February 12, 2006
Parent-Child Communication Processes: Preventing Children’s Health- Risk Behavior
By Riesch, Susan K; Anderson, Lori S; Krueger, Heather A
PURPOSE. Review individual, family, and environmental factors that predict health-risk behavior among children and to propose parentchild communication processes as a mechanism to mediate them.
CONCLUSIONS. Improving parent-child communication processes may: reduce individual risk factors, such as poor academic achievement or self-esteem; modify parenting practices such as providing regulation and structure and acting as models of health behavior; and facilitate discussion about factors that lead to involvement in healthrisk behaviors.
PRACTICE IMPLICATIONS. Assessment strategies to identify youth at risk for health-risk behavior are recommended and community-based strategies to improve communication among parents and children need development.
Search terms: Healthcare disparities, parent-child relations, prevention, risk factors
Accepted for publication August 17, 2005.
The events of late childhood and young adolescence can shape a child's life course, and as such, the future of an entire society (Carnegie Council on Adolescent Development, 1999). Recognizing this, preventing children from engaging in health-risk behaviors is a target of Healthy People 2010 (U.S. Department of Health and Human Services [USDHHS], 2002). Inappropriate eating and sleeping habits and a sedentary lifestyle affect how children grow, develop, and perform in school (Troiano & Hegal, 1998). Engaging in behaviors such as tobacco and alcohol use, early sexual involvement, and weapon carrying puts children at risk for health problems that are extremely costly to society (Mrazek & Haggerty, 1994) and may accentuate their vulnerabilities to health disparities.
Previous research has indicated that a key mechanism in preventing health-risk behavior is the parent-child communication processes. A parent is a person who brings up and cares for another (Merriam-Webster, 2005), which includes other individuals who function in a primary parenting role such as grandparents, stepparents, foster parents, and guardians. The communication processes that have been shown to reduce health-risk behavior are characterized by open expression of ideas and feelings, satisfaction with the family system, family caring, and ability to manage conflict. Communication processes are modifiable, and thus may be a promising target for intervention to mediate health-risk behavior among children even in the presence of individual, family, and community factors that typically predict involvement.
The purpose of this paper is to provide an overview of individual, family, and environmental factors that increase the probability of health-risk behavior among children and to propose parent-child communication processes as a mechanism to mediate those factors. This is a theoretical paper to stimulate thinking among clinicians by proposing a model of health-risk behavior prevention. Figure 1 depicts our conceptual model for reducing health-risk behaviors in middle childhood.
Health disparities are inequalities or inequities as a result of environment, access, quality, and utilization of health care, health status, or particular health outcomes (Carter-Pokas & Baquet, 2002). This paper is pertinent to the issue of health disparities because the factors that predict health-risk behavior among children and adolescents-individual, family, and community factors-overlap with those that characterize populations who do not typically benefit from ongoing preventive health care. Furthermore, the health-risk behaviors themselves may affect health status and outcomes that contribute to health disparities. Pediatric nurses and other healthcare providers can reduce health disparities by taking steps to (a) prevent children from engaging in health-risk behaviors and (b) promote positive eating, exercise, and sleep behaviors.
Pediatric nurses and other healthcare providers have a number of strategies available to prevent or modify health-risk behavior. Examples include a number of nationally tested programs such as the Community Tool Kit for early sexual activity prevention (Sexuality Information and Education Council of the United States [SIECUS], 2005), Teens Against Tobacco Use for tobacco use prevention (American Lung Association, 2005), and Heart Power! for overweight prevention (American Heart Association, 2005).
Another promising strategy that may appeal to pediatric nurses is aimed at the family level of intervention. Because family and communication processes are modifiable and may mediate the effects of risk factors, identifying risk factors and promoting communication processes may reduce the need for health care associated with health-risk behaviors such as treatment of diseases (i.e., injuries, cancers, sexually transmitted infections, obesity).
Background, Significance, and Literature Review
Health-Risk Behavior: Overview and Definition
Health-risk behaviors contribute to the leading causes of mortality and morbidity among children, are established during childhood, extend into adulthood, and are interrelated. Participation in these activities compromises well-being, health, and life-course development that may contribute to disparities in health care. Health-risk behavior includes: (a) activities that contribute to unintentional and intentional injuries and violence, (b) tobacco use, (c) alcohol and other drug use, (d) sexual behavior, (e) dietary practices, and (f) physical inactivity according to the Centers for Disease Control and Prevention (Grunbaum et al., 2004).
According to Grunbaum et al. (2004), activities that contribute to unintentional injuries include not wearing seat belts or helmets, riding with a driver who has been drinking alcohol, and swimming without a lifeguard. Activities that contribute to intentional injuries and violence include weapon carrying, physical fighting, feeling unsafe at school, participating in theft, and thinking about suicide. Tobacco use includes cigarette smoking and tobacco chewing. Alcohol use includes drinking beer, wine, and liquor, and drug use generally refers to accepting street drugs, smoking marijuana, and inhaling fumes of butane, glue, or gasoline to get high. Sexual behavior includes "going out" with a boyfriend or girlfriend and holding hands, putting arms around, or kissing a boyfriend or girlfriend. Eating habits refer to trying to lose weight very fast, whereas exercise refers to engaging in sports or vigorous physical activity that raises the heart rate and results in sweating for at least 20 min almost everyday. Sleep habits refer to the number of hours of sleep the child gets each weeknight.
Health-Risk Behavior: Prevalence
The prevalence of experimental smoking (ever smoked a whole cigarette) was 4% among 9-year-olds, 7% among 10-year-olds, 16% among 12-year-olds, 30% among 13-year-olds, and 42% among 14-year- olds (Harrell, Bangdiwala, Deng, Webb, & Bradley, 1998). Bush and Iannotti (1993) reported that 13% of nearly 5,000 fourth graders surveyed used cigarettes (more than a puff), 17% had used alcohol (without parental permission), and 2% had used marijuana. Of 45 children assessed in a rural Indiana community, Finke, Chorpenning, French, Leese, and Siegel (1996) found seven (15%) had inhaled butane, glue, or gasoline. Long and Boik (1993) followed 250 third through fifth graders and found 40% had tried alcohol by age 10. Loveland-Cherry, Ross, and Kaufman (1999) documented alcohol use by 61 out of 428 (14%) fourth graders. Eighteen percent of sixth graders were found to have ever used alcohol in a study by Spoth, Redmond, and Lepper (1999). According to Wells et al. (1992), White children tend to experiment with alcohol at younger ages than other racial or ethnic groups. Fifth graders recently surveyed in Wisconsin demonstrated significant risk for unintentional injury, with 58% reporting not wearing bicycle helmets, 70% reporting not wearing seat belts, and 45% reporting having been in a physical fight; however, none had smoked cigarettes, chewed tobacco, or smoked marijuana, and only 4% had tried alcohol (Riesch et al., unpubl.).
Figure 1. Conceptual Model for Reducing Health-Risk Behaviors in Middle Childhood
Poor eating habits contribute to disordered eating, dental caries, iron deficiency anemia, inconsistent performance of daily activities, and the tripling of childhood obesity in the United States in the past 30 years, with one in four children overweight or at risk (USDHHS, 2000). Lack of regular exercise affects bone and muscle development, body weight, stress and anxiety, self-esteem, and strength and endurance (Luepker, 1999). As children develop into adolescence, marked changes occur in the sleep-wake patterns (Stein, Mendelsohn, Obermeyer, Amromin, & Benca, 2001). Poor sleeping habits contribute to negative mood, poor school performance and behavior problems (Levy, Gray-Donald, Leech, Zvagulis, & Pless, 1986), accidents (Leger, 1994), and smoking (Patten, Choi, Gillin, & Pierce, 2000).
Health-risk behaviors have direct effects upon physical health status. Among low-income children, health-risk behaviors may accentuate an already poor physical health status caused by a potential history of low birth weight, lead contamination, prematurity, and prenatal exposure to alcohol and illegal drugs (McLoyd, Ceballo, & Mangelsdorf, 1996).
Taken together, the literature indicates that (a) healthrisk b\ehaviors among youth ages 9 to 11 years are studied by isolated research groups whose intent is to identify the prevalence of a single behavior, with typically small samples, and without intent to build upon previous studies, (b) no national survey exists, and (c) youth ages 9 to 11 are beginning to engage in health-risk behavior and developing practices that may contribute to poor health outcomes, particularly among low-income children, which could result in health disparities.
National data on middle and high school children, from sources such as Youth Risk Behavior Surveillance Survey (YRBSS) (Grunbaum et al., 2004), Monitoring the Future (Johnston, CXMalley, Bachman, & Schulenberg, 2004), and the National Longitudinal Study on Adolescent Health (Udry & Bearman, 1999) indicate that health-risk behavior is prevalent by the end of middle school. By ninth grade, many adolescents are frequently engaging in behaviors that could compromise their lifetime health and well-being. Thus, the ideal time for prevention activities is the transition from elementary to middle school.
Two conceptual approaches to human behavior, (a) the bio- ecological perspective on human development (Bronfenbrenner & Morris, 1998) and (b) the ecological risk and protective theory (Bogenschneider, 1996), guide thinking about the risk factors, mediation processes, and outcomes. Each of these approaches is summarized in Table 1 and briefly discussed here.
Table 1. Concepts Pertinent to Preventing Childhood Health-Risk Behavior Across Frameworks
Since 1974, Bronfenbrenner and Morris (1998) have argued for an ecological approach to studying and understanding development. In contrast to artificial situations, Bronfenbrenner and Morris advocated that humans be studied in the actual environments in which they live. They postulated that human development takes place through processes of progressively more complex reciprocal interaction between an active, evolving biopsychological human organism and the persons, objects, and symbols in its immediate external environment. Interaction must occur on a fairly regular basis over an extended period of time. Enduring interactions are referred to as proximal processes that are the primary engines of development. Furthermore, the form, content, and direction of the proximal processes affecting development may vary systematically as a joint function of the following: the characteristics of the developing person, the environment (both immediate and more remote) in which the processes are taking place, the nature of the developmental outcomes under consideration, and the social continuities and changes occurring over time through the life course and the historical period during which the person lived. The model is used in research designs that permit simultaneous investigations of process, person, contexts, and time (PPCT). Involvement in childhood health-risk behavior is conceptualized as a developmental outcome influenced by person, process, context, and time factors.
According to Bronfenbrenner and Morris (1998), the person is considered to have six biopsychological characteristics. First is disposition, which includes traits such as impulsiveness, explosiveness, distractibility, curiosity, and deferring immediate gratification. Resources constitute biopsychological liabilities and assets to engage effectively in proximal processes and include ability, experience, knowledge, and skill. Demand is the capacity to invite or discourage reactions from the social environment of a kind that can disrupt or foster processes of psychological growth (personality). The other three biopsychological characteristics are age, gender, and ethnicity.
In this conceptual approach, communication processes are the enduring interactions to express warmth, attachment, concern, and interest between and among parents and children. It is a progressively more complex reciprocal activity that occurs on a regular basis over extended periods of time with at least one parent or adult with whom the child has developed a strong, mutual, irrational attachment preferably for life (Bronfenbrenner & Morris, 1998).
Ecological Risk and Protective Theory (ERPT)
ERPT was developed by Bogenschneider (1996) and integrates the perspectives of the bio-ecological theory of human development (Bronfenbrenner & Morris, 1998) and developmental contextualism (Lerner, 1995). The bio-ecological theory suggests that it is necessary to identify risk and protective processes at several levels of human ecology, including individual, family, peer, school, and community settings. Developmental contextualism emphasizes how these processes vary as children mature and settings change. It moves the bio-ecological model through time and space, emphasizing the dynamic and reciprocal nature of development and relationships. The ecological risk approach identifies those processes that can potentially mitigate youth development. Simultaneously, the protective approach identifies processes that can magnify the likelihood of positive development by enhancing children's ability to deal with risk situations and by promoting growth, adaptation, and competence. Individual, family, and environmental factors can protect children from the risk impact and may help children learn to cope effectively with future stresses and to overcome sequelae of past hazards. Communication is an interpersonal skill to solve problems and to develop bonds with family, friends, and other social institutions (Bogenschneider, 1996).
The bio-ecological perspective provides a developmental parent- child communication focus, and the ERPT provides developmental contextualism. Both approaches advocate family communication processes and the individual, family, and community risk and protective factors. Taken together, both approaches account for the known factors that have been established to predict youth health- risk behaviors and their short- and long-term consequences.
Concepts Pertinent to Health-Risk Behavior and Parent-Child Communication
In Figure 1, outcome is depicted in the farthest column to the right. Outcome refers to an event to be prevented or promoted (Kraemer et al., 1997). Children's engagement in health-risk behavior is the outcome to be prevented. Health-risk behavior is an intermediate outcome that has the potential to result in one of the classic long-term negative outcomes of injury, disease, disability, or death. Our model focuses exclusively on the intermediate outcome of health-risk behavior.
Risk factors are agents, exposures, characteristics, experiences, or events that, if present, are associated with an increase in the probability of an outcome (Kraemer et al., 1997). They are correlates shown to precede the outcome (Kraemer, Stice, Kazdin, Offord, & Kupfer, 2001). In Figure 1, risk factors categorized as individual, family, or environment have been demonstrated in prior research to predispose children to participate in health-risk behavior, and many are nonmodifiable, whereas others are modifiable (Kraemer et al, 2001). The conceptual definitions for the individual, family, and environment risk factors are summarized in Table 1.
Individual risk factors include biological, cognitive, and psychosocial developmental processes. Family risk factors include selected parental demographic characteristics, parenting practices, and parent-child relationships. Environment risk factors include neighborhood, school, and community characteristics. Each risk factor category is discussed in depth below.
Individual risk factors: Biological. This factor refers to the many physical and physiological changes of puberty. The timing of puberty, that is, "on time" and "off time," affects self-esteem (Brooks-Gunn, Peterson, & Eichorn, 1997). Early-maturing girls are at risk for eating disorders, early sexual activity, and substance use, whereas late-maturing boys are at risk for problems with alcohol (Graber, Lewisohn, seeley, & Brooks-Gunn, 1997). Contrary to the myth that the brain is mature by puberty, recent findings from neuroscience and pediatric psychiatry demonstrate that the prefrontal cortex of the brain, responsible for selfcontrol, judgment, emotional regulation, organization, and planning, continues to mature through age 20 (Paus et al., 1999). There is ample evidence to suggest that hormones play an important role in health-risk behavior initiation. For example, serum testosterone and estrogen levels have been found to correlate with the development of secondary sexual characteristics, which in turn predict sexual activity (Udry & Billy, 1987). African American children tend to experiment with sexual behavior at younger ages than other racial or ethnic groups, presumably because they tend to enter puberty earlier (Brooks-Gunn et al, 1997; Udry & Billy, 1987). Early sexual activity may lead to sexually transmitted diseases, increased number of sexual partners, or pregnancy, resulting in limited educational achievement, social mobility, and access to quality health care that in turn may contribute to health disparities. These factors provide a biological perspective for children's involvement in health-risk behavior and are typically nonmodifiable, although they may be modified with medical intervention.
Individual risk factors: Cognitive. This factor refers to the tendency of later elementary school-age children to think concretely; to have one-dimensional perspectives, limited problem- solving skills, and language capacity; and to see things in absolute terms (Juszczak & Sadler, 1999). They may not possess the cognitive ability to manage the difficulties of new and stressful situations that risk situations may present. Cognitive development has been expressed as academic achievement. Low academic achievement and limited school success in late childhood are strong correlates of risk b\ehavior (Allen, Moore, Kuperminc, & Bell, 1998; Donovan, Jessor, & Costa, 1999) but are typically modifiable.
Individual risk factors: Psychosocial. This factor refers to developing self-esteem, adopting a socially approved conventional behavior structure, cultivating social relationships among peers, and achieving autonomy and individuation while maintaining emotional ties to parents and family (Jessor & Jessor, 1977). Psychological autonomy is the child's expression of individuality with an expectation toward increasing independence (Herman, Dornbusch, Herron, & Herring, 1997). Involvement in formalized religious and school activities, expressed as church and school attendance, is an example of adapting the values of conventional behavior (Donovan et al., 1999). These risk factors are typically modifiable.
To summarize the discussion of individual factors, early or late pubertal development, poor school achievement, low self-esteem, nonaffiliation with religion or school, lack of close friends, and psychological dependence are risk factors that increase the likelihood of childhood health-risk behavior. These individual factors may exert a disproportionate negative effect on racial and ethnic minority children (National Institute of Mental Health [NIMH], 2001). Nurse clinicians may observe these factors to identify youth who potentially may become involved in health-risk behavior. Developing strategies to prevent health-risk behavior may emphasize reducing, ameliorating, or mitigating these factors.
Family risk factors: Parental demographic characteristics. These factors refer to selected demographic factors such as parent's marital status, education, occupation, income, and their health behavior practices (Goodson, Evans, & Edmundson, 1997). Parental separation or divorce is associated with health-risk behavior (DeGarmo, Forgatch, & Martinez, 1999; Miller, Norton, Fan, & Christopherson, 1998; Newcomer & Udry, 1987) and parent's education level is typically negatively associated with early onset of health- risk behaviors (Miller et al., 1998; Small & Luster, 1994). Economic pressures influence family relationships and thereby adolescent adjustment, including health-risk behaviors (Conger, Ge, Elder, Lorenz, & Simons, 1994; Conger et al., 1991). These risk factors are typically nonmodifiable and found at higher prevalence among ethnic and racial minority families (Siantz & Smith, 1994).
Family risk factors: Parenting practices. This factor refers to the presence of parents at key times during the day (Resnick et al., 1997), religiosity (Donovan et al., 1999), and the quality of the parent-child relationship (Noller, 1995). Parental monitoring and involvement substantially reduced adolescent sexual activity in a study by Small and Luster (1994). The first and most compelling finding published from the National Longitudinal Study on Adolescent Health (Resnick et al., 1997) was that family connectedness, a measure of quality of family relationships, consistently protected adolescents from engaging in health-compromising behaviors. Parents serve as models for health behaviors and communicate expectations about them (Costa, Jessor, & Donovan, 1989), provide or withhold household access to weapons and substances such as cigarettes or alcohol (Resnick et al., 1997), and are responsible for regulation and structure (curfew, established mealtimes) (Small & Luster, 1994; Jessor, Van Den Bos, Vanderryn, Costa, & Turbin, 1995; Resnick et al.). These risk factors are typically modifiable. Cross-cultural studies have found differences in parenting styles between ethnic minority groups (for example, Smetana & Chuang, 2001).
Family risk factors need to be viewed in concert with individual and environmental factors. Increased likelihood of engaging in health-risk behavior may operate through direct instigation (peer influence), increased vulnerability (low self-esteem), or opportunity (poor parental monitoring, access to substances, behavior modeling) (Jessor et al., 1995).
To summarize, family risk factors include parents separated and without a partner, being educated beyond secondary school, earning at least a moderate income, and parents abstaining from health-risk behaviors themselves. Parents who do not limit access to weapons and substances, provide supervision at key times such as before and after school and at bedtime, communicate behavioral expectations such as disapproval of smoking, drinking, and sexual involvement, provide structure such as curfew and established mealtimes, and place value on relationships may contribute toward healthrisk behavior among children. These factors tend to be prevalent among low-income families who are the same populations experiencing health disparities. As with the individual factors, nurse clinicians may identify families who possess the characteristics that predict health-risk behavior and work toward prevention by addressing these factors.
Environmental risk factors: School. This term refers to two crucial factors-characteristics of the school and a child and family's sense of school connectedness. Dramatically, school connectedness was significantly associated with every health- compromising behavior assessed in the National Longitudinal Study of Adolescent Health. School connectedness is related to characteristics that underpin the quality of schools, such as average daily attendance, dropout rate, classroom size, educational level of the teachers, and parent involvement (Resnick et al., 1997). School also provides opportunities for peer group socialization.
Environmental risk factors: Neighborhood. This term represents the census track in which families reside. Families choose their neighborhood based on two factors that are generally homogeneous- family socioeconomic status and race/ethnicity (Leventhal & Brooks- Gunn, 2000). Parental behavior may be the primary mechanism through which neighborhood influences operate. For example, parents access neighborhood resources such as child care and schools, develop relationships with other families, and develop supervision and monitoring systems based on the physical environment of the neighborhood. Neighborhood factors, particularly safety and the lack of a neighborhood organization, and informal supervision and monitoring by neighbors, foster health-risk behavior (Gabriel, Hopson, Haskins, & Powell, 1996).
Environmental risk factors: Community. This term encompasses the city, suburb, or village that includes neighborhoods and schools. Community characteristics such as intolerance and undervaluing of children by providing limited opportunities for social gathering, employment, and volunteerism, and lax enforcement of laws against sales of cigarettes, alcohol, and drugs, constitute factors predictive of child health-risk behavior (Gabriel et al., 1996; Hawkins, Catalane, Kosterman, Abbott, & Hill, 1999; Rutter, 1993).
In summary, environmental risk factors include school characteristics that demonstrate poor quality and little potential for parent and child involvement. Also included are neighborhood characteristics that demonstrate lack of safety, social networks, and formal and informal supervision of children, and community characteristics that demonstrate intolerance and undervaluing of children. Nurse clinicians may be in a position to address or reverse some environmental factors. The environmental factors that predict youth health-risk behavior participation also tend to be prevalent among populations prone to health disparities.
A mediating process refers to mechanisms that, if present, inhibit the effects of the risk factors. It occurs in a causal pathway from the independent variables (risk factors) to a dependent variable (health-risk behavior) and the mediating process also varies with the independent variable. Parent-child communication processes, the middle column in Figure 1, are proposed to mediate the effects of risk factors on health-risk behavior. Parent-child communication processes are the degree to which the parent and the child are satisfied with how the family functions in terms of rules, relationships, and connectedness; the degree of openness with which communication is perceived between a parent and a child; the parent and child's ability to manage conflicts; and to what degree the child perceives their family meets their care needs. Each of these processes is addressed in more depth below.
Communication. This term refers to the assertive and inoffensive expression of ideas and feelings, and the attentive and accurate receiving of ideas expressed by others (Robin, 1979). It is modifiable (Riesch et al., 1993). Thus, communication processes can be enhanced to mediate those factors that ordinarily would predict health-risk behavior. It is important, however, to consider cultural and ethnicity issues when examining adolescent-parent relationships. Cross-cultural studies have found differences in family communication, conflict, values, and parenting practices among ethnic minority groups (Chao, 2001; Chao & Tseng, 2002; Cooper, Baker, Polichar, & Welsh, 1994; Deater-Deckard, Dodge, Bates, & Pettit, 1996; Harkness & Super, 2002; Harwood, Leyendecker, Carlson, Asencio, & Miller, 2002; Knight, Virdin, & Roosa, 1994; McAdoo, 2002; Smetana & Chuang, 2001). For instance, it has been found that in Caucasian samples, restrictive, harsh discipline is related to child behavioral problems, whereas this was not found in an African American sample (Deater-Deckard et al., 1996). It has been argued that this type of discipline may be protective in a dangerous urban environment (Magnus, Cowen, Wyman, Fagen, & Work, 1999). Obedience, responsibility, and respect for elders may be stronger values in African American, Native American, Hispanic, and Asian American families than in European American families where individualism and independence are more highly valued (Grotevant,1998). The overall goal of parents, however, across any ethnic, minority, or cultural group is to assure a child's successful transition to adulthood (Garcia Coll & Pachter, 2002). There is general agreement among the experts that certain parent and family characteristics, among them, family communication processes, are associated with better outcomes in youth (Collins, Maccoby, Steinberg, Hetherington, & Bornstein, 2000; Gorman-Smith, Tolan, Henry, & Horsheim, 2000; Simpson, 2001; Steinberg, 2001).
Perceived open communication. This is the ability to share feelings, approach difficult topics, and ask for help. Wills and Cleary (1996) demonstrated that open communication was inversely related to substance use. Perceived poor communication with at least one parent was strongly associated with adolescent selfharm (Tulloch, Blizzard, & Pinkus, 1997). Among late adolescents, Marta (1997) reported that adolescents' perceptions of support and openness in communication, with both mothers and fathers, were inversely related to an index of psychosocial risk, and that the presence of problem communication with mothers and fathers was directly related to the psychosocial risk index. Among a sample of adolescents ages 14 to 16 years, Clark and Sheilds (1997) documented that perceiving communication as open with either of one's parents is significantly associated with less serious forms of delinquency. Communication that is perceived as open protects against a child's involvement in health-risk behaviors (Gordon Rouse, Ingersoll, & Orr, 1998; Jaccard, Dittus, & Gordon, 1996; Metzler, Noell, Biglan, Ary, & Smolkowski, 1994; Miller et al., 1998; Resnick et al., 1997; Taris & Semin, 1998; Taris, Semin, & Bok, 1998).
Satisfaction with the family system. This is the degree to which family members like the family system both in terms of flexibility with family rules, roles, and relationships and of connectedness or emotional bonding (Olson, 1994). High family satisfaction is correlated with intimacy development in later relationships (Romig & Bakken, 1992), less severe family problems (Marett, Sprenkle, & Lewis, 1992), lower incidence of sexual intercourse among 14-17 year olds (Jaccard et al., 1996), and less use of hard drugs (Piercy, VoIk, Trepper, Sprenkle, & Lewis, 1991).
Family caring. This term is defined as the bonding and attachment youth perceive they have to the family (Hawkins, Catalano, & Miller, 1992). Metzler et al. (1994) reported that children with high family involvement experienced less conflict and more supervision from their parents and consequently less risky sexual behavior. Similarly, Hawkins, Lishner, Catalano, and Howard (1986) indicated that low family involvement weakened adolescents' relationships with their families, thereby increasing their susceptibility to negative peer influences. Baumrind (1991), Herman et al. (1997), and Steinberg (1991) demonstrated that poor family management practices and low family bonding consistently related to low ages of alcohol initiation.
Family problem solving. Conflict resolution is the ability to deal with, solve, or settle disputes or disagreements over issues of concern to parents and children without anger and other self- concept-eroding strategies, by using negotiation, compromise, or other self-conceptenhancing strategies (Olson & Ryder, 1978; Robin, 1985). Family problem solving includes behaviors and interactions that are part of an ongoing dynamic system wherein patterns of behavior and ways of relating to one another develop over time (Melby & Conger, 1999). In this system, the tactics used to advance each individual's interests determine intrafamilial conflict. The ability to reason/negotiate and resolve conflicts is a tactic that supports family functioning and parent-child communication (Strauss, Hamby, Boney-McCoy, & Sugarman, 1996).
The effects of a high level of family conflict have been shown by Robins (1992) to predict alcohol misuse among adolescents. Kashani, Burbach, and Rosenberg (1988) found high family conflict to be associated with adolescent depressive symptomatology that could lead to intentional injury such as suicide.
To summarize, prior study of parent-child communication processes indicates that children who perceive their communication with their parent(s) as open, are satisfied with the family system, perceive their family cares, and have the ability to solve conflicts are less likely to engage in health-risk behavior in the presence of risk factors that may predict such behavior. Nurses, in their practice, may observe salient characteristics of communication between children and parents. What is needed is a selection of theory and science-based interventions targeted at individuals, families, and communities that build communication processes. Communication processes are a life skill that may generalize to relationships with peers, teachers, employers, and healthcare providers and thus have influence beyond the parent-child relationship (Institute of Medicine [IOM], 2002).
A number of investigators and national surveys document that by middle school, children are likely to be involved in health-risk behavior. Risk factors categorized as individual, family, and environmental predict health-risk behavior participation. Some risk factors are modifiable. Parent-child communication processes such as openness, satisfaction with the family system, caring, and conflict resolution ability are modifiable and may mediate children's health- risk behavior in the presence of factors shown to predict such involvement.
Blum et al. (2000) reported that some health-risk behaviors are disproportionately high among lowincome youths of color, but that the demographic factors predicted less than 10% of youth risk behaviors. Thus, by emphasizing demographic group differences, well- meaning interventions may, in fact, be built upon variables that are not amenable to change and would not significantly influence later behavioral outcomes. Although it is recommended that subpopulations be targeted to reduce health disparities, a universal approach to health-risk behavior prevention among youth is considered most appropriate (IOM, 1994).
The mechanism by which improving parent-child communication works to reduce health-risk behavior may be that the processes change the modifiable risk factors. Thus, improving parent-child communication processes may directly affect some or all of the individual risk factors, such as academic achievement, self-esteem, psychological autonomy, religion and school affiliation, number of friends, and school connectedness. Improving the parent-child communication process may modify parenting practices, such as providing regulation and structure, being involved, monitoring, developing school connectedness, communicating expectations, and acting as models of health behavior and practices. Improving communication processes should facilitate discussion about risk factors that could lead to accidents or involvement in health-risk behaviors and improve parents' expressions and children's understandings of values surrounding health-risk behavior. For all these reasons, we propose parent-child communication processes as a key target of intervention to prevent children's participation in health-risk behavior. We believe such a strategy addresses the Institute of Medicine's (2003a) recommendation that a multicomponent intervention for the primary prevention of problem behavior in middle students be tested for efficacy.
If this model is supported by empirical testing, then it should result in assessment strategies to identify youth at risk for health- risk behavior initiation and in multidisciplinary, community-based strategies to improve communication processes among parents and children. By intervening to prevent health-risk behaviors, health disparities among children vulnerable to the consequences of intentional injury and violence, unintentional injury, tobacco use, alcohol and other drug use, early sexual involvement, and unhealthy diet, exercise, and sleep practices may be avoided (IOM, 2003b).
How Do I Apply This Information to Nursing Practice?
Until the model is empirically supported, based upon the bio- ecological perspective, the ERPT, and the literature, the following assessment and intervention strategies are suggested for pediatric nurses to provide quality care to ethnically diverse children aimed at preventing health-risk behaviors:
1. Ask children about school, their achievements or struggles, how connected they feel, and how their attendance is. These questions will help the nurse assess risks around individual cognitive factors or what Bronfenbrenner refers to as disposition characteristics.
2. Ask children about their friends, what they like to do, if they are members of a religion or spiritual group, and what their aspirations for the future are. These questions will help the nurse to assess risks around individual psychosocial factors or what Bronfenbrenner refers to as demand characteristics.
3. Assess pubertal development and provide anticipatory guidance if puberty is late or early. This will help the nurse to assess biological risks or what Bronfenbrenner refers to as resource characteristics.
4. Use a few direct questions to assess self-esteem (a resource characteristic), such as: What are your best qualities? What are you proud of? What do you like about yourself? What are you better at than most people? Children vulnerable for low self-esteem may have difficulty answering these questions.
5. Ask children about their perceptions of their family's rules (curfew, meals, bedtime, having to be home after school) and ideas about family connectedness (parents know their friends, are active at their school, ask them about their activities, give advice, and know their expectations). These questions will help the nurse assess family or parenting practice risks referred to byBogenschneider as developmental contexts.
6. Ask children about their perceptions of their neighborhood. For example, are there places to hang out and volunteer? Do neighbors talk and help one another? Do you eat at each other's homes? Is it safe? These questions will help the nurse assess community risks referred to by Bogenschneider as developmental contexts.
7. Pediatric nurses can ask children directly about their intentions and behaviors around helmet wearing; alcohol, tobacco, and other drug use; sexual behaviors; and health habits; and advise them about the potential harms of these activities.
8. Pediatric nurses can arrange to have a number of referral opportunities for families to address individual and family risk factors. Ideas for such referral resources include those developed and sponsored by national groups. Pdiatrie nurses can collaborate and communicate with schools and community agencies to access, sponsor, or develop family capacity building programs.
Although health disparities are part of a larger social political context, much can be done at the individual, family, and community levels to prevent behaviors that may contribute to such disparities among pediatric populations. Preventing health-risk behaviors that may be addictive or predispose a child to poor physical status is one strategy nurses can adapt in everyday practice.
The ideal time for prevention activities is the transition from elementary to middle school.
Early or late pubertal development, poor school achievement, low self-esteem, nonaffiliation with religion or school, lack of close friends, and psychological dependence are risk factors that increase the likelihood of childhood health-risk behavior.
The environmental factors that predict youth health-risk behavior participation also tend to be prevalent among populations prone to health disparities.
What is needed is a selection of theory and science-based interventions targeted at individuals, families, and communities that build communication processes.
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Susan K. Riesch, DNSc, is a professor of nursing, Waisman Center for Human Development and Neurosciences; Lan S. Anderson, MS, RN, CPNP, is a doctoral candidate and predoctoral fellow; and Heather A. Krueger, APNP, is a doctoral candidate, School of Nursing, University of Wisconsin-Madison, WI.
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