Social:Shift-and-persist model

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The Shift-and-persist model has emerged in order to account for unintuitive, positive health outcomes in some individuals of low socioeconomic status.[1][2] A large body of research has previously linked low socioeconomic status to poor physical and mental health outcomes, including early mortality.[3][4][5][6] Low socioeconomic status is hypothesized to get "under the skin" by producing chronic activation of the sympathetic nervous system and hypothalamic–pituitary–adrenal axis, which increases allostatic load, leading to the pathogenesis of chronic disease.[7] However, some individuals of low socioeconomic status do not appear to experience the expected, negative health effects associated with growing up in poverty. To account for this, the Shift-and-Persist Model proposes that, as children, some individuals of low socioeconomic status learn adaptive strategies for regulating their emotions ("shifting") and focusing on their goals ("persisting") in the face of chronic adversity.[1] According to this model, the use of shift-and-persist strategies diminishes the typical negative effects of adversity on health by leading to more adaptive biological, cognitive, and behavioral responses to daily stressors.

Shift strategies

Broadly, "shift" strategies encompass a variety of cognitive and emotion self-regulation approaches that individuals use to deal with stress, including cognitive restructuring, reframing, reappraisal, and acceptance strategies, which change the meaning of a stressor or reduce its emotional impact.[1] These shift strategies particularly focus on changing one's response to a stressor, instead of attempting to change the situation or stressor itself.[1][8][9] As shift strategies depend more on internal processes (self-control and regulation), than external resources, it is hypothesized that shift strategies may be particularly adaptive responses to the chronic, uncontrollable stressors that are associated with low socioeconomic status.

Persist strategies

According to Chen and Miller, "persist" strategies are any strategies that help individuals to maintain optimism about the future, create meaning from their experiences of challenge and hardship, and persist "with strength in the face of adversity."[1]

Measurement

To evaluate the combination of shift-and-persist strategy use, distinct "shift" and "persist” constructs were initially measured separately by using multiple, self-report measures of reappraisal, emotional reactivity, and future orientation in early research on this model.[2]

In 2015, Chen and colleagues published the Shift-and-Persist Scale, which is a combined self-report measure that assesses both shift and persist strategies.[10] The Shift-and-Persist Scale has been validated for use with adults and teenagers.[10] The questionnaire asks respondents to rate how well 14 statements about various approaches to dealing with life stressors apply to them on a 1-4 scale.[11] Out of the 14 items on the measure, 4 assess a respondent's use of shift strategies, 4 load onto persist strategies, and 6 items are non-relevant distractors that are ignored during scoring. When scoring the Shift-and-Persist Scale, one item (#4) is reverse-scored. This scale is publicly available online.[11]

A simplified 5-item Shift-and-Persist scale has also been published for use with younger children and adolescents (ages 9–15).[12] Total scores on this version of the Shift-and-Persist Scale range from 0-20, such that higher scores are indicative of greater use of shift-and-persist strategies. This scale is also publicly available online and has been previously used in research with children from kindergarten through 8th grade.[12][13]

Proposed mechanisms

Reduction of the harmful biological effects of stress

The shift-and-persist model mainly hypothesizes that these strategies have protective effects for the health of low socioeconomic status individuals because they affect biological and physiological stress response tendencies that are relevant for disease.[1] There is some evidence that shift responses (e.g., reappraisal) to acute stressors are associated with attenuated physiological responses to stress, including reduced cardiovascular reactivity.[14][15] Specifically, reappraisal has been linked to a "healthier" pattern of hypothalamic–pituitary–adrenal axis response characterized by a rapid return to homeostasis (i.e., faster cortisol recovery) in the wake of a stressor.[16] Persist tendencies, such as optimism, have also been associated with adaptive immune responses and faster cortisol recovery.[17][18] By constraining the magnitude and duration of biological stress responses, including cardiovascular, hypothalamic–pituitary–adrenal axis, and inflammatory responses to stress, shift-and-persist responses are hypothesized to prevent the wear and tear on these systems that increases allostatic load and risk for chronic diseases of aging.[1]

Cross-sectional studies provide some evidence that greater emotion regulation abilities are associated with reduced health risk on a variety of indicators of allostatic load.[19][20] Similarly, self-reported trait levels of optimism and purpose in life have been linked to better concurrent health and health trajectories over time.[21][22][23][24][25] However, most of the health benefits associated with shift-and-persist consistent strategies are only seen in low socioeconomic status samples.[26][27]

Enhancement of adaptive biological stress-recovery systems

Another alternative, but not mutually exclusive hypothesis, is that shift-and-persist strategies affect health by increasing or up-regulating biological responses that enhance stress recovery and resilience. In particular, the parasympathetic nervous system's functioning may be enhanced by shift-and-persist response tendencies.[1] Emotion regulation abilities that are consistent with shift-coping have been linked to greater parasympathetic nervous system functioning at rest, as indexed by higher levels of high-frequency heart rate variability.[28] Further, the parasympathetic nervous system is highly integrated with, and may contribute to the down-regulation of hypothalamic–pituitary–adrenal axis and immune system stress responses that influence allostatic load over time.[29][30] Although parasympathetic nervous system activity is correlated with aspects of shift-and-persist coping, it is not yet established that the use of these strategies actually increases parasympathetic nervous system activity.

The oxytocin system has also been identified as another potential mechanism by which shift-and-persist strategies could influence health outcomes.[1] Oxytocin is a hormone that has been linked to a wide range of positive social and emotional functions and can be used to effectively attenuate hypothalamic–pituitary–adrenal axis and sympathetic nervous system responses to stress.[31][32][33] However, there is little research examining the interplay between shift-and-persist strategy use and the oxytocin system.

Impact on health behaviors

It has also been proposed that shift-and-persist strategies may buffer health outcomes in individuals of low socioeconomic status by affecting health behaviors.[1] Previous research has demonstrated that, regardless of socioeconomic status, individuals with emotion regulation difficulties are also likely to engage in poorer health behaviors, including over-eating, sedentary lifestyle, risky sexual health behaviors, and drug use.[34][35][36][37] Individuals of low socioeconomic status who learn to regulate their emotions more effectively, by using "shift" strategies in childhood, may be more likely than their peers with emotion regulation difficulties to establish and sustain positive health behaviors throughout development. Similarly, persist strategies that help individuals to maintain a positive focus on the future may also affect wellbeing through health behaviors.[1] Prior studies have linked being "future-oriented" to lower levels of drug use and sexual risk behaviors.[38] Therefore, it is possible that individuals who regularly use shift-and-persist strategies will be more likely to practice positive health behaviors, which promote healthy development and aging.[citation needed]

However, it is important to note that the relationships between emotion regulation abilities and health behavior are bidirectional. Health behaviors, such as physical activity and sleep hygiene, can also have powerful effects on our capacity to successfully regulate emotions.[39][40]

Research support for associations with health

Since 2012, integrative research groups concerned with clinical health psychology, social psychology, psychoneuroimmunology, and public health have begun to evaluate the relationships postulated by the shift-and-persist model. The majority of empirical studies on this topic test whether shift-and-persist strategies are associated with differential health outcomes in low vs. high socioeconomic status samples.

Thus far, high levels of shift-and-persist strategy use have been linked to:

Although it has been proposed that a variety of psychological interventions for at-risk youth of low socioeconomic status may reduce health disparities, in part, by increasing shift-and-persist tendencies in families, the majority of studies on shift-and-persist have been cross-sectional. Therefore, it remains unknown if shift-and-persist strategies play a causal role in reducing the negative impact of low socioeconomic status on health.[47][49] More longitudinal and treatment studies are needed to evaluate directional and causal hypotheses based upon the shift-and-persist model.

See also

References

  1. ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 Chen, Edith; Miller, Gregory E. (2012-03-01). ""Shift-and-Persist" Strategies: Why Being Low in Socioeconomic Status isn't Always Bad for Health". Perspectives on Psychological Science 7 (2): 135–158. doi:10.1177/1745691612436694. ISSN 1745-6916. PMID 23144651. 
  2. ↑ 2.0 2.1 Chen, Edith; Miller, Gregory E.; Lachman, Margie E.; Gruenewald, Tara L.; Seeman, Teresa E. (2012). "Protective Factors for Adults From Low-Childhood Socioeconomic Circumstances: The Benefits of Shift-and-Persist for Allostatic Load" (in en). Psychosomatic Medicine 74 (2): 178–186. doi:10.1097/PSY.0b013e31824206fd. ISSN 0033-3174. PMID 22286848. 
  3. ↑ Adler, Nancy E.; Boyce, Thomas; Chesney, Margaret A.; Cohen, Sheldon; Folkman, Susan; Kahn, Robert L.; Syme, S. Leonard (1994). "Socioeconomic status and health: The challenge of the gradient." (in en). American Psychologist 49 (1): 15–24. doi:10.1037/0003-066x.49.1.15. ISSN 1935-990X. PMID 8122813. https://semanticscholar.org/paper/db3ec5962ef688a1f0cc331bbd2f5a2496e424b3. 
  4. ↑ McLaughlin, Katie A.; Breslau, Joshua; Green, Jennifer Greif; Lakoma, Matthew D.; Sampson, Nancy A.; Zaslavsky, Alan M.; Kessler, Ronald C. (2011). "Childhood socio-economic status and the onset, persistence, and severity of DSM-IV mental disorders in a US national sample". Social Science & Medicine 73 (7): 1088–1096. doi:10.1016/j.socscimed.2011.06.011. ISSN 0277-9536. PMID 21820781. 
  5. ↑ Mackenbach, Johan P.; Stirbu, Irina; Roskam, Albert-Jan R.; Schaap, Maartje M.; Menvielle, Gwenn; Leinsalu, Mall; Kunst, Anton E. (2008-06-05). "Socioeconomic Inequalities in Health in 22 European Countries" (in en). New England Journal of Medicine 358 (23): 2468–2481. doi:10.1056/NEJMsa0707519. ISSN 0028-4793. PMID 18525043. 
  6. ↑ Braveman, Paula A.; Cubbin, Catherine; Egerter, Susan; Williams, David R.; Pamuk, Elsie (2010). "Socioeconomic Disparities in Health in the United States: What the Patterns Tell Us" (in en). American Journal of Public Health 100 (S1): S186–S196. doi:10.2105/AJPH.2009.166082. ISSN 0090-0036. PMID 20147693. 
  7. ↑ McEwen, Bruce S. (1998-01-15). Flier, Jeffrey S.; Underhill, Lisa H.. eds. "Protective and Damaging Effects of Stress Mediators" (in en). New England Journal of Medicine 338 (3): 171–179. doi:10.1056/NEJM199801153380307. ISSN 0028-4793. PMID 9428819. 
  8. ↑ Heckhausen, J.; Schulz, R. (1995). "A life-span theory of control". Psychological Review 102 (2): 284–304. doi:10.1037/0033-295x.102.2.284. ISSN 0033-295X. PMID 7740091. 
  9. ↑ Heckhausen, Jutta; Wrosch, Carsten; Schulz, Richard (2010). "A motivational theory of life-span development". Psychological Review 117 (1): 32–60. doi:10.1037/a0017668. ISSN 1939-1471. PMID 20063963. 
  10. ↑ 10.0 10.1 Chen, Edith; McLean, Kate C.; Miller, Gregory E. (2015). "Shift-and-Persist Strategies: Associations With Socioeconomic Status and the Regulation of Inflammation Among Adolescents and Their Parents" (in en). Psychosomatic Medicine 77 (4): 371–382. doi:10.1097/PSY.0000000000000157. ISSN 0033-3174. PMID 26167560. 
  11. ↑ 11.0 11.1 University, © Stanford; Stanford; California 94305. "Shift and Persist (Teen, Adult) | SPARQTools" (in en). http://sparqtools.org/mobility-measure/shift-and-persist-teen-adult/. 
  12. ↑ 12.0 12.1 University, © Stanford; Stanford; California 94305. "Shift and Persist (Child) | SPARQTools" (in en). http://sparqtools.org/mobility-measure/shift-and-persist-child/. 
  13. ↑ Kallem, Stacey; Carroll-Scott, Amy; Rosenthal, Lisa; Chen, Edith; Peters, Susan M.; McCaslin, Catherine; Ickovics, Jeannette R. (2013). "Shift-and-persist: A protective factor for elevated BMI among low-socioeconomic-status children" (in en). Obesity 21 (9): 1759–1763. doi:10.1002/oby.20195. ISSN 1930-739X. PMID 23671041. 
  14. ↑ Gross, J. J. (1998). "Antecedent- and response-focused emotion regulation: divergent consequences for experience, expression, and physiology". Journal of Personality and Social Psychology 74 (1): 224–237. doi:10.1037/0022-3514.74.1.224. ISSN 0022-3514. PMID 9457784. 
  15. ↑ El-Sheikh, Mona; Harger, JoAnn (2001). "Appraisals of marital conflict and children's adjustment, health, and physiological reactivity.". Developmental Psychology 37 (6): 875–885. doi:10.1037/0012-1649.37.6.875. ISSN 1939-0599. PMID 11699760. 
  16. ↑ Raymond, Catherine; Marin, Marie-France; Juster, Robert-Paul; Lupien, Sonia J. (2019-05-04). "Should we suppress or reappraise our stress?: the moderating role of reappraisal on cortisol reactivity and recovery in healthy adults" (in en). Anxiety, Stress, & Coping 32 (3): 286–297. doi:10.1080/10615806.2019.1596676. ISSN 1061-5806. PMID 30908108. 
  17. ↑ Segerstrom, Suzanne C.; Taylor, Shelley E.; Kemeny, Margaret E.; Fahey, John L. (1998). "Optimism is associated with mood, coping, and immune change in response to stress.". Journal of Personality and Social Psychology 74 (6): 1646–1655. doi:10.1037/0022-3514.74.6.1646. ISSN 1939-1315. PMID 9654763. 
  18. ↑ Puig-Perez, Sara; Villada, Carolina; Pulopulos, Matias M.; Almela, Mercedes; Hidalgo, Vanesa; Salvador, Alicia (2015). "Optimism and pessimism are related to different components of the stress response in healthy older people". International Journal of Psychophysiology 98 (2): 213–221. doi:10.1016/j.ijpsycho.2015.09.002. ISSN 0167-8760. PMID 26348260. 
  19. ↑ Kinnunen, Marja-Liisa; Kokkonen, Marja; Kaprio, Jaakko; Pulkkinen, Lea (2005). "The associations of emotion regulation and dysregulation with the metabolic syndrome factor". Journal of Psychosomatic Research 58 (6): 513–521. doi:10.1016/j.jpsychores.2005.02.004. ISSN 0022-3999. PMID 16125518. 
  20. ↑ Roy, Brita; Riley, Carley; Sinha, Rajita (2018-08-07). "Emotion regulation moderates the association between chronic stress and cardiovascular disease risk in humans: a cross-sectional study". Stress 21 (6): 548–555. doi:10.1080/10253890.2018.1490724. ISSN 1025-3890. PMID 30084712. 
  21. ↑ Bower, Julienne E.; Kemeny, Margaret E.; Taylor, Shelley E.; Fahey, John L. (1998). "Cognitive processing, discovery of meaning, CD4 decline, and AIDS-related mortality among bereaved HIV-seropositive men.". Journal of Consulting and Clinical Psychology 66 (6): 979–986. doi:10.1037/0022-006x.66.6.979. ISSN 0022-006X. PMID 9874911. 
  22. ↑ Ryff, Carol D.; Singer, Burton H.; Dienberg Love, Gayle (2004-09-29). "Positive health: connecting well-being with biology". Philosophical Transactions of the Royal Society of London. Series B, Biological Sciences 359 (1449): 1383–1394. doi:10.1098/rstb.2004.1521. ISSN 0962-8436. PMID 15347530. 
  23. ↑ Räikkönen, K.; Matthews, K. A.; Flory, J. D.; Owens, J. F.; Gump, B. B. (1999). "Effects of optimism, pessimism, and trait anxiety on ambulatory blood pressure and mood during everyday life". Journal of Personality and Social Psychology 76 (1): 104–113. doi:10.1037/0022-3514.76.1.104. ISSN 0022-3514. PMID 9972556. 
  24. ↑ Friedman, Elliot M.; Hayney, Mary; Love, Gayle D.; Singer, Burton H.; Ryff, Carol D. (2007). "Plasma interleukin-6 and soluble IL-6 receptors are associated with psychological well-being in aging women". Health Psychology 26 (3): 305–313. doi:10.1037/0278-6133.26.3.305. ISSN 0278-6133. PMID 17500617. 
  25. ↑ Sims, Mario; Glover, LáShauntá M.; Norwood, Arnita F.; Jordan, Christina; Min, Yuan-I; Brewer, LaPrincess C.; Kubzansky, Laura D. (2019). "Optimism and cardiovascular health among African Americans in the Jackson Heart Study". Preventive Medicine 129: 105826. doi:10.1016/j.ypmed.2019.105826. ISSN 0091-7435. PMID 31473218. 
  26. ↑ Grewen, Karen; Girdler, Susan S.; West, Sheila G.; Bragdon, Edith; Costello, Nancy; Light, Kathleen C. (2000). "Stable Pessimistic Attributions Interact with Socioeconomic Status to Influence Blood Pressure and Vulnerability to Hypertension". Journal of Women's Health & Gender-Based Medicine 9 (8): 905–915. doi:10.1089/152460900750020946. ISSN 1524-6094. PMID 11074957. 
  27. ↑ Morozink, Jennifer A.; Friedman, Elliot M.; Coe, Christopher L.; Ryff, Carol D. (2010). "Socioeconomic and psychosocial predictors of interleukin-6 in the MIDUS national sample.". Health Psychology 29 (6): 626–635. doi:10.1037/a0021360. ISSN 1930-7810. PMID 20954777. 
  28. ↑ Appelhans, Bradley M.; Luecken, Linda J. (2006). "Heart Rate Variability as an Index of Regulated Emotional Responding". Review of General Psychology 10 (3): 229–240. doi:10.1037/1089-2680.10.3.229. ISSN 1089-2680. 
  29. ↑ THAYER, J. F; STERNBERG, E. (2006-11-01). "Beyond Heart Rate Variability: Vagal Regulation of Allostatic Systems". Annals of the New York Academy of Sciences 1088 (1): 361–372. doi:10.1196/annals.1366.014. ISSN 0077-8923. PMID 17192580. Bibcode: 2006NYASA1088..361T. 
  30. ↑ Tracey, Kevin J. (2009). "Reflex control of immunity". Nature Reviews. Immunology 9 (6): 418–428. doi:10.1038/nri2566. ISSN 1474-1741. PMID 19461672. 
  31. ↑ Ditzen, Beate; Schaer, Marcel; Gabriel, Barbara; Bodenmann, Guy; Ehlert, Ulrike; Heinrichs, Markus (2009-05-01). "Intranasal oxytocin increases positive communication and reduces cortisol levels during couple conflict". Biological Psychiatry 65 (9): 728–731. doi:10.1016/j.biopsych.2008.10.011. ISSN 1873-2402. PMID 19027101. 
  32. ↑ Ross, Heather E.; Young, Larry J. (2009-10-01). "Oxytocin and the neural mechanisms regulating social cognition and affiliative behavior". Frontiers in Neuroendocrinology. Hormones & Social Behavior 30 (4): 534–547. doi:10.1016/j.yfrne.2009.05.004. ISSN 0091-3022. PMID 19481567. 
  33. ↑ Gutkowska, Jolanta; Jankowski, Marek (2008). "Oxytocin revisited: It is also a cardiovascular hormone". Journal of the American Society of Hypertension 2 (5): 318–325. doi:10.1016/j.jash.2008.04.004. ISSN 1933-1711. PMID 20409913. 
  34. ↑ Rizor, Asha; Callands, Tamora; Desrosiers, Alethea; Kershaw, Trace (2017-07-03). "(S)He's Gotta Have It: Emotion Regulation, Emotional Expression, and Sexual Risk Behavior in Emerging Adult Couples". Sexual Addiction & Compulsivity 24 (3): 203–216. doi:10.1080/10720162.2017.1343700. ISSN 1072-0162. PMID 31662601. 
  35. ↑ Casagrande, Maria; Boncompagni, Ilaria; Forte, Giuseppe; Guarino, Angela; Favieri, Francesca (2019-08-31). "Emotion and overeating behavior: effects of alexithymia and emotional regulation on overweight and obesity". Eating and Weight Disorders 25 (5): 1333–1345. doi:10.1007/s40519-019-00767-9. ISSN 1590-1262. PMID 31473988. 
  36. ↑ Harvey, Samuel B.; Hotopf, Matthew; Øverland, Simon; Mykletun, Arnstein (2010). "Physical activity and common mental disorders" (in en). British Journal of Psychiatry 197 (5): 357–364. doi:10.1192/bjp.bp.109.075176. ISSN 0007-1250. PMID 21037212. 
  37. ↑ Bechara, Antoine (2005-10-26). "Decision making, impulse control and loss of willpower to resist drugs: a neurocognitive perspective". Nature Neuroscience 8 (11): 1458–1463. doi:10.1038/nn1584. ISSN 1097-6256. PMID 16251988. 
  38. ↑ Robbins, Reuben N.; Bryan, Angela (2004-07-01). "Relationships Between Future Orientation, Impulsive Sensation Seeking, and Risk Behavior Among Adjudicated Adolescents". Journal of Adolescent Research 19 (4): 428–445. doi:10.1177/0743558403258860. ISSN 0743-5584. PMID 16429605. 
  39. ↑ Bernstein, Emily E.; McNally, Richard J. (2018-10-01). "Exercise as a buffer against difficulties with emotion regulation: A pathway to emotional wellbeing". Behaviour Research and Therapy 109: 29–36. doi:10.1016/j.brat.2018.07.010. ISSN 0005-7967. PMID 30081242. 
  40. ↑ Vantieghem, Iris; Marcoen, Nele; Mairesse, Olivier; Vandekerckhove, Marie (2016-04-18). "Emotion regulation mediates the relationship between personality and sleep quality". Psychology & Health 31 (9): 1064–1079. doi:10.1080/08870446.2016.1171866. ISSN 0887-0446. PMID 27021392. 
  41. ↑ Chen, Edith; Miller, Gregory E.; Lachman, Margie E.; Gruenewald, Tara L.; Seeman, Teresa E. (2012). "Protective factors for adults from low-childhood socioeconomic circumstances: the benefits of shift-and-persist for allostatic load". Psychosomatic Medicine 74 (2): 178–186. doi:10.1097/PSY.0b013e31824206fd. ISSN 1534-7796. PMID 22286848. 
  42. ↑ Kallem, Stacey; Carroll-Scott, Amy; Rosenthal, Lisa; Chen, Edith; Peters, Susan M.; McCaslin, Catherine; Ickovics, Jeannette R. (2013). "Shift-and-persist: A protective factor for elevated BMI among low-socioeconomic-status children". Obesity 21 (9): 1759–63. doi:10.1002/oby.20195. ISSN 1930-7381. PMID 23671041. 
  43. ↑ Chen, Edith; McLean, Kate C.; Miller, Gregory E. (2015). "Shift-and-Persist Strategies". Psychosomatic Medicine 77 (4): 371–382. doi:10.1097/psy.0000000000000157. ISSN 0033-3174. PMID 26167560. 
  44. ↑ Chen, Edith; Lee, William K.; Cavey, Lisa; Ho, Amanda (2012-12-20). "Role Models and the Psychological Characteristics That Buffer Low-Socioeconomic-Status Youth From Cardiovascular Risk". Child Development 84 (4): 1241–1252. doi:10.1111/cdev.12037. ISSN 0009-3920. PMID 23278857. 
  45. ↑ Chen, Lihua; Li, Xiaoming; Imami, Ledina; Lin, Danhua; Zhao, Junfeng; Zhao, Guoxiang; Zilioli, Samuele (2019). "Diurnal Cortisol in a Sample of Socioeconomically Disadvantaged Chinese Children: Evidence for the Shift-and-Persist Hypothesis". Psychosomatic Medicine 81 (2): 200–208. doi:10.1097/PSY.0000000000000659. ISSN 1534-7796. PMID 30531205. 
  46. ↑ Chen, Edith; Strunk, Robert C.; Trethewey, Alexandra; Schreier, Hannah M. C.; Maharaj, Nandini; Miller, Gregory E. (2011). "Resilience in low-socioeconomic-status children with asthma: adaptations to stress". The Journal of Allergy and Clinical Immunology 128 (5): 970–976. doi:10.1016/j.jaci.2011.06.040. ISSN 1097-6825. PMID 21824649. 
  47. ↑ 47.0 47.1 Lam, Phoebe H.; Miller, Gregory E.; Chiang, Jessica J.; Levine, Cynthia S.; Le, Van; Shalowitz, Madeleine U.; Story, Rachel E.; Chen, Edith (2018-08-06). "One size does not fit all: Links between shift-and-persist and asthma in youth are moderated by perceived social status and experience of unfair treatment". Development and Psychopathology 30 (5): 1699–1714. doi:10.1017/s0954579418000913. ISSN 0954-5794. PMID 30078386. 
  48. ↑ Christophe, N. Keita; Stein, Gabriela Livas; Martin Romero, Michelle Y.; Chan, Michele; Jensen, Michaeline; Gonzalez, Laura M.; Kiang, Lisa (2019-08-01). "Coping and Culture: The Protective Effects of Shift-&-Persist and Ethnic-Racial Identity on Depressive Symptoms in Latinx Youth" (in en). Journal of Youth and Adolescence 48 (8): 1592–1604. doi:10.1007/s10964-019-01037-8. ISSN 1573-6601. PMID 31134561. 
  49. ↑ Miller, Gregory E.; Brody, Gene H.; Yu, Tianyi; Chen, Edith (2014-08-05). "A family-oriented psychosocial intervention reduces inflammation in low-SES African American youth" (in en). Proceedings of the National Academy of Sciences 111 (31): 11287–11292. doi:10.1073/pnas.1406578111. ISSN 0027-8424. PMID 25049403. Bibcode: 2014PNAS..11111287M. 



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