Recent studies suggest that children’s emotional difficulties may impact their parents’ psychological well-being, and certain protective factors could mitigate this association. The existing literature points to self-compassion as a potential protective factor against stress and difficulties. To this end, the present study aimed to explore the potential protective role of parents’ self-compassion in the prospective relationship between children’s emotional regulation difficulties and parents’ depressive symptoms.
Method
The initial sample consisted of 214 children (53.3% girls; Mage = 12.71, SD = 1.37) and their parents: 209 mothers (Mage = 46.74 years, SD = 4.42) and 181 fathers (Mage = 48.85 years, SD = 5.42). The participants answered self-report questionnaires in a two-wave longitudinal study conducted over one year. A multilevel analysis was performed to examine the predictive pathways of parents’ depressive symptoms from children’s emotional regulation difficulties, parents’ self-compassion, and their interaction. Gender differences were addressed in the predictive associations.
Results
Children’s emotional regulation difficulties predicted their parents’ depressive symptoms after one year, and this association was found to become attenuated as parents’ self-compassion increased. No significant gender differences were found for depressive symptoms or self-compassion, and parents’ gender did not moderate any of the longitudinal associations.
Conclusion
Children’s emotional regulation difficulties may increase risk for parental depressive symptoms, but parental self-compassion mitigates this relationship.
Preregistration
This study was not preregistered.
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In recent years, an extensive line of research has examined the predictive role of parents’ depressive symptoms on children’s emotional and behavioral difficulties (Côté et al., 2018; Reeb et al., 2015). However, studies on the influence of children’s emotional and behavioral difficulties on their parents’ depressive symptoms have been relatively limited (Johnco et al., 2021; Vismara et al., 2022). Likewise, research on the protective factors that could mitigate the impact of children’s emotional and behavioral difficulties on their parents’ depressive symptoms is scarce (Cheung et al., 2022). The existing literature identified self-compassion as an important protective factor when individuals face difficulties (Cary & Felver, 2020).
Transactional models of development suggest that children should be considered active agents both within their own development and with respect to the changes that their parents experience in the parenting process and their own well-being (Leve & Cicchetti, 2016). Children’s emotional and behavioral difficulties can be a major stressor for parents and increase their risk of developing depressive symptoms (Johnco et al., 2021). Several cross-sectional studies have found significant associations between children’s emotional and behavioral difficulties and depressive symptoms in both parents (Henry et al., 2020; Sweeney & MacBeth, 2016; Vismara et al., 2022). Few longitudinal studies have focused on evaluating the predictive association from children’s emotional and behavioral difficulties to their parents’ depressive symptoms. Some recent longitudinal studies have, however, concluded that children’s emotional and behavioral difficulties predict the development of depressive symptoms in their parents (Hou et al., 2020; McAdams et al., 2015).
With few exceptions (Schulz et al., 2021), the majority of the studies have focused on mothers and concluded that children’s emotional and behavioral difficulties predict higher levels of depressive symptoms in this particular group (Shaw et al., 2016). However, little is known about whether the same predictive association holds for fathers. In this regard, the literature reveals a dearth of evidence on the development of depressive symptoms in both parents predicted by their own child’s emotional and behavioral difficulties (Schulz et al., 2021).
The majority of the studies on the relationship between parents’ depressive symptoms and child’s emotional and behavioral difficulties have focused on internalizing symptoms (McAdams et al., 2015; Schulz et al., 2021; Shaw et al., 2016; Sweeney & MacBeth., 2016; Vismara et al., 2022), or more specifically on child’s anxiety and depression symptoms (Henry et al., 2020; Hou et al., 2020; Johnco et al., 2021), measured with different instruments. The methodological heterogeneity, both in measuring the emotional and behavioral difficulties variables and in naming the variables, makes it challenging to reach conclusions.
Some researchers have posited that a common transdiagnostic element in many psychological problems are emotion regulation difficulties (Aldao et al., 2016). Gratz and Roemer (2004) defined the construct of emotional regulation difficulties as a maladaptive emotional response manifested in a number of aspects, including a lack of emotional awareness, lack of emotional clarity, difficulties in impulse control when distressed, difficulties in engaging in goal-directed behaviors, nonacceptance of negative emotional responses, and a limited access to effective emotional regulation strategies. These aspects subsequently formed the basis of the Difficulties in Emotion Regulation Scale, which was proposed by the same authors (Gómez-Simón et al., 2014). Emotional regulation difficulties in children have not only been associated with a wide range of emotional problems common to different internalizing and externalizing disorders among children (Villalta et al., 2018), but also with internalizing symptoms in parents such as depressive symptoms (Ip et al., 2021).
In addition to clarifying the predictive role of children’s emotion regulation difficulties in the depression of both fathers and mothers (Goodman et al., 2020), previous studies have highlighted the importance of identifying protective factors that could be developed through interventions (e.g., Jefferson et al., 2020; Torbet et al., 2019). For instance, in recent years, there has been a growing interest in parents’ self-compassion as a protective factor for negative parenting and both parents’ and children’s mental health (Cary & Felver, 2020; Neff & Faso, 2015; Psychogiou et al., 2016).
Self-compassion refers to a person’s ability to be kind to themselves, non-judgmental, sympathetic to unavoidable suffering, and able to maintain focus on present experiences (Neff, 2003b). In addition, self-compassion captures the capacity for self-care in the face of negative experiences, such as handling a situation in which a child exhibits difficulties in emotional regulation (Neff et al., 2007). The findings from several studies indicate that self-compassion is associated with lower levels of depressive symptoms, both cross-sectionally (Bakker et al., 2019) and longitudinally (López et al., 2018; Soysa & Wilcomb, 2015). These studies suggested that self-compassion could be an especially relevant factor when analyzing the development of depressive symptoms during stressful life processes, such as parenthood (Neff, 2023). In this vein, Kabat-Zinn and Kabat-Zinn (1998) have argued that self-compassion could help parents handle the difficulties of emotional regulation presented by their child in a more sensitive and understanding way, since self-compassion allows parents to act from the recognition, understanding, and avoidance of reactive and negative thoughts. In another study, self-compassionate parents were able to respond more adaptively to parenting challenges than those who scored lower in self-compassion, and this may help to avoid the consequences of the non-conscious and inflexible management of these stressful situations on parental well-being (Cheung et al., 2022).
There is evidence from cross-sectional studies indicating a significant negative correlation between self-compassion, symptoms of depression, and parents’ stress, mostly in samples of parents of children with autism spectrum disorder (Neff & Faso, 2015; Torbet et al., 2019) and other intellectual and developmental disabilities (Robinson et al., 2018), and meager in community samples (Gouveia et al., 2016; Hawkins et al., 2019). However, most of the participants in these studies were mothers, and there is a lack of studies on the effect of self-compassion on fathers’ symptoms. Moreover, there is a shortage of longitudinal studies about self-compassion in parents (Soysa & Wilcomb, 2015). While some authors did find that self-compassion significantly and negatively predicts depressive symptoms in Chinese parents, as indicated in a study that recruited balanced samples of mothers and fathers (Cheung et al., 2022), there was little evidence of the protective role of parents’ self-compassion in the predictive association. Specifically, more longitudinal designs with balanced samples of mothers and fathers are needed to further explore the connection between child’s emotional difficulties and their parents’ depressive symptoms.
In terms of gender differences in self-compassion, a meta-analysis concluded that men present with higher levels of self-compassion compared to women (Yarnell et al., 2015). However, the authors stressed that caution is needed when analyzing gender differences in self-compassion, as the effect size in this case was small (Cohen, 1988). The broader literature indicates that most studies aimed at addressing the role of self-compassion in parents collected very small or non-existent samples of fathers and used a cross-sectional design (Song et al., 2023). One of the few studies to examine the differences in self-compassion between mothers and fathers indicated that fathers exhibited significantly higher levels of self-compassion than mothers (Wang et al., 2024). In this case also, the effect size was relatively small.
Regarding gender differences in depressive symptoms, the literature consistently reveals that women report higher levels of depressive symptoms than men (Hyde & Mezulis, 2020). Likewise, in the few studies that have focused on differences in depressive symptoms between mothers and fathers, it was observed that mothers tend to score higher on depressive symptoms than fathers (Shafer et al., 2017).
In order to respond to the gaps detected in the literature, the main objective of the present study was to analyze the protective role of self-compassion in the predictive association between child’s emotional regulation difficulties and their parents’ depressive symptoms through a longitudinal and multi-informant design. It was hypothesized that self-compassion would predict fewer depressive symptoms, while emotional regulation difficulties would predict more depressive symptoms, and the association between emotional regulation difficulties and depressive symptoms would be lower among parents with higher levels of self-compassion. It was also addressed gender differences between parents in the study variables and in the longitudinal associations between children’s emotional regulation difficulties and parents’ depressive symptoms, as well as between parents’ self-compassion and depressive symptoms. It was expected to find gender differences in parents’ self-compassion and depressive symptoms, with fathers scoring higher in self-compassion and mothers scoring higher in depressive symptoms. Moreover, it was expected that the positive predictive association of child’s emotional regulation difficulties and parents’ depressive symptoms would be stronger in mothers. In addition, given that men generally score higher on self-compassion and lower on depressive symptoms, the negative impact of self-compassion on depressive symptoms was expected to be stronger in fathers than in mothers (Yarnell et al., 2019).
Method
Participants
The sample was composed of triads of a child, a mother, and a father from the same family from a community sample. In Wave 1 (W1), 214 children, 213 mothers, and 187 fathers participated. In Wave 2 (W2), one year later, the participants included all the children, 209 mothers, and 181 fathers. The children were between the fourth and eighth grades and were aged nine to 15 years (Mage(W1) = 12.71, SD = 1.37), of whom 53.3% identified as girls and 46.7% as boys. The mothers were between 32 and 59 years old (Mage(W1) = 46.74 years, SD = 4.42), and the fathers were between 32 and 78 years old (Mage(W1) = 48.85 years, SD = 5.42). Of the parents, 90.1% were Spanish, 8.7% were South American, 0.2% were African, 0.3% were Asian, and 0.7% were from other European countries. Following the criteria of the Spanish Society of Epidemiology and Family and Community Medicine (2000), 22.34% of the families belonged to a low socioeconomic level, 19.17% to a medium–low level, 17.87% to a medium level, 15.32% to a medium–high level, and 25.3% to a high level.
Procedure
After the ethics committee of the University of Deusto approved the study, the participants were contacted. An information letter was sent to 11 randomly selected schools in Bizkaia (Spain) specifying the objectives of the study, together with informed consent documentation for parents. Seven of the schools agreed to participate in the study. All parents consented to their children’s participation in the study.
The researchers went to the schools for each of the two waves. For the first wave, the researchers briefed the children in the classrooms of the purpose of the study, emphasizing that their participation was voluntary and confidential. They were also informed that they could leave the study at any time. Once the questionnaires were distributed, the children took about 20 min to answer the questionnaires on their sociodemographic variables and emotional regulation difficulties.
The children were asked to take home an envelope with two questionnaires: one for the mother and one for the father. The questionnaires included a description of the study and instructions for completing the sections on sociodemographic variables, depressive symptoms, and self-compassion. A numerical code was used to link the parents’ responses with those of their children. Those parents who responded to the questionnaire returned their answers to the school in the same envelope, and the researchers collected the envelopes after a few days. The same procedure was followed for the second wave of the study.
Measures
The children’s emotional regulation difficulties were measured through a short 18-item version (Victor & Klonsky, 2016) of the Difficulties in Emotion Regulation Scale (Gratz & Roemer, 2004). The children responded to these 18 items (e.g., “I pay attention to how I feel,” “When I’m upset, I feel guilty for feeling that way”) on a 5-point Likert scale (1 = almost never, 2 = sometimes, 3 = half of the time, 4 = most of the time, 5 = almost always). Positive items were reverse coded, and McDonald's omega was 0.92.
Parents’ depressive symptoms were assessed through the depression subscale of the Depression Anxiety and Stress Scales (Lovibond & Lovibond, 1995; Spanish adaptation: Daza et al., 2002). The parents provided answers to 7 items (e.g., “I couldn’t seem to experience any positive feeling at all,” “I felt that I had nothing to look forward to”) on a 4-point Likert scale (0 = did not apply to me at all, 1 = applied to me to some degree or some of the time, 2 = applied to me to a considerable degree or a good part of the time, 3 = applied to me very much or most of the time). McDonald's omega for this scale was 0.81.
Parents’ self-compassion was assessed with a short 12-item version (Raes et al., 2011; Spanish adaptation: García-Campayo et al., 2014) of the Self-Compassion Scale (Neff, 2003a). Parents responded to 12 statements (e.g., “When I’m feeling down, I tend to feel like most other people are probably happier than I am,” “When something upsets me, I try to keep my emotions in balance”) on a 5-point Likert scale (1 = almost never, 2 = rarely, 3 = sometimes, 4 = usually, 5 = almost always). Negative items were reverse coded, and, for the current study, McDonald's omega for the scale was 0.86.
Data Analyses
IBM SPSS 27 was used to analyze the descriptive data and Pearson correlations between the study variables. In addition, t-tests were conducted to examine gender differences in parents’ depressive symptoms and self-compassion. The result of Little’s missing completely at random test was statistically non-significant (χ2(66) = 67.529, p = 0.43), so missingness was addressed by full information maximum likelihood. A multilevel analysis was conducted with Mplus 8.9, using robust maximum likelihood estimation. The hypothesized model included two levels. Level 1 consisted of the parent level and included parents’ depressive symptoms, self-compassion, gender, and the gender x self-compassion interaction term as predictors of parents’ depressive symptoms at W2. The intercepts and slopes were randomly specified. Level 2 consisted of the family level and included the child’s emotional regulation difficulties as a predictor of the intercepts and slopes of the association reported in Level 1. The initial model included the child’s gender and age, but as these factors were not significantly associated with the rest of the variables, they were eliminated from the model. Children’s emotional regulation difficulties were grand mean centered. Figure 1 displays the conceptual model. Interaction plots were created using the Excel template developed by Dawson (2021).
Table 1 displays the means, standard deviations, and correlation coefficients among the study variables. The correlations between parents’ depressive symptoms at W1 and W2 were significant and large (r = 0.51, p < 0.001). Self-compassion in W1 was significantly and negatively correlated with parents’ depressive symptoms in both W1 (r = -0.34, p < 0.001) and W2 (r = -0.30, p < 0.001), but these associations were moderate. The remaining correlations were not significant.
Table 1
Means, Standard Deviations, and Correlation Coefficients Between Study Variables
1
2
3
M
SD
1. Child’s Emotion Regulation Difficulties W1
2.51
0.70
2. Parents’ Self-compassion W1
-0.07
3.43
0.60
3. Parents’ Depressive Symptoms W1
-0.03
-0.34***
1.23
0.32
4. Parents’ Depressive Symptoms W2
0.10
-0.30***
0.51***
1.22
0.35
W1 = Wave 1, W2 = Wave 2. *** p < 0.001
The findings indicated no significant differences (t(798) = -0.34, p = 0.37, Cohen’s d = 0.02) between mothers and fathers in self-compassion. In addition, no significant gender differences were found in depressive symptoms at W1 (t(398) = 0.72, p = 0.24, Cohen’s d = 0.09) and W2 (t(388) = 1.34, p = 0.09, Cohen’s d = 0.11).
A multilevel longitudinal analysis was performed to examine the predictive paths from child’s emotional regulation difficulties, parents’ gender, parents’ self-compassion x child’s emotional regulation difficulties, parents’ gender x parents’ self-compassion, parents’ gender x child’s emotional regulation difficulties, and parents’ gender x parents’ self-compassion x child’s emotional regulation difficulties to parents’ depressive symptoms in W2. Autoregressive effects from parents’ depressive symptoms at W1 to parents’ depressive symptoms at W2 were also examined.
The intraclass correlation for Level 2 was 0.35, indicating that the intra-subject and inter-subject variabilities were sufficient to justify the suitability of the family-level analysis. The model results (Table 2 and Fig. 2) indicated that the autoregressive path of parents’ depressive symptoms was statistically significant. In addition, children’s emotional regulation difficulties significantly and positively predicted their parents’ depressive symptoms. However, parents’ self-compassion did not predict parents’ depressive symptoms. A significant interaction between child’s emotional regulation difficulties and parents’ self-compassion indicated that self-compassion moderated the predictive association between child’s emotional regulation difficulties and parents’ depressive symptoms. Figure 3 displays the predictive association between children’s difficulties in emotion regulation in W1 and parents’ depressive symptoms in W2, which were correlated with low (z = -1) and high (z = 1) scores on self-compassion. The findings indicated that children’s emotional regulation difficulties predicted higher depressive symptoms among parents in W2 only when parents’ self-compassion was low. Parents gender did not moderate any of the predictive associations in the model.
Table 2
Results of the Multilevel Model
Coefficients
β
SE
95% CI
p
Low
High
Intercept
0.64
0.12
0.38
0.87
< 0.001
W1 Parents’ Depressive Symptoms
0.47
0.11
0.26
0.68
< 0.001
W1 Child’s Emotion Regulation Difficulties
0.05
0.03
0.01
0.11
0.03
W1 Parents’ Self-compassion
-0.03
0.02
-0.12
-0.00
0.15
W1 Child’s Emotion Regulation Difficulties x W1 Parents’ Self-compassion
-0.06
0.03
-0.11
-0.00
0.02
Parents’ Gender
0.01
0.02
-0.03
0.12
0.73
W1 Child’s Emotion Regulation Difficulties x Parents’ Gender
-0.02
0.03
-0.10
0.04
0.51
W1 Parents' Gender X Parents’ Self-compassion
-0.03
0.03
-0.13
0.02
0.39
W1 Child’s Emotion Regulation Difficulties x Parents' Gender x W1 Parents’ Self-compassion
0.05
0.03
-0.01
0.13
0.12
W1 = Wave 1
Fig. 2
Results of the Multilevel Model. Note. S1 = Slope 1, S2 = Slope 2, S3 = Slope 3. W1 = Wave 1, W2 = Wave 2. * p < 0.05; ** p < 0.01; *** p < 0.001. The dashed lines indicate paths that are not statistically significant
While a long tradition of research has examined the role of parental problems in the well-being of children, this study built on recent works that emphasize the role of children’s emotional regulation difficulties in parental well-being (Hentges et al., 2021; Hou et al., 2020). The results of this study indicate that children’s emotional regulation difficulties predict parents’ depressive symptoms, and these findings were congruent with the few longitudinal studies that have been conducted through multi-informant approaches combining child and parent reports (Johnco et al., 2021; Schulz et al., 2021). For example, Schulz et al. (2021) found that adolescents’ internalizing symptoms predicted their mothers’ internalizing symptoms, but not those of their fathers. In this case, the researchers combined measures of depressive and anxiety symptoms to refer to internalizing symptoms. Similarly, Johnco et al. (2021) showed that both adolescents’ anxiety and depressive symptoms predicted parents’ depressive symptoms, but not parents’ anxiety symptoms. It is, however, important to point out that 95% of the parents’ sample was represented by the mothers. The present study supported the findings of these previous studies, but with a more balanced sample of mothers and fathers and specific measures of parents’ depressive symptoms. Therefore, given the findings of the present and previous studies, it seems that child’s emotional difficulties could be a source of problems, arguments, and stressful situations within the family, thus having a negative impact on parents’ well-being.
In this study, self-compassion was not longitudinally associated with parents’ depressive symptoms. These results did not match those of other studies, where a negative predictive association of parents’ self-compassion with depressive symptoms was found (Cheung et al., 2022; Soysa & Wilcomb, 2015). However, as longitudinal studies are scarce, it is important that future studies continue to analyze the predictive associations between parents’ self-compassion and depressive symptoms to better understand the longitudinal relationships between these variables. Although there was no direct main effect of parents’ self-compassion on parents’ depressive symptoms in W2, parents’ self-compassion was cross-sectionally associated with parents’ depressive symptoms in W1. This finding was consistent with other cross-sectional studies, where a negative and significant association between parents’ self-compassion and depressive symptoms was reported. For example, the same conclusion was reached in cross-sectional studies focused on evaluating the association between self-compassion and depressive symptoms in parents of children with autism spectrum disorder or other intellectual and developmental disabilities (Bohadana et al., 2019; Wong et al., 2016), parents with major depressive disorders (Bakker et al., 2019), and also parents of community samples (Gouveia et al., 2016; Hawkins et al., 2019).
More importantly, the present study analyzed whether parents’ self-compassion reduced the negative impact of children’s emotional regulation difficulties on parents’ depressive symptoms. Consistent with our hypothesis, the findings indicated that self-compassion buffered the effect of child’s emotional regulation difficulties on parents’ symptoms. Therefore, self-compassion in parents could be considered an advantageous attitude for coping with their child’s emotional difficulties with understanding, sensitivity, non-judgment, and adaptive responses, so that parental well-being is protected (Cheung et al., 2022). However, it is crucial to underline that the effect size of moderation was small. Nevertheless, these results added evidence to studies analyzing the moderating role of self-compassion in the relationship between stressful life events and depressive symptoms (Ford et al., 2017; Körner et al., 2015). Specifically, these studies indicated that while traditional theories of depression have tended to evaluate risk factors for depression, in recent years, there has been a tendency to locate protective factors that mitigate depressive symptoms. These protective factors, such as self-compassion, could be very beneficial to consider when designing and implementing interventions for coping with parental stress.
The last objective of this study was to respond to a gap detected in the literature regarding differences in self-compassion between fathers and mothers. In the present study, no significant gender differences were found in self-compassion. Previous studies comparing women and men have indicated that men tend to score higher when rating their self-compassion than women do (Hyde & Mezulis, 2020; Yarnell et al., 2015). Considering these discrepancies, differences in self-compassion between mothers and fathers would have to be analyzed in more detail in future research (Song et al., 2023). Furthermore, in this study, there were no gender differences between the parents in depressive symptoms. This was unexpected, since previous literature has pointed out that women generally report higher levels of depressive symptoms than men (Shorey et al., 2022), and that mothers tend to score higher on depressive symptoms than fathers (Shafer et al., 2017). Future studies should address this issue, as research on differences in depressive symptoms between mothers and fathers with balanced samples is meager. In fact, the lack of differences in the present study may be due to the relatively small sample size. Finally, it was found that parents’ gender did not moderate any of the predictive associations tested in this study. This means that children’s emotional regulation difficulties affect both mothers’ and fathers’ depressive symptoms equally, and that self-compassion protects them from these effects in the same way.
Limitations and Future Research
There were some limitations to this study. First, the triad sample was small, so future research is encouraged to gather larger samples that would allow for the inclusion of other variables and thus the development of a more extensive and detailed picture of the model. Second, there was a lack of diversity in the sample, so future research could benefit from analyzing cultural and socioeconomic differences as recent studies have indicated that self-compassion and depression vary across cultures (Lou et al., 2022). Likewise, it would be valuable to test whether these same associations occur within a clinical context. Third, in the present study, children’s emotional regulation difficulties were only measured in W1, so the bidirectionality between the child’s and parents’ variables was not analyzed. This could serve to complete what was proposed by the transactional theory of development (Sameroff, 2009). Therefore, future longitudinal studies could determine whether there are bidirectional relationships between children’s and parents’ difficulties to better address these effects within the family context (Larrucea-Iruretagoyena & Orue, 2023). Additionally, future studies may examine whether the absence of gender differences observed in this study may be attributed to the fact that fathers are increasingly assuming a more active role in child rearing. Finally, the results of the present study should be read with caution since the variable of emotional regulation difficulties may encompass a wide range of psychological difficulties. Therefore, future research is encouraged to test whether the relationships found in this study also apply to more specific psychological symptoms.
Despite these limitations, the present study not only contributed relevant results about the effect that child’s emotional regulation difficulties have on their parents’ depressive symptoms, but also evidenced the capacity of self-compassion to mitigate this effect. This could be very beneficial for future interventions designed in the family context (Han & Kim, 2023). Among other approaches, these interventions could include adaptations of mindfulness-based cognitive therapy to cultivate self-compassion among parents.
Regarding the design of the study, this work was based on a multi-informant, multilevel, and longitudinal approach, which responds to many of the calls made in previous studies. In addition, balanced samples in terms of the number of mothers and fathers were used, as this has been one of the most underlined problems in the literature on family studies. In this way, it was provided important data on issues related to parenting and parental mental health, as drawing global conclusions from samples generally composed of mothers would be impossible.
The present study stressed the need for further research on the effect of children’s difficulties on their parents’ well-being, since the focus so far has been on analyzing the effects of parents’ difficulties on their children, and it seems that the tendency is for there to be bidirectionality between them. In addition, this study provides evidence of a possible protective factor that may help mitigate this negative effect on parents’ mental health. Thus, future researchers are encouraged to explore other protective factors that may be of service in interventions in the family context.
Acknowledgements
We would like to thank all the families for their participation in this study.
Statements and Declarations
Ethics Approval
The Ethics Committee of the University of Deusto approved this study (Ref. ETK-36/20–21).
Informed Consent
Informed consent was obtained from all parents, and assent was obtained from all adolescent participants.
Conflict of Interest
The authors have no competing interests to declare that are relevant to the content of this article.
Use of Artificial Intelligence
Artificial Intelligence was not used.
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