The impact of emotion regulation on the establishment of the therapeutic alliance in post-divorce group intervention: A multilevel approach.

OBJECTIVE: The present study focuses on the impact of emotion regulation on the establishment of the therapeutic alliance in a context of post-divorce group intervention. METHOD: The study involved 177 divorced parents and 60 therapists and was developed through multilevel path analysis. RESULTS: The data showed an association between emotion regulation and therapeutic alliance across the difficulties of adaptation to divorce, although the results were different from the perspective of the participant and of the therapist and between the individual and the group level. CONCLUSION: The study highlights the relevant role of emotion regulation in post-divorce adaptation and in the success of the establishment of the therapeutic alliance, while clarifying the formation of the alliance from the viewpoints of the individual and the therapist. The study also highlights the need to understand the alliance at both the individual and the group level, in order to design therapeutic interventions.

Association of Parental Divorce With Oral Health in U.S. Children and Adolescents.

Purpose: To examine the association between parental divorce or separation (PDS) and oral health outcomes in children and adolescents in the United States (U.S.), and learn whether the association was mediated by a lack of needed dental care in the past 12 months. Methods: Data obtained from a sample of individuals who participated in the 2020 to 2021 National Survey of Children's Health (NSCH), representing 65,790,496 U.S. children and adolescents, were analyzed. A child's exposure to PDS was the independent variable. The outcome of interest was pediatric oral health, measured through parental responses to survey questionnaires indicating whether their child had dental caries, toothaches, and/or bleeding gums within the past 12 months. Analyses included descriptive statistics, bivariate analyses, logistic regression, and casual mediation analysis. Results: After controlling for demographic factors and insurance coverage, children who experienced PDS, had 30 percent higher odds of suffering from oral health problems versus those who did not (odds ratio equals 1.29; 95 percent confidence interval equals 1.16 to 1.45). The association appeared to be partially mediated by failure to receive needed dental care. Conclusions: Parental divorce or separation is associated with the oral health of children and adolescents in the United States. Findings from this population-based study highlight the potential impact of PDS on children's oral health.

Investigating the relationship between internet addiction, domestic violence, and emotional divorce among married women in Tehran.

BACKGROUND: Identifying the factors affecting emotional divorce due to the negative consequences of this social problem in women can play an important role in preventing its occurrence. Therefore, the present study aimed to investigate the relationship between internet addiction, domestic violence, and emotional divorce among married women in Tehran. METHODS: A cross-sectional survey was conducted among married women in Tehran, Iran. Sampling was conducted first through a multi-stage cluster method and then continued using a random method. Tehran was divided into five parts: central, northern, southern, eastern, and western. The sample size was divided by 5, resulting in 80 participants selected from each part. In each part, two regions were selected, and in each region, 40 houses were randomly selected. Researchers visited the selected houses, and the questionnaires were filled out at home by the women. Tools such as Gottman's Emotional Divorce Test, Young's Internet Addiction Test, and the Domestic Violence against Women Survey were used to collect data. Descriptive and inferential statistics were used to analyze the data in SPSS (version 24) software. RESULTS: A total of 400 women participated in the study. 46% of all married women suffered emotional divorce. The analysis of these tests showed that are positive and significant relationships between emotional divorce and internet addiction (r = 0.626, p < 0.0001), emotional divorce and domestic violence (r = 0.632, p < 0.0001), and internet addiction and domestic violence (r = 0.455, p < 0.0001). It was also found that there are significant negative relationships between emotional divorce and both the level of education (r=-0.115, p = 0.021) and employment status (r=-0.512, p < 0.0001). Additionally, there are significant negative relationships between internet addiction and age (r=-0.285, p < 0.0001), duration of marriage (r=-0.237, p < 0.0001) and employment status (r=-0.694, p < 0.0001). Furthermore, it was revealed that there are significant negative relationship between domestic violence and age (r=-0.104, p = 0.037) and level of education (r=-0.156, p = 0.002). CONCLUSION: Almost half of the married women in this study experienced emotional divorce, internet addiction, and domestic violence. These factors have a direct relationship with emotional divorce. Future studies are needed to understand how internet addiction might be associated with separation, emotional divorce and family problems.

Association Between Adverse Childhood Experiences and Cognitive Decline: Findings From the Behavioral Risk Factor Surveillance System, 2015-2016.

ABSTRACT: We aim to study Adverse childhood experiences' (ACEs') association with cognitive decline during adulthood. We reviewed data on subjective cognitive decline (SCD) for those ≥45 years of age. Logistic regression analysis, odds ratio, and 95% confidence interval (CI) assessed the association between ACEs and SCD. We analyzed an adult survey (N = 3900, mean age: 60.9 years, male: 46%). The most common ACE reported was household substance abuse (22.4%), followed by parental divorce/separation (20.9%). The prevalence of SCD in those having at least one ACE was higher than those without any (16.5% vs. 8.1%, p < 0.001). SCD positively correlated with the number of ACEs (p < 0.001). The odds of SCD increase in proportion to the increase in the number of ACEs experienced. These findings should be replicated in a larger population while controlling for confounding factors.

Physical and Psychological Symptomatology, Co-Parenting, and Emotion Socialization in High-Conflict Divorces: A Profile Analysis.

Although the consequences of divorce and conflict have been extensively studied, most research has focused on children rather than ex-spouses, although variables such as parental health or co-parenting may have an influence on children's development through processes such as emotion socialization. In addition, the relationship between these variables has never been considered in high-conflict divorces. Therefore, the present study aimed to analyze the impact of physical and psychological symptomatology and co-parenting on the emotion socialization patterns of parents experiencing high-conflict divorces. Furthermore, the moderating role of resilience was considered, as it has been highly studied as a coping mechanism in adverse situations but barely in divorce at the parental level. For this purpose, a Latent Profile Analysis was carried out with Mplus 8.10, using a sample of 239 parents from Family Visitation Centers. Results revealed, on the one hand, that parents with fewer physical and psychological symptoms sowed more emotion socialization behaviors than those with more symptomatology. On the other hand, in situations of high interparental conflict, the role of co-parenting and resilience seems less relevant than that of physical and psychological symptomatology when analyzing parental skills like emotion socialization.

Intergenerational Transmission of Divorce in Sweden, 1920-2015.

Many studies demonstrate an intergenerational transmission of divorce with a focus primarily on more recent decades; however, the extent to which this relationship is deeply rooted or has changed over time remains unclear. Explanations, including sociodemographic and interpersonal factors, have been offered as links between parental divorce and the stability of offspring's marriage. We use individual-level longitudinal data from the Scanian Economic-Demographic Database to estimate the intergenerational transmission of divorce among first marriages in Sweden over the period 1920-2015. Our investigation focuses on the correlation between parental divorce and offspring's divorce during the transition from a low- to a high-divorce regime. Findings reveal surprising stability in the transmission despite fundamental societal change over the years. Notably, the risk of divorce is highest when either the wife or both spouses have experienced parental divorce. Moreover, the transmission of divorce across time appears to be stronger and more stable for women than for men. These results suggest the intergenerational transmission of divorce is part of the divorce transition and highlight the role of women's independence in this intricate but not yet fully understood process.

It got me thinking: The impact of participating in a divorce decision-making interview.

Although there is literature documenting the reasons for and outcomes of divorce, there is limited research about the divorce decision-making process. Researchers with the National Divorce Decision-Making Project interviewed (n = 30) people in the process of making a divorce decision. One year later they conducted a second interview (n = 22) with the same sample to track any changes in participants' divorce ideation. The current study reports on the results of a thematic analysis of participants' responses to the final question, "How did the initial interview impact your thinking about the future of your marriage?" Three salient themes emerged from the data: (1) talking got me thinking, (2) thinking got me acting, and (3) the conversation was (surprisingly) therapeutic. The authors highlight possible clinical implications and directions for future research.

Associations Between Divorce Histories and Unhealthy Alcohol Use Among Middle Aged and Older Adults.

Background: Unhealthy alcohol use has been considered a coping strategy related to stressful and traumatic life events such as relationship loss. Yet, the effects of marital status on health behaviors are generally studied cross-sectionally or over one transition. We explored associations between the frequency and quantity of alcohol use with the number of episodes and duration of separation/divorce events across adulthood among English adults in mid to later life. Methods: This study used life history data from wave 3 (2006/07) of the English Longitudinal Study of Aging to compute marital sequences based on marital status at each year of age from 18 years of 6,355 adults aged 50-80 years. These sequences were used to compute the portion of adulthood spent separated/divorced and the number of episodes of divorce. These variables were used as predictors in logistic regressions predicting unhealthy alcohol use, while also controlling for current marital status. Results: We found that the number of episodes of separation/divorce increased the odds of drinking ≥5 days/week and binge drinking (≥6 drinks/occasion for women; ≥8 drinks/occasion for men), whereas the portion of adulthood spent divorced was not associated with drinking frequency or binge drinking. Some nuances by gender were also noted. Conclusions: Recurrent transitions into separation/divorce over adulthood appears to increase risk of unhealthy alcohol use in mid to later life beyond the risks associated with current marital status.

Cohort profile: the Dynamics of Family Conflict (FamC) study in Norway.

PURPOSE: The Dynamics of Family Conflict (FamC) prospective cohort study was set up to investigate how and why interparental conflicts and family relations develop over time, and in which contexts which types of conflicts and relations are most negative for which children. FamC focuses on the family within a scope spanning macrolevel as well as microlevel processes. PARTICIPANTS: Families were recruited from MoBa (pilot project) and family counselling offices across Norway when parents attended parental counselling, therapy or mandatory mediation in relation to parental relationship dissolution. All families were thus experiencing challenges and/or going through a family transition. Families were eligible for the study if parents had at least one joint child between 0 and 16 years. Both parents and up to five children from the same family could participate. A total of 2871 families were recruited (participation rate wave 1: 78%) and an estimated 55% of parents (based on wave 1 data) were divorced/separated. Additional data were obtained from therapists/mediators at the family counselling offices about the family, and childcare or schoolteachers provided data on the youngest (0-6 years) children. FINDINGS TO DATE: Results show that interparental conflict patterns vary with family constellation. Interparental conflict severity is inversely related to the discrepancy between child-reported and parent-reported child reactions to interparental conflicts, and child-self-reported reactions are higher relative to parent-reported child reactions. Other findings show that family characteristics (eg, the number and age of children in the family and financial difficulties) are predictive of the type of residence arrangement that parents practice. FUTURE PLANS: The cohort is ideally suited for cross-cultural comparisons and further examination of family processes and dynamics including parent repartnering, step-parents and new family members, associations between different family constellations and child adjustment, and fathering, father-child relationship and child adjustment. There are plans for further follow-up data collection.

Associations of parental divorce with student mental health and academic outcomes: A quantitative study in rural China.

BACKGROUND: This paper examines the prevalence, correlates, and developmental consequences of divorce among junior high school students in rural China. Specifically, we investigate the connections between parental divorce and student mental health and academic performance, while also examining whether a student's living arrangement after divorce influences these outcomes. METHODS: Data were collected from 17,955 students across 122 rural junior high schools in China on their mental health, characteristics, and academic performance. Mental health was measured using the self-reported Strengths and Difficulties Questionnaire. RESULTS: About 8.35 % of the students had divorced parents, with increased risk observed for students who were only children, had migrant mothers, or had higher educated mothers (ORs = 4.35, 29.94, and 1.78, respectively; Bonferroni-adjusted p < 0.05). Students with divorced parents exhibited a higher likelihood of internalizing (0.032), externalizing (0.052) abnormality (Bonferroni-adjusted p < 0.001) and scored 0.203 SD lower on the math test (Bonferroni-adjusted p < 0.001). Living arrangements post-divorce, either with a mother or a father, equally negatively impacted student mental health and academic performance, with a mitigating effect observed when grandparental childcare was provided. LIMITATIONS: Our study faced limitations in assessing the influence of grandparental childcare on coping with parental divorce due to challenges in gauging the extent of such support for students residing with a parent after divorce. This study did not empirically find differences by ethnicity; further in-depth case study is needed to better illuminate the findings. CONCLUSIONS: Parental divorce among young students in rural China is associated with adverse developmental outcomes. These findings underscore the importance of implementing targeted programs in rural China to mitigate these risks and provide support for young students with divorced parents.

The impact of a breast cancer diagnosis on marital outcomes and factors associated with divorce and separation.

Objective: To analyze marital outcomes, divorce or separation, and its association with demographic, socioeconomic, and clinicopathological factors among breast cancer (BC) survivors after 2-years of diagnosis. Methods: We performed a retrospective analysis of marital status at baseline and at years 1 and 2 of follow-up of women aged ≥ 18 years diagnosed with invasive BC participating in the AMAZONA III (GBECAM0115) study. The BC diagnosis occurred between January 2016 and March 2018 at 23 institutions in Brazil. Results: Of the 2974 women enrolled in AMAZONA III, 599 were married or living under common law at baseline. Divorce or separation occurred in 35 (5.8%) patients at 2 years of follow-up. In the multivariate analysis, public health insurance coverage was associated with a higher risk of marital status change (8.25% vs. 2.79%, RR 3.09, 95% CI 1.39 - 7.03, p = 0.007). Women who underwent mastectomy, adenomastectomy or skin-sparing mastectomy were associated with a higher risk of divorce or separation (8.1% vs. 4.49%, RR 1.97, 95 CI 1.04 - 3.72, p = 0.0366) than those who underwent breast-conserving surgery. Conclusion: Women covered by the public health system and those who underwent mastectomy, adenomastectomy or skin-sparing mastectomy were associated with a higher risk of divorce or separation. This evidence further supports the idea that long-term marital stability is associated with a complex interplay between socioeconomic conditions and stressors, such as BC diagnosis and treatment. ClinicalTrials Registration: NCT02663973.

Who Divorces Whom: Unilateral Divorce Legislation and the Educational Structure of Marriage.

The introduction of unilateral divorce legislation (UDL) starting in the late 1960s led to spikes in U.S. divorce rates. We ask whether making divorce easier affected the educational structure of marriage. Using marriage and divorce certificate data covering 1970-1988, we provide new evidence on the evolution of the educational structure of marriage inflows (newlyweds) and outflows (divorces). Next, we leverage the timing of UDL introduction across states to estimate its effects on both flows. We find that UDL affected the educational structure of divorce but not of new marriages: it made generally unstable hypogamous couples (women married to less educated partners) less likely to divorce and made homogamous couples more stable than hypergamous ones (women married to more educated partners).

Traumatic brain injury and long-term associations with work, divorce and academic achievement.

OBJECTIVE: Traumatic brain injuries (TBI), irrespective of severity, may have long-term social implications. This study explores the relationships between TBI severity and outcomes related to work stability, divorce, and academic achievement. METHODS: Using a Danish nationwide sample of persons with and without TBI, we employed case-control and longitudinal cohort designs. The case-control design utilized individuals aged 18 to 60 years and examined work stability. Each case, employed at time of TBI, was compared with 10 matched controls. The cohort design utilized individuals alive from 1980 to 2016 with and without TBI and assessed the likelihood of 1) divorce and 2) higher-level education. TBI exposures included concussion, skull fractures, or confirmed TBI. RESULTS: TBI cases exhibited higher odds ratios (OR) for work instability at all follow-ups compared to controls. Increased TBI severity was associated with a higher risk of work instability at 2-year follow-up (concussion: OR = 1.83; skull fracture: OR = 2.22; confirmed TBI: OR = 4.55), and with a higher risk of not working at 10-year follow-up (confirmed TBI: OR = 2.82; concussion: OR = 1.63). The divorce incidence rate ratio (IRR) was elevated in individuals with TBI (males: IRR = 1.52; females: IRR = 1.48) compared to those without TBI. Individuals with childhood TBI had reduced chances of attaining high school degree or higher (males: IRR = 0.79; females: IRR = 0.85) compared to those without TBI. CONCLUSION: TBI is associated with an increased long-term risk of social consequences, including work instability, divorce, and diminished chances of higher education, even in cases with concussion.

Transfer behaviors in stroke and dementia development associated with environmental risks.

AIM: Chronic diseases are influential components of stroke, one of the dominant reasons for dementia and premature mortality. Environmental risks are risk factors for transitioning from stroke to dementia. This study addresses the transition behaviors in stroke and dementia development associated with chronic diseases and environmental risks. METHODS: This study is an integrated survey of medical and environmental informatics concerning stroke patients' quality of life. A total of 10 627 stroke patients diagnosed in Taiwan were surveyed in this study. A covariate model and subgroup analysis were used to evaluate the influence of chronic diseases and environmental risk factors (i.e., divorce rate, unemployment rate, solitariness rate, temperature, and air pollution rate) on stroke and the corresponding dementia transition behaviors. RESULTS: This study constructed a total of 98 covariate analysis models, consisting of 14 transition types [10 transitions from chronic diseases to stroke (5 metabolic risk states × 2 stroke states) and 4 transitions from stroke to dementia (2 stroke states × 2 dementia states)] by 7 covariates (i.e., sex, age, divorce rate, unemployment rate, temperature, air pollution, and solitariness rate). Among the 98 transitions, 26 were statistically significant. CONCLUSIONS: Sex, age, divorce rate, unemployment rate, temperature, and air pollution rate exerted a partially significant influence on the transition from chronic diseases to stroke. Sex, age, unemployment rate, and temperature partially influenced the transition from stroke to dementia. This study also considered high-risk sub-populations of stroke patients, particularly males aged 65 years and below. Geriatr Gerontol Int 2024; 24: 766-772.

Testing the Impacts of Rational-Emotive Couple Intervention in a Sample of Parents Seeking Divorce.

Marital burnout has not been extensively studied despite its huge consequences on family wellbeing and quality of family life. This study, using randomised-controlled trial, tested the impact of rational-emotive couple intervention on marital burnout in a sample of parents seeking a divorce. A total of 67 parents who participated during the rational-emotive couple intervention (RECI) were assessed using the marital burnout scale, Beck depression inventory, and parent rational and irrational beliefs scale. Crosstabulation, multivariate test analysis, and bivariate analysis were used to analyse the data collected. Results show a significant reduction of marital burnout in RECI group participants, and significant improvement was maintained at the follow-up stage. The result of the group and gender interaction effect shows no significant interaction effect of group and gender on participants' marital burnout at Time two and Time 3, respectively. The results indicate that a decrease in parents' irrational beliefs accounts for marital burnout among couples seeking a divorce. Marital burnout is positively associated with depression among couples seeking a divorce. This study concludes that the RECI is an effective intervention that reduces marital burnout which is a direct consequence of irrational beliefs which later metamorphose into depressive symptoms.

Divorce and physical health: A three-level meta-analysis.

Divorce is often considered a major and stressful life transition. Given that divorcees are overrepresented in primary care and there is a association between individuals' physical health and psychological adjustment, potential post-divorce health problems are of concern. Yet, empirical evidence is lacking on the magnitude of the overall physical health risk after divorce, on possible differences across specific pathologies, and on factors that may increase or reduce this risk. The current meta-analysis addresses these issues. We identified 94 studies including u = 248 relevant effect sizes, based on N = 1,384,507 participants. Generally, compared to married individuals, divorcees showed significantly worse self-reported health (OR = 1.20, [1.08-1.33]), experienced more physical symptoms (OR = 1.34, [1.17-1.53]), and had a higher risk for diabetes (OR = 1.18 [1.05-1.33]), joint pathologies (OR = 1.24, [1.14-1.34]), cardiovascular (OR = 1.24, [1.09-1.41]) and cerebrovascular conditions (OR = 1.31, [1.14-1.51]), and sexually transmitted diseases (OR = 2.48, [1.32-4.64]). However, they had no increased risk of hypertension, hypercholesterolemia, cancer and cancer development, disabilities or limitations, or cognitive pathologies. Nor did divorcees significantly differ from married individuals when aggregating all pathologies to measure overall physical health problems (OR = 1.14, [0.85 to 1.54]). Yet, moderation analyses revealed that being female, unemployed, childless, or having a lower education constitutes a higher risk for overall physical health problems after divorce. The same applied to having a heavy alcohol consumption, lack of exercise, and being overweight. Our meta-analysis shows that divorcees are at heightened risk of certain pathologies, with sexually transmitted diseases as a particular post-divorce hazard. These findings call for more awareness among counsellors and physicians on divorcees' health conditions and the characteristics that make divorcees even more vulnerable to health problems.

At the Intersection of Adverse Life Course Pathways: The Effects on Health by Migration Status.

Adverse life events are major causes of declining health and well-being, but the effects vary across subpopulations. We analyze how the intersection of migration status and sex relates to two main adverse life events-job loss and divorce-thereby affecting individual health and well-being trajectories. Using data from the German Socio-Economic Panel (1984-2017), we apply descriptive techniques and individual fixed-effects regressions to analyze how job loss and divorce influence the health of immigrants and nonimmigrants. Our results support the hypothesis that immigrants suffer more from adverse life events than nonimmigrants in both the short and the long run. Relative to nonimmigrants, immigrants have a health advantage at younger ages, which becomes a disadvantage at older ages, and this faster decline at older ages is particularly steep among immigrants who experience adverse life events. These results help explain the vanishing health advantage of immigrants by showing that they are exposed to a double disadvantage over the life course: immigrants are more likely than nonimmigrants to suffer from adverse life events, such as job loss, and these events typically have a larger impact on their health. Our findings are the first to provide evidence regarding the consequences of different adverse life events and how they relate to the intersection of migration status and sex. Moreover, our results highlight the importance of intersectional analyses in research on immigrant health.

Mothers' parental divorce experience in childhood and their children's mental health: Mediating role of maternal education.

BACKGROUND: Adverse childhood experiences (ACEs) of mothers have been shown to be associated with children's mental health and behavior problems. It is important to identify effective intervention points to prevent negative consequences among children. This study aimed to investigate whether mothers' education is protective against children's depressive symptoms in families with mothers who experienced parental divorce in childhood. METHODS: Data from a cross-sectional study of 5th and 8th grade children and their caregivers in a prefecture in Japan were used. Final analytic sample consisted of 9666 child-caregiver pairs. Mediation analyses using inverse odds weighting were performed where the exposure was maternal experience of parental divorce in childhood, outcome was child depressive symptoms, and potential mediators were maternal education beyond high school, maternal mental health, and household income. RESULTS: Maternal experience of parental divorce was associated with an elevated risk of child depressive symptoms (risk ratio: 1.22, 95 % confidence interval (CI): 1.07-1.39). Mediation analyses indicated that the combination of maternal education, maternal depression and household income mediated about half of the total effect. In the model where maternal education was the sole mediator, maternal education mediated nearly half of the total effect (risk ratio: 1.10, 95 % CI: 1.01-1.20). LIMITATIONS: Results should be cautiously interpreted given observational and cross-sectional nature of the data. CONCLUSIONS: Maternal education beyond high school may be protective against negative mental health consequences among children due to mothers' experience of parental divorce. Further studies are needed regarding potential mechanisms and the roles of other potential mediators.

Reassessing Chronic Strain: A Research Note on Women's Income Dynamics After Divorce and Separation.

The economic consequences of divorce and separation for women are commonly associated with the chronic strain model, according to which women's losses are large and persistent. This research note shifts the focus to a crisis model highlighting women's potential of, and routes to, recovery from initial losses. Drawing on German Socio-Economic Panel data (1984-2021) on women in marital and cohabiting unions (N ∼ 27,000 women, N ∼ 3,400 divorces and separations), we use fixed-effects regression models and event-history models to analyze changes in equivalized monthly household income and poverty risk across the process of divorce and separation. Results show that most women recovered from their initial economic declines. Although initial losses were common and often sizable, large fractions of women eventually returned to or exceeded the household income expected in the absence of divorce and separation. Recovery was facilitated by the "traditional" route of repartnering and the "modern" route of women mobilizing their productive skills. Both routes appeared more important than the absence of barriers, such as children in the household. We conclude that for the majority of women, the economic consequences of divorce and separation are better described as a temporary crisis than as a chronic strain.

Mandated Parent Education: Applications, Impacts, and Future Directions.

Mandated participation in parent education programs is a common practice across the United States for families who are undergoing divorce or who are involved in the child welfare or juvenile justice systems. Mandates to participate in parenting programs create substantial challenges for families, service providers, and service systems. Furthermore, the type and quality of the parenting services accessed vary widely, and their impacts need to be better understood. To address this need, an overview of the current state of the empirical literature on the impacts and outcomes of mandated parenting interventions for divorce and in child welfare and juvenile justice settings is provided, and suggestions to the field are offered to refine research related to mandated parenting programs. Given the challenges that mandated parenting programs pose, an alternative approach that views parenting through a public health lens is highlighted to build on the growing body of research on the impacts of population-wide applications of parenting support programs, and as a possible way to decrease the number of parents who are required to attend parenting programs. Opportunities to advance universal parenting support within a range of community settings, including primary care, early childhood education, and community mental health systems are offered. Gaps in knowledge regarding mechanisms of action of universal supports and impacts on the number of parents mandated to treatment are highlighted, and future directions for research in this area are suggested.