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Director's Report to the National Advisory Council on Drug Abuse - February, 2006

Research Findings - Prevention Ressearch

Raising Healthy Children Intervention Decreases Drug Use Frequency

Raising Healthy Children (RHC) is a preventive intervention designed to promote positive youth development by targeting developmentally appropriate risk and protective factors. In this study, the authors tested the efficacy of the RHC intervention on reducing adolescent alcohol, marijuana, and cigarette use. Ten public schools with 959 1st- and 2nd-grade students (54% male students, 18% minority, 28% low socioeconomic status), were matched and assigned randomly to either intervention or control conditions. A 2-part latent growth modeling strategy was used to examine change in both use versus nonuse and frequency of use outcomes when students were in Grades 6-10. Results indicated significant (p < .05) intervention effects in growth trajectories for frequency of alcohol and marijuana use but not for use versus nonuse. These findings provide support for preventive interventions that take a social development perspective in targeting empirically supported risk and protective factors and demonstrate the use of 2-part models in adolescent substance use research. Brown, E., Catalano, R., Fleming, C., Haggerty, K. and Abbott, R. Adolescent Substance Use Outcomes in the Raising Healthy Children Project: A Two-Part Latent Growth Curve Analysis. J Consult Clin Psychol, 73(74), pp. 699-710, 2005.

The Public Costs of Early Conduct Problems

This study explored the economic implications of conduct disorder (CD) among adolescents in 4 poor communities in the United States, participating in the Fast Track prevention project. The investigators examined a range of expenditures related to conduct disorder across multiple public sectors, including mental health, general health, school, and juvenile justice. Fast Track is a randomized controlled trial examining the efficacy of a multi-level, multi-year intervention to prevent conduct problems. Families with children identified as high risk for aggression were recruited during the child's kindergarten year and randomized to either the intervention or the comparison group, and a low risk control group was enrolled (n=1191; 50% African American, 47% Caucasian; 3% other). Fast Track families have been followed annually through 12th grade. This study focuses on 664 youth in the high risk comparison and low risk control groups, and used self- and parental-report data to estimate expenditures during a 7-year period in late adolescence (grades 6 through 12). Expenditures were contrasted for youths with CD and youths with oppositional defiant disorder, elevated symptoms (no CD diagnosis), and all others. Diagnosis was determined with a structured assessment. Additional public costs per child related to CD exceeded $70,000 over a 7-year period. The authors concluded that public expenditures on youths with CD are substantially larger than for youths with closely related conditions, reflecting the importance of prevention and early treatment for the disorder. Foster, E., Jones, D. and Jones, D.T. The High Costs of Aggression: Public Expenditures Resulting from Conduct Disorder. Am J Public Health, 95(10), pp. 1767-1772, 2005.

Community Coalitions and Adoption of Drug Prevention Programs

The study examined the relationship between six characteristics of community coalitions (size of region covered, structure, professional representation, resource sharing, size, and breadth of prevention stakeholder representation) and community organizational progress in adopting drug prevention programs. The study utilized baseline data from community leaders (n = 533) in 24 cities from Step Towards Effective Prevention (STEP), a multi-state, multi-city randomized trial that is evaluating the effects of a television-based prevention training intervention on adoption of evidence-based drug prevention programs. Confirmatory factor analysis yielded a measurement model with a good fit to the data on four of the characteristics. Structural equation modeling showed that these characteristics had significant positive relationships to organizational progress, with the exception of size of the region covered. Results suggest that coalitions which have a clear structure, professional focus, resource sharing, and a smaller service region are likely to show the most progress in adopting evidence-based drug prevention programs. Jasuja, G.K., Chou, C., Bernstein, K., Wang, E., McClure, M. and Pentz, M. Using Structural Characteristics of Community Coalitions to Predict Progress in Adopting Evidence-based Prevention Programs. Evaluation and Program Planning, 28(2), pp. 173-184, 2005.

Patterns of HIV Prevalence Among Injection Drug Users in Cross-Border Areas of Vietnam and China

This study assessed patterns of injecting drug use and HIV prevalence among injecting drug users (IDUs) in an international border area along a major heroin trans-shipment route. It included cross-sectional surveys of IDUs in 5 sites in Lang Son Province, Vietnam (n = 348) and 3 sites in Ning Ming County, Guangxi Province, China (n = 308). Respondents were recruited through peer referral ("snowball") methods in both countries, and also from officially recorded lists of IDUs in Vietnam. A risk behavior questionnaire was administered and HIV counseling and testing conducted. Participants in both countries were largely male, in their 20s, and unmarried. A majority of subjects in both countries were members of ethnic minority groups. There were strong geographic gradients for length of drug injecting and for HIV seroprevalence. Both mean years injecting and HIV seroprevalence declined from the Vietnamese site farthest from the border to the Chinese site farthest from the border. 10.6% of participants in China and 24.5% of participants in Vietnam reported crossing the international border in the 6 months prior to interview. Crossing the border by IDUs was associated with (1) distance from the border, (2) being a member of an ethnic minority group, and (3) being HIV seropositive among Chinese participants. It was concluded that reducing the international spread of HIV among IDUs will require programs at the global, regional, national, and "local cross border" levels. Des Jarlais, D., Johnston, P., Friedmann, P., Kling, R., Liu, W., Ngu, D., Chen, Y., Hoang, T., Donghua, M., Van, L., Tung, N., Binh, K. and Hammett, T. Patterns of HIV Prevalence Among Injecting Drug Users in the Cross-border Area of Lang Son Province, Vietnam, and Ning Ming County, Guangxi Province, China. BMC Public Health, 5, pp. 89-96, 2005.

Normative Beliefs and Substance Initiation

The current study investigated the effects of baseline levels of academic achievement and longitudinal trends in normative beliefs on adolescent substance initiation across a 42-month time period. Participants were 272 rural adolescents who were an average of 12.3 years old at the baseline assessment. Academic achievement positively predicted the intercept and negatively predicted the growth-trajectory of normative beliefs regarding peer substance behavior. Further, baseline academic achievement negatively predicted initial levels, as well as the growth-trajectory, of substance initiation. The discussion addresses the influence of academic achievement and normative beliefs on substance initiation and the utility of latent growth curve modeling in studying longitudinal change. In addition, implications for prevention programming are discussed. Lillehoj, C.J., Trudeau, L. and Spoth, R. Longitudinal Modeling of Adolescent Normative Beliefs and Substance Initiation. Journal of Alcohol and Drug Education, 49(2), pp. 7-41, 2005.

Assertiveness and Alcohol Use in Rural Adolescents

There is evidence of higher prevalence rates for alcohol use among rural adolescents relative to urban adolescents. Strategies aimed at preventing adolescent alcohol use typically include the development of social skills to resist peer pressure; among the social skills frequently targeted is assertiveness. Self-report data were collected from a sample of rural adolescents (N-470) participating in a longitudinal preventive intervention study. Five hypothesized dimensions of assertiveness were validated with confirmatory factor analysis: specific substance refusal, individual rights, transaction, justice and social approach. Using gender as a between-subject factor, plus time and assertiveness as within-subject factors to predict an alcohol use composite index, repeated measures analysis revealed a number of significant findings. Several assertiveness dimensions were found to have significant effects on the alcohol use index (specific substance refusal, individual rights, and justices associate lower alcohol involvement; social assertiveness was associated with higher involvement). Moreover, there were significant two and three way interaction effects with time and gender. Goldberg-Lillehoj, C.J., Spoth, R. and Trudeau, L. Assertiveness Among Young Rural Adolescents: Relationship to Alcohol Abuse. J. Child and Adol Sub Abuse, 14(3), pp. 39-67, 2005.

Religiosity and Drug Use Among Mexican and Mexican American Youth

Among a predominately Mexican and Mexican American sample of preadolescents, religiosity protected against lifetime alcohol, cigarette, and marijuana use and recent alcohol and cigarette use when religious affiliation was controlled. When religiosity was controlled, however, adolescents with no religious affiliation and adolescents who were religiously affiliated reported similar substance use outcomes. Interaction effects demonstrated that the protective effect of greater religiosity operated more strongly in some religions than in others for selected outcomes. Overall, the impact of religiosity on reported drug use did not differ significantly for more and less acculturated Latino youth. Marsiglia, F., Kulis, S., Nieri, T. and Parsai, M. God Forbid! Substance Use Among Religious and Nonreligious Youth. Am J Orthopsychiatry, 75(4), pp. 585-598, 2005.

Effects of Culturally Adapted Parent Management Training

A randomized experimental test of the implementation feasibility and the efficacy of a culturally adapted Parent Management Training intervention was conducted with a sample of 73 Spanish-speaking Latino parents with middle-school-aged youth at risk for problem behaviors. Intervention feasibility was evaluated through weekly parent satisfaction ratings, intervention participation and attendance, and overall program satisfaction. Intervention effects were evaluated by examining changes in parenting and youth adjustment for the intervention and control groups between baseline and intervention termination approximately 5 months later. Findings provided strong evidence for the feasibility of delivering the intervention in a larger community context. The intervention produced benefits in both parenting outcomes (i.e., general parenting, skill encouragement, overall effective parenting) and youth outcomes (i.e., aggression, externalizing, likelihood of smoking and use of alcohol, marijuana, and other drugs). Differential effects of the intervention were found related to youth nativity status such that parents of U.S.-born youth benefited more from participation in the intervention than parents of foreign-born youth. Martinez, C., and Eddy, J. Effects of Culturally Adapted Parent Management Training on Latino Youth Behavioral Health Outcomes. J Consult Clin Psychol, 73(5), pp. 841-851, 2005.

Rural Youth Attitudes Towards Substance Use and Violence

To determine the effectiveness of multi-component prevention campaigns (media and other community wide interventions) the authors conducted 15 focus groups with 169 male and female 6th-, 7th-, and 8th- graders. Participants were recruited from small to mid-size communities across the US. The focus groups examined youth attitudes towards their own use and their peers'' use of alcohol, tobacco, drugs, and violence. Several key findings emerged that may be utilized in future multi-component campaigns. First, youth value spending unstructured time with their friends. In terms of tobacco use, both boys and girls are worried about getting caught by their parents; but girls are more concerned about the physical effects of smoking in terms of their attractiveness to members of the opposite sex. In terms of alcohol use, girls were concerned about the dangers of drinking and driving (especially girls in 8th grade) and the pressure to have sex if a date is inebriated. Hispanic youth were more concerned about being a good role model for younger siblings than Caucasian youth. In terms of violence, girls were more likely to spread rumors while boys were more likely to engage in verbal and or physical violence. Finally, both boys and girls preferred prevention and intervention campaigns that were based on real situations and experiences, reflected their culture, were positive, and stress the capabilities of an individual to take action. Kelly, K.J., Comelle, M.G. and Edwards, R.W. Attitudes of Rural Middle-School Youth Toward Alcohol, Tobacco, Drugs, and Violence. The Rural Educator, 25(3), pp. 19-24, 2004.

Which Comes First in Adolescence - Sex and Drugs or Depression

The notion that adolescents self-medicate for depression with substance use and sexual behaviors is widespread, but the temporal ordering of depression and these risk behaviors is not clear. This study tests whether gender-specific patterns of substance use and sexual behavior precede and predict depression or vice versa. Data from the National Longitudinal Study of Adolescent Health were weighted to produce population estimates. The sample includes 13,491 youth, grades 7 to 11, interviewed in 1995 and again one year later. Multivariate logistic regression analyses, conducted in 2004, tested temporal ordering, controlling for covariates. The main outcome measures were depression, as measured by a modified Center for Epidemiological Studies-Depression Scale (CES-D), and three behavior patterns: (1) abstaining from sexual intercourse and drug use, (2) experimental behavior patterns, and (3) high-risk behavior patterns. Results showed that overall, sex and drug behaviors predicted an increased likelihood of depression, but depression did not predict sex and drug behaviors. Among girls, both experimental and high-risk behavior patterns predicted depression. Among boys, only high-risk behavior patterns increased the odds of later depression. Depression did not predict behavior in boys, or experimental behavior in girls; but it decreased the odds of high-risk behavior among abstaining girls (RRR=0.14) and increased the odds of high-risk behavior (RRR=2.68) among girls already experimenting with substance use. Engaging in sex and drug behaviors placed adolescents, especially girls, at risk for future depression. Mechanisms of these relationships are yet to be determined. Hallfors, D.D., Waller, M.W., Bauer, D. and Ford, C.A. Which Comes First in Adolescence - Sex and Drugs or Depression? Am J Prev Med, 29(3), pp. 163-170, 2005.

Attitudes Toward HIV Prevention in China and Vietnam

Success of HIV prevention projects for injection drug users (IDUs) depends on the support of the community in which they are implemented. This article presents data from cross-sectional community surveys of HIV knowledge and attitudes toward peer-based HIV prevention interventions for IDUs in a border area of Lang Son Province, Vietnam and Ning Ming County, Guangxi Province, China. Analysis of these surveys at baseline and 18 months reveal generally high or improving levels of HIV knowledge and positive attitudes toward the interventions in both countries. Levels and knowledge tended to be higher in Vietnam than in China. Interviews with staff and peer educators suggest that the project's community education program efforts have increased support for the interventions and contributed to their smooth implementation. However, the community surveys also reveal some continuing deficits in HIV knowledge and understanding of the interventions, including perceptions that provision of new syringes will result in increased drug use. Additional education, including dissemination of countervailing project data, is needed to address these deficits and further increase community support for the interventions. Hammett, T., Norton, G., Kling, R., Liu, W., Chen, Y., Binh, K., Dong, H. and DesJarlais, D. Community Attitudes Toward HIV Prevention for Injection Drug Users: Findings from a Cross-border Project in Southern China and Northern Vietnam. J Urban Health, 82(4), pp. iv34-iv42, 2005.

Consistent Predictors of Substance Use in Emerging Adulthood are Male Gender and Previous Use

This 5-year longitudinal study followed a group of 848 adolescents attending an alternative high school in the emerging adulthood years and measured their adult role taking and substance use. Psychological factors at baseline, and adult role taking at the follow-up were examined as correlates of substance use during emerging adulthood. At this stage of life 74% of subjects were employed, 30% were married or engaged, and 53% had at least one child. One third of subjects were daily cigarette smokers, and 24% had used marijuana in the past 30 days. Forty-seven percent had experienced negative consequences of alcohol or drug use in the last year. The most consistent positive predictors of substance use in emerging adulthood were male gender and previous drug use. Addiction concern was a consistent negative predictor. After controlling for baseline psychosocial variables, attending school and being married at the five-year follow-up were negative correlates of both personal consequences and problems related to alcohol or drug use. Pentz, M.A., Mares, D., Schinke, S. and Rohrbach, L.A. Tobacco, Alcohol, and Other Drug Use Among High-risk Young People: A Five-year Longitudinal Study From Adolescence to Emerging Adulthood. Journal of Drug Issues, 35(2), pp. 333-356, 2005.

Implicit, Associative Memory Processes Influence Drug Use Motivation

This study evaluated the mediating role of implicit cognitive processes in the prediction of alcohol and marijuana use and examined the relationships between dissociative experiences, implicit processes, and sensation seeking in models of drug use and problem experiences. Participants were 467 diverse at-risk adolescents in California. Results from latent variable models revealed that implicit cognition independently predicted alcohol and marijuana use and mediated the predictive effects of sensation seeking on drug use. Dissociative experiences did not predict implicit cognition or drug use in this sample, though this factor was a significant predictor of problem experiences and was positively correlated with sensation seeking. This research provides evidence suggesting that implicit, associative memory processes are influential in drug-use motivation. Ames, S.L., Sussman, S.Y., Dent, C.W., and Stacy, A.W. Implicit Cognition and Dissocative Experiences as Predictors of Adolescent Substance Use. American Journal of Drug and Alcohol Abuse, 31(1), pp. 129-162, 2005.

Coping Strategies and Mental Health Services

This study examined the relationship among trauma, coping, depression, and mental health service seeking in a probability sample of sheltered homeless and low-income housed women. Results highlight the diversity of trauma. In a longitudinal analysis, women who lived in shelters or experienced major violence had a twofold increase in their risk of depression over the 6-month follow-up. In a cross-sectional analysis, childhood sexual abuse, living in a shelter, physical violence, childhood physical abuse, and death or injury of a friend or relative predicted avoidant coping and symptoms of depression. Active coping and depression predicted mental health service seeking among traumatized women. Modifying coping strategies may ameliorate some of the negative impact of trauma and potentially enhance mental health service use among at-risk women. Rayburn, N.R., Wenzel, S.L., Elliott, M.N., Hambarsoomians, K., Marshall, G.N. and Tucker, J.S. Trauma, Depression, Coping, and Mental Health Service Seeking Among Impoverished Women. J Consult Clin Psychol, 73(4), pp. 667-677, 2005.

American Indian Girls Exceed American Indian Boys, White Girls and White Boys in Cigarette, Marijuana, Alcohol and Inhalant Use

This article documents the prevalence of self-reported substance use among White and American Indian adolescents enrolled in 7th grade in 1997 in a Northern Plains state. Data were collected by self-administered questionnaire preceding adolescents' participation in a randomized field trial of Project Alert (a 7th and 8th grade prevention curriculum). Rates of lifetime and past-month use of cigarettes and marijuana were higher among American Indians than among Whites of the same gender. American Indian girls exceeded American Indian boys as well as White girls and White boys on lifetime and past-month use of cigarettes, marijuana, alcohol and inhalants; differences in cigarette and inhalant use reached statistical significance. These findings add to the sparse literature on substance use among adolescents as young as 12 through 13 years old and underscore the importance of examining gender-specific substance use patterns early in adolescence. Spear, S., Longshore, D. and McCaffrey, D. Prevalence of Substance Use Among White and American Indian Young Adolescents in a Northern Plains State. Journal of Psychoactive Drugs, 37(1), pp. 1-16, 2005.

Drug Use and Violence: Psychopharmacological Influences

This study examined relationships between illegal and legal drug use and violence perpetration and victimization as well as possible mediators of these relationships. Subjects were continuation high school students followed prospectively over 5 years. Results indicated that illegal drug use predicted violence and victimization 5 years later and that earlier victimization was also associated with later illegal drug use. A measure intending to tap a psychopharmacological effects system was found to mediate the relationships between illegal drug use and victimization and violence. Results suggest that violence and victimization prevention efforts may benefit by addressing the psychopharmacological effects of adolescent illegal drug use. Weiner, M.D., Sussman, S., Sun, P. and Dent, C. Explaining the Link Between Violence Perpetration, Victimization and Drug Use. Addict Behav, 30(6), pp. 1261-1266, 2005.

Adolescent Risk and Protection for Exposure to Community Violence

Community violence is recognized as a significant public health problem. However, a paucity of research has examined risk factors for community violence exposure across domains relevant to adolescents or using longitudinal data. This study examined youth aggressive behavior in relation to community violence exposure among a community epidemiologically defined longitudinal sample of 582 (45% female; 86% African American) urban middle school students (10-13 years of age). The participants were initially assessed in the fall of first grade as part of an evaluation of two school-based preventive interventions conducted by the Johns Hopkins University. In this article, internalizing behaviors, deviant peer affiliation, and parental monitoring were examined as moderators of the association between aggressive behavior and exposure to community violence over time. For males with aggressive behavior problems and deviant peer affiliation or low parental monitoring, co-occurring anxiety symptoms protected against subsequent witnessing community violence. In contrast, males with aggressive behavior problems and co-occurring depressive symptoms were at increased risk for witnessing community violence. These findings suggest that aggressive behavior, depressive symptoms, and deviant peer affiliation are potential risks for exposure to community violence. Also, increasing youth vigilance of surroundings or awareness of danger may be a possible means of reducing risk. Lambert, S., Ialongo, N., Boyd, R. and Cooley, M. Risk Factors for Community Violence Exposure in Adolescence. Am J Community Psychol, 36(1-2), pp. 29-48, 2005.

Changing Face of HIV/AIDS Among Native Populations

Despite progress in addressing the HIV/AIDS crisis in some populations, major challenges in the prevention of HIV/AIDS in Native American communities remain. This article details information about the biological, social, economic, and behavioral cofactors related to the rise in HIV/AIDS in Native American communities and follows with issues related to special populations and consideration of the unique prevention needs prevention in these subpopulations. The need for increased HIV testing is discussed as is the need for Native-specific programs and interventions. Finally, changes in the recognition of the culturally specific needs of Native American people are discussed and new resources are presented. Vernon, I. and Jumper-Thurman, P. The Changing Face of HIV/AIDS Among Native Populations. Journal of Psychoactive Drugs, 37(3), pp. 247-255, 2005.

Optimizing and Evaluating Behavioral Interventions

Although the optimization of behavioral interventions offers the potential of both public health and research benefits, currently there is no widely agreed-upon principled procedure for accomplishing this. This article suggests a multiphase optimization strategy (MOST) for achieving the dual goals of program optimization and program evaluation in the behavioral intervention field. MOST consists of the following three phases: (a) screening, in which randomized experimentation closely guided by theory is used to assess an array of program and/or delivery components and select the components that merit further investigation; (b) refining, in which interactions among the identified set of components and their interrelationships with covariates are investigated in detail, again via randomized experiments, and optimal dosage levels and combinations of components are identified; and (c) confirming, in which the resulting optimized intervention is evaluated by means of a standard randomized intervention trial. To make the best use of available resources, MOST relies on design and analysis tools that help maximize efficiency, such as fractional factorials. A slightly modified version of an actual application of MOST to develop a smoking cessation intervention is used to develop and present the ideas. MOST has the potential to husband program development resources while increasing our understanding of the individual program and delivery components that make up interventions. Considerations, challenges, open questions, and other potential benefits are discussed. Collins, L., Murphy, S., Nair, V. and Strecher, V. A Strategy for Optimizing and Evaluating Behavioral Interventions. Ann Behav Med, 30(1), pp. 65-73, 2005.

Cross-Cultural Assessment of Perceived Competence in Rural South-African and Rural African-American Families

This study explored psychometric differences in baseline data from rural African-American and rural South-African adolescents to establish the cross-cultural validity of the Harter Perceived Competence Scale. This scale consists of three sub-scales measuring cognitive, social, and physical competencies. The goals of the study were to examine the psychometric properties of a Sepedi (Northern Soto) translated scale with a sample of rural Black South African 12-year-olds; and to compare the mean scores for the rural SA adolescents to a comparable sample of rural African American 12-year-olds. Two hundred twenty-three African American families and 157 South African families participated in the study. Results revealed that the internal consistency reliability was stronger for the African American sample (Cronbach''s alpha= .79 vs. .52). The African American sample also scored higher on the cognitive and social competency sub-scales. Principle components analysis revealed a three-factor solution (Perceived Cognitive Competency, Perceived Social Competency, and Perceived Lack of Competency) for both samples. The three factors accounted for 55% of the observed variance in the African American sample and 53% of the observed variance in the South African sample. Harrison, M.G., Malaka, D., Amoateng , A.Y. and Toldson, I. Perceived Competence of Rural South African and Rural African-American Families: A Cross-Cultural Assessment of Structural Validity. Ethnicity and Disease, 15(Summer 2005), pp. 379-386, 2005.

Focus Group Qualitative Data as Basis for Prevention Program in India

Findings of Focus Group Discussions (FGDs) were used as a formative assessment for Project MYTRI (Mobilizing Youth for Tobacco Related Initiatives in India), a randomized, multi-component, school-based trial to prevent and control tobacco use among youth in India. Forty-eight FGDs were conducted with students (N = 435) in sixth and eighth grades in six schools in Delhi, India. Key findings include: (a) students in government schools reported as "consumers" of tobacco, whereas students in private schools reported as "commentators"; (b) parents and peers have a strong influence on youth tobacco use; (c) chewing gutkha (a type of chewing tobacco) is considered less harmful and more accessible than smoking cigarettes; (d) schools are not promoting tobacco control activities; and (e) students were enthusiastic about the role government should play in tobacco control. Mishra, A., Arora, M., Stigler, M.H., Komro, K.A., Lytle, L.A., Reddy, K.S., and Perry, C.L. Indian Youth Speak About Tobacco: Results of Focus Group Discussions With School Students. Health Education and Behavior, 32, pp. 363-379, 2005.

Acculturative Stress and Resilience in Mexican American Youth

This article describes how Mexican-American youth utilize their energy, creativity, and resilience in order to cope with cultural tensions that arise from acculturative processes, role conflicts, family and peer interactions, school challenges, and identity formation processes. In order to examine how Mexican-American adolescents cope with stressors and traumas, focus groups and interviews were conducted. Participants consisted of 30 Mexican-American students and dropouts ranging in age from 13 to 18 years. The youth came from an urban setting with low socioeconomic status and consisted of both students and dropouts. This ethnographic study suggests that many Mexican-American adolescents navigate stressors and traumas in such a way that transforms the potentially distressing events into life-affirming rites of passage. Holleran, L. K. and Jung, S. Acculturative Stress, Violence, and Resilience in the Lives of Mexican-American Youth. Stress, Trauma, and Crisis, 8, pp. 107-130, 2005.


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