Significant Predictors Of Psychological Distress Research Articles

The Mediating Effect of Post-Traumatic Growth on the Relationship between Adverse Childhood Experiences and Psychological Distress in Adults

Background: Research has shown that Adverse Childhood Experiences (ACEs) are prevalent and are associated with psychological distress. Some studies indicate facing these adversities can lead to post-traumatic growth. This study aims to assess the impact of ACEs on psychological distress and post-traumatic growth and to determine the mediating effect of post-traumatic growth between ACEs and psychological distress, in a sample of adults. Methods: In this study, there were 521 participants (mean = 31.32, SD = 12.28), who answered the following surveys online: a sociodemographic questionnaire, the Family ACE Questionnaire, the Kessler Psychological Distress Scale (K10) and the Post-Traumatic Growth Inventory (PTGI). Results: ACEs were positive and significant predictors of psychological distress, and the “Change in the perception of the self and life in general” factor of post-traumatic growth was the strongest predictor of lower perceived psychological distress. Post-traumatic growth did not mediate the relationship between ACEs and psychological distress. Conclusions: These findings contribute to the improvement of clinical practice and health policies and highlight the need for a more in-depth understanding of the impact of ACEs on mental health.

Maternal distress during the COVID-19 outbreak: A socio-ecological perspective.

Mothers faced an increased risk of adverse mental health outcomes during the COVID-19 pandemic compared to other populations. However, there is little data on the factors that placed mothers at increased risk of distress. The present study explored a range of individual, familial, and environmental factors associated with psychological distress in mothers during the COVID-19 pandemic. This repeated cross-sectional study was composed of a convenience sample of mothers who completed an online survey that included a demographic questionnaire, an emotion regulation questionnaire, and the Depression, Anxiety, and Stress scale. The survey was administered during the second and third lockdowns in Israel in 2020-2021. The study included 575 mothers (M age = 39). The findings of a hierarchical regression indicated that individual-level factors, composed of age and emotion regulation tendencies predicted psychological distress. The family-level factors of household income and number of children in the family also predicted distress. In terms of environmental-level factors, COVID-19-related media consumption and school status (open or closed) were also significant predictors of psychological distress. Importantly, the results showed that the most important predictors of psychological distress in mothers during the COVID-19 outbreak were school closures, household income, and the use of adaptive and maladaptive emotion regulation strategies. The findings highlight the intersection of individual, familial, and environmental factors in mothers' mental health during crises.

Spirituality, Intolerance and Fear of COVID-19: Psychological Distress Among Older Adults in Pakistan.

The present study aimed to investigate the role of spirituality, intolerance of uncertainty (IU), and fear of COVID-19 as correlates and predictors of psychological distress among older adults in Pakistan and also assess the gender differences among research variables. Using a quantitative correlational survey research design, a sample of 150 (75 = Men, 75 = Women) older adults aged 55 years and above from different cities of Pakistan were approached through a non-probability purposive sampling strategy. Participants completed the Daily Spiritual Experience Scale, Intolerance of Uncertainty Scale IUS-12, Fear of COVID-19, and Kessler Psychological Distress Scale-K10. Spirituality has a significant negative relationship with psychological distress. Whereas, IU (Inhibitory anxiety and prospective anxiety) and fear of COVID-19 have a significant positive relationship with psychological distress. Results also showed that spirituality, IU dimensions, and fear of COVID-19 emerged as significant predictors of psychological distress among older adults after controlling for the effect of covariates. In addition, elderly females significantly showed more spirituality, less IU, and fear of COVID-19 as compared to elderly males. It is proposed that mental health care plays an important role in treating the psychological needs of older adults in pandemic situations and that further study is needed to develop effective solutions for older persons in stressful situations such as pandemics.

Predictors of Psychological Distress for Bi + Individuals during the COVID-19 Pandemic

Bisexual and pansexual (bi+) individuals remain understudied subpopulations of the lesbian, gay, bisexual, transgender and queer (LGTBQ+) community, despite experiencing complex stressors and stigma by both LGBTQ + and heterosexual communities. In this study, we used correlation analyses, hierarchical linear regression and moderation analyses to explore the relationships between societal stressors (concern about COVID and discrimination) and a protective factor (social support) in a sample bi + undergraduate and graduate students. The correlation results revealed positive, bivariate relationship between worry about COVID and psychological distress, along with everyday discrimination and psychological distress. The correlation results also revealed a negative bivariate correlation between social support and psychological distress for bi + participants. Hierarchical linear modeling revealed that worry about COVID, everyday discrimination and social support were significant predictors of psychological distress for bi + individuals. Finally, moderation analyses revealed that social support moderated the relationship between everyday discrimination and psychological distress but not the relationship between COVID-Worry and Psychological Distress for bi + individuals. Findings from the present study will help inform clinicians of specific risks to bi + individual’s mental health when working with this population, specifically regarding the impact of the COVID-19 pandemic.

Basic Psychological Needs, Coping, and Psychological Distress Among Orphans Living in Orphan

The purpose of the study is to explore the relationship of basic psychological needs, coping, and psychological distress among orphans living in orphanages. To examine the relationship between these variables quantitative method was used. A convenient sampling technique was used to collect the data. The sample consisted of 200 orphans of which 153 was male and 47 was female. The data was collected with the help of self-report measures i.e., Basic Psychological Needs Satisfaction and Frustration Scale (B`1234PNSF) by Van der Kaap-Deeder (2015), Coping Inventory for Stressful Situations (CISS-21) by Somia (2020) and DASS-21 by Aslam (2017). The data was analyzed on the SPSS 26 version. There was a significant relationship between basic psychological needs frustration and psychological distress. Avoidance-focused coping and emotion-focused coping were significant predictors of psychological distress. Psychological distress was positively predicted by avoidance-focused coping and emotion-focused coping.

Significant predictors of psychological distress in the group of Polish young adults during the COVID-19 epidemic outbreak: Sequential mediation model

Significant predictors of psychological distress in the group of Polish young adults during the COVID-19 epidemic outbreak: Sequential mediation model

The Relationship Between Weight Stigmatization, Avoidance, Enjoyment and Participation in Physical Activity and Sport, and Psychological Distress

Objectives: The psychosocial factors affecting physical activity (PA) and sport participation are not well understood but need to be to gain the psychological benefits of PA and sport. In this study, we sought to establish the relationship between weight stigmatization, the tendency to avoid, or participate in and/or enjoy PA and sport, and psychological distress.Methods: We collected demographic details and measures of the constructs of interest from 578 undergraduate students via an online survey. We ran bivariate correlations and multivariate linear regression models to establish statistical relationships between the variables of interest. Results: In bivariate correlations, weight stigmatization and the tendency to avoid PA were significantly associated with greater psychological distress. Greater enjoyment of PA and sport was related with less psychological distress; however, participation in PA and sport was not associated with psychological distress. In multivariate regression analyses, weight stigma, internalized weight stigma and the tendency to avoid PA and sport were significant predictors of psychological distress, accounting for 22% of the variance in psychological distress scores.Conclusion: In this study, we found that addressing internalized weight stigma requires urgent action to promote better mental health through PA and sport participation. We propose a conceptual model to explore these relationships.

Rates and correlates of psychological distress and PTSD among persons with physical disabilities in Cambodia

BackgroundCompared to the general population, persons with disabilities are at increased risk of poor mental health. The aim of this study was to determine the rates and correlates of psychological distress and post-traumatic stress disorder (PTSD) among persons with physical disabilities in Cambodia.MethodsFrom July to December 2021 data were collected as part of a mental health screening programme for persons with physical disabilities who access prosthetic and orthotic services. Psychological distress was measured using the Kessler-10 (K-10) and PTSD using the PC-PTSD-5. Bivariate and multiple linear regression analyses were conducted to identify factors associated with levels of psychological distress and PTSD among this population.ResultsOur study found a high prevalence of psychological distress and PTSD in this patient cohort. Of the 213 participants, 31.5% were likely to be experiencing mild to moderate psychological distress indicative of a mental health disorder, with 13.6% likely to have a severe mental health disorder. Sixty-five percent of patients reported experiencing PTSD symptoms, with forty-six percent meeting the criteria for probable PTSD. Psychological distress was associated with pathological worry, rumination, and facets of mindfulness. Rumination and pathological worry were found to be significant predictors of psychological distress. PTSD symptoms were associated with pathological worry but not facets of mindfulness or rumination. Facets of mindfulness and pathological worry were found to be significant predictors of PTSD.ConclusionIntegration of mental health services within the disability sector is required to address psychological distress and PTSD symptoms among people with physical disabilities in Cambodia. Health system interventions, such as screening, referral, and the training of health providers, need to be strengthened. Further studies focussing on the psychosocial determinants of mental health of persons with disabilities in Cambodia are required.

Military-related relocation stress and psychological distress in military partners.

Spouses/partners play a crucial role in providing support to military service members (SMs), maintaining a sense of stability for the family, and supporting the overall mission of the armed forces. However, several aspects of the military lifestyle may impact their own psychological health. Much research has focused on the role of SMs' deployments and posttraumatic stress disorder (PTSD) symptoms in partners' distress, but no study has yet quantitatively investigated these factors in tandem with the common military life stressor of frequent relocations. The present study investigated the degree to which problems from service-related moves, couple deployment separation, and SMs' PTSD symptoms uniquely predict partner psychological distress. Data were collected from female partners of Army soldiers who completed online surveys across four timepoints (over 1.5 years) following a deployment. Surveys assessed psychological distress, perceptions of SMs' PTSD symptoms, problems from service-related moves, and deployment separation. Multilevel modeling was used, with longitudinal data treated as repeated measures (i.e., not modeling change over time). Results indicated that problems from service-related moves were associated with greater psychological stress, even when accounting for SMs' PTSD symptoms and deployment separation. Deployment separation itself was not a significant predictor of psychological distress. Findings indicate that problems associated with frequent moves may be a significant contributor to increased psychological distress for partners above and beyond challenges associated with SMs' PTSD symptoms. Recommendations for future research and limitations are also provided. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

EXPLORING THE ASSOCIATION OF MEANING IN LIFE WITH PSYCHOLOGICAL DISTRESS IN MALE PATIENTS WITH SUBSTANCE USE DISORDER IN PAKISTAN

The objective of the present research is to explore the predictive association of meaning in life (presence & search) with psychological distress (depression, anxiety & stress) in people with substance use disorder. Sample of the present study comprised 200 Muslim participants (male patients with substance use disorder), ages ranging from 18 to 45 years (M =18; SD =6.55). The sample was recruited from different substance use treatment and rehabilitation centers situated in different areas of Karachi, through purposive sampling. Instruments used in this study were the Personal Information Form, Meaning in Life Questionnaire (MLQ; Stegaer, et al., 2006), and Depression Anxiety and Stress Scale (DASS; Lovibond, & Lovibond, 1995). Regression analysis shows a significant predictive relationship of meaning in life (i.e., presence & search of the meaning) with depression (adj R2=.988, F (2, 198) =8278.46, P < .0001(, anxiety (adj R2=.943, F (2, 198) =1659.82, P < .0001(, stress (adj R2=.982, F (2, 198) =5390.78, P < .0001(. Overall findings revealed that meaning in life is a significant predictor of psychological distress (i.e., depression, anxiety & stress) in people with SUD. The finding and implications are discussed in detail. Keywords: Meaning in life, presence, search, depression, anxiety, stress, substance use disorder

Mindfulness, Valuing, and Emotion Regulation in the Prediction of Psychological Distress: Mindfulness and Valuing in Psychological Distress

The present study aims to examine the role of mindfulness, valuing (progress and obstruction), and strategies for emotion regulation (reappraisal and suppression) in prediction of psychological distress among university students. A total of 332 undergraduate students (237 females, 95 males) from the Faculty of Education of one state and one private university participated in the study. The data, which was analyzed by using hierarchical multiple regression, indicated that valuing and mindfulness were significant predictors of psychological distress. On the other hand, emotion regulation, which encompasses reappraisal and suppression, was seen to be an insignificant predictor of psychological distress. Among the variables, the obstruction subscale of valuing contributed most to the model. Overall, this study highlights that having a ‘value-based life’ and ‘mindful living’ are protective factors which may reduce the likelihood of experiencing high levels of psychological distress among university students. The results were discussed in the light of the literature.

Prevalence and associated factors of psychological distress of patients with stroke attending the clinics of the National Institute of Neurology of the National Hospital of Sri Lanka, Colombo

INTRODUCTION: Stroke is the fifth leading cause of disability adjusted life years lost in Sri Lanka. A vast range of factors lead to psychological distress among stroke patients causing poor outcomes such as limitations of daily activities, poor rehabilitation outcomes, social isolation, and poor financial recovery. Nevertheless, there is a scarcity of data on this topic, in both foreign and local literature. OBJECTIVES: To assess the prevalence of psychological distress and identify the factors associated with it among the patients with stroke attending the clinics of National Institute of Neurology (NIN), National Hospital of Sri Lanka (NHSL), Colombo. METHODS: A descriptive cross-sectional study with an analytical component was conducted among 177 patients with stroke attending the clinics of National Institute of Neurology, National Hospital of Sri Lanka, Colombo who were sampled by multistage random sampling. The 10-item Kessler psychological distress scale was used to assess the psychological distress while the Barthel Index and the modified Rankin Scale were used to assess the dependence on the Activities of Daily Living (ADL) and disability status respectively. Data was collected regarding socio-demographic, behavioral, family and caregiver, stressful life events, stroke and other health related factors using a pretested interviewer administered questionnaire. Chi-square tests, simple logistic regression was used for bivariate analysis followed by multivariate analysis via binary logistic regression. Results obtained from the final regression model were expressed using odds ratios with 95% confidence intervals whilst associations with p-value < 0.05 were significant in all types of analyses. RESULTS: The mean age of the participants with stroke was 59.6 (SD 12.285) years. The prevalence of psychological distress among stroke patients was found to be 23.3% (95% CI: 16.1 - 31.9) using the validated K10 score of ≥22. During bivariate analysis, none of the sociodemographic, family and caregiver related, and stressful life event related factors were significantly associated while past personal history and family history of psychiatric disorders, frequency of engagement in physical and leisure time activities prior to the stroke event, time since the last stroke event, level of disability and dependence on ADL (p < 0.05) were found to be significant predictors of psychological distress. The results of regression identified five independent predictors with a R2 of 0.772. There, the presence of psychological distress was significantly predicted by age (b = -.134, p < 0.05), gender (b = 4.262, p = 0.05), patient being the sole source of income (b = 3.207, p < 0.05), ii level of disability (b = 2.568, p < 0.001) and past personal history of psychiatric disorders (b = 5.151, p < 0.05). CONCLUSION: The prevalence of psychological distress among patients with stroke attending the clinics of the NIN, NHSL, Colombo is high and is associated with several health and non-health related factors. A standard routine screening method should be formulated for early diagnosis of patients at risk of psychological distress supplemented by a multidisciplinary approach including psychosocial support starting from the initial out-patient management of stroke patients.

Non-Pathological Psychological Distress among Mainland Chinese in Canada and Its Sociodemographic Risk Factors amidst the Pandemic.

A sample of 731 Mainland Chinese aged 16 or older completed an on-line survey to examine their attitudes, behavioural, and psychological responses towards COVID-19. Non-pathological psychological distress was assessed with a 7-item self-report scale to capture common emotional reactions towards COVID-19. A factor analysis revealed a single-factor structure of the 7-item COVID-19 psychological distress scale (Eigen λ = 3.79). A composite psychological distress index (PDI) score was calculated from these items and used as the outcome variable. Multivariate regression models identified age, financial satisfaction, health status, and perceived/experienced discrimination as significant predictors of psychological distress (ps ≤ 0.05). Mainland Chinese in Canada who were over 25, in poor financial/health status, or with perceived/experienced discrimination were at a higher risk for COVID-19-related psychological distress. The health inequity across these factors would inform the services to mitigate mental health risk in minority groups.

How do threat to life and state anxiety disturb the psychological functioning of Polish adults during coronavirus pandemic?

The aim of this study was to answer the following question: how do threat to life and state anxiety predict psychological functioning in a coronavirus pandemic among Polish adults aged 18-65 years? The web-based cross-sectional survey was applied to 1466 Polish respondents (1074 women, 73.3%) aged 18-65 years. They were divided into four age groups (18-25; 26-35; 36-45; 46-65). All participants completed: General Functioning Questionnaire (GFQ), State Anxiety Inventory (STAI-S), and General Sense of Threat to Life Scale (GSTLS). The youngest adults (aged 18-25 years) manifested significantly higher psychological distress, state anxiety, and a sense of threat to life compared to all the older participants. A sense of threat to life and state anxiety were significant predictors of psychological distress during the COVID-19 epidemic, where state anxiety mediates the relation between threat to life and psychological distress. The youngest participants constitute a risk group for psychological difficulties during the pandemic situation. The COVID-19 psychological distress could be significantly predicted by the two kinds of emotional state such as threat to life and anxiety.

Partnership Status and Mental Health in a Nationally Representative Sample of Sexual Minorities.

Research has consistently shown mental health differences between sexual minority subgroups with bisexual people often reporting higher levels of psychological distress than lesbians and gay men. Relationship status has been suggested, but not well studied, as a potential factor contributing to subgroup differences in mental health. Using a national probability sample of non-transgender sexual minority adults across 3 age cohorts (18-25, 34-41, 52-59 years), we assessed group differences in psychological distress (Kessler 6) between lesbian/gay (N = 505), bisexual (N = 272), and queer/pansexual (N=75) respondents. We examined whether relationship status (single/partnered) moderated the relationship between sexual identity and psychological distress. Among those that were partnered, we tested whether key partner characteristics related to sexual identity - gender of partner (cisgender same-sex/transgender or cisgender different-sex) and partner sexual identity (same or mixed sexual orientation relationship) - were significantly associated with psychological distress. In bivariate analyses, bisexual and queer/pansexual respondents reported more psychological distress than gay/lesbian respondents, among both men and women. In multivariable analyses, there was not a significant main effect of sexual identity, but there was a significant interaction between sexual identity and partnership status on psychological distress among women. Specifically, while there were no significant differences in psychological distress between subgroups of single women, among partnered women, queer/pansexual women had more distress than lesbian/gay women. Further, partnership was associated with reduced distress among lesbian/gay women, but not among bisexual or queer/pansexual women. Among men, there were no significant interaction effects between sexual identity and partnership status on psychological distress. Being in a mixed orientation relationship, but not gender of partner, was a significant predictor of psychological distress among both women and men across sexual identities. Additional research should assess the partnership dynamics contributing to the association between partnership characteristics and mental health among sexual minority populations.

Exposure to Parental Violence During Childhood and Later Psychological Distress Among Arab Adults in Israel: The Role of Gender and Sense of Coherence.

Exposure to parental violence in childhood is a significant predictor of psychological distress in adulthood. Factors at the individual level may explain the variance in psychological distress among adults exposed to parental violence. The current study examined the effect of exposure to different forms (i.e., physical violence and psychological aggression) and different patterns of parental violence (i.e., witnessing interparental violence, experiencing parental violence) on later psychological distress. The mediating role of sense of coherence (SOC) and the moderating role of gender in this relationship were also examined. A cross-sectional survey was conducted among 604 married Arab adults in Israel (age = 20-60, M = 33.5, SD = 6.52) using a retrospective, self-administered questionnaire. Results indicate a significant positive relationship between all forms and types of parental violence explored in the current study with levels of psychological distress. Furthermore, exposure to parental violence correlated negatively with SOC, and low levels of SOC predicted higher levels of psychological distress. SOC was found to partially mediate the relationship between exposure to parental violence and psychological distress. Gender differences were found only with regard to experiencing physical violence as a predictor of psychological distress, indicating that the relationship between these variables is stronger in females. These results highlight the importance of SOC as a personal resource and its role in promoting psychological wellbeing. Healthcare practitioners should be aware of possible gender differences in psychological distress among Arab adults exposed to parental violence.

Psychological Distress, Post-Traumatic Stress, and Suicidal Ideation Among Resettled Nepali-Speaking Bhutanese Refugees in the United States: Rates and Predictors.

Bhutanese refugees may exhibit psychological distress (PD), post-traumatic stress (PTS), and suicidal ideation (SI), but little is known about predictors of these mental health problems. To examine rates and predictors of PD, PTS, and SI among Bhutanese refugees. Cross-sectional correlational study of 209 Bhutanese refugees in Midwestern United States. Data were collected using the Hopkins Symptom Checklist/Nepali version and Refugee Health Screener-15/PTS subscale and then analyzed using simultaneous multiple regression. Rates of PD, PTS, and SI were 18.7%, 8.1%, and 7.7%, respectively. Significant predictors of PD were a history of mental health treatment (p<.001) and fewer years of schooling (p = .032). Predictors of PTS were history of mental health treatment (p<.001), female gender (p = .016), fewer years of schooling (p = .012), and being single/previously married (p = .004). PTS predicted SI (ρ<.001). Health providers should routinely assess Bhutanese refugees' mental health status for timely further assessment and treatment.

Social isolation, social support, and psychological distress among the elderly during the COVID-19 pandemic: A cross-sectional study from central India.

In the present COVID-19 pandemic, social distancing measures have been advised to protect elderly from infection which might have led to poor mental health state. A cross-sectional study was carried out to assess the magnitude of social isolation, social support, and psychological distress among the elderly during the COVID-19 pandemic in Central India. The estimated sample size was 1535. The sample was equally distributed among rural, semiurban, and urban strata of districts. Social isolation was measured using Lubben's Social Network Scale-Revised, and psychological distress was assessed using Kessler K10 Psychological Distress Scale. Other parameters such as a history of COVID-19 illness and COVID-19 vaccination were assessed. The prevalence of social isolation was higher at 23.6% during the COVID-19 pandemic compared to before the pandemic period (15.0%). The majority perceived a high level of social support during the pandemic (55.3%) and 39.9% received moderate support. Overall, 18.4% of the respondents had psychological distress. Out of them, 56.2% had mild distress, 20.1% had moderate distress, and 23.7% had severe distress. Significant predictors of psychological distress were female gender, lower socioeconomic status, history of COVID-19 disease among the participants, social isolation, and lack of social support. Social isolation and lack of social support were significant predictors of psychological distress among the elderly during the pandemic.

Psychological distress in children and adolescent disaster survivors.

This study aimed to clarify the association between mental and behavioral changes and subsequent psychological distress among children and adolescents living in areas affected by the 2011 Great East Japan Earthquake. We conducted a two-wave study, with waves 1 and 2 occurring in 2011 and 2014, respectively. Data of 462 respondents aged 9-14 years during wave 1 and who participated in both surveys were used in the present analysis. A factor analysis was performed using the mental and behavioral changes reported by respondents in wave 1. Psychological distress was defined as a score of ≥5 on the six-item Kessler Psychological Distress Scale, as measured in wave 2. With the factors generated in this analysis set as independent variables, the odds ratios (OR) (95% confidence intervals, 95% CIs) for psychological distress were calculated using logistic regression, adjusting for age, sex, house damage, living environment, and loss of family or friends. Psychological distress was present in 108 (23.4%) of the respondents. The factor analysis yielded three factors describing mental and behavioral changes: interpersonal issues, brain fog, and anxiety and panic. Of these, interpersonal issues were significantly associated with subsequent psychological distress, with an OR of 2.59 (95% CI 1.58-4.25). This association did not change even when stratified by age and sex. This study suggests that interpersonal issues are a significant predictor of psychological distress in children and adolescents living in areas affected by a large-scale disaster.

Feeling unsafe as a source of psychological distress in early adolescence

RationaleSymptoms of psychological distress at an early age have proved to undermine adolescents' academic achievements, as well as their personal and social well-being. The literature acknowledges a wide range of risk factors that cause psychological distress, while at the same time emphasizing the role of social support as a protective factor. On the other hand, feelings of unsafety as a possible source of psychological distress have been so far largely overlooked in the literature. ObjectiveThe present study explores the consequences of a specific stressor (feeling unsafe) and asks whether social support can act as a moderator in the association between subjective unsafety and psychological distress. MethodsA multi-group structural equation model was run with a sample of 2876 young adolescents aged 10–12 enrolled in educational centers in the city of Barcelona, Spain. ResultsThe results show that direct exposure to sibling violence at home and bullying at school are significant predictors of psychological distress, regardless of biological sex. The hypothesis of a negative correlation of subjective perceptions of unsafety on psychological distress is also supported, although neighborhood-based risk factors emerge as a greater source of distress for females than for males. The involvement of supportive adults is associated with lower levels of perceptions of unsafety and distress in both groups, but girls seem capable of drawing more effectively on alternative sources of support, specifically their peers, to enhance their safety at school and in the neighborhood. ConclusionOverall, gender differences in our model overlap with socio-environmental inequalities (low income, exposure to violence and conflictual public spaces), thus suggesting that an intervention into the root causes of these inequalities could contribute to lowering psychological distress in early adolescence.