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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