Last data update: May 06, 2024. (Total: 46732 publications since 2009)
Records 1-15 (of 15 Records) |
Query Trace: Ford DC[original query] |
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Impact of the United States federal child tax credit on childhood injuries and behavior problems
Rostad WL , Klevens J , Ports KA , Ford DC . Child Youth Serv Rev 2019 107 Children who grow up in poverty are at risk for various poor outcomes. Socioeconomic policies can shape the conditions in which families are raising children and may be effective at reducing financial strain and helping families obtain economic sufficiency, thereby reducing risk for poor health outcomes. This study used data from two surveys conducted in the US, the National Longitudinal Survey of Youth 1979 (NLSY79) and the NLSY79 Young Adult survey to determine whether the U.S. Federal Child Tax Credit (CTC), a socioeconomic policy that provides tax relief to low- and middle-income families to offset the costs of raising children, is associated with child well-being, as indicated by whether the child had injuries requiring medical attention and behavioral problems. Fixed-effects models, accounting for year and state of residence, detected a lower likelihood of injuries requiring medical attention (OR = 0.58, 95% CI [0.40, 0.86]) and significantly fewer behavior problems (b = -2.07, 95% CI [-4.06, -0.08]) among children with mothers eligible to receive a CTC, but only when it was partially refundable (i.e., mothers could receive a tax refund for a portion of the CTC that exceeds their tax liability) for families making as little as $3000 a year. Tax credits like the CTC have the potential to alleviate financial strain among families, and consequently, may have impacts on injury and behavior problems. |
Adverse childhood experiences increase risk for prescription opioid misuse
Merrick MT , Ford DC , Haegerich TM , Simon T . J Prim Prev 2020 41 (2) 139-152 The United States is in the midst of an opioid overdose epidemic, with a significant portion of the burden associated with prescription opioids. In response, the CDC released a Guideline for Prescribing Opioids for Chronic Pain, which promotes access to treatment for opioid use disorder. Decades of research have linked childhood adversity to negative health and risk behavior outcomes, including substance misuse. Our present study builds upon this work to examine the relationship between adverse childhood experiences (ACEs) and prescription opioid misuse. We compiled data from the Behavioral Risk Factor Surveillance System implemented by Montana and Florida in 2010 and 2011, respectively. Logistic regressions (run in 2017) tested the associations between ACEs and subsequent prescription pain medicine/opioid misuse outcomes in adulthood. ACEs were prevalent, with 62.7% of respondents in Montana and 50% in Florida reporting at least one ACE. The presence of ACEs was positively associated with prescription opioid misuse across both samples. Respondents reporting three or more ACEs had increased odds of taking opioids more than prescribed, without a prescription, and for the feeling they cause. Our results support a strong link between ACEs and prescription opioid misuse. Opportunities to prevent opioid misuse start with assuring safe, stable, nurturing relationships and environments in childhood and across the lifespan to prevent ACEs from occurring, and intervening appropriately when they do occur. Substance use prevention programs for adolescents, appropriate pain management and opioid prescribing protocols, and treatments for opioid use disorder can address ACEs by enhancing treatment safety and effectiveness and can reduce the intergenerational continuity of early adversity. |
Vital Signs: Estimated proportion of adult health problems attributable to adverse childhood experiences and implications for prevention - 25 states, 2015-2017
Merrick MT , Ford DC , Ports KA , Guinn AS , Chen J , Klevens J , Metzler M , Jones CM , Simon TR , Daniel VM , Ottley P , Mercy JA . MMWR Morb Mortal Wkly Rep 2019 68 (44) 999-1005 INTRODUCTION: Adverse childhood experiences, such as violence victimization, substance misuse in the household, or witnessing intimate partner violence, have been linked to leading causes of adult morbidity and mortality. Therefore, reducing adverse childhood experiences is critical to avoiding multiple negative health and socioeconomic outcomes in adulthood. METHODS: Behavioral Risk Factor Surveillance System data were collected from 25 states that included state-added adverse childhood experience items during 2015-2017. Outcomes were self-reported status for coronary heart disease, stroke, asthma, chronic obstructive pulmonary disease, cancer (excluding skin cancer), kidney disease, diabetes, depression, overweight or obesity, current smoking, heavy drinking, less than high school completion, unemployment, and lack of health insurance. Logistic regression modeling adjusting for age group, race/ethnicity, and sex was used to calculate population attributable fractions representing the potential reduction in outcomes associated with preventing adverse childhood experiences. RESULTS: Nearly one in six adults in the study population (15.6%) reported four or more types of adverse childhood experiences. Adverse childhood experiences were significantly associated with poorer health outcomes, health risk behaviors, and socioeconomic challenges. Potential percentage reductions in the number of observed cases as indicated by population attributable fractions ranged from 1.7% for overweight or obesity to 23.9% for heavy drinking, 27.0% for chronic obstructive pulmonary disease, and 44.1% for depression. CONCLUSIONS AND IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: Efforts that prevent adverse childhood experiences could also potentially prevent adult chronic conditions, depression, health risk behaviors, and negative socioeconomic outcomes. States can use comprehensive public health approaches derived from the best available evidence to prevent childhood adversity before it begins. By creating the conditions for healthy communities and focusing on primary prevention, it is possible to reduce risk for adverse childhood experiences while also mitigating consequences for those already affected by these experiences. |
Associations between adverse childhood experiences and acquired brain injury, including traumatic brain injuries, among adults: 2014 BRFSS North Carolina
Guinn AS , Ports KA , Ford DC , Breiding M , Merrick MT . Inj Prev 2018 25 (6) 514-520 Adverse childhood experiences (ACEs) can negatively affect lifelong health and opportunity. Acquired brain injury (ABI), which includes traumatic brain injury (TBI) as well as other causes of brain injury, is a health condition that affects millions annually. The present study uses data from the 2014 North Carolina Behavioral Risk Factor Surveillance System to examine the relationship between ACEs and ABI. The study sample included 3454 participants who completed questions on both ABI and ACEs. Multivariable logistic regression models were used to determine the relationship between ACEs and ABI as well as ACEs and TBI. Sexual abuse, emotional abuse, physical abuse, household mental illness and household substance abuse were significantly associated with ABI after adjusting for age, race/ethnicity, gender and employment. Compared with those reporting no ACEs, individuals reporting three ACEs had 2.55 times the odds of having experienced an ABI; individuals reporting four or more ACEs had 3.51 times the odds of having experienced an ABI. Examining TBI separately, those who experienced sexual abuse, physical abuse, household mental illness and had incarcerated household members in childhood had greater odds of reported TBI, after adjusting for age, race/ethnicity, gender and income. Respondents reporting three ACEs (AOR=4.16, 95% CI (1.47 to 11.76)) and four or more ACEs (AOR=3.39, 95% CI (1.45 to 7.90)) had significantly greater odds of reporting TBI than respondents with zero ACEs. Prevention of early adversity may reduce the incidence of ABI; however, additional research is required to elucidate the potential pathways from ACEs to ABI, and vice versa. |
Prevalence of adverse childhood experiences from the 2011-2014 Behavioral Risk Factor Surveillance System in 23 states
Merrick MT , Ford DC , Ports KA , Guinn AS . JAMA Pediatr 2018 172 (11) 1038-1044 Importance: Early adversity is associated with leading causes of adult morbidity and mortality and effects on life opportunities. Objective: To provide an updated prevalence estimate of adverse childhood experiences (ACEs) in the United States using a large, diverse, and representative sample of adults in 23 states. Design, Setting, and Participants: Data were collected through the Behavioral Risk Factor Surveillance System (BRFSS), an annual, nationally representative telephone survey on health-related behaviors, health conditions, and use of preventive services, from January 1, 2011, through December 31, 2014. Twenty-three states included the ACE assessment in their BRFSS. Respondents included 248934 noninstitutionalized adults older than 18 years. Data were analyzed from March 15 to April 25, 2017. Main Outcomes and Measures: The ACE module consists of 11 questions collapsed into the following 8 categories: physical abuse, emotional abuse, sexual abuse, household mental illness, household substance use, household domestic violence, incarcerated household member, and parental separation or divorce. Lifetime ACE prevalence estimates within each subdomain were calculated (range, 1.00-8.00, with higher scores indicating greater exposure) and stratified by sex, age group, race/ethnicity, annual household income, educational attainment, employment status, sexual orientation, and geographic region. Results: Of the 214157 respondents included in the sample (51.51% female), 61.55% had at least 1 and 24.64% reported 3 or more ACEs. Significantly higher ACE exposures were reported by participants who identified as black (mean score, 1.69; 95% CI, 1.62-1.76), Hispanic (mean score, 1.80; 95% CI, 1.70-1.91), or multiracial (mean score, 2.52; 95% CI, 2.36-2.67), those with less than a high school education (mean score, 1.97; 95% CI, 1.88-2.05), those with income of less than $15000 per year (mean score, 2.16; 95% CI, 2.09-2.23), those who were unemployed (mean score, 2.30; 95% CI, 2.21-2.38) or unable to work (mean score, 2.33; 95% CI, 2.25-2.42), and those identifying as gay/lesbian (mean score 2.19; 95% CI, 1.95-2.43) or bisexual (mean score, 3.14; 95% CI, 2.82-3.46) compared with those identifying as white, those completing high school or more education, those in all other income brackets, those who were employed, and those identifying as straight, respectively. Emotional abuse was the most prevalent ACE (34.42%; 95% CI, 33.81%-35.03%), followed by parental separation or divorce (27.63%; 95% CI, 27.02%-28.24%) and household substance abuse (27.56%; 95% CI, 27.00%-28.14%). Conclusions and Relevance: This report demonstrates the burden of ACEs among the US adult population using the largest and most diverse sample to date. These findings highlight that childhood adversity is common across sociodemographic characteristics, but some individuals are at higher risk of experiencing ACEs than others. Although identifying and treating ACE exposure is important, prioritizing primary prevention of ACEs is critical to improve health and life outcomes throughout the lifespan and across generations. |
Violence-related disparities experienced by black youth and young adults: Opportunities for prevention
Sheats K , Irving SM , Mercy J , Simon TR , Crosby A , Ford DC , Merrick M , Annor F , Morgan RE . Am J Prev Med 2018 55 (4) 462-469 INTRODUCTION: The purpose of this study is to characterize violence-related disparities experienced by young blacks in the U.S. Reducing violence experienced by blacks, particularly youth, who are at substantially higher risk, is essential to improving the health of blacks in the U.S. METHODS: Data from four independent data sets for youth and adults were analyzed to examine rates of homicide, assault, injury from a physical fight, bullying victimization, and missing school because of safety concerns for non-Hispanic blacks and whites aged 10-34 years between 2010 and 2015. Disparities in adverse childhood experiences (e.g., exposure to violence and household challenges) and physical/mental health outcomes in adulthood were examined. Data were analyzed in 2017. RESULTS: Black adolescents and young adults are at higher risk for the most physically harmful forms of violence (e.g., homicides, fights with injuries, aggravated assaults) compared with whites. In addition, black adults reported exposure to a higher number of adverse childhood experiences than whites. These adverse childhood experiences were positively associated with increased odds of self-reported coronary heart disease, fair or poor physical health, experiencing frequent mental distress, heavy drinking, and current smoking. CONCLUSIONS: Disproportionate exposure to violence for blacks may contribute to disparities in physical injury and long-term mental and physical health. Understanding the violence experiences of this age group and the social contexts surrounding these experiences can help improve health for blacks in the U.S. Communities can benefit from the existing evidence about policies and programs that effectively reduce violence and its health and social consequences. |
Estimated rates of influenza-associated outpatient visits during 2001-2010 in six US integrated health care delivery organizations
Zhou H , Thompson WW , Belongia EA , Fowlkes A , Baxter R , Jacobsen SJ , Jackson ML , Glanz JM , Naleway AL , Ford DC , Weintraub E , Shay DK . Influenza Other Respir Viruses 2017 12 (1) 122-131 BACKGROUND: Population-based estimates of influenza-associated outpatient visits including both pandemic and inter-pandemic seasons are uncommon. Comparisons of such estimates with laboratory-confirmed rates of outpatient influenza are rare. OBJECTIVE: To estimate influenza-associated outpatient visits in six US integrated health care delivery organizations enrolling ~7.7 million persons. METHODS: Using negative-binomial regression methods, we modeled rates of influenza-associated visits with ICD-9-CM-coded pneumonia or acute respiratory outpatient visits during 2001-10. These estimated counts were added to visits coded specifically for influenza to derive estimated rates. We compared these rates with those observed in two contemporaneous studies recording RT-PCR-confirmed influenza outpatient visits. RESULTS: Outpatient rates estimated with pneumonia visits were 39 (95% confidence interval [CI], 30-70) and 203 (95% CI, 180-240) per 10,000 person-years, respectively, for inter-pandemic and pandemic seasons. Corresponding rates estimated with respiratory visits were 185 (95% CI, 161-255) and 542 (95% CI, 441-823) per 10,000 person-years. During the pandemic, children aged 2-17 years had the largest increase in rates (when estimated with pneumonia visits, from 64 [95% CI, 50-121] to 381 [95% CI, 366-481]). Rates estimated with pneumonia visits were consistent with rates of RT-PCR-confirmed influenza visits during 4 of 5 seasons in one comparison study. In another, rates estimated with pneumonia visits during the pandemic for children and adults were consistent in timing, peak, and magnitude. CONCLUSIONS: Estimated rates of influenza-associated outpatient visits were higher in children than adults during pre-pandemic and pandemic seasons. Rates estimated with pneumonia visits plus influenza-coded visits were similar to rates from studies using RT-PCR-confirmed influenza. This article is protected by copyright. All rights reserved. |
Adverse childhood experiences and suicide risk: Toward comprehensive prevention
Ports KA , Merrick MT , Stone DM , Wilkins NJ , Reed J , Ebin J , Ford DC . Am J Prev Med 2017 53 (3) 400-403 The field of suicide prevention has had numerous promising advances in recent decades, including the development of evidence-based prevention strategies, the National Suicide Prevention Lifeline (1-800-273-TALK), the Suicide Prevention Resource Center, and a revised National Strategy for Suicide Prevention.1 Despite these important advances, suicide prevention still lacks the breadth and depth of the coordinated response truly needed to reduce suicide morbidity and mortality. Suicide prevention requires a comprehensive approach that spans systems, organizations, and environments, combining treatment and intervention with primary prevention efforts beginning in childhood so they can set the stage for future health and well-being. Adverse childhood experiences (ACEs), including exposure to child abuse and neglect, are well-documented risk factors for suicidality,2–4 and a viable suicide prevention target; however, suicide prevention efforts seldom focus here. The following provides an overview of suicide prevention and intervention, and suggestions for comprehensive suicide prevention programs that address ACE prevention. | The context for suicide prevention in the U.S. is sobering. In 2015, a total of 44,193 individuals died by suicide, and between 1999 and 2015, suicide rates increased more than 25%.5 Emergency departments recorded 1.4 million discharges for self-inflicted injuries, and acute care hospitals recorded an additional 758,000 discharges in 2013.6 These numbers represent only a fraction of individuals experiencing suicidal ideation. According to self-report survey data, 1.3 million adults attempted suicide, 2.7 million made plans for suicide, and 9.7 million adults seriously considered suicide in 2015.7 |
Adverse childhood experiences and life opportunities: Shifting the narrative
Metzler M , Merrick MT , Klevens J , Ports KA , Ford DC . Child Youth Serv Rev 2017 72 141-149 Substantial research shows that early adversity, including child abuse and neglect, is associated with diminished health across the life course and across generations. Less well understood is the relationship between early adversity and adult socioeconomic status, including education, employment, and income. Collectively, these outcomes provide an indication of overall life opportunity. We analyzed data from 10 states and the District of Columbia that used the adverse childhood experiences (ACE) module in the 2010 Behavioral Risk Factor Surveillance System to examine the association between ACEs and adult education, employment, and income. Compared to participants with no ACEs, those with higher ACE scores were more likely to report high school non-completion, unemployment, and living in a household below the federal poverty level. This evidence suggests that preventing early adversity may impact health and life opportunities that reverberate across generations. Current efforts to prevent early adversity might be more successful if they broaden public and professional understanding (i.e., the narrative) of the links between early adversity and poverty. We discuss our findings within the context of structural policies and processes that may further contribute to the intergenerational continuity of child abuse and neglect and poverty. |
Unpacking the impact of adverse childhood experiences on adult mental health
Merrick MT , Ports KA , Ford DC , Afifi TO , Gershoff ET , Grogan-Kaylor A . Child Abuse Negl 2017 69 10-19 Exposure to childhood adversity has an impact on adult mental health, increasing the risk for depression and suicide. Associations between Adverse Childhood Experiences (ACEs) and several adult mental and behavioral health outcomes are well documented in the literature, establishing the need for prevention. The current study analyzes the relationship between an expanded ACE score that includes being spanked as a child and adult mental health outcomes by examining each ACE separately to determine the contribution of each ACE. Data were drawn from Wave II of the CDC-Kaiser ACE Study, consisting of 7465 adult members of Kaiser Permanente in southern California. Dichotomous variables corresponding to each of the 11 ACE categories were created, with ACE score ranging from 0 to 11 corresponding to the total number of ACEs experienced. Multiple logistic regression modeling was used to examine the relationship between ACEs and adult mental health outcomes adjusting for sociodemographic covariates. Results indicated a graded dose-response relationship between the expanded ACE score and the likelihood of moderate to heavy drinking, drug use, depressed affect, and suicide attempts in adulthood. In the adjusted models, being spanked as a child was significantly associated with all self-reported mental health outcomes. Over 80% of the sample reported exposure to at least one ACE, signifying the potential to capture experiences not previously considered by traditional ACE indices. The findings highlight the importance of examining both cumulative ACE scores and individual ACEs on adult health outcomes to better understand key risk and protective factors for future prevention efforts. |
Development and evaluation of a short adverse childhood experiences measure
Wade R Jr , Becker BD , Bevans KB , Ford DC , Forrest CB . Am J Prev Med 2016 52 (2) 163-172 INTRODUCTION: Clinicians require tools to rapidly identify individuals with significant childhood adversity as part of routine primary care. The goal of this study was to shorten the 11-item Behavioral Risk Factor Surveillance System Adverse Childhood Experiences (ACEs) measure and evaluate the feasibility and validity of this shortened measure as a screener to identify adults who have experienced significant childhood adversity. METHODS: Statistical analysis was conducted in 2015. ACE item responses obtained from 2011-2012 Behavioral Risk Factor Surveillance System data were combined to form a sample of 71,413 adults aged ≥18 years. The 11-item Behavioral Risk Factor Surveillance System ACE measure was subsequently reduced to a two-item screener by maintaining the two dimensions of abuse and household stressors and selecting the most prevalent item within each dimension. RESULTS: The screener included household alcohol and childhood emotional abuse items. Overall, 42% of respondents and at least 75% of the individuals with four or more ACEs endorsed one or both of these experiences. Using the 11-item ACE measure as the standard, a cut off of one or more ACEs yielded a sensitivity of 99%, but specificity was low (66%). Specificity improved to 94% when using a cut off of two ACEs, but sensitivity diminished (70%). There was no substantive difference between the 11-and two-item ACE measures in their strength of association with an array of health outcomes. CONCLUSIONS: A two-item ACE screener appropriate for rapid identification of adults who have experienced significant childhood adversity was developed. |
Adverse childhood experiences and sexual victimization in adulthood
Ports KA , Ford DC , Merrick MT . Child Abuse Negl 2015 51 313-22 Understanding the link between adverse childhood experiences (ACEs) and sexual victimization (SV) in adulthood may provide important information about the level of risk for adult SV and sexual re-victimization among childhood sexual abuse (CSA) survivors. In the present paper, we explore the relationship between ACEs, including CSA, and SV in adulthood. Data from the CDC-Kaiser ACE Study were used to examine the effect of experiences of early adversity on adult SV. Adult HMO members (n=7,272) undergoing a routine health exam provided detailed information about ACEs that occurred at age 18 or younger and their experiences of SV in adulthood. Analyses revealed that as ACE score increased, so did risk of experiencing SV in adulthood. Each of the ACE variables was significantly associated with adult SV, with CSA being the strongest predictor of adult SV. In addition, for those who reported CSA, there was a cumulative increase in adult SV risk with each additional ACE experienced. As such, early adversity is a risk factor for adult SV. In particular, CSA is a significant risk factor for sexual re-victimization in adulthood, and additional early adversities experienced by CSA survivors may heighten adult SV risk above and beyond the risk associated with CSA alone. Given the interconnectedness among various experiences of early adversity, adult SV prevention actions must consider how other violence-related and non-violence-related traumatic experiences may exacerbate the risk conferred by CSA on subsequent victimization. |
Childhood adversity and adult chronic disease: an update from ten states and the District of Columbia, 2010
Gilbert LK , Breiding MJ , Merrick MT , Thompson WW , Ford DC , Dhingra SS , Parks SE . Am J Prev Med 2014 48 (3) 345-9 BACKGROUND: Adverse childhood experiences (ACEs), including child abuse and family dysfunction, are linked to leading causes of adult morbidity and mortality. Most prior ACE studies were based on a nonrepresentative patient sample from one Southern California HMO. PURPOSE: To determine if ACE exposure increases the risk of chronic disease and disability using a larger, more representative sample of adults than prior studies. METHODS: Ten states and the District of Columbia included an optional ACE module in the 2010 Behavioral Risk Factor Surveillance Survey, a national cross-sectional, random-digit-dial telephone survey of adults. Analysis was conducted in November 2012. Respondents were asked about nine ACEs, including physical, sexual, and emotional abuse and household member mental illness, alcoholism, drug abuse, imprisonment, divorce, and intimate partner violence. An ACE score was calculated for each subject by summing the endorsed ACE items. After controlling for sociodemographic variables, weighted AORs were calculated for self-reported health conditions given exposure to zero, one to three, four to six, or seven to nine ACEs. RESULTS: Compared to those who reported no ACE exposure, the adjusted odds of reporting myocardial infarction, asthma, fair/poor health, frequent mental distress, and disability were higher for those reporting one to three, four to six, or seven to nine ACEs. Odds of reporting coronary heart disease and stroke were higher for those who reported four to six and seven to nine ACEs; odds of diabetes were higher for those reporting one to three and four to six ACEs. CONCLUSIONS: These findings underscore the importance of child maltreatment prevention as a means to mitigate adult morbidity and mortality. |
Examination of the factorial structure of adverse childhood experiences and recommendations for three subscale scores
Ford DC , Merrick MT , Parks SE , Breiding MJ , Gilbert LK , Edwards VJ , Dhingra SS , Barile JP , Thompson WW . Psychol Violence 2014 4 (4) 432-444 OBJECTIVE: The purpose of the current investigation is to assess and validate the factor structure of the Behavioral Risk Factor Surveillance System's (BRFSS) Adverse Childhood Experience (ACE) module. METHOD: ACE data available from the 2009 BRFSS survey were fit using exploratory factor analysis (EFA) to estimate an initial factorial structure. The exploratory solution was then validated using confirmatory factor analysis (CFA) with data from the 2010 BRFSS survey. Lastly, ACE factors were tested for measurement invariance using multiple group factor analysis. RESULTS: EFA results suggested that a 3-factor solution adequately fit the data. Examination of factor loadings and item content suggested the factors represented the following construct areas: Household Dysfunction, Emotional/Physical Abuse, and Sexual Abuse. Subsequent CFA results confirmed the 3-factor solution and provided preliminary support for estimation of an overall latent ACE score summarizing the responses to all available items. Measurement invariance was supported across both gender and age. CONCLUSIONS: Results of this study provides support for the use of the current ACE module scoring algorithm, which uses the sum of the number of items endorsed to estimate exposure. However, the results also suggest potential benefits to estimating 3 separate composite scores to estimate the specific effects of exposure to Household Dysfunction, Emotional/Physical Abuse, and Sexual Abuse. |
Do maladaptive behaviors exist at one or both ends of personality traits?
Pettersson E , Mendle J , Turkheimer E , Horn EE , Ford DC , Simms LJ , Clark LA . Psychol Assess 2014 26 (2) 433-46 In the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; American Psychiatric Association, 2013) personality disorder trait model, maladaptive behavior is located at one end of continuous scales. Widiger and colleagues, however, have argued that maladaptive behavior exists at both ends of trait continua. We propose that the role of evaluative variance differentiates these two perspectives and that once evaluation is isolated, maladaptive behaviors emerge at both ends of nonevaluative trait dimensions. In Study 1, we argue that evaluative variance is worthwhile to measure separately from descriptive content because it clusters items by valence regardless of content (e.g., lazy and workaholic; apathetic and anxious; gullible and paranoid; timid and hostile, etc.), which is unlikely to describe a consistent behavioral style. We isolate evaluation statistically (Study 2) and at the time of measurement (Study 3) to show that factors unrelated to valence evidence maladaptive behavior at both ends. We argue that nonevaluative factors, which display maladaptive behavior at both ends of continua, may better approximate ways in which individuals actually behave. |
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