Parenting in a post-conflict region: Associations between observed maternal parenting practices and maternal, child, and contextual factors in northern Uganda.

Studies show that war leads to an increase in harsh parenting and a decrease in parental warmth, which in turn has a devastating impact on children's development. However, there is insufficient research on the factors that affect parenting in post-conflict regions. In addition, most previous studies on the role of parenting in the context of war rely on self-reports, which are subject to a number of limitations. To complement existing research, the present cross-sectional study used behavioral observations of 101 mothers and their 6-12 year old children to assess parenting in post-conflict northern Uganda. The aim of the current study was to explore associations between observed maternal warmth and coercion and self-reported socioeconomic status (e.g., mother's educational level) as well as maternal (e.g., posttraumatic stress disorder), child (e.g., externalizing problems), and social contextual factors (e.g., family violence). Results show a link between observed parenting, child characteristics, and family violence. Higher levels of children's externalizing problems were associated with more severe maternal coercion. In addition, a negative association was found between family violence and maternal warmth. Findings are discussed in terms of their implications for prevention and intervention programs and the use of behavioral observations in post-conflict environments.

Expanding the Traumatic Stress Framework to Incorporate a Socioecological Family Systems Perspective.

Over the past few decades, there has been a growing interest among systemic researchers and clinicians to address issues related to psychological traumatic stress. Yet, research in this area has largely focused on intrapersonal and physiological processes in conceptualizing traumatic stress and its various outcomes. Despite the usefulness of intrapersonally focused models of traumatic stress, this approach has its limitations. Emerging evidence indicates that both proximal contexts, such as family, and distal socioecological contexts, such as political and environmental systems, can have a profound effect on traumatic stress risk, presentation, and recovery. In the present article, we review and synthesize emerging research on traumatic stress and integrate findings from intrapersonally and systemically focused models of traumatic stress. We propose and present evidence for what we term the dynamic socioecological framework of traumatic stress, a heuristic framework for conceptualizing the interactions between different forms of traumatic stress. This framework puts forward the dimensions of traumatic stress typology, severity, and timing, underscoring how traumatic stress risk, presentation, and recovery are highly dependent upon the systems in which people are embedded. We conclude with a discussion of the research and clinical implications of this conceptual framework.

Durante las últimas décadas, ha habido un interés cada vez mayor entre los investigadores y los profesionales clínicos sistémicos en abordar los problemas relacionados con el estrés traumático psicológico. Sin embargo, las investigaciones en esta área se han centrado en gran medida en los procesos intrapersonales y fisiológicos a la hora de conceptualizar el estrés traumático y sus diferentes resultados. A pesar de la utilidad de los modelos intrapersonales de estrés traumático, este enfoque tiene sus limitaciones. Hay nuevos indicios de que los contextos proximales, como la familia, y los contextos socioecológicos distales, como los sistemas políticos y ambientales, pueden tener un efecto profundo en el riesgo, la presentación y la recuperación del estrés traumático. En el presente artículo, analizamos y sintetizamos las investigaciones nuevas sobre estrés traumático e integramos los resultados de los modelos intrapersonales y sistémicos de este tipo de estrés. Proponemos y presentamos pruebas para lo que llamamos el marco socioecológico dinámico del estrés traumático, un marco heurístico para conceptualizar las interacciones entre las diferentes formas de estrés traumático. Este marco propone los aspectos de tipología, intensidad y desarrollo cronológico del estrés traumático, subrayando cómo el riesgo, la presentación y la recuperación del estrés traumático son sumamente dependientes de los sistemas en los cuales están integradas las personas. Terminamos con un debate de la investigación y las consecuencias clínicas de este marco conceptual.

A Phenomenological Study on the Experience of Syrian Asylum-Seekers and Refugees in the United States.

Violence in Syria has displaced an unprecedented number of people from their homes. While couple/family therapy (C/MFT) scholars have explored migration experiences, particularly among refugees, there is still limited research using a bioecological framework. This exploratory study examined the experiences of Syrian asylum-seekers and refugees living in the United States using a qualitative phenomenological approach. Twelve Syrians (n = 8 men, n = 4 women) between 20 and 52 years of age (M = 35.8, SD = 10.7) were interviewed about their experiences across three stages of resettlement: (1) pre-resettlement, (2) resettlement/migration, and (3) post-resettlement. Findings suggest that the effects of conflict-induced displacement and resettlement permeate across multiple ecologies. These range from the individual and his or her interpersonal relationships to their larger community and society. C/MFTs should account for contextual factors while becoming familiar with the sociopolitical impact of displacement and resettlement in their clinical work with this population.

La violencia en Siria ha desplazado a un número de personas sin precedentes de sus hogares. Si bien los especialistas en terapia de pareja, conyugal y familiar han analizado las experiencias de migración; particularmente entre los refugiados, aun hay escasas investigaciones que usan un marco bioecológico. Este estudio exploratorio analizó las experiencias de los solicitantes de asilo y los refugiados sirios que viven en Estados Unidos utilizando un enfoque fenomenológico cualitativo. Se entrevistó a doce sirios (n = 8 hombres, n = 4 mujeres) de entre 20 y 52 años (M = 35.8, SD = 10.7) con respecto a sus experiencias en tres etapas del reasentamiento: (1) prereasentamiento, (2) reasentamiento/migración, y (3) posreasentamiento. Los resultados sugieren que los efectos del desplazamiento inducido por el conflicto, junto con el reasentamiento, penetran en las ecologías. Estos pueden variar desde la persona y sus relaciones interpersonales hasta su comunidad y sociedad más amplias. Por lo tanto, la terapia de pareja, conyugal y familiar debería justificar los factores contextuales y a la vez familiarizarse con el efecto sociopolítico del desplazamiento y el reasentamiento en su trabajo clínico con esta población.

Perceptions of War Trauma and Healing of Marital Relations Among Torture-surviving Congolese Couples Participating in Multicouple Therapy.

Citizens of the Democratic Republic of Congo (DRC) experienced widespread torture during national wars between 1998 and 2003. Couples who survived and stayed intact suffered tremendous relationship stress. This study used a critical ethnography framework to explore the prewar, wartime, and postwar experiences of 13 torture-surviving couples who participated in a 10-session Torture-Surviving Couple Group in 2008 in the DRC. The group was designed to address the relational effects of torture and war trauma. Participants reported profound negative effects of the war on their relationships; mostly positive experiences during the group, including marital and peer connection and relationship growth; and a number of improvements in their relationship after the group. Implications include support for the use of relational interventions informed by both treatments for traumatic stress and couple approaches to promote trauma healing. Future directions call for increased funding, research, training, and clinical action to treat the effects of traumatic stress on relational family dynamics.

Los ciudadanos de la República Democrática del Congo (RDC) sufrieron torturas generalizadas durante las guerras nacionales entre 1998 y 2003. Las parejas que sobrevivieron y se mantuvieron intactas sufrieron un estrés relacional enorme. Este estudio utilizó un marco etnográfico fundamental para analizar las experiencias en tiempos de preguerra, de guerra y de posguerra de 13 parejas sobrevivientes de la tortura que participaron en un grupo de parejas sobrevivientes de la tortura consistente en diez sesiones en 2008 en la RDC. El grupo se diseñó para abordar los efectos relacionales del trauma de la tortura y la guerra. Los participantes informaron efectos negativos profundos de la guerra en sus relaciones; mayormente experiencias positivas durante el grupo, por ejemplo, la conexión conyugal y entre pares y el crecimiento de la relación; y varias mejoras en su relación después del grupo. Entre las conclusiones se encuentran el respaldo del uso de intervenciones relacionales avaladas tanto por los tratamientos para el estrés traumático como por los enfoques de pareja para promover la recuperación del trauma. Las futuras direcciones requieren mayor financiamiento, investigación, capacitación y acción clínica para tratar los efectos del estrés traumático en la dinámica familiar relacional.

Latinx Mental Health Scholars' Experiences with Cultural Adaptation and Implementation of Systemic Family Interventions.

An increasing number of culturally adapted family-level interventions address mental health disparities with marginalized populations in the United States. However, with these developments many barriers have arisen, such as challenges with degree of cultural fit, engagement, and sustainability. We conducted 12 elite phenomenological interviews with mental health scholars involved in prevention and intervention family research with various Latinx communities within and outside of the United States. These scholars discussed their experiences of overcoming barriers in their research. We used thematic analysis to code and analyze participant responses, and our findings support the gaps in previous literature and highlight potential pathways to overcoming barriers in cultural adaptation research. Themes included the need for: (a) better understanding of the intersection between culture and context; (b) community-centered approaches to addressing implementation challenges; and (c) structural changes within institutional, governmental, and political levels. We discuss implications for researchers and practitioners working with Latinx families.

Un número cada vez mayor de intervenciones adaptadas culturalmente a nivel familiar abordan las desigualdades en la salud mental con poblaciones marginadas en los Estados Unidos. Sin embargo, con estos avances han surgido muchos obstáculos, como las dificultades con el grado de integración cultural, la participación y la sostenibilidad. Realizamos veinte entrevistas fenomenológicas selectas con investigadores de la salud mental dedicados a la investigación familiar en materia de prevención e intervenciones con varias comunidades latinas dentro y fuera de los Estados Unidos. Estos investigadores comentaron sus experiencias de superación de los obstáculos en su investigación. Utilizamos el análisis temático para decodificar y analizar las respuestas de los participantes; nuestros resultados respaldan la falta de datos en publicaciones previas y destacan las posibles vías para superar los obstáculos en la investigación sobre la adaptación cultural. Los temas incluyeron la nacesidad de: (a) una mejor comprensión del enlace entre la cultura y el contexto; (b) enfoques centrados en la comunidad para abordar las dificultades de implementación; y (c) cambios estructurales dentro de los niveles institucionales, gubernamentales y políticos. Debatimos las implicancias para los investigadores y los profesionales que trabajan con familias latinas.

Adaptive Recruitment and Parenting Interventions for Immigrant Latino Families with Adolescents.

Parenting programs are an effective strategy to prevent multiple risky outcomes during adolescence. However, these programs usually enroll one caregiver and have low attendance. This study evaluated the preliminary results, cost, and satisfaction of adaptive recruitment and parenting interventions for immigrant Latino families. A mixed methods study was conducted integrating a pre-post design with embedded qualitative and process evaluations. Fifteen immigrant Latino families with an adolescent child aged 10-14 were recruited. Two-caregiver families received a home visit to increase enrollment of both caregivers. All families participated in an adaptive parenting program that included group sessions and a one-to-one component (online videos plus follow-up telephone calls) for those who did not attend the group sessions. The intervention addressed positive parenting practices using a strengths-based framework. Primary outcomes were the proportion of two-parent families recruited and intervention participation. Secondary outcomes were change in parenting self-efficacy, practices, fidelity, costs, and satisfaction. Participants completed questionnaires and interaction tasks before and after participating in the intervention. In addition, participants and program facilitators completed individual interviews to assess satisfaction with the program components. Overall, 23 parents participated in the intervention; 73% of two-parent families enrolled with both parents. Most participants completed 75% or more of the intervention. Fathers were more likely to use the one-to-one component of the intervention than mothers (p = .038). Participants were satisfied with program modifications. In sum, adaptive recruitment and parenting interventions achieved high father enrollment and high participation. These findings warrant further evaluation in randomized trials.

Bioecological Implications of Narrative Exposure Therapy in Low-Resource Settings: Individual, Family, Community, and Socio-Political Contexts.

Traumatic stress can have detrimental effects on individuals, families, and communities. Narrative Exposure Therapy (NET) is an evidence-based intervention for decreasing individuals' posttraumatic stress disorder (PTSD) symptoms and has been tested in some of the most challenging contexts, such as in post-conflict refugee camps. Although the focus of NET is on reducing individual PTSD symptoms, the impact of NET can be seen beyond the individual level. The purpose of this manuscript was to examine some of the ecological implications of using NET with trauma-affected populations in low-resource settings. We highlight select implications of NET that extend beyond the individual to systemic effects at the family, community, and sociopolitical levels using several case examples. Finally, we outline limitations and future directions for improving the delivery of NET in settings with limited resources.

Narrative Exposure Therapy: A Proposed Model to Address Intimate Partner Violence-Related PTSD in Parenting and Pregnant Adolescents.

Pregnant and parenting adolescents experience high rates of intimate partner violence (IPV) and its sequelae posttraumatic stress disorder (PTSD) and depression. Narrative exposure therapy (NET) is an innovative intervention that has demonstrated strong preliminary evidence in improving mental health. The specific aims of this article are 3-fold: (1) provide a brief background about IPV-related PTSD and depression among pregnant and parenting adolescents; (2) describe NET's theoretical principles, its therapeutic process, and provide a review of existing evidence; and (3) discuss NET as a potential treatment to address the mental health burden among adolescents experiencing IPV-related PTSD and depression.

Preparing the Field for Feasibility Testing of a Parenting Intervention for War-Affected Mothers in Northern Uganda.

In this article, we discuss the successful implementation of an adapted evidence-based parenting intervention for families affected by two decades of war in Northern Uganda. The adaptation and adoption of such interventions to support mental health and family functioning is widely endorsed by prevention scientists and considered a priority in global mental health. The preparation and early adoption phases of engaging with a highly vulnerable community affected by war trauma are documented in this paper along with a discussion of the steps taken to adapt a parenting intervention for cultural and contextual fit. This study is a component of an overall program of research aimed at reducing the long-term negative effects of war on parenting practices and childhood outcomes, which have considerable implications for preventing mental, neurological, and substance-use disorders. The processes described here cover a 4-year period culminating in the implementation of the nine-session Enhancing Family Connection intervention piloted with a group of 14 mothers. The lessons in cultural adaptation have been valuable and the feasibility results promising for further testing the intervention.

Severe Childhood Autism: The Family Lived Experience.

This research examined the experiences of families living with a child with severe autism. There is limited literature on the experiences of families when a child has severe autism as distinct from milder autism and includes the voices of multiple family members. Van Manen's phenomenological approach was used for data collection and analysis. This approach allowed for the use of innovative data sources, including unstructured individual and family interviews, observations, and family lifelines (a pictorial, temporal picture with comments of the families lives). This study included 29 interviews with 22 participants from 11 families. All data were creatively triangulated and interpreted. Six essential themes were identified. First, families experienced autism as mysterious and complex because it is an invisible and unpredictable condition with diagnostic challenges. Second, families described severe autism behaviors that often caused self-injury, harm to others and damaged homes. Third, profound communication deficits resulted in isolation between the family and child. Fourth, families discussed the unrelenting stress from lack of sleep, managing the child's developmental delays, coordinating and financing services, and concern for the child's future. Fifth, families described consequences of isolation from friends, school, the public, and health providers. Sixth, families portrayed their need for compassionate support and formed 'hybrid families' (nuclear, extended families and friends) to gain support. Study results can be utilized to educate nurses/other providers about the unique needs of families with children with severe autism and could influence health care policies to improve the care for families caring for children with severe autism.

Understanding Attendance in a Community-Based Parenting Intervention for Immigrant Latino Families.

Community-based participatory research (CBPR) can help increase the attendance in community programs. Padres Informados, Jovenes Preparados (PIJP) is a program that aims to prevent tobacco and other substance use among Latino youth by promoting positive parenting. Although the trial used CBPR approaches, attendance was inconsistent. In the present study, factors associated with attendance and nonattendance and recommendations to maximize participation were explored in 12 brief feedback discussions (BFDs) with participants and in 10 in-depth interviews (IDIs) with facilitators who delivered PIJP. Content analysis guided two pairs of researchers, who independently coded emerging themes and categories (κ = .86 for BFDs and .73 for IDIs). Data from BFDs and IDIs were merged and interpreted together. We grouped factors that positively affected participation into three categories: individual and family (e.g., motivation), program (e.g., offering food and childcare and having facilitators who are trusted), and research (e.g., having incentives). Barriers to participation were grouped into four categories: individual and family (e.g., family conflicts), sociocultural (e.g., community and cultural beliefs), program (e.g., fixed schedules), and research (e.g., recruitment procedures). Participants provided recommendations to address all types of barriers. Although PIJP used CBPR, complete satisfaction of community needs is difficult. Effective community programs must address participants' needs and preferences.

Assessing the feasibility of providing a parenting intervention for war-affected families in northern Uganda.

This article reports the results of a feasibility study of an intervention, Enhancing Family Connection (EFC), conducted in Northern Uganda in 2012. Enhancing Family Connection's sessions were an adaption of the Parent Management Training, Oregon model. Three interrelated areas of feasibility were assessed: (a) acceptability, (b) usability, and (c) limited efficacy. This study utilized questionnaires and semi-structured interviews completed by mothers and a focal child pre- and post-intervention. Results indicated that mothers found the intervention acceptable to their families and culture and showed promise for Enhancing Family Connection's efficacy in changing parenting behaviors. This study supports continued development of this intervention.

The intersections of culture and power in clinician and interpreter relationships: A qualitative study.

Ongoing racial/ethnic health disparities place increasing emphasis on the importance of interpreters in mental health treatment. Yet there is a limited body of research examining how interpreters and clinicians work together in delivering care. This article used an ethno-culturally informed qualitative procedure to ask interpreters and clinicians about their experiences in cross-language mental health treatment. Seventeen semistructured interviews were conducted with 10 interpreters and 7 clinicians. The interplay of power was experienced differently by interpreters and clinicians as exemplified by 3 categories of meaning: Interpreters speaking out, The relationship matters, and Who has the power? The authors recommend future research focus on the clinician-interpreter relationship as an essential piece of cross-cultural mental health delivery.

Exploring the mental health effects of political trauma with newly arrived refugees.

We explored the mental health effects of war trauma and torture as described by 111 refugees newly arrived in the United States. We used ethnocultural methodologies to inform 13 culture-specific focus groups with refugees from Bhutan (34), Burma (23), Ethiopia (27), and Somalia (27). Contrary to the belief that stigma prevents refugees from discussing mental health distress, participants readily described complex conceptualizations of degrees of mental health distress informed by political context, observation of symptoms, cultural idioms, and functional impairment. Recommendations for health care providers include assessment processes that inquire about symptoms in their political context, the degree of distress as it is culturally conceptualized, and its effect on functioning. Findings confirm the cross-cultural recognition of symptoms associated with posttraumatic stress disorder; however, refugees described significant cultural variation in expressions of distress, indicating the need for more research on culture-bound disorders and idioms of distress.

A pilot examination of the use of narrative therapy with individuals diagnosed with PTSD.

Narrative therapy is a postmodern, collaborative therapy approach based on the elaboration of personal narratives for lived experiences. Many aspects of narrative therapy suggest it may have great potential for helping people who are negatively affected by traumatic experiences, including those diagnosed with posttraumatic stress disorder (PTSD). The potential notwithstanding, narrative therapy is relatively untested in any population, and has yet to receive empirical support for treatment among survivors of trauma. A pilot investigation of the use of narrative therapy with 14 veterans with a diagnosis of PTSD (11 treatment completers) is described. Participants completed structured diagnostic interviews and self-report assessments of symptoms prior to and following 11 to 12 sessions of narrative therapy. After treatment, 3 of 11 treatment completers no longer met criteria for PTSD and 7 of 11 had clinically significant decreases in PTSD symptoms as measured by the Clinician Administered PTSD Scale. Pre- to posttreatment effect sizes on outcomes ranged from 0.57 to 0.88. These preliminary results, in conjunction with low rates of treatment dropout (21.4%) and a high level of reported satisfaction with the treatment, suggest that further study of narrative therapy is warranted as a potential alternative to existing treatments for PTSD.

Intergenerational patterns of substance abuse among urban American Indian families.

Substance abuse continues to be a family problem in American Indian (AI) families. This article highlights findings from a two generation study on substance abuse among nine AI families. Five common themes shared by the parent and adult child groups included early onset of substance abuse, minimization of substance abuse (and a subtheme of efforts to control use), taking accountability for substance abuse (and a subtheme about perpetuated stereotypes), turning point moments in use (and a subtheme of negotiating and exploring sobriety), and perceptions of the abstinence only approach. Clinical implications are discussed in light of the findings.

Intergenerational transmission of traumatic stress and relational disruptions among Cambodian refugee families in the United States.

Cambodian refugees resettled in the United States were severely affected by genocidal trauma and have been trapped in decades of intergenerational transmission of traumatic stress and relational disruptions without much public attention. This manuscript reports on data collected as part of a Cambodian needs assessment that employed methodological principles of critical ethnography and was grounded by a human ecological theoretical model. Eighteen professionals who served Cambodian communities were interviewed. The interviews were transcribed in Khmer or/and English and analyzed using the Developmental Research Sequence resulting in three domains (Pre-Migration, During Migration, and Post Resettlement in the United States) and four categories (i.e. Impact on Self, Couple Relationships, Parent-Child Relationships, and Context) within each domain. The thematic findings emphasize intergenerational transmission of psychopathology, disruptions in parent-child relationships, and a critical need to support parents to promote positive child development within Cambodian communities.

Systemic effects of the COVID pandemic on rural black American men's interpersonal relationships: A phenomenological examination.

The COVID-19 pandemic was a socionatural disaster that unprecedentedly disrupted the daily lives of individuals, families, and communities. Prior research indicates that Black American men living in rural contexts, particularly in Southern parts of the United States of America, were disproportionately affected by the psychological and economic effects of the pandemic. Despite these disparities, few studies have examined the pandemic's impact on rural Black American men's social networks. This study aimed to explore the effects of the COVID-19 pandemic on rural Black American men's interpersonal relationships. Informed by the principles of critical ethnography and guided by van Manen's hermeneutic phenomenology, seventeen men were interviewed using a semi-structured interview protocol. Interviews were transcribed and then analyzed using an iterative thematic reduction process consistent with van Manen's approach. Four themes were generated: Familial Reorganization, Adaptive Fatherhood, Rona Romance, and Essential Community. Participants recounted how the pandemic motivated them to improve their relationships with family members and children but contributed additional stress to their romantic relationships. Participants further recounted how their friendships were the least impacted as they were willing to make exceptions to their normal protective protocols to socialize with close friends. Participants also noted feeling disconnected from their wider community because they could not attend church even though their religious beliefs remained unchanged. Findings highlight the need for scholars, clinicians, and policymakers to consider men's relational health when developing and implementing pandemic recovery efforts, as it can significantly influence their ability to recuperate mentally and physically. Future research should be dedicated to (1) investigating the effects of the COVID-19 pandemic on fathers, as prior research has nearly exclusively focused on mothers' experiences and (2) delineating protective effects of rural Black American men's involvement in the Black Church from their individual spiritualities to gain a more comprehensive understanding of the influence of contextual crisis on their long-term health and wellbeing.

Complex Posttraumatic Stress Disorder Links Trauma Exposure and Suicidal Behaviors Among Sexual Minority Populations: A New Target in Suicide Prevention?

Exposure to potentially traumatic events and posttraumatic stress are known risk factors for suicidal thoughts and behaviors (STB). Research suggests that sexual minorities are disproportionately exposed to traumatic events and experience greater STB than their heterosexual peers, although few studies have explored connections between these parallel disparities. Further, existing literature may implicate complex posttraumatic stress disorder (CPTSD) as a potential mechanism in the trauma-suicide connection among sexual minorities. This study uses a sample from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC-III; n = 1351) to test structural equation models for associations between trauma exposure, heterosexist discrimination, and CPTSD with suicide attempt status. We found CPTSD mediated associations between exposure to traumatic events and presence of a lifetime suicide attempt among sexual minority male and female samples. Discrimination demonstrated a synergistic effect on the association between trauma exposure and CPTSD, but, among males, CPTSD did not fully explain associations between discrimination and suicide attempts. Our findings suggest that CPTSD should be considered an important mechanism in the trauma-suicide connection for sexual minorities and may be a potentially important target for suicide prevention and that interventions should address the influence of discrimination on traumatic stress in this high-risk population.

A Systematic Review of Evidence-Based Family Interventions for Trauma-Affected Refugees.

Family connections are crucial for trauma-affected refugees from collectivistic cultures. Evidence-based family interventions are consistently promoted to support a host of mental and relational health needs of families exposed to traumatic stressors; however, there is still limited research focused on cultural adaptation and the testing of the effectiveness of these interventions on some of the most disenfranchised populations in the aftermath of forced displacement. This systematic review was conducted to examine the reach of existing evidence-based family interventions implemented with newly resettled refugees globally. Studies included in this review include those testing the effectiveness of a systemic treatment with pre and post intervention evaluation, studies with or without control groups, and studies that include at least one family member in addition to the target participants. Twelve studies met the inclusion criteria. Barriers to conducting randomized control trials with displaced refugee populations are discussed. Recommendations are made for future studies to include a focus on scientifically rigorous multi-method designs, specific cultural adaptation frameworks, and the integration of relational aspects rather than focusing only on individual adjustment. Global displacement continues to rise; therefore, it is imperative that the mental health and wellbeing of displaced populations be treated with a comprehensive, multi-level framework.