Published online October 1, 2007
PEDIATRICS Vol. 120 No. 4 October 2007, pp. e984-e991 (doi:10.1542/peds.2006-3172)
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ARTICLE

Family Breakup and Adolescents' Psychosocial Maladjustment: Public Health Implications of Family Disruptions

Christelle Roustit, MDa,b, Basile Chaix, PhDa,b and Pierre Chauvin, MD, PhDa,b,c

a Research Group on the Social Determinants of Health and Healthcare, INSERM U707, Paris, France
b Université Pierre et Marie Curie-Paris 6, UMR S 707, Paris, France
c Assistance Publique-Hôpitaux de Paris, Hôpital Saint Antoine, Department of Public Health, Paris, France


   ABSTRACT
TOP
 ABSTRACT
METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
OBJECTIVES. Recent changes in family structure are associated with an increase in psychosocial maladjustment in adolescents. We examined, from a public health intervention perspective, the association between family breakup and psychosocial maladjustment in adolescents and assessed the mediating role of family-functioning variables.

METHODS. We analyzed data from the Social and Health Survey of Children and Adolescents in Quebec, Montreal, Canada, which was conducted in 1999. Sample-weighted logistic regression analyses were performed to determine the risk of internalizing disorders, externalizing disorders, substance abuse, and alcohol consumption in relation to family breakups and family-functioning variables, after adjusting for socioeconomic factors.

RESULTS. All 4 of the indicators of psychosocial maladjustment were significantly associated with family breakup. The association between family breakups and internalizing disorders was mediated by parental psychological distress and low paternal emotional support. Independently, the witnessing of interparental violence was also strongly associated with internalizing disorders. For the other 3 outcomes, that is, externalizing disorders, substance abuse, and alcohol consumption, family breakup and family-functioning variables had independent effects.

CONCLUSIONS. Family-based interventions and social approaches are complementary support modalities for adolescents experiencing family disruptions.

Key Words: adolescent health • epidemiology • family issues • health promotion • socioeconomic factors

Abbreviations: ISQ—Institut de la Statistique du Québec • aOR—adjusted odds ratio • CI—confidence interval

Past literature suggests that changes in family structure over the last 3 decades may have had deleterious effects on the well-being of children at different developmental stages in childhood.1–3 Numerous studies have examined the consequences of parental divorce on children's scholastic performance, psychological adjustment, conduct, social competence, and relationships with their parents.4,5 These studies have found that children from divorced families experience lower levels of well-being across these domains than children from intact families.6 The consequences of these behavioral, psychological, and cognitive development impairments include higher risks of internalizing and externalizing disorders, substance abuse, and alcohol consumption in adolescence.7–9 Moreover, studies with a long-term follow-up design suggest a continuum between these disorders in childhood and social integration in adult life.10–12

Over the last 40 years, changes in family structure in industrialized countries may have had a significant impact on the mental health of the adolescent population, which is of decisive importance for public health.13,14 For instance, in Canada, with the adoption of the Divorce Act in 1968, the divorce rate increased fivefold15 from the late 1960s to the mid-1980s, and in the late 1980s ~74000 children were children of divorce.16 In the United States as well, where almost half of all marriages end in divorce, the divorce rate was 3.6 per thousand inhabitants in 2005 (or a total of 1.07 million divorces), which is still one of the highest in the world, even if it has been declining in recent years.17

Theoretical perspectives18 explaining the link between family breakup and negative outcomes in children emphasize 2 components of the child's developmental foundations: family functioning19 and the socioeconomic environment.20 The family stress perspective assumes that parenting competence is compromised by the parental psychological distress that results from marital separation or financial difficulties,21,22 whereas the investment perspective argues that a child's well-being is decreased by the possible dramatic decline in the standard of living in the custodial household caused by his or her parents' separation.

These 2 theoretical perspectives give rise to distinct types of preventive approaches that constitute a highly promising avenue for promoting adolescent health. First, family centered approaches are aimed at supporting parents to relieve their distress and improve the quality of the parent-child relationship. In the United States, preventive interventions have been developed, such as the Mother Program and the Mother Plus Child Program, which focus on improving effective coping, reducing negative thoughts about divorce stressors, increasing the father's access to the child, and reducing interparental conflict.23,24 Second, and concurrently, social programs for improving the living conditions of separated parents and their children have hinged on welfare policy issues involving societal changes.25,26 For instance, a comparison between the United States and northern European countries showed that, in the 1990s, <10% of Scandinavian children living in single-mother families resided in poor households (ie, with an income below half of the national median income per consumer unit), whereas the figure was ~60% in the United States.27

From a public health intervention perspective, many previous studies were limited in 2 ways. First, researchers failed to properly control for the effects of social and contextual factors, and, second, they did not make an operating choice when selecting quantifiable variables for their statistical analyses to make the results operational for use by legislative bodies. For these reasons, useful family-dysfunction variables as associated factors and/or mediators of the association between family breakups and psychosocial adaptation problems have been studied very little in the general population from a public health perspective. As well, these mediating factors need to be tested to better understand the effects of family breakups.

First, we investigated the association between family breakup experiences during childhood and internalizing and externalizing disorders, substance abuse, and alcohol consumption in adolescents. Then, after controlling for socioeconomic factors, we examined whether specific family-functioning conditions were associated with these different outcomes and wether they mediated some part of the effect of family breakups on psychosocial maladjustment.


   METHODS
TOP
 ABSTRACT
 METHODS
RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Subjects and Database
This study was based on data from the Social and Health Survey of Children and Adolescents,28 which was conducted in Quebec, Montreal, Canada, in 1999 by the Institut de la Statistique du Québec (ISQ). This cross-sectional survey was based on a 2-stage cluster random sample of 2346 adolescent schoolchildren aged 13 and 16 years (and their 1983 parents). The sample was stratified according to the status of the area (remote areas and other areas), the language of instruction (French or English), and the school's private or public status. Data were collected by means of 2 self-administered questionnaires, 1 completed by the children and the other by their parents. The survey protocol and the data-collection process were submitted to the ISQ Ethics Committee for approval. Written informed consent was obtained from all of the adolescents, their parents, and the board of the participating schools.

Psychosocial Maladjustment Outcomes
Four main outcomes were studied: internalizing disorders, externalizing disorders, substance abuse, and alcohol consumption. Internalizing disorders were defined as the presence of a high level of psychological distress and/or a suicide attempt. The psychological distress index was evaluated by a 14-item scale measuring the occurrence of symptoms associated with depression, anxiety, reactive aggressiveness, and cognitive disorders during the week before the survey. The scale's internal and external validity was demonstrated by Deschesnes29 in a Quebec adolescent population in previous surveys. A high level of psychological distress corresponds with the highest quintile of this 0- to 100-range scale. Suicidal behavior was defined as ≥1 suicide attempt or suicidal thoughts over the child's lifetime.30

The externalizing disorder variable consisted of 2 indicators: behavioral disorders and/or oppositional attitudes (with or without defiance). These indicators were defined on the basis of items in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, of the American Psychiatric Association. Behavioral disorders implied the occurrence of ≥3 of the following disturbing behaviors during the previous 6 months: assault or fighting, cruelty to animals, damaging property, theft or fraud, or a serious violation of the law. Binary variables indicated the presence or absence of internalizing and externalizing disorders.

Substance abuse was defined as the use of marijuana or hashish, cocaine, solvents, hallucinogenics, unprescribed drugs, and/or other illicit drugs during the child's lifetime and was measured by the qualitative frequency scale of Botvin et al,31 which ranges from "never" to "each week." Alcohol consumption was reported as an intake frequency during the previous 12 months and was divided into 3 categories (never or only tried, once a month or less, or more than once a month).

Independent Variables
Family breakup was our main independent variable. It was defined according to the answer to the following question asked to the parent, "Does the child live with both of his/her biological parents?" (yes or no). If the child did not live with both of her or his parents, the reason was indicated (divorce or separation, death of the mother and/or father, no cohabitation, or other). In the case of separation or divorce, additional information was gathered on the duration of the separation, the interparental relationships, and the type of contact between the adolescent and the noncustodial parent.

In addition to basic individual sociodemographic factors (age and gender), 2 dimensions of individual factors were taken into account in our analyses: 3 family-functioning variables and 4 socioeconomic variables. The family-functioning dimension was composed of parental support, interparental violence, and parental psychological distress. Parental support was assessed separately for each parent by the adolescents using the scale developed by Schaefer32 and validated in a previous Canadian study.33 In the present study, the reference period was the previous month, and the score, which ranged from 0 to 16, was divided into 3 categories (low, moderate, and high). Interparental violence was based on items from the Conflict Tactics Scale, which contains questions about a large range of violent behaviors (from verbal abuse to physical assault).34,35 A dichotomous variable indicated whether the child had witnessed interparental violence during his or her lifetime. The parental psychological distress index was evaluated by a 14-item scale completed by the respondent parent. A high level of psychological distress corresponded with the highest quintile of the scale.

Family socioeconomic status was assessed on the basis of the following variables: parental education level (primary, secondary, professional training, college, or university), annual family income per consumer unit (5 categories: very poor, poor, low middle, high middle, or rich), food insecurity (yes or no), and parental employment status (≥1 employed parent or both parents unemployed).

Statistical Analysis
The first step of the analysis consisted of examining the association between family breakup and our 4 maladjustment outcomes. We estimated binary or multinomial logistic regression models for each of these outcomes while controlling for gender and socioeconomic variables. The models were estimated for each age group separately, then for the entire sample (the 2 age groups were pooled), with adjustment for age. Second, we tested the associations between the presence of family breakup and each of the family-functioning variables, using binary or multinomial logistic regression models adjusted for age, gender, and socioeconomic status. Lastly, the family-functioning variables significantly associated with family breakup at step 2 were introduced into the step 1 models. We compared the effects of family breakup before and after their introduction into the models (these final models enabled us to estimate the effect of the family-functioning variables as such when controlling for family breakup as well). Interactions between age and family breakup and between significant predictive variables in the final models were systematically tested. The data in the original ISQ data set were weighted to adjust for selection probabilities, to reduce nonresponse bias, and to adjust for population distribution. Proper SPSS 12.0 (SPSS Inc, Chicago, IL) procedures were used to perform the statistical analysis.


   RESULTS
TOP
 ABSTRACT
 METHODS
 RESULTS
DISCUSSION
 CONCLUSIONS
 REFERENCES
 
A total of 3256 adolescents were selected as per the research protocol. Of this number, 2993 were eligible for the survey, and of the eligible adolescents, 2346 (78.3%) completed the questionnaire, as did the parents of 1983 (66.2%) of these children. Among these 2346 teens, 28% lived in a non–2-biological-parent family.

In Table 1, the adjusted odds ratio (aOR) estimates the increase in the risk of psychopathological problems for children living in a nonnuclear family as compared with those living with both of their parents. The results confirm that, in the overall sample, adolescents not living with both of their biological parents were at higher risk for all of the psychosocial maladjustment outcomes, except psychological distress, that is, internalizing disorders, externalizing disorders, substance abuse, and alcohol consumption. This association was adjusted for the adolescents' age and gender and for family socioeconomic variables. No differences were observed when comparing the effect of family breakup between the 2 age groups, except for suicide attempts and oppositional attitudes, for which an effect was found only in the younger group (interaction terms indicated stronger effects of family breakup among the younger adolescents for these outcomes, P < .05). The higher risk of internalizing disorders (aOR: 1.38; 95% confidence interval [CI]: 1.07–1.79) for adolescents living in nonnuclear families in the overall sample was because of the strong effect on suicide attempt in the 13-year age group (aOR: 3.65; 95% CI: 1.61–8.30).


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  		TABLE 1 Associations Between Family Breakup and Psychosocial Maladjustment as Outcome Variables

 
Table 2 shows the independent effect of living in a nonnuclear family on selected family-functioning variables from logistic regression models adjusted for age, gender, and socioeconomic status variables. Living in a 1-biological-parent household was significantly associated with a low level of maternal or paternal emotional support and with parental psychological distress. However, adolescents living in a nonnuclear family had not witnessed more interparental violence during their lifetime than adolescents living with both of their parents. All of the associations were similar in both age groups, with smaller P values in the 13-year-old age group.


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  		TABLE 2 Associations Between Family Breakup and Family-Functioning Variables as Outcomes

 
Table 3 shows changes in the effect of family breakup on psychosocial maladjustment after introducing family-functioning variables into the models. Paternal support had an effect on all of the outcomes and maternal support only on externalizing disorders and substance abuse. Parental psychological distress was associated with internalizing and externalizing disorders, whereas interparental violence was strongly associated only with internalizing disorders.


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  		TABLE 3 Multivariate Logistic Regression for Internalizing Disorders, Externalizing Disorders, Substance Abuse, and Alcohol Consumption in the Entire Study Population: The Effect of Family Breakup and Family Functioning

 
The effect of family breakup on internalizing disorders was reduced to nonsignificance when we adjusted for the family-functioning variables, which indicates that this effect was largely mediated by parental psychological distress and low paternal emotional support. In the full model, the witnessing of interparental violence was also associated with internalizing disorders. Interestingly, the mediating role of family-functioning variables was much weaker for externalizing disorders. Considering 2 separate models with suicide attempt and the adolescent's psychological distress as the outcomes, we noted a strong effect of exposure to interparental violence on suicide attempt (aOR: 3.15; 95% CI: 1.58–6.30) and on psychological distress (aOR: 1.88; 95% CI: 1.42–2.50).


   DISCUSSION
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
CONCLUSIONS
 REFERENCES
 
One of our 2 objectives was to examine the association between family breakup and psychosocial maladjustment in adolescents. This study, which was based on the Social and Health Survey of Children and Adolescents in Quebec, confirms the results of several previous studies on the existence of such an association.6–9,36 We found that the effect of family breakups was weaker on internalizing disorders than on externalizing problems and addictions.3 Moreover, we found that the mediating role of specific family-functioning variables in the association between family breakup and psychosocial maladjustment was greater for internalizing disorders than for externalizing disorders.

However, our study had several limitations. First, because of the cross-sectional nature of the data, we were unable to establish a causal link between family functioning and psychosocial maladjustment in the teenagers. Second, distal social factors were not taken into account. However, many studies highlight their association with conduct disorders (eg, urban violence and neighborhood quality).37,38 Third, the literature identifies physical or sexual abuse in childhood as 1 of the predictive factors for substance abuse,39 which is higher among children living in a nonintact family.40 The hypothesis that having been maltreated is a confounding factor in the association between family breakup and addiction could not be tested in our study. Lastly, we did not take into account the different types of family disruptions (divorce or separation, parental death, or single mother) because of the inadequate sample size in each subgroup. However, some studies have shown that each type of family breakup is associated with psychopathological disorders with specific underlying processes.41

We found that 3 family-functioning variables had an effect on adolescents' psychosocial maladjustment. First, paternal emotional support had an effect on all of the psychopathological disorders. This finding concurs with the father loss perspective, which assumes that children of divorce are handicapped by the absence of 1 parent from the household. In their meta-analysis, Amato and Keith2 found lower scores on measures of well-being in children experiencing parental divorce compared with children in intact, 2-parent families. Furthermore, they report that the presence of a stepfather or stepmother in the household does not necessarily improve the child's functioning.

Second, parental psychological distress had an effect only on internalizing and externalizing disorders but not on psychoactive substance use. In the literature, the effects of parental distress are explained in a family process model.42 According to this model, children of parents with parental distress are exposed to insecure marital attachment and marital conflict and come to feel that their own well-being is threatened. This model includes child gender as 1 potential effect modifier, which was confirmed in our study: girls presented with more internalizing disorders and boys with more externalizing disorders. Moreover, in the literature, adolescent girls have been reported to exhibit greater vulnerability to intrafamilial stress. In our study, this could explain the impact of interparental violence, our third family-functioning variable, on internalizing disorders only. To explain this link between interparental conflict and child psychological disorders, several authors propose a mediational model. Marital conflict is believed to affect parenting practices, which, in turn, affects the child's adjustment.43

The other objective of our study was to explore a mediating effect of selected family-functioning variables on the association between family breakup and adolescent psychosocial maladjustment. We found that lack of paternal support and parental distress were significant mediating factors in the association between family breakup and internalizing disorders. Moreover, witnessing interparental violence was strongly associated with internalizing disorders. This is consistent with the link between depressive symptoms and domestic violence described previously in the literature44,45 and could concur with the following explanatory mechanisms suggested by clinical practice: family breakups are, to a large extent, detrimental to children because of the atmosphere in which the separation occurs and because of the resulting quality of the interparental relationships. However, the prevalence of interparental violence is not higher in cases of marital separation than in intact 2-parent families, but its impact on children could be more harmful.46 In 1998, from a prevention perspective, the American Academy of Pediatrics Committee on Child Abuse and Neglect recommended routine screening for domestic violence as part of anticipatory guidance during the well-child visit.47 Moreover, in the case of parental separation, developing mediation programs is one of the means of preventing highly pathogenic loyalty conflict targeted at the child. These programs also make it possible to preserve filiation links with the noncustodial parent, one of the cornerstones of preventing psychosocial maladjustment in adolescents.48,49 Lastly, our results showed the link between family structure and externalizing disorders on the one hand and family structure and the precocity of the first experiments with alcohol and/or drug use on the other. Because we did not observe family-functioning variables to have a mediating effect, additional research is needed to better understand the mechanisms whereby family breakup leads to these maladjustment outcomes.


   CONCLUSIONS
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
REFERENCES
 
Preventing psychosocial maladjustment in adolescents requires a better knowledge of the transformations that the traditional family model is presently undergoing. Parental separation triggers a process of grieving and a period of reorganization of family relationships.50 During this period, where feelings and painful emotions are exacerbated, practitioners can play a role. By supporting adolescents, a major task is the integration of these emotions over time and the reinforcement of children's self-esteem, which is lowered in the case of family dissolution. In addition, family relationships have to be renegotiated to redefine family boundaries, where legitimacy of both parents is to be recognized by adolescents.51 This process of renegotiation must be explained to the parents. Indeed, the clarity and the security of the relationships in a separated family ensure the necessary cohesion on which the adolescent's identity builds. Helping this task means supporting interindividual communication in the separated family to redefine the roles of its members. For the parents, this redefinition makes it possible to disentangle the marital role, a major source of interparental conflicts, and the parental role. The ultimate goal is reestablishing the balance between love and authority of both parents for their children. More broadly, the impact of psychosocial maladjustment on the well-being of children and later on their psychosocial integration during young adulthood warrants 2 other sets of interventions: legal interventions aimed also at reinforcing family relationships (divorce mediation or joint custody) and social interventions for enhancing social support for children and their families and for increasing financial resources through public policies.


   ACKNOWLEDGMENTS
 
The research team on the social determinants of health and health care received a grant from the "Avenir" program of the French National Institute of Health and Medical Research to carry out this study.

We are grateful to the Quebec Statistics Institute (Quebec, Canada), which provided the data set from the Social and Health Survey of Children and Adolescents in Quebec performed in 1999. We gratefully thank Lucie Gingras, head of the Centre d'Accès aux Données de Recherche de l'Institut de la Statistique du Québec (Montreal, Canada).


   FOOTNOTES
 
Accepted Mar 14, 2007.

Address correspondence to Christelle Roustit, MD, INSERM U707, Research Group on the Social Determinants of Health and Healthcare, 27 rue Chaligny, 75012 Paris, France. E-mail: roustit{at}u707.jussieu.fr

The findings and conclusions in this article are those of the authors and do not necessarily represent the views of the Quebec Statistics Institute.

The authors have indicated they have no financial relationships relevant to this article to disclose.


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 RESULTS
 DISCUSSION
 CONCLUSIONS
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PEDIATRICS (ISSN 1098-4275). ©2007 by the American Academy of Pediatrics




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