MCHB EPI Atlanta Conference
 
December 5 - 7, 2006

You've Got to Accentuate the Positive:

Research on Protective Factors for Child Well-Being

LISA YOUNGBLADE: It’s really a great privilege to follow these three speakers because many of the things that I want to say to you they’ve already said, and so I may focus a little bit different, following some of the main points that they’ve made, and focus on a segment of the population: Children and Youth with Special Healthcare Needs, and think about positive development for this part of the population. And there’s a good reason to focus on this group depending on how you choose to define children with special healthcare needs. Estimates range from five to 30 percent of the population of children under the age of 18 manifests a special healthcare need. And let me just be upfront that throughout this talk I’m going to be using a fairly broad definition of special healthcare needs in defining children as having one as having sort of a functional limitation or service needs above and beyond what typically developing children need. So I’m not going to be focusing on any specific disorder or disability but really as a group.

We also spend a lot of time thinking about programs to promote health and educational outcomes for children with special healthcare needs, and so I thought it would be really helpful to think about, “What about positive youth development for this?” Not just access to healthcare, not just maintaining through school but really focusing on promoting positive development.

So as you’ve heard from the speakers, there are a number of comprehensive models available to predict problem behavior and if you look at the literature there’s a long history on this--several decades worth of work of really comprehensive models that have tried to reduced risky behavior, externalizing kinds of behavior, conduct disorder, problems at school, and so on. Much more recently, the past decade or so, really an attention to promoting optimal development. What’s interesting about these models is that they really focus on the fact that kids live in multiple, overlapping, intersecting worlds. There are multiple layers of individual’s environments that we need to take into account and thinking about development, whether it’s negative development or positive development. These include contexts like family, schools, peers, neighborhoods--the things you’ve been thinking about and hearing about this morning.

What’s interesting about the field of positive youth development is that it really highlights the fact that, to promote optimal development we don’t only need to focus on reducing negative behavior but really growing the strength and competencies and the positive aspects of development that prepare youth for the future. The other speakers have spoken profoundly about this so I’ll just leave it there.

Again, you’ve heard several people talk about critical dimensions of important social context that are related to positive youth development. Things like interpersonal connections, regulation of behavior through monitoring supervision, the promotion of autonomy, safety supervision monitoring, the provision of resources and opportunities for skill building, and really importantly, the integration across settings. I thought about this last night. Everybody is talking about the news—anybody who’s seen CNN last night with the brilliant thing that New York City has done by banning trans fats by July 2007 in restaurants in the city. That’s part of it as it’ll only be so effective as getting schools on board, families on board, kids on board, and so on. So really focusing on integrating across settings. But when all these things are evident--when there’s connection, when there’s regulation, when we promote autonomy, when there’s safety, when there’s supervision--when these things are evident you thrive and there’s very good empirical evidence about that.

Nevertheless, when you look at the literature, there are a number of concerns, and I just wanted to briefly highlight them. Particularly early on in the field of studying optimal development, there really, tends to be a focus on single rather than multiple context, or if there are multiple context, a focus on schools and families, or schools and communities, or families and communities, but not necessarily the multiple layers that children are in. And this becomes even more compounded when you think about each context, not only are there multiple of them, but they have promotive factors, things that promote health and well-being, as well as risk factors that lead to detrimental outcome. So it gets very complicated.

On top of that, if you think about a comprehensive model or picture understanding about optimal youth development, not only are there multiple context, multiple risk and promotive factors at each level of the context but there’s multiple developmental outcomes we should be paying attention to. Because again, a focus on optimal development includes both reducing negative behavior as well as promoting positive behavior and health and well-being.

Another issue when you look at the literature is really samples, and it’s interesting to talk to a group of epidemiologists. You all are in the field where you get worried with sample sizes of 500, “Wait, that’s bad.” I come from a field where we do cartwheels with sample sizes of 500. So again, it limits what we can say about generalized ability. And specifically, I wanted to talk for a moment about generalized ability, the children and youth with special health care needs. Now, it’s an interesting thing because on one hand you might expect there to be differences certainly on outcome measures. So you might expect there to be for example different on--differences on academic outcomes or cognitive scores for children with the developmental disability versus typically developing children or you might expect differences in externalizing behavior between the children with--child with autism versus a child without. So you might expect mean level differences on any kind of developmental outcome that you look at. On the other hand, if you think about the processes and what predicts those outcomes, you might not expect so many differences. So a warm close parent-child relationship is likely to be associated with things like self-esteem, social competence, and so on whether or not a child has the disability. So the outcome level might be different but the process is similar. It’s also interesting to think about context differences because particularly for you--those of you in the health field, you spend a lot of time thinking about the health care system, public health programs, and so on. Certain things like access to health care, having a usual source of care, having health insurance which is highly correlated with having a usual source of care might--is important for all children but might be a little bit more important for kids who have complex needs. So perhaps that developmental context variable to the health care system may have different--a differential impact on outcome. So the issue of generalized ability to--on children and youth with special health care needs is an interesting one.

Now, I want to illustrate some of these. So we took a look at the 2003 National Survey of Children’s Health to try and develop a model of this multi-layer that has risk and promotive factors and I’ll talk about those in a minute. We focused on adolescents and we heard from other panels about the importance of adolescents. It’s a time of transition. Another reason for looking at it for us was in a time of transition you see things sometimes in greater belief than you see earlier. So a lot of things I’m going to talk about today are likely applicable to much younger children. But because of other developmental processes that are going out with adolescence you might see them a little more saliently.

So our interest was in comparing risk and promotive factors for families who had adolescents with identified special health care needs, again, a very broad definition of special health care needs and families with no identified special health care need on a range of positive and negative outcomes. We, as I’ve just explained, hypothesized, there’ll probably differences in outcome based on special health care need status. We predicted though for all kids that--I think about my grandmother who always said, “Good comes from good. Bad comes from bad.” So our predictions about how contextual factors would work--were much in line with that then negative risk factors in context would be associated with negative increase, negative behaviors decrease positive outcomes. The same would be true about positive promotive factors within context in positive outcomes. We also hypothesized that all of these levels if they’re entered simultaneously into progression, family, school, and community, and health care, variables would be significantly associated with outcomes. But then we’re also interested in exploring the salience of these different variables based on special health care need status.

Now, we picked the National Survey of Children’s Health for a couple of reasons and I think this is an interesting one for you to take back to your states because one of the great things about this you can look at it--the data nationally, you could also look at it at a state level. It’s a random digital sample of households with children under the age 18. Parents and guardians are the respondents. Just to give you a sense of the sample size, there’s 102,353 completed interviews about 55 percent response rate and there are sample rates included in the data that can generalize to non-institutional--the non-institutionalized population of children in each state and nationwide and we’re going to be focusing on the national data.

Just to give you an overview of the demographics, I’m not going to spend a lot of time on these. Although these--we use as control variables in all our analysis. About 42,305 of the surveys were for adolescents age 11 to 17. On average, the script was about 14 years of age, half female, generally healthy although 21 percent met a screening criteria for special health care need, primarily White, non-Hispanic about 60 percent had household education of greater than high school in terms of the respondent, about half of it, kids who are in two parent homes and about half or between 100 and 400 percent of the federal poverty level.

So we focused on six commonly studied developmental outcomes. We had three positive indicators and three negative indicators. Again, the idea is you want to promote positive, reduce negative. So social competence referred to things like social skills, respect for others, empathy, conflict resolution, health promoting behavior was a composite of things like good diet, appropriate exercise, getting enough sleep, having an appropriate body weight. Self-esteem referred to just a single item about sort of self-efficacy. Externalizing behavior was a composite of aggression, conduct problems so really acting out kind of aggressive behavior. Internalizing behavior referred to depression, anxiety, social withdrawals so taking things internally. And then academic problems were achievement learning difficulties and grade repetitions. So let me just show you some descriptive information about this. Now, the numbers on the side are a little bit irrelevant, I wanted to put everything on one slide. So for the next couple of descriptive slides the comparison you want to make is for each variable between the blue and the purple bar not across variables. So the fact that social competence bars are much higher than the others is just because of the scaling of the variable, not because there’s a lot more of it or it’s more important than the other variables. But if you look across this, it’s interesting to see that there are--and these are all significant differences that adolescence with special healthcare needs are reported to have less social competence, engage in less health-promoting behavior than their counterparts with no special healthcare needs, also greater levels of externalizing and internalizing behavior as well as academic problems. But I want you to focus on the self-esteem one. Contrary to our expectations, kids with special health care needs were reported to have higher self-esteem than kids without. And it’s an interesting thing to think about it in the context of their health challenge, and so it might be that a health challenges sometimes the agent that provokes resilience and the pride that comes from achievement, from--in the face of adversity maybe what’s being reflected in the self-esteem. So the point is there’s some significant differences in these outcome variables based on special health care needs status.

We also looked at a number of predictive domains and I’m going to go through this a little bit quickly. What’s great about this data set is that it was very well designed in terms of being inclusive. There’s a lot of information about different aspects of family functioning and these are just the sampling of things that you could choose to look at. So we divided up our list of predictors into family promotive, family risk behavior, so things like family engagement in the child’s life. So does the parent know who the kid’s friends are? What they’re doing after school and so on? Family closeness, parent-child closeness, healthy role modeling, so do parents eat well, exercise, model good appropriate behavior? Household rules, this is primarily about TV. TV’s a huge one. We’ve heard that earlier. Communication skills whether the child is safe and home, whether parents are coping well with parenthood and whether they have emotional support available. On the risks side, we looked at several variables including family aggression, so the level of conflict in the household. An interesting one called parent aggravation and this really essentially is a conglomerate of variables that are anger, frustration, feeling that you’re sacrificing for your child kind of a resentment variable. And then negative health modeling, sort of family smoking. So again, just to look descriptively between families, adolescents those with special health care needs and those who don’t. We looked at, again, differences and for the most part there aren’t huge differences. I highlighted the one at the bottom right-hand corner, on aggravation. This one’s going to come up to be later in the talk in a very salient predictor but again, if you look across these different things, their main differences are small, they’re all relatively statistically significant. Parents of adolescents with special healthcare needs report greater engagement in the teen’s life but less family aggressions, it’s a good thing. There’s also a pattern of findings though that highlight challenges for these families: less closeness, less primal health, and healthy role modeling, and greater levels of aggravation, as I said.

Just briefly, there’s much less information in here although quite a bit about school and neighborhood variables. And so we were able to select several promotive and risk factors so school and neighborhood safety to the extent that the child goes to a safe school and there’s perceptions of the neighborhood being relatively safe. Connectedness so that kids have somebody they can talk to, so identified place that other parents trust. And then on the flip side sort of negative risks, so the perception that there’s bad influence in the neighborhood and then school violence and bullying, and from the--and what I mean by bullying is that their child is being bullied, not that they are being the bully, then we also looked at healthcare. So again, some differences on the whole, kids with--families of children with special health care needs reported greater safety, greater connection, and less negative influence, and less perceptions of school violence. And not surprisingly children with special health care need were more likely to report--their parents were more likely to report the usual source of care.

So let me just very briefly kind of go through some multi-variant things and get to the kind of the key points here. We did a bunch of regressions, six regressions run separately for the families with special health care needs, families without. All the variables were entered simultaneously so that’s 12 regressions, multiple variables and if you trust me, this is a lot of numbers. So what I’m going to do is just kind of summarize some findings. The first is how well worth these contextual factors able to explain outcomes? If you look across this board, on the whole we did pretty good. We explained between nine and about 56 percent of the variance. Did very poorly in terms of predicting health-promoting behavior. Luckily, there’s lots of other sessions today and tomorrow for you to learn some more about that, but that was when we were not so successful at predicting. We were more successful at predicting negative outcomes and positive outcomes against sort of not surprising given the state or the literature that we know we’ve had a longer history in trying to do this. And on the whole, a little bit better at predicting variance in the model for families without a special health care need child as compared to those with one except in the case of self-esteem. So overall impression, if you look across these 12 things, there’s a lot of numbers to put on the slide. The risk in promotive factors function in a way we hypothesize so good things tend to go with good things, so closeness, engagement and so on, lead to things like social competence, self-esteem, and plus externalizing behavior, less internalize behavior, and less academic problems. What’s interesting about this is again, you look across 12 regressions, there’s not much difference for most of the predictors between the two groups. Most of the coefficients are rather small although they’re all statistically significant, but there’s some interesting findings and I just wanted to point out a couple of them, and that resonate with what you’ve heard before. The first is parent-child closeness was a strong predictor of self-esteem unless problematic academic outcomes for both kids with special health care needs and those without but was more strong, was a stronger--had a bigger effect for kids with special health care needs. I mean there’s a long tradition. You heard about it earlier, about the importance of connection in the family. Parent-child communication: promotes social competence and less externalizing behavior, again, for both groups but more so for kids with special health care needs. So talking to kids matters. Dinnertime conversation: understanding what their lives are about and promoting communication. Parent aggravation: I highlighted earlier that this had a strong effect and was one of the most consistent effects in these analysis. All of which it was true for all kids, but all of which were amplified for families with adolescence with a special health care needs. So less social competence, lower self-esteem, greater externalizing, internalizing behavior, and greater academic problems. So if you’re thinking about programs and working with families, a focus on the stress that family’s have and trying to alleviate some of that is likely to have very good outcomes for families. The last thing I wanted to say is that about the regret--two last things. The next to last thing is that school violence and bullying, so being bullied not they’re doing it, being bullied but strongly related to less self-esteem, greater internalizing behavior, and more academic problems for adolescents with special health care needs as well as those without.

Now, there’s a quirky little finding and I just wanted to highlight it. I don’t want to make too much of it because I think it really needs to be replicated, but to me it speaks to resilience. And that is that there is a small positive relationship between social competence in kids with special health care need and school violence. So in those really tough environments and you can think about kids in schools who might have disability, and maybe somewhat different than other kids. For some part of those kids, some percentages of those kids they were able to turn it into a strength factor.

The last thing I want to say is that the usual source of care had similar results for both groups of kids that kids that had a usual source of care, had regular contact with the health care environment evinced greater social competence and less externalizing and internalizing behavior and fewer academic problems. It was a small but significant effect. It was similar for both groups of kids. But what’s really interesting about this to me is if you look at the literature when we have a lot of information in models in the health care world; typically don’t look at psychosocial and academic outcomes. Similarly, we have a lot of models and predictors in the psychological, developmental psychology world, educational world that look at multiple predictors but don’t necessarily include the health care system. I find it rather interesting to see this connection.

All right, so what does this suggest and I am done. Any efforts, and this you’ve heard repeatedly to ameliorate problem behavior as well as to promote healthy and competent behavior need to include multiple salient contacts. We need to combine efforts in looking at families, schools, peers, communities, health care system. And for focusing on the population of children with special health care needs, there are mean differences and outcomes, but the processes and the resources necessary to promote optimal development are similar for both groups of kids. So thinking about programs and thinking about carve outs for kids with special health care needs and should we be focusing on them? Yes, absolutely. We should be identifying them. But we should be thinking about the same sorts of resources, strengths, promotive factors that we do with typically developing children. And when those provisions are available, you thrive.

This is on the handout that you have. There’s information about places you can go. I just want to highlight a couple of them. You’ve heard about Assets for Youth, there’s a link on that one pager to the Search Institute. It’s a place to think about operationalizing as you work in programs and data collection. Operationalizing what’s meant by different levels of the environment. The National Survey of Children’s Health is on the CDC website under slates. Again, there’s a link on the page. And then the University of Washington, The Seattle Social Development Project has done a lot towards operationalizing community, strengths and community risks at multiple levels of family, schools, et cetera. And there are measures there that you can find, too. So thank you.