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. Author manuscript; available in PMC: 2025 Sep 1.
Published in final edited form as: Behav Ther. 2024 Mar 18;55(5):913–921. doi: 10.1016/j.beth.2024.03.003

Family Accommodation in Anxious Irritable and Anxious Non-irritable Youth

Rotem S Budagzad-Jacobson 1, Regina M Musicaro 2, Carla E Marin 1, Wendy K Silverman 1, Eli R Lebowitz 1
PMCID: PMC11341947  NIHMSID: NIHMS2006180  PMID: 39174269

Abstract

Family accommodation is a significant contributor to the maintenance and course of youth anxiety. There is also high co-occurrence of anxiety and irritability in youth. Research is lacking, however, on the influence of irritability in the association between anxiety and family accommodation, including among youth with clinically diagnosed anxiety disorders. We therefore examined this issue in a sample of clinic-referred anxious irritable and anxious non-irritable youth. Youth (N = 645, Mage = 9.86 years, SD = 2.92) and their parents completed diagnostic interviews and questionnaires assessing youth anxiety, irritability, and family accommodation. Based on both youth and parent ratings, family accommodation was significantly and positively associated with youth anxiety and irritability. Anxious irritable youth rated family accommodation significantly higher than anxious non-irritable youth. In addition, youth self-rated irritability levels significantly moderated the association between their anxiety and family accommodation. No moderation effect was found for the parent ratings. Based on the youth ratings, our overall findings show that parents of anxious irritable youth are more accommodating of their children’s anxiety, compared with parents of anxious non-irritable youth. Anxiety levels also predict family accommodation more strongly in youth with lower levels of irritability. Our findings provide novel insights about accommodation behaviors in families of anxious irritable youth and suggest its potential utility as a treatment target when working with anxious irritable youth.

Keywords: anxiety, irritability, family accommodation, youth

Child and adolescent (henceforth youth) irritability, the elevated proneness to anger as a reaction to frustration, presents in roughly 3% - 5% of youth and is one of the most common reasons for referrals to psychiatric evaluation and care (Brotman et al., 2017; Leibenluft, 2017, Stringaris et al., 2018). Cross-sectional and longitudinal community- and clinic-based studies document the high co-occurrence of anxiety and irritability (Dickstein et al., 2005; Savage et el., 2015; Stoddard et al., 2014; Vidal-Ribas et al., 2016). Approximately 50% of anxious youth present with clinical levels of irritability, even after accounting for co-occurring disorders, such as depression and oppositional defiant disorder (Cornacchio et al., 2016; Dickstein et al., 2005; Shimshoni et al., 2020). Despite the high co-occurrence of anxiety and irritability, youth who are both anxious and irritable remain an understudied group (Stoddard et al., 2014). The insufficient attention is especially notable given that past studies included irritable youth, but these studies did not parse irritability out as a variable (e.g., Lebowitz et al., 2013; Storch et al., 2010).

Results from a cross-sectional, multi-informant study served to validate the distinctiveness of anxious non-irritable youth and anxious irritable youth (Shimshoni et al., 2020). Specifically, in an examination of 230 youth with anxiety disorders and their mothers, Shimshoni and colleagues (2020) found that anxious irritable youth are diagnosed with more anxiety disorders, have higher anxiety levels, and show more anxiety-related psychosocial impairment, compared with non-irritable youth with anxiety disorders. Further, mothers of anxious irritable youth reported significantly higher parenting stress and rated their child’s anxiety significantly more impairing to family functioning, compared with mothers of anxious non-irritable youth. These distinctions between anxious irritable and anxious non-irritable youth were found even after adjusting for anxiety severity, across a variety of factors, and not only on symptoms of either anxiety or irritability. Results from Stoddard et al. (2017) similarly support a meaningful distinction between youth anxiety with and without irritability based on neuroimaging/pathophysiology data, showing differences in neural response to emotional stimuli. Given the high comorbidity rate between anxiety-irritability, alongside the differences between the anxious irritable and anxious non-irritable groups, there is a need to examine the anxiety-irritability subgroup using both dichotomous and continuous methods (Shimshoni et al., 2020).

One factor associated with functional impairment and anxiety severity is family accommodation (FA) (e.g., Lebowitz et al., 2013). FA refers to changes in family members’ behaviors, particularly parents, aimed at preventing or alleviating anxiety and related distress in anxious youth. FA’s high prevalence is well-documented, with 97% to 100% of parents of anxious youth endorsing engaging regularly in FA (Lebowitz et al., 2013; Zavrou et al., 2019). FA is a significant contributor to the development and maintenance of youth anxiety (Lebowitz et al., 2013), and has become a key target in youth anxiety reduction (Lebowitz et al., 2014). Although FA is highly relevant to youth anxiety, little is known about its associations with the presence or absence of irritability. We know of only two relevant studies, with inconsistent findings, with only one focusing particularly on anxiety (Cabrera et al., 2023; Guzick et al., 2021). The first study, among 161 clinically referred youth (ages 7 to 17 years) with obsessive-compulsive disorder (OCD; which has commonalities with anxiety), found a significant positive association between FA and irritability based on parent ratings (Guzick et al., 2021). This finding would seem to parallel Shimshoni and colleagues’ (2020) finding that anxiety-related impairment is higher in anxious irritable youth.

A positive association between irritability and anxiety is also understandable at a theoretical level. One explanation could be that parents of anxious irritable children accommodate more to reduce their own distress. This would align with other past findings that parents of anxious irritable children report higher parenting stress and higher impairment of family functioning, compared with parents of anxious non-irritable youth (Shimshoni et al., 2020).

A second explanation is that parents of anxious irritable youth accommodate to alleviate their child’s distress. This would align with findings from O’Connor and colleagues (2020) suggesting that parent accommodation is associated less with their own distress level and more by the parent’s perception of the child’s distress, a perception that could be acutely elevated in the presence of irritability. These possible theoretical explanations are not mutually exclusive, and both can occur, potentially creating a vicious cycle in which the child’s distress affects the parent’s distress and vice versa. These “cycle” or “trap” ideas harken back to those associated with the coercion cycle (Patterson, 1982) and protection trap (Silverman & Kurtines, 1996).

As noted however, another study did not find a significant cross-sectional association between irritability and FA (Cabrera et al., 2023), In this study of 128 clinically anxious treatment referred youth, the baseline association between FA and irritability was positive but reached only trend level of significance, though post-treatment FA was correlated significantly with pre-treatment irritability. Altogether, the scant and inconsistent findings underscore the need for more research.

As previously stated, previous research shows a high comorbidity rate between anxiety and irritability, an established relation between anxiety symptoms and accommodation, and the recent findings from Guzick et al.’s study (2021) shed light on the positive association between irritability and FA. Given the association irritability has with the severity of anxiety symptoms and anxiety related impairment (Shimshoni et al., 2020; Stoddard et al., 2014), it is likely that irritability can also influence the association between anxiety and FA. In other words, the extent of irritability symptoms can either strengthen or weaken the association between anxiety and FA. For instance, the association between youth anxiety symptoms and their parents’ accommodating behavior might be stronger in the presence of higher irritability symptoms rather than lower levels of irritability. This is supported by previous findings in youth with OCD and anxiety disorders, where family accommodation (FA) is linked to increased symptom severity (Lebowitz et al., 2013).

Conversely, the presence of overlapping symptoms between anxiety and irritability could render the influence of irritability less significant, since the symptoms of irritability (e.g., anger lashes, outbursts) could overshadow the impact of the anxiety symptoms on FA, thereby weakening the combined impact of comorbid anxiety and irritability on FA.

Lastly, the overlap between anxiety and irritability related symptoms can make the influence of irritability on FA insignificant. However, given previous findings suggesting irritable anxious youth are a distinct subgroup (Shimshoni et al., 2020; Stoddard et al, 2017), it is likely that irritability will have a significant impact on the relation between anxiety and FA.

Our study addresses the two notable research gaps we have outlined: 1) assessing the difference in FA rates between anxious irritable and anxious non-irritable youth and 2) examining the contribution of irritability to the previously established relation between anxiety and FA.

Current Study

Given the important role of FA in maintaining anxiety, our primary interest was to examine for the first time whether the relations between anxiety and FA vary for different levels of youth irritability in a sample of youth referred to an anxiety disorders specialty research clinic. We also examined whether parents of clinically anxious irritable youth accommodate their child’s anxiety more than parents of clinically anxious non-irritable youth. Following past work (e.g., Shimshoni et al., 2020), and given the widely observed discrepancies between youth and parent ratings (e.g., De Los Reyes & Kazdin, 2005), we collected youth and parent ratings for all measures and tested the respective informant data separately. We expected significant correlations between irritability and anxiety, between FA and irritability, and between FA and youth anxiety (Cabrera et al., 2023; Guzick et al., 2021; Lebowitz et al., 2013; Stoddard et al., 2014). We hypothesized higher accommodation levels among parents of anxious irritable youth, compared with parents of anxious non-irritable youth. We also hypothesized that youth irritability would significantly moderate the association between youth anxiety and FA. In the absence of prior research on the directional role of irritability in the association between anxiety and FA accommodation, we refrained from making a specific direction hypothesis.

Method

Participants

Participants were 645 youths who met diagnostic criteria for anxiety disorders and their parents (majority were mothers, only four father). Youth ranged in age from 6 to 17 years (Mage = 9.86 years, SD = 2.92), with a majority (72.8%) aged 6 to 11 years. Slightly more than one half of the youth participants (51.7%) were males, 45% were females and 3.3% did not disclose (based on parent completed Information sheet). The majority were White (81%), followed by Multiracial (8.4%), Black/African American (3.4%), Asian (2.3%), and 4.9% did not disclose. Regarding youth ethnicity, 10.7% percent were Hispanic/Latino, 83.3% were European American and 6% did not disclose. Annual household income was below $61,000 for 11.9% of families, between $61,000 and $99,999 for 18%, above $100,000 for 60.5%, and 9.6% of families did not disclose. Regarding parents’ educational background, 0.8% did not graduate from high school, 8.4% had some college education, 4.9% completed high school/General Education Diploma, 39.2% held bachelor’s, associate or technical degrees, 43% held advanced degrees, and 3.7% did not disclose.

Procedure

The study was approved by the University Institutional Review Board. After a brief phone screen, an evaluation was scheduled and upon arrival, informed consent and assent were obtained from parents and youths, respectively, prior to any study procedures. This was followed by parents and youths completion of semi-structured diagnostic interview and questionnaires.

Measures

Diagnostic Instrument

The Anxiety Disorders Interview Schedule for DSM-IV, Child and Parent (ADIS-IV-C/P; Silverman & Albano, 1996) is a semi-structured diagnostic interview administered to parents and their children, separately, to establish youth anxiety diagnoses. Evidence supports the ADIS-IV-C/P’s satisfactory test-retest reliability and concurrent validity (Silverman et al., 2001).

Youth-and Parent-Completed Questionnaires

Affective Reactivity Index (ARI-C/P; Stringaris et al., 2012).

The ARI is a 6-item measure assessing the threshold, duration, and frequency of youth irritability, with parallel youth and parent versions. Items are rated on a 3-point Likert scale, ranging from 0 (not true) to 2 (certainly true). The total score is calculated by the sum of items (ranges from 0–12), with higher summed scores indicating greater irritability severity. The ARI has high test-retest reliability and satisfactory concurrent validity estimates (Tseng et al., 2017; Wilson et al., 2022). As in past work (Shimshoni et al., 2020; Stoddard et al., 2014), we used a score of 3 or above to classify youth as irritable. In the current sample, McDonald’s omegas were .85 and .91 for youth- and parent-report, respectively.

Multidimensional Anxiety Scale for Children–2nd Edition (MASC-2; March, 2013).

The MASC-2 is a 50-item measure assessing youth anxiety symptoms with parallel youth and parent versions. Items are rated on a 4-point Likert scale, ranging from 0 (never) to 3 (often). The total score is calculated by the sum of items (ranges from 0–150), with higher summed scores indicating higher anxiety severity. The MASC-2 has high retest reliability and satisfactory concurrent validity estimates (Etkin et al., 2021; Wood et al., 2002). In the current sample, McDonald’s omegas were .93 and .90 for youth- and parent-report, respectively.

Family Accommodation Scale – Anxiety (FASA; Lebowitz et al., 2013, 2015).

The 9-item FASA is a measure assessing parent accommodation of youth anxiety with parallel youth and parent versions. The items are rated on a 5-point Likert scale, ranging from 0 (never) to 4 (daily). The total score is calculated by the sum of items (ranges from 0–36), with a higher summed scores indicating higher accommodation. FASA has high test-retest reliability and shows convergent and discriminant validity with measures of anxiety and depression (Lebowitz et al., 2013, 2019). McDonald’s omegas for total accommodation scores in this sample were .79 and .88 for youth- and parent-report, respectively.

Data Analytic Plan

We conducted all analyses in SPSS (version 28). We first examined our sample’s sociodemographic characteristics and conducted independent t-tests and chi-square analyses to determine whether there were any significant differences between anxious irritable and anxious non-irritable youth along sociodemographics. We next examined bivariate correlations between all study variables. This was followed by independent t-tests to examine mean differences in FA between anxious irritable and anxious non-irritable youth, based both on youth-report and parent-report. We used multiple linear regressions (MLR) using product terms (Jaccard & Tursi, 2003) to test whether irritability moderates the association between youth anxiety symptom severity and FA. With N = 645 participants and alpha set at .05, power of 0.80 was available to detect interaction effects as small as f2 = 0.03 (a small effect). We tested the effect of the interaction between anxiety and irritability on FA in separate models for the youth- and parent-report variables. Because past research shows influences of youth age and youth sex on youth anxiety (Cornacchio et al., 2016; Schleider et al., 2018), we controlled for these two variables in all regression models.

We conducted a simple slope analysis for significant interaction effect and probed significant regions of moderation using the Johnson-Neyman (J-N) procedure (1936).

Results

Descriptive Statistics and Preliminary Analyses

T-tests and chi-square analyses examining sociodemographic differences between anxious irritable and anxious non-irritable youth showed non-significant results. Bivariate correlations and descriptive statistics for parent-reported and youth-reported continuous variables are presented in Table 1. For both youth- and parent-report, youth irritability symptoms were significantly and positively correlated with youth anxiety and FA. Correlations between youth- and parent-report of the same measures were significant and positive, ranging between .18 < r < .37.

Table 1:

Pearson’s Bivariate Correlations Between Study Variables

Variable M SD 1 2 3 4 5
1. MASC 2-C 69.95 25.74
2. FASA-C 12.47 6.84 .32**
3. ARI-C 3.96 3.27 .40** .11**
4. MASC 2-P 68.25 19.68 .18** .23** .01
5.FASA-P 16.55 8.34 .02 .19** .07 .44**
6. ARI-P 3.76 3.50 .03 .01 .37** .24** .26**
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Note. FASA-P = Family Accommodation Scale – Anxiety Parent Report; FASA-C = Family Accommodation Scale – Anxiety Child Report; MASC 2-P = Multidimensional Anxiety Scale for Children – Parent; MASC 2-C = Multidimensional Anxiety Scale for Children – Child; ARI-P= Affective Reactivity Index, Parent Report; ARI-C= Affective Reactivity Index, Child Report.

*

indicates p < .05.

**

indicates p < .01.

Youth Self-Ratings

Mean Difference in FA Between Anxious Irritable and Anxious Non-Irritable Youth

Based on the youth self-ratings mean scores of youth irritability in our sample were above the ARI score of 3 (M = 3.96, SD = 3.27), which has been used to classify youth as anxious irritable in past research (e.g., Shimshoni et al., 2020; Stoddard et al., 2014). Compared with anxious non-irritable youth (M = 11.86, SD = 7.40), anxious irritable youth (M = 12.94, SD = 6.40) reported significantly higher levels of FA, t(609) = 1.93, p < .01.

Youth Irritability Severity as a Moderator of Youth Anxiety And FA

Results for the regression models are presented in Table 2. Based on youth report, anxiety symptoms significantly predicted FA, controlling for age, sex, and irritability symptoms. Irritability did not significantly predict family accommodation when controlling for age, sex, and anxiety symptoms. The interaction between irritability and anxiety also significantly predicted FA, indicating that the relation between anxiety and FA varied by levels of irritability.

Table 2:

Multiple Regression Analysis for Variables Predicting Family Accommodation

Youth-report Parent-report
Variable B 𝛽 𝑆𝐸 95% CI B 𝛽 𝑆𝐸 95% CI
Constant 12.80** .28 16.17** .42
Youth age −.10 −.04 .93 −.285, .079 −.44** −.15 .10 −.646, −.240
Youth sex −.46 −.03 .54 −1.521, .602 .81 .05 .60 −.374, 1.995
Youth anxiety .09** .33 .01 .066, .112 .16** .39 .02 .135, .197
Youth irritability −.01 −.00 .09 −.190, .170 .40** 0.17 .89 .226, .578
IrritabilityX-anxiety −.00** −.10 .00 −.014, −.002 −.00 .00 .01 −.010, .00
R 2 .12 .24
F 15.73 ** 37.29 **
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Note.

*

indicates p < .05.

**

indicates p < .01.

To probe the significant interaction effect between anxiety and irritability based on youth-report, we examined the slopes of the associations between youth anxiety and FA scores at different levels of youth irritability using the J-N procedures. The results show that as irritability levels increased, the relation between anxiety and FA decreased. The irritability value defining the J-N region of significance was 5.8 (90.8% of youth were below this value).

Parent-Ratings of Youth

Mean Difference in FA Between Anxious Irritable and Anxious Non-Irritable Youth

Like the youth self-ratings, mean scores of youth irritability based on parent ratings were above the ARI score of 3 (M = 3.76, SD = 3.4). No significant mean difference in FA was found between anxious non-irritable youth (M = 14.56, SD = 7.86) and anxious irritable youth (M = 18.26, SD = 8.36) based on the parent ratings of FA, t(617) = 5.6, p > 0.05.

Youth Irritability Severity as a Moderator of Youth Anxiety and FA

For the parent ratings of their child, youth anxiety symptoms significantly predicted FA when controlling for age, sex, and irritability symptoms. Irritability also significantly predicted FA when controlling for youth age, sex, and anxiety symptoms. However, the interaction between irritability and anxiety did not significantly predict FA.

Discussion

In line with our study’s hypotheses, we found anxious irritable youth report that their parents accommodate their anxiety symptoms more than anxious non-irritable youth. We also found based on youth self-ratings that irritability significantly moderates the association between youth anxiety and FA. Finally, based on both youth self-ratings and parents’ ratings of their child, we found significant correlations between irritability and anxiety, between FA and irritability, and between FA and youth anxiety, consistent with past research (Guzick et al., 2021; Lebowitz et al., 2013; Stoddard et al., 2014).

Our findings contribute to the nascent literature on FA and irritability, and parallel Guzick and colleagues’ (2021) finding of a significant positive association between irritability and accommodation in youth with OCD based on parent reports. These findings suggest that parents’ experiences of “walking on eggshells” around their irritable children may be exacerbated among parents of anxious irritable children (Stringaris et al., 2018).

These results can be supported by either of the three explanations we presented earlier. It is possible that FA is higher in anxious irritable children because parents feel they need to accommodate these children more to reduce their owns distress, to reduce anger outbursts and other behavioral manifestation of irritability. For instance, if a parent is concerned that their child, who has separation anxiety, will “cause a scene” when they leave the child alone at soccer practice, the parent may decide to stay the entire duration of practice to avoid the distress of their child’s outburst if they were to leave. This explanation is in line with the study by Shimshoni et and colleagues (2020) that parents of anxious irritable youth experience higher levels of parenting stress compared to parents of children with anxiety alone.

An alternative explanation is that parents of anxious irritable youth may be more accommodating to lessen their child’s distress. This is in line with O’Connor and colleagues’ (2020) findings that parents are likely to go to greater lengths to prevent their children from experiencing severe distress. Returning to the earlier example, a parent may decide not to leave a soccer practice, out of concern that their absence might trigger extreme anxiety in their child, potentially hindering their child’s participation in practice and potentially exacerbating the child’s anxiety in the long term, including at future practices.

Finally, another possibility is that both explanations are complementary. Parents of anxious irritable youth may engage in more FA both to mitigate their own distress as well as reduce their child’s distress. A parent may stay with their child during soccer practice out of concern that leaving could exacerbate their child’s anxiety, which, in turn, would alleviate their own distress. Alternatively, parents may accommodate because they worry that their own distress could “feed into” their child’s anxiety and worsen it, and thus the vicious cycle or protection trap continues, which maintains the child’s anxiety in the long term.

Our second hypothesis was that irritability would moderate the association between youth anxiety and FA. Our results partially support this hypothesis in that we found a significant moderation effect for the youth model, but not the parent model. Specifically, based on youth reports, youth anxiety severity was more strongly associated with FA when the irritability levels were low. As the youth irritability levels increased, the association between youth anxiety and FA became more moderate. Perhaps in the absence of clinical irritability, the youth’s anxiety may be the most predictive of FA and thus the association between anxiety and FA is stronger for anxious non-irritable youth. However, if anxiety and irritability are both present, the anxiety may be dampened by the irritability symptoms, regardless of the youth’s anxiety severity. For instance, parents of a child with separation anxiety and no irritability may sleep by their child’s side if the child is extremely anxious about sleeping alone. However, if the child is both anxious and irritable, the parents may accommodate by agreeing to sleep beside them even when the anxiety is lower, because not doing so could provoke an angry outburst or temper tantrum.

Additional results from the regression models are further noteworthy. While anxiety, age, and irritability all significantly predicted parent’s ratings of FA, only anxiety and the interaction between anxiety and irritability significantly predicted FA based on the youth report. This pattern of findings may reflect differences in how parents and children perceive youth anxiety and irritability and underlines the importance of the multi-informant approach applied in our study. Discrepancies between parent and youth reports of behavioral and emotional symptoms are common in both non-clinical and clinical samples (De Los Reyes & Kazdin, 2005). Parent ratings may accurately reflect youth irritability symptoms expressed in external behaviors such as temper tantrums and meltdowns, whereas youth ratings may reflect the internal emotional experience of irritability. Finally, the main effects of the youth’s age and anxiety severity in predicting FA are consistent with past findings that parents accommodate younger children more than older children or adolescents, and that anxiety has a significant association with FA (Lebowitz et al., 2013; Schleider et al., 2018).

Limitations And Future Directions

We are unable to draw causal inferences due to our study’s cross-sectional design. Prospective designs are needed, as well as research with diverse samples to determine our findings’ generalizability. Finally, we used only youth- and parent-completed measures of our constructs of interest. Future research would benefit from inclusion of additional measures including clinician and behavioral measures (De Los Reyes & Kazdin, 2005).

Clinical Implications

Our findings suggest that treatment targeting FA could be beneficial for anxious irritable youth, as suggested as well by a recent study with a treatment-seeking sample of clinically anxious youth and their parents (Cabrera et al., 2023). This study found high levels of youth irritability at pretreatment were associated with high levels of FA after receiving cognitive behavioral therapy (CBT), which in turn was contemporaneously associated with high levels of youth anxiety at post-CBT (Cabrera et al., 2023). Treatments that target systematically parent accommodation, such as Supportive Parenting for Anxious Childhood Emotions and family-based CBT protocols (SPACE; Lebowitz et al., 2014; Kagan et al., 2022) and CBT protocols that target systematically reducing parent use of negative reinforcement which has conceptual/clinical overlap with FA as per the protection trap (Silverman & Kurtines 1994; Silverman et al., 2021), might prove particularly beneficial when working with anxious irritable youth.

Moreover, our findings regarding the moderating effect of irritability on the relation between anxiety and FA sheds lights on possible underlying mechanisms explaining FA behaviors. To effectively reduce FA behaviors, it is important to not only recognize FA behaviors, but also the contexts in which they occur. Although our cross-sectional study cannot demonstrate causality, our findings can guide future studies examining the conditions under which irritability drives FA, and the interplay between these factors can aid in the development of more effective and precise treatment protocols (e.g., tailored to the clinical presentation of anxious irritable youth).

Our study like many studies raises more questions than it answers. Nonetheless, the findings are novel and pave the way for future research that will continue to advance understanding of the associations among youth anxiety, irritability, and family accommodation. Such research can help toward developing more effective and precision-based interventions in this scantly studied area.

Figure 1 -.

Figure 1 -

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Johnson-Neyman region of significance (Youth-Report)

Highlights.

  • Anxious irritable youth rated accommodation higher than anxious non-irritable youth.

  • Irritability moderated the association between their anxiety and accommodation.

  • Anxiety predicts accommodation more strongly in anxious non-irritable youth.

Conflict of Interest:

The study was supported by National Institute of Mental Health grants K23MH103555, R61MH115113, and R33MH115113. Grant recipients include Eli Lebowitz. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. We have no additional financial or non-financial interests to disclose.

Funding:

This study was supported by National Institute of Mental Health grants K23MH103555, R61MH115113, and R33MH115113. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Footnotes

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