The
impact of caring and connectedness on adolescent health and well-being
M.
D. Resnick, L. J. Harris and R. W. Blum 1993
University of Minnesota Children Youth and Family Consortium. Permission
is granted to create and distribute copies of this document for noncommercial
purposes provided that the author and CYFC receive acknowledgment
and this notice is included.
By M. D. Resnick (1), L. J. Harris (2) and R. W. Blum (3)
(1) Division of Health Management and Policy, (2) National Adolescent
Health Resource Centre and (3) Division of General Pediatrics and
Adolescent Health, University of Minnesota, Minneapolis, Minnesota,
United States. Accepted for publication 23 July 1993.
Abstract:
This study of over 36,000 7th-12th grade students focused on protective
factors against the quietly disturbed and acting out behaviours, which
together represent the major social morbidities of adolescence. Multivariate
models developed separately for girls and boys repeatedly demonstrated
the protective function of caring and connectedness in the lives of
youth, particularly a sense of connectedness to family and to school.
A sense of spirituality, as well as low family stress (referring to
poverty, unemployment substance use and domestic violence) also functioned
as protective factors. Measures of caring and connectedness surpassed
demographic variables such as two parent vs. single parent family
structure as protective factors against high risk behaviours. Interventions
for youth at-risk must critically examine the ways in which opportunities
for a sense of belonging may be fostered, particularly among youth
who do not report any significant caring relationships in their lives
with adults.
Key words: adolescent health; caring; protective factors; resiliency.
Numerous
reports have documented the shift from biological to social causes
of morbidity and mortality among adolescents. These trends belie the
traditional view that adolescence is a time of optimal health and
well-being (1-7). Other trends, particularly the rising proportion
of children and adolescents living in poverty, patterns of school
drop out and poor school performance, disaffection, alienation, and
the pervasive impact of racism and limited economic opportunities
lend urgency to the need for communities to respond to the health
and social needs of their youth, and for policy makers and funders
to help assure a better fit between health and social programmes and
the youth problems they are intended to address (8-16).
In
1986, a National Invitational Conference on the Health Futures of
Adolescents was convened with support from the Maternal and Child
Health Bureau in Washington DC. The goal of that conference was: to
identify the major health related concerns that will face youth through
the year 2000, delineate the present state of knowledge in each of
the major issues, and develop a blueprint for the next 15 years for
research, demonstration programming and training (17).
The
report on that conference which was published in the November 1988
supplement of the Journal of Adolescent Health Care featured the recommendations
of seven work groups, compiled from the 136 experts participating
in the conference from the fields of public health, medicine, clinical
and developmental psychology, social ecology and health education,
nursing nutrition, sociology and social work. One key recommendation
which cross-cut the work group reports was the need for development
of comprehensive population- based studies of adolescent health problems,
concerns, risk behaviours and resiliency so that prevention and intervention
programmes could be responsive to the most salient issues affecting
youths within communities. Further, it was recommended that interventions
aimed at promoting adolescent health and reducing risk behaviours
respond to the clustering of those behaviours, with an understanding
that social morbidities tend to co-occur, contrary to the assumptions
of narrowly defined categorical programmes (18). On an international
scale, the same proposal was incorporated as a top priority in the
recommendations of the Scientific and Technical Advisory Group to
the Adolescent Health Section of the World Health Organization. This
recommendation emphasized the value of developing comprehensive, population
based studies of adolescent health and risk behaviours so that communities,
states and nations could prioritize among adolescent health issues,
identify protective factors that reduce the likelihood of health compromising
behaviours, and move effectively to promote the well-being of adolescents
at greatest risk (19).
In
the United States, the Maternal and Child Health Bureau funded a major
initiative called the Adolescent Health Database Project, to demonstrate
the feasibility of establishing a statewide database of health status
indicators, risk behaviours, and adolescent health concerns. This
project enabled the development, testing, and widespread use of a
standardized instrument (the Adolescent Health Survey) in order to
develop a comprehensive adolescent health database for programme and
policy development, planning and research purposes. The survey has
been administered to over 60 000 adolescents nationally, including
statewide surveys in Minnesota, Alaska, Delaware, and a national survey
of rural, reservation based American Indian youth. The purpose of
this comprehensive assessment of adolescent health, risk behaviours
and resiliency factors is to provide valid, timely information to
key decision makers and information users, including legislators,
health, social service and education professionals, youth workers,
parents, and others involved with or on behalf of youth.
The
primary vehicle for dissemination of information obtained from these
surveys has been the development of local feedback reports to each
participating school or community, as well as publications designed
for professional, scholarly audiences (20-27). These have been augmented
by the development of numerous specialty reports in the form of monographs
that have been distributed to thousands of decision makers at the
state, regional, national and international levels (28-33). Data from
the Adolescent Health Survey have been utilized for advocacy, curriculum.
programme and policy development at the state and national levels,
and for grant writing by community based agencies that have utilized
the survey data to identify key health issues among adolescents, prioritize
among them, and seek funding to initiate or further develop services
for youth.
More
recently, attention is being turned to analyses of these large scale
datasets that focus on resiliency and protective factors in the lives
of young people. Much of scientific inquiry in adolescent health has
traditionally focused on the correlates of problemness or pathology.
Here, a focus on resiliency means that inquiry is directed toward
understanding success and well- being, identifying those factors that
buffer against the stresses of everyday life that might otherwise
result in adverse physical, social or psychological outcomes for youth
(34-38). Longitudinal studies of resiliency have incorporated biological,
psychological, familial, and broader social variables into models
that predict who, in adolescence or adulthood will be characterized
by high functional effectiveness and life satisfaction. A repeated
finding in these analyses has been the centrality of caring relationships
between children and adults, including relationships within and outside
the family, for the development of resilient adolescents and young
adults (39, 40).
This
focus on caring as a protective factor presents an important direction
for programmes, policy and practice. The shift toward social morbidities
among young people means that the major threats to their health and
well-being are increasingly rooted in the organization, economics,
opportunities and expectations of everyday life. This means that the
search for protective factors against a variety of adverse outcomes
must include an understanding of adolescents' social relationships
and feelings of connections to others as they experience and live
the developmental changes of their physical, social and psychological
selves. Unfortunately, the presence of nurturing relationships between
adults and children cannot be treated as a given. Rather, problems
stemming from youth disaffection and alienation are seen as a growing
by-product of post-modern society. Sociologist Phillip Slater made
the observation over 20 years ago that three human desires are deeply
and uniquely frustrated by Western culture (41). These include:
(1) The desire for community-the wish to live in trust and fraternal
co-operation with one's fellows in a fetal and visible collective
entity.
(2) The desire for engagement-the wish to come directly to grips
with social and interpersonal problems and to confront on equal
terms an environment which is not composed of ego-extensions.
(3) The desire for dependence-the wish to share responsibility for
the control of one's impulses and the direction of one's life. Reflecting
these sentiments, Michael Lerner describes the misguided emphasis
on individuality in Western culture, which, like Slater, he regarded
as frustrating the deeply felt yearning for M. D. Resnick et al.
connectedness between people, working to create meaning and happiness
in the context of an interdependent community of human beings (42).
With
these perspectives as a framework, the current analysis focuses on
the experience of caring and connectedness as protective, nourishing
factors in the biographies of young people. Put another way, does
the experience of caring, and the feeling of connectedness to others
demonstrably result in greater well being, and correspondingly less
health compromising behaviours among teenagers? This report describes
recent secondary analyses of the Minnesota Adolescent Health Survey,
including an examination of protective factors against two clusters
of risk behaviours (acting out behaviours and quietly disturbed behaviours)
that characterize the predominant morbidities of youth.
METHODS
The datasource for this analysis is the Minnesota Adolescent Health
Database, derived from a sample of 36254 7th-12th grade public school
students throughout Minnesota who completed the Adolescent Health
Survey. This comprehensive questionnaire elicits self-report information
from adolescents in the following areas: demographic and biographical
data: relation ships with family, friends and other adults; school
performance and conduct: personal worries and concerns; body image;
help seeking and utilization of services; nutrition and eating behaviour;
disordered eating; sexual behaviours; sexual orientation; substance
use; mental health and suicidal involvement, physical and sexual abuse;
anti- social behaviours; other risk-taking behaviours.
Questionnaire
development, content, and psychometric properties of scales and indices
are described in other publications (20, 21, 23-28). Schools were
selected through a multi-stage stratified cluster sampling design,
stratified by school district size, with random sampling occurring
within each stratum for each grade level. In each school, all students
within designated grades were asked to complete the questionnaire
within a classroom setting. Trained survey administrators were available
to answer questions, to ensure standardized test administration, and
to protect confidentiality.
Scales
and risk behaviour clusters
Initial
work on the dataset focused on development and refinement of measures
to be used in subsequent analyses related to caring and connectedness.
Standard data reduction and scaling techniques were used to develop
psychometrically robust indicators of key constructs including six
separate measures related to caring as well as aggregated scales of
caring and connectedness. These measures were tested for internal
consistency, construct validity and examined for their distributional
properties. Final, usable scales and indicators were created as both
continuous and ordinal measures, to facilitate their use in cross-tabular
form and in multivariate analyses (Harris, L., Resnick, M. D., Rosenwinkel,
K., and Glum, R. W, Technical Report on the Adolescent Health Survey:
Psychometric Properties of Scales and Indices. Minneapolis: University
of Minnesota Adolescent Health Training Program, 1990, unpubl. data).
Drawing
upon theoretical and empirical work that has identified the co-occurrence
of high-risk behaviours among adolescents, composite variables were
created to tap the major morbidities of adolescents as behavioural
clusters (13, 43-46). Nine individual scales were subject to factor
analysis, identifying two broader clusters of risk behaviours, each
with factor loadings of 0.5 or greater (noted in parentheses after
each variable name). These clusters included Acting Out Behaviours
and Quietly Disturbed Behaviours. Acting out behaviours included polydrug
use (0.737), school absenteeism (0.684), risk of unintentional injury
(0.677), (e.g. drinking and driving, not wearing seat-belts, use of
motorcycles or all-terrain vehicles without a helmet, driving in the
back of open pick-up trucks), pregnancy risk (0.606), (including risk
of either becoming pregnant or causing a pregnancy, based on a scaled
combination of frequency of sexual intercourse and type and frequency
of contraceptive use), and delinquency risk (0.556). Quietly disturbed
behaviours included poor body image (-0.800), disordered eating (0.785),
(hinging, deliberately vomiting as a strategy for weight loss, chronic
dieting, fear of loss of control of eating), emotional stress (0.686),
and suicidal involvement (0.514), (ideation or actual attempts). Generally,
boys were more characterized by the acting out behaviours, girls by
the quietly disturbed behaviours, although there was cross-over by
gender, particularly among girls. For example, of those girls who
exhibited two or more quietly disturbed behaviours, 80% were at high
risk for at least one acting out behaviour. Of those engaging in two
or more acting out behaviours, 65% also engaged in at least one quietly
disturbed behaviour. Some 80% of students fell into the high-risk
category for at least one of the behaviours, with about 10% at high-risk
for four or more behaviours.
With the completion of scale development and assessment of the clustering
of high-risk behaviours, the identification of protective factors
for each cluster was accomplished through the development of four
discriminant function models, permitting a multivariate identification
of variables that best sort or differentiate comparison groups. Protective
factors were separately assessed for boys and girls against each of
the two clusters of high risk behaviours. Particular attention was
directed to the presence of measures of caring and connectedness as
salient protective factors across each of these analyses. It was hypothesized
that in comparison with demographic variables, the indicators related
to caring and connectedness would emerge as more powerful protective
factors against high-risk behaviours.
RESULTS
Results are presented for the four stepwise discriminant models which
describe protective factors in the order of their explanatory power.
As noted in Table 1, a common set of factors in each of the four discriminant
models related to various aspects of connectedness. As hypothesized,
these measures were more powerful protective factors than demographic
variables against both clusters of high-risk behaviours, for both
boys and girls. Among girls, the most powerful protective factor against
the quietly disturbed behaviours was family connectedness, referring
to adolescents who indicated they enjoyed, felt close to and cared
for by family members. This variable alone explained 12.5% of variance
in group classification. School connectedness, the second explanatory
variable in the stepwise equation, referred to students who enjoyed
school, experiencing a sense of belonging and connectedness to it
(which did not always correspond with high academic performance).
Family stress, the third explanatory variable, was a composite measure
of parental unemployment, poverty, domestic violence, and parental
substance use, with low family stress functioning as a protective
factor. Spiritual connectedness referred to those students who defined
themselves as spiritual or religious individuals. The last factor,
age, was positively related to risk, with younger adolescents indicating
less involvement in quietly disturbed behaviours than their older
counterparts. Together, these five variables correctly classified
71.8% of adolescents, including close to 9 in 10 of those at low risk
for quietly disturbed behaviours (Table 2).
A
similar set of explainer variables functioned as protective factors
against the acting out behaviours for girls, as described in Table
3. In addition, the last variable to remain in the stepwise model
indicated that girls in two parent families were less likely than
those in single parent families to be involved in acting out behaviours.
These five variables correctly classified 71.2% of girls, including
close to 8 in 10 at high risk for acting out behaviours.
Among
boys, three protective factors against the quietly disturbed behaviours
were identified, including family connectedness, school connectedness,
and low family stress. These correctly classified 71.2% of boys overall,
including 72% of those at low risk for quietly disturbed behaviours,
and 64% of those at high risk. The final discriminant model for acting
out behaviours in boys included the full set of variables found in
the girls' model for this behaviour cluster. School connectedness
was the single most powerful variable in the equation, with two parent
family entering as the last explanatory variable in the model.
DISCUSSION
Protective factors were identified for quietly disturbed and acting
out behaviours, representing two clusters of health compromising behaviours
that encompass the major social morbidities of adolescents. Separate
analyses were conducted for boys and girls. Across all four models,
measures of caring and connectedness predominated as protective factors.
While family structure and socioeconomic status are both prominent
in popular explanations of high-risk behaviours among youth (expressed
most frequently as concern about the 'breakdown' of families and family
values, particularly among resource-deprived families), socioeconomic
status did not remain in any of the models, meaning that adolescents
could not be differentiated as low or high-risk for quietly disturbed
and acting out behaviours on the basis of their families' socioeconomic
status, after the preceding variables were taken into account. As
far as two parent vs. single parent status was concerned, two parent
family composition proved to be the weakest, though significant, explanatory
variable in the models describing protective factors against the acting
out behaviours. Results indicated that boys and girls from two parent
families were somewhat less likely to be involved in such behaviours
than their counterparts from single parent families. The most powerful
protective factors across models were family and school connectedness.
What is striking about the family connectedness variable is that this
factor referred to a sense of belonging and closeness to family, in
whatever way family was comprised or defined by the adolescent. Thus,
the centrality of families in the promotion of well-being among young
people was reaffirmed, but without specifying the form or composition
that families must take in order to serve this protective function.
At the core of family connectedness is the adolescent's experience
of being connected to at least one caring, competent adult in a loving,
nurturing relationship. Similar results have been reported by investigators
assessing resiliency and well-being among youth who otherwise would
be expected to be at high risk for multiple adverse health and social
outcomes (47-52).
School
connectedness was the most salient protective factor for both boys
and girls against the acting out behaviours, second in importance
after family connectedness for the quietly disturbed behaviours. These
findings underscore the importance of schools as a primary source
of connectedness with adults. and with the broader community as perceived
and experienced by the adolescent. The analysis does not reveal whether
a sense of connectedness with school resides in relationships with
particular teachers, coaches, or other personnel, or through a generalized
feeling of belonging within the overall school environment. With school
connectedness superseding family connectedness as a protective factor
against the acting out behaviours, we infer that schools can and do
play a vital role in reducing the likelihood of health-jeopardizing
behaviours among girls and boys by providing a sense of belonging
that may not also be provided by other sources such as family or peers.
Supporting this inference from cross-sectional data is the fact that
academic remediation is foremost among intervention strategies directed
at reducing the risk of such acting out behaviours as teenage pregnancy
and juvenile delinquency (10-12, 13, 54). But the findings also suggest
that academic performance is but one component of this sense of connectedness,
since the underlying construct was composed of both an indicator of
typical school performance and attitude toward school. Thus, for students
who may not be academically proficient, and for whom there may be
only marginal room for improvement, it is particularly important that
schools provide vehicles that promote a sense of belonging, by providing
opportunities to develop and demonstrate other forms of competency,
including work-study, technical skills, and involvement in visual,
musical and dramatic arts. The salience of school connectedness as
a protective factor against adolescent high-risk behaviours strengthens
the arguments of educators, health officials, and youth advocates
that there must be closer collaboration between the health and education
sectors in order to promote both the well-being and educability of
young people (10, 55, 56).
The
importance of religious or spiritual connectedness in these multivariate
assessments is consistent with other analyses that have demonstrated
that adolescents who describe themselves as more religiously observant
or affiliated with religious institutions are less likely to engage
in high-risk behaviours than their counterparts (43). This finding
suggests the important roles that parents and religious institutions
can play in fostering spirituality in young people, as well as a sense
of belonging and connectedness with religious institutions which can
enable positive peer and adult relationships and social experiences
(57).
There
are important research questions that flow from these analyses. Specifically,
at what point in the life trajectory of an adolescent are the protective
effects of caring and connectedness simply too late? In other words,
if a young person has been socialized in a climate of uncertainty,
fear and disaffection, can adult connectedness, positive environmental
consistency, and the nurturance of confidence and competence, which
are all the hallmarks of successful interventions, overcome the impetus
toward distress and self-destructive behaviours? Paediatrics as a
field has always maintained that early intervention is preferable
over addressing serious needs after-the-fact. In public health, primary
prevention is far superior to secondary prevention, given the opportunity
for early identification and intervention with people at risk. So,
for health and social service professionals, educators, youth workers
and parents, the critical intervention question becomes: in the absence
of opportunities or initiatives for primary prevention of the social
morbidities of youth, what 'package' of interventions will be most
effective beyond the point of primary prevention, when young people
have already embarked on behaviours that seriously increase the likelihood
of 'rotten outcomes'?
We
know from the literature on programmes for youth at risk, that for
interventions to successfully deter adolescents away from destructiveness
and lowered lifelong effectiveness, the intervention must be as intense
as the need itself (9). Our analyses indicate that fostering a sense
of caring and connectedness between adolescents and adults should
be an integral part of interventions designed to promote resiliency
and protective factors, increase adolescents' competency and effective
functioning, and promote a sense of meaningful place in the world.
How this should best be done for very high-risk youth populations,
in our view, frames the pre eminent human services delivery questions
for the 1990s. Such questions are reminiscent of the treatment-outcome
models generated in pharmacy, medicine, and mental health research
over the past decade: what kinds of interventions or experiences,
provided to which group of adolescents, result in optimal out comes?
In other words, what works best with whom?
While
these analyses identify caring and connectedness as essential components
of health promotion, we recognize, as Mechanic recently noted, that
love alone cannot rectify a lifetime of neglect (58). Caring, while
extraordinarily important in the lives of young people, is not a substitute
for correcting fundamental threats to health, rooted in the economic
disparities that have become increasingly manifest due to both deliberate
government policies and a shifting economic infrastructure that strains
the ability of families and individuals to thrive or function. In
fact, the sense of disaffiliation of growing numbers of young people,
noted with alarm by many commentators (18), is accentuated by trends
in the economy which make it increasingly harder for families to earn
sufficient income with benefits, to meet the costs of housing, food,
and everyday living.
Our
models point to the protective function of low family stress, and
each of the elements of family stress measured within this construct,
including unemployment, substance abuse and domestic violence, are
directly associated with economic deprivation. Once deficits in connectedness
as well as heightened levels of family stress were adjusted or accounted
for, socioeconomic status did not enter into the multivariate assessments
of protective factors against health- compromising behaviours. But
lifting families out of poverty remains a most feasible strategy for
health promotion that can be addressed on the policy level. As an
age group, economic hardship is most keenly felt by the young.
Recently
released Census Bureau data in the United States underscore the widening
economic gap between old and young people spawned during the 1980s,
showing that, as a group, elderly people generally held their own
during the economic fluctuations of the decade, while the nation's
children increasingly slipped into poverty. Of those who became poor
in the decade of the 1980s, 25% were under 18 years of age, while
one in 25 was age 65 or older, owing in good measure to the indexing
of Social Security payments to inflation (59) and the fact that the
United States made a deliberate decision to eliminate poverty in a
large proportion of the elderly population through age-related entitlements.
No similar commitment has been made to children and youth. The need
for redress of this economic disparity was clearly articulated in
the United States by the National Commission on Children in its call
for progressive economic policies that would benefit children, youth,
and families (60). This bipartisan proposal represents an important
step beyond the popular political rhetoric that explains poverty and
its accompanying morbidities for children and youth with a conservative
moral determinism that exclusively blames those at highest risk for
their own predicament, with the accompanying assertion that as far
as remedy is concerned, 'nothing works' (61).
But the salience of caring and connectedness as protective factors
against the social morbidities of adolescents also suggests that more
than an economic determinism is needed to promote adolescent health
and well-being. We maintain that while reducing the prevalence of
poverty must remain an enduring goal for pro-child and pro-family
policy, those who craft and implement interventions to reduce the
quietly disturbed and acting out behaviours must also deliberate on
how and whether the elements of their interventions address the underlying
need for adolescent belonging. With the urge toward connectedness
representing one of our deepest human desires (42), caring as a conscious,
explicit quality must pervade the people and programmes that seek
to optimize the life course of adolescents, particularly those at
highest risk.
ACKNOWLEDGMENTS
The authors would like to acknowledge the Lilly Endowment, Inc.,
the Minnesota Women's Fund and the Maternal and Child Health Bureau
for their support of this research.
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