Reliability and validity of PROMIS® pediatric family relationships short form in children 8-17 years of age with chronic disease

Social Support, Stress, and Mental Health: Examining the Stress-Buffering Hypothesis in Adolescent Football Athletes

CONTEXT

Football sport participation has been linked to both positive and negative effects on overall health. Social support, a network that provides individuals with resources to cope effectively, may positively influence one's stress and mental health. However, little research has been conducted on adolescent football players.

OBJECTIVE

To examine the relationships among social support, psychological stress, and mental health in adolescent football athletes.

DESIGN

Cross-sectional study.

SETTING

High school athletes during the precompetitive and postcompetitive football season in rural Alabama.

PATIENTS OR OTHER PARTICIPANTS

Black and African American adolescent athletes (N = 93) competing for a school-sponsored football team.

MAIN OUTCOME MEASURE(S)

After a competitive season, participants completed a battery of social support, psychological stress, and mental health symptom measures using the National Institutes of Health Toolbox Application and Patient-Reported Outcomes Measurement Information System. The T-score means, Pearson correlations, and multiple regression analyses were calculated.

RESULTS

Social support was negatively correlated with psychological stress (emotional support, r = -0.386; family relationships, r = -0.412; peer relationships, r = -0.265) and mental health (depression, r = -0.367 and r = -0.323 for emotional support and family relationships, respectively), whereas psychological stress and mental health (depression, r = 0.751; anxiety, r = 0.732) were positively correlated. In regression analyses, social support measures (ie, emotional support, family relationships, and peer relationships) were used to predict psychological stress (F = 7.094, P < .001, R2 = 0.191), depression symptoms (F = 5.323, P < .001, R2 = 0.151), and anxiety symptoms (F = 1.644, P = .190, R2 = 0.052).

CONCLUSIONS

In line with the stress-buffering hypothesis, social support in the form of family relationships and overall emotional support garnered through sport participation may reduce psychological stress and help to preserve the mental health of football athletes. These findings indicate that perceived social support may act as a positive resource for the coping of Black and African American adolescent athletes. Further research is warranted to understand the effects of stress and social support on the mental health of adolescents, particularly racial and ethnic minorities who are underrepresented in the athletic training literature.

Association of mental health-related patient reported outcomes with blood pressure in adults and children with primary proteinuric glomerulopathies

INTRODUCTION

The prevalence of mental health disorders including anxiety and depression is increasing and is linked to hypertension in healthy individuals. However, the relationship of psychosocial patient-reported outcomes on blood pressure (BP) in primary proteinuric glomerulopathies is not well characterized. This study explored longitudinal relationships between psychosocial patient-reported outcomes and BP status among individuals with proteinuric glomerulopathies.

METHODS

An observational cohort study was performed using data from 745 adults and children enrolled in the Nephrotic Syndrome Study Network (NEPTUNE). General Estimating Equations for linear regression and binary logistic analysis for odds ratios were performed to analyze relationships between the exposures, longitudinal Patient-Reported Outcome Measurement Information System (PROMIS) measures and BP and hypertension status as outcomes.

RESULTS

In adults, more anxiety was longitudinally associated with higher systolic and hypertensive BP. In children, fatigue was longitudinally associated with increased odds of hypertensive BP regardless of the PROMIS report method. More stress, anxiety, and depression were longitudinally associated with higher systolic BP index, higher diastolic BP index, and increased odds of hypertensive BP index in children with parent-proxy patient-reported outcomes.

DISCUSSION/CONCLUSION

Chronically poor psychosocial patient-reported outcomes may be significantly associated with higher BP and hypertension in adults and children with primary proteinuric glomerulopathies. This interaction appears strong in children but should be interpreted with caution, as multiple confounders related to glomerular disease may influence both mental health and BP independently. That said, access to mental health resources may help control BP, and proper disease and BP management may improve overall mental health.

Recommendations for Patient-Reported Outcomes Measurement Information System pediatric measures in youth with chronic pain: a COnsensus-based Standards for the selection of health Measurement INstruments systematic review of measurement properties

ABSTRACT

The Patient-Reported Outcome Measurement Information System (PROMIS) pediatric measures assess physical, emotional, and social health among children and adolescents. However, their measurement properties have not been systematically examined in youth with chronic pain. A systematic review applying the COnsensus based Standards for the selection of health Measurement INstruments (COSMIN) methodology was conducted to evaluate self-reported PROMIS pediatric measures in youth with chronic pain, assessing 8 measurement properties across all versions (item bank, short form, and computer adaptive testing) from 63 studies covering 25 measures. Moderate or high-quality evidence was most available for content validity, structural validity, internal consistency (measurement precision), and construct validity. Four short-form PROMIS pediatric measures-mobility, anxiety, depressive symptoms, and physical stress experiences-achieved recommendation for the use in chronic pain clinical trials; 7 approached recommendation and 14, including the commonly used PROMIS Pediatric Pain Interference Scale, would be recommended with further evidence. Recommendations were also provided for the use of each measure in observational studies. Overall, based on the existing evidence, a total of 11 self-reported PROMIS pediatric short-form measures, including pain intensity, pain behavior, mobility, sleep disturbance, sleep-related impairment, anxiety, depressive symptoms, psychological stress experiences, physical stress experiences, family relationships, and positive effect, are recommended or approaching recommendation for use in youth ages 8 to 19 years with chronic pain. Research is needed to further establish test-retest reliability, measurement errors, cross-cultural validity, and responsiveness. Future work should expand the evaluation of PROMIS pediatric measures in subpopulations of youth with chronic pain, particularly young children and those with neurodevelopmental disabilities.

The incidence of late-detected developmental dysplasia of the hip and its functional outcomes: a 17-year cohort study using selective ultrasound screening

BACKGROUND AND PURPOSE

We aimed to establish the incidence of late-detected developmental dysplasia of the hip (DDH) with a selective ultrasound (US) examination over 17 years using the femoral head coverage (FHC) as a US measurement. The secondary aim was to establish the everyday function using patient-reported outcome measures (PROMs).

PATIENTS AND METHODS

The incidence of late-detected DDH was based on 60,844 children. Patients diagnosed for the first time after 3 months and before the age of 8 years were included. In the second part of the study, consent to participate was mandatory. PROMIS-25 Pediatric, PROMIS-25 Parent, and EQ-5D-5L were used according to the patient's age to assess everyday function.

RESULTS

The incidence of late-detected DDH was 0.48/1,000. The median age at diagnosis was 8 months (range 4-41 months), with a tendency to require repeated treatment with open surgery if DDH was diagnosed later. Most children reported no or minor health problems with a mean of 18 years' follow-up.

CONCLUSION

We found that selective US examination of the hips by measuring the FHC is a reliable method to examine newborns for DDH resulting in a low incidence of late-detected DDH amounting to 0.48/1,000 newborn children.

Validation of the simplified Chinese version of PROMIS Parent Proxy-25 Profile in parents of children with cancer

PURPOSE

To determine the psychometric properties of the Patient-reported Outcomes Measurement Information System Parent Proxy-25 Profile (PROMIS-25) in a sample of Chinese parents of children with cancer.

DESIGN AND METHODS

A cross-sectional sample (N = 148) of parents with children aged 5-17 years living with cancer was recruited. Each participant completed sociodemographic and clinical questionnaires and PROMIS-25. The flooring and ceiling effects were calculated. Reliability was determined by the Cronbach's alpha and split-half coefficient. Factor structure was examined by factor analysis. Model fit and graphical plots were assessed to test the assumptions of Rasch model-based item response theory (IRT). Differential item functioning (DIF) was assessed in terms of gender, age, and treatment stage.

RESULTS

PROMIS-25 demonstrated some flooring and ceiling effect, excellent reliability (Cronbach's α > 0.7 for all six domains), and the six-domain factor structure was supported. The IRT assumptions were met in terms of unidimensionality, local independence, monotonicity, and measurement equivalence with acceptable DIF in terms of gender, age, diagnosis, and treatment stage.

CONCLUSION

PROMIS-25 is a highly reliable and valid instrument for evaluating children with cancer that assesses important health-related quality of life domains of child cancer.

PRACTICE IMPLICATION

Chinese parents of children with cancer and healthcare providers could use PROMIS-25 to assess the symptoms of children.

Vision-related quality of life compared to generic measures in retinoblastoma survivors

PURPOSE

To (1) Compare vision-related quality of life (VRQOL) in adolescent and young adult (AYA) unilateral versus bilateral retinoblastoma (RB) survivors using a vision-targeted measure and a generic health-related quality of life (HRQOL) measure and (2) Assess associations among VRQOL and generic HRQOL domains and overall QOL and estimate associations of the VRQOL and HRQOL domains with overall QOL.

METHODS

The National Institute for Health (NIH) Toolbox® VRQOL instrument, PROMIS®-29 Profile v 2.1, and a single-item QOL measure were administered in a cross-sectional study of 101 RB survivors. Reliability for multi-item scales was estimated. Product-moment and Spearman rank correlation coefficients and stepwise ordinary least squares were used to measure associations of other variables with overall QOL.

RESULTS

Significantly worse VRQOL was reported by bilateral than unilateral RB survivors. Cronbach's alpha coefficients for all VRQOL scales ranged from 0.83 to 0.95. Medium to large correlations were found between all NIH Toolbox® VRQOL scales and the PROMIS®-29 measures. Depression and ability to participate in social roles and activities from the PROMIS®-29 Profile accounted for 38% of the variance in overall QOL with the psychosocial domain of the NIH Toolbox® VRQOL explaining 16% of the variance.

CONCLUSION

VRQOL is impaired in bilateral RB survivors. VRQOL is associated substantially with the PROMIS-29 generic HRQOL measure but has significant unique associations with overall QOL. The NIH Toolbox® VRQOL measure provides important information about the vision-related effects on daily life of AYA RB survivors.

Integration of Patient-reported Outcome Measures in Pediatric Hematology: A Qualitative Methods Study

Patient-reported outcome measures (PROMs) are self-reported questionnaires that allow patients and families to evaluate health-related experiences without influence or oversight from health care professionals. This study aimed to rate the relevance of existing PROMs for pediatric hematology patients, as identified by a recent systematic review, as well as to evaluate the receptivity of electronic PROM integration into clinical practice. Focus groups and interviews were conducted with children (10) and parents (19) impacted by nonmalignant hematological disorders, as well as with health care professionals (6). We observed strong support for the TranQol in thalassemia (100% for both parents [P] and children [C]); the Canadian Haemophilia Outcomes-Kids' Life Assessment Tool (CHO-KLAT) (100% P, 75% C) and Haemophilia Quality of Life questionnaire (Haemo-QoL) (100% P and C) in hemophilia; the Pediatric Quality of Life Inventory (PedsQL) Sickle Cell Module (75% P, 100% C); and the Kids ITP Tool in immune thrombocytopenia (100% P, 66.7% C). Generic tools such as the PedsQL Generic were met with mixed support. Electronic PROM integration received universal support. We obtained strong support for the integration of a web-based platform into clinical practice and a preference for disease-specific PROMs over generic PROMs. Future projects may explore the development of a child-friendly Canadian web-based platform to standardize quality-of-life evaluation within the clinical encounter.

Psychometric validity of the Montgomery and Åsberg Depression Rating Scale for Youths (MADRS-Y)

BACKGROUND

Because of all the serious consequences of major depressive disorder (MDD), it is important to screen for MDD in adolescents. The aim of this study was to test the psychometric properties of the newly developed self-report depression scale MADRS-Y for adolescents in a normative Swedish sample.

METHODS

The study included 620 adolescents in the age range of 12-20 years old. The normative sample was randomly split into two equal parts, to perform principal component analysis (PCA) on sample one and confirmatory factor analysis (CFA) on sample two. We investigated the psychometrics.

RESULTS

The result from the PCA suggested that all 12 potential items should be used, and the items loaded on the same construct of depression. The CFA supported the one-factor structure with good fit indices. Measurement invariance was confirmed, allowing interpretation regardless of gender or age differences. Reliability was good, α .89, for both samples separately. Test-retest reliability was good to excellent (intraclass correlation coefficients = .87 and .91). Evidence of convergent and discriminant validity was shown.

CONCLUSIONS

The results in the current study suggest that the MADRS-Y is a brief, reliable, and valid self-report questionnaire of depressive symptoms for adolescents in the general population.

The distinct longitudinal impact of pain catastrophizing on pain interference among youth living with sickle cell disease and chronic pain

Youth living with chronic sickle cell disease (SCD) pain are at risk for psychosocial distress and high levels of pain catastrophizing that contribute to functional impairment. This study aimed to identify the unique long-term impact of pain catastrophizing on pain impairment among youth with SCD. Youth with chronic SCD pain (N = 63, 10-18 years old, 58.3% female, 95.1% Black or African American) were recruited within comprehensive SCD clinics and completed a battery of measures at baseline and 4-months follow-up. A linear hierarchical regression examined baseline demographic and clinical characteristics (child SCD genotype, age, and average pain intensity), psychosocial functioning (anxiety, depression), and pain catastrophizing as predictors of pain interference at 4-months follow-up. Pain catastrophizing was the only unique predictor of pain interference at 4-months follow-up. Among youth with chronic SCD pain, pain catastrophizing warrants greater consideration as an important predictor that influences pain management and overall functioning.

Caregiver Engagement Enhances Outcomes Among Randomized Control Trials of Transitional Care Interventions: A Systematic Review and Meta-analysis

BACKGROUND

Fluctuations in health among chronically ill adults result in frequent health care transitions. Some interventions to improve patient outcomes after hospitalization include caregiver engagement as a core component, yet there is unclear evidence of the effects of this component on outcomes.

OBJECTIVE

The objective of this study was to synthesize evidence regarding the attention given to caregiver engagement in randomized control trials of transitional care interventions (TCIs), estimate the overall intervention effects, and assess caregiver engagement as a moderator of intervention effects.

METHODS

Three databases were systematically searched for randomized control trials of TCIs targeting adults living with physical or emotional chronic diseases. For the meta-analysis, overall effects were computed using the relative risk (RR) effect size and inverse variance weighting.

RESULTS

Fifty-four studies met criteria, representing 31,291 participants and 66 rehospitalizations effect sizes. Half (51%) the interventions lacked focus on caregiver engagement. The overall effect of TCIs on all-cause rehospitalizations was nonsignificant at 1 month (P=0.107, k=29), but significant at ≥2 months [RR=0.89; 95% confidence interval (CI): 0.82, 0.97; P=0.007, k=27]. Caregiver engagement moderated intervention effects (P=0.05), where interventions with caregiver engagement reduced rehospitalizations (RR=0.83; 95% CI: 0.75, 0.92; P=0.001), and those without, did not (RR=0.97; 95% CI: 0.87, 1.08; P=0.550). Interventions with and without caregiver engagement did not differ in the average number of components utilized, however, interventions with caregiver engagement more commonly employed baseline needs assessments (P=0.032), discharge planning (P=0.006), and service coordination (P=0.035).

DISCUSSION

Future TCIs must consistently incorporate the active participation of caregivers in design, delivery, and evaluation.

Acceptability of the Mantram Repetition Program to Reduce Stress in Adolescent Survivors of Pediatric Cancer or Brain Tumors

A mixed-methods approach was used to explore the acceptability of the Mantram Repetition Program (MRP) to reduce stress in adolescents with a history of pediatric cancer or brain tumor. Five male participants diagnosed at ages 1-14 years and currently, ages 13-18 years, completed assessments of stress, anxiety, and sleep disturbance and were interviewed about the acceptability of a mantram repetition intervention. Adolescent survivors reported low to moderate levels of stress, anxiety, and sleep disturbance. Data indicate that the MRP is acceptable among adolescent survivors of pediatric cancer and brain tumors, and face-to-face intervention delivery is preferred.

Measuring mental wellness among adolescents living with a physical chronic condition: a systematic review of the mental health and mental well-being instruments

Background

Globally, promoting mental health and well-being among adolescents has become a public health priority, especially for adolescents living with a physical chronic condition (CC), as research suggests they may be more at risk of developing mental health co-morbidities. Valid and reliable instruments are needed to measure and better understand mental health and mental well-being among adolescents living with a CC. To this end, we reviewed studies reporting on mental health and well-being instruments used in adolescent populations living with a chronic physical condition/disease globally.

Methods

We used a systematic review method guided by PRISMA to identify assess mental health and mental well-being instruments used in adolescents living with a CC. In this instance, mental health instruments were defined as those representing negative domains of mental health (i.e. depression and anxiety) while mental well-being instruments included positive aspects of mental health (i.e. self-concept and resilience).

Results

We identified 22 articles, which included 31 instruments that were used to measure either mental health (n = 8) or mental well-being (n = 15) or both (n = 8) in adolescents living with a CC. Of these, thirteen studies used a Health-Related Quality of Life (HRQoL) scale to measure mental health and/or mental well-being. The KIDSCREEN questionnaires and the Strengths and Difficulties Questionnaire were identified as being frequently used across the 22 studies. Additionally, 7 out of the 31 instruments were disease specific, with 3 focusing on adolescents with diabetes. All the instruments were developed in high income countries and adapted for use in lower- and middle-income countries (LMICs). Adolescents with Type 1 Diabetes (n = 7) and HIV (n = 4) were researched in 11 out of 22 studies. Only eight studies were conducted in LMIC, of which four were in Africa.

Conclusions

HRQoL instruments are useful in measuring mental health and well-being in adolescents living with a CC. However, relatively few valid measures of mental health and mental well-being for adolescents living with a CC exist, which accentuates the paucity of research on mental health and mental well-being of adolescents who are living with a CC. Specific measures need to be developed in and for LMICs where cultural contexts affect mental well-being in unique ways.

Systematic review registration: PROSPERO CRD42020186707.

Psychometrics of three Swedish physical pediatric item banks from the Patient-Reported Outcomes Measurement Information System (PROMIS)®: pain interference, fatigue, and physical activity

BACKGROUND

The Patient-Reported Outcomes Measurement Information System (PROMIS®) aims to provide self-reported item banks for several dimensions of physical, mental and social health. Here we investigate the psychometric properties of the Swedish pediatric versions of the Physical Health item banks for pain interference, fatigue and physical activity which can be used in school health care and other clinical pediatric settings. Physical health has been shown to be more important for teenagers' well-being than ever because of the link to several somatic and mental conditions. The item banks are not yet available in Sweden.

METHODS

12- to 19-year-old participants (n = 681) were recruited in public school settings, and at a child- and psychiatric outpatient clinic. Three one-factor models using CFA were performed to evaluate scale dimensionality. We analyzed monotonicity and local independence. The items were calibrated by fitting the graded response model. Differential Item analyses (DIF) for age, gender and language were calculated.

RESULTS

As part of the three one-factor models, we found support that each item bank measures a unidimensional construct. No monotonicity or local dependence were found. We found that 11 items had significant lack of fit in the item response theory (IRT) analyses. The result also showed DIF for age (seven items) and language (nine items). However, the differences on item fits and effect sizes of McFadden were negligible. After considering the analytic results, graphical illustration, item content and clinical relevance we decided to keep all items in the item banks.

CONCLUSIONS

We translated and validated the U.S. PROMIS item banks pain interference, fatigue and physical activity into Swedish by applying CFA, IRT and DIF analyses. The results suggest adequacy of the translations in terms of their psychometrics. The questionnaires can be used in school health and other pediatric care. Future studies can be to use Computerized Adaptive Testing (CAT), which provide fewer but reliable items to the test person compared to classical testing.

Psychometric evaluation of the PROMIS social function short forms in Chinese patients with breast cancer

Background

The diagnosis of breast cancer and the subsequent treatment undermine patients’ participation in social activities. This study aimed to carry out a cross-cultural adaption and analysis of the construct validity and reliability of the Chinese version of the PROMIS social function short forms in patients with breast cancer.

Methods

This study utilized a cross-sectional research design, and was registered in the Chinese Clinical Trial Registry (ChiCTR2000035439). After a standardized cross-cultural adaption process, a psychometric evaluation was performed of the Chinese version of the PROMIS social function short forms. Using convenience sampling, eligible patients with breast cancer from tertiary hospitals in China were enrolled from January 2019 to July 2020. Participants completed the sociodemographic information questionnaire, the PROMIS social function short forms, the Functional Assessment of Cancer Therapy-Breast, the PROMIS emotional support short form and the PROMIS anxiety short form.

Results

Data were collected from a sample of 633 patients whose mean age was 48.1 years. The measures showed an absence of floor and ceiling effects. Regarding construct validity, the results of confirmatory factor analysis supported the original two-factor structure of the PROMIS social function short forms. In addition, the measures were found to have acceptable known-group validity, measurement invariance, and convergent and discriminate validity. Regarding reliability, the Cronbach’s α was high for all items (> 0.70).

Conclusion

The Chinese version of the PROMIS social function short forms was demonstrated to be a valid and reliable measure for the assessment of social function in Chinese patients with breast cancer. Additional psychometric evaluation is needed to draw firm conclusions.

Considerations to Support Use of Patient-Reported Outcomes Measurement Information System Pediatric Measures in Ambulatory Clinics

OBJECTIVE

To identify challenges to the use of Patient-Reported Outcomes Measurement Information System (PROMIS) Pediatric measures in the ambulatory pediatric setting and possible solutions to these challenges.

STUDY DESIGN

Eighteen semistructured telephone interviews of health system leaders, measurement implementers, and ambulatory pediatric clinicians were conducted. Five coders used applied thematic analysis to iteratively identify and refine themes in interview data.

RESULTS

Most interviewees had roles in leadership or the implementation of patient-centered outcomes; 39% were clinicians. Some had experience using PROMIS clinically (44%) and 6% were considering this use. Analyses yielded 6 themes: (1) selection of PROMIS measures, (2) method of administration, (3) use of PROMIS Parent Proxy measures, (4) privacy and confidentiality of PROMIS responses, (5) interpretation of PROMIS scores, and (6) using PROMIS scores clinically. Within the themes, interviewees illuminated specific unique considerations for using PROMIS with children, including care transitions and privacy.

CONCLUSIONS

Real-world challenges continue to hamper PROMIS use. Ongoing efforts to disseminate information about the integration of PROMIS measures in clinical care is critical to impacting the health of children.

Influences of health and environmental deprivation on family relationships among children with chronic disease

PURPOSE

Families play a key role in managing chronic illness. Among chronically ill children, we describe the Patient-Reported Outcomes Measurement Information System (PROMIS) Family Relationships measure over time and its associations with sociodemographics, environmental deprivation, and health.

METHODS

Parents of children aged 8-18 years with asthma (n = 171), type 1 diabetes (n = 199), or sickle cell disease (n = 135), recruited in pediatric clinics and emergency departments (ED), completed demographic surveys. Every six months for up to three years, children completed PROMIS Family Relationships, Anxiety, and Depressive Symptoms short forms (T-scores; mean 50, SD = 10), and a 5-level health status item. Linear mixed models were fit to estimate associations.

RESULTS

Older baseline age was associated with weaker family relationships. For example, for each 3-year higher baseline age, relationships were 3 points weaker for males (- 3.0; 95%CI - 5.7 to - .0.2) and females (- 3.1; 95%CI - 6.0 to - 0.3) with asthma recruited in the ED. For each 1-unit higher mean overall health, relationships were 4.6 points (95%CI 3.2-6.1) stronger for children with diabetes and about 2 points stronger for children with asthma (2.3; 0.7-3.9) and sickle cell disease (2.1; 0.3-3.9). Family relationships were 0.3-0.5 points weaker for each 1-unit increment in mean anxiety or depressive symptoms across all three diseases. Relationships were not significantly associated with environmental deprivation and generally stable over time.

CONCLUSIONS

Family relationships were weaker among older children and generally stable over time, yet fluctuated with physical and mental health. Monitoring PROMIS Family Relationships scores may facilitate referrals for chronically ill children who need support.

Effects of homophobic name-calling and verbal sexual harassment on substance use among young adults

Verbal aggression victimization, such as homophobic name-calling, has been linked to heavier substance use among young people, but little longitudinal research has examined how different types of victimization may affect substance use or whether certain psychosocial factors moderate these risks. In a diverse cohort (N  = 2,663), latent transition analysis was used to model heterogeneity in victimization (age 19) and substance use (age 20). Four victimization (high victimization, homophobic name-calling only, verbal sexual harassment only, and low victimization) and three substance use (poly-substance use, alcohol, and cannabis only, low all) classes were identified. The high victimization and homophobic name-calling only classes had the highest probabilities of transitioning into the poly-substance use class, and the high victimization class had the highest probability of transitioning into the alcohol and cannabis only class. The probability of transitioning into the low all substance use class was highest in the low victimization class and lowest in the high victimization class. For the high victimization class, greater depressive symptoms increased the odds, and better peer relationship quality decreased the odds, of transitioning into the poly-substance use and alcohol and cannabis only classes. For the homophobic name-calling only class, greater depressive symptoms increased the odds of transitioning into the poly-substance use class. Homophobic name-calling, alone or in combination with verbal sexual harassment, is a risk factor for escalating substance use in young adulthood, especially among victims with depressive symptoms.