Psychosomatics 45:500-507, December 2004
© 2004 The Academy of Psychosomatic Medicine
Family, Health, and Adolescence
Nicolas Zdanowicz, M.D., Ph.D.,
Pascal Janne, Ph.D., and
Christine Reynaert, M.D., Ph.D.
Received June 5, 2003; revision received March 23, 2004; accepted April 7, 2004. From the Université Catholique de Louvain. Address reprint requests to Dr. Zdanowicz, Service de psychosomatique, Clinique de Mont-Godinne, Université Catholique de Louvain, 5530 Yvoir, Belgium; nicolas.zdanowicz{at}pscl.ucl.ac.be (e-mail).
|
ABSTRACT
|
The present research examined the correlations between types of family relationships and adolescents' beliefs about their own health. "Healthy" adolescents (N=765) completed both the Multidimensional Health Locus of Control questionnaire and Olson's scale assessing family cohesion and adaptability. They were compared to a group of 358 adolescents diagnosed with mental disorders. Cohesion in the family of origin was a significant factor in the adolescents' feeling of control over their own health as well as in the level of power they attributed to other people. Among these adolescents, adaptability of the family of origin was positively correlated with stronger feelings of control over one's own health and with lower levels of belief in chance. Family relations were significant in the adolescents' acquisition of feelings of control over their own health.
Key Words: adolescence • family • Olson • MHLC
|
INTRODUCTION
|
About 10 years ago, the development of preventive medicine became a major objective in many developed countries. The populations that are targeted to benefit from these campaigns of prevention are teenagers, young adults, and their parents. These populations are considered more likely to be influenced and to adopt behaviors in favor of their health. However, what do we really know about the evolution of health at this age and about its correlates with family dynamics? Until now, the largest number of studies on the evolution of health have been conducted with the Multidimensional Health Locus of Control (MHLC),1 even though new instruments for addressing these issue have since been developed.
In 1978, Wallston and colleagues developed the MHLC, which measures the respondent's beliefs about his or her responsibility in determining his or her own health status. This scale is multidimensional as it enables the identification of three different types of belief: two are "external" in nature, and one is "internal." Internally controlled individuals tend to believe that the reinforcements they encounter depend on the behaviors they perform. This dimension is measured with the subscale for "internality health locus of control." Externally controlled individuals tend to believe 1) that their health is either the result of chance or fate (this belief is assessed by the subscale for "chance health locus of control") or 2) that it results from others' actions (this belief is assessed by the subscale for "powerful others health locus of control"). Finally, the relation between internal and external tendencies can be calculated through the internality/externality ratio.2 The development of this scale has triggered considerable research, including a review by Pauwels et al.,3 which has indicated that, especially through primary and secondary individual preventive attitudes, the MHLC is a good predictor of respondents' medical as well as psychiatric health. It is nevertheless important to remember that, as with all scales, the MHLC suffers from several limitations and seems particularly less appropriate for assessing respondents' will to control and the value they assign to health.4
After reviewing the relevant literature on this topic, we found only two studies that have used the MHLC with adolescents. Besides confirming the usefulness and stability of the MHLC during adolescence, the study by Stanton et al.5 also pointed at gender differences in locus of control. More specifically, Stanton and associates found that the levels of attribution of health locus of control to chance and to powerful others vary between the ages of 13 and 15 but only among female subjects. The second study, conducted by Nada-Raja and colleagues,6 included more than 800 young people 15 years old. While this research did not study the influence of age on MHLC scores, it still found gender differences in levels of internality regarding health locus of control (higher levels among male subjects) and in levels of attribution to powerful others (lower among male subjects). In addition, the preceding research showed that negative life events and mothers' beliefs about their own locus of control had a significant influence on their daughters' level of internality. A positive correlation of internality with a high level of social support and/or self-perception of strength was also found among male subjects.
One particularity of the MHLC is that item 7, which is used to assess belief in powerful others as a locus of control over health, measures respondents' belief in the influence their families have over their own health. However, we do not know of any study that has ever been published on this particular item. No study has demonstrated whether, as we can reasonably assume, people's attitudes toward their own health are influenced by their family's educational as well as relational patterns. Thus, while a particular family might promote in its members a sense of control over their individual health, another might promote a more fatalistic disposition. In addition to research measuring the relationship between MHLC scores and adolescence, other studies have used Olson's scale7 to investigate the relationship between family functioning and illness among adolescents. More precisely, Olson's circumplex model aims at assessing two dimensions (axes) of a given relational system at work: cohesion and adaptability. "Cohesion" is defined as "the emotional ties each member of a family develops towards the other members," and "adaptability" is defined as "the conjugal or family system's ability to change its power structure and relational rules and roles in response to a stressful situation or development." A self-rating version of this scale is the FACES III (Family Adaptability and Cohesion Evaluation Scale),8 which enables a quick, quantitative evaluation of the two axes, thereby describing the interactive and structural style within the system under study. The model is conceived in such a way that "family health" is found in the median values of the two axes. In other words, "family cohesion" is measured by a value found on the "separated-linked" continuum, and "system adaptability" is measured by a value found on the "structured-flexible" continuum.9 Studies with adolescents have shown significant differences in family functioning between families containing an adolescent member with psychiatric or medical pathology and families without an ill adolescent (Table 1).
View this table:
[in this window]
[in a new window]
|
TABLE 1. Previous Studies Using Olson's Scale7 to Assess the Cohesion and Adaptability of Families of Children or Adolescents With Psychiatric or Other Medical Illnesses
|
Thus, we have, on the one hand, some information about the evolution of feelings about one's control over one's health during adolescence and, on the other hand, information about the role played by family dynamics in some disorders. However, research on the effect of family dynamics on feelings about control over health is lacking. Our objective was to try to build a bridge between family dynamics and adolescents' attributions of responsibility for their own health. In order to test the hypothesis that these variables are associated, we studied the correlations between the functioning of the family of origin and the MHLC scores of a group of "healthy" adolescents and compared those to similar correlations for a group of adolescents with psychiatric disorders (henceforth referred to as "unhealthy" adolescents). For the latter group, we avoided selecting any particular pathology for two reasons. First, the research conducted with Olson's scale included a great variety of disorders (Table 1), and second, the research results described by Prange et al.15 and by us17 suggest that family characteristics are associated with vulnerability to disorders in general rather than to a particular one.
|
METHOD
|
The present research took place between December 1998 and June 1999. The subjects completed the MHLC and the FACES III questionnaires. We used Fontaine's French version of Olson's scale18 and Mortreu's French version of the MHLC.19
Participants and Procedure
The healthy subjects were selected by using two different strategies—a procedure that aimed at including adolescents from varied cohorts and backgrounds. The first recruitment took place in each of the 6 grades of three secondary public schools (i.e., with ages normally ranging from 12 to 18 years) in the province of Namur (Belgium). Under a psychiatrist's supervision, these adolescents were asked to answer a sociodemographic questionnaire (age, gender, high school level, nationality) and to complete the MHLC and Olson's scale assessing their family of origin. The second group of subjects was selected by 4th-year psychology students at the Catholic University of Louvain, who distributed to adolescents they were acquainted with an anonymous questionnaire whose items included sociodemographic variables (birth date and gender) as well as the MHLC and Olson's scale. It should be noted that the "healthy" subjects were considered normal by default. Thus, although they were not recruited in a hospital or another health facility, we cannot exclude the possibility that some of them might actually have been hospitalized for one or another reason. To limit this possibility and because of the frequency of depressive disorders at this age, the young people completed the Zung Self-Rating Depression Scale.20
The unhealthy group was constituted from data that were systematically collected from 1989 to December 1998 among hospitalized patients in the Psychosomatic Medicine and Psychopathology Units at the Mont-Godinne University Clinics of the Catholic University of Louvain. At the very beginning of their hospitalization, the patients systematically completed the MHLC and Olson's scale and provided general sociodemographic data (birth date and gender) under the supervision of a psychologist. For each patient it was the first hospitalization, the admission was voluntary, and the patient was not coming from any residential type of service. In an attempt to control the effect of the length of the enrollment period, every result was controlled by using the date of admission as a covariate. We disregarded these patients' diagnoses in order to respect the diagnostically nonspecific nature of our hypotheses. The patients' diagnoses are shown in Table 2 for information purposes only. Patients who were initially enrolled on the basis of DSM-III-R diagnoses have been rediagnosed with DSM-IV on the basis of their initial DSM-III-R diagnosis, symptoms at admission, and past psychiatric history. For the most frequent disorders, such as mood disorders, we have previously reported our results.21
Regardless of whether they belonged to the healthy or unhealthy group, the candidates had to be 1) between the ages of 13 and 25 years, 2) single or living as an unmarried couple, 3) unemployed, receiving public assistance, or a student. The World Health Organization22 proposed these three criteria as determining the "condition of adolescence." In order to further homogenize our groups, the subjects had to be Caucasian, French-speaking, and students.
Analysis
SPSS for Windows 95/98/NT Advanced Model 9.0S was used for our statistical analyses. Given the considerable number of observations, the necessity to analyze the influence of several covariates, and the need not to change statistical methods during the analysis, we used only parametric tests. Pearson's chi-square test was used to compare proportions. Pearson's r coefficient was used to assess correlations between continuous variables, eventually controlled for partial correlation (with a covariate). Student's t test was used for comparisons of quantitative variables. The significance levels were tendency, significance (p< 0.05), and strong significance (p<0.01). All the statistics were two-tailed. Results are displayed in the following order: analysis of the demographic variables (age and gender), discussion of the impact of these variables, comparisons of the scores for the two groups on Olson's scale and the MHLC, and hypothesis testing (results of the correlations between the MHLC and Olson's scale). Other standard demographic variables, such as ethnic origin, occupation, and educational level, were not considered relevant in the present study since the first two had already been established as criteria for selection in the research design and the educational level is directly dependent on age.
|
RESULTS
|
Ten healthy subjects exceeded the threshold score of 0.699 on the Zung scale (suspicion of depressive state), and 39 were excluded from the protocol because of missing data.
Demographic Characteristics
The total study group comprised 1,123 subjects, ages 13 to 25 years, with a mean age of 18.8 (SD=3). The unhealthy group included 358 subjects, ages 14 to 25, normally distributed, with a mean age of 20.5 (SD=3). The healthy group included 765 subjects, ages 13 to 25, normally distributed, with a mean age of 18.3 (SD=3). The difference in age between the healthy and unhealthy groups was statistically significant (t=13.18, df=1121, p<0.001).
In the healthy group, the sex ratio was 0.75 (329 men for 436 women) as compared to a sex ratio of 0.56 (129 men for 229 women) in the unhealthy group. This between-group difference was statistically significant (Pearson's  2=69.11, df=1, p<0.001).
Not only were the differences between the two groups in age and sex distribution meaningful, but previous research (see introduction) also suggests that both gender and age influence the results on the MHLC and Olson's scale. Consequently, it seems clear that these variables have to be controlled.
Groups Differences on MHLC and FACES III
As Table 3 shows, Student's t tests indicate significant differences both on the MHLC and Olson's scale between the healthy and unhealthy groups. These results replicate both the patterns typically found in the literature for the MHLC and Olson's scale (see introduction), i.e., more cohesive and adaptive families among healthy subjects, greater internality in regard to health locus of control, and less attribution of control over health to higher powers.23 Consequently, they can be considered as a control of the validity of this study.
View this table:
[in this window]
[in a new window]
|
TABLE 3. Scores on the Multidimensional Health Locus of Control Questionnaire (MHLC) and Olson's Scale of Family Cohesion and Adaptability for 765 Healthy Adolescents and 358 Adolescents Hospitalized for Psychiatric Disorders
|
Hypothesis Testing
Table 4 confirms our hypothesis about a link between beliefs about control over health and family dynamics. For the entire study group, there were positive relationships between cohesion in the family of origin and the results for internality and belief in powerful others' control over health. A positive relationship was also found between family adaptability and the results for internality and the internality/externality ratio. Finally, a negative relationship was observed between family adaptability and belief that chance controls health.
View this table:
[in this window]
[in a new window]
|
TABLE 4. Correlations, Controlled for Gender and Age, Between Scores on the Multidimensional Health Locus of Control Questionnaire (MHLC) and Olson's Scale of Family Cohesion and Adaptability for Healthy Adolescents and Adolescents Hospitalized for Psychiatric Disorders
|
If we examine the influence of the dichotomous variable of belonging to either the healthy or unhealthy group, we can add three observations. First, this dichotomous variable does not seem to influence the relationship between family cohesion and internality (2=0.63, df=1, p=0.43), but in contrast, the relationship between cohesion and belief in powerful others as a health locus of control appears stronger (r2) and more genuine (p) among the healthy subjects (2=3.66, df=1, p=0.05). This finding is troubling since we know that in the healthy group cohesion is high and the belief in powerful others as a locus of control is less (see Table 3). However, we also know that among the healthy adolescents, age has a negative influence on the belief in powerful others' control (Figure 1) and that age is also correlated with decreasing family cohesion (see Figure 2). Hence, the findings seem to suggest that the combined effects of the interaction of age with belief in powerful others and the interaction of age with family cohesion are stronger than the effect of the interaction between family cohesion and belief in powerful others (in which the influences of age and gender do not appear because they are statistically controlled). It thus appears that the first two combined effects tend to limit or even weaken the latter.
View larger version (49K):
[in this window]
[in a new window]
|
FIGURE 1. Relationship Between Age and Belief in Powerful Others' Control Over Healtha for 762 Healthy Adolescentsb
aThis measure is a subscale of the Multidimensional Health Locus of Control questionnaire.1
bPearson's partial correlation between healthy subjects' age and belief in powerful others as a locus of control over health, controlled for gender: r=–0.17, p<0.001. Data were derived from previous research.26
|
View larger version (42K):
[in this window]
[in a new window]
|
FIGURE 2. Relationship Between Age and Family Cohesiona for 734 Healthy Adolescentsb
aThis measure is one of the axes in Olson's scale for family cohesion and adaptability.7
bPearson's partial correlation between healthy subjects' age and family cohesion, controlled for gender: r=–0.10, p=0.008. Data were derived from previous research.26
|
Second, the dichotomous variable, healthy versus unhealthy, does not seem to influence the association either between family adaptability and the internality/externality ratio (2=0.92, df=1, p=0.34) or between family adaptability and internality (2=2.30, df=1, p=0.13).
Third, with regard to the link between family adaptability and belief in chance as a locus of control over health, it is interesting that whereas the adaptability of the healthy adolescents' families was correlated with less belief in chance, this influence was not present among the unhealthy adolescents (2=3.78, df=1, p=0.05).
|
DISCUSSION
|
In the studies that have explored the relationships between family variables and pathology among adolescents (Table 1), the most interesting finding we uncovered is their "missing link" aspect. Indeed, while reviewing this literature, one can only wonder about the origin of the mechanisms that link family functioning to pathology. In the present research, it appears that the style of family dynamics is significant in the formation of adolescents' attributive judgments as to who or what is responsible for their health.
It thus appears that a cohesive family supports its adolescent members' beliefs in their own ability to influence their health, as does a minimal degree of trust in "the other" (which is necessary in a patient-doctor relationship). It also appears that flexible families ensure an internal/external attributive judgmental process that fosters their adolescent members' belief in their sense of worth and diminishes healthy adolescents' attribution of health control to chance or "fate."
It is true that one can also interpret the results presented here differently and approach the pathology-family link in the reverse order: i.e., How does illness influence our beliefs, and how do these beliefs shape our family system? If we cannot disregard the fact that our interactions partially follow this logic as well, its probability is nevertheless quite weak for at least two reasons. First, it makes more intuitive sense to assume that the direction of these interrelations originates in the family, as it is itself "formative" of beliefs about locus of control, than to assume a reverse order. Second, although we know of no prospective research on the MHLC (except the 5-year longitudinal work by Thomas and Hooper,24 which studied the probability of social integration among 65-year-olds as a function of their MHLC scores rather than investigating pathology proper), there is indirect evidence that supports this point of view.3 Thus, as is the case in adult diabetes, for which internality can be correlated with patients' better control over pathology,25 we can posit that beliefs about locus of control influence health rather than the other way around.
Limitations
The main restriction on the present study is the weak proportion of explained variance, but we would have been astonished (and a bit worried) if attitudes toward health depended solely on family variables. The second restriction regarding the validity of our results is the duration of recruitment of the unhealthy subjects. Indeed, the fact of having controlled the results for the date of hospitalization does not allow us to totally exclude sociocultural conditions (e.g., divorce, illness of parents), pharmacologic treatment, or other factors (e.g., childhood medical conditions) that might have influenced our results.
Conclusions
From a practical point of view, we wonder whether the enhancement of health among young people would warrant the deployment of preventive measures whereby parents would be encouraged to adopt more flexible and cohesive health-related attitudes with their adolescent children rather than rigid and poorly structured ones. Such a message could be conveyed both during medical consultations and through media campaigns. From a therapeutic point of view, the results of this study suggest that parents must be supported in the same sense during their adolescent children's pathological afflictions. From a theoretical point of view, it seems that we can speak of a developmental aspect of health in the same way that we speak of a developmental aspect of pathology. Health, especially one's effort to control one's health, is an ever-evolving attribute from childhood to adulthood to which we must attend. Furthermore, such a developmental approach to heath is not reduced to a child or an adolescent's individual condition but is developing in the midst of a family system. This theoretical aspect evokes the psychodynamic clinician's emphasis on adolescence as a salutary crisis that contributes to health. This theoretical developmental perspective nevertheless introduces a fundamental difference: it approaches pathology as an insufficient development of health, rather than as a manifestation that contributes to more health. Of course, we need outcome studies to confirm all this.
|
REFERENCES
|
- Wallston KA, Wallston BS, De Vellis R: Development of the multidimensional health locus of control (MHLC) scale. Health Educ Mono 1978; 6:160–170
- Reynaert C, Janne P, Delire V, Pirard M, Randour P, Collard E, Installe E, Coche E, Cassiers L: To control or to be controlled? from health locus of control to morphine during patient-controlled analgesia. Psychother Psychosom 1995; 64:74–81[Medline]
- Pauwels A, Janne P, Reynaert C: De différents modèles de croyances envers la santé au vécu subjéctif de contrôle vis-à-vis de la santé: une tentative d'approche intégrative. J Thérapie Comportementale et Cognitive 1999; 9:99–107
- Conner M, Norman P: Predicting Health Behaviour. Buckingham, UK, Open University Press, 1999
- Stanton WR, Nada-Raja S, Langley J: Stability in the structure of health locus of control among adolescents. Br J Clin Psychol 1995; 34:279–287
- Nada-Raja S, McGee R, Williams S: Health beliefs among New Zealand adolescents. J Paed Child Health 1994; 30:523–529[Medline]
- Olson DH, Killorin E: Clinical Rating Scale for Circumplex Model (revised version). St Paul, University of Minnesota, Family Social Science, 1985
- Olson DH: Circumplex Model VII: validation studies and FACES III. Fam Process 1986; 25:337–351[CrossRef][Medline]
- Reynaert C, Janne P, Zdanowicz N, Vause M, Vervier J-F: Description du système familial par ses membres: le sentiment d'autonomie. Cahiers des Sciences Familiales et Sexologiques 1993; 17:95–111
- Coburn J, Ganong L: Bulimic and non-bulimic college females' perceptions of family adaptability and family cohesion. J Adv Nurs 1989; 14:27–33[Medline]
- Kashani JH, Allan WD, Dahlmeier JM, Rezvani M, Reid JC: An examination of family functioning utilizing the circumplex model in psychiatrically hospitalized children with depression. J Affect Disord 1995; 35:65–73[Medline]
- Lawler MK, Volk R, Viviani N, Mengel MB: Individual and family factors impacting diabetic control in the adolescent: a preliminary study. Matern Child Nurs J 1990; 19:331–345[Medline]
- Lundholm JK, Waters JE: Dysfunctional family systems: relationships to disordered eating behaviors among university women. J Subst Abuse 1991; 3:97–106[Medline]
- Michaels CR, Lewandowski LJ: Psychological adjustment and family functioning of boys with learning disabilities. J Learn Disabil 1990; 23:446–450
- Prange ME, Greenbaum PE, Silver SE, Friedman RM, Kutash K, Duchnowski AJ: Family functioning and psychopathology among adolescents with severe emotional disturbances. J Abnorm Child Psychol 1992; 20:83–102[CrossRef][Medline]
- Tubiana RN, Moret L, Czernichow P, Chwalow J: The association of poor adherence and acute metabolic disorders with low levels of cohesion and adaptability in families with diabetic children. Acta Paediatr 1998; 87:741–746[CrossRef][Medline]
- Zdanowicz N, Janne P, Reynaert C: Role of the family during adolescence (abstract). Eur Psychiatry 2002; 17(suppl 1):114–115
- Fontaine P: Famille saines: esquisse conceptuelle générale, in Dictionnaire Clinique des Thérapies Familiales Systémiques. Edited by Benoît JC, Malarewicz JA. Paris, Editions Sociales Francaises, 1988, pp 267–282
- Janne P: De la douleur à la plainte: pour une compréhension psychosomatique de l'ischémie myocardique dite silencieuse (doctoral thesis). Yvoir, Belgium, Université Catholique de Louvain, Faculté de Psychologie et des Sciences de l'Education, 1989
- Zung WWK: A self-rating depression scale. Arch Gen Psychiatry 1965; 12:63–70
- Zdanowicz N, Coremans E, Verdicq S, Reynaert C: La dépression à l'adolescence: une maladie de l'internalité? (abstract). Arch Pédiatr 2002; 9(suppl 2):298
- Organisation Mondiale de la Santé/World Health Organization: La santé des jeunes: un défi, un espoir. Geneva, OMS/WHO, 1994
- Zdanowicz N, Reynaert C, Janne P: Comparaison du MHLC entre une population d'adolescents "sains" et "en souffrance." Rev Psychiatr Psychol Med 2002; 54:27–33
- Thomas PD, Hooper EM: Healthy elderly: social bonds and locus of control. Res Nurs Health 1983; 6:11–16[Medline]
- Reynaert C, Janne P, Donckier J, Buysschaert M, Zdanowicz N, Lejeune D, Cassiers L: Locus of control and metabolic control. Diabète Métab 1995; 21:180–187[Medline]
- Zdanowicz N, Janne P, Reynaert Ch: Changes in health locus of control during adolescence of student. Eur J Psychiatry 2003; 2:107–115
Get information about faster international access.
Privacy Policy
Copyright © 2004
Academy of Psychosomatic Medicine.
All rights reserved.
Home
| Search
| Current Issue
| Past Issues
| Subscribe
| All APPI Journals
| Help
| Contact Us
|
TOP
ABSTRACT
INTRODUCTION
