Going it alone: Examining interpersonal sensitivity and hostility as mediators of the link between perfectionism and social disconnection.

OBJECTIVE: Perfectionism is linked to a variety of mental health conditions in university students. The Perfectionism Social Disconnection Model posits that perfectionistic individuals exhibit off-putting interpersonal behaviors (i.e., rejection sensitivity and hostility), which lead to social disconnection, and in turn contribute to psychological distress. Although several longitudinal studies have found that social disconnection mediates the link between perfectionistic traits and psychological distress, less is known about how perfectionism leads to social disconnection. The present study aimed to address this gap. METHODS: A sample of 877 university students completed one survey a month for three consecutive months. RESULTS: Our random-intercept cross-lagged panel model results showed significant positive associations between the random intercepts of socially prescribed and self-oriented perfectionism with rejection sensitivity, hostility, and loneliness, with stronger associations for socially prescribed perfectionism. In addition, the random intercept of other-oriented perfectionism showed positive associations with hostility but not rejection sensitivity or loneliness. Moreover, almost all cross-lagged paths were nonsignificant. CONCLUSION: Collectively, these findings indicate that although perfectionistic traits may be associated with rejection sensitivity and hostility to varying degrees at the between-person level, these behaviors may not cause social disconnection at the within-person level.

Students' perceptions of the rules and restrictions of gender at school: A psychometric evaluation of the Gender Climate Scale (GCS).

Research in the field of gender and sexuality diversity and, more specifically, negative attitudes toward gender and sexuality diverse individuals, has acknowledged the relationship between individuals' endorsement of sex-differentiated, normative gender roles and their attitudes toward gender and sexuality diversity. Such work has highlighted how normative expectations of gender, drawn from binarized gender roles, sit at the heart of homophobic and transphobic attitudes. Previous research in high school settings has measured gender and sexuality diverse (GSD) students' experiences of homo/transphobic harassment as an element of 'school climate' with regard to acceptance of gender and sexuality diversity. However, to date, no research has measured GSD students' perceptions about how valued binarized, gender-normative roles are at their schools, or the ways in which these norms might impact, and potentially constrain, these students' academic and social schooling lives. The aim of the present study was to address this gap by developing and testing a new, multidimensional measure (the Gender Climate Scale; GCS) of GSD students' ideas about how gender norms function within their school. Using a convenience sample of 2,376 Australian high school students who identify as GSD, the GCS was evaluated for its reliability, construct, and criterion validity and measurement invariance using confirmatory factor analysis (CFA) methods. Findings revealed that the estimates produced from the GCS were reliable, valid, and invariant across student reported gender (male/female/non-binary) and location (urban/rural). Criterion validity was supported, with GCS factors representing the promotion of traditional gender roles in the schooling environment negatively associated with perceived school belonging and inclusion and positively associated with bullying and social isolation. Future research with the GCS can inform school and curriculum policy on this important measure of school climate, not just for GSD students but for whole student cohorts.

Examining the Prospective Bidirectional Associations between Subjective and Objective Attractiveness and Adolescent Internalizing Symptoms and Life Satisfaction.

Research has consistently shown that more physically attractive individuals are perceived by others to be happier and better psychologically adjusted than those perceived as less attractive. However, due to the lack of longitudinal research in adolescents, it is still unclear whether poor mental health predicts or is predicted by either objective or subjective attractiveness during this critical developmental period. The purpose of the current study was to examine prospective bidirectional associations between both subjective and objective ratings of attractiveness, life satisfaction and symptoms of social anxiety, depression and eating disorders (i.e., internalizing symptoms) from early to mid-adolescence. Participants (T1: N = 528, 49.9% girls; Mage = 11.19; SD = 0.55) were followed annually over four time points. The cross-lagged panel model results revealed evidence of prospective associations between both forms of attractiveness and life satisfaction and internalizing symptoms, which were driven more by changes in the mental health outcomes than by changes in the subjective and objective attractiveness ratings. The results also indicated that the pattern, strength, and direction of the associations tested were robust across boys and girls, and white and non-white ethnic groups. Overall, the findings suggest that it is important to find effective ways of educating adolescents who are unhappy with their appearance that making changes to improve their mental health, rather than focusing on their physical appearance, will have benefits not only for how they perceive themselves but also for how they are perceived by others.

A longitudinal investigation of sleep hygiene as a mediator linking parental warmth with adolescent sleep.

STUDY OBJECTIVES: Parental warmth in adolescence protects sleep in early adulthood, yet the nature, directions, and mechanisms of this association across adolescence are unknown. This study examined parental warmth, adolescent sleep hygiene and sleep outcomes (morning/eveningness, school night sleep duration, and daytime sleepiness) across five annual waves, spanning four years, using a cross-lagged panel design. METHODS: Adolescents and one primary caregiver (96% mothers) completed questionnaires assessing parental warmth (child- and parent-report) and adolescent sleep hygiene and sleep (child-report), across five annual waves: Wave 1 (N = 531, Mage = 11.18, SD = 0.56, 51% male), Wave 2 (N = 504, Mage = 12.19, SD = 0.53, 52% male), Wave 3 (N = 478, Mage = 13.19, SD = 0.53, 52% male), Wave 4 (N = 440, Mage = 14.76, SD = 0.47, 51% male), and Wave 5 (N = 422, Mage = 15.75, SD = 0.49, 51% male). RESULTS: Greater child-reported parental warmth was indirectly associated with better adolescent sleep (greater morningness, longer school night sleep duration, less sleepiness) through healthier sleep hygiene. The inverse was also often observed. Warmth had a direct relationship with sleep duration and sleepiness, independent of sleep hygiene. Parent-reported parental warmth did not predict, nor was predicted by child-reported adolescent sleep. CONCLUSIONS: Parental warmth may protect against developmental changes in adolescent sleep, partially by improving sleep hygiene practices. Similarly, inadequate adolescent sleep may negatively impact parental warmth via deteriorating sleep hygiene. Sleep hygiene emerged as a key mechanism for protecting adolescent sleep and parent-child relationships.

The associations between basic psychological need satisfaction at work and the wellbeing of Indigenous and non-Indigenous employees.

We investigated how satisfaction of the basic psychological needs at work was associated with the psychological and physical wellbeing of Indigenous and non-Indigenous employees both within and outside of the workplace. Participants included 1,146 Indigenous (n = 559) and non-Indigenous Australians (60.9% female), aged 18 to 81 years (Mage = 43.54) who were recruited through their employer or online advertisements. Structural equation modelling (SEM) was used to analyse the data, and Indigenous status and occupation type were investigated as moderators. Results revealed that independent of income, autonomy satisfaction was related to better physical and psychological health, satisfaction of the need for relatedness was associated with increased family and community thriving, and competence satisfaction was linked to decreased psychological distress. Results also showed that autonomy, competence, and relatedness need satisfaction was lower among Indigenous employees compared to non-Indigenous employees. Moderation analyses suggested that relatedness at work was especially important for non-Indigenous employees' connection with their community, as were high levels of competence satisfaction for Indigenous employees. These findings are discussed in the context of self-determination theory and the implications for organizations wanting to improve the wellbeing of their Indigenous and non-Indigenous workforce.

Risk for social anxiety in early adolescence: Longitudinal impact of pubertal development, appearance comparisons, and peer connections.

OBJECTIVES: The aims of this study were to determine the impact of adolescent-relevant risk factors on changes in social anxiety symptoms from pre-to early-adolescence. METHODS: From 2016 to 2018, 528 youth (51% boys) were tested in three annual waves across grades 6, 7, and 8 (M ages 11.2, 12.7, 13.7 years). Through online surveys youth reported on peer relationships that were combined into two latent factors: 1) appearance comparisons, comprising youth reports of appearance comparisons relative to others in general and while using social media, along with perceived attractiveness; and 2) positive peer connections, comprising youth reports of group affiliation, school belonging, and peer victimisation. Youth and their parents also reported on the youth's level of pubertal development as well as the youth's level of social anxiety using previously validated questionnaires. Social anxiety was also assessed with structured diagnostic interview. RESULTS: Separate cross-lagged panel models were used to model longitudinal associations between all risk factors and youth, parent, and interviewer-reported measures of social anxiety. Of the associations tested, only appearance comparisons directly predicted increases in social anxiety symptoms 12 months later across all models. More advanced pubertal development was associated with increased appearance comparisons the following year. On the other hand, higher levels of social anxiety predicted subsequent reductions in positive peer connections in parent and interviewer models. CONCLUSIONS: These results highlight the important and interconnected impact of pubertal development and appearance comparisons on both the development of social anxiety symptoms during early adolescence, as well as the social consequences of social anxiety.

A mixed methods study of an online intervention to reduce perfectionism.

Perfectionism is linked to a variety of mental health conditions in university students. Guided by the Perfectionism Social Disconnection Model, the purpose of the current mixed methods feasibility study was to evaluate the acceptability and potential effectiveness of a brief online intervention designed to reduce the negative consequences of perfectionism in university students. Seventy university students (83.9% female; M age = 19) reporting moderate to extreme levels of perfectionism completed the two hour 'Intentional Imperfection Program' (IIP). The IIP includes techniques to increase mindfulness, compassion for self and others, distress tolerance, and social skills. Participants completed self-report measures at baseline and at a two-week follow-up. Quantitative data showed statistically significant small to moderate reductions in self-oriented perfectionism (d = -0.48, p < .001), socially-prescribed perfectionism (d = 0.40, p < .001), hostility (r = 0.53, p < .001), rejection sensitivity (d = 0.37, p < .001), depression (r = -0.47, p < .001), and anxiety (r = -0.33, p = .010) and a small increase in perceived social support (r = -0.29, p = .023). Thematic analyses of qualitative data indicated that participants found the IIP feasible, enjoyable, and useful. A brief online intervention may be a feasible way of reducing the negative consequences of perfectionism among university students. A randomised control trial is warranted to further evaluate the efficacy of the IIP. This research was registered with the Australian New Zealand Clinical Trials Registry (no. ACTRN12620000574943).

Eye-tracking to assess anxiety-related attentional biases among a large sample of preadolescent children.

A considerable body of research in adults has demonstrated that anxiety disorders are characterised by attentional biases to threat. Findings in children have been inconsistent. The present study examined anxiety-related attention biases using eye tracking methodology in 463 preadolescents between 10 and 12 years of age, of whom 92 met criteria for a DSM-5 anxiety disorder and 371 did not. Preadolescent's gaze was recorded while they viewed adolescent face pairs depicting angry-neutral and happy-neutral expressions with each face pair presented for 5000 ms. No group differences were observed across any eye tracking indices including probability of first fixation direction, latency to first fixation, first fixation duration and dwell time. The sample overall showed faster initial attention towards threat cues, followed by a later broadening of attention away from threat. There is a need to identify the types of threats and the developmental period during which visual attention patterns of anxious and non-anxious youth diverge to inform more developmentally sensitive treatments.

Latent stability and change in subgroups of social anxiety and depressive symptoms in adolescence: A latent profile and transitional analysis.

BACKGROUND: Social anxiety and depressive symptoms increase markedly during adolescence. Most research examining the emergence of these symptoms has used a variable-centered approach providing little information about how these symptoms group together in individuals over time. METHOD: A person-centered approach utilizing latent profile and latent transitional analyses was applied to a large adolescent sample (N = 2742, Mage=13.65; SD=0.63; 47.9% girls). Subgroups differing in their expressions of social anxiety and depressive symptoms at each of four annual time points were identified and then change in membership of these groups was evaluated. RESULTS: Four subgroups were identified: 1. Low Distress, 2. Socially Anxious, 3. Dysphoric, and 4. Comorbid. The low distress group was the largest and most stable, followed by the socially anxious group, who most commonly transitioned into the comorbid group. In contrast, the dysphoric group were most likely to remit and move to the low distress group. The comorbid group was the smallest and least stable, although once in this group, three quarters of adolescents remained in this group over time. CONCLUSION: Early intervention is particularly imperative for socially anxious adolescents with or without comorbid depressive symptoms as they are the least likely to improve across the adolescent years.

The role of parenting behaviors in the bidirectional and intergenerational transmission of depression and anxiety between parents and early adolescent youth.

BACKGROUND: Parenting is a modifiable factor proposed to underpin the transmission of anxiety and depression from parents to children. This study examined the role of parenting in the intergenerational transmission of anxiety and depression across pre- and early adolescence. METHOD: Participants were 531 youth (Mage = 11.18, SD = 0.56; 50.85% boys) and their parent. Child and parent anxiety and depression, and parental rejection, warmth and overprotection were assessed annually over 3 years. Bidirectional relationships between parent and child anxiety and depression, and the mediating role of parenting behaviors, were examined using cross-lagged panel models. RESULTS: Results suggest bidirectional associations over time between parent and child depression, and parental rejection and child depression. Parental rejection and low warmth were associated with increases in child depression, but did not mediate depression transmission. Parental anxiety was associated with increases in child anxiety and depression, but there was no bidirectional association from child psychopathology to parental anxiety. There was little evidence that parenting predicted changes in child anxiety over time. Child anxiety and depression were associated with subsequent increases in parental depression. CONCLUSION: Parental depression, rejection and low warmth are independent risk factors for child depression. Parental rejection may also be a consequence of parenting a depressed youth. Parenting did not account for the apparent transmission of parental anxiety to increased child anxiety and depression. Child psychopathology increases risk of parental depression. Parental rejection may be an important modifiable risk factor for youth depression in early adolescence, and may also reduce later risk of parent depression.

The Empirical Status of Cue Exposure and Response Prevention Treatment for Binge Eating: A Systematic Review.

Approximately 50% of individuals fail to obtain treatment benefits when undergoing cognitive-behavioral therapy (CBT) for binge-eating behaviors, making it necessary to evaluate additional approaches. Cue exposure and response prevention (CERP) is one such approach, although its effectiveness across studies has been inconsistent. This may be due to inconsistent implementation of theoretically based CERP strategies. This possibility has not yet been systematically investigated. To address this gap, this review investigated which CERP strategies have been incorporated into treatment protocols for binge eating, and if the use of certain strategies improves treatment effectiveness. Relevant studies were identified through reference lists, grey literature, and searches of electronic databases using multiple search terms related to CERP and binge eating, which resulted in 18 eligible studies. Most studies were underpowered, many were of low methodological quality, and none of the included studies utilized all of the strategies that have been recommended to optimize CERP. Despite these weaknesses, CERP appeared to reduce the frequency of binge eating in the short and long term. This review underscores the need for higher quality research that utilizes larger samples and uniform outcome measures that are more strongly grounded in theory. Such research would help improve treatment outcomes for binge eating.

The bidirectional relationships between peer victimization and internalizing problems in school-aged children: An updated systematic review and meta-analysis.

The current research examined the bidirectional effects between internalizing problems and peer victimization within a meta-analytic framework. The study also investigated several potential moderators of these effects which have not been examined previously in relation to meta-analytic studies. Only longitudinal studies examining the association between internalizing symptoms and peer victimization from five online databases were included and after screening 7,122 articles, 85 studies were included with a total of 117,520 participants. Results supported a bidirectional relationship between internalizing symptoms and peer victimization with small effects for both: victimization to internalizing, r = .18 and internalizing to victimization, r = .19. There were few differences between effects based on moderators. The effects were consistent across youth's age and sex. Although significant effects in both directions were shown for most forms of victimization, internalizing more strongly predicted cyber victimization than traditional forms of victimization. The results hold implications for theories of the interplay between peer relationships and internalizing psychopathology and may help to improve treatment or early intervention programs.

Reevaluating Cue Exposure and Response Prevention in a Pilot Study: An Updated Treatment for Binge Eating Disorder.

Approximately half of individuals with binge eating disorder (BED) fail to improve when treated with cognitive behavioral therapy; thus, better treatments are needed. Cue exposure and response prevention (CERP) may be one option, but its full potential for reducing binge eating remains unknown because prior applications for binge eating have not utilized the broad range of strategies believed to optimize exposure therapy. The current single-subject AB design investigated the acceptability and effectiveness of a comprehensive CERP treatment among 8 women who met DSM-5 criteria for binge eating disorder. Changes in the number of binges were measured from baseline to the end of treatment, and desire to eat, salivation, and idiographic expectancies of aversive outcomes to food-cue exposure (idiographic CS-US expectancies), including expectancies about ability to tolerate distress when exposed to food cues were measured across the course of treatment. Statistical analysis revealed a significant reduction in the number of binges from baseline to the end of treatment. Across the course of treatment, desire to eat and idiographic CS-US expectancies reduced, and distress tolerance expectancies increased. No participants dropped out and all reported being maximally satisfied with the treatment. Based on these findings, future randomized-control trials with larger samples should examine the efficacy of CERP and mechanisms underlying change with the aim of establishing a more effective treatment for binge eating disorder.

Risk and Protective Factors for Prospective Changes in Adolescent Mental Health during the COVID-19 Pandemic.

The restrictions put in place to contain the COVID-19 virus have led to widespread social isolation, impacting mental health worldwide. These restrictions may be particularly difficult for adolescents, who rely heavily on their peer connections for emotional support. However, there has been no longitudinal research examining the psychological impact of the COVID-19 pandemic among adolescents. This study addresses this gap by investigating the impact of the COVID-19 pandemic on adolescents' mental health, and moderators of change, as well as assessing the factors perceived as causing the most distress. Two hundred and forty eight adolescents (Mage = 14.4; 51% girls; 81.8% Caucasian) were surveyed over two time points; in the 12 months leading up to the COVID-19 outbreak (T1), and again two months following the implementation of government restrictions and online learning (T2). Online surveys assessed depressive symptoms, anxiety, and life satisfaction at T1 and T2, and participants' schooling, peer and family relationships, social connection, media exposure, COVID-19 related stress, and adherence to government stay-at-home directives at T2 only. In line with predictions, adolescents experienced significant increases in depressive symptoms and anxiety, and a significant decrease in life satisfaction from T1 to T2, which was particularly pronounced among girls. Moderation analyses revealed that COVID-19 related worries, online learning difficulties, and increased conflict with parents predicted increases in mental health problems from T1 to T2, whereas adherence to stay-at-home orders and feeling socially connected during the COVID-19 lockdown protected against poor mental health. This study provides initial longitudinal evidence for the decline of adolescent's mental health during the COVID-19 pandemic. The results suggest that adolescents are more concerned about the government restrictions designed to contain the spread of the virus, than the virus itself, and that those concerns are associated with increased anxiety and depressive symptoms, and decreased life satisfaction.

Longitudinal Associations between Coping Strategies and Psychopathology in Pre-adolescence.

Much of the literature investigating the association between coping and psychopathology is cross-sectional, or associations have been investigated in a unidirectional manner; hence, bidirectionality between coping and psychopathology remains largely untested. To address this gap, this study investigated bidirectional relations between coping and psychopathology during pre-adolescence. Participants (N = 532, 51% male) and their primary caregiver both completed questionnaires assessing pre-adolescents' coping (i.e., avoidant, problem solving, social support seeking) and symptoms of psychopathology (i.e., generalized anxiety, social anxiety, depression, eating pathology) in Wave 1 (Mage = 11.18 years, SD = 0.56, range = 10-12) and Wave 2 (Mage = 12.18 years, SD = 0.53, range = 11-13, 52% male), one year later. Cross-lagged panel models showed child-reported avoidant coping predicted increases in symptoms of generalized and social anxiety, and eating pathology. In separate child and parent models, symptoms of depression predicted increases in avoidant coping. Greater parent-reported child depressive symptoms also predicted decreases in problem solving coping. Taken together, results suggest unique longitudinal associations between coping and psychopathology in pre-adolescence, with avoidant coping preceding increases in symptoms of anxiety and eating pathology, and depressive symptoms predicting later increases in maladaptive coping.

Evidence that Different Types of Peer Victimization have Equivalent Associations with Transdiagnostic Psychopathology in Adolescence.

Experiences of peer victimization are common in adolescence and have been associated with a broad variety of psychopathology in adolescence. The present study aimed to test whether some types of victimization are more harmful than others; whether the harms associated with different types of peer victimization are specific to particular domains of psychopathology; and whether these relationships vary by gender. Participants included adolescents aged 14-15 from a nationally representative cohort study (n= 3335; mean age 14.4 years; 49.1% female; 90.1% spoke English as the main language at home). Participants provided self-report information on their experiences of peer victimization, as well as symptoms of depression, anxiety, conduct problems, hyperactivity and inattention, and substance use. These data were analyzed in a dimensional and hierarchical framework using latent variable indirect effects modeling. The associations between peer victimization and psychopathology were not unique to specific symptom domains, but rather showed broadband associations with all symptom domains via a transdiagnostic association with general psychopathology. For example, an average of only 9% of the total relationship with each symptom domain was unique to the symptom-domain level, with the remaining proportion accounted for by higher-order factors (i.e., internalizing, externalizing, and general psychopathology). Further, the strength of the relationships did not vary as a function of the type of peer victimization experience (i.e., physical, verbal, or relational), and showed evidence of strict measurement invariance by gender. These findings suggest that peer victimization might present a useful target for the prevention of general psychopathology.

The use of social media by Australian preadolescents and its links with mental health.

OBJECTIVES: Preadolescent social media use is normative and could influence mental health. This study investigated: (a) Differences between preadolescent users and non-users of various social media platforms on mental health, (b) unique links between time spent on those platforms, appearance-based activities on social media, and mental health, and (c) the moderating role of biological sex on those relationships. METHOD: Preadolescent youth (N = 528; 50.9% male) completed online surveys. RESULTS: Users of YouTube, Instagram, and Snapchat reported more body image concerns and eating pathology than non-users, but did not differ on depressive symptoms or social anxiety. Appearance investment uniquely predicted depressive symptoms. Appearance comparisons uniquely predicted all aspects of mental health, with some associations stronger for females than males. CONCLUSIONS: Preadolescents could be encouraged to reduce their opportunities to make appearance comparisons and to invest less in their appearance on social media. Preadolescents may benefit from social media intervention programs.

Adolescent development and risk for the onset of social-emotional disorders: A review and conceptual model.

The adolescent developmental stage appears to be a sensitive period for the onset of several particular forms of mental disorder that are characterised by heightened emotionality and social sensitivity and are more common in females than males. We refer to these disorders (social anxiety disorder, generalised anxiety disorder, eating disorders, major depression) collectively as the social-emotional disorders. The aim of this paper is to address an important question in the understanding of social-emotional disorders - why do these disorders commonly begin during adolescence? We present a conceptual model that describes some of the key changes that occur during adolescence and that addresses some hypothesised ways in which these changes might increase risk for the development of social-emotional disorders. An overview of the extant empirical literature and some possible directions for future research are suggested. The model points to interesting links between psycho-social risk factors that should highlight potentially fruitful directions for both psychopathology research and early intervention programs.

Measuring repetitive negative thinking: Development and validation of the Persistent and Intrusive Negative Thoughts Scale (PINTS).

Repetitive negative thinking (RNT) is a key risk and maintenance factor for many psychological disorders and is considered a transdiagnostic process. However, there are few disorder-neutral measures that assess RNT in adults, only 1 of moderate length considered suitable for children, and none that are validated for both children and adults. This study aimed to address this gap by developing a brief measure of RNT that can be used with both children and adults and can be quickly administered in research and clinical contexts. In Study 1, we administered the new 5-item Persistent and Intrusive Negative Thoughts Scale (PINTS) to 527 children (50.3% boys; Mage = 11.2). A 1-factor model fit well and was invariant for boys and girls. The scale showed high internal consistency and good stability across a 2-week interval. The PINTS was significantly associated with measures of depression, anxiety, and disordered eating and was weakly associated with adaptive forms of coping, demonstrating good divergent validity. In Study 2, there were 419 adults (38.9% men; Mage = 31.7) who completed the PINTS. The results replicated and extended the results of Study 1 by demonstrating that the PINTS had good construct, convergent, and criterion validity as well as good internal consistency and stability over time and was invariant across gender and age. It was concluded that the PINTS is a brief, valid, and useful tool for investigating RNT as a transdiagnostic process in the etiology and maintenance of psychological disorders in both children and adults. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

The Preteen Perfectionist: An Evaluation of the Perfectionism Social Disconnection Model.

This research investigated associations between socially prescribed and self-orientated perfectionism, and the social functioning of 510 preteens (Mage = 11.2). The study focused on predictions from the Perfectionism Social Disconnection Model (PSDM) by determining whether rejection sensitivity and social isolation, in that sequence, mediated the associations between both perfectionism types and mental health outcomes. Employing both survey and experimental methods, findings indicated that both types of perfectionism in preadolescence were associated with increased interpersonal difficulty, rejection sensitivity and feelings of social isolation, as well as higher levels of eating disorder symptoms, depression, and anxiety. Results from serial mediation analyses found general support for the theoretical predictions of the PSDM for socially prescribed perfectionism, and extending upon previous research, for self-orientated perfectionism. The age of the sample suggests that both forms of perfectionism may be important targets in programs to prevent the development of mental health problems.