PEDIATRICS Vol. 121 No. 3 March 2008, pp. e612-e618 (doi:10.1542/peds.2007-2156)
ARTICLE |
Beyond the "Big Talk": The Roles of Breadth and Repetition in Parent-Adolescent Communication About Sexual Topics
a Rand, Pittsburgh, Pennsylvania
b Rand, Santa Monica, California
c Department of Psychology, Virginia Commonwealth University, Richmond, Virginia
d Department of Pediatrics, David Geffen School of Medicine
e Department of Health Services, School of Public Health, University of California, Los Angeles, California
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ABSTRACT |
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OBJECTIVE. Most studies of parent-adolescent communication about sexuality focus on the frequency of communication without distinguishing between the breadth of topics covered and repetition. The goal of this study was to assess the independent influence of breadth and repetition of sexual discussion on adolescents' perceptions of their relationship and communication with their parents.
METHODS. Data came from 312 adolescents who, along with their parents, were control participants in a randomized, controlled trial to evaluate a worksite-based intervention designed to improve parent-adolescent sexual communication. Adolescents completed surveys before the intervention (time 1) and at 1 week, 3 months, and 9 months after the intervention (times 2, 3, and 4, respectively). At each survey, adolescents reported whether they had discussed each of 22 sex-related topics with their parent. Breadth was defined as the number of topics discussed for the first time between times 1 and 4, and repetition was defined as the number of previously discussed topics repeated during that period.
RESULTS. Adolescents whose sexual communication with their parents involved more repetition felt closer to their parents, felt more able to communicate with their parents in general and about sex specifically, and perceived that discussions with their parents about sex occurred with greater openness than did adolescents whose sexual communication with their parents included less repetition. Breadth of communication was associated only with the perceived ease of parent-adolescent sexual communication: adolescents who discussed more new topics with their parents between times 1 and 4 felt that their sexual discussions occurred with greater openness than did adolescents who discussed fewer topics.
CONCLUSIONS. Clinicians may want to advise parents about the value of discussing sexual topics repeatedly with their children, because this may provide parents an opportunity to reinforce and build on what they have taught their children and provide children the opportunity to ask clarifying questions as they attempt to put their parents' sexual education into practice.
Key Words: adolescent sexual behavior • communication • parent-child relationship • parental influence
Adolescents frequently engage in sexual behaviors that put them at risk for adverse outcomes, including unintended pregnancy1 and sexually transmitted diseases.2 Parents have a significant potential to reduce adolescent sexual risk behaviors and promote healthy adolescent sexual development.3,4 One way that parents may realize this potential is by communicating with their children about sexual behaviors and decision-making early and often.5–7 Studies have found that adolescents whose parents communicate with them about sexuality are more likely to delay intercourse and, if they have intercourse, to use contraception and have fewer partners.8–15
Some researchers have suggested that the effectiveness of parent communication in influencing adolescent sexual behavior depends on the breadth of the communication, that is, whether the communication encompasses a narrow or wide range of topics.16 Parent-adolescent communication about sexuality, however, is often not very far reaching. Because most parents do not feel comfortable or competent talking with their adolescents about sexual issues,17–19 they tend to limit conversations to "safe" topics, such as developmental changes (eg, menstruation and other pubertal changes), impersonal aspects of sexuality (eg, reproductive facts), and negative consequences, such as AIDS and sexually transmitted diseases.16,20,21 In contrast, parents tend to avoid or cover in a cursory way more private topics, such as masturbation, the psychological and experiential aspects of sexuality such as orgasm or sexual decision-making, and how to obtain and use condoms.20,22,23 It is, therefore, not surprising that a significant majority of both adolescents and parents feel dissatisfied with such restricted communication about sexuality.21 In general, teenagers perceive a gap between the topics that their parents cover during sexual discussions and the more delicate topics about which they are concerned.24,25
Other than being narrow in scope, parent-adolescent conversation about sexuality is often of poor quality. When parents talk about sex and sexuality with their adolescent children, they are often defensive, avoidant, impersonal, unsupportive, and rule-oriented.23,26–29 In observational studies, parental communication about sex and sexuality, compared with communication about other topics, is indirect and involves more dominance, less turn-taking, and lower levels of comfort, whereas adolescent communication about sex versus other topics involves more contempt, dishonesty, and avoidance.27,30–32
Not only is this manner of communicating likely to foster adolescent disengagement and hinder open, productive discussion,33 it is also likely to reduce the possibility that parents and teens will revisit or follow-up on their conversations about sexuality. Repetition of sexual communication is likely to be important for several reasons. Repetition may enhance an adolescent's understanding, processing, and acceptance of parental sexual messages34–36 and increase the likelihood that the right message will be delivered at the right time.16 In addition, repeated communication (as opposed to 1-shot discussions) is likely to increase feelings of comfort regarding sexual conversation, convey sincere parental interest to the adolescent, and foster a more connected parent-adolescent relationship, effects, which, in turn, have important implications for promoting adolescent sexual health.
Until now, no study has examined repetition as an aspect of sexual communication. This may be attributable, in part, to a lack of sufficient data. Few studies on parent-adolescent sexual communication are longitudinal,37,38 and those that are longitudinal are nearly always limited to assessments at 2 time points. In our study, we used data collected at 4 time points to assess the independent influence of increasing breadth and repetition of sexual discussion on adolescents' perceptions of the parent-adolescent relationship, including their perceptions of parent-adolescent communication in general and of communication about sex in particular. We predicted that increasing breadth and repetition of parent-adolescent sexual communication would be independently associated with improved perceptions of the quality of the parent-adolescent relationship, as well as with the quality of parent-adolescent communication in general and about sex specifically. We expected that repetition of communication would be a more consistent predictor of these outcomes than would breadth of communication, partly because repetition of communication is unlikely to occur in the absence of comfortable, open, and engaged communication.
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METHODS |
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Participants and Procedure
Data for this investigation came from individuals who took part in a randomized, controlled trial to evaluate Talking Parents, Healthy Teens, an 8-week worksite-based parenting intervention designed to help parents improve communication with their adolescent children and thereby reduce adolescent sexual risk behaviors.39 Thirteen public and private (for-profit and nonprofit) southern California worksites were selected for the study. The program and study were advertised to all of the employees at these worksites via e-mail, flyers, and newsletters. Parents who lived with 1 or more 6th- to 10th-graders were eligible for participation. Sites were staggered over time, with data collection from April 2002 to December 2005. The Rand/University of California, Los Angeles, institutional review boards approved the study.
Parents completed a baseline self-administered survey at their worksite and provided consent for eligible children (all 6th- to 10th-graders in the household) to receive mailed surveys; 96% of eligible children also provided baseline surveys (that included an assent statement). Several steps were taken to ensure that adolescents' data would not be revealed to their parents. We encouraged adolescents to complete surveys in private and answer all of the questions truthfully. We also stressed the notion of adolescent confidentiality with parents at baseline, asking parents to not look at their children's surveys and to allow the adolescents to mail surveys back themselves. Stamped, self-addressed envelopes were provided for this purpose, as was a toll-free number if adolescents had questions.
Approximately 1 month after the baseline (time 1) data collection, parents (and their adolescent children) were randomly assigned to intervention and control groups within 8 strata via computer-generated random numbers. Within each worksite, random assignment was stratified by factorial combinations of 3 dichotomous parent characteristics: (1) gender, (2) managerial or professional job status, and (3) above or below the median baseline number of sexual topics discussed with adolescents. Control-condition parents completed surveys only; they did not participate in the intervention. Parents and children completed follow-up surveys at 1 week, 3 months, and 9 months after the intervention (times 2, 3, and 4, respectively). Parents completed follow-up surveys during group sessions at work or were mailed the surveys if they were unable to attend the worksite group survey sessions. Intervention and control group parents were separated when completing follow-up surveys. Although parents in the intervention condition were asked not to share information about the intervention with their coworkers, 20% of control parents reported at the first follow-up either talking with intervention parents about the program or seeing the program's educational materials.
Adolescents received and returned all of the surveys by mail. If at any time point we did not receive a completed survey, we called or e-mailed adolescents and sent replacement surveys if necessary. Analyses for the current investigation used data from the 93% of control adolescents (N = 312) who completed the baseline survey and all 3 of the follow-up surveys.
Measures
When reporting on their communication and relationship with their parents, adolescents reported on interactions with the parent who was participating in the study.
Communication Variables
At baseline, adolescents reported whether they had ever discussed with their mother or father each of 22 sex-related topics (eg, "how you will make decisions about whether to have sex," "consequences of [getting pregnant/getting someone pregnant]," "how to choose a method of birth control," "what it feels like to have sex," "how well condoms can prevent sexually transmitted diseases," and "how to say no if someone wants to have sex and you don't want to"). We summed the number of baseline topics discussed. At each follow-up survey, adolescents were presented with the same list of 22 topics and asked to report whether they had discussed each topic with their mother or father since the last survey. At each follow-up, we calculated the number of new topics discussed for the first time between the previous and follow-up survey and the number of previously discussed topics repeated during that period. To create a measure of increased breadth of communication, we summed the number of new topics (those not discussed prebaseline) that were discussed at least once at times 2 through 4. To create a measure of repetition of communication, we summed the number of repeated topics discussed at times 2 through 4.
Outcome Variables
All of the outcome variables were measured at baseline and time 4. Because least-squares regression models assume normally distributed errors and are particularly sensitive to violations of that assumption in the form of excessively skewed (asymmetrical) response distributions,40,41 we collapsed the minimum number of response categories necessary to make the skewness of each outcome variable's response distribution acceptable. In some cases, this resulted in different numbers of response categories for variables with the same original response options.
To measure perceptions of the quality of the parent-adolescent relationship, we asked adolescents, "How would you rate your overall relationship with your [mother/father] (1 = terrible, 7 = excellent)?" To reduce the skewness of the response distribution on this measure, we combined the bottom 4 response categories (terrible, very poor, poor, and fair), yielding a 4-category measure. To measure perceptions of the closeness of the parent-child relationship, we asked adolescents, "How close do you feel to your [mother/father] (1 = not at all close, 4 = very close)?" To measure general parent-adolescent communication ability, we asked adolescents, "How would you rate your ability to communicate with your [mother/father] in general (1 = terrible, 7 = excellent)?" To reduce skewness, we combined the bottom 3 response categories (terrible, very poor, and poor), yielding a 5-category measure. To measure parent-adolescent sexual communication ability, we asked adolescents, "How would you rate your ability to communicate with your [mother/father] about sexual topics (1 = terrible, 7 = excellent)?" Finally, adolescents completed a 7-item measure assessing openness of communication with their mother or father about sexual topics (eg, "I feel comfortable asking my [mother/father] about sexual topics," "My [mother/father] and I talk openly and freely about sexual topics," and "My [mother/father] seems comfortable having conversations about sexual topics with me") using a 4-point response scale of strongly agree, somewhat agree, somewhat disagree, and strongly disagree. Items were recoded as needed so that higher scores indicate greater perceived openness of communication and then averaged (
= .85).
Demographic Covariates
Demographic characteristics known to be associated with parent-adolescent communication were included in all of the models as covariates. These characteristics included the age and gender (0 = male, 1 = female) of the adolescent; the age, gender (0 = male, 1 = female), race or ethnicity (4 dummy coded variables comparing black, Asian, Latino, and other race or ethnicity with white), and educational attainment (1 = less than a 4-year college degree, 2 = 4-year college degree, and 3 = at least some graduate school) of the parent; logarithm of household income; and whether the gender of the adolescent and parent were the same (0 = no, 1 = yes).
Statistical Analysis
Analyses were implemented by using Mplus 4.12 (Muthén & Muthén, Los Angeles, CA).42 We first tested simple associations between parent and adolescent demographic characteristics and breadth and repetition of communication. We then used linear regression to model each outcome as a function of the communication variables and demographic covariates. In these regression models, we also included the baseline value of each outcome as a covariate when predicting the corresponding time 4 variable.
Attrition Weights, Clustering, and Imputation
We define as our inferential population the adolescent children of parents who volunteered to be randomly assigned. We modeled baseline child nonresponse from baseline data supplied by parents. We modeled differences between the retained control children and those who missed any of the 3 follow-up surveys using baseline measures, including demographics and baseline measures of communication. The little selective attrition observed was related to child gender. Weights were the inverse of predicted probabilities from multivariate logistic regressions. All of the analyses used these nonresponse and attrition weights. The unit of response was the child. Mplus accounts for clustering of children within parents (22.5% of control parents had >1 participating child) and the effects of nonresponse and attrition weights on SEs by deriving corrected SEs of the regression parameter estimates.42
The mean rate of item-level missingness was 1.1%. To avoid any bias and loss of information that would result from excluding cases with missing data, the missing values were imputed by using a Markov chain Monte Carlo approach,43,44 a commonly used method for simulating random draws of the missing data from a predictive distribution.45 Because of the low rates of missingness, we used a single imputation from PROC MI.46
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RESULTS |
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Sample Characteristics
The mean age of the analytic sample (N = 312) was 13.3 years (SD: 1.5 years) at baseline; 52% were girls. The average baseline age of their participating parents was 44.0 years (SD: 6.5 years). Seventy percent of parents were women, 17% were black, 14% were Asian, 19% were Latino, 45% were white, and 5% had some other racial or ethnic background. More than half of the parents (56%) had at least a 4-year college degree.
Relationship Among Communication Variables
Means and intercorrelations among the 3 communication variables are presented in Table 1. The tendency to discuss sex with increasing breadth from time 1 to time 4 was positively associated with the tendency to repeat topics (r = .39; P < .001), but not to such an extent that would raise concerns about multicollinearity.
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Simple Associations Between Demographic and Communication Variables
Simple associations between parent and adolescent demographic characteristics and the communication variables are presented in Tables 2 and 3. All of the associations between demographic characteristics and the number of new topics discussed between baseline (time 1) and time 4 control for the number of topics discussed at baseline. Child gender was not associated with the number of topics discussed as of baseline or with repetition of topics, but it was associated with the number of new topics discussed between times 1 and 4. Compared with girls, boys discussed more new topics with their parents. Parent gender was associated with all 3 of the communication variables. Compared with fathers, mothers had discussed more topics with their children as of baseline, discussed more new topics between times 1 and 4, and repeated more topics. Parent-adolescent gender concordance was associated with the number of topics discussed as of baseline but not with increased breadth or repetition of communication. Parent education was negatively associated with the number of topics discussed as of baseline and with repetition of communication but was not associated with the number of new topics discussed between times 1 and 4. Parent race or ethnicity, adolescent age, parent age, and household income were not associated with any of the communication variables at this level of analysis.
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Multivariate Regression Models
Table 4 presents the results of the multivariate regression models predicting adolescents' perceptions of their relationship and communication with their parents. A preliminary set of models revealed no multivariate association between any of our outcome variables and adolescent gender, parent gender, adolescent-parent gender concordance, parent race or ethnicity, household income, or parent education. Therefore, we omitted these demographic variables from the final multivariate models. Whether these demographic variables were included or excluded from the models did not affect the multivariate associations between the communication variables and the outcomes.
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As can be seen in Table 4, repetition of topics was consistently associated with adolescents' perceptions of their relationship and communication with their parents. Adolescents whose sexual communication with their parents involved greater repetition of topics perceived their relationship with their parents to be closer, had more positive perceptions about their ability to communicate with their parents in general and about sex specifically, and felt that their sexual discussions with their parents occurred with greater openness than did adolescents whose sexual communication with their parents included less repetition of topics. Breadth of sexual communication was associated only with adolescent's perceptions of the openness of parent-adolescent sexual communication: adolescents who discussed more new topics with their parents between times 1 and 4 felt that their sexual discussions occurred with greater openness than did adolescents who discussed fewer topics. Neither increased breadth nor repetition of communication was associated with adolescents' perceptions of the quality of their relationship with their parents. Finally, parent age and child age were each associated with perceived openness of sexual communication. Younger children and children of older parents perceived greater openness than did their counterparts.
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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The lingering concept of the "big talk" on sex in popular culture may lead parents to believe that a 1-time discussion is the preferred approach to providing sexuality education to their children. To the contrary, our study's results suggest that such a discussion is unlikely to make teens more positive in their perceptions of the parent-adolescent relationship or parent-adolescent communication. In particular, we found that repetition of sexual communication is a more robust predictor of adolescents' perceptions of the closeness of their relationship with their parents and communication with their parents than is breadth of communication.
The closeness of the parent-child relationship has important implications for adolescent sexual health. Research has shown, for example, that when adolescents are positively connected with their parents (eg, feel satisfied in their relationships), they are less likely to initiate intercourse at a young age or engage in frequent intercourse and are more likely to use contraception.47–49 Moreover, close parent-adolescent relationships are also likely to foster high quality (and repeated) parent-adolescent sexual communication. For example, studies have shown that parent-adolescent communication about sex is easier when it builds on a general pattern of open communication in the relationship.17,50 There is also evidence to suggest that parent-adolescent communication reduces adolescent sexual risk-taking only if adolescents feel that their parents are open, skilled, and comfortable during discussions of sex-related topics.29
Our results do not imply that the breadth of sexual communication is unimportant. Adolescents whose parents cover many topics in their discussions with them about sex are probably more likely to have the knowledge they need to make sound sexual decisions than are adolescents whose parents restrict sexual discussion to only a few topics. Our results suggest, however, that parents who take a checklist approach to broadening their sexual discussion with their children are unlikely to have as great an influence on their children as parents who introduce new sexual topics and then develop them through repeated discussions.
Some limitations of our study should be kept in mind when considering the results. First, our analyses used adolescent-reported data from a sample of families in which a parent agreed to participate in a study evaluating an 8-week program to improve their sexual communication with their adolescent children. Additional research is needed to determine whether the associations observed in this study are also found among broader samples of parents and their adolescent children. A second limitation is that these findings are correlational and cannot, therefore, establish causality. Nevertheless, by focusing on changes in sexual communication over time and how those changes related to changes in adolescents' perceptions of their relationship and interactions with their parents, we can be confident about the direction and timing of the observed associations. We also controlled for the potentially confounding influence of many demographic characteristics that are known to be associated with parent-adolescent communication and the quality of parent-child relationships.
The outcomes that we focused on, perceptions of the parent-adolescent relationship and the quality of general and sexual communication, are intermediary to adolescent sexual behavior. Although these outcomes are important in their own right, it is essential that future studies establish the roles of breadth and repetition of parent-adolescent sexual communication in adolescent sexual risk taking. Additional research is also required to determine what specific aspects of repeated communication drive adolescents' perceptions of their relationship and communication with their parents. Is it that adolescents perceive repeated communications as a sign of their parents' commitment to their relationship and welfare? Are parents who return to sexual topics of discussion more confident and knowledgeable about the topics they discuss? Does greater repetition increase the perceived importance of the message and/or the likelihood that adolescents will recall the message when engaged in sexual decision-making? Uncovering the answer to questions such as these will provide additional insight into the importance of parent-adolescent communication and its relevance for adolescent sexual risk taking.
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CONCLUSIONS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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In this study we found that repetition of sexual communication is an important predictor of teens' perceptions of the closeness of their relationship with their parents and their ability to communicate with their parents about sexual topics and in general. The American Academy of Pediatrics suggests that pediatricians encourage parents to engage in reciprocal, honest, and open dialogue about sexuality with their children beginning early in their child's life.51 In light of our findings, clinicians may also wish to stress to parents the value of discussing sexual topics repeatedly with their children. This repeated sexual communication may provide parents an opportunity to reinforce and build on what they have taught their children and provide children the opportunity to ask clarifying questions as they attempt to put their parents' lessons into practice.
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ACKNOWLEDGMENTS |
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This project was supported by National Institute of Mental Health grant RO1 MH61202 and Centers for Disease Control and Prevention cooperative agreement U48/DP000056.
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FOOTNOTES |
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Accepted Aug 21, 2007.
Address correspondence to Steven C. Martino, PhD, Rand, 4570 Fifth Ave, Suite 600, Pittsburgh, PA 15213. E-mail: martino{at}rand.org
The authors have indicated they have no financial relationships relevant to this article to disclose.
Dr Schuster's current affiliation is Rand, Santa Monica, California; and the Children's Hospital Boston/Harvard Medical School, Boston, Massachusetts.
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