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. Author manuscript; available in PMC: 2023 Mar 1.
Published in final edited form as: Depress Anxiety. 2021 Nov 11;39(3):192–200. doi: 10.1002/da.23224

Bidirectional and Interactive Effects of Child Temperament and Parenting in Early Childhood on the Trajectory of Social Anxiety in Adolescence

Nicole E Lorenzo 1,*, Danielle R Novick 1, Kaylee Seddio 2, Kathryn A Degnan 3, Heather A Henderson 4, Alisa N Almas 5, Andrea Chronis-Tuscano 6, Nathan Fox 7
PMCID: PMC8901539  NIHMSID: NIHMS1754711  PMID: 34762343

Abstract

Introduction:

Research suggests that certain parenting behaviors are best suited to promote optimal child development, depending on a child’s distinctive temperamental presentation. This multi-method, longitudinal study examines the interactive effect of parenting and temperament in early childhood on the developmental trajectory of social anxiety in adolescence.

Methods:

Longitudinal growth modeling was used to examine the developmental trajectory of child social anxiety from age 9–15 and the interactive effect of parenting and child temperament at 36-months on the developmental trajectory of child social anxiety from age 9–15.

Results:

The slope of social anxiety from age 9–15 suggested a decrease in social anxiety throughout early adolescence. Furthermore, 36-month behavioral inhibition predicted the trajectory of child social anxiety from age 9–15 when parents displayed low and high levels of dismissive and supportive parenting (at 36-months).

Conclusions:

Results support an interactive effect of infant temperament and parenting in early childhood (at 36-months) on the developmental trajectory of child social anxiety from age 9–15. Specifically, results suggest that engaging highly inhibited children with high supportive and low dismissive parenting may help reduce social anxiety over time in adolescence. Furthermore, parenting needs may differ for children high or low in behavioral inhibition in order to impact the developmental trajectory of social anxiety in adolescence, such that children who are high BI seem to benefit from low dismissive and high supportive parenting, and children who are low in BI seem to benefit more from high dismissive parenting.

Introduction

Anxiety disorders are among the most common and impairing psychological problems impacting youth, affecting up to one-fifth of children and one-third of adolescents (Bufferd et al., 2012; Lavigne et al., 2009; Merikangas et al., 2010). Although anxiety can emerge early, social anxiety slowly increases in children starting at age 9 and peaks in adolescence (Deardorff et al., 2007). Given the unrelenting course of social anxiety (Steinert et al., 2013), elucidating early risk factors for the development and unfolding of anxiety symptoms during adolescence can help identify individuals in most need of early intervention. Importantly, the rapid developmental changes in early childhood significantly influence the parent-child relationship, as children begin to develop independence (e.g., feeding and walking on their own) and parents balance providing support and autonomy. Developmental research has examined interactive links between different temperamental styles and contextual factors as predictors of social anxiety (Chronis-Tuscano et al., 2018), with limited research examining these processes from early childhood through adolescence (for an exception, see Hudson et al., 2019).

Behavioral Inhibition as a Risk Factor for Anxiety

The temperamental trait most closely linked with the development of anxiety and other internalizing problems is behavioral inhibition (BI). BI is a heritable temperamental style (Smith et al., 2012) characterized by heightened fear, reticence, and arousal in the context of unfamiliar people, situations, or objects (Kagan et al., 1988). Precursors and characteristics underlying BI (e.g. “high reactivity”) are well-defined and can be reliably measured in children as young as 3–4 months (Hirshfeld-Becker et al., 2014; Kagan et al., 1988).

Research has demonstrated moderately stable continuity in BI from early childhood through middle childhood (Fox et al., 2001). Importantly, children who exhibit the highest stability in BI over time are at increased risk for the development of anxiety disorders (Biederman et al., 2001; Chronis-Tuscano et al., 2009; Hudson et al., 2011, 2019). Specifically, meta-analytic data demonstrates that BI is a robust predictor of later social anxiety (Clauss & Blackford, 2012). Nevertheless, it is important to note that roughly half of children with elevated BI do not go on to present with clinical levels of social anxiety (Kathryn A. Degnan et al., 2011; Gladstone & Parker, 2005), indicating that endogenous and contextual factors may serve to impede the continuity of BI.

The Impact of Parenting on Anxiety

Parenting has been found to be a central, though not unique, contextual factor, independently accounting for a small proportion of the variance in child psychopathology (Kawabata et al., 2011). Several negative parenting practices have been implicated in the development of child anxiety, including overprotective, permissive, and oversolicitous parenting behaviors (Murray et al., 2009; Williams et al., 2009), as well as highly sensitive parenting which has been shown to maintain anxious behaviors across early childhood (Hane et al., 2010). In contrast to parenting employed in situations to ensure child safety, overly-protective, directive and comfort-inducing (i.e., overly supportive) parenting may serve to reinforce child dependence on their parents and low self-efficacy. Though these parenting behaviors have been shown to directly influence later child anxiety, meta-analytic data indicates that parenting accounts for merely 4% of the variance in child anxiety (McLeod et al., 2007), suggesting that other influences are at play. However, the meta-analyses included studies that examined all types of anxiety, children and adolescents of different ages, and cross-sectional studies, which limit the ability to understand developmental processes. Given the literature supporting the effects of BI on social anxiety, our hypothesis is that the interactive effect of BI and parenting is a likely predictor of social anxiety.

Interactive Effects of Parenting and BI

Though parenting and BI have each been shown to have main effects on the development of social anxiety, research suggests that it is the transactional relations between these factors across time that influence the stability of BI (Ryan & Ollendick, 2018). Such models focus on the dynamic interplay between children and their environments, ultimately highlighting mechanisms by which endogenous and exogenous factors influence developmental outcomes. Research has been framed to detect whether the influence of BI depends on (i.e., is moderated) the presence of co-occurring parenting behaviors (or vice versa). These models focus on multiplicative effects, with the interaction of BI and parenting, or the fit between parenting and child temperament, accounting for more variability in child psychopathology outcomes compared to parenting or temperament alone (Ryan & Ollendick, 2018). Parenting behaviors including sensitivity, overprotective/controlling, and oversolicitous or overly supportive behaviors have been indicated as moderators of the stability of BI (e.g., Booth-LaForce et al., 2012). Specifically, inhibited children are more likely to develop anxiety in the context of these parenting behaviors within a developmental psychopathology framework (Coplan et al., 2008; Kathryn Amey Degnan et al., 2008; Lewis-Morrarty et al., 2012). That is, overly sensitive parenting in early childhood, and overprotective and overly supportive parenting in childhood through adolescence, leads to greater BI stability and risk for anxiety.

Gaps in the Literature

Despite the well-established literature on main effects of BI on social anxiety, longitudinal research supporting interactive effects of parenting on the development of social anxiety over time is limited (for an exception see Hudson et al., 2019). Additionally, most of the work in this area is limited to parent report measures of temperament and/or parenting. Consequently, parenting is often collapsed into a positive or negative composite, suggesting a need to disentangle specific parenting behaviors as they influence later social anxiety symptoms over time (McLeod et al., 2007). Furthermore, despite the known associations between early temperament and later anxiety, little is known about the developmental trajectory of social anxiety in children or adolescents who display highly reactive temperament profiles as toddlers.

Current Study

This multi-method, prospective longitudinal study addresses these gaps by examining a transactional model of parenting and temperament on social anxiety, from toddlerhood through adolescence. Social anxiety throughout childhood is often stable and markedly increases approaching adolescence (Deardorff et al., 2007). Given the temperamentally at-risk sample used in the current study, we expected an increasing slope of anxiety from childhood through adolescence. Additionally, given the heterogenous nature of anxiety and several contextual factors (e.g., peers, trauma, parent mental health) not examined in the current study, we expected significant variability in the slope of social anxiety. Furthermore, we present an interactive model wherein BI by parenting interactions were expected to predict the developmental course of child social anxiety symptoms from age 9–15-years (Figure 1). Specifically, we expected high supportive (i.e., overly solicitous or overly supportive), high dismissive, and low task directive parenting to predict steeper increases in social anxiety over time for children higher in BI a 36-months.

Figure 1.

Figure 1.

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Interactive model of interactive effects of parenting and child temperament on the developmental trajectory of child social anxiety.

Note. Child sex and 4-year anxiety were also included in the model but not displayed in the current figure.

Method

Participants

Participants included 291 parent-child dyads who were recruited as part of a longitudinal study on temperament and child socioemotional development in a metropolitan Mid-Atlantic region of the United States. Participants initially included four-month-old infants who were screened for temperament and selected to participate based on their reactivity (See Hane et al., 2008, for a detailed description of screening and recruitment). Infants with higher levels of negative and positive reactivity in the presence of novelty were oversampled for a wider range of temperamental variability than a community sample. Parents reported child demographics at four-months-old: 55% female, 69.1% White, 16.5% Black, 7.2% Hispanic, 3.1% Asian, 3.4% other, and < 1% missing. Most parents reported having a two- or four- year college education or more (77.6%). The study was IRB approved and all parents were consented prior to participation at each assessment.

Measures

Parenting (36-months).

Parenting was measured using an unpredictable-toy task during a home visit (Penela, 2009). The three-minute task was designed to elicit fear in the child (Lab-TAB; Goldsmith & Rothbart, 1993). During the task, an experimenter brought a toy dinosaur into the room that made unpredictable sounds and movements. The toy was turned on and left on the floor near the parent and child. This interaction was coded for nine parenting behaviors, coding the presence or absence of behaviors during 30-second epochs, totaling six epochs. The following behaviors were coded: (1) Comfort-Verbal: praising or complimenting the child (e.g., “You are doing a great job”), (2) Comfort-Physical: positive physical touch, (3), Verbal Instruction: suggesting a strategy to reduce negative affect, (4) Narrating: describing what is going on or what the child is doing, (5) Task Directing-Verbal: suggesting or telling the child what to do (e.g., “Come here.”), (6) Task Directing-Physical: physically suggesting what the child should do (e.g., moving the child’s hand to open a box), (7) Quiz-Task: asking questions directly to the child, (8) Quiz/label-feeling: describing or asking about how the child is feeling, and (9) Dismissive: ignoring the child or being critical about the child.

A total count of each behavior was created by summing the frequency of each parenting behavior; proportion scores were calculated across the six possible epochs. These codes were combined into factors based on a principal component analysis demonstrating a three-component solution (1) Dismissive parenting (Quiz-Task, Narrating, and Dismissive codes), (2) Task Directive parenting (Task Directing-Physical and Task Directing-Verbal codes), and (3) Supportive parenting (Comfort-Verbal, Verbal Instruction, and Quiz/Label-Feelings). Comfort-physical behavior loaded equally well on all factors and therefore was not included in any of the final components.

Behavioral Inhibition (36-months).

BI was measured during a lab visit when children participated in several standardized activities at 36-months. During these activities, children were made to engage with unfamiliar persons and objects (Fox et al., 2001). Consistent with previous work, observations were coded for latency to approach, proportion of time in proximity to their caregiver, and latency to verbalize. Codes were standardized and averaged to create a composite for BI. Higher composite scores indicate higher BI. The intra-class correlations (ICCs), computed for 20% of cases, ranged from .97 to .99.

Anxiety Symptoms (4-years).

Parents reported on child anxiety symptoms when children were 4-years old using the Child Behavior Checklist (CBCL; Achenbach & Rescorla, 2000). The CBCL is a 99-item parent report questionnaire about child behavior and emotion. Items are rated on a 3-point scale from (0) not true to (2) very true. To account for prior levels of anxiety symptoms, the anxiety problems domain of the CBCL at age 4 was controlled for in final analyses. In the current sample, the anxiety domain demonstrated adequate internal consistency, α = .63.

Social Anxiety Symptoms (9-, 12-, 15-years).

Child participants completed the Screen for Child Anxiety Related Emotional Disorders (SCARED; Birmaher et al., 1997) at their 9-, 12-, and 15-year lab visits. The SCARED is a 41-item questionnaire about anxiety, that includes a social anxiety subscale. Items are rated on a 3-point scale from (0) almost never to (2) often, with higher scores suggesting higher levels of anxiety. In the current sample, the social anxiety subscale demonstrated good internal consistency at all three assessments, α’s>.78.

Data Analyses

Structural equation modeling with Mplus 8 (Muthén & Muthén, 2018) was used to test (1) the developmental trajectory of social anxiety in early adolescence (age 9–15 years) and (2) an interactive model with child temperament (i.e., BI) and parenting(measured at 36 months) predicting the developmental trajectory. Specifically, parenting consisted of three dimensions: supportive, dismissive, and task directive. The latent intercept factor represented the level of anxiety at the first time point (age 9). The latent slope factor represented the linear change in anxiety across the three later assessments (ages 9, 12, & 15), by constraining paths for each assessment to 0, 1, and 2, respectively. The intercept (age 9) and slope (ages 9, 12, & 15) of social anxiety were predicted as the multiplicative effect of parenting and BI. Additionally, child anxiety symptoms at 4 years was modeled as a predictor of the intercept and slope to account for anxiety symptoms present before age 9.

Of the original sample (N=291), 198 had data on 36-month BI, 205 had data on 36-month parenting, 167 had data on 9-year social anxiety, 176 on 12-year social anxiety, and 162 on 15-year social anxiety. Patterns of missing data suggested that maternal education was correlated with missing data on 9-year social anxiety, p < .05, such that participants with missing data were more likely to have mothers with a graduate education. Therefore, maternal education was included in analyses. Missing data on all other variables was not significantly associated with any demographic variables. A full information maximum-likelihood estimator with robust standard errors (i.e., MLR) was used to account for missing data (Enders & Bandalos, 2001; Kline, 2011) and any skew and kurtosis among our key variables. We examined the Comparative Fit Index (CFI), Root Mean Square Error of Approximation (RMSEA), and Standardized Root Mean Square Residual (SRMR) indices to determine model fit; CFI values ≥ 0.95, RMSEA values ≤ 0.05, and SRMR ≤ 0.06 are indicative of excellent fit (Tabachnick & Fidell, 2013).

Results

Descriptive Analyses

For preliminary analyses, we examined correlations between variables of interest and demographic variables (i.e., child sex, child race/ethnicity, maternal education). Independent samples t-tests revealed significant differences in social anxiety symptoms between males and females, with females having higher levels at 12 (males M= 11.28, SD= 6.32; females M = 17.04, SD=9.72) and 15-years (males M= 11.51, SD= 6.82; females M = 19.11, SD=10.11). Therefore, child sex was included as a covariate in the final analyses. No other demographic variables were correlated with child social anxiety symptoms and therefore were not included for parsimony. Descriptive statistics and bivariate associations for key variables are shown in Table 1.

Table 1.

Means, standard deviations, and correlations with confidence intervals

Variable (age of assessment) M SD 1 2 3 4 5 6 7 8
1. Child Sex *
2. Anxiety (4-years) 2.86 2.34 −.01
3. BI (36-months) −0.01 0.48 .07 .04
4. Task Directive (36-months) 0.41 0.22 −.09 .01 −.13
5. Supportive (36-months) 0.12 0.15 .06 .07 −.07 .20
6. Dismissive (36-months) −0.41 0.15 −.04 .08 .09 .13 .09
7. Child Social Anxiety (9-years) 5.44 3.13 .07 .08 .11 .08 .17 .08
8. Child Social Anxiety (12-years) 4.94 3.58 .29 .17 .02 .05 .09 .13 .36
9. Child Social Anxiety (15-years) 5.58 3.79 .31 .14 .08 .04 .03 .16 .26 .57
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Note. M = Mean; SD= standard deviation; Bold indicates p < .05.

*

1 (Male), 2 (Female).

Social Anxiety Growth Model

An unconditional growth curve model was used to examine the trajectory of social anxiety from age 9–15. The model fit the data well, RMSEA = .05 [90% CI:.0 −0.11]; CFI = .98; SRMR = .03. Results from this model suggested that social anxiety decreased over time for the sample (Figure 2). Specifically, the initial levels of social anxiety were 5.64 and then declined 0.69 at each assessment. Furthermore, we examined the variance in the intercept and slope to determine if there was significant variability in changes over time and the starting point. The average intercept variance for social anxiety was 3.32 (p =.027), which suggests that there was significant variability in social anxiety at age 9. The average slope variance for social anxiety was .227 (p =.019), which suggests that there was significant variability in the trajectory of social anxiety from age 9 to 15. Additionally, the slope and intercept were not significantly correlated (p = .610).

Figure 2.

Figure 2.

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Trajectories of child social anxiety from 9–15 years

Interactive Model of Parenting and BI on Social Anxiety Symptoms

The interactive model fit the data well, RMSEA = .02 [90% CI = .00 −.06]; CFI = .99; SRMR = .02. All unstandardized and standardized path coefficients, including the covariates, are reported in Table 2. The 9-year child social anxiety symptoms intercept mean was 6.41 (SD = .82). The slope of child social anxiety symptoms decreased on average (M = −2.09; SD = .71), replicating the unconditional growth model.

Table 2.

Standardized and unstandardized estimates for interactive model.

Outcome Predictors β B SE p LoCI UpCI
Child Social Anxiety (Intercept) Parenting: Task Directive (36-months) 1.19 .13 .12 .284 −0.98 3.35
Child Social Anxiety (Intercept) Parenting: Supportive (36-months) 2.25 .17 .13 .162 −0.91 5.41
Child Social Anxiety (Intercept) Parenting: Dismissive (36-months) 1.39 .11 .13 .416 −1.97 4.75
Child Social Anxiety (Intercept) BI (36-months) 0.81 .19 .13 .114 −0.19 1.81
Child Social Anxiety (Intercept) BI x Task Directive Interaction (36-months) −0.45 −.02 .12 .858 −5.31 4.43
Child Social Anxiety (Intercept) BI x Supportive Interaction (36-months) 8.89 .27 .13 .036 0.59 17.19
Child Social Anxiety (Intercept) BI x Dismissive Interaction (36-months) −1.48 .11 .12 .697 −8.90 5.95
Child Social Anxiety (Intercept) Anxiety (4-years) 0.09 .11 .12 .367 −0.10 0.28
Child Social Anxiety (Intercept) Maternal Education −0.58 −.24 .12 .048 −1.15 −0.01
Child Social Anxiety (Slope) Parenting: Task Directive (36-months) −0.53 −.07 .11 .522 −2.17 1.10
Child Social Anxiety (Slope) Parenting: Supportive (36-months) −1.29 −.12 11 .263 −3.55 0.97
Child Social Anxiety (Slope) Parenting: Dismissive (36-months) 0.92 .09 .11 .433 −1.38 3.22
Child Social Anxiety (Slope) BI (36-months) −0.27 −.08 .11 .460 −0.97 0.44
Child Social Anxiety (Slope) BI x Task Directive Interaction (36-months) −1.69 −.10 .11 .348 −5.24 1.85
Child Social Anxiety (Slope) BI x Supportive Interaction (36-months) −6.02 −.22 .11 .044 −11.86 −0.17
Child Social Anxiety (Slope) BI x Dismissive Interaction (36-months) 8.68 .34 .11 .002 3.21 14.15
Child Social Anxiety (Slope) Anxiety (4-years) 0.05 .08 .09 .438 −0.06 0.19
Child Social Anxiety (Slope) Child Sex 1.37 .42 .09 .000 0.86 1.89
Child Social Anxiety (Intercept) Maternal Education −0.06 −.03 .11 .785 −0.49 0.37
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Note: Child sex is coded as 1 = Male and 2 = Female; BI = Behavioral Inhibition; LoCI = Lower Confidence Interval; UpCI= Upper Confidence Interval.

As shown in Figure 3 and Table 2, the interaction between BI and supportive parenting predicted the social anxiety intercept at age 9 (b= 8.89, p = .036) and the slope from ag 9–15 (b= −6.02, p = .044). Namely, adolescents identified as high BI, whose parents engaged in high supportive parenting displayed greater social anxiety at age 9, compared to those engaged in low supportive parenting. However, at the following assessments (i.e., the slope from 9–15), adolescents whose parents engaged in high supportive parenting showed the sharpest decrease, compared to adolescents whose parents engaged in low supportive parenting.

Figure 3.

Figure 3.

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Trajectories of child social anxiety from 9–15 years for different levels of BI and supportive parenting

In contrast, the interaction between BI and dismissive parenting was not predictive of the social anxiety intercept at age 9 (p = .697) but was predictive of the slope (b= 8.681, p = .002). For adolescents identified as high BI, whose parents engaged in high dismissive parenting showed relative stability in social anxiety over time, compared to adolescents whose parents engaged in low dismissive parenting, who demonstrated decreases in social anxiety over time (see Figure 3). On the other hand, there was the opposite effect for adolescents identified as low BI, such that there was a sharper decrease in social anxiety for adolescents whose parents engaged in high dismissive parenting.

Discussion

Social anxiety has been associated with significant negative outcomes ranging from poor self-esteem (Tillfors et al., 2012) to major depression and suicide (Arditte et al., 2016). Therefore, understanding early risk factors and, in particular, the transactional effects of individual characteristics (i.e., temperament) and environmental context (i.e., parenting), is crucial to the development of prevention and intervention programs. Using longitudinal growth modeling we examined the developmental trajectory of social anxiety in early adolescence, and early predictors of this trajectory from toddlerhood including child temperament and parenting.

Contrary to expectations and surprisingly, the overall trajectory of social anxiety decreased from 9–15 years on average. This may be a result of the characteristics of our sample enriched for infant reactivity, resulting in higher-than-average social anxiety at 9-years (i.e., potentially an earlier peak in anxiety), rather than the typical increase throughout adolescence resulting in regression toward the mean. However, there was significant variability in the slope which could be explained by the interactive effects.

There was a main effect of parenting, specifically supportive parenting, on 9-year child social anxiety symptoms, such that higher levels of supportive parenting predicted higher 9-year child social anxiety symptoms. This is line with previous work suggesting that overly supportive parenting reinforces anxious behavior by minimizing the opportunities that the child has to navigate stressful social situations, instead of scaffolding more child independence and active coping in response to the anxiety-evoking situation (Rubin et al., 2002). This intercept finding is in line with our expected hypothesis and the previous literature on overly supportive parenting. However, the developmental trajectory (i.e., slope) finding was contrary to our expectations.

Specifically, the interaction between 36-month parenting and child BI predicted the developmental trajectory of child anxiety symptoms from 9–15 years. Most importantly, distinct aspects of parenting differentially impacted the relation between child BI and the trajectory of social anxiety symptoms. Low and high levels of supportive and dismissive parenting, respectively, each moderated the effect of child BI on child social anxiety symptoms. These findings suggest that social anxiety levels were highest for children high in BI, with those who experienced high supportive parenting having the steepest decrease in social anxiety over time. One possible explanation is that as adolescents become more independent, having supportive parents may help reduce the adolescent’s social anxiety. However, given the opposite finding of highly supportive parenting increasing social anxiety at age 9, it is important to acknowledge that there is likely a “sweet spot” by which supportive parenting can be helpful, but too much support may reduce the child’s autonomy and need for independence.

Furthermore, for children high in BI, high dismissive parenting may result in greater stability of (i.e., less of a reduction in) social anxiety symptoms, and low dismissive parenting may support more of a decrease in social anxiety symptoms in early adolescence. This is in line with our finding related to supportive parenting, such that, children who are high on BI likely benefit from parents who are not dismissive of their behaviors and emotions. It is important to note that for children low in BI, dismissive and supportive parenting had the opposite effect, highlighting the importance of “goodness of fit” between child characteristics and parenting practices (Chess & Thomas, 1991). Lastly, it is important to note that task directive parenting did not result in any significant direct or interactive effects on social anxiety in the current sample. It is possible that task directive parenting may require further examination to determine the relation between a more directive parenting style based on child temperament. This is of particular importance when considering parenting interventions that often teach directive parenting styles and following the child’s lead.

There are several strengths to the current study, including the long-term prospective longitudinal design and multimethod assessments; however, some limitations should be noted. First, the sample includes mostly white, well-educated families which limits generalizability to more diverse populations. Furthermore, early childhood anxiety measured at age 4 demonstrated relatively low reliability which may not have allowed for the strongest control of the early development of anxiety. Additionally, parenting was coded during a three- minute task designed to elicit fear which may not fully capture an overall picture of parenting across different tasks/contexts.

Despite these limitations, the current study highlights the interactive nature of temperament and parenting on child social anxiety symptoms using a multimethod, longitudinal design spanning toddlerhood through adolescence. Particularly notable is that the findings vary depending on the type of parenting and the degree of BI. Findings suggest that identifying children most at risk for developing child social anxiety symptoms should include an examination of both child temperament and parenting, as different combinations (i.e., “goodness of fit”) may differentially affect risk. Understanding how these interactive factors come to impact the trajectory of child social anxiety symptoms is an important next step in the field of developmental psychopathology.

Figure 4.

Figure 4.

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Trajectories of child social anxiety from 9–15 years for different levels of BI and dismissive parenting

Funding:

This work was supported by the National Institute of Mental Health (U01MH093349) and (R01MH118320 – 02S1).

Footnotes

Conflict of Interest: Dr. Chronis-Tuscano reports personal fees from Oxford University Press, outside the submitted work.

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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