Public health nurse-delivered cognitive behavioral therapy for postpartum depression: Assessing the effects of maternal treatment on infant emotion regulation.

The effects of maternal postpartum depression (PPD) on offspring emotion regulation (ER) are particularly deleterious as difficulties with ER predict an increased risk of psychopathology. This study examined the impact of maternal participation in a public health nurse (PHN)-delivered group cognitive behavioral therapy (CBT) intervention on infant ER. Mothers/birthing parents were ≥ 18 years old with an Edinburgh Postnatal Depression Scale (EPDS) score ≥ 10, and infants were < 12 months. Between 2017 and 2020, 141 mother-infant dyads were randomized to experimental or control groups. Infant ER was measured at baseline (T1) and nine weeks later (T2) using two neurophysiological measures (frontal alpha asymmetry (FAA) and high-frequency heart rate variability (HF-HRV)), and informant-report of infant temperament. Mothers were a mean of 30.8 years old (SD = 4.7), 92.3% were married/ common-law, and infants were a mean of 5.4 months old (SD = 2.9) and 52.1% were male. A statistically significant group-by-time interaction was found to predict change in HF-HRV between T1 and T2 (F(1,68.3) = 4.04, p = .04), but no significant interaction predicted change in FAA or temperament. Results suggest that PHN-delivered group CBT for PPD may lead to adaptive changes in a neurophysiological marker of infant ER, highlighting the importance of early maternal intervention.

Shyness and inhibitory control in preschool dyads: An actor-partner model of social behavior.

The risk potentiation model of cognitive control posits that inhibitory control heightens children's risk for problematic outcomes in the context of shyness because it limits shy children's ability to engage flexibly with their environment. Although there is empirical support for the risk potentiation model, most studies have been restricted to parent report of children's outcomes and do not consider the influence of shyness and inhibitory control on other children's social behavior. In the present study, we used an actor-partner interdependence model to examine whether shyness and inhibitory control at Time 1 (N = 105, 52 girls, Mage = 3.50 years; 87% White; Mincome = between $75,000 and $100,000 in Canadian dollars) predicted children's own and their partner's observed social behavior with an unfamiliar peer at Time 2 (Mage = 4.76 years). When the child's own inhibitory control was high, the child's own shyness was negatively associated with their own approach behaviors but negatively associated with their partner's avoidance behaviors. However, when the child's own inhibitory control was low, the child's own shyness was unrelated to their own approach behaviors but positively associated with their partner's avoidance behaviors. Although inhibitory control was negatively associated with approach-related behavior for some shy children, this did not translate to more avoidance from the social partner. These results highlight the importance of examining the child's own behavior in addition to their partner's behavior when considering children's socioemotional development. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

How biology shapes the development of shyness within specific contexts: A longitudinal, cross-lagged investigation.

Shyness is a temperamental trait that refers to fear and wariness in the face of social novelty and is known to have a biological basis. One proposed physiological correlate of shyness has been the change in respiratory sinus arrhythmia (RSA) from baseline to a stressor. However, past research linking shyness and RSA change has been mixed, which may be, in part, due to a failure to carefully consider the context under which RSA change is measured and the directionality of relations. Using a longitudinal design and cross-lagged analysis (N = 103, 52 girls), we examined parent-reported shyness and RSA change during a stranger approach task (social stressor) and a locked box task (nonsocial stressor) at ages 3 (Mage at Time 1 = 3.50 years, SDage = 0.19 years) and 4 (Mage at Time 2 = 4.76 years, SDage = 0.38). Cardiac vagal withdrawal during the stranger approach task, but not during the frustration task, at age 3 positively predicted shyness at age 4. Shyness at age 3 did not predict cardiac vagal change in either context at age 4. We also found that changes in RSA measured during the frustration task were stable across time, but changes in RSA measured during the stranger approach task were not stable across time, suggesting a developmental change in physiological regulatory systems to social threat. These results suggest that, although biology may come first in shaping children's behavior, this relation depends critically on the context and the incentives in the child's environment. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Children's Shyness, Frontal Brain Activity, and Anxiety in the Perioperative Context.

Although preoperative anxiety affects up to 75% of children undergoing surgery each year and is associated with many adverse outcomes, we know relatively little about individual differences in how children respond to impending surgery. We examined whether patterns of anterior brain electrical activity (i.e., a neural correlate of anxious arousal) moderated the relation between children's shyness and preoperative anxiety on the day of surgery in 70 children (36 girls, Mage = 10.4 years, SDage = 1.7, years, range 8 to 13 years) undergoing elective surgery. Shyness was assessed using self-report approximately 1 week prior to surgery during a preoperative visit (Time 1), preoperative anxiety was assessed using self-report, and regional EEG (left and right frontal and temporal sites) was assessed using a dry sensory EEG headband on the day of surgery (Time 2). We found that overall frontal EEG alpha power moderated the relation between shyness and self-reported preoperative anxiety. Shyness was related to higher levels of self-reported anxiety on the day of surgery for children with lower average overall frontal alpha EEG power (i.e., higher cortical activity) but not for children with higher average overall frontal alpha EEG power (i.e., lower cortical activity). These results suggest that the pattern of frontal brain activity might amplify some shy children's affective responses to impending surgery. Findings also extend prior results linking children's shyness, frontal brain activity, and anxiety observed in the laboratory to a real-world, ecologically salient environment.

Maternal involvement and adolescents' psychological and academic adjustment after COVID-19 return-to-school: A one-year longitudinal study.

The current study examined the idea that maternal involvement during the COVID-19 school closure period could contribute to the development of adolescents' daily routines, which could ultimately associate with their psychological and academic adjustment after return-to-school. Data were collected from 520 Chinese adolescents (Mage = 12.75 years, SDage = 1.48 years) and their mothers during the COVID-19 school closure and one year after return-to-school. Results indicated that maternal involvement in both education and leisure activities predicted more consistent adolescents' daily routines during the school closure period and then contributed to their more consistent daily routines after return-to-school, resulting in less psychological maladjustment and better academic outcomes. Findings highlight the importance of maternal involvement and daily routines in the context of COVID-19.

Distinct trajectories of caregiver-toddler physiological attunement during routine vaccinations.

Introduction: Toddlers rely on their caregivers for regulatory support when faced with pain-related distress. The caregiver's ability to support their toddler relies on their capacity to regulate their own distress and respond effectively to the child's need for support. The aim of the current study was to describe patterns of caregiver-toddler physiological co-regulatory patterns, also known as attunement, during routine vaccinations across the second year of life. Methods: Caregiver-toddler dyads (N = 189) were part of a longitudinal cohort observed at either 12-, 18-, or 24-month well-baby vaccinations. Parallel-process growth-mixture modeling was used to examine patterns of dyadic physiological co-regulatory responses, indexed by high-frequency heart rate variability (HF-HRV). Results: Three groups of dyads were discerned. The largest group (approximately 80%) demonstrated physiological attunement, with a stable and parallel regulatory pattern of HF-HRV from baseline to postneedle. The second group (7.9%) had parallel regulatory trajectories but with notably lower (ie, less regulated) HF-HRV values, which indicates independent regulatory responses (ie, a lack of attunement among dyad members). The third group (11.1%) showed diverging regulatory trajectories: Caregivers showed a stable regulatory trajectory, but toddlers demonstrated a steep decrease followed by an increase in HF-HRV values that surpassed their baseline levels by the third minute postneedle. Post hoc analyses with the HF-HRV groupings explored heart rate patterns and potential predictors. Conclusions: These findings elucidate potential adaptive and maladaptive co-regulatory parasympathetic patterns in an acute pain context.

Brain structure and function in the fourth decade of life after extremely low birth weight: An MRI and EEG study.

OBJECTIVE: To examine potential long-term effects of extremely low birth weight (ELBW; ≤ 1000 g) on adult brain structure, brain function, and cognitive-behavioral performance. METHODS: A subset of survivors from the prospectively-followed McMaster ELBW Cohort (n = 23, MBW = 816 g) and their peers born at normal birth weight (NBW; ≥ 2500 g; n = 14, MBW = 3361 g) provided T1-weighted magnetic resonance imaging (MRI) brain scans, resting electroencephalographic (EEG) recordings, and behavioral responses to a face-processing task in their early thirties. RESULTS: Visual discrimination accuracy for human faces, resting EEG alpha power, and long-distance alpha coherence were lower in ELBW survivors than NBW adults, and volumes of white matter hypointensities (WMH) were higher. Across groups, face-processing performance was correlated positively with posterior EEG spectral power and long-distance alpha and theta coherence, and negatively with WMH. The associations between face-processing scores and parietal alpha power and theta coherence were reduced after adjustment for WMH. CONCLUSIONS: Electrocortical activity, brain functional connectivity, and higher-order processing ability may be negatively affected by WMH burden, which is greater in adults born extremely preterm. SIGNIFICANCE: Decrements in electrocortical activity and behavioral performance in adult ELBW survivors may be partly explained by increased WMH volumes in this vulnerable population.

Early neurodevelopment in the offspring of women enrolled in a randomized controlled trial assessing the effectiveness of a nutrition + exercise intervention on the cognitive development of 12-month-olds.

Experimental data on the effects of lifestyle interventions on fetal neurodevelopment in humans remain scarce. This study assessed the impact of a pregnancy nutrition+exercise intervention on offspring neurodevelopment at 12 months of age. The Be Healthy in Pregnancy (BHIP) randomized controlled trial (RCT) randomly assigned pregnant persons with stratification by site and body mass index (BMI) to bi-weekly nutrition counselling and high dairy protein diet, walking goal of 10,000 steps/day plus usual prenatal care (UPC; intervention group) or UPC alone (control group). This study examined a subset of these mothers (> 18 years, singleton pregnancy, BMI <40 kg/m2, and enrolled by ≤12 weeks gestation) and their infants (intervention = 42, control = 32), assessing cognition, language, motor, social-emotional, and adaptive functioning at 12 months using the Bayley Scales of Infant and Toddler Development third edition (BSID-III) as the outcome measure. We also examined if maternal factors (prepregnancy BMI, gestational weight gain (GWG)) moderated associations. Expressive language (MD = 9.62, 95% CI = (9.05-10.18), p = 0.03, ƞ2p = 0.07) and general adaptive composite (GAC) scores (MD = 103.97, 95% CI = (100.31-107.63), p = 0.04, ƞ2p = 0.06) were higher in infants of mothers in the intervention group. Effect sizes were medium. However, mean cognitive, receptive language, motor, and social-emotional scale scores did not differ between groups. A structured and monitored nutrition+exercise intervention during pregnancy led to improved expressive language and general adaptive behavior in 12-month-olds, but not cognitive, receptive language, motor, or socioemotional functioning. While these experimental data are promising, further research is needed to determine the clinical utility of nutrition+exercise interventions for optimizing infant neurodevelopment.

Developmental patterns of children's shyness: Relations with physiological, emotional, and regulatory responses to being treated unfairly.

The dysregulation of social fear has been widely studied in children's shyness, but we know little about how shy children regulate during unfair treatment. We first characterized developmental patterns of children's shyness (N = 304, ngirls = 153; 74% White, 26% Other) across 2 (Mage = 2.07), 3 (Mage = 3.08), 4 (Mage = 4.08), and 6 (Mage = 6.58) years of age. Data collection occurred from 2007 to 2014. At age 6, the high stable group had higher cardiac vagal withdrawal and lower expressed sadness and approach-related regulatory strategy than the low stable group when being treated unfairly. Although shy children may be more physiologically impacted by being treated unfairly, they may mask their sadness to signal appeasement.

Risk and protective factors in predicting pediatric acute postsurgical pain: A systematic review and meta-analysis.

OBJECTIVE: Acute postsurgical pain (APSP), defined as pain within 3 months after surgery, is reported in most surgical pediatric patients, and a significant number of patients experience pain interfering with their daily life activities. We aimed to identify perioperative and psychosocial factors associated with APSP severity in pediatric patients undergoing surgery. METHOD: MEDLINE, EMBASE, CINAHL, PsycINFO, Web of Science, and CENTRAL were searched from database inception to October 2021. Studies that reported an association between risk or protective factors and acute pain in children were included. The primary outcome was the magnitude of association between identified factors and APSP, as measured by standardized effect sizes. RESULTS: Thirty-eight studies (7,936 participants aged 1-18 years) were included. Meta-analysis of 12 studies (1,192 participants) revealed child preoperative pain, pain immediately after surgery, anticipated pain, temperament, pain catastrophizing, age, preoperative anxiety, parent pain catastrophizing, and parent preoperative anxiety were positively associated with APSP. Child pain coping efficacy was protective against APSP. We identified several modifiable child and parent psychosocial factors as predictors of APSP severity. CONCLUSION: Given the small degree of association between identified factors and postsurgical pain, there is value in pursuing other factors that may better explain the variability in pain. Recognizing patients at risk for moderate to severe APSP enables early implementation of interventions to minimize pain burden. Interventions to enhance coping, an adaptive characteristic, may also help to reduce APSP. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Dynamic changes in postnatal growth predict adolescent mental health problems in survivors of extremely low birth weight (ELBW).

Although individuals born at extremely low birth weight (ELBW; ≤1000 g) are known to be at greater risk for mental health problems than individuals born at normal birth weight (NBW; ≥2500 g), contributions of postnatal growth to these relations have not been fully explored. We compared individual differences in the Ponderal Index [(PI; weight(kg)/height(m3)] and head circumference (HC) in predicting internalizing and externalizing behaviors in childhood and adolescence in a cohort of ELBW survivors (N = 137) prospectively followed since birth. Baseline models indicated that infants who were born thinner or with smaller HC showed greater PI or HC growth in the first 3 years. Latent difference score (LDS) models showed that compensatory HC growth in the first year (ΔHC = 20.72 cm), controlled for birth HC, predicted ADHD behaviors in adolescence in those born with smaller HC. LDS models also indicated that the PI increased within the first year (ΔPI = 1.568) but decreased overall between birth and age 3 years (net ΔPI = -4.597). Modeling further showed that larger increases in the PI in the first year and smaller net decreases over 3 years predicted more internalizing behaviors in adolescence. These findings suggest early growth patterns prioritizing weight over height may have negative effects on later mental health in ELBW survivors, consistent with developmental programming theories.

The impact of peer-delivered cognitive behavioral therapy for postpartum depression on infant emotion regulation.

BACKGROUND: Postpartum depression (PPD) affects up to one in five and negatively affects mothers, birthing parents, and their infants. The impact of PPD exposure on infant emotion regulation (ER) may be particularly harmful given its associations with later psychiatric problems. It remains unclear if treating maternal PPD can improve infant ER. OBJECTIVE: To examine the impact of a nine-week peer-delivered group cognitive behavioral therapy (CBT) intervention on infant ER assessed across physiological and behavioral levels. METHODS: Seventy-three mother-infant dyads were enrolled in a randomized controlled trial from 2018 to 2020. Mothers/birthing parents were randomized to the experimental group or waitlist control group. Measures of infant ER were collected at baseline (T1) and nine weeks later (T2). Infant ER was assessed using two physiological measures (frontal alpha asymmetry (FAA) and High Frequency-Heart Rate Variability (HF-HRV)), and parental-report of infant temperament. RESULTS: Experimental group infants displayed more adaptive changes in both physiological markers of infant ER from T1 to T2 (FAA (F(1,56) = 4.16, p = .046) and HF-HRV (F(1,28.1) = 5.57, p = .03)) than those in the waitlist control group. Despite improvements in maternal PPD, no differences were noted in infant temperament from T1 to T2. LIMITATIONS: A limited sample size, potential lack of generalizability of our results to other populations, and an absence of long-term data collection. CONCLUSIONS: A scalable intervention designed for those with PPD may be capable of adaptively improving infant ER. Replication in larger samples is needed to determine if maternal treatment can help disrupt the transmission of psychiatric risk from mothers/birthing parents to their infants.

Caregiver and Child Distress as Predictors of Dyadic Physiological Attunement During Vaccination.

OBJECTIVE: Previous research discerned 3 groups of caregiver-toddler dyads that differed in their physiological coregulatory patterns, also known as physiological attunement, during routine vaccinations in the second year of life. One group of dyads (80% of sample) displayed an attuned regulatory pattern, and 2 groups of dyads (20% of sample) showed maladaptive attunement patterns (ie, a lack of attunement or misattunement). The objective of the current study was to examine how well the pain-related distress of children and caregivers during vaccination predicted these patterns. METHODS: Caregiver-toddler dyads (N = 189) were part of a longitudinal cohort observed at either 12-, 18-, or 24-month vaccination appointments. The caregiver's self-report of worry was assessed before and after the needle, and the child behavioral pain-related distress was also measured during the vaccination appointment. Logistic regression was used to determine how well these variables predicted caregiver-child physiological attunement patterns, as indexed by high-frequency heart rate variability. RESULTS: Higher behavioral pain-related distress at various timepoints after the needle were associated with membership in the dyad groups that showed misattunement or lack of attunement. Further, caregivers with higher preneedle worry and lower postneedle worry had a greater likelihood of belonging to groups that showed a maladaptive attunement pattern. DISCUSSION: Findings suggest that caregivers who experience distress associated with their toddlers' vaccination experience more difficulty coregulating with their child during vaccination, and these children are at risk of experiencing higher levels of pain-related distress. This research highlights the need to help caregivers support their children's regulation during vaccination.

Latent profiles of children's shyness: Behavioral, affective, and physiological components.

Shyness can manifest on behavioral, affective, and physiological levels, but little is known about how these components cluster. We coded behavioral expressions of avoidance/inhibition, collected self-reported nervousness, and measured cardiac vagal withdrawal in 152 children (Mage  = 7.82 years, 73 girls, 82% White) to a speech task in 2018-2021. A latent profile analysis using these behavioral, affective, and physiological indicators revealed four profiles: average reactive (43%), lower affective reactive (20%), higher affective reactive (26%), and consistently higher reactive (11%). Membership in the higher reactive profile predicted higher parent-reported temperamental shyness across 2 years. Findings provide empirical support for the long-theorized idea that shyness might exist as an emotional state but also represents a distinct temperamental quality for some children.

iGen or shyGen? Generational Differences in Shyness.

Generation Z (1997-2012) has been characterized in the popular media as more socially inhibited, cautious, and risk averse than prior generations, but are these differences found between generations on an empirical level? And, if so, are these differences observable within generations in response to acute events such as the COVID-19 pandemic? Using a simplified time-lagged design to control for age effects, we examined between-group differences in self-reported shyness in young adult participants (N = 806, age: 17-25 years) at the same developmental age and university from the millennial generation (tested: 1999-2001; n = 266, Mage = 19.67 years, 72.9% female) and Generation Z (tested: 2018-2020), the latter generation stratified into prepandemic (n = 263, M = 18.86 years, 82.4% female) and midpandemic (n = 277, Mage = 18.67 years, 79.6% female) groups. After first establishing measurement invariance to ensure trustworthy group comparisons, we found significantly higher mean levels of shyness across each successive cohort, starting with millennials, through Generation Z before the pandemic, to Generation Z during the pandemic.

Preliminary findings of emotion regulation in 12-month-old infants of mothers enrolled in a randomized controlled trial assessing a nutrition + exercise intervention.

Improved offspring emotion regulation (ER) has been associated with maternal intake of single nutrients or exercise during pregnancy but has not been examined in randomized trials. We investigated the impact of a maternal nutrition + exercise intervention during pregnancy on offspring ER at 12 months of age. Mothers in the Be Healthy In Pregnancy randomized controlled trial were randomly assigned to an individualized nutrition + exercise intervention plus usual care (UC) or UC alone (control group). A multimethod assessment of infant ER using parasympathetic nervous system function (high frequency heart rate variability [HF-HRV] and root mean square of successive differences [RMSSD]) as well as maternal reports of infant temperament (Infant Behavior Questionnaire- Revised short form) was completed with a subsample of infants of enrolled mothers (intervention = 9, control = 8). The trial was registered at www.clinicaltrials.gov (NCT01689961). We observed greater HF-HRV (M = 4.63, SD = 0.50, p = .04, ƞ2 p  = .25) and RMSSD (M = 24.25, SD = 6.15, p = .04, ƞ2 p  = .25) in infants of mothers in the intervention versus control group. Intervention group infants also had higher maternally rated surgency/extraversion (M = 5.54, SD = 0.38, p = .00, ƞ2 p  = .65) and regulation/orienting (M = 5.46, SD = 0.52, p = .02, ƞ2 p  = .81), and lower negative affectivity (M = 2.70, SD = 0.91, p = .03, ƞ2 p  = .52). These preliminary results suggest that pregnancy nutrition + exercise interventions could improve infant ER but these findings require replication in larger, more diverse samples.

Shyness subtypes and associations with social anxiety: A comparison study of Canadian and Chinese children.

Previous research has shown that there are distinct types of children's shyness within eastern and western cultures, with different origins, developmental courses, and outcomes. However, the measures used to examine children's shyness in eastern contexts have been developed almost exclusively in the North American context. Whether shyness subtypes and their predictive associations are conserved between western and eastern cultures on a children's shyness measure developed in an eastern context is an empirical question. Here we examined (a) whether two subtypes from the Chinese Shyness Scale (i.e., anxious and regulated) were identified in a western context, and (b) whether cultural context moderated the relation between the two subtypes of shy behavior and a widely used western characterized social anxiety measure. The participants were children aged 3-5 years from China (Mage  = 4.46 years, SD = 0.64, n = 182, 53.8% boys) and Canada (Mage  = 3.99 years, SD = 0.82, n = 201, 42.3% boys). The results indicated that the two shyness subtypes and the one-factor social anxiety construct were identified in both cultures. Subsequently, latent moderation structural equation modelling revealed that anxious shyness was significantly and positively related to social anxiety in children from both countries, but more strongly in Canada. Conversely, regulated shyness was significantly and positively related to social anxiety in Canadian children, but not in Chinese children. Findings are discussed regarding possible cultural explanations for why the relations between two Chinese shyness subtypes and social anxiety are different in Chinese and Canadian contexts and their implications to understanding cross-cultural differences in developmental shyness. RESEARCH HIGHLIGHTS: Two subtypes of shyness (anxious and regulated shyness) reported in China were identified in both China and Canada Country/culture moderated the relation between shyness subtypes and social anxiety Anxious shyness was positively related to social anxiety in both countries Regulated shyness was positively related to social anxiety in Canadian children, but not in Chinese children.

Infant Negativity Moderates Trajectories of Maternal Emotion Across Pregnancy and the Peripartum Period.

Background: Although the effects of maternal behavior on the development of child emotion characteristics is relatively well-established, effects of infant characteristics on maternal emotion development is less well known. This gap in knowledge persists despite repeated calls for including child-to-mother effects in studies of emotion. We tested the theory-based postulate that infant temperamental negativity moderates longitudinal trajectories of mothers' perinatal symptoms of anxiety and depression. Method: Participants were 92 pregnant community women who enrolled in a longitudinal study of maternal mental health; symptoms of anxiety and depression were assessed during the second and third trimesters of pregnancy and again at infant age 4 months. A multimethod assessment of infants' temperament-based negative reactivity was conducted at infant age 4 months. Results: Maternal symptoms of anxiety showed smaller postnatal declines when levels of infant negativity were high. Negative reactivity, assessed via maternal report of infant behavior, was related to smaller postnatal declines in maternal anxiety, while infant negative reactivity, at the level of neuroendocrine function, was largely unrelated to longitudinal changes in maternal anxiety symptoms. Infant negativity was related to early levels, but largely unrelated to trajectories of maternal symptoms of depression. Limitations: Limitations of this work include a relatively small and low-risk sample size, the inability to isolate environmental effects, and a nonexperimental design that precludes causal inference. Conclusions: Findings suggest that levels of infant negativity are associated with differences in the degree of change in maternal anxiety symptoms across the perinatal period.

Shyness, inhibitory control, and social support seeking in preschoolers: Role of familiar and unfamiliar contexts.

The risk potentiation model of cognitive control posits that inhibitory control may heighten the risk for problematic outcomes among some temperamental styles characterized by high reactivity. Because shyness is a temperamental style defined as wariness and heightened reactivity to social novelty, we examined whether the interaction between shyness and inhibitory control predicted social support seeking differently depending on context using a between-subjects design. Typically developing preschoolers (N = 167, 52% female, Mage = 4.05 years, SDage = .77 years) were observed during a model building task that included a familiar (i.e., with their mother) or unfamiliar (i.e., with a novel adult female) social context. In the unfamiliar context, shyness was negatively associated with social support seeking at relatively high levels of inhibitory control, in line with the risk potentiation model of control. However, in the familiar context, we found that shyness was positively associated with social support seeking at relatively high levels of inhibitory control. These results suggest that high levels of inhibitory control may potentiate social fear for preschoolers who are also shy and that these relations may depend on contextual factors. (PsycInfo Database Record (c) 2023 APA, all rights reserved).