Child Maltreatment Fatality Review: Purposes, Processes, Outcomes, and Challenges.

Better understanding of the causes and circumstances of maltreatment deaths of children is needed to prevent tragedy. The purpose of this article is to facilitate understanding of child maltreatment fatality review processes and their outcomes. A literature review was conducted through searches of the databases PubMed, PsycINFO, and EMBASE and through citations in publications. Over 165 publications were reviewed and 55 were selected for inclusion. Papers were from the United States, England, Ireland, Northern Ireland, Netherlands, France, Canada, Australia, South Africa, Switzerland, Saudi Arabia, Japan, and China. These were included if they described fatality review goals, authority, procedures, and outcomes. Although we searched databases on a continual basis during the preparation of this review, we could have missed publications, particularly those in newspapers and journals that are not included in large-scale databases or cited in other articles. Improvement of fatality review requires diligence by individuals and organizations that provide information to the reviewers. Among challenges to the review process are varying criteria for review, misclassifications of the manner of death, inadequate or incomplete forensic and medical investigations, lack of information about the perpetrator, diversity of the community, concealment of the cause of death by parents or other caregivers, and disagreement among reviewers about the results of their inquiries. Institutional challenges are also present, which include the need for funding, privacy issues on obtaining information, updating reviewer training, lack of follow-up by institutional authorities on the recommendations of the reviews, and research facilitating the review of maltreatment fatalities.

Deployment Status and Child Neglect Types in the U.S. Army.

Increases in combat deployments have been associated with rises in rates of child neglect in U.S. military families. Although various types of child neglect have been described in military families, it is unknown whether deployment status is associated with specific types of child neglect and whether other factors, such as substance misuse, play a role. To determine the contribution of service member deployment status to the risk of specific child neglect types, data were collected from 390 substantiated U.S. Army child neglect case files. The contributions of deployment status at the time of the neglect incident and parental alcohol or drug-related misuse to risk of neglect types were examined controlling for military family rank and child age. Compared to never deployed families, families with a service member concurrently deployed at the time of the neglect incident were at higher risk for failure to provide physical needs, lack of supervision, and educational neglect, but at lower risk for emotional neglect. Being previously deployed incurred risk for moral-legal neglect. Substance misuse added risk for moral-legal and educational neglect. Findings indicate the need for tailored prevention strategies to target different periods within the deployment cycle.

Documented family violence and risk of suicide attempt among U.S. Army soldiers.

Suicide attempt (SA) rates in the U.S. Army increased substantially during the wars in Afghanistan and Iraq. This study examined associations of family violence (FV) history with SA risk among soldiers. Using administrative data from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS), we identified person-month records of active duty, Regular Army, enlisted soldiers with medically documented SAs from 2004 to 2009 (n = 9650) and a sample of control person-months (n = 153,528). Logistic regression analyses examined associations of FV with SA, adjusting for socio-demographics, service-related characteristics, and prior mental health diagnosis. Odds of SA were higher in soldiers with a FV history and increased as the number of FV events increased. Soldiers experiencing past-month FV were almost five times as likely to attempt suicide as those with no FV history. Odds of SA were elevated for both perpetrators and those who were exclusively victims. Male perpetrators had higher odds of SA than male victims, whereas female perpetrators and female victims did not differ in SA risk. A discrete-time hazard function indicated that SA risk was highest in the initial months following the first FV event. FV is an important consideration in understanding risk of SA among soldiers.

Risk of Suicide Attempt Among Soldiers in Army Units With a History of Suicide Attempts.

Importance: Mental health of soldiers is adversely affected by the death and injury of other unit members, but whether risk of suicide attempt is influenced by previous suicide attempts in a soldier's unit is unknown. Objective: To examine whether a soldier's risk of suicide attempt is influenced by previous suicide attempts in that soldier's unit. Design, Setting, and Participants: Using administrative data from the Army Study to Assess Risk and Resilience in Servicemembers (STARRS), this study identified person-month records for all active-duty, regular US Army, enlisted soldiers who attempted suicide from January 1, 2004, through December 31, 2009 (n = 9650), and an equal-probability sample of control person-months (n = 153 528). Data analysis was performed from August 8, 2016, to April 10, 2017. Main Outcomes and Measures: Logistic regression analyses examined the number of past-year suicide attempts in a soldier's unit as a predictor of subsequent suicide attempt, controlling for sociodemographic features, service-related characteristics, prior mental health diagnosis, and other unit variables, including suicide-, combat-, and unintentional injury-related unit deaths. The study also examined whether the influence of previous unit suicide attempts varied by military occupational specialty (MOS) and unit size. Results: Of the final analytic sample of 9512 enlisted soldiers who attempted suicide and 151 526 control person-months, most were male (86.4%), 29 years or younger (68.4%), younger than 21 years when entering the army (62.2%), white (59.8%), high school educated (76.6%), and currently married (54.8%). In adjusted models, soldiers were more likely to attempt suicide if 1 or more suicide attempts occurred in their unit during the past year (odds ratios [ORs], 1.4-2.3; P < .001), with odds increasing as the number of unit attempts increased. The odds of suicide attempt among soldiers in a unit with 5 or more past-year attempts was more than twice that of soldiers in a unit with no previous attempts (OR, 2.3; 95% CI, 2.1-2.6). The association of previous unit suicide attempts with subsequent risk was significant whether soldiers had a combat arms MOS or other MOS (ORs, 1.4-2.3; P < .001) and regardless of unit size, with the highest risk among those in smaller units (1-40 soldiers) (ORs, 2.1-5.9; P < .001). The population-attributable risk proportion for 1 or more unit suicide attempts in the past year indicated that, if this risk could be reduced to no unit attempts, 18.2% of attempts would not occur. Conclusions and Relevance: Risk of suicide attempt among soldiers increased as the number of past-year suicide attempts within their unit increased for combat arms and other MOSs and for units of any size but particularly for smaller units. Units with a history of suicide attempts may be important targets for preventive interventions.

Suicide attempts in U.S. Army combat arms, special forces and combat medics.

BACKGROUND: The U.S. Army suicide attempt rate increased sharply during the wars in Iraq and Afghanistan. Risk may vary according to occupation, which significantly influences the stressors that soldiers experience. METHODS: Using administrative data from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS), we identified person-month records for all active duty Regular Army enlisted soldiers who had a medically documented suicide attempt from 2004 through 2009 (n = 9650) and an equal-probability sample of control person-months (n = 153,528). Logistic regression analyses examined the association of combat occupation (combat arms [CA], special forces [SF], combat medic [CM]) with suicide attempt, adjusting for socio-demographics, service-related characteristics, and prior mental health diagnosis. RESULTS: In adjusted models, the odds of attempting suicide were higher in CA (OR = 1.2 [95% CI: 1.1-1.2]) and CM (OR = 1.4 [95% CI: 1.3-1.5]), but lower in SF (OR = 0.3 [95% CI: 0.2-0.5]) compared to all other occupations. CA and CM had higher odds of suicide attempt than other occupations if never deployed (ORs = 1.1-1.5) or previously deployed (ORs = 1.2-1.3), but not when currently deployed. Occupation was associated with suicide attempt in the first ten years of service, but not beyond. In the first year of service, primarily a time of training, CM had higher odds of suicide attempt than both CA (OR = 1.4 [95% CI: 1.2-1.6]) and other occupations (OR = 1.5 [95% CI: 1.3-1.7]). Discrete-time hazard functions revealed that these occupations had distinct patterns of monthly risk during the first year of service. CONCLUSIONS: Military occupation can inform the understanding suicide attempt risk among soldiers.

Characteristics, Classification, and Prevention of Child Maltreatment Fatalities.

BACKGROUND: Preventing child maltreatment fatalities is a critical goal of the U.S. society and the military services. Fatality review boards further this goal through the analysis of circumstances of child deaths, making recommendations for improvements in practices and policies, and promoting increased cooperation among the many systems that serve families. The purpose of this article is to review types of child maltreatment death, proposed classification models, risk and protective factors, and prevention strategies. METHODS: This review is based on scientific and medical literature, national reports and surveys, and reports of fatality review boards. FINDINGS: Children can be killed soon after birth or when older through a variety of circumstances, such as with the suicide of the perpetrator, or when the perpetrator kills the entire family. Death through child neglect may be the most difficult type of maltreatment death to identify as neglect can be a matter of opinion or societal convention. These deaths can occur as a result of infant abandonment, starvation, medical neglect, drowning, home fires, being left alone in cars, and firearms. Models of classification for child maltreatment deaths can permit definition and understanding of child fatalities by providing reference points that facilitate research and enhance clinical prediction. Two separate approaches have been proposed: the motives of the perpetrator and the circumstances of death of the child victim. The latter approach is broader and is founded on an ecological model focused on the nature and circumstances of death, child victim characteristics, perpetrator characteristics, family and environmental circumstances, and service provision and need. Many risk factors for maternal and paternal filicide have been found, but most often included are young maternal age, no prenatal care, low education level, mental health problems, family violence, and substance abuse. Many protective factors can be specified at the individual, family, and community level. Early interventions for children and families are facilitated by the increased awareness of service providers who understand the risk and protective factors for intentional and unintentional child death. DISCUSSION/IMPACT/RECOMMENDATIONS: There is currently no roadmap for the prevention of child maltreatment death, but increased awareness and improved fatality review are essential to improving policies and practices. Prevention strategies include improving fatality review recommendations, using psychological autopsies, serious case reviews, and conducting research. We recommend a public health approach to prevention, which includes a high level of collaboration between agencies, particularly between the military and civilian. The adoption of a public health model can promote better prevention strategies at individual, family, community, and societal levels to address and improve practices, policies, and public attitudes and beliefs about child maltreatment. The process of making recommendations on the basis of fatality review is important in terms of whether they will be taken seriously. Recommendations that are too numerous, impractical, expensive, lack relevance, and are out of step with social norms are unlikely to be implemented. They can be helpful if they are limited, focused, lead to definitive action, and include ways of measuring compliance.

An Examination of Potential Misclassification of Army Suicides: Results from the Army Study to Assess Risk and Resilience in Servicemembers.

Debate continues about the accuracy of military suicide reporting due to concerns that some suicides may be classified as accidents to minimize stigma and ensure survivor benefits. We systematically reviewed records for 998 active duty Army deaths (510 suicides; 488 accident, homicide, and undetermined deaths; 2005-2009) and, using research criteria, reclassified 8.2% of the nonsuicide cases to definite suicide (1), suicide probable (4), or suicide possible (35). The reclassification rate to definite suicide was only 0.2% (1/488). This low rate suggests that flagrant misclassification of Army deaths is uncommon and surveillance reports likely reflect the "true" population of Army suicides.

Medically Documented Suicide Ideation Among U.S. Army Soldiers.

We used administrative data to examine predictors of medically documented suicide ideation (SI) among Regular Army soldiers from 2006 through 2009 (N = 10,466 ideators, 124,959 control person-months). Enlisted ideators (97.8% of all cases) were more likely than controls to be female, younger, older when entering service, less educated, never or previously deployed, and have a recent mental health diagnosis. Officer ideators were more likely than controls to be female, younger, younger when entering service, never married, and have a recent mental health diagnosis. Risk among enlisted soldiers peaked in the second month of service and declined steadily, whereas risk among officers remained relatively stable over time. Risk of SI is highest among enlisted soldiers early in Army service, females, and those with a recent mental health diagnosis.

Early Intervention for Post-Traumatic Stress Disorder, Depression, and Quality of Life in Mortuary Affairs Soldiers Postdeployment.

U.S. Army mortuary affairs (MA) soldiers experience stressors of deployment and exposure to the dead, increasing risk for post-traumatic stress and depression. This study examines Troop Education for Army Morale, a postdeployment early intervention based on Psychological First Aid. MA soldiers (N = 126) were randomized to intervention or comparison groups 1-month postdeployment. Intervention sessions were held at 2, 3, 4, and 7 months. Assessments of post-traumatic stress disorder (PTSD), depression, and quality of life (QOL) were conducted at 1, 2, 3, 4, 7, and 10 months for both groups. At baseline, 25.0% of the total sample had probable PTSD (17-item PTSD Checklist M = 35.4, SD = 16.9) and 23.6% had probable depression (9-item Patient Health Questionnaire Depression Scale M = 7.8, SD = 6.9). Over 10 months, PTSD and depression symptoms decreased and QOL improved for the total sample. At study conclusion, intervention and comparison groups were not different. Intervention group males showed a transient symptom increase at 2 to 3 months. Males attended fewer intervention sessions than females. Lower attendance was associated with more symptoms and lower QOL. Higher attendance was associated with greater intervention benefits. Findings highlight the need for better understanding postdeployment interventions and facilitating attendance. Further intervention for MA soldiers is indicated.

Risk Factors, Methods, and Timing of Suicide Attempts Among US Army Soldiers.

IMPORTANCE: Suicide attempts in the US Army have risen in the past decade. Understanding the association between suicide attempts and deployment, as well as method and timing of suicide attempts, can assist in developing interventions. OBJECTIVE: To examine suicide attempt risk factors, methods, and timing among soldiers currently deployed, previously deployed, and never deployed at the time this study was conducted. DESIGN, SETTING, AND PARTICIPANTS: This longitudinal, retrospective cohort study of Regular Army-enlisted soldiers on active duty from 2004 through 2009 used individual-level person-month records to examine risk factors (sociodemographic, service related, and mental health), method, and time of suicide attempt by deployment status (never, currently, and previously deployed). Administrative data for the month before each of 9650 incident suicide attempts and an equal-probability sample of 153 528 control person-months for other soldiers were analyzed using a discrete-time survival framework. MAIN OUTCOMES AND MEASURES: Suicide attempts and career, mental health, and demographic predictors were obtained from administrative and medical records. RESULTS: Of the 9650 enlisted soldiers who attempted suicide, 86.3% were male, 68.4% were younger than 30 years, 59.8% were non-Hispanic white, 76.5% were high school educated, and 54.7% were currently married. The 40.4% of enlisted soldiers who had never been deployed (n = 12 421 294 person-months) accounted for 61.1% of enlisted soldiers who attempted suicide (n = 5894 cases). Risk among those never deployed was highest in the second month of service (103 per 100 000 person-months). Risk among soldiers on their first deployment was highest in the sixth month of deployment (25 per 100 000 person-months). For those previously deployed, risk was highest at 5 months after return (40 per 100 000 person-months). Currently and previously deployed soldiers were more likely to attempt suicide with a firearm than those never deployed (currently deployed: OR, 4.0; 95% CI, 2.9-5.6; previously deployed: OR, 2.7; 95% CI, 1.8-3.9). Across deployment status, suicide attempts were more likely among soldiers who were women (currently deployed: OR, 3.4; 95% CI, 3.0-4.0; previously deployed: OR, 1.5; 95% CI, 1.4-1.7; and never deployed: OR, 2.4; 95% CI, 2.3-2.6), in their first 2 years of service (currently deployed: OR, 1.9; 95% CI, 1.5-2.3; previously deployed: OR, 2.2; 95% CI, 1.9-2.7; and never deployed: OR, 3.1; 95% CI, 2.7-3.6), and had a recently received a mental health diagnosis in the previous month (currently deployed: OR, 29.8; 95% CI, 25.0-35.5; previously deployed: OR, 22.2; 95% CI, 20.1-24.4; and never deployed: OR, 15.0; 95% CI, 14.2-16.0). Among soldiers with 1 previous deployment, odds of a suicide attempt were higher for those who screened positive for depression or posttraumatic stress disorder after return from deployment and particularly at follow-up screening, about 4 to 6 months after deployment (depression: OR, 1.4; 95% CI, 1.1-1.9; posttraumatic stress disorder: OR, 2.4; 95% CI, 2.1-2.8). CONCLUSIONS AND RELEVANCE: Identifying the timing and risk factors for suicide attempt in soldiers requires consideration of environmental context, individual characteristics, and mental health. These factors can inform prevention efforts.

Types, Subtypes, and Severity of Substantiated Child Neglect in U.S. Army Communities.

BACKGROUND: Neglect has been linked to short-term and long-term deleterious outcomes in children, but has received little attention in the research literature. OBJECTIVE: Identify types, subtypes, and severity of child neglect in a sample of substantiated cases at 4 U.S. Army installations. Describe demographic correlates of victims and offenders by type and subtype. PARTICIPANTS: Data were collected from archived clinical records. A stratified random sample of 100 substantiated child neglect case files were selected per site (N = 400). Data from a single child per case file were used. RESULTS: 5 types and 17 subtypes of neglect were represented, singly or in combination, with varying severity. Lack of Supervision was most common (n = 177, 35.3%), followed by Emotional Neglect (n = 159, 31.8%), Failure to Provide Physical Needs (n = 131, 26.2%), Moral-Legal Neglect (n = 20, 4%), and Educational Neglect (n = 13; 2.6%). Child neglect occurred mostly among young children and in young enlisted families. CONCLUSIONS: Current results highlight the need to focus on types, subtypes, and severity of neglect incidents that provide specific understanding of child risk to better inform policy. Further study should examine specific risk factors and their relationship to neglect types and severity outcomes.

MILITARY FAMILIES: MEASUREMENT OF COMMUNITY RESOURCE ADEQUACY.

Understanding features of community strength both on and off the military installation will help identify and address the needs of military families. This study introduced a measure to identify adequacy of community resources for military families. Using confirmatory factor analysis with data from 717 service users (M age = 37.3 yr., SD = 10.6) representing four large U.S. Army installations, two domains of community resource adequacy were identified: resources on the installation and resources off the installation. This measure could be used in health research with military families and in improving resources available to this population.

Stress and resilience in military mortuary workers: care of the dead from battlefield to home.

The death of a military service member in war provokes feelings of distress and pride in mortuary workers who process the remains. To further understand their reactions, the authors interviewed 34 military and civilian personnel to learn more about their work stresses and rewards. They review stresses of anticipation, exposure, and experience in handling the dead and explore the personal, supervisory, and leadership strategies to reduce negative effects and promote personal growth. These results can be applied to many other situations requiring planning, implementing, and supervising mortuary operations involving mass death.

Suicide among soldiers: a review of psychosocial risk and protective factors.

Suicide is difficult to predict and prevent and remains a leading cause of death worldwide. Although soldiers historically have had a suicide rate well below that of the general population, the suicide rate among members of the U.S. Army has increased markedly over the past several years and now exceeds that of the general population. This paper reviews psychosocial factors known to be associated with the increased risk of suicidal behavior in general and describes how some of these factors may be especially important in understanding suicide among soldiers. Moving forward, the prevention of suicide requires additional research aimed at: (a) better describing when, where, and among whom suicidal behavior occurs, (b) using exploratory studies to discover new risk and protective factors, (c) developing new methods of predicting suicidal behavior that synthesize information about modifiable risk and protective factors from multiple domains, and (d) understanding the mechanisms and pathways through which suicidal behavior develops. Although the scope and severity of this problem is daunting, the increasing attention and dedication to this issue by the Armed Forces, scientists, and society provide hope for our ability to better predict and prevent these tragic outcomes in the future.

Child neglect in Army families: a public health perspective.

Military families include 2.9 million people, with approximately 40% of all service members having at least one child. Rates of child neglect in this population have increased in recent years, but little is known about the characteristics of the neglect. To better identify targets for intervention, it is necessary that we refine our understanding of child neglect in the military. In this review, we examine definitions of child neglect and the specific definitions used by the U.S. Army. We identify domains of neglect and caregiver behaviors and affiliated. We suggest that this approach can inform prevention efforts within the Institute of Medicine's framework for preventive interventions. Understanding risk and protective factors in the military family are important to interventions for child neglect in military families.

Deployment and the probability of spousal aggression by U.S. Army soldiers.

OBJECTIVE: To determine the relationship between length of soldier deployment and self-reports of moderate and severe spousal violence. METHODS: The Conflict Tactics Scale was used to measure self-reports of behaviors exhibited in marital conflict. Surveys were administered to a 15% random sample of 26,835 deployed and nondeployed married active duty U.S. Army men and women in the 50 United States during the period 1990 to 1994. Multinomial logistic regression and ordered probit analysis were used to estimate the probabilities of moderate and severe violence by length of deployment. RESULTS: After controlling for demographic variables, the probability of severe aggression was significantly greater for soldiers who had deployed in the past year compared with soldiers who had not deployed. CONCLUSIONS: Deployment contributes a significant but small increase to the probability of self-reported spousal aggression during a 1-year period. Although deployment is a military operation, similar effects may be observed in certain civilian occupations.

Alcohol use in nonmutual and mutual domestic violence in the U.S. Army: 1998-2004.

The association between alcohol use and substantiated incidents of nonmutual and mutual domestic violence between U.S. Army enlisted soldiers and their spouses was examined for the period 1998-2004. Maltreatment was always more severe in nonmutual incidents. Female victims experienced more severe maltreatment than males. Male offenders and victims were more likely to be drinking than females. For victims of both sexes, severity was greater when offenders were drinking. Older males were more likely to be offenders in nonmutual incidents. White males were more likely than Black or Hispanic males to be offenders in nonmutual incidents. There is a need for both domestic violence and alcohol treatment programs to focus on the increased risk of abuse when alcohol is involved.

Establishing and maintaining a volunteer victim advocate program to assist victims of domestic violence in the U.S. Army.

A descriptive evaluation of a volunteer victim advocacy (VA) program was conducted to assist domestic violence victims on the scene of a domestic violence incident on a 24-hour per day basis at a U.S. Army installation. A total of 87 volunteers contributed data to this evaluation. The VAs conducted on-the-spot client safety planning using risk factor assessment. Additional information was given to the client about post programs and services. VAs were evaluated and monitored through initial, periodic, and exit interviews. They were asked about their training needs, the most difficult situations they confronted, what they did best, and whether the VA program met their personal needs. While the Army supports victim advocacy by regulation, it often does not provide sufficient funds to support the hiring of the necessary staff. Hence, a volunteer program may be the only feasible approach to provide advocacy assistance for abused spouses in the Army above a minimum level. Drawing on the services of trained volunteers allowed the Family Advocacy Program at this installation to accomplish its mandated mission. Suggestions for further research in VA programs are presented.

Characteristics of domestic violence incidents reported at the scene by volunteer victim advocates.

At a single U.S. Army installation from 1997 to 2005, domestic violence volunteer victim advocates assisted 1,417 clients in 1,380 physical and 301 verbal abuse incidents. The average soldier and spouse population during this time was slightly less than 10,000. Advocates went to the scene of the incident to talk to the victim to ensure that her/his rights were observed, to determine whether the victim was safe, was referred to the hospital social work service for assessment, and had the information necessary to negotiate the complex military and community systems. The advocate inquired of the victim the characteristics of the incident and risk factors in the history of the relationship. In many incidents, risk factors indicated a history of serious violence by the offender including an increasing level of violence, stalking, and assaults. Frequently reported precipitants of incidents were relationship problems, jealously, and infidelity. Spouses often reported previous attempts to leave and to get help. Advocates play an important role in gathering information uniquely available at the scene that can be useful in planning education and intervention programs to reduce domestic violence in the Army, the military services, and civilian society.

Spouse abuse and alcohol problems among white, African American, and Hispanic U.S. Army soldiers.

BACKGROUND: Prior studies suggest racial/ethnic differences in the associations between alcohol misuse and spouse abuse. Some studies indicate that drinking patterns are a stronger predictor of spouse abuse for African Americans but not whites or Hispanics, while others report that drinking patterns are a stronger predictor for whites than African Americans or Hispanics. This study extends prior work by exploring associations between heavy drinking, alcohol-related problems, and risk for spouse abuse within racial/ethnic groups as well as variations associated with whether the perpetrator is drinking during the spouse abuse incident. METHODS: Cases (N=7,996) were all active-duty male, enlisted Army spouse abusers identified in the Army's Central Registry (ACR) who had also completed an Army Health Risk Appraisal (HRA) Survey between 1991 and 1998. Controls (N=17,821) were matched on gender, rank, and marital and HRA status. RESULTS: We found 3 different patterns of association between alcohol use and domestic violence depending upon both the race/ethnicity of the perpetrator and whether or not alcohol was involved in the spouse abuse event. First, after adjusting for demographic and psychosocial factors, weekly heavy drinking (>14 drinks per week) and alcohol-related problems (yes to 2 or more of 6 alcohol-related problem questions, including the CAGE) were significant predictors of domestic violence among whites and Hispanics only. Also for the white soldiers, the presence of family problems mediated the effect of alcohol-related problems on spouse abuse. Second, alcohol-related problems predicted drinking during a spouse abuse incident for all 3 race groups, but this relation was moderated by typical alcohol consumption patterns in Hispanics and whites only. Finally, alcohol-related problems predicted drinking during a spouse abuse incident, but this was a complex association moderated by different psychosocial or behavioral variables within each race/ethnic group. CONCLUSION: These findings suggest important cultural/social influences that interact with drinking patterns.