21.67%; females = 16) who were assessed as displaying withdrawn behaviour, and 15 (10.48%; females = 5) displaying aggressive behaviour. An open-ended semi-structured interview was administered to teachers, who described children with socially withdrawn behaviour as introverted and untalkative, children with aggressive behaviour as hostile, rule-breaking and highly active, and children with socially withdrawn or aggressive behaviour as isolated, even though different reasons were provided. The results of the sociometric status in children with socially withdrawn or aggressive behaviour are discussed.

Peer victimization and social anxiety in adolescence: a comparison between migrant and native students in Italy.

The first aim of this study is to investigate the relationship between bullying victimization and social anxiety in native and migrant adolescents in Italy. Specifically, it was hypothesized that migrant adolescents (in comparison with natives) experience more frequent episodes of bullying victimization, which in turn, may be a risk factor for the development of social anxiety symptoms. The second aim of the study is to explore the relationships from reflected minority categorization to perceived ethnic discrimination at school and social anxiety symptoms, in the subgroup of migrant students. Results showed that the migrant (vs. native) status was predictive of higher scores in social anxiety dimensions (Fear of Negative Evaluation, Social Avoidance and Distress in New Situations, and General Social Avoidance Distress), via the mediating effect of increased peer victimization. Moreover, in the subgroup of migrant participants, an indirect effect of reflected minority categorization on social anxiety was observed, mediated by perceived ethnic discrimination at school. These findings may contribute to the understanding of health inequalities among migrant and native people in the Italian context. Limitations and practical implications of the study were discussed.

Enhancing social outcomes in autistic youth: Assessing the impact of PEERS® booster sessions.

BACKGROUND: The Program for the Education and Enrichment of Relational Skills (PEERS®) is a social skills training program for autistic adolescents and those facing social challenges. Its efficacy has been established worldwide, including in Italy. Although booster interventions are a potentially valuable strategy to maintain improvements over time, there is currently no research on the efficacy of providing booster sessions of PEERS® following the traditional treatment. AIMS: This study aims to evaluate the efficacy of PEERS® Booster sessions in a sample who had previously participated in a traditional PEERS® Adolescent program. METHODS AND PROCEDURES: A longitudinal non-randomized study was conducted involving 21 autistic adolescents, divided into the treatment group undergoing PEERS® Booster sessions and the control group without it. OUTCOMES AND RESULTS: The study evaluated the primary outcomes (social abilities) and secondary outcomes (co-occurrences, executive functions) at two-time points (pre- and post-treatment). No significant differences were found between groups on baseline measures and primary outcomes. However, there were significant group differences between pre- and post-treatment on primary outcomes (social awareness and social communication) and secondary outcomes (externalizing problems). CONCLUSIONS AND IMPLICATIONS: The efficacy of the PEERS® Booster Sessions shows promise and clinical implications were also discussed.

Social Anxiety and Drunkorexia Behaviors among Adolescents and Young Adults: The Moderating Role of Resilience.

Background: Existing evidence showed that social anxiety represents a significant factor in eating disorders. However, to our knowledge, no prior study has examined the association between social anxiety and drunkorexia behaviors. Objectives: The present study aimed at exploring the relationship between social anxiety and drunkorexia behaviors, and investigating resilience as a moderator of this relationship. Participants were 333 adolescents and young adults aged 15-24 years (Mage=18.26, SDage= 1.55; 66% females) who completed an online survey. Results: The results indicated that drunkorexia behaviors were positively correlated to three dimensions of social anxiety; however, only fear of negative evaluation had a significant predictive effect. In addition, resilience only moderated the relationship between fear of negative evaluation and drunkorexia behaviors, such that youths reporting high fear of negative evaluation and low resilience showed greater drunkorexia behaviors, whereas youths reporting high resilience showed no correlation between fear of negative evaluation and drunkorexia behaviors. Conclusions: The findings highlight the importance of drunkorexia interventions and preventive measures aimed at strengthening youths' resilience and ability to effectively manage stress and social anxiety (i.e., fear of negative evaluation).

Program for the Education and Enrichment of Relational Skills (PEERS®) for Italy: A Randomized Controlled Trial of a Social Skills Intervention for Autistic Adolescents.

The Program for the Education and Enrichment of Relational Skills (PEERS®) is an intervention targeting social skills for autistic adolescents and those with other social challenges. The efficacy of the PEERS® on adolescents has been extensively explored but the program has not been validated in Italy. In the present study, we adapted PEERS® to Italian culture and evaluated its efficacy in an Italian sample. A Randomized Controlled Trial was conducted, analyzing the results of 37 autistic adolescents who were randomly assigned to two groups: experimental group (TG) and waitlist group (WL). The primary outcomes (social abilities) and secondary outcomes (co-occurring conditions, executive functions) were assessed at four time points. No differences were found at pre-treatment between groups on baseline measures and primary outcomes. At post-treatment, significant group differences emerged in primary outcomes (social knowledge and social performance) and secondary outcomes (emotion regulation). The groups' results pooled together (TG + WL) confirmed the findings at post-treatment and showed further changes in primary outcomes (global social competence and social cognition) and secondary outcomes (externalizing problems, emotive and behavioral total problems, functional problems related to depressive symptoms). The improvements were maintained at a 3-month follow-up, except for global social competence and social cognition. Additionally, new results emerged regarding internalizing problems and global executive functioning. The efficacy of the Italian version of PEERS® was ascertained on primary and secondary outcomes. Innovative findings on emotion regulation, behavioral problems, and depression symptoms also emerged.Clinical trial registration information Program for the Education and Enrichment of Relational Skills (PEERS®) for Italy. An RCT's Study on Social Skills Intervention for Adolescents with Autism Spectrum Disorder (ASD). URL: http://clinicaltrials.gov . TRN: NCT05473104. Release Date: July 21, 2022.

Motivations for Social Withdrawal, Mental Health, and Well-Being in Emerging Adulthood: A Person-Oriented Approach.

Emerging adults seek solitude because of different underlying motivational and emotional processes. The current short-term longitudinal study aimed to: (1) identify subgroups of socially withdrawn emerging adults characterized by different motivations for solitude (shyness, unsociability, social avoidance) and affect (positive, negative); and (2) compare these subgroups in terms of indices of internalizing difficulties and life-satisfaction. Participants were N = 348 university students (Mage = 21.85 years, SD = 3.84) from Italy, who completed online questionnaires at two-time points separated by three months. Results from a latent profile analysis (LPA) suggested three distinct subgroups characterized by different social withdrawal motivations (i.e., shy, unsociable, and socially avoidant), as well as a non-withdrawn subgroup (characterized by low social withdrawal motivations, low negative affect, and high positive affect). Among the results, the socially avoidant subgroup reported the highest levels of social anxiety, whereas the avoidant and shy subgroups reported the highest loneliness and lowest life satisfaction. The unsociable subgroup appeared to be the most well-adjusted subgroup of socially withdrawn emerging adults and reported similar levels of life satisfaction as the non-withdrawn subgroup. Our findings confirmed the heterogeneity of emerging adults' experiences of solitude, with different motivations for social withdrawal appearing to confer a differential risk for maladjustment.

The Impact of Delayed School Start Times During COVID-19 on Academic Performance: A Longitudinal Naturalistic Study in Italian High Schools.

Background: Delaying school start times has been proposed as a potential solution to address chronic sleep curtailment among adolescents and its negative consequences on their physical and mental well-being. This study investigates the impact of delayed school start times due to the COVID-19 pandemic on academic achievement. Subjects and Methods: Two separate observational studies were conducted involving high school students from the first/second year (n=232) (Study 1) and from the final year (n=39) (Study 2). Multivariate Analyses of Covariance were performed to assess for statistical differences in academic performance (ie, global, humanistic, and scientific performance) and absenteeism (ie, number of school absences). Two main factors were considered: "school start time" (ie, standard-8:00 AM vs late-9:40 AM) and "time interval" (ie, first academic semester vs second academic semester), controlling for the school year (Study 1) and circadian preference (Study 2). Results: Delaying school start times was positively associated with better academic performance in scientific subjects among first/second-year students (F1,229=6.083, p=0.026) and global academic performance among last-year students (F1,35=4.522, p=0.041). Furthermore, first/second-year students significantly increased their school achievement (F1,229>29.423, p<0.001) and school absences (F1,229=66.160, p<0.001) during the second semester of the academic year. No significant effect of "school start time" on school attendance was observed. Additionally, circadian preference was found to be a significant covariate among last-year students, with early chronotypes exhibiting better academic performance (r>0.369, p<0.025). Conclusion: These findings confirm past evidence about the beneficial effects of delayed school start times on academic outcomes, with the additional advantage of observing them within a natural context that emerged during the pandemic. Further research is needed to explore the phenomenon more systematically and take into account the broader implications of implementing this change.

Individualism-Collectivism and COVID-19 Prevention Behaviors in Young Adults: The Indirect Effects of Psychological Distress and Pandemic Fears.

Stemming on the theoretical framework of individualism-collectivism, this study aims to interpret COVID-19 prevention behaviors in young adults in the light of cultural orientations, hypothesizing the mediating role of two pandemic affects (i.e., fear for COVID-19 consequences and psychological distress during pandemic). Participants were 296 young adults living in Italy (Mage = 23.96, SDage = 3.04; 79.7% women), who completed an online anonymous survey. Data were gathered from December 2020 to May 2021. A path analysis model explored direct and indirect relationships among study variables. Psychological distress significantly reduced the compliance with prevention measures, whereas pandemic fears increased it. The collectivistic orientations (Vertical Collectivism and Horizontal Collectivism) positively predicted prevention behaviors via increasing pandemic fears. The egalitarian dimensions (Horizontal Individualism and Horizontal Collectivism) were positive predictors of compliance via reducing psychological distress during pandemic. Finally, Vertical Individualism was a risk factor that negatively predicted prevention behaviors both directly and indirectly, via increasing psychological distress. The results provide new insights into the emotional mechanisms that link individualism and collectivism orientations to COVID-19 prevention behaviors, with interesting implications for public health policies, prevention, and future research.

Exploring the relationship between dysfunctional metacognitive processes and orthorexia nervosa: the moderating role of emotion regulation strategies.

BACKGROUND: Dysfunctional metacognitive processes and emotional dysregulation have been widely documented in the eating disorder literature. Despite numerous research and recent consensus suggesting the categorization of orthorexia nervosa as a form of eating disorder, no previous study has examined whether aberrant metacognitive processes also correlate with orthorexia nervosa tendencies. This paper investigates potential associations between symptoms of orthorexia nervosa and dysfunctional metacognitive processes while also exploring whether such relationships may be influenced by adaptive/maladaptive emotion regulation strategies. METHODS: We conducted a cross-sectional study in all Lebanese governorates. In total, 423 Lebanese adults completed an online questionnaire including the Teruel Orthorexia Scale, the Emotion Regulation Questionnaire, the Difficulties in Emotion Regulation Scale - 16 Item Version, and the Metacognitions Questionnaire - Short Form. RESULTS: Higher physical activity, expressive suppression, emotion regulation difficulties, positive metacognitive beliefs about worry, and need to control thoughts were significantly associated with higher orthorexia nervosa. Additionally, the emotion regulation strategies moderated the relationships between two dysfunctional metacognitive processes and orthorexia nervosa. Specifically, cognitive self-consciousness was negatively related to orthorexia nervosa only in individuals with low (versus higher) emotion suppression (maladaptive emotion regulation strategy). In contrast, negative beliefs about worry uncontrollability and danger positively predicted orthorexia nervosa only in individuals with lower (versus high) cognitive reappraisal (adaptive emotion regulation strategy). Lower socio-economic status and having a university level of education compared to secondary level were significantly associated with lower orthorexia nervosa. CONCLUSION: Our study provides the first empirical evidence for the existence of significant associations between dysfunctional metacognitive processes and orthorexia nervosa. It also highlights that these pathways are considerably modulated by individuals' ability to regulate their emotions adaptively versus maladaptively. Our findings thus suggest that therapies aimed at improving thought monitoring and emotional regulation may be beneficial for individuals with symptoms of orthorexia nervosa.

Body image impact on quality of life and adolescents' binge eating: the indirect role of body image coping strategies.

PURPOSE: The role of body image in adolescent binge eating is widely confirmed, albeit the various facets of this relationship are still mostly unexplored. Within the multidimensional body image framework, this study hypothesized the indirect effects of three body image coping strategies (positive rational acceptance, appearance fixing, avoidance) in the expected relationship between the perceived impact of body image on individuals' quality of life and binge eating symptoms. METHODS: Participants were 715 adolescents aged 15-21 years (49.1% girls) recruited in Italian schools. An anonymous self-report online survey was administered. A multiple mediation model was tested. RESULTS: A more positive perceived impact of body image on quality of life was a negative predictor of adolescents' binge eating, controlling for individual levels of body satisfaction. Three indirect effects were found in this relationship: on one hand, the positive body image impact reduced binge eating via increasing positive rational acceptance (M1), and via reducing avoidance (M2); on the contrary, the positive body image impact also enhanced binge eating via increasing appearance fixing (M3). CONCLUSIONS: The body image impact on quality of life can be alternatively protective-when adaptive coping is solicited, and maladaptive strategies are reduced-or a risk factor, which may increase binge eating by soliciting appearance fixing. LEVEL III: Evidence obtained from cohort or case-control analytic studies.

Psychological Difficulties in Children and Adolescents during the COVID-19 Lockdown: The Effects of Spending Free Time with Parents or Using Digital Devices.

The present study investigated protective and risk factors for psychological difficulties in children and adolescents during the COVID-19 lockdown. Specifically, the role of increased use of digital devices (DDs) for recreational purposes and the role of free time spent with parents were explored. Furthermore, the possible mediating effect of increased use of DDs in the relationship between free time spent with parents and psychological difficulties was tested. Participants were 4412 Italian children and adolescents, divided into two groups: children aged 6-10 years (n = 2248) and adolescents aged 11-18 years (n = 2164). Data were collected in Italy during the national lockdown and questionnaires were completed online by parents, who reported on their children's habits. The daily use of DDs increased significantly during the lockdown compared to the previous period, in both children and adolescents. Additionally, psychological difficulties increased in both children and adolescents during the lockdown, with a more severe impairment for children. Increased use of DDs during the lockdown positively predicted psychological difficulties (children: beta = 0.18, p < 0.001; adolescents: beta = 0.13, p < 0.001), while free time spent with parents was protective (children: beta = -13, p < 0.001; adolescents: beta = -0.12, p < 0.001). For children (but not adolescents), increased use of DDs mediated the effects of free time spent with parents on psychological difficulties (children: beta = -0.01, 95% CI [-0.018, -0.002]; adolescents: beta = -0.003, 95% CI [-0.009, 0.003]). The findings provide new insights for education and research.

Sexting Behaviors Before and During COVID-19 in Italian and Colombian Young Adults.

Introduction: Recent research highlight increasing at-risk online sexual activities and behaviors during the COVID-19 pandemic among young adults. Specifically, sexting refers to exchanging sexually suggestive messages, photos, and videos through technological devices, and it can be placed on a continuum from safer to riskier behavior. This study aims to improve our knowledge about sexting behaviors in Italian and Colombian young adults before and during the COVID-19 pandemic. Methods: A survey online was filled in by all recruited participants through a snowball sampling procedure (from December 2019 to June 2021) both in Italy and Colombia, resulting in a total of 2931 participants (2051 from Italy and 880 from Colombia) aged 18 to 35 years old (Mage = 23.85; SDage = 3.63; 67.6% girls). Results: Italian youth were more engaged in risky sexting than Colombian participants, while Colombians indicated being more engaged in non-consensual sexting than Italians. Sexual minority people reported more sharing their own sexts, higher levels of sexting under pressure, and 3.2 times more risky sexting than exclusively heterosexual counterparts. During the pandemic period, participants sent their own sexts 1.5 times more and were less involved in non-consensual sexting than in the pre-pandemic era. Conclusions: The present research could help understand better the cultural dynamics underlying the differences in sexting behaviors, suggesting the relevance of investigating how sexting behaviors and online at-risk activities have changed since the pandemic started. Policy Implications: Results provide implications for educational and prevention programs to improve young people's awareness of sexting behaviors.

The Cerebellum Gets Social: Evidence from an Exploratory Study of Cerebellar, Neurodevelopmental, and Psychiatric Disorders.

Social prediction is a key feature of social cognition (SC), a function in which the modulating role of the cerebellum is recognized. Accordingly, cerebellar alterations are reported in cerebellar pathologies, neurodevelopmental disorders, and psychiatric conditions that show SC deficits. Nevertheless, to date, no study has directly compared populations representative of these three conditions with respect to SC and cerebellar alterations. Therefore, the present exploratory study aimed to compare the SC profiles of individuals with cerebellar neurodegenerative disorders (CB), autism (ASD), bipolar disorder type 2 (BD2), or healthy subjects (HS) using a battery of social tests requiring different degrees of prediction processing. The patterns of cerebellar gray matter (GM) alterations were compared among the groups using voxel-based morphometry. Compared to HS, the clinical groups showed common SC deficits in tasks involving a moderate to high level of prediction. The behavioral results of the clinical groups are consistent with the presence of overlapping GM reduction in cerebellar right Crus II, an area notably involved in complex social processing and prediction. Although exploratory and preliminary, these results deepen the cerebellar role in social prediction and highlight the transdiagnostic value of the cerebellum in social functioning and prediction in pathologies of different aetiologies, forecasting novel possibilities for shared interventions.

Relationship between Executive Functions, Social Cognition, and Attachment State of Mind in Adolescence: An Explorative Study.

BACKGROUND: The passage from pre-adolescence to adolescence is presented as a turning point for the achievement of those abilities in social understanding as they commonly appear in adulthood. Developmental perspectives point to the possible role of neuro-cognitive maturation and social experiences to facilitate this growth. This paper has the goal to goalsto propose a valid and reliable measure of the new quantitative and qualitative advancements in social understanding occurring in the adolescent passage; relying on this, the research has two main objectives (a) to establish the associations between the advancements in social understanding and the executive functions held responsible for the neuro-cognitive rearrangements of adolescence; (c) to evidence the significant associations between attachment models and the development of social understanding in this phase of life. METHODS: 100 subjects (50 boys and 50 girls, aged 11-15) were administered with AICA, SCORS, CNT, Stroop Color-Word Test, and WISC-III. RESULTS: Advancements in the complexity of self-other representations and mentalization of interpersonal exchanges significantly occurs in the passage from pre-adolescence to adolescence and seem to be promoted by increased performances in executive control and cognitive shifting. Dismissing state of mind with respect to attachment is associated with lower development of social understanding in adolescence. The neurocognitive reorganization that underlies the passage from pre-adolescence to adolescence seems to provide the scaffolding for more sophisticated interpretations of the social world. Past and current affective experience can boost or hinder the full deployment of such human maturational potential. Given the importance of social cognition for adjustment and psychopathology, clinical intervention should target the amelioration of individual and family abilities in social reasoning and mentalization.

The Psychological Impact of the COVID-19 Pandemic on Alcohol Abuse and Drunkorexia Behaviors in Young Adults.

The COVID-19 outbreak negatively affected young adults' psychological well-being, increasing their stress levels and symptoms of anxiety and depression, and potentially triggering health-risk behaviors. The present study was aimed at investigating the psychological impact of the COVID-19 pandemic on alcohol abuse and drunkorexia behaviors among young adults living in Italy. Participants were 370 emerging adults (63% women, 37% men; Mage = 21.00, SDage = 2.96, range: 18-30) who were recruited through an online survey between November 2021 and March 2022. Participants completed measures of alcohol abuse, drunkorexia behaviors, negative life experiences, and post-traumatic symptoms related to the COVID-19 outbreak. The results showed that the emotional impact and negative life experiences associated with the pandemic predicted both alcohol abuse and drunkorexia behaviors, albeit in different ways. Specifically, the number of negative life experiences during the pandemic and the tendency to avoid COVID-19-related negative thoughts positively predicted alcohol abuse; and the presence of intrusive thoughts associated with the pandemic significantly predicted the frequency of drunkorexia behaviors. Implications for research and clinical practice are discussed.