Association Between Maladaptive Eating Behaviors Among Black Women and Vicarious Racial Discrimination Following a High-Profile Event.

OBJECTIVE: Evidence suggests that racial discrimination causes stress among non-Hispanic Black women, and some Black women may cope with exposure to vicarious racial discrimination by engaging in maladaptive eating behaviors. METHODS: We examined eating behaviors among Black women (N = 254) before and after Freddie Gray's death while in police custody. Maladaptive eating behaviors were assessed using the three-factor eating questionnaire. Our independent variables included the following: (1) time period and (2) geographic proximity to the event. Three two-way analysis of covariance tests were conducted to assess potential effects of geographic proximity (close, distant), time period in relation to unrest (before, after unrest), and their interaction on emotional eating, uncontrolled eating, and cognitive restraint controlling for participant age. RESULTS: There was a statistically significant main effect of proximity to the unrest on emotional eating, F (1, 252) = 5.64, p = .018, and partial η2 = .022 such that women living in close geographic proximity to the unrest reported higher mean levels of emotional eating as compared to those living more distant to the unrest. There was also a borderline statistically significant interaction between geographic proximity and time period on cognitive restraint, F (1, 252) = 3.89, p = .050, and partial η2 = .015. CONCLUSION: Our study found a relationship between vicarious racial discrimination and maladaptive eating behaviors among Black women. Future work should examine stress related to vicarious racial discrimination and maladaptive eating behaviors longitudinally.

Cost-Effectiveness a Parenting Skills Program Implemented in Public PreK Schools in Disadvantaged Urban Communities.

BACKGROUND: Little is known about the cost-effectiveness of parent training programs when offered universally in U.S. elementary schools in disadvantaged urban communities. OBJECTIVE: To estimate the cost-effectiveness of a universal school-based implementation study of the Chicago Parent Program (CPP). METHODS: CPP was offered universally from 2014 to 2017 to parents of PreK students in 12 Baltimore City Title 1 schools (n = 380; 61.1% Black/African American, 24.1% Hispanic). CPP program implementation and operating costs were estimated using microcosting methods and data drawn from study records. A Complier Average Causal Effects (CACE) framework was used to estimate an Incremental Cost Effectiveness Ratio (ICER) for CPP's average cost per child per 1% decrease in conduct problem prevalence at follow-up. This ICER was then compared with comparable ICERs for four parenting interventions that have been implemented and evaluated in Europe: Connect, Incredible Years, COPE, and Comet. RESULTS: CPP cost $937.51 per child (95% CI: $902.09 to $971.92). Adjusted CACE estimates indicated that CPP resulted in a 31.4% reduction (95% CI: -39.7% to -23.9%) in conduct problem prevalence at follow-up among children whose parents attended CPP. The mean ICER for CPP was $29.86 per each 1% reduction in prevalence (95% CI: $21.05 to $50.71). CPP's ICER was similar to ICERs for Connect ($25.50) and COPE ($29.72), and less than ICERs for Incredible Years ($50.36) and Comet ($59.69). CONCLUSION: School-based CPP offered universally to parents of children transitioning to Kindergarten in extremely disadvantaged U.S. urban communities was found to offer relatively good value compared with similar parenting programs that are widely used in Europe.

A Mixed-Methods Evaluation of Virtually Delivered Group-Based Mothers and Babies for Latina Immigrant Mothers.

BACKGROUND: Immigrant Latinas are at higher risk for postpartum depression (PPD) than the general perinatal population, yet face numerous barriers to accessing mental health services. The goal of this study was to pilot an enhanced virtual group delivery of a PPD prevention program, Mothers and Babies (MB), among immigrant Latinas engaged in early childhood programming. METHODS: Forty-nine Spanish-speaking mothers participated in one of four MB virtual groups, facilitated by trained bilingual staff at affiliated early learning centers. MB was enhanced to also target social determinants of health. A mixed-methods design was used to evaluate MB using participant interviews and pre-post surveys measuring depressive symptoms, parenting distress, and self-efficacy to manage emotions. RESULTS: On average, participants attended 69% of MB virtual sessions and rated group cohesiveness at a 4.6 on a 5-point scale. Paired-samples t tests showed significant reductions in depressive symptoms (Cohen's d = 0.29; p = .03) and parenting distress (Cohen's d = 0.31; p = .02), and improved self-efficacy to manage emotions (Cohen's d = -0.58; p < .001). Participants reported both benefits and drawbacks of the virtual format and provided largely favorable feedback on program enhancements. CONCLUSIONS: Results provide initial evidence for the acceptability, feasibility, and effectiveness of an enhanced virtual group PPD prevention program for immigrant Latinas, delivered in partnership with local early learning centers. These findings have important implications for extending the reach of preventive interventions among a population that faces many structural and linguistic barriers to traditional forms of mental health service delivery.

When Adverse Childhood Experiences Present to a Statewide Child Psychiatry Access Program.

Many children experience adversity, yet few receive needed psychiatric services. Pediatric primary care providers (PCPs) are uniquely positioned to intervene but often lack training and resources to provide patients with adverse childhood experiences (ACEs) the psychiatric support they need. The current study examines characteristics of youth with and without ACEs who were the focus of PCP contacts with a statewide child psychiatry access program (CPAP). Compared to those without ACEs, patients with ACEs were more often receiving medication treatment at time of CPAP contact, prescribed two or more psychotropic medications, and diagnosed with two or more mental health disorders. Study findings indicate that patients with ACEs for whom PCPs sought CPAP support were experiencing more clinically severe and complex mental health concerns. These findings underscore the important role of CPAPs in supporting PCPs with pediatric patients who have ACEs and will inform training provided by CPAPs to PCPs.

Long-term consequences of bullying involvement in first grade.

Few prospective studies have examined how early bullying experiences impact long-term adjustment and the differential impact of children's co-occurring bullying and peer victimization involvement on adjustment in adulthood. This study addressed these gaps by examining subgroups of first graders involved in bullying and associations with four outcomes in early adulthood, including (a) Major Depression diagnosis, (b) post-high school suicide attempt, (c) on-time high school graduation, and (d) criminal justice involvement. Additionally, middle school standardized reading test scores and suspensions were examined as potential mechanisms through which early bullying involvement is associated with adult outcomes. Participants were 594 children from nine urban elementary schools in the United States who participated in a randomized controlled trial of two school-based universal prevention interventions. Latent profile analyses using peer nominations identified three subgroups: (a) High involvement bully-victims, (b) Moderate involvement bully-victims, and (c) Low/No involvement youth. Compared to the No/Low involvement class, High involvement bully-victims were less likely to graduate high school on time (OR = 0.48, p = .002) and Moderate involvement bully-victims were more likely to be involved in the criminal justice system (OR = 1.37, p = .02). High bully-victims were at greater risk for both not graduating high school on-time and criminal justice system involvement, which were partially explained by 6th grade standardized reading test scores and suspensions. Moderate bully-victims were less likely to graduate high school on time, which was partially explained by 6th grade suspensions. Findings highlight how early bully-victim involvement increases risk for difficulties that affect adult quality of life.

Associations Between Social Determinants of Health, Chronic Absence From School, and Teacher Ratings of Parents' Engagement in Early Education.

This study examined associations between four indicators of social determinants of health (SDOH; parent education, poverty, material hardships, and child health problems), chronic school absence, and teachers' ratings of parents' engagement in their children's education. Surveys were collected from 304 parents and 26 teachers from eight Baltimore City Public Schools. Results revealed that teachers' ratings of parent engagement were consistently lower among families experiencing adverse SDOH and/or whose children were chronically absent; however, there was no significant relationship between teachers' ratings of parent engagement and child health problems. Additionally, chronic absence partially mediated the relationship between three SDOH indicators (total material hardships, parent education level, and child health problems) and teacher-rated parent engagement. Poverty was excluded from mediation analysis due to evidence of multicollinearity suppressive effects. Addressing the SDOH assessed in this study may be an effective strategy to reduce chronic absence, promote parent engagement, and foster equity in education.

Characteristics of Patients Served by a Statewide Child Psychiatry Access Program.

OBJECTIVE: Maryland's Behavioral Health Integration in Pediatric Primary Care (BHIPP) is a child psychiatry access program offering child-adolescent psychiatry consultation, resource and referral networking, and direct-to-patient mental health intervention. This study investigated characteristics of patients for whom primary care providers sought BHIPP services. METHODS: Data from 6,939 unique patient contacts between October 2012 and March 2020 were collected on service type, demographic characteristics, presenting concerns, clinical severity, clinicians' diagnostic impressions, current treatments, and BHIPP recommendations. Descriptive statistics and latent class analysis were used. RESULTS: Of the 6,939 patient contacts, 38.6% were for direct-to-patient mental health intervention, 27.3% for child-adolescent psychiatry consultation, and 34.2% for resource and referral networking. In total, 50.3% of patients were female, 58.7% were White, and 32.7% were already receiving mental health services. Latent class analysis identified four classes of presenting concerns: anxiety only (44.2%); behavior problems only (30.7%); mood and anxiety (17.1%); and attention, behavior, and learning problems (8.0%). Compared with patients in the anxiety-only class, those in the attention, behavior, and learning problems class were more likely to receive direct-to-patient mental health intervention (OR=3.59), and BHIPP clinicians were more likely to recommend in-office behavioral interventions for those in the mood and anxiety class (OR=1.62) and behavior problems-only class (OR=1.55). CONCLUSIONS: Patients supported through BHIPP varied in presenting concerns, condition severity and complexity, current receipt of services, and BHIPP utilization. Latent class analysis yielded more clinically useful information about the nature and complexity of patients' concerns than did consideration of individual presenting concerns.

Positive Childhood Experiences Associate with Adult Flourishing Amidst Adversity: A Cross Sectional Survey Study with a National Sample of Young Adults.

The purpose of this study was to examine the prevalence of PCEs among young adults in Mainland China and the extent to which the cumulative number of PCEs moderates the associations between ACEs and flourishing in adulthood. Between August and November 2020, we used convenience and snowball sampling to recruit 9468 young adults, ages 18-35, enrolled in undergraduate or graduate programs at universities in Mainland China to participate in a survey, which included measures on flourishing, exposure to ACEs and PCEs, and demographic characteristics. Approximately 92% of participants reported experiencing seven to nine PCEs, with harmonious family relationships (96.9%), feeling supported by friends (96.8%) and being treated fairly at school (96.3%) being the most common PCEs reported. Results of the multiple regression indicated that the cumulative number of PCEs statistically significantly moderated the relation between the cumulative number of ACEs and flourishing (interaction term b = -0.060 [-0.071, -0.049], p < 0.001, adjusted R2 = 0.183); as the number of ACEs increased up through eight ACEs, decreases in flourishing were smaller among those with higher numbers of PCEs. PCEs are common among young adults from Mainland China and serve a potential buffering effect against exposure to ACEs.

Higher exposure to childhood adversity associates with lower adult flourishing.

BACKGROUND: Adverse childhood experiences (ACEs) are prevalent and associated with negative health and social outcomes. However, our understanding of how patterns of ACEs exposure relate to positive outcomes in adulthood remains limited. This study aims to identify patterns of ACEs and examine associations with flourishing in a sample of Chinese young adults. METHODS: This cross-sectional study was conducted from August to November 2020. Young adults, ages 18-35, enrolled in undergraduate or graduate programs at universities in Mainland China were recruited through convenience and snowball sampling to participate in a survey. The exposure to ACEs was measured by the twelve-item Chinese version of the ACE-International Questionnaire. Additional measures included six domains of flourishing assessed using the Chinese version of the Flourishing Measure, and demographic covariates (i.e., gender, age, year in university, marital status). Descriptive statistical analysis and latent class analysis (LCA) were performed using SPSS 27 and Mplus 8.5. RESULTS: Participants included 9468 young adults (mean age = 20.1 years). Majority of participants were female (75.3%), undergraduate students (96.4%), and single (79.8%). Approximately 56% of participants reported at least one ACE; 7.0% reported four or more ACEs. Emotional neglect (33.2%), household violence (20.6%), and parental separation/divorce (13.9%) were the most frequently reported ACEs. LCA identified three ACEs classes: multiple maltreatment and household violence (4.7%), emotional neglect and household violence (16.2%), and low ACEs (79.1%). Individuals in the low ACEs class had the highest level of flourishing whereas individuals in multiple maltreatment and household violence had the lowest level of flourishing in all six domains. There were no significant differences in flourishing between the multiple maltreatment and household violence and the emotional neglect and household violence classes except in the physical and mental health (means = 6.17 vs 6.51, p = 0.02) and the financial and material stability domains (means = 5.25 vs 5.66, p = 0.04). CONCLUSIONS: Patterns of multiple ACEs exposures were associated with lower levels of flourishing. Our findings have implications for efforts to prevent ACEs exposure through monitoring and promoting family well-being and routine screening to identify those with ACEs exposure to prevent negative social and health sequelae.

Characteristics of Primary Care Providers' Consultations With a Statewide Child Psychiatry Access Program Regarding Autism Spectrum Disorder.

BACKGROUND: Child Psychiatry Access Programs (CPAPs) provide consultative support for pediatric primary care providers (PCPs) to treat co-morbid mental health (MH) symptoms among patients with Autism Spectrum Disorder (ASD). OBJECTIVES: We examined differences in illness severity, comorbidity, and psychotropic medication use between patients with and without ASD for whom primary care providers sought consultation from Maryland's CPAP. METHODS: We examined N = 3641 Maryland's CPAP consultations from 2012 to 2019; n = 311 were consultations for ASD. Demographics, treatment recommendations, diagnoses, and Clinical Global Impression-Severity scores were collected. Patients who received psychotropic medication or psychotherapy by any mental health provider were defined as comanaged. Descriptive statistics and logistic regression were conducted. Sample size for regression was N = 1854. RESULTS: Compared with non-ASD, patients with consults for ASD were more often male (P < 0.001), aged 0-5 years (P < 0.001), severely ill (Clinical Global Impression-Severity > 4) (P < 0.001), and prescribed stimulants, nonstimulant attention-deficit hyperactivity disorder medications, and antipsychotic medications (P < 0.001). Controlling for key covariates, consultations for youth displaying aggression were 3.02 times (P < 0.001) more likely, with Clinical Global Impression-Severity > 4 were 2.36 times (P < 0.001) more likely, and prescribed antipsychotics were 4.30 times more likely to concern an ASD patient (P < 0.001). A larger proportion of ASD patients (vs. non-ASD) had comorbid psychiatric diagnoses of attention-deficit hyperactivity disorder, a learning disability, and disruptive behavior disorder vs. a smaller proportion with major depressive disorder. CONCLUSIONS: ASD patients for whom primary care providers sought Maryland's CPAP consultation were more severe and complex than non-ASD patients in terms of comorbid diagnoses and medication regimen.

Education on the Social Determinants of Mental Health in Child and Adolescent Psychiatry Fellowships.

OBJECTIVE: This article describes survey results from child and adolescent psychiatry (CAP) fellowship program directors regarding attitudes of their programs' capacity to effectively educate fellows on the social determinants of mental health and program directors' perceived importance of doing so. METHODS: A survey asking about six topics within the social determinants of mental health was disseminated to all CAP program directors with email addresses found in the Fellowship and Residency Electronic Interactive Database (FREIDA) (n = 134). Data were exported using the Qualtrics survey platform. RESULTS: Fifty-three program directors (40%) responded to the survey. Overall, 98% of program directors felt education on the social determinants of mental health was "essential" for fellowship training, but there were significant differences in perceived relative importance and effectiveness of education provided across topics. Familial factors were rated as significantly more important than structural, historical, and economic factors. Structural and historical factors were viewed as being taught less effectively than other factors. Educational, structural, and historical factors and neighborhood factors were allotted significantly less instructional time than familial factors. CONCLUSIONS: While there is near-universal consensus that social determinants of mental health education are critical for fellowship training, program directors feel that social determinants of mental health topics differ in importance and are taught at varying levels of effectiveness. These findings highlight the need for intra-institutional and or inter-institutional collaboration for social determinants of mental health educational content development if CAP programs are to prepare trainees to best serve their most vulnerable patients.

Beliefs as Mediators of Relations Between Exposure to Violence and Physical Aggression During Early Adolescence.

This study examined beliefs about aggression and self-efficacy for nonviolent responses as mediators of longitudinal relations between exposure to violence and physical aggression. Participants were a predominantly African American (79%) sample of 2,705 early adolescents from three middle schools within urban neighborhoods with high rates of violence. Participants completed measures across four waves (fall, winter, spring, and summer) within a school year. Beliefs supporting proactive aggression, beliefs against fighting, and self-efficacy for nonviolence partially mediated relations between witnessing violence and physical aggression. Indirect effects for beliefs supporting proactive aggression and self-efficacy were maintained after controlling for victimization and negative life events. Beliefs supporting proactive aggression mediated the effects of violent victimization on physical aggression, but these effects were not significant after controlling for witnessing violence and negative life events. The findings underscore the importance of examining the unique pathways from witnessing community violence versus violent victimization to physical aggression.

Latent classes of aggression and peer victimization: Measurement invariance and differential item functioning across sex, race-ethnicity, cohort, and study site.

Peer victimization is common and linked to maladjustment. Prior research has typically identified four peer victimization subgroups: aggressors, victims, aggressive-victims, and uninvolved. However, findings related to sex and racial-ethnic differences in subgroup membership have been mixed. Using data collected in September of 2002 and 2003, this study conducted confirmatory latent class analysis of a racially-ethnically diverse sample of 5415 sixth graders (49% boys; 50.6% Black; 20.9% Hispanic) representing two cohorts from 37 schools in four U.S. communities to replicate the four subgroups and evaluate measurement invariance of latent class indicators across cohort, sex, race-ethnicity, and study site. Results replicated the four-class solution and illustrated that sociodemographic differences in subgroup membership were less evident after accounting for differential item functioning.

Trends in Mental Health Concerns Reported to Two Pediatric Mental Health Care Access Programs During the COVID-19 Pandemic.

OBJECTIVE: Pediatric Mental Health Care Access (PMHCA) programs increase access to mental health care by providing training, consultation, and resource-referral support to primary care providers (PCPs). The authors compared trends in services provided by two PMHCA programs during the COVID-19 pandemic. METHODS: Maryland and Mississippi PMHCA programs had 2,840 contacts with PCPs from January 2019 to March 2021. Descriptive trends on PMHCA program utilization, service type, clinical severity, diagnostic complexity, and PCP contact reasons were reported. RESULTS: Both programs observed significant increases in call volume during the COVID-19 pandemic compared with before COVID-19. Increases were observed in calls regarding patients with multiple diagnoses (Maryland, 20% to 37%; Mississippi, 0% to 11%) as well as patients with mood and anxiety symptoms. CONCLUSIONS: Changes in PMHCA program usage suggest that PCPs identified more complex mental health concerns, particularly regarding mood and anxiety, during the pandemic than before COVID-19. Trends underscore the importance of PMHCA programs in supporting PCPs with managing pediatric mental health concerns.

Characteristics of Providers Using a Child Psychiatry Access Program.

OBJECTIVE: Child psychiatry access programs (CPAPs) help increase access to mental health services. This study aimed to provide information on the types of pediatric primary care clinicians (PPCCs) who call Maryland's CPAP. METHODS: Descriptive statistics and multinomial logistic regressions were conducted with data from 676 PPCCs who called Maryland's CPAP at least once between October 2012 and June 2019. RESULTS: On average, PPCCs contacted Maryland's CPAP 6.8 times. Providers who called seven or more times were more likely to have an allopathic or osteopathic medicine degree and to specialize in pediatrics. Providers calling from rural regions were less likely to call only for referrals. CONCLUSIONS: Most PPCCs contacted the CPAP for consultation or referrals but not both. PPCCs in rural areas were more likely to call for consultation, suggesting that they may be more likely to manage the care of patients with mental health conditions themselves, because of a lack of resources in their locations.

Pediatric Primary Care Provider Comfort with Mental Health Practices: A Needs Assessment of Regions with Shortages of Treatment Access.

OBJECTIVES: Nearly 50% of children with a mental health concern do not receive treatment. Child Psychiatry Access Programs like Behavioral Health Integration in Pediatric Primary Care (BHIPP) address regional shortages of mental health treatment access by providing training and consultation to primary care providers (PCPs) in managing mental health concerns. This study assessed PCPs' comfort with mental health practices to inform expansion of BHIPP services. METHODS: Pediatric PCPs in 114 practices in three rural regions of Maryland were recruited to participate in a survey about their comfort with mental health practices and access to mental health providers for referral. Descriptives, Friedman's test, and post hoc pairwise comparisons were used to examine survey responses. RESULTS: Participants were 107 PCPs. Most respondents were physicians (53.3%) or nurse practitioners/physician's assistants (39.3%). Friedman's test, χ2(7)= 210.15, p<.001, revealed significant within and between-group differences in PCP comfort with mental health practices. Post hoc pairwise comparisons indicated greater comfort providing mental health screening and referrals compared to prescribing psychiatric medications, providing psychoeducation or in-office mental health interventions. A Wilcoxon-signed rank test showed significantly more respondents agreed they could find a therapist than a psychiatrist in a timely manner, Z= -5.93, p<.001. CONCLUSIONS: Pediatric PCPs were more comfortable with providing mental health assessment and referrals than treatment. However, PCPs reported difficulty finding therapists and psychiatrists for their patients. Findings underscore the need for longitudinal training to increase PCP comfort with mental health treatment. Additionally, strategies such as telepsychiatry are needed to address the disproportionate need for child psychiatrists.

Patterns of Adolescents' Appraisals of Responses to Problem Situations: Associations with Aggression, Victimization, and Contextual Factors.

Although considerable research has examined factors that influence social-cognitive processes related to aggression, few studies have examined the factors that influence adolescents' appraisal of the effectiveness of responses, particularly nonviolent alternatives to aggression. This study addressed that gap by examining patterns of adolescents' perceived effectiveness of nonviolent and aggressive responses to hypothetical problem situations and their relations with aggression, victimization, and individual and contextual risk factors. The participants were a predominantly African American (90%) sample of 1469 students (55% female; mean age = 12.7 years; age range = 11-16) from three middle schools who completed measures of perceived effectiveness, self-efficacy, aggression and victimization, and contextual factors. Ratings of adolescents' physical, relational, and verbal aggression and victimization, nonviolent and prosocial behavior were also obtained from their teachers. Latent class analysis identified four subgroups of adolescents including distinguishes effective, mixed support, everything works, and nothing works. Subgroups differed on measures of aggression, victimization, prosocial and nonviolent behavior, self-efficacy for nonviolence, witnessing community violence, and parents' and peers' support for nonviolence and aggression. The findings underscore the importance of designing violence prevention programs to target the unique needs of subgroups of adolescents.

A Systematic Review of the Methods Used to Evaluate Child Psychiatry Access Programs.

BACKGROUND: There is a well-documented gap between the need for and availability of mental health services for children nationwide. To address this gap, over 30 regional Child Psychiatry Access Programs (CPAPs) provide psychiatric consultation and other services to primary care providers. OBJECTIVE: Summarize the methods used to evaluate CPAPs in the United States. DATA SOURCES: PubMed, PsychInfo, CINAHL, and reference checking. STUDY APPRAISAL METHODS: A systematic literature review was conducted searching 3 databases. The search produced 307 unique articles, 278 were excluded for irrelevance, leaving 29 for data extraction. Data extracted included author(s), publication year, provider types, CPAP formats, study sample, design, outcomes examined, results, and limitations. Articles were also appraised for quality using the Johns Hopkins Nursing Evidence-Based Practice Evidence Level and Quality Guide. RESULTS: The 29 articles evaluated 13 unique CPAPs. Most evaluations used nonexperimental observational designs (68.9%), 6.9% used quasi-experimental designs, and none used true experimental designs. Evaluations examined the following outcomes: usage of program services (82.8%), provider satisfaction (48.3%), provider comfort/confidence with managing mental health concerns (31.0%), provider practice change (24.1%), patient outcomes (13.7%), and family satisfaction (6.9%). Outcomes were measured using surveys, qualitative interviews, or insurance claims data. LIMITATIONS: Review was limited to articles published in English in 3 databases or identified by reference checking. CONCLUSIONS: Evaluations of CPAPs have largely been descriptive in nature, focusing primarily on program usage and provider satisfaction. Few studies have examined the impact of CPAPs on patients, families, or health systems. Future studies should evaluate the broader impacts of CPAPs.

Adolescents' Appraisal of Responses to Problem Situations and Their Relation to Aggression and Nonviolent Behavior.

OBJECTIVE: This study investigated adolescents' appraisals of responses to problematic situations and their relations to behavioral intentions for aggressive and nonviolent behavior. A key question was whether ratings of effective and ineffective nonviolent responses and aggressive responses reflect distinct constructs or opposite ends of a single dimension. METHOD: A sample of 183 students at three middle schools in an urban public school system serving a mostly African American population completed measures of aggression, and rated responses to hypothetical situations on five dimensions: behavioral intention, effectiveness, descriptive norms, and anticipated reactions from friends and parents. Responses included nonviolent responses and aggressive responses to problematic situations identified in previous qualitative studies. Nonviolent responses were categorized as effective or ineffective based on ratings by a community sample of youth and adults. RESULTS: Confirmatory factor analyses supported separate factors representing ratings of effective responses and aggressive responses for each domain. Regression analyses indicated that ratings of aggressive responses were more strongly related to aggressive intentions, and ratings of effective responses were more strongly related to intentions to use effective responses. Adolescents who varied in their level of aggression differed in their ratings of aggressive and nonviolent responses. Those reporting higher levels of aggression showed less differentiation between effective and ineffective nonviolent responses compared with those reporting lower levels. CONCLUSIONS: These findings underscore the need for further efforts to identify factors that promote effective nonviolent behavior versus those that support aggression. They have important implications for the development of violence prevention programs.