The role of environmental sensitivity in the mental health of Syrian refugee children: a multi-level analysis.

Individuals with high environmental sensitivity have nervous systems that are disproportionately receptive to both the protective and imperilling aspects of the environment, suggesting their mental health is strongly context-dependent. However, there have been few consolidated attempts to examine putative markers of sensitivity, across different levels of analysis, within a single cohort of individuals with high-priority mental health needs. Here, we examine psychological (self-report), physiological (hair hormones) and genetic (polygenic scores) markers of sensitivity in a large cohort of 1591 Syrian refugee children across two waves of data. Child-caregiver dyads were recruited from informal tented settlements in Lebanon, and completed a battery of psychological instruments at baseline and follow-up (12 months apart). Univariate and multivariate Bayesian linear mixed models were used to examine a) the interrelationships between markers of sensitivity and b) the ability of sensitivity markers to predict anxiety, depression, post-traumatic stress disorder, and externalising behaviour. Self-reported sensitivity (using the Highly Sensitive Child Scale) significantly predicted a higher burden of all forms of mental illness across both waves, however, there were no significant cross-lagged pathways. Physiological and genetic markers were not stably predictive of self-reported sensitivity, and failed to similarly predict mental health outcomes. The measurement of environmental sensitivity may have significant implications for identifying and treating mental illness, especially amongst vulnerable populations, but clinical utility is currently limited to self-report assessment.

A Bayesian approach for exploring person × environment interaction within the environmental sensitivity meta-framework.

BACKGROUND: For investigating the individual-environment interplay and individual differences in response to environmental exposures as captured by models of environmental sensitivity including Diathesis-stress, Differential Susceptibility, and Vantage Sensitivity, over the last few years, a series of statistical guidelines have been proposed. However, available solutions suffer of computational problems especially relevant when sample size is not sufficiently large, a common condition in observational and clinical studies. METHOD: In the current contribution, we propose a Bayesian solution for estimating interaction parameters via Monte Carlo Markov Chains (MCMC), adapting Widaman et al. (Psychological Methods, 17, 2012, 615) Nonlinear Least Squares (NLS) approach. RESULTS: Findings from an applied exemplification and a simulation study showed that with relatively big samples both MCMC and NLS estimates converged on the same results. Conversely, MCMC clearly outperformed NLS, resolving estimation problems and providing more accurate estimates, particularly with small samples and greater residual variance. CONCLUSIONS: As the body of research exploring the interplay between individual and environmental variables grows, enabling predictions regarding the form of interaction and the extent of effects, the Bayesian approach could emerge as a feasible and readily applicable solution to numerous computational challenges inherent in existing frequentist methods. This approach holds promise for enhancing the trustworthiness of research outcomes, thereby impacting clinical and applied understanding.

Genetic and subjective sensitivity, relationship dynamics, and psychological distress in couples.

Positive and negative aspects of intimate relationships influence mental health and well-being in couples. According to the environmental sensitivity framework, individuals differ in how strongly they are affected by their environment, with some individuals being more or less sensitive to both negative and positive experiences. The present study examined the longitudinal associations between positive and negative relationship dynamics, including marital satisfaction, positive bonding, and negative communication, and psychological distress as well as the extent to which individual differences in genetic and subjective measures of environmental sensitivity moderated the association between relationship dynamics and psychological distress in a sample of couples in the U.S. Army (n = 238 individuals representing 152 unique couples). Sensitivity was measured by self-report and a polygenic score derived from previous genome-wide association study results. Separate three-level multilevel models were conducted for each relationship dynamic and sensitivity variable. Only for subjective (i.e., self-reported) sensitivity did significant cross-level interactions emerge in predicting psychological distress, whereas no such interactions were found for genetic (i.e., polygenic score) sensitivity. Specifically, lower marital satisfaction and positive bonding were associated with higher psychological distress among subjectively highly sensitive individuals, and higher negative communication was associated with higher psychological distress among subjectively highly sensitive individuals. Findings suggest that both low positive and high negative relationship dynamics may have a greater effect on psychological distress among highly sensitive individuals, which may help to inform tailored intervention to meet the unique needs of couples. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Causal relationships in longitudinal observational data: An integrative modeling approach.

Much research in psychology relies on data from observational studies that traditionally do not allow for causal interpretation. However, a range of approaches in statistics and computational sciences have been developed to infer causality from correlational data. Based on conceptual and theoretical considerations on the integration of interventional and time-restrainment notions of causality, we set out to design and empirically test a new approach to identify potential causal factors in longitudinal correlational data. A principled and representative set of simulations and an illustrative application to identify early-life determinants of cognitive development in a large cohort study are presented. The simulation results illustrate the potential but also the limitations for discovering causal factors in observational data. In the illustrative application, plausible candidates for early-life determinants of cognitive abilities in 5-year-old children were identified. Based on these results, we discuss the possibilities of using exploratory causal discovery in psychological research but also highlight its limits and potential misuses and misinterpretations. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Hair hormone data from Syrian refugee children: Perspectives from a two-year longitudinal study.

For numerous issues of convenience and acceptability, hair hormone data have been increasingly incorporated in the field of war trauma and forced displacement, allowing retrospective examination of several biological metrics thought to covary with refugees' mental health. As a relatively new research method, however, there remain several complexities and uncertainties surrounding the use of hair hormones, from initial hair sampling to final statistical analysis, many of which are underappreciated in the extant literature, and restrict the potential utility of hair hormones. To promote awareness, we provide a narrative overview of our experiences collecting and analyzing hair hormone data in a large cohort of Syrian refugee children (n = 1594), across two sampling waves spaced 12 months apart. We highlight both the challenges faced, and the promising results obtained thus far, and draw comparisons to other prominent studies in this field. Recommendations are provided to future researchers, with emphasis on longitudinal study designs, thorough collection and reporting of hair-related variables, and careful adherence to current laboratory guidelines and practices.

Beyond developmental psychopathology: Positive child development.

The field of developmental psychopathology has made significant contributions to our understanding of both typical and atypical development. However, while there are established theories for developmental psychopathology with detailed criteria for pathological outcomes, there is less agreement regarding development under optimal conditions and the definition of positive outcomes. In this conceptual paper, I make the case that a better understanding of positive child development is crucial because it will not only advance our general knowledge on human development but also complement current work on developmental psychopathology. After defining positive development as the development of positive functioning in children, such as skills, strengths, competencies, and wellbeing, rather than the absence of problems, current concepts with relevance for positive development are reviewed, before highlighting gaps in our knowledge on positive development and suggestions for future research. Although several of the reviewed frameworks provide important contributions to the conceptualization of positive development, most of them focus on positive functioning in adults with limited consideration of development in the early years. More research is needed that specifically targets the development of positive outcomes from early childhood onward in order to develop a more comprehensive and holistic theory of positive child development.

The role of environmental sensitivity in post-traumatic stress symptoms in Lebanese children and adolescents.

Children differ substantially in their sensitivity to the quality of their environment. Some are more sensitive and more likely to develop Post-Traumatic Stress Disorder (PTSD) in response to Childhood Adversities (CAs), but might also benefit more from Positive Home Experiences (PHE). The aim of this study is to investigate the role of Environmental Sensitivity (ES), CAs and PHEs in PTSD development in children and adolescents. Data was collected from N = 2,569 children/adolescents. PTSD symptoms, CAs, PHEs and ES were assessed with self-report measures. We found that higher ES and CAs emerged as risk factors for PTSD development whereas higher levels of PHEs protected against PTSD. ES moderated the effects of CAs (ß = 1.08, p < .001) on PTSD symptoms in the total sample. This moderating effect was more pronounced in girls, suggesting that highly sensitive girls with high childhood adversities were more likely to have higher PTSD symptoms than girls with low levels of sensitivity (ß = 1.09, p < .001). In conclusion, Environmental Sensitivity played an important role as a risk factor for PTSD and as a moderating factor that accentuated the main effects of childhood adversities, particularly in girls.

Feasibility and acceptability of phone-delivered psychological therapy for refugee children and adolescents in a humanitarian setting.

BACKGROUND: Refugee children are at high risk of mental health problems but face barriers to accessing mental health services, a problem exacerbated by a shortage of mental health professionals. Having trained lay counsellors deliver therapy via telephone could overcome these barriers. This is the first study to explore feasibility and acceptability of telephone-delivered therapy with refugee children in a humanitarian setting. METHODS: An evidence-based intervention, Common Elements Treatment Approach, was adapted for telephone-delivery (t-CETA) and delivered by lay counsellors to Syrian refugee children in informal tented settlements in the Beqaa region of Lebanon. Following delivery of t-CETA, semi-structured interviews were conducted with counsellors (N = 3) and with children who received t-CETA (N = 11, 45% female, age 8-17 years) and their caregivers (N = 11, 100% female, age 29-56 years) (N = 25 interviews). Thematic content analysis was conducted separately for interviews with counsellors and interviews with families and results were synthesized. RESULTS: Three themes emerged from interviews with counsellors and four themes from interviews with families, with substantial overlap between them. Synthesized themes were: counselling over the phone both solves and creates practical and logistical challenges; t-CETA is adapted to potential cultural blocks; the relationship between the counsellor and the child and caregiver is extremely important; the family's attitude to mental health influences their understanding of and engagement with counselling; and t-CETA works and is needed. Counselling over the phone overcame logistical barriers, such as poor transportation, and cultural barriers, such as stigma associated with attending mental health services. It provided a more flexible and accessible service and resulted in reductions in symptoms for many children. Challenges included access to phones and poor network coverage, finding an appropriate space, and communication challenges over the phone. CONCLUSIONS: Despite some challenges, telephone-delivered therapy for children shows promising evidence of feasibility and acceptability in a humanitarian context and has the potential to increase access to mental health services by hard-to-reach populations. Approaches to addressing challenges of telephone-delivered therapy are discussed. Trial Registration ClinicalTrials.gov ID: NCT03887312; registered 22nd March 2019.

The important role of mothers during displacement: Direct and indirect effects of the refugee context on Syrian refugee children's mental health.

Refugee children are at increased risk for mental health problems, including post-traumatic stress, depression, and externalizing problems. The refugee environment, maternal mental health, and parenting may reduce or exacerbate that risk. This study investigated their direct and indirect associations with child mental health cross-sectionally in a sample of Syrian refugee child-mother dyads in Lebanon in 2017-19. Mediating pathways were tested using structural equation modeling with 1446 dyads (child: Mage = 11.39, 52.1% females) and again 1 year later with 872 (child: Mage = 12.17, 53.1% females) of the original sample. Mediating pathways from the refugee environment through maternal mental health and parenting to child outcomes were detected, emphasizing the importance of a holistic approach to refugee mental health.

Risk and resilience in Syrian refugee children: A multisystem analysis.

Refugee children are often exposed to substantial trauma, placing them at increased risk for mental illness. However, this risk can be mitigated by a capacity for resilience, conferred from multiple ecological systems (e.g., family, community), including at an individual biological level. We examined the ability of hair cortisol concentrations and polygenic scores for mental health to predict risk and resilience in a sample of Syrian refugee children (n = 1359). Children were categorized as either at-risk or resilient depending on clinical thresholds for posttraumatic stress disorder, depression, and externalizing behavior problems. Logistic regression was used to examine main and interacting effects while controlling for covariates. Elevated hair cortisol concentrations were significantly associated with reduced resilience (odds ratio (OR)=0.58, 95%CI [0.40, 0.83]) while controlling for levels of war exposure. Polygenic scores for depression, self-harm, and neuroticism were not found to have any significant main effects. However, a significant interaction emerged between hair cortisol and polygenic scores for depression (OR=0.04, 95%CI [0.003 0.47]), suggesting that children predisposed to depression were more at risk for mental health problems when hair cortisol concentrations were high. Our results suggest that biomarkers (separately and in combination) might support early identification of refugee children at risk for mental health problems.

What drives change in children receiving telephone-delivered Common Elements Treatment Approach (t-CETA)? A multiple n = 1 study with Syrian refugee children and adolescents in Lebanon.

BACKGROUND: Although the evidence-base for mental health and psychosocial support (MHPSS) interventions in humanitarian settings is growing rapidly, their mechanisms of change remain poorly understood despite the potential to improve the effectiveness and reach of interventions. OBJECTIVE: This study aimed to explore the mechanisms or factors that drive change in a modular transdiagnostic telephone-delivered mental health intervention, Common Elements Treatment Approach (t-CETA). PARTICIPANTS AND SETTING: Participants were Syrian refugee children and adolescents living in tented settlements in Lebanon. METHODS: We used a multiple n = 1 design, drawing on secondary data from 9 children who completed t-CETA during a pilot randomized controlled trial. RESULTS: Children with historical war-related trauma were more likely to show significant improvement across symptom clusters by the end of treatment compared to children presenting with depression related to daily living conditions. Children also showed fluctuating symptoms during the early stages of treatment (engagement and cognitive restructuring) but significant decline in symptoms after the trauma module (prolonged imaginal exposure) and depression module (behavioral activation). Salient external life events identified were starting or dropping out of school, working, change in living conditions, family conflict and the October Revolution; and interpersonal factors of parental engagement (with or without full attendance) and counsellor skills in building rapport were also identified as having an impact on treatment success. CONCLUSIONS: Implications of our findings are discussed in terms of integrating active ingredients into MHPSS programming, and building on parental and multi-sector involvement in child and adolescent mental health care in humanitarian settings.

Effects of war exposure on pubertal development in refugee children.

Increasing research shows pubertal development accelerates following threats while it decelerates following deprivation. Yet, these environmental stressors are unlikely to occur in isolation. We investigated how war exposure and energetic stress impact pubertal development using data from the longitudinal Biological Pathways of Risk and Resilience in Syrian Refugee Children study. Our sample included 1,600 male and female Syrian refugee children and their caregivers who lived in temporary settlements in Lebanon. We hypothesized that (a) energetic stress suppresses pubertal development; (b) war exposure accelerates pubertal timing in boys and increases risk of menarche in girls, but only when energetic stress is low; and (c) when energetic stress is elevated, effects of war exposure on pubertal development will be attenuated. Among boys, we did not find support for Hypothesis 1, but Hypotheses 2 and 3 were supported. Exposure to morbidity/mortality threats accelerated pubertal timing; this effect was attenuated under conditions of elevated energetic stress. Among girls, we found support for Hypothesis 1, but not for Hypotheses 2 and 3. Elevated energetic stress decreased the risk of menarche in girls. Neither war exposure, nor any interactions with energetic stress, predicted risk of menarche. Sensitivity analyses revealed a significant interaction between bombing exposure and the amount of time since leaving Syria. Bombing decreased the risk of menarche, but only for girls who had left Syria four or more years prior to data collection. We discuss implications for translational efforts advocating for puberty screening in medical and mental health settings to identify trauma-exposed youth. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Individual Differences in Adolescents' Civic Engagement: The Role of Civic Discussions with Parents and Environmental Sensitivity.

The main goal of the current study was to examine the direct and moderating effects of civic discussions with parents and environmental sensitivity using both the total score and its specific dimensions (i.e., Aesthetic Sensitivity, AES; Ease of Excitation, EOE; Low Sensitivity Threshold, LST) on youth civic engagement (attitudes and behaviours). The empirical analysis relied on a questionnaire-based survey conducted on a sample of 438 adolescents (30% males), aged between 14 and 18 years (M = 16.50, SD = 1.36). We used a structural equation model (SEM) with latent variables and the latent moderated structural equation (LMS) method to test our hypotheses. Our results showed that civic discussions with parents were positively and significantly associated with general environmental sensitivity and with AES and predicted both civic attitudes and civic behaviours; EOE was negatively and significantly related to civic behaviours; AES was positively and significantly related to civic attitudes; and LST was not significantly related to either civic attitudes or behaviours. Contrary to our expectations, environmental sensitivity did not moderate the relationship between civic discussions with parents and civic engagement. Our study further highlights the relevance that parents have in shaping their children's civic engagement and makes a novel contribution regarding how differences in perceiving and processing environmental stimuli can affect beliefs and behaviours toward community issues among young individuals.

A test of the instability hypothesis in low- and middle-income countries.

The instability hypothesis proposes that family structure transitions lead to negative child outcomes through the pathway of stress. However, in many cases, family structure transitions are not associated with stress or negative child outcomes, suggesting that there are specific circumstances under which transitions are more or less stressful. Using five rounds of data (ages 1-15) from the Young Lives study (N = 8,062) which follows children and their caregivers in Ethiopia, India, Peru, and Vietnam, we had two aims: (a) to test the instability hypothesis, and (b) to examine the specific circumstances under which family structure transitions lead to stress and worsened child physical health. First, we used multilevel mediation to assess whether financial stress mediated the link between family structure transitions and children's physical health. We then added household size, multigenerational household, and horizontally extended kin household as moderators to the family structure transition-financial stress relationship. We found that financial stress did not mediate the link between family structure transitions and children's physical health in any of the Young Lives countries. We found some moderated mediation effects for household size and multigenerational households in Peru and Vietnam, but effect sizes were small. These findings highlight the need to further unpack the instability hypothesis to understand the specific circumstances under which family structure transitions lead to stress and worsened child outcomes. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Prenatal programming of environmental sensitivity.

According to several theories, people differ in their sensitivity to environmental influences with some more susceptible than others to both supportive and adverse contextual conditions. Such differences in environmental sensitivity have a genetic basis but are also shaped by environmental factors. Herein we narratively build on our previous work proposing that prenatal experiences contribute to the development of environmental sensitivity. This hypothesis of prenatal programming of postnatal plasticity has considerable empirical support. After presenting illustrative animal and human evidence consistent with this claim, we discuss a range of biological mechanisms likely involved in the pathway from prenatal stress exposure to postnatal environmental sensitivity. We also consider work suggesting that genetic differences, gender, as well as the timing, duration and intensity of prenatal exposures may moderate the effects of prenatal programming on postnatal environmental susceptibility or sensitivity. Before concluding, we highlight "unknowns in the prenatal programming of environmental sensitivity" and their practical implications. Ultimately, we conclude that prenatal stress does not necessarily predispose individuals to problematical development, but rather increases sensitivity to both adverse and supportive postnatal contexts. Thus, prenatal stress may actually foster positive development if paired with supportive and caring postnatal environments.

Mental health and psychosocial support in humanitarian settings: research priorities for 2021-30.

We describe an effort to develop a consensus-based research agenda for mental health and psychosocial support (MHPSS) interventions in humanitarian settings for 2021-30. By engaging a broad group of stakeholders, we generated research questions through a qualitative study (in Indonesia, Lebanon, and Uganda; n=101), consultations led by humanitarian agencies (n=259), and an expert panel (n=227; 51% female participants and 49% male participants; 84% of participants based in low-income and middle-income countries). The expert panel selected and rated a final list of 20 research questions. After rating, the MHPSS research agenda favoured applied research questions (eg, regarding workforce strengthening and monitoring and evaluation practices). Compared with research priorities for the previous decade, there is a shift towards systems-oriented implementation research (eg, multisectoral integration and ensuring sustainability) rather than efficacy research. Answering these research questions selected and rated by the expert panel will require improved partnerships between researchers, practitioners, policy makers, and communities affected by humanitarian crises, and improved equity in funding for MHPSS research in low-income and middle-income countries.

Sensory processing sensitivity in adolescents reporting chronic pain: an exploratory study.

Introduction: Sensory processing sensitivity (SPS) describes a genetically influenced trait characterized by greater depth of information processing, lower sensory threshold, and ease of overstimulation. It is hypothesized that SPS plays a crucial role in the context of chronic pain.Objectives: This exploratory study examined SPS as a correlate of pain intensity and pain-related disability in a sample of adolescents reporting chronic pain. Methods: Adolescents reporting chronic pain were contacted through social media and through specialized pain clinics. Participants completed online questionnaires on their levels of SPS, pain features, emotion regulation, and quality of life. A series of analysis of variances (ANOVAs) were calculated to detect differences between 3 SPS groups (ie, high, medium, and low sensitivity) regarding emotion regulation, quality of life, and pain features. Multiple linear regressions were conducted to predict pain intensity, pain-related disability, and quality of life. Results: In total, 103 participants completed the survey (68.9% female, Mage 17.9). Back pain was the most frequently reported pain location. Proportion of highly sensitive individuals was large (45.68%). The ANOVA revealed significant differences between sensitivity groups related to quality-of-life subscales, namely, for physical (F(2, 100) = 7.42, P < 0.001), emotional (F(2, 100) = 6.11, P < 0.001), and school functioning (F(2, 100) = 3.75, P = 0.03). High sensitivity was not predictive of pain but of health-related quality of life. Conclusions: Our results indicate that SPS is an important and prevalent characteristic to consider in the context of chronic pain in adolescents, specifically regarding the quality of life.

War exposure, post-traumatic stress symptoms and hair cortisol concentrations in Syrian refugee children.

Altered secretion of cortisol, the primary effector of the hypothalamus-pituitary-adrenal axis, has been proposed as a means by which traumatic experiences compromise later mental health. However, despite the popularity of cortisol as a potential biomarker for stress and adversity, findings are inconsistent, and little is known about the impact of war-related trauma on stress physiology of children and adolescents. Here we aimed to evaluate the relationships between war exposure, current living conditions, hair cortisol concentrations (HCC) and post-traumatic stress disorder (PTSD) symptoms in a large cohort of Syrian refugee children and adolescents (6-18 years) and their caregiver. This longitudinal observational study assessed Syrian refugee children and adolescents in two waves, 1 year apart, within informal tented settlements in Lebanon. The relationships between war exposure, time since leaving Syria, PTSD symptoms and HCC were investigated using linear mixed-model regression utilising both waves of data collected (Y1: N = 1574, Y2: N = 923). Hair cortisol concentration was positively, but weakly associated with the number of war-related events experienced. This was limited to those who were at least 12 years old at the time of war exposure. Conversely, HCC decreased with time since leaving Syria. HCC was also associated with PTSD symptoms but not with the quality of their current living conditions. This study revealed that changes to hypothalamic-pituitary-adrenal axis activity may accompany both earlier war exposure and current PTSD symptoms in children and adolescents. Additionally, early adolescence may be a particularly sensitive time in terms of trauma-related changes to the hypothalamic-pituitary-adrenal axis.

The culturally and contextually sensitive assessment of mental health using a structured diagnostic interview (MINI Kid) for Syrian refugee children and adolescents in Lebanon: Challenges and solutions.

Elevated rates of mental health difficulties are frequently reported in conflict-affected and displaced populations. Even with advances in improving the validity and reliability of measures, our knowledge of the performance of assessment tools is often limited by a lack of contextualization to specific populations and socio-political settings. This reflective article aimed to review challenges and share lessons learned from the process of administering and supervising a structured clinical interview. We administered the MINI International Neuropsychiatric Interview for Children and Adolescents (MINI Kid) and used the Clinical Global Impression (CGI) severity scale with N = 119 Syrian refugee children (aged 8-17) resident in ITSs in Lebanon. Qualitative data were derived from supervision process notes on challenges that arose during assessments, analyzed for thematic content. Five themes were identified: (1) practical and logistical challenges (changeable nature of daily life, competing demands, access to phones, temporary locations, limited referral options); (2) validity (lack of privacy, trust, perceptions of mental health, stigma, false positive answers); (3) cultural norms and meaning (impact of different meanings on answers); (4) contextual norms (reactive and adaptive emotional and behavioral responses to contextual stress); and (5) co-morbidity and formulation (interconnected and complex presentations). The findings suggest that while structured assessments have major advantages, cultural and contextual sensitivity during assessments, addressing practical barriers to improving accessibility, and consideration for inter-connected formulations are essential to help inform prevalence rates, treatment plans, and public health strategies.

Predictors of psychological risk and resilience among Syrian refugee children.

OBJECTIVES: War-exposed refugee children are at elevated risk for mental health problems, but a notable proportion appear resilient. We aimed to investigate the proportion of Syrian refugee children who can be considered resilient, and applied a novel approach to identify factors predicting individual differences in mental health outcomes following war exposure. METHODS: The sample included 1,528 war-exposed Syrian refugee children and their primary caregiver living in refugee settlements in Lebanon. Children were classed as having low symptoms (LS) if they scored below clinically validated cut-offs for post-traumatic stress disorder (PTSD), depression and externalising behaviour problems. Children scoring above any cut-off were classified as having high symptoms (HS). Each LS child was matched with one HS who reported similar war exposure, to test what differentiates children with similar exposures but different outcomes. RESULTS: 19.3% of the children met our resilience criteria and were considered LS. At the individual level, protective traits (e.g. self-esteem; OR = 1.51, 95% CI [1.25, 1.81]) predicted LS classification, while environmental sensitivity (OR = 0.69, 95% CI [0.59, 0.82]), poorer general health (OR = 0.71, 95% CI [0.58, 0.87]) and specific coping strategies (e.g. avoidance; OR = 0.90, 95% CI [0.85, 0.96]) predicted HS classification. Social/environmental predictors included perceived social support (OR = 1.23, 95% CI [1.02, 1.49]), loneliness and social isolation (OR = 0.85, 95% CI [0.80, 0.90]), child maltreatment (OR = 0.96, 95% CI [0.94, 0.97]), and caregiver mental and general health (e.g. caregiver depression; OR = 0.94, 95% CI [0.92, 0.97]). CONCLUSIONS: Future research should take multiple dimensions of functioning into account when defining risk for mental health problems and consider the identified predictors as potential targets for interventions.