Adolescent caffeine use and problematic school behavior: A longitudinal analysis of student survey data and teacher observations.

INTRODUCTION: Caffeine is a psychostimulant possessing arousal, motor activation, and reinforcing properties, which is consumed daily by most adolescents aged 12-19 years. Although current understanding of the implications of adolescent caffeine consumption for school behaviors remains incomplete, studies have shown that in addition to acute effects of the drug, in common with other habit-forming psychoactive substances, regular use leads to physical dependence, evidenced by recurring negative withdrawal symptoms. METHODS: Employing two waves of longitudinal data, we tested the prospective association between daily caffeine use and homeroom teacher-observed self-control and problem behavior in a sample of middle-school students in 20 schools in West Virginia in the United States. Caffeine was operationalized with two dichotomized variables, daily consumption of <100 mg, and daily consumption of >100 mg, versus no daily use. Gender, mother's education, family financial status, social support by primary caregiver and adults in school, and school climate, were applied as covariates in linear mixed models. RESULTS: Daily caffeine use of >100 mg was robustly and inversely associated with self-control and positively associated with problem behavior. CONCLUSIONS: Caffeine consumption and associated withdrawal symptoms may be an important factor in problematic school behavior among adolescents. Recent advent of highly concentrated caffeine products (e.g., caffeine "shots") commonly marketed directly at youth, should give rise to concerns including consideration about limiting caffeine consumption among children and youth.

Beyond School Climate: Conceptualizing the School as a Protective Factor Approach.

BACKGROUND: The school climate concept has been promising, but has long-standing critiques that have not been adequately addressed to date. The School as a Protective Factor approach represents one attempt to offer a new approach that builds on and extends beyond the concept of school climate while addressing previously identified limitations. CONTRIBUTIONS TO THEORY: The School as a Protective Factor approach offers a new framework for conceptualizing, measuring, and establishing protective school social and learning environments that co-promote academic achievement and student health in schools, especially student mental health and substance use/abuse prevention. This new framework includes clear definitions, explicit goals, firmly established constructs, validated measures, and an intentionally parsimonious approach that prioritizes the implementation of well-established, high-impact constructs. CONCLUSIONS AND IMPLICATIONS FOR SCHOOL HEALTH POLICY, PRACTICE, AND EQUITY: The School as a Protective Factor approach presents a simple, easy-to-use means of ensuring a school social environment that meets the developmental, academic, and health needs of all children and adolescents while maximizing protection across a range of desired outcomes. Perhaps most importantly, it does so in a manner that is manageable and easily integrated into every aspect of schooling, resonates with the practical experience of school personnel, and includes brief, effective, and free measurement tools.

The Icelandic Prevention Model Evaluation Framework and Implementation Integrity and Consistency Assessment.

The Icelandic Prevention Model (IPM) follows a systematic but flexible process of community capacity building, data collection, analysis, dissemination, and community-engaged decision-making to guide the data-informed selection, prioritization, and implementation of intervention strategies in preventing adolescent substance use. This paper describes two new evaluation tools intended to assess the: 1) integrity of IPM implementation, and 2) unique aspects of IPM implementation in different community contexts. These evaluation tools include a: 1) five-phase IPM Evaluation Framework for Assessing Value Across Communities, Cultures, and Outcomes (IPM-EF); and 2) 10-Step IPM Implementation Integrity and Consistency Assessment (IPM-IICA) that utilizes both quantitative (scored) and qualitative (narrative) data elements to characterize implementation integrity and consistency at both community coalition and school community levels. The IPM-EF includes five phases. Phase 1: Describe the Intervention Context; Phase 2a: Document the Extent to Which the 10 Steps of the IPM were Implemented (using the IPM-IICA scored); Phase 2b: Document the Unique Community-Specific Methods Used within the 10 Steps of the IPM to Tailor Local Intervention Delivery (using the IPM-IICA narrative); Phase 3: Measure Changes in Community Risk and Protective Factors; Phase 4: Measure the Outcomes Associated with the IPM; and Phase 5: Investigate Multiple Full Cycles Over Time.

Path-dependence of the Plio-Pleistocene glacial/interglacial cycles.

We find strong path dependence in the evolution of the Plio-Pleistocene glaciations using CLIMBER-2 Earth System Model simulations from the mid-Pliocene to modern preindustrial (3 My-0 My BP) driven by a gradual decrease in volcanic carbon dioxide outgassing and regolith removal from basal ice interaction. Path dependence and hysteresis are investigated by alternatively driving the model forward and backward in time. Initiating the model with preindustrial conditions and driving the model backward using time-reversed forcings, the increase in volcanic outgassing back-in-time (BIT) does not generate the high CO2 levels and relatively ice-free conditions of the late Pliocene seen in forward-in-time (FIT) simulations of the same model. This behavior appears to originate from nonlinearities and initial state dependence in the carbon cycle. A transition from low-amplitude sinusoidal obliquity (~41 ky) and precession (~23 ky) driven glacial/interglacial cycles to high-amplitude ~100 ky likely eccentricity-related sawtooth cycles seen between -1.25 My and -0.75 My BP (the Mid-Pleistocene transition or "MPT") in FIT simulations disappears in BIT integrations depending on the details of how the regolith removal process is treated. A transition toward depleted regolith and lowered atmospheric CO2 levels are both required to reproduce the MPT.

Beyond School Climate: Validating the School as a Protective Factor-Brief Survey.

BACKGROUND: The conceptual framework for School as a Protective Factor approach was presented in a companion article in this issue of the journal. The current article describes the validation of the School as a Protective Factor-Brief (SPF-Brief), a 13-item survey measuring the 3 core constructs and 13 defining characteristics of this framework. METHODS: The SPF-Brief was validated through 2 studies. The developmental study used a longitudinal design including 1349 participants who completed surveys over 5 semesters, while the validation study used a cross-sectional design with 2775 participants. Both studies included middle and high school students. Factor analysis, growth model analysis, criterion-related validation, and outcome analysis were employed. RESULTS: Analyses provided strong evidence supporting the reliability and validity of the instrument and conceptual framework. Higher SPF-Brief scores were associated with higher math grades, English grades, and quality of life, as well as lower rates of anxiety, depression, conduct disorder, alcohol, e-cigarette, tobacco, and cannabis use. Effect size estimates ranged from moderate to strong. CONCLUSIONS: These findings suggest the utility of the SPF-Brief instrument and the School as a Protective Factor framework. Together, they may offer advantages to the traditional school climate approach.

Earth at risk: An urgent call to end the age of destruction and forge a just and sustainable future.

Human development has ushered in an era of converging crises: climate change, ecological destruction, disease, pollution, and socioeconomic inequality. This review synthesizes the breadth of these interwoven emergencies and underscores the urgent need for comprehensive, integrated action. Propelled by imperialism, extractive capitalism, and a surging population, we are speeding past Earth's material limits, destroying critical ecosystems, and triggering irreversible changes in biophysical systems that underpin the Holocene climatic stability which fostered human civilization. The consequences of these actions are disproportionately borne by vulnerable populations, further entrenching global inequities. Marine and terrestrial biomes face critical tipping points, while escalating challenges to food and water access foreshadow a bleak outlook for global security. Against this backdrop of Earth at risk, we call for a global response centered on urgent decarbonization, fostering reciprocity with nature, and implementing regenerative practices in natural resource management. We call for the elimination of detrimental subsidies, promotion of equitable human development, and transformative financial support for lower income nations. A critical paradigm shift must occur that replaces exploitative, wealth-oriented capitalism with an economic model that prioritizes sustainability, resilience, and justice. We advocate a global cultural shift that elevates kinship with nature and communal well-being, underpinned by the recognition of Earth's finite resources and the interconnectedness of its inhabitants. The imperative is clear: to navigate away from this precipice, we must collectively harness political will, economic resources, and societal values to steer toward a future where human progress does not come at the cost of ecological integrity and social equity.

Postoperative shunt failure following hemispherectomy in pediatric patients with pre-existing hydrocephalus.

OBJECTIVE: The risk of hydrocephalus following hemispherectomy for drug resistant epilepsy (DRE) remains high. Patients with pre-existing hydrocephalus pose a postoperative challenge, as maintaining existing shunt patency is necessary but lacks a clearly defined strategy. This study examines the incidence and predictors of shunt failure in pediatric hemispherectomy patients with pre-existing ventricular shunts. METHODS: We performed a retrospective chart review at our center to identify pediatric patients diagnosed with DRE who were treated with ventricular shunt prior to their first hemispherectomy surgery. Demographic and perioperative data were obtained including shunt history, hydrocephalus etiology, epilepsy duration, surgical technique, and postoperative outcomes. Univariate analysis was performed using Fisher's exact test and Pearson correlation, with Bonferroni correction to a = 0.00625 and a = 0.01, respectively. RESULTS: Five of nineteen (26.3%) patients identified with ventriculoperitoneal shunting prior to hemispherectomy experienced postoperative shunt malfunction. All 5 of these patients underwent at least 1 shunt revision prior to hemispherectomy, with a significant association between pre- and post-hemispherectomy shunt revisions. There was no significant association between post-hemispherectomy shunt failure and valve type, intraoperative shunt alteration, postoperative external ventricular drain placement, hemispherectomy revision, lateralization of shunt relative to resection, postoperative complications, or postoperative aseptic meningitis. There was no significant correlation between number of post-hemispherectomy shunt revisions and age at shunt placement, age at hemispherectomy, epilepsy duration, or shunt duration prior to hemispherectomy. CONCLUSIONS: Earlier shunt revision surgery may portend a subsequent need for shunt revision following hemispherectomy. These findings may guide neurosurgeons in counseling patients with pre-existing ventricular shunts prior to hemispherectomy surgery.

Role of atmospheric resonance and land-atmosphere feedbacks as a precursor to the June 2021 Pacific Northwest Heat Dome event.

We demonstrate an indirect, rather than direct, role of quasi-resonant amplification of planetary waves in a summer weather extreme. We find that there was an interplay between a persistent, amplified large-scale atmospheric circulation state and soil moisture feedbacks as a precursor for the June 2021 Pacific Northwest "Heat Dome" event. An extended resonant planetary wave configuration prior to the event created an antecedent soil moisture deficit that amplified lower atmospheric warming through strong nonlinear soil moisture feedbacks, favoring this unprecedented heat event.

Predictive factors of hydrocephalus development in pediatric patients undergoing hemispherectomy for intractable epilepsy.

OBJECTIVE: Hemispherectomy surgery is an effective procedure for pediatric patients with intractable hemispheric epilepsy. Hydrocephalus is a well-documented complication of hemispherectomy contributing substantially to patient morbidity. Despite some clinical and operative factors demonstrating an association with hydrocephalus development, the true mechanism of disease is incompletely understood. The aim of this study was to investigate a range of clinical and surgical factors that may contribute to hydrocephalus to enhance understanding of the development of this complication and to aid the clinician in optimizing peri- and postoperative surgical management. METHODS: A retrospective chart review was conducted on all pediatric patients younger than 21 years who underwent hemispherectomy surgery at the Cleveland Clinic between 2002 and 2016. Data collected for each patient included general demographic information, neurological and surgical history, surgical technique, pathological analysis, presence and duration of perioperative CSF diversion, CSF laboratory values obtained while an external ventricular drain (EVD) was in place, length of hospital stay, postoperative aseptic meningitis, and in-hospital surgical complications (including perioperative stroke, hematoma formation, wound breakdown, and/or infection). Outcomes data included hemispherectomy revision and Engel grade at last follow-up (based on the Engel Epilepsy Surgery Outcome Scale). RESULTS: Data were collected for 204 pediatric patients who underwent hemispherectomy at the authors' institution. Twenty-eight patients (14%) developed hydrocephalus requiring CSF diversion. Of these 28 patients, 13 patients (46%) presented with hydrocephalus during the postoperative period (within 90 days), while the remaining 15 patients (54%) presented later (beyond 90 days after surgery). Multivariate analysis revealed postoperative aseptic meningitis (OR 7.0, p = 0.001), anatomical hemispherectomy surgical technique (OR 16.3 for functional/disconnective hemispherectomy and OR 7.6 for modified anatomical, p = 0.004), male sex (OR 4.2, p = 0.012), and surgical complications (OR 3.8, p = 0.031) were associated with an increased risk of hydrocephalus development, while seizure freedom (OR 0.3, p = 0.038) was associated with a decreased risk of hydrocephalus. CONCLUSIONS: Hydrocephalus remains a prominent complication following hemispherectomy, presenting both in the postoperative period and months to years after surgery. Aseptic meningitis, anatomical hemispherectomy surgical technique, male sex, and surgical complications show an association with an increased rate of hydrocephalus development while seizure freedom postsurgery is associated with a decreased risk of subsequent hydrocephalus. These findings speak to the multifactorial nature of hydrocephalus development and should be considered in the management of pediatric patients undergoing hemispherectomy for medically intractable epilepsy.

Social Support for Rural Gender Diverse Youth Compared to Cisgender Peers.

PURPOSE: Gender diverse youth (GDY) experience higher rates of mental health concerns than their cisgender peers, but these can be ameliorated by feeling support from family, school, and community. Little is known about how youth perceptions of support vary by gender identity, especially for younger adolescents and those living in rural areas. METHODS: Youth ages 12-19 years completed anonymous surveys including measures of perceived support and a two-step gender identity question. GDY (n = 206) were further categorized into binary and nonbinary gender identities. An additional 500 randomly selected cisgender youth were included for comparison. Multivariate analyses of variance with Tukey post hoc tests were employed to test GDY group differences while accounting for the interaction between scaled measures. RESULTS: Cisgender youth had the highest perceived support across all support measures while youth who shared both binary and nonbinary aspects of their gender identity had the lowest rates of perceived support. The F tests for between-subject effects were statistically significant (p <.001) for all six support measures, and multivariate group testing was statistically significant with Wilks' λ 6.38(18,1621.17) = 0.82; p <.001. DISCUSSION: Despite research demonstrating a strong association between perceived support and improved mental health outcomes, GDY in our sample had lower rates of perceived support at the family, school, and community levels. GDY with both binary and nonbinary gender identities had the lowest levels of perceived support. Further research is needed to see if this finding is consistent in other populations and to develop targeted interventions to improve perceived support for this population.

The impact of adjuvant EGFR-TKIs and 14-gene molecular assay on stage I non-small cell lung cancer with sensitive EGFR mutations.

Background: Currently, the role of EGFR-TKIs as adjuvant therapy for stage I, especially IA NSCLC, after surgical resection remains unclear. We aimed to compare the effect of adjuvant EGFR-TKIs with observation in such patients by incorporating an established 14-gene molecular assay for risk stratification. Methods: This retrospective cohort study was conducted at the First Affiliated Hospital of Guangzhou Medical University (Study ID: ChNCRCRD-2022-GZ01). From March 2013 to February 2019, completely resected stage I NSCLC (8th TNM staging) patients with sensitive EGFR mutation were included. Patients with eligible samples for molecular risk stratification were subjected to the 14-gene prognostic assay. Inverse probability of treatment weighting (IPTW) was employed to minimize imbalances in baseline characteristics. Findings: A total of 227 stage I NSCLC patients were enrolled, with 55 in EGFR-TKI group and 172 in the observation group. The median duration of follow-up was 78.4 months. After IPTW, the 5-year DFS (HR = 0.30, 95% CI, 0.14-0.67; P = 0.003) and OS (HR = 0.26, 95% CI, 0.07-0.96; P = 0.044) of the EGFR-TKI group were significantly better than the observation group. For subgroup analyses, adjuvant EGFR-TKIs were associated with favorable 5-year DFS rates in both IA (100.0% vs. 84.5%; P = 0.007), and IB group (98.8% vs. 75.3%; P = 0.008). The 14-gene assay was performed in 180 patients. Among intermediate-high-risk patients, EGFR-TKIs were associated with a significant improvement in 5-year DFS rates compared to observation (96.0% vs. 70.5%; P = 0.012), while no difference was found in low-risk patients (100.0% vs. 94.9%; P = 0.360). Interpretation: Our study suggested that adjuvant EGFR-TKI might improve DFS and OS of stage IA and IB EGFR-mutated NSCLC, and the 14-gene molecular assay could help patients that would benefit the most from treatment. Funding: This work was supported by China National Science Foundation (82022048, 82373121).

Climate change will accelerate the high-end risk of compound drought and heatwave events.

Compound drought and heatwave (CDHW) events have garnered increased attention due to their significant impacts on agriculture, energy, water resources, and ecosystems. We quantify the projected future shifts in CDHW characteristics (such as frequency, duration, and severity) due to continued anthropogenic warming relative to the baseline recent observed period (1982 to 2019). We combine weekly drought and heatwave information for 26 climate divisions across the globe, employing historical and projected model output from eight Coupled Model Intercomparison Project 6 GCMs and three Shared Socioeconomic Pathways. Statistically significant trends are revealed in the CDHW characteristics for both recent observed and model simulated future period (2020 to 2099). East Africa, North Australia, East North America, Central Asia, Central Europe, and Southeastern South America show the greatest increase in frequency through the late 21st century. The Southern Hemisphere displays a greater projected increase in CDHW occurrence, while the Northern Hemisphere displays a greater increase in CDHW severity. Regional warmings play a significant role in CDHW changes in most regions. These findings have implications for minimizing the impacts of extreme events and developing adaptation and mitigation policies to cope with increased risk on water, energy, and food sectors in critical geographical regions.

Possible role of caffeine in nicotine use onset among early adolescents: Evidence from the Young Mountaineer Health Study Cohort.

BACKGROUND: Preventing nicotine use onset among children and youth is an important public health goal. One possible contributor that has received little empirical investigation is caffeine use. The goal of this study was to examine the possible contribution of caffeine to nicotine onset during early adolescence. METHODS: We used data from the Young Mountaineer Health Study Cohort. Survey data were collected from 1,349 (response rate: 80.7%) 6th grade students (mean age at baseline 11.5 years) in 20 middle schools in West Virginia during the fall of 2020 and spring of 2021. We limited our analyses to students reporting never having used any form of nicotine at baseline. Logistic regression was employed in analyses. RESULTS: Approximately 8% of participants reported having used nicotine at least once between baseline and the follow-up, and 4.7% reported solely using electronic nicotine delivery systems (ENDS) and no other forms of nicotine. In multivariable analyses, we controlled for many environmental, social, and behavioral variables known to influence nicotine use such as alcohol use, peer substance use, and perceived access to nicotine. We formulated our main independent variable, caffeine consumption, as continuous deciles. Any nicotine use, as well as ENDS use only at follow-up, were modeled as dependent variables. Caffeine was significantly associated with nicotine use in both models with ORs of 1.15 (1.04-1.27) and 1.13 (1.00-1.28). CONCLUSIONS: Caffeine consumption among 6th grade non-nicotine users was associated with nicotine use at approximately 6-months follow-up.

Preliminary impact of the adoption of the Icelandic Prevention Model in Tarragona City, 2015-2019: A repeated cross-sectional study.

Background: There is a great need for effective primary prevention intervention strategies to reduce and delay onset of adolescent substance use. The Icelandic Prevention Model (IPM) showed great success in Iceland over the past twenty plus years, however, evidence for the transferability of model is still somewhat limited. Using data collected in Tarragona during regional efforts to begin adoption of the IPM in Catalonia, this study tested the transferability and stability of the core risk and protective factor assumptions of the IPM overtime and examined trends of lifetime smoking, e-cigarette-use, alcohol-use, intoxication, and cannabis-use within the same time period. Methods: This study includes responses from 15- to 16-years-olds from two region-wide samples taken in 2015 and 2019 in Tarragona (N = 2,867). Survey questions assessed frequency of lifetime: smoking, e-cigarette-use, alcohol-use, intoxication, and cannabis-use, and the core model assumptions. Demographic data were also collected. Logistic regression models of main effects with and without time interaction were used to test assumptions and their stability across time. Chi-square tests and Wilcoxon-Mann-Whitney U tests were used to compare prevalence of substance use and mean scores of primary prevention variables respectively. Results: Lifetime: smoking (-7%, p < 0.001) and cannabis-use (-4%, p < 0.001) decreased, and e-cigarette-use increased (+33%, p < 0.001) in Tarragona. Lifetime intoxication (-7%, p < 0.001) decreased in a single zone exclusively. Most core model assumptions held in their hypothesised direction across time. The strongest positive association was observed between time spent with parents during weekends and reduced odds of lifetime smoking (OR: 0.62, 95%CI: 0.57-0.67) and the strongest negative association was observed between being outside after midnight and increased odds of lifetime intoxication (OR: 1.41, 95%CI: 1.32-1.51). Mean scores of primary prevention variables also changed disproportionately in Tarragona. Conclusion: This study confirms that the core IPM assumptions are similar in Tarragona as in Iceland and other contexts previously examined. They also indicate that prevalence of lifetime smoking, intoxication, and cannabis-use decreased disproportionately in Tarragona between 2015 and 2019 during the first phase of regional adoption of the model. Thus, targeting model assumptions represents a viable primary prevention strategy for communities that hope to reduce smoking, alcohol-use, intoxication, and cannabis-use among adolescents.

Management of Patients with Spine Tumors Strengthened by a Dedicated Multidisciplinary Spine Tumor Board: A 15-Year Single-Institutional Experience.

BACKGROUND: Patients with spine tumors frequently require timely, multistep, and multidisciplinary care. A Spine Tumor Board (STB) provides a consistent forum wherein diverse specialists can interact, facilitating complex coordinated care for these patients. This study aims to present a single, large academic center's STB experience specifically reviewing case diversity, recommendations, and quantifying growth over time. METHODS: All patient cases discussed at STB from May 2006 (STB inception) to May 2021 were evaluated. Collected data submitted by presenting physicians and formal documentation completed during the STB are summarized. RESULTS: A total of 4549 cases were reviewed by STB over the study period, representing 2618 unique patients. Over the course of the study, a 266% increase in number of cases presented per week was observed (4.1 to 15.0). Cases were presented by surgeons (74%), radiation oncologists (18%), neurologists (2%), and other specialists (6%). The most common pathologic diagnoses discussed were spinal metastases (n = 1832; 40%), intradural extramedullary tumors (n = 798; 18%), and primary glial tumors (n = 567; 12%). Treatment recommendations included surgery, radiation therapy, or systemic therapy for 1743 cases (38%), continued routine follow-up/expectant management for 1592 cases (35%), supplementary imaging to better clarify the diagnosis for 549 cases (12%), and variable tailored recommendations for the remainder of cases (18%). CONCLUSIONS: Care of patients with spine tumors is complex. We believe that the formation of a stand-alone STB is instrumental to accessing multidisciplinary input, enhancing confidence in management decisions for both patients and providers, assisting with care orchestration, and improving quality of care for patients with spine tumors.

Characterization of root-associated fungi and reduced plant growth in soils from a New Mexico uranium mine.

Characterizing the diverse, root-associated fungi in mine wastes can accelerate the development of bioremediation strategies to stabilize heavy metals. Ascomycota fungi are well known for their mutualistic associations with plant roots and, separately, for roles in the accumulation of toxic compounds from the environment, such as heavy metals. We sampled soils and cultured root-associated fungi from blue grama grass (Bouteloua gracilis) collected from lands with a history of uranium (U) mining and contrasted against communities in nearby, off-mine sites. Plant root-associated fungal communities from mine sites were lower in taxonomic richness and diversity than root fungi from paired, off-mine sites. We assessed potential functional consequences of unique mine-associated soil microbial communities using plant bioassays, which revealed that plants grown in mine soils in the greenhouse had significantly lower germination, survival, and less total biomass than plants grown in off-mine soils but did not alter allocation patterns to roots versus shoots. We identified candidate culturable root-associated Ascomycota taxa for bioremediation and increased understanding of the biological impacts of heavy metals on microbial communities and plant growth.

Social Support and Perceptions of COVID-19-related Emotional Impact on Mental Health Among Early Adolescents in Appalachia.

BACKGROUND: Young people who experience higher levels of social support from their schools and families have been shown to be less likely to develop symptoms of negative mental health outcomes such as depression and anxiety.1-4 This raises questions concerning how young people's stress and psychological changes due to the COVID-19 pandemic as well as social support during this time have affected their overall mental health. The aim of this study was to assess the association between sources of parental- and school-level social support and youth perceptions of COVID-19-related emotional impact on mental health among early adolescent girls and boys in Appalachia. METHODS: Using linear regression, we analyzed the first and third wave of survey data from the larger parent study (Young Mountaineer Health Study) cohort, collected in 20 middle schools throughout West Virginia in the fall of 2020 and fall of 2021 (N = 1349, mean age: 11.5, response rate: 80.7%). RESULTS: Approximately half of participants reported knowing someone that had been sick with COVID-19. Those experiencing higher levels of perceived COVID-19-related emotional impact reported greater levels of depression, anxiety, and anger. Both parental and school-level social support were associated with better mental health outcomes. CONCLUSIONS: Early adolescent perceptions of COVID-19-related emotional impact were associated with depression, anxiety, and anger and moderated by social support at home and in school among 11-12-year-old youth in Appalachia.