Academic Functioning Research Articles

Mindful Awareness Practices (MAPs) in Adolescents With ADHD and Cognitive Disengagement Syndrome (CDS): A Pilot Open Trial.

Objective: Very few studies have investigated intervention approaches that may be efficacious for youth with ADHD and co-occurring cognitive disengagement syndrome (CDS) symptoms. This study examined the feasibility, acceptability, and preliminary efficacy of a mindfulness-based intervention for adolescents with ADHD and co-occurring CDS symptoms. Methods: Fourteen adolescents ages 13 to 17 years (35.71% female; 64.29% White, 7.14% Black, 28.57% Multiracial) with ADHD and elevated CDS symptoms completed the 8-week group-based Mindful Awareness Practices (MAPs) program developed for individuals with ADHD. We collected measures of CDS, ADHD, mind-wandering, mindfulness, and other difficulties and functioning at baseline, 1-month post-intervention, and 3-month post-intervention to examine preliminary efficacy. We measured participant session attendance, session engagement, at-home practice adherence, and satisfaction of adolescents and caregivers at 1-month post-intervention to examine feasibility and acceptability. We also collected qualitative feedback from adolescents and caregivers at 1-month post-intervention. Results: The intervention was overall feasible to administer, and caregivers and adolescents reported satisfaction with the intervention despite some difficulties with attendance and engagement. We observed improvements to both caregiver- and adolescent-reported CDS symptoms and ADHD-inattentive symptoms from pre-intervention to post-intervention time points, though findings across 1- and 3-month follow-up differed based on informant. We also observed improvements to some indices of adolescent-reported mind-wandering, mindfulness, brooding rumination, and academic functioning. For caregiver report, the only other noted improvement was for executive functioning. No improvements were reported by teachers. Conclusions: Findings support the initial feasibility, acceptability, and preliminary efficacy of MAPs for adolescents with ADHD and co-occurring CDS symptoms on a range of outcomes. Larger trials with a randomized design are warranted to further examine mindfulness-based interventions for adolescents with ADHD and co-occurring CDS symptoms.

Identifying Culturally Relevant School Support Profiles and Links to Academic Functioning in Adolescents.

There is limited knowledge about patterns of adolescents' experiences of general teacher support and support for critical consciousness and cultural competence development in school settings, which are key experiences proposed to promote academic functioning. Furthermore, less is known about potential developmental and ethnic-racial differences in these patterns. Using a person-centered approach, this study examined culturally relevant school support profiles in a sample of sixth and ninth grade students (N = 717; 49.9% girls) from the U.S. Southwest. Participants were aged 10 to 18 years (M = 13.73; SD = 1.54) and were ethnoracially diverse (31.8% Hispanic/Latinx, 31.5% Multiethnic, 25.7% White, 7.3% Black or African American, 1.4% Asian American or Pacific Islander, 1.4% American Indian or Alaska Native, and 1% Arab, Middle Eastern, or North African). Four culturally relevant school support profiles were identified: (1) low general, devoid cultural & critical support; (2) moderate general, moderate cultural, & devoid critical support; (3) high general, moderate cultural & critical support; and (4) high general, cultural, & critical support. Youth in the high general, cultural, & critical support profile had higher concurrent emotional and behavioral engagement. No significant differences were found between early (6th grade) and middle adolescent (9th grade) youth, pointing to the relevance and associations of the identified profiles across development. One significant difference emerged when comparing White and ethnoracially minoritized youth; among White youth, those in the high general, cultural, & critical support and high general, moderate cultural & critical support profiles had higher academic expectations than those in the low general, devoid cultural & critical support profile. The discussion focuses on characterizing heterogeneous and culturally relevant school support profiles, the associations between these profiles and indicators of academic functioning for ethnoracially diverse youth to advance developmental theory and the importance of promoting culturally relevant school support practices to foster developmental competencies among youth.

Concussion Health Improvement Program (CHIP): study protocol for a randomized controlled optimization trial for youth with persistent post-concussive symptoms

BackgroundUp to 1.9 million youth in the USA sustain a concussion each year, and up to 30% experience persistent post-concussive symptoms (PPCS) lasting 1 month or more. PPCS can substantially interfere with social, emotional, and academic functioning. Despite these concerns, few evidence-based treatments are available for youth with PPCS. We previously found effectiveness in treating youth with concussion using a collaborative care intervention that integrates mental health care into a medical model, with improvements in concussive symptoms and quality of life at 1 year. Using the multiphase optimization strategy (MOST) framework, we now aim to assess the contribution of each of the three components that were part of collaborative care: concussion-focused cognitive behavioral therapy (cf-CBT), parenting skills training (PST), and care management (CM).MethodsThe MOST factorial design examines all three intervention components with two levels of each (present or absent), resulting in 8 possible treatment combinations. We will recruit 368 youth with PPCS from 2 geographic locations (Seattle and Dallas), randomizing them to 1 of 8 treatment groups. Youth and/or parents will attend treatment sessions via video conferencing software over 3 months, and complete surveys regarding primary outcomes (concussive symptoms and health-related quality of life) and secondary outcomes (sleep, pain, mood, and parental distress) at 6 weeks and 3, 6, and 12 months. We will also assess potential mediators and moderators to allow for future tailoring and refinement.DiscussionThe overarching goal of this investigation is to determine which collaborative care components (delivered individually or in combination) are most effective in treating PPCS in concussion-exposed youth. The investigation will inform mental health screening, intervention, and referral procedures for youth and families following concussion. At the completion of this study, we will have an optimized and refined intervention for youth with PPCS ready for large-scale implementation and dissemination.Trial registrationClinicalTrials.gov NCT06036147. Registered on September 13, 2023.

English Language and Career Development in African Higher Education: An Overview

The internationalization of higher education in most countries is linked to the “global interests” that supplement the supremacy of the English language above academic research functions including conventional research and publications. This paper aims to (1) describe the rationale behind the adoption of the English language in higher education, and (2) to understand the relationship between the English language and career development at African universities. This overview article analyzed relevant resources sourced from databases such as Scopus, Google Scholar, and Web of Science from January 2022 to July 2022 using the PQRS framework as an analytical tool. The analysis of the academic resources identified five main reasons for the adoption of the English language adoption in African universities: ideology, institutional integration, the knowledge society; globalization, and financial dependence. However, there are diverse views about the effect of the English language and career development in universities in Portuguese-speaking countries such as Mozambique. The paper concludes with challenges of English adoption and improvement of language policy schemes for research and publication in a Portuguese-speaking university.

Examining the Psychosocial Factors of Mental Health Well-being Among Medical University Students: Gender-based Analyses

The mental health of university students is a major concern due to the various stressors they face, including academic pressures, social dynamics, and personal development challenges. Previous studies have shown that gender differences significantly impact how students perceive and express psychological distress. This study aimed to identify these differences in the context of academic stress, social support, self-esteem, academic motivation, and family functioning, and their association with psychological distress. The study involved 2206 medical students in a cross-sectional study at a medical university in Ningxia, western China. The data analysis revealed significant gender differences in scores for academic stress, social support, and academic motivation. Academic stress, social support, and family functioning were found to be significantly associated with psychological distress for both genders. However, academic motivation was found to significantly influence psychological distress only among male students, while self-esteem had an impact on female students. These findings highlight the need for tailored mental health services in universities to address gender-specific needs, such as providing counseling services that focus on coping with academic stress and strengthening social and familial support networks to improve student well-being.

Perceptions of Academic Performance, Impairment, and Mental Health in University Students With and Without ADHD.

This study aims to investigate the impact of positive illusory bias (PIB) on the relationship between ADHD symptoms and functioning in college students, with a focus on gender differences. The sample consisted of 195 college students, including 148 with ADHD and 47 without ADHD. Measures of ADHD symptomatology, life satisfaction, affect, gender identity, and impairment were collected, along with cumulative grade point average. ADHD symptomatology was inversely linked to subjective well-being, with PIB acting as a significant moderator. Functional impairment was predicted by ADHD symptoms and subjective well-being, while social impairment and academic functioning were predicted by PIB and well-being. Significant gender differences were found, particularly in the interaction between PIB and ADHD symptoms for non-binary individuals. This study suggests that PIB is relevant for emerging adults with ADHD enrolled in higher education. Subjective well-being and PIB act as buffers against the detrimental functional and social effects of ADHD symptoms in emerging adult college students. The study highlights the importance of considering gender-specific approaches in understanding and supporting the mental health of this population.

The role of focused attention in learning from early childhood to late adolescence: Implications of neonatal brainstem compromise following preterm birth.

This comprehensive longitudinal study explored for the first time the interrelations between neonatal brainstem abnormalities, focused attention (FA), and learning-following a preterm cohort (N = 175; 46.3% female; predominantly White) from birth (2003-2006) to 17 years. The findings indicated that FA during early childhood was associated with language outcomes in toddlerhood (n = 131) and academic and attention self-report indices in late adolescence (n = 44). Pilot assessments indicated that FA at 17 years (n = 25) was also associated with concurrent academic and attention functioning. Structural equation modeling analyses revealed that neonatal brainstem functioning, manifested in auditory brainstem response patterns, was associated with early-life FA competence, which affected learning development. Implications underscore the essential role of early brainstem function and FA in shaping childhood learning trajectories.

Corrigendum: School (socie)ties: individual and school level differences in the association between ethnic/racial victimization and academic functioning

Corrigendum: School (socie)ties: individual and school level differences in the association between ethnic/racial victimization and academic functioning

A - 40 Food Insecurity Is Associated with Serious Cognitive Difficulties among Adolescents with Attention-Deficit/Hyperactivity Disorder and Learning Disabilities

Abstract Objective Youth with neurodevelopmental disorders, such as attention-deficit/hyperactivity disorder (ADHD) and learning disabilities (LD), experience cognitive difficulties in their daily lives. Food insecurity, a public health problem, disproportionately affects youth with neurodevelopmental disorders and is associated with mental health and academic functioning. We examined the association between parent-reported food insecurity and cognitive difficulty among youth after adjusting for factors associated with cognitive difficulty. Methods The 2022 National Survey of Children’s Health, conducted in the United States, is designed to provide parent-reported information on the health and well-being of children and adolescents. Associations between cognitive difficulty, food insecurity, adverse childhood experiences (ACEs), psychiatric conditions, flourishing, receiving federal assistance, and low socioeconomic status were analyzed using binary logistic regressions. Results There were 6422 youth (aged 6–17) with ADHD and/or LD (63.4% boys). Around half had parent-reported serious cognitive difficulties (50.5%). A third (31.9%) were reported to have mild food insecurity and 6.7% had moderate/severe food insecurity. In the multivariable model [χ2(6) = 1138.25, p < 0.001; Nagelkerke R2 = 0.22], food insecurity [Odds Ratio (OR) = 1.21; 95% confidence interval (CI) = 1.07–1.34)] was an independent predictor of serious cognitive difficulty, in addition to ACEs (OR = 1.121, 95%CI = 1.075–1.168), anxiety or depression (OR = 2.279, 95%CI = 2.041–2.545), flourishing (OR = 0.473, 95%CI = 0.442–0.505), and free or reduced school meals (OR = 1.244, 95%CI = 1.108–1.397). Conclusion Food insecurity was independently associated with parent-reported cognitive problems among youth with ADHD and LD. Better understanding the mechanisms that underlie the associations between food insecurity, other social determinants of health, and cognitive difficulties can facilitate the development of targeted, evidence-informed interventions to bolster functional and academic outcomes for youth with neurodevelopmental disorders.

A - 44 Value of Repeat Neuropsychological Assessments in Children with Complex Birth and Neurological Injuries

Abstract Objective Extremely low birth weight, in-utero insult, and PVL are associated with an array of neurodevelopmental complications. PVL is most common in very premature. Associated complications in this case study include diffuse demyelination, cerebellar atrophy, and arthrogryposis. Data from serial assessments reveal preservation of intelligence, decoding, and social skills. Implications for the role of repeat assessments in guiding education and intervention are discussed. Method The subject was an 18-year-old male with extremely low birth weight, in-utero insult, PVL, cerebellar atrophy, delayed myelination, and arthrogryposis. His presentation also included craniosynostosis. Three outpatient neuropsychological assessments were completed over eight years. Assessments included measures of intellectual, academic, neurocognitive, and emotional functions. Results Despite multiple physical and neurological impairments, assessments revealed preserved verbal and nonverbal intelligence, phonemic awareness, computation skills, and social cognition. Deficits were evident in processing speed, rapid naming, math fluency, word fluency, working memory, and executive functions. Academic strengths were evident in reading and written expression. Checklists revealed inattention and impulsivity with strengths in social cognition (See data tables). Conclusions This study demonstrates both variability in outcome following a complex birth history and neurological history and the value of repeat neuropsychological assessments. Assessment data was used to identify and build upon preserved skills and focus intervention strategies. Maintained verbal and nonverbal reasoning skills, in the context of strong social cognition, significantly contributed to progress, self-esteem, and future goals. Repeat neuropsychological assessment is well-suited for such cases. Access to such assessments is critical and should be regarded as medically necessary to guide intervention and promote positive outcomes.

The role of working memory and organizational skills in academic functioning for children with attention-deficit/hyperactivity disorder.

Children with attention-deficit/hyperactivity disorder (ADHD) exhibit difficulties with organizational skills such as task planning, managing materials, and organizing activities that have downstream consequences on academic functioning. At the same time, deficits in working memory have been linked with both the organizational skills difficulties and academic underachievement and underperformance observed in children with ADHD and have been hypothesized to account for the link between organizational and academic functioning. However, the extent to which working memory and organizational skills independently versus jointly contribute to ADHD-related academic difficulties remains unclear. The present study is the first to examine the unique and shared roles of working memory and organizational skills for explaining ADHD-related underachievement and underperformance in a clinically evaluated sample of 309 children with and without ADHD (Mage = 10.34, SD = 1.42; 123 girls; 69.6% White Not Hispanic or Latino). Bias-corrected, bootstrapped latent path analyses revealed that working memory and organizational skills together accounted for 100% of the academic achievement (d = -1.09) and 80.6% of the academic performance (d = -0.58) difficulties exhibited by children with ADHD. Working memory (d = -0.95 to -0.26), organizational skills (d = -0.30 to -0.11), and shared variance across working memory and organizational skills (d = -0.13 to -0.06) each independently predicted ADHD-related difficulties in both academic achievement and performance outcomes. These findings are consistent with models suggesting that working memory has downstream consequences for functional impairments in ADHD, as well as evidence that organizational skills and working memory are each important predictors of ADHD-related academic functioning. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Multidisciplinary, Interdisciplinary, and Transdisciplinary Approaches to Neurodevelopmental Disability Interventions: A Brief Overview

Neurodevelopmental disabilities in children, affecting personal, social, academic, or occupational functioning, present a global challenge. Neurodevelopmental issues contribute significantly to learning disabilities, emphasizing the need for early intervention. The Rashtriya Bal Swasthya Karyakram (RBSK), a government program launched in 2013, is a multidisciplinary initiative addressing child health. This article compares three distinct approaches – multidisciplinary, interdisciplinary, and transdisciplinary – in the context of early intervention. Multidisciplinarity utilizes knowledge from various disciplines, while interdisciplinarity synthesizes links between disciplines, and transdisciplinarity integrates sciences beyond traditional boundaries. Challenges in early intervention, particularly with RBSK, include limited awareness and accessibility, necessitating ongoing efforts and innovations. This study concludes by emphasizing the transformative potential of embracing innovative solutions to create a more inclusive and equitable future for children with neurodevelopmental difficulties and their families.

Identifying Children With Hearing Loss: The Key Role of School Nurses in Evidence-Based Screenings.

Undetected hearing loss in school-aged children can impact academic and social functioning and have a life-long impact on the student. The prevalence of hearing loss increases as children reach school age, which highlights the importance of regular, evidence-based hearing screening. This article identifies the barriers to screening that school nurses may face, reviews the two evidence-based methods for childhood hearing screening, and reinforces the need for school nurses to conduct and advocate for regular hearing screening for all students.

Unique and interactive roles of economic stress and discrimination on heterogeneous development among Chinese American adolescents: An 8-year longitudinal study.

Chinese American youth as a group are often labeled as "model minorities." Yet, this label ignores the vast heterogeneity within Chinese Americans and implies that they are immune to environmental stressors. Using an 8-year longitudinal study of 444 (54% female; initial Mage = 13-year-old) Chinese American adolescents, we identified two (well- vs. poorly adjusted) concurrent and three (stably well-adjusted, improved, and risk) latent transition profiles from early adolescence to emerging adulthood based on six indicators of academic, behavioral, and socioemotional functioning. Multilevel modeling revealed higher levels of family economic stress or discrimination independently associated with higher likelihood to be in the subgroup of adolescents with poorly adjusted patterns across development. Within an individual, Chinese American adolescents were more likely to have worse adjustment patterns in the year when they experienced higher economic stress or discrimination relative to other study years, suggesting that their adjustment are sensitive to the fluctuation of stress level during development. Longitudinally, those who experienced higher family economic stress or discrimination at early adolescence were more likely to become at risk when they reached adulthood. Higher discrimination predicted the likelihood to be in the improved groups but only among adolescents with low (but not high) economic stress, suggesting that the influence of discrimination may vary by family socioeconomic status. Findings (a) challenge the model minorities assumption, (b) highlight the importance of capturing multiple ecological contexts associated with heterogeneous development among Chinese American adolescents, and (c) provide longitudinal evidence to social policies aiming to reduce wealth disparities and anti-Asian racism. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Low-resource multi-granularity academic function recognition based on multiple prompt knowledge

PurposeFine-tuning pre-trained language models (PLMs), e.g. SciBERT, generally require large numbers of annotated data to achieve state-of-the-art performance on a range of NLP tasks in the scientific domain. However, obtaining fine-tuning data for scientific NLP tasks is still challenging and expensive. In this paper, the authors propose the mix prompt tuning (MPT), which is a semi-supervised method aiming to alleviate the dependence on annotated data and improve the performance of multi-granularity academic function recognition tasks.Design/methodology/approachSpecifically, the proposed method provides multi-perspective representations by combining manually designed prompt templates with automatically learned continuous prompt templates to help the given academic function recognition task take full advantage of knowledge in PLMs. Based on these prompt templates and the fine-tuned PLM, a large number of pseudo labels are assigned to the unlabelled examples. Finally, the authors further fine-tune the PLM using the pseudo training set. The authors evaluate the method on three academic function recognition tasks of different granularity including the citation function, the abstract sentence function and the keyword function, with data sets from the computer science domain and the biomedical domain.FindingsExtensive experiments demonstrate the effectiveness of the method and statistically significant improvements against strong baselines. In particular, it achieves an average increase of 5% in Macro-F1 score compared with fine-tuning, and 6% in Macro-F1 score compared with other semi-supervised methods under low-resource settings.Originality/valueIn addition, MPT is a general method that can be easily applied to other low-resource scientific classification tasks.

Academic Readiness among Young Children Treated for Brain Tumors: A Multisite, Prospective, Longitudinal Trial.

Young children treated for central nervous system (CNS) malignancies are at high risk for difficulties with academic functioning due to increased vulnerability of the developing brain and missed early developmental opportunities. Extant literature examining academics in this population is limited. We investigated academic readiness, its clinical and demographic predictors, and its relationship with distal academic outcomes among patients treated for CNS tumors during early childhood. Seventy patients with newly diagnosed CNS tumors were treated on a prospective, longitudinal, multisite study with chemotherapy, with or without photon or proton irradiation. Patients underwent assessments of academic skills at baseline, six months, one year, and then annually for five years. Assessments measured academic readiness and academic achievement in reading and math. Mixed linear models revealed slowed development of academic readiness skills over time. Socioeconomic status (SES) was predictive of academic readiness at all time points. Other demographic (eg, age at treatment) and clinical (eg, shunt status, treatment exposure) variables were not predictive of academic readiness. Distal reading difficulties were proportionally greater than normative expectations while math difficulties did not differ. Academic readiness was predictive of distal academic outcomes in reading and math. Treatment for CNS malignancies in early childhood appears to slow development of academic readiness skills, with SES predictive of risk. Academic readiness skills were predictive of subsequent academic achievement. A disproportionate number of long-term survivors performed below age-based expectations in reading. These findings suggest the need for monitoring and interventions targeting early academic skills in this population.

Does grit predict thriving or is it the other way around? A latent cross-lagged panel model on the triarchic model of grit and the 5Cs of positive youth development.

Grit, defined as passion and perseverance to achieve long-term goals, has been associated with adolescents' optimal academic and psychological functioning. However, the role of grit in adolescents' positive youth development (PYD)-characterized by the 5Cs known as competence, confidence, connection, character, and caring-remains unknown. Using latent cross-lagged panel modeling, this study examined the longitudinal relations between the triarchic model of grit (TMG) dimensions (i.e., perseverance of effort, consistency of interest, and adaptability to situations), and the 5Cs of PYD while controlling for specific socio-demographic covariates (gender, age, SES, and school type). Data were obtained from 1620 Filipino adolescents (Mage = 17.15; SDage = 1.00) in November 2021 and May 2022. Results show that grit dimensions predicted subsequent PYD dimensions, but not vice versa. Specifically, while perseverance and adaptability were linked to higher levels of competence, confidence, and character, consistency was associated with lower levels of competence and confidence six months later. Results highlight the importance of grit's dimensions in facilitating PYD characteristics among adolescents, especially efficacy-related Cs (competence and confidence). Theoretical and practical implications in promoting adolescent thriving and well-being are discussed.

Indicators of Wellness Among Social Work Students within an Urban Setting During Times of Crisis

ABSTRACT The emergence of a global emergency, Covid-19, forced social work programs to shift to virtual teaching, disrupting students’ learning abruptly. Social work students reported negative impacts from the pandemic on academic functioning as well as financial and emotional wellbeing. This study examines the relationships between demographic predictors (age, race, type of social work program, caregiver status, first-generation college student, household size) and challenges (emotional, academic/professional, financial, technological) social work students experienced during the pandemic. Participants included 332 BSW and MSW students from an urban university. Binomial regressions were conducted to determine the significance between student demographics and types of challenges. A Poisson regression was performed to determine the significance between student demographics and the total number of challenges. Students living in larger households, students with greater caregiver demands, BSW students, and students of color reported a greater number of challenges related to juggling school with caregiver demands, job searching, managing finances, food and housing, coping with grief and loss, and feeling disconnected with school (ps <.05). These findings contribute to the emerging body of literature on the impact of COVID-19 by informing ways social work schools can better address students’ educational, professional, financial, and emotional wellbeing during times of worldwide crisis.

Studyholism as a New Potential OCD-Related Disorder: What Evidence Have We Gathered until Now? A Narrative Review.

In 2017, Loscalzo and Giannini introduced the new potential clinical condition of studyholism (or obsession toward study) and a comprehensive model including its possible antecedents and outcomes. Then, emphasizing the value of avoiding an aprioristic (addiction) framework in analyzing problematic overstudying, they suggested conducting research on this new construct to unveil its internalizing and/or externalizing nature while also avoiding the over-pathologizing of a common behavior such as studying. Seven years after the first publication about studyholism, growing evidence concerning its antecedents suggested that studyholism might be defined as an OCD-related disorder (or, more generally, as an internalizing disorder). Moreover, the research about its outcomes highlighted that it is a problem behavior deserving attention as it is associated with academic, psychological, physical, and social downsides. Therefore, this paper aims to review the scientific literature published concerning studyholism to illuminate if it might be conceptualized as an OCD-related disorder based on its symptomatology, antecedents, and impact on individuals' academic, physical, and psychological functioning. Given that it is a new construct, it is of critical value to systematize the findings gathered until now as it can help scholars interested in students' well-being to have a clear understanding concerning the importance of screening studyholism since childhood, as this will help favor academic success and well-being and reduce the risk for school dropout. Finally, this paper presents an agenda for future research on studyholism, and it highlights the importance of further analyzing problematic overstudying using different theoretical perspectives (such as the behavioral addiction conceptualization) to unveil its real nature.

ADHD - Treatment Options and Consequences of Neglect

Purpose of Research: Attention Deficit Hyperactivity Disorder (ADHD) is one of the most frequently diagnosed neurodevelopmental disorders. It is estimated to occur in approximately 5-10% of children and adolescents. This paper aims to highlight the challenges faced by individuals suffering from ADHD, present risk factors, summarize current treatment methods, and outline the consequences of neglecting treatment. Methods: Databases such as PubMed, Medline, and ResearchGate were used. Basic Results: The goal of ADHD treatment is to reduce the severity of symptoms and improve the social, academic, and emotional functioning of children and adolescents. The choice of treatment and the selection of a specific medication depend on the patient's age and coexisting disorders. Conclusions: ADHD often coexists with other mental disorders, complicating diagnosis and treatment. Lack of or ineffective treatment has consequences such as learning difficulties, disruptions in peer and family relationships. It correlates with higher rates of traffic accidents, accidental injuries, earlier onset, and higher rates of substance abuse.