| HOME | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|---|
| ||||||||||||||||||||||||||||||||
TOPIC 6. CUMULATIVE ADVERSITY AND HEALTH INEQUALITIES |
1 Iowa State University, Ames.
2 University of California–Davis.
Address correspondence to K. A. S. Wickrama, Institute for Social and Behavioral Research, 2625 North Loop Drive, Suite 500, ISU Research Park, Ames, IA 50010-8296. E-mail: s2kas{at}iastate.edu
Abstract
Objectives. The authors' objective was to investigate processes that account for the transmission of socioeconomic adversity from one generation to the next through mental disorder and physical illness.
Methods. The present longitudinal study of 485 youth used structural equation models to test an intergenerational model proposing that: (a) stressful childhood experiences in the family of origin contribute to the development of mental disorder and physical illness during adolescence both directly and indirectly through disruption in an adolescent's transition to young adulthood; (b) during the transition to adulthood, mental disorders and physical illnesses increase in part through reciprocal influence; and (c) both the levels of and changes in mental disorder and physical illness are independently associated with adverse life circumstances during early adulthood.
Results. Findings generally supported the hypothesized model. Family of origin adversity contributed to the impaired mental and physical health of adolescents. This influence was largely mediated through adolescents' disrupted transition to young adulthood. Levels of both mental and physical illnesses independently contributed to young adult adversity. Levels of physical health problems influenced changes in mental disorders. Changes in both mental and physical illnesses are also associated with young adult adversity.
Discussion. The study demonstrates key mediating pathways in the intergenerational transmission of social adversity and also highlights the importance of improving both socioeconomic and health resources for adolescents.
LIFE circumstances may increase risk for adolescent mental disorder and physical illness. In particular, various stressful life events and economic difficulties representative of family adversity can contribute to the impaired physical health of adolescents through various mechanisms (Bradley & Corwyn, 2002
). First, children from socioeconomically disadvantaged families are more likely to be born with physical health problems. Second, adverse family circumstances impinge on the ability to provide proper nutrition, timely immunization, and adequate access to health care for children. Third, poor parental practices, as well as poor health and behavior training associated with family adversity may also contribute to adolescent poor physical health. Fourth, chronically stressful life experiences of adolescents associated with family adversity may exert direct deleterious effects on biological functioning. Finally, family adversity imposes structural constraints on choices regarding health-related behaviors of adolescents that could result in an unhealthy lifestyle (Wickrama, Conger, Wallace, & Elder, 1999).
Numerous studies also demonstrate an association between family adversity and adolescent mental health problems (Conger et al., 1994). Family adversity may directly contribute to an adolescent's diminished psychological resources, sense of continuing entrapment, anger, hopelessness, frustration, and other negative emotions (Brown, 2002).
Stressful daily experiences also have psychological consequences for parents. Psychological problems, such as depression, can contribute to low commitment to parenting, parents' rejecting and hostile behavior toward their children, and other ineffective parental practices. Parent psychological and behavioral problems may directly contribute to adolescent mental health problems (Conger et al., 1994).
Adverse life circumstances are significantly linked to a person's location in the socioeconomic structure (Dohrenwend et al., 1998). Social stress research documents that individuals of lower socioeconomic status (SES) experience more stressful events and circumstances than do people of higher SES (Dohrenwend et al.). Most chronic diseases are overrepresented among individuals of lower SES (House et al., 1994). However, only a few studies have shown that an emergent pattern of health inequalities is already evident by late adolescence (Wickrama, Conger, Wallace, and Elder, 2003). In the present study, we use family income, parental education, and family structure (two parent vs divorced single parent) as three indicators of SES. Thus, the theoretical model for this study begins with the socioeconomic position of parents, which is hypothesized to influence family adversity defined by stressful life circumstances (see Figure 1, Path 1). Furthermore, we propose that family adversity will directly influence adolescent mental disorder and physical illness (Paths 2a and 2b).
|
). For most adolescents, the "rush to adulthood" associated with a disrupted transition represents a chronically stressful life situation that places excessive demands on an individual not sufficiently prepared emotionally, socially, or financially for adult and family responsibilities (Elder, George, & Shanahan, 1996). Recent research on the transition to adulthood has demonstrated the stressfulness and negative health consequences of early nonnormative events among youth, especially during the transition to adulthood (Wheaton & Gotlib, 1997; Wickrama et al., 2003). Thus, we also expect that family adversity may contribute to youth mental and physical health through adolescents' disrupted development (Figure 1, Paths 3, 3a, and 3b).
Mutual Influences Between Mental Disorder and Physical Illness
Previous studies show that children with serious physical health problems are also significantly more likely to have mental health problems. Physical health problems may contribute to mental health problems both directly and indirectly. First, internalized problems such as depression may be caused physiologically by physical illness itself or through side effects resulting from medications used to treat a disease. Second, the degree of functional impairment, predictability of course, and change in physical appearance may contribute to mental health problems (Lewinsohn, Seeley, Hibbard, Rohde, & Sack, 1996). Finally, socioeconomic failures and lack of achievement due to impaired physical health may also erode mental health (Figure 1, Paths 4a and 4b).
Influence of Mental Disorder and Physical Illness on Adult Adversity
Evidence shows that both mental and physical illness during adolescence may influence young adult life circumstances through several mechanisms (Miech, Caspi, Moffit, Wright, & Silva, 1999). First, adolescents with mental and physical health problems may not develop the competencies necessary for typical levels of social and educational attainment. Second, depressed individuals, compared with nondepressed persons, receive less social support, limiting a resource that can aid individual success (Figure 1, Paths 5a and 5b).
In summary, we consider a two-step process hypothesized to account for the transmission of socioeconomic problems from one generation to the next through mental disorder and physical illness (Hayward & Gorman, 2004). Consistent with the social causation hypothesis (Bradley & Corwyn, 2002; House et al., 1994; O'Rand & Hamil-Lucker, 2004), we first examine the possibility that early adversity in the family of origin influences adolescent mental disorder and physical illness directly and indirectly through increased risk for disrupted transition to young adulthood. Consistent with the social selection hypothesis (Miech et al., 1999), we also propose that impaired health leads to greater adversity in the lives of young adults. This conceptual framework suggests that mental disorders and physical illnesses will be mutually influential. Thus, we hypothesize that both level and change in mental disorder and physical illness will independently contribute to adverse life circumstances during young adulthood (Figure 1, Paths 5a and 5b).
METHODS
Sample and Procedures
Data come from the Family Transitions Project, which combined participants from two earlier studies: the Iowa Youth and Families Project (IYFP) and the Iowa Single Parent Project (SPP). The IYFP began in 1989 and involved 451 families in eight Iowa counties. Families were eligible to participate if the target adolescent (7th grade, median age of 12.7 years) and a sibling within 4 years of the target's age lived with two biological parents (see Wickrama et al., 2003, for further sample description). The SPP began in 1991 with selection of households that contained a target adolescent in the same grade as those in the IYFP. The SPP included data from 107 divorced single mothers.
We tested our theoretical model by combining data from the IYFP and SPP samples. An attrition analysis examined possible differences in demographic characteristics between families that dropped out of either the IYFP or SPP studies and those used in this study. Only mean levels of parental education differed across groups with lower levels reported by dropouts relative to complete cases but only among IYFP families. We used pairwise deletion to obtain an analysis sample of complete cases containing 485 target youth (394 from IYFP and 91 from SPP). In addition, we used listwise deletion to obtain a second analysis sample of complete cases that contained data from 445 families. We conducted analyses within the structural equation modeling framework using covariance matrices produced by both pairwise and listwise deletion. Because use of both matrices produced essentially identical results, we present findings for the larger pairwise deletion sample.
Measures
Family SES during adolescence
Family SES was captured using measures of family structure, parental education, and family income in 1991. Family income was measured by parent reported total earned income of the family from all sources (does not include child support and welfare). For adolescents from two-parent families, father's and mother's education level in 1991 were summed to form the measure of parental education. The same procedure was followed for adolescents from divorced families except that mother's level of education was doubled to construct the parental education measure because father's education was unavailable. Family structure was coded 1 for single-parent families and 2 for two-parent families.
Family adversities during adolescence
The construct of family adversity was defined using mothers' reports in 1991 of family economic problems and negative life events based on lists adapted from Dohrenwend, Krasnoff, Alexander, and Dohrenwend (1978). The measure of economic problems was created by summing "yes" responses to items indicating whether families experienced (yes = 1) or did not experience (no = 0) each of 25 economic problems including receipt of government assistance; sale of property because of financial difficulties; loan foreclosure; cut in salary; financial loss in business, investments, or property; use of savings because of financial problems; sale or relinquishment of farmland, business property, or other property because of financial problems; loss of a job; or other financial difficulties. Similarly, the measure of negative life events was created by summing mothers' "yes" responses to stressful life events the family had experienced (yes = 1) or not experienced (no = 0) during the previous 12 months, including death of a family member, becoming the victim of a crime, involvement in a lawsuit, or other negative events.
Disrupted transition to young adulthood
Adolescent disrupted transition was indexed by counting (yes = 1; no = 0) nonnormative life events and experiences reported by adolescents in 1994 (including dropping out of high school and unemployment at age 18 as well as sexual intercourse, pregnancy, cohabitation, marriage, or leaving home) that occurred early in comparison to national normative ages (Wickrama, Merten, & Elder, in press). For example, the average age of first sexual intercourse among males and females in the United States is 16 (Centers for Disease Control and Prevention, 1996), whereas the average childbearing age for women in the United States at the start of this decade was 24.6 years (Mathews & Hamilton, 2002). In addition, Kreiter (2003) found that young adults in the United States report being 21.1 years old on average when they leave home. The disrupted transition index ranged from 0 to 7 with a mean of 0.51.
Mental disorders during the transition to adulthood
Mental disorders for the target youth were assessed using the University of Michigan's modified Composite International Diagnostic Interview (UM-CIDI; Kessler, 1994). This fully structured diagnostic interview generates Diagnostic and Statistical Manual of Mental Disorders (3rd edition, revised) (American Psychiatric Association, 1987) estimates of psychiatric disorder onsets and recurrences for adolescents and adults. We used the UM-CIDI to estimate both affective (manic episode, hypomania, major depressive episode, and dysthymia), and anxiety (social phobia, simple phobia, panic disorder, agoraphobia without panic disorder, generalized anxiety, and posttraumatic stress) disorders in 1997 and 1999. The mental disorder measure involved a count of these disorders experienced by the year of measurement. Because Kessler and colleagues (1994) have shown that aggregation of disorders has the greatest significance for clinical impairment and social costs, we focused on the number of different or recurring disorders.
Physical illness during the transition to adulthood
The measure of physical illness was constructed using respondent reports of symptoms and diseases. Respondents indicated (yes = 1, no = 0) whether during the past year they had one or more of the symptoms for 47 physical illnesses during 1997 and 1999. Because physical illness information was only available for 1997 and 1999, we included mental disorder measures from 1997 and 1999 only in the following analyses to directly compare morbidity across both domains.
Adversity during early adulthood
Young adult adversity was captured by indicators of young adults' economic problems and negative life events. Target youth were asked to indicate whether they had experienced economic problems or negative life events during the past 12 months (yes = 1, no = 0). The lists of economic problems and negative life events were modified slightly from the measures used in the family of origin to better reflect experiences of early adulthood. Items such as "have problems with married children," "have a child who got involved with drug use," and "place a parent in a nursing home" were removed from negative life events, and items such as "lose a scholarship or financial aid for attending school" and "not work enough hours because you are attending school" were added to economic problems. The measures of economic problems and negative life events were created by summing "yes" responses to corresponding items (complete lists of economic problems and negative life events can be obtained from the authors upon request).
RESULTS
We estimated a latent-variable structural equation model to evaluate the complete theoretical model in Figure 1. The analysis using covariance matrices as input into LISREL VIII (Scientific Software International, Chicago, IL) provided maximum likelihood estimates of the model coefficients. Figure 2 presents the results from this analysis. All factor loadings were statistically significant and substantial, ranging from.56 to.72. As shown in Figure 2, each dimension of SES significantly predicted family adversity (e.g., ß = –.17, p <.05 for income to adversity). In addition, family adversity predicted the level of adolescent physical illness (ß =.20) and a disrupted transition to adulthood (ß =.28). Adolescent disrupted transition predicted the level of mental disorder in 1997 (ß =.20) and changes in both mental disorder and physical illness from 1997 to 1999 (ß =.18 and.17, respectively). The level of mental disorder correlated with physical illness in 1997 (r =.28) even after controlling for family adversity (not shown in the figure). This indicates that the comorbid association between mental disorder and physical illness is not spurious due to the effect of family adversity and a disrupted adolescent transition.
|
DISCUSSION
The findings of this study generally supported the theoretical model. As expected, SES in the first generation was associated with adversity. Coresiding two-parent families experienced fewer stressful life events than did divorced single-mother families. This reflects enhanced adults' "person power" of two-parent families. Better educated parents and higher income households reported fewer stressful events and conditions than did parents with less education and lower incomes. Also as expected, adversity in one generation predicted adversity in the next. Consistent with theory, disrupted transition to young adulthood coupled with mental and physical health problems occurring during the transition to adulthood mediated intergenerational continuity in social adversity. These results underscore the importance of adversity for multiple domains of health. Moreover, they provide additional evidence that the transition to adulthood is a period of increasing vulnerability for onset of mental disorder and the emergence of physical health problems (Wickrama et al., 2003). These findings suggest that a disrupted transition to young adulthood is largely responsible for relative changes in health status as well as shaping both mental and physical health trajectories during this period of life. Lack of an association between adolescent disrupted transition and initial level of physical illness coupled with the effect of disrupted transition on change in physical health indicate that it takes several years for physical health consequences stemming from disrupted transition to manifest.
Consistent with the social causation perspective, our findings indicate that family adversity produces negative health consequences initiating a possibly self-perpetuating process. These results are consistent with the life-course perspective in that early stressful family experiences appear to produce cumulative consequences from one stage of the life course to another (Elder et al., 1996; Wickrama et al., 2003). We also found that family adversity influences change in mental health indirectly through the initial level of physical illness. The cycle continues as poor mental and physical health selects youth into adverse life circumstances. That is, youth from disadvantaged families may be trapped in a self-perpetuating cycle of adversity and poor health across the life course involving both social causation and social selection processes. As a result, poor health, adversity, and inequality may accumulate over the life course and across generations.
Although the findings from the present study are generally consistent with the hypothesized model, several factors limit the generalizability of the results. First, these analyses must be replicated with urban samples. Second, replications must involve a broader cross-section of the population that includes greater ethnic diversity. Third, research with more objective physical health measures including physician reports and biological data is needed. Fourth, future investigations need to extend the period available for studying changes in health. The two waves of health data available in this study provide a bare minimum of information for drawing inferences about change. Future research should also seek to extend these findings by examining additional factors that may operate to mediate or moderate the observed associations among the present study constructs.
Despite noted limitations in this research, the findings from this study have several theoretical and practical implications. First, this study demonstrated that early social disadvantage has a robust influence on both the physical and mental health of adolescents. These findings suggest that negative health outcomes may be diminished by programs that reduce the impact of family disadvantage and associated stressful events. Such programs may more importantly reduce family influence on adolescent disrupted transition to adulthood curbing subsequent influence on mental and physical health. The successes of intervention programs illustrate the importance of involving not only disadvantaged families but also local communities and schools in the initiation and implementation of interventions (see Durlak & Wells, 1997). Examples of such community- and school-involved efforts include Development-in-Context Evaluation (DICE; Weiss & Greene, 1992) and community coalitions (Spoth, Greenberg, Bierman, & Redmond, 2004). These coalitions foster a multilevel approach to promote and develop resilient factors useful for coping with adolescent health risks at both the family and individual level. Our findings also indicate that improved understanding of the comorbidities and reciprocities between mental and physical health may lead to more effective health interventions and medical treatments that consider these mutual influences.
Acknowledgments
During the past several years, support for this research has come from multiple sources including the National Institute of Mental Health (MH00567, MH19734, MH43270, MH48165, MH51361), the National Institute on Drug Abuse (DA05347), the Bureau of Maternal and Child Health (MCJ-109572), the MacArthur Foundation Research Network on Successful Adolescent Development among Youth in High-Risk Settings, and the Iowa Agriculture and Home Economics Experiment Station (Project No. 3320).
References
This article has been cited by other articles:
 |
|
 |
|
  M. McEniry, A. Palloni, A. L. Davila, and A. G. Gurucharri Early Life Exposure to Poor Nutrition and Infectious Diseases and Its Effects on the Health of Older Puerto Rican Adults J. Gerontol. B. Psychol. Sci. Soc. Sci., November 1, 2008; 63(6): S337 - S348. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||
| HOME | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|---|
