Stealing among High School Students: Prevalence and Clinical Correlates

Abstract

Although stealing among adolescents appears to be fairly common, an assessment of adolescent stealing and its relationship to other behaviors and health issues is incompletely understood. A large sample of high school students (n=3999) was examined using a self-report survey with 153 questions concerning demographic characteristics, stealing behaviors, other health behaviors including substance use, and functioning variables such as grades and violent behavior. The overall prevalence of stealing was 15.2% (95%CI: 14.8–17.0). Twenty-nine (0.72%) students endorsed symptoms consistent with a diagnosis of DSM-IV kleptomania. Poor grades, alcohol and drug use, regular smoking, sadness and hopelessness, and other antisocial behaviors were all significantly (p<.05) associated with any stealing behavior. Stealing appears fairly common among high school students and is associated with a range of potentially addictive and antisocial behaviors. Significant distress and loss of control over this behavior suggests that stealing often has significant associated morbidity.

INTRODUCTION

The lifetime prevalence of stealing appears fairly high. A recent, large epidemiological study of adults found that 11.3% of the general population admitted to having shoplifted in their lifetimes.¹ This finding is consistent with estimates by the National Association of Shoplifting Prevention that 1 in 11 (9.1%) people have shoplifted during their lifetime.² Stealing in adults has been associated with other antisocial behaviors, psychiatric comorbidity (e.g., substance use disorders, pathological gambling, and bipolar disorder), and impaired psychosocial functioning.¹ Stealing appears to start generally in childhood or adolescence, with approximately 66% of individuals who reported lifetime stealing beginning before age 15 years.¹

Despite the early age of onset of stealing, as well as the significant adult morbidity associated with this behavior, stealing among adolescents has historically received relatively little attention from clinicians and researchers. Limited research suggests that adolescents who steal have impairments in problem-solving skills and a cognitive bias toward inappropriate solutions to problems.³ Other research suggests that parent-child difficulties, school failure, and negative peer influences underlie adolescent stealing.⁴

Although stealing may be fairly common, it is unclear how many adolescents who steal suffer from kleptomania. Kleptomania, characterized by a diminished ability to resist recurrent impulses to steal objects that are not needed for their monetary or personal use, has been relatively understudied across the lifespan and particularly in adolescents with propensities for stealing.⁵ In the present study, we assessed a large sample of public high school students regarding stealing behaviors. Although previous research suggests that stealing and antisocial behaviors are linked,^{1, 6} no study has systematically examined the relationship of stealing to a range of behaviors and health functioning. Given the incomplete data on the co-occurrence of stealing and other variables among young people, the purpose of this study was to fill these gaps in knowledge. Specifically, we sought to: 1) examine the prevalence and sociodemographic correlates of different severity levels of stealing in adolescents; 2) investigate health correlates in high school students who steal; and 3) examine the different severity levels and clinical characteristics of stealing and determine differences in students whose stealing merits the diagnosis of kleptomania. Recognizing possible differences in stealing severity among adolescents may have clinical and health implications. It is also important to recognize associations between stealing and health variables as identifying and treating the stealing behavior may significantly improve the prognosis of other behaviors.

METHODS

Study Procedures and Sampling

The study procedure has been previously described in detail.⁷ In summary, the study team mailed invitation letters to all public four-year and non-vocational or special education high schools in the state of Connecticut. These letters were followed by phone calls to all principals of schools receiving a letter to assess the school’s interest in participating in the survey. In order to encourage participation, all schools were offered a report following data collection that outlined the prevalence of stealing and other health behaviors in that school. Schools that expressed an interest were contacted to begin the process of obtaining permission from school boards and/or school system superintendents, if this was needed.

In addition, targeted contacts were made to schools that were in geographically underrepresented areas to ensure that the sample was representative of the state. The final survey therefore contains schools from each geographical region of the state of Connecticut, and it contains schools from each of the three tiers of the state’s district reference groups (DRGs) (i.e. groupings of schools based on the socioeconomic status of the families in the school district). Sampling from each of the three tiers of the DRGs was intended to create a more socioeconomically representative sample. Although this was not a random sample of public high school students in Connecticut, the sample obtained in this study is similar in demographics to the sample of Connecticut residents enumerated in the 2000, census ages 14–18.⁸

Once permission was obtained from the necessary parties in each school, letters were sent through the school to parents informing them about the study and outlining the procedure by which they could deny permission for their child to participate in the survey if they wished. In most cases, parents were instructed to call the main office of their child’s high school to deny permission for their child’s participation. From these phone calls, a list of students who were not eligible to participate was compiled for reference on the survey administration day. If no message was received from a parent, parental permission was assumed. These procedures were approved by all participating schools and by the Institutional Review Board of the Yale University School of Medicine.

In most cases, the entire student body was targeted for administration of the survey. Some schools conducted an assembly where surveys were administered, while others had students complete the survey in every health or English class throughout the day. In each case, the school was visited on a single day by a number of research staff who explained the study, distributed the surveys, answered questions, and collected the surveys.

Students were told that participation was voluntary and that they could refuse to complete the survey if they wished, and were also reminded to keep surveys anonymous by not writing their name or other identifying information anywhere on the survey. Students were given a pen for participating. If a student was not eligible to participate because a parent had denied permission, or personally declined to participate, this student was allowed to work on schoolwork while the other students completed the survey. The refusal rate was under 1%.

Measures

The survey consisted of 153 questions concerning demographic characteristics, stealing behavior, other health behaviors including substance use, and functioning variables such as grades and violent behavior.

Stealing behavior was assessed by asking how many times the person stole from stores or people in a typical week. Possible answers to this were: “never,” “less than 7 times,” “7 to 14 times,” “15–20 times,” and “21 or more times”. Those who reported any stealing were then asked 6 additional questions: (1) “Have you ever tried to cut back on stealing things?” (2) “Has a family member ever expressed concern about the amount of time you spend stealing things?” (3) “Have you ever missed school, work or other important social activities because you were stealing?” (4) “Do you think you have a problem with excessive stealing?” (5) “Have you ever experienced an irresistible urge or uncontrollable need to steal things?” and (6) “Have you ever experienced a growing tension or anxiety that can only be relieved by stealing?” Three of the questions were based on the Minnesota Impulse Disorders Interview, a valid and reliable screen for adolescent kleptomania,⁹ and reflect DSM-IV criteria for kleptomania: Trying to cut back on stealing and an irresistible urge to steal reflect Criterion A; growing tension or anxiety that is only relieved by stealing mirrors both Criteria B and C.⁵ Therefore, students who endorsed all three of these questions were placed in the kleptomania group, while other respondents who reported stealing but did not endorse all three symptoms were placed in the non-kleptomania stealing group.

Demographics included gender, race, Hispanic ethnicity, grade, and family structure (live with one parent, two parents, or some other configuration). Health and functioning variables included grade average (A’s and B’s, C’s, D’s and F’s); extracurricular activities (including employment); tobacco use (categorized as “never”, “once or twice”, “occasionally but not regularly”, “regularly in the past”, or “regularly now”); lifetime marijuana use defined as any use in the past 30 days; alcohol frequency categorized as none, light (1–5 days), moderate (6–19 days), or heavy (20 days or more); lifetime use of other drugs (categorized as “any” or “none”); current caffeine use (none, 1–2 drinks per day, 3 or more drinks per day); a two week period of feeling sad or hopeless and losing interest in usual activities (assessing for depression symptomatology) in the past 12 months; past 12-months history of getting into a fight requiring medical attention; and past 12-months report of carrying a weapon of any kind to school.

Data Analysis

Data were double-entered from the paper surveys into an electronic database. Random spot checks of completed surveys and data cleaning procedures were performed to ensure that data were accurate and not out of range.

Distribution characteristics of all variables were examined. Only participants with complete data on the dependent variable were included in analyses. Baseline demographic data were evaluated for differences between those with complete data and those without complete data using t-tests for parametric data and Mann-Whitney U tests for nonparametric data. Participants were divided into three groups: no stealing, non-kleptomania stealing, and kleptomania. Differences between the three groups were examined using Pearson chi-square. All comparison tests were two-tailed.

Multivariable analyses were conducted using multinomial logistic regression models with the three-group stealing variable as the dependent variable. The three groups were compared using odds ratios from these models, adjusting for demographic characteristics found to distinguish the three groups in bivariate analyses. Because all pairwise comparisons of three groups were performed, p values were corrected to 0.02 to allow for multiple comparisons.

RESULTS

Demographics of the sample are presented (Table 1). The overall prevalence of stealing was 15.2% (95%CI: 14.8–17.0). Twenty-nine students (0.72% of the entire sample, 4.6% of those who steal) endorsed stealing symptoms consistent with a DSM-IV diagnosis of kleptomania. Males were more likely to have reported stealing than were girls. African-Americans and Asian-Americans were more likely to have reported stealing. Those students in 9^th grade were more likely to have stolen, and students living with two parents were less likely to have stolen (Table 1).

Table 1.

Demographic Variables for High School Students Based on Stealing Behavior

Variable	No stealing (N=3373, 84.11%)*		Non-Kleptomania stealing (N=608,15.16%)		Kleptomania (N=29, 0.72%)		X2	p
	n	%	n	%	n	%
Gender
Male	1477	81.06	331	18.17	14	0.77	25.67	<0.0001
Female	1863	86.93	267	12.46	13	0.61
African-American
Yes	307	78.52	81	20.72	3	0.77	10.44	0.0054
No	3066	84.72	527	14.56	26	0.72
White
Yes	2609	85.07	437	14.25	21	0.68	8.85	0.012
No	764	81.02	171	18.13	8	0.85
Asian
Yes	120	76.92	33	21.15	3	1.92	8.07	0.0177
No	3253	84.41	575	14.92	26	0.67
Other race
Yes	468	81.11	105	18.2	4	0.69	4.83	0.0895
No	2905	84.62	503	14.65	25	0.73
Hispanic
Yes	2849	74.29	130	24.76	5	0.95	43.06	<0.0001
No	390	85.53	459	13.78	23	0.69
Grade
9th	1008	81.49	218	17.62	11	0.89	10.5	0.105
10th	934	84.68	162	14.69	7	0.63
11th	899	85.21	149	14.21	7	0.66
12th	523	86.59	77	12.75	4	0.66
Family structure
One parent	725	79.67	175	19.23	10	1.1	47.67	<0.0001
Two parents	2470	86.64	366	12.84	15	0.53
Other	144	73.1	49	24.87	4	2.03

^*cells may not sum to these totals due to missing data;

Ns represent actual number of respondents in each category;

%s indicate weighted percentages

Among those students who stole, a small percentage (4.6%) met criteria for kleptomania (Table 2). Those meeting criteria for kleptomania stole more frequently than other students reporting stealing (p=0.0028) and were more likely to report missing activities due to stealing, having a problem with stealing, and having family members express concern over their stealing behavior (p<.0001; Table 2).

Table 2.

Characteristics of Stealing Behavior, Among Students Who Report Stealing

Characteristic	Level	Non-Kleptomania Stealing (n=608)		Kleptomania (n=29)		X2	p
		n	%	n	%
Frequency of stealing in a typical week	<7 times	458	75.33	15	51.72	14.11	0.0028
	7–14 times	46	7.57	3	10.34
	15+ times	104	17.11	11	37.93
Ever tried to cut back?*		195	32.07	29	100	56.02	<0.0001
Family expressed concern?		109	17.93	23	79.31	63.48	<0.0001
Missed activities to steal?		66	10.87	17	58.62	55.61	<0.0001
Do you think you have a problem?		80	13.2	28	96.55	136.22	<0.0001
Experienced irresistable urge to steal?*		136	22.37	29	100	86.91	<0.0001
Experienced growing tension only relieved by stealing?*		55	9.05	29	100	200.02	<0.0001
Total number of items endorsed	0	288	47.37	0	0	448.26	<0.0001
	1	136	22.37	0	0
	2	88	14.47	0	0
	3	62	10.2	1	3.45
	4	27	4.44	4	13.79
	5	7	1.15	8	27.59
	6	0	0	16	55.17

^*These are required to be in the Kleptomania group;

Ns represent actual number of respondents in each category;

%s indicate weighted percentages

Table 3 presents the unadjusted associations between health and functioning variables and the three stealing groups. These analyses indicate that all of the variables assessed (poor grades, lack of extra-curricular activities, regular smoking, any drug use, heavy alcohol use, heavy caffeine use, endorsement of sadness and hopelessness, and other antisocial behaviors (e.g., fighting, carrying weapons)) were all significantly associated with stealing.

Table 3.

Clinical Variables for High School Students Based on Stealing Behavior

Variable	No stealing (N=3373, 84.11%)*		Non-Kleptomania stealing (N=608,15.16%)		Kleptomania (N=29, 0.72%)		X2	p
	n	%	n	%	N	%
Grade average
A’s and B’s	2061	88.87	245	10.56	13	0.56	118.66	<0.0001
C’s	919	79.91	224	19.48	7	0.61
D’s and F’s	306	70.34	122	28.05	7	1.61
Extra-curricular activities
Yes	2607	85.78	194	13.62	11	0.59	26.74	<0.0001
No	766	78.89	414	19.98	18	1.13
Smoking, lifetime
Never	2203	90.66	220	9.05	7	0.29	239.68	<0.0001
Occasionally	745	78.34	197	20.72	9	0.95
Regularly	343	65.71	168	32.18	11	2.11
Marijuana, lifetime
Yes	1065	72.35	386	26.22	21	1.43	249.65	<0.0001
No	2105	91.6	187	8.14	6	0.26
Sip of alcohol, lifetime
Yes	2724	82.35	556	16.81	28	0.85	39.35	<0.0001
No	468	93.41	32	6.39	1	0.2
Current alcohol frequency
Never regular	649	86.53	97	12.93	4	0.53	68.19	<0.0001
Light	575	81.68	122	17.33	7	0.99
Moderate	544	79.3	139	20.26	3	0.44
Heavy	184	64.56	95	33.33	6	2.11
Other drug use, lifetime
Yes	154	50.49	140	45.9	11	3.61	297.36	<0.0001
No	2639	87.62	361	11.99	12	0.4
Caffeine use
None	685	87.37	95	12.12	4	0.51	109.23	<0.0001
1–2 drinks per day	1868	87.74	249	11.7	12	0.56
2+ drinks per day	730	73.59	250	25.2	12	1.21
Sad or hopeless 2+weeks
Yes	620	74.79	197	23.76	12	1.45	74.29	<0.0001
No	2608	86.88	381	12.69	13	0.43
Serious fights
Yes	130	51.18	113	44.49	11	4.33	240.13	<0.0001
No	3168	86.37	484	13.2	16	0.44
Carry a weapon
Yes	441	60.58	272	37.36	15	2.06	377.43	<0.0001
No	2871	89.61	320	9.99	13	0.41

^*cells may not sum to these totals due to missing data;

Ns represent actual number of respondents in each category;

%s indicate weighted percentages

Logistic regression models calculated associations between health and functioning variables and stealing groups, adjusted for gender, grade, and race/ethnicity (Table 4). Those reporting stealing were more likely than non-stealers to report poor grades (C’s and lower among non-kleptomania stealers, D’s and F’s among kleptomania stealers), smoking at any level, smoking marijuana, drinking alcohol (at any level among non-kleptomania stealers, heavily among kleptomania stealers), using other drugs, getting into serious fights, and carrying a weapon. Non-kleptomania stealers were more likely to drink two or more caffeine drinks a day than were non-stealers, but there was no significant association with caffeine use among kleptomania stealers. Both kleptomania and non-kleptomania groups were significantly less likely to report sadness or hopelessness than respondents who reported no stealing.

Table 4.

Clinical Comparison of High School Students Based on Stealing Behavior

Variable		Non-Kleptomania stealing vs. Non-stealers		Kleptomania versus Non-stealers		Kleptomania vs Non-Kleptomania Stealers
		OR	p	OR	p	OR	p
Grade average (ref: A’s and B’s)
	C’s	1.801	<.0001	1.201	0.7016	0.67	0.4034
	D’s and F’s	2.903	<0.0001	3.038	0.0303	1.04	0.9309
Extra-curricular activities (ref: No)	Yes	0.649	<0.0001	0.476	0.0665	0.74	0.4514
Smoking, lifetime (ref: never)
	Occasionally	3.02	<0.0001	3.99	0.0085	1.33	0.5974
	Regularly	5.44	<0.0001	12.95	<0.0001	2.38	0.0899
Marijuana, lifetime (ref: No)	Yes	4.73	<0.0001	7.84	<0.0001	1.67	0.3075
Sip of alcohol, lifetime (ref: No)	Yes	3.54	<0.0001	5.35	0.1032	1.52	0.6916
Current alcohol frequency (ref: Never regular)
	Light	1.48	0.0115	2.2	0.2162	1.49	0.5404
	Moderate	2.01	<0.0001	0.713	0.699	0.36	0.242
	Heavy	4.05	<0.0001	7.67	0.0027	1.89	0.3547
Other drug use, lifetime (ref: No)	Yes	6.43	<0.0001	15.74	<0.0001	2.44	0.0499
Caffeine use (ref: None)
	1–2 drinks per day	0.969	0.8142	0.944	0.9228	1.02	0.9661
	2+ drinks per day	2.38	<0.0001	2.44	0.1313	0.97	0.9701
Sad or hopeless 2+weeks (ref: No)	Yes	2.25	<0.0001	3.80	0.0016	1.69	0.2228
Serious fights (ref: No)	Yes	4.77	<0.0001	14.6	<0.0001	3.03	0.0098
Carry a weapon (ref: No)	Yes	5.17	<0.0001	7.89	<0.0001	1.52	0.3266

Models are adjusted for gender, grade, race/ethnicity

There were also two significant differences between non-kleptomania and kleptomania stealers. High school students meeting criteria for kleptomania were significantly more likely to use other drugs and more likely to get into serious fights than were non-kleptomania stealers (Table 4).

DISCUSSION

To our knowledge, this study is the first to examine the prevalence of stealing and kleptomania among adolescents and their associations with a broad range of problematic behaviors in a large community sample of high school students. The multiple strengths of the survey, including the high response rate, large community sample, and detailed questions regarding stealing behavior, allow for the systematic investigation of stealing with and without kleptomania with respect to a broad range of adolescent health and functioning measures. The finding that approximately 15% of high school students had stolen in their lifetimes is consistent with findings from large population-based surveys of adults (11.3%),¹ and further supports findings that stealing behavior typically starts in childhood and adolescence. Although only 0.72% of the total sample endorsed symptoms consistent with kleptomania, the prevalence is comparable to that from a recent survey of college students (0.4%).¹⁰

Stealing was associated with multiple measures of adverse functioning including poor grades, regular smoking, any drug use, heavy alcohol use, endorsement of sadness and hopelessness, and other antisocial behaviors such as fighting and carrying weapons. In addition, about 15% of non-kleptomania stealers reported 3 or more of the six problems related to kleptomania. These findings suggest that the majority of stealing is not directly accounted for by kleptomania and raises questions regarding how best to classify and target (in prevention and treatment efforts) the majority of adolescent stealing.

Other findings in this study provide clues as to possible etiologies of stealing behavior in adolescents. In students who stole, stealing was associated with alcohol and drug use, heavy caffeine use, and regular smoking. Those who stole reported symptoms consistent with addictive behaviors - urges to steal, spending a significant amount of time engaged in the behavior (approximately one-quarter of the adolescents who stole did so more than 7 times per week), attempts to cut back, missed opportunities due to behavior, and a calming effect of the stealing. These findings suggest that perhaps stealing in some adolescents is part of a larger constellation of addictive behaviors which include smoking, alcohol and drugs, and that these associations become stronger as stealing behavior becomes more pathological.

Stealing may co-occur with substance abuse, such as alcohol, drugs or nicotine, for multiple reasons. Biological (e.g., genetic) factors, such as those contributing to impulsivity or related constructs, may contribute to participation in multiple addictive behaviors.¹¹ Stealing and substance abuse may also be related to common social or environmental factors, such as substance abuse disinhibiting someone and leading to stealing. Specific influences of stealing (calming, stimulating, attention-related, coping with stress) may enhance stealing experiences. Conversely, students who steal may try unsuccessfully to cope with guilt by using drugs and alcohol. The extent to which the relationship between stealing and substance abuse is mediated by specific environmental, genetic or other biological factors warrants further examination. Screening for stealing as part of other addictive behaviors may prove useful in both the prevention and possible treatment of a variety of addictive behaviors in this age group.

The stealing behavior of these high school students may, however, have multiple etiologies. Other antisocial behaviors (e.g., fighting, carrying weapons) were also significantly associated with a history of stealing. This finding is consistent with previous research that found stealing to be one of many antisocial behaviors seen in delinquent youth.^6,12,13 This finding may suggest that some of the stealing behavior may be attributable to antisocial traits in these students.

This study found that high school students who had stolen were significantly more likely to have poor grades. It has been suggested that school failure contributes to a complex chain of events leading to antisocial behaviors.¹⁴ Conversely, addictive behaviors such as stealing and substance abuse may lead to poor school performance.¹⁵ Further research (e.g., longitudinal) is needed to better understand the nature of this observed association between problematic behavior and poor grades and to identify directionality and mediating and moderating factors.

The data yield several important conclusions. First, stealing among high school students is fairly common and associated with a broad range of behavioral problems. Second, students who steal exhibit a range of addictive and socially unacceptable behaviors. Although the stealing may reflect a larger pattern of antisocial behaviors, there has been relatively little research exploring stealing correlates with broad indices of psychopathology. The current findings indicate that stealing, whether reaching criteria for kleptomania or not, is associated with significant behavioral problems particularly in the area of substance use and abuse. Although there are no diagnostic criteria for degrees of stealing behaviors except kleptomania, the findings suggest that stealing for many adolescents may be considered within a spectrum of addictive and disinhibited behaviors. The diagnosis of kleptomania, however, is controversial, especially in adolescents, and the question of when a behavior becomes a disorder is particularly relevant to adolescents because deviations from normal behavior are not solely related to factors within the individual but instead may reflect interactions between the adolescent and their social context.¹⁶ Depending upon that context, a behavior may reflect a problem or an adaptive response.¹⁷ Focusing on a categorical psychiatric disorder, such as kleptomania, may ignore dispositional characteristics (e.g., impulsiveness, sensation-seeking) and their relationship to externalizing problems.¹⁸ Regardless of the underlying mechanisms for the association between stealing and other externalizing behaviors, these results raise concern that stealing in some adolescents may be reflective of a broader psychopathology of addiction. This has implications for primary care or school settings, where screening and brief interventions around stealing, smoking and other drug use could be implemented.

These data have important forensic implications as well. The findings demonstrate that adolescent stealing behavior lies along a continuum of severity, and that stealing behavior at all levels of severity appears to be associated with a range of problematic behaviors. Forensic psychiatrists should therefore assess any adolescent stealing for a range of associated problems. Because stealing may be a cause, an effect, or an associated symptom of other difficulties, such as school performance, drug use, or emotional problems, the forensic psychiatrist needs to be aware of the relationship between stealing and these other problematic behaviors so as to recommend proper treatment interventions for the associated behaviors (for example, chemical dependency treatment) to prevent re-offending. These findings also suggest that for some adolescents, stealing may be consistent with a diagnosis of kleptomania. In those cases, forensic psychiatrists must screen for kleptomania and make courts aware of the growing literature of evidence-based treatments for kleptomania.¹⁹

This study has several important limitations. First, the cross-sectional nature of the data precludes our ability to establish temporal patterns between stealing and other problematic behaviors. It is therefore possible to suggest several competing, though not necessarily mutually exclusive, explanations, all of which are consistent with the data. For example, drugs or alcohol may disinhibit adolescents and result in an array of impulsive behaviors, including stealing. Alternatively, there is a strong social component to antisocial behavior in adolescence,²⁰ and therefore social variables, such as peer-groups, may give rise to a variety of externalizing behaviors of which stealing is only one.²¹ Second, economic data of the families was not obtained and therefore it is unclear to what extent necessity, or perceived necessity, contributed to the stealing behavior. This information could prevent the unnecessary pathologizing of behavior. Stealing behavior generated from significant poverty, for example, may be adaptive or even accepted in those circumstances. Third, although 0.7% of students appear to have met criteria for kleptomania, the study did not conduct individual clinical interviews with these students. Also, DSM-IV diagnostic criterion E (“the stealing is not better accounted for by conduct disorder, a manic episode, or antisocial personality disorder”) was not part of the survey. There are several problems with making diagnoses based on self-report surveys without clinical correlations and without using the exclusionary criteria for kleptomania. Our results may overestimate the diagnosis of kleptomania in this population. Without the exclusionary criterion, the validity and reliability of the kleptomania diagnosis are in question. Other psychiatric diagnoses (for example, bipolar disorder, conduct disorder, substance use disorders) may explain the endorsement of severe stealing behavior.

This study highlights the need for future research. In particular, research focusing on a possible biological basis for the associations between stealing, substance abuse, and other problematic behaviors is needed. Additionally, given the clinical, legal, and public health concerns of these associations, future research should address both primary and secondary interventions.