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Adolescents with learning disabilities: risk and protective factors associated with emotional well-being: findings from the National Longitudinal Study of Adolescent Health
JOURNAL OF ADOLESCENT HEALTH 2000;27:340–348
FELLOWSHIP FORUM
Adolescents With Learning Disabilities: Risk and Protective Factors Associated With Emotional WellBeing: Findings From the National Longitudinal Study of Adolescent Health MARIA VERONICA SVETAZ, M.D., MARJORIE IRELAND, Ph.D., AND ROBERT BLUM, M.D.
Purpose: To identify differences in emotional wellbeing among adolescents with and without learning disabilities and to identify risk and protective factors associated with emotional distress. Methods: Cross-sectional analysis of adolescent inhome interview data of the National Longitudinal Study of Adolescent Health. A total of 20,780 adolescents were included in this study of whom 1,301 were identified as having a learning disability. Initially, emotional distress, suicidal behaviors, and violence involvement were compared among those adolescents with and without learning disabilities using Student’s t-test for the continuous or semicontinuous variables and Chi-square for the dichotomous variables. Subsequently, logistic regression analyses were conducted to identify which variables were most strongly associated with risk and protective factors for emotional distress. Results: Adolescents with learning disabilities had twice the risk of emotional distress, and females were at twice the risk of attempting suicide and for violence involvement than their peers. While educational achievement is below that of peers, connectedness to school is comparable. So, too, is connectedness to parents. Connectedness to parents and school was identified as most strongly associated with diminished emotional distress,
From the Division of General Pediatrics and Adolescent Health, University of Minnesota, Minneapolis, Minnesota Dr. Svetaz completed this work while a fellow in the Adolescent Health Program, University of Minnesota. She is currently in the Family Medicine Residency Training Program at Regions Medical Center, St. Paul, Minnesota. Address correspondence to: Dr. R.W. Blum, University Gateway, Department of General Pediatrics and Adolescent Health, Suite 260, 200 Oak Street S.E., Minneapolis, Minnesota 55455-2002. Manuscript accepted April 7, 2000. 1054-139X/00/$–see front matter PII S1054-139X(00)00170-1
suicide attempts, and violence involvement among adolescents with learning disabilities. Conclusions: Given the increased association with emotional distress, suicidal attempts, and violence involvement, clinicians need to assess social and emotional as well as educational and physical functioning of these young people. We also need to be aware of the role protective factors play in the lives of young people with learning disabilities. © Society for Adolescent Medicine, 2000 KEY WORDS: Adolescent health Emotional well-being Gender differences Learning disabilities Risk and protective factors Suicidal attempt Violence involvement
In the very early days of this century, when cyberliteracy and mastery of technology seem to be the basic ingredients for survival in the competitive job market, the number of children and adolescents with learning disabilities (LDs) appears to be increasing (1–3). Today, LDs appear to have a prevalence in the order of 5% of children and youth (2). The association between LDs and emotional problems has been well described (3– 6). Although the federal definition of LDs excludes those that are secondary to emotional disturbance, adolescents with LDs have a high incidence of emotional and behavioral problems (3–11). Additionally, Jackson et
© Society for Adolescent Medicine, 2000 Published by Elsevier Science Inc., 655 Avenue of the Americas, New York, NY 10010
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al. (12) found that compared with non–learning disabled peers, those with LDs saw themselves to be significantly less socially competent and were rated lower in social competency by their respective teachers. Given that a critical element of social skills is the ability to accurately perceive the environment and interpersonal relationships, this deficit contributes to social isolation. Deficits of social perception improve during developmental maturation; however, for those with LDs, it appears that a lag persists through adolescence (12). One limitation of previous research on youth with LDs is that most samples have been drawn from a clinical or relatively small school sample. Additionally, studies have rarely explored the association between LDs and risk behaviors. Finally, there is not much information about outcomes and risk and protective factors among adolescents with LDs and emotional distress. The present analysis focused on two questions: (a) How did individual, family, and school factors differ for a nationally representative sample of youth with LDs from peers without such conditions, and (b) which factors were associated with increased and diminished risk of emotional distress for youth with learning disabilities?
Methods The Sample Data were obtained from the National Longitudinal Study of Adolescent Health (Add Health Study). This is a longitudinal study of adolescents in grades 7 through 12 and the multiple social contexts in which they live. Initially 80 high schools were identified across the United States, a high school being defined as a school with at least 30 students and an 11th grade. Subsequently, the primary feeder school (e.g., middle or junior high school) was identified; however, since not all schools had a feeder school, a total of 134 schools were identified and agreed to participate (79% of the sample). Of those, 129 (96%) hosted an in-school confidential survey completed in 1994 –1995 by 90,118 young people. From this group plus the school rosters of all 134 schools, a subsample was identified of whom 20,780 youths in grades 7 through 12 agreed to participate in an in-depth interview. The first wave of the in-home interview was conducted between April and December 1995, took approximately 90 minutes to complete, and all the information was recorded directly onto a laptop
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computer using a CASI-technology, thereby minimizing data entry errors and enhancing response confidentiality for sensitive questions. Of those adolescents interviewed at home, a parent (usually a mother) was recruited to participate in an interview of 30-min duration. Also, 84.6% of young people had a parent respondent (n ⫽ 17,661). The present analysis drew on the subsample for whom both parent and adolescent data are available. In the present analysis, LD was defined as an affirmative response of parents to two questions: (a) Does your adolescent have a LD and (b) has he or she ever been in special education classes? The comparison group consisted of those adolescents whose parents answered “no” to both questions. Because of the complex sampling design, each case was assigned a weight so that the resulting analyses are generalizable to the U.S. adolescent population. These sample weights were used in the analyses. The final sample consisted of 16,340 adolescents (78.6%) of whom 1603 met the criteria for LDs. The sample of young people with LDs were disproportionally male (twice that of females), older than the comparison group, and more likely to be on welfare. In addition, they were slightly more likely to be African-American or Hispanic and less likely to be from two-parent families (Table 1). Measures The three outcome variables included: suicide attempt, emotional distress, and violent behavior. Suicide attempt was based on a dichotomous variable: “Have you attempted suicide in the last year?” Violence involvement was based on an eight-item scale that has a Cronbach ␣ of .83. Emotional distress was measured by a 17-item scale that had a Cronbach ␣ of .86. Details on scale construction have been previously reported (13). Independent variables were selected according to the theoretical framework using items in three domains that previously have been shown to be significant: individual characteristics, family context, and school context. Analysis Bivariate statistics were used to explore the first research question of similarities and differences between youth with LD and their peers, including Chi-square for dichotomous variables and the Student’s t-test for continuous or quasicontinuous variables (Tables 2 and 3).
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Table 1. Demographics Variables Demographics Variables Age (yr) Male Female Gender Male Female Race/Ethnicity European American African-American Hispanic Parents on welfare Two-parent family Male Female
Without Learning Disabilities % or Mean
Number (14,737)
15.6 15.4
With Learning Disabilities % or Mean
Number (1,603)
15.6 15.6
p Value NS NS
48.0% 52.0%
7,077 7,661
67.0% 33.0%
1,074 530
⬍.001 ⬍.001
91.2% 88.0% 89.7% 10.0% 55.0% 58.0% 53.4%
9,708 2,268 1,704 1,448 8,012 3,977 4,035
8.8% 12.0% 10.3% 18.0% 41.0% 40.0% 43.4%
933 308 196 263 605 389 216
⬍.001 ⬍.001 ⬍.01 ⬍.001 ⬍.001
NS ⫽ not significant.
Results Bivariate Comparisons Individual Context (Table 2). To explore the relationships of having a LD with the emotional outcomes of emotional distress, suicide attempts, and violence involvement, odds ratios were computed controlling for age, gender, grade, socio-economic status (SES), family structure, and race. Having a LD was associated with nearly double the odds ratio (OR) for emotional distress (OR 1.89 overall; 1.96 for males; 1.81 for females). Likewise, the OR was 1.67 overall for suicide (1.43 for males; 1.84 for females). Violence involvement was also greater for both males (OR ⫽ 1.25) and females (OR ⫽ 1.90), compared with peers. Adolescents with LDs were at least twice as likely as teens without LDs to report emotional distress: 24% vs. 12% for boys (⌾2 ⫽ 93.96; p ⫽ .001) and 33% vs. 12% for girls (⌾2 ⫽ 42.02; p ⫽ .001). Boys with LDs were also twice as likely to report suicidal attempts: 4% vs. 2% (⌾2 ⫽ 10.08; p ⫽ .002); the same was true for girls with LDs: 9% vs. 5% (⌾2 ⫽ 12.23; p ⫽ 0.001). Secondly, youths with LDs were significantly more likely than others to report involvement in violent behaviors: 31% vs. 25% for boys (⌾2 ⫽ 13.28; p ⫽ .001) and 20% vs. 11% for girls (⌾2⫽ 35.55; p ⫽ .001). They were also more likely to have witnessed or have been a victim of a violent act. This was especially true for adolescent girls (t ⫽ 4.66; p ⫽ .0001). Adolescents with LDs were more likely to report carrying weapons: 13% vs. 9%, with differences reported for both boys: 16.2% vs. 13.3% (⌾2 ⫽ 5.99;
p ⫽ .014) and girls: 7% vs. 4.3% (⌾2 ⫽ 5.68; p ⫽ .017). They felt that they were more likely to die at a younger age (t ⫽ ⫺5.08; p ⫽ .001) and they were less likely to have a religious identity (t ⫽ 10.83; p ⫽ .001). Both boys and girls with LDs were more likely than peers to perceive that they look younger than their current age: 15% vs. 8% (⌾2 ⫽ 70.29; p ⫽ .001). Adolescents with LDs reported initiating intercourse at a younger age than peers without LDs, a difference that was statistically significant only for boys (t ⫽ 2.59; p ⫽ .01). In addition, having intercourse before the age of 12 was more commonly reported for girls with LDs than peers (3% vs. 1%; ⌾2 ⫽ 17.10; p ⫽ .0001). Interestingly, there was no statistically significant difference between groups on the prevalence of pregnancy: 7% vs. 6% (⌾22 ⫽ 0.22; p ⫽ .639). Additionally, substance use (alcohol, marijuana, cigarettes, and other illegal drugs) was lower in youth with LDs than peers. Family Context (Table 3). Adolescents with LDs were as likely to report that they feel connected to their families as were those in the comparison group. They were less likely, however, to report that they engaged in activities with their parents (t ⫽ 8.16;p ⬍ .0001); but they reported more parental presence throughout the day, (e.g., a parent home after school t ⫽ 3.52; p ⫽ .0004). They perceived parental expectations for their successful school completion to be lower than did peers without learning disabilities (t ⫽ 10.15; p ⫽ .0001). Adolescents with LDs were also more likely to report a recent suicide in their family than the comparison group: 5.5% vs. 4.3%
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Table 2. Individual Context Variables, by Gender Independent Variables Variables Emotional distress* Male Female Suicide* Male Female Violence* Male Female Victim/Witness of violence* Male Female Carry weapon* Male Female Likelihood of untimely death* Male Female Religious identity** Male Female Chronic illness* Male Female Looks younger* Male Female Looks older* Male Female Age of sexual debut** (yr) Male Female Intercourse before 12 years old* Male Female Ever pregnant* Alcohol use* Male Female Marijuana use* Male Female Other illegal drug use* Male Female Smoking* Male Female
Without Learning Disabilities
With Learning Disabilities
p Value
% or Mean
Number
% or Mean
Number
12.0% 21.0%
832 1,561
24.0% 33.0%
228 161
⬍.001 ⬍.001
2.0% 5.0%
139 389
4.0% 9.0%
36 44
⬍.01 ⬍.001
25.0% 11.0%
1,741 816
31.0% 20.0%
292 94
⬍.001 ⬍.001
0.8% 0.3%
6,683 7,661
1.0 0.7
749 31
⬍.01 ⬍.001
13.3% 4.3%
908 326
16.2 7.0
152 412
⬍.01 ⬍.05
1.5% 1.5%
6,691 7,671
1.8 1.9
746 412
⬍.001 ⬍.001
6.2% 6.7%
6,704 7,690
5.0 5.7
772 430
⬍.01 ⬍.001
12.8% 11.6%
903 889
16.2% 21.0%
175 109
⬍.01 ⬍.001
9.0% 7.4%
613 553
14.3% 16.0%
132 73
⬍.001 ⬍.001
14.4% 13.0%
985 972
11.5% 11.0%
113 55
⬍.01 NS
14.0% 14.7
2,407 2,659
13.5 14.5
252 125
⬍.01 NS
5.0% 1.0% 6.0%
345 93 465
6.3% 3.0% 7.0%
68 18 29
⬍.05 ⬍.001 NS
32.2% 28.8%
2,182 2,167
22.0% 18.3%
203 87
⬍.001 ⬍.001
28.2% 24.8%
1,886 1,851
25.0% 16.6%
227 77
⬍.05 ⬍.001
12.3% 11.5%
836 868
9.8% 10.5%
91 50
⬍.05 NS
22.9% 24.0%
1,345 1,555
26.8% 20.0%
230 89
⬍.05 NS
* percentage: variable is a dichotomous or was dichotomized for the analysis (Chi-square). ** mean: variable is a scale 0 to 10 (Student’s t-test). NS ⫽ not significant.
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Table 3. Family and School Context Variables, by Gender Independent Variables Variables Family connectedness** Male Female Parent-Adolescent activities** Male Female Parental presence** Male Female Recent family suicide* Male Female Parental school expectation** Male Female Gun at home* Male Female School connectedness** Male Female Skip school** Male Female Trouble in school** Male Female Students are prejudged* Male Female Repeated a grade* Male Female
Without Learning Disabilities
With Learning Disabilities
p Value
% or Mean
Number
% or Mean
Number
7.5 7.3
6,703 7,684
7.4 7.3
768 425
⬍.05 NS
1.8 1.9
6,698 7,675
1.5 1.7
764 423
⬍.001 ⬍.001
7.2 7.2
6,654 7,592
7.3 7.3
751 418
⬍.05 ⬍.01
38 38
NS ⬍.01
3.4% 5.0%
233 383
4.0% 8.2%
8.6 8.6
6,651 7,589
8.0 8.0
732 400
⬍.001 ⬍.001
31.0% 18.5%
2,090 1,389
25.3% 14.0%
237 64
⬍.001 ⬍.01
6.4 6.4
6,695 7,665
6.3 6.3
765 427
⬍.05 NS
0.6 0.5
6,923 7,824
0.8 0.7
840 460
⬍.001 ⬍.05
1.0 0.9
6,836 7,678
1.3 1.1
814 441
⬍.001 ⬍.001
43.1% 43.3%
2,919 3,201
35.7% 33.3%
331 150
⬍.001 ⬍.001
20.3% 14.2%
1,395 1,076
49.3% 43.0%
476 207
⬍.001 ⬍.001
* percentage: variable is a dichotomous or was dichotomized for the analysis (Chi-square). ** mean: variable is a scale 0 to 10 (Student’s t-test). NS ⫽ not significant.
(OR ⫽ 1.3; ⌾2 ⫽ 4.15; p ⫽ .04). This was especially true and highly significant among females: 8.2% vs. 5% (OR ⫽ 1.67; ⌾2 ⫽ 8.55; p ⫽ .003). School Context (Table 3). School connectedness did not differ significantly for young people with or without LDs. Both boys and girls with LDs were less likely to report that they perceived prejudice from other students in their schools than did comparison groups. Among the girls, 33.3% of the LD group felt that the students were prejudiced, compared with 43.3% of the comparison group (⌾2 ⫽ 17.5; p ⫽ .001). Among the boys, 35.7% of the LD group reported that the students in their school were prejudiced, compared with 43.1% of the comparison group (⌾2 ⫽ 18.03; p ⫽ .001).
Adolescents with LDs were far more likely to report having repeated a grade than their peers: girls 42.52% vs. 14.24% (⌾2 ⫽ 273.3; p ⫽ .001); boys 49.3% vs. 20.36% (⌾2 ⫽ 388.7; p ⫽ .001). Both boys (t ⫽ 6.6; p ⫽ .0001) and girls (⌾2 ⫽ 5.26; p ⫽ .0001) were more likely than peers to report that they get into trouble in school. They were also more likely to report having skipped school without a clear reason (boys t ⫽ 3.96, p ⫽ .0001; girls t ⫽ 2.36, p ⫽ .018). Multiple Regression Analyses Significant intercorrelation was found among the three dependent variables for youth with LDs (Table 4). Specifically, youth with LDs who had emotional distress reported eight times the number of suicide
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Table 4. Risk and Protection-Associated Factors for Emotional Distress, Suicide and Violence Among Adolescents With Learning Disabilities Emotional Distress
Emotional distress Suicide Violence Perceived risk of untimely death Victim Somatic complaints Religious identity Looks younger Look older Weapon carrying Cigarette use Marijuana use Alcohol use Sexual orientation Even had sex Had sex before 12 years old Family connectedness Parental school expectation Parental activities Parental presence Family suicide Gun at home Parents’ education level School connectedness Grade point average School prejudice Skip school Trouble Repeat a grade
Suicide
OR
p
3.80 2.69 3.40 1.89 4.74 0.73 0.57 1.42 2.50 2.41 2.20 2.18 1.55 1.53 2.30 0.14 1.16 1.19 1.56 2.15 1.18 0.92 0.11 0.46 1.77 1.19 2.00 1.51
⬍.001 ⬍.001 ⬍.001 ⬍.01 ⬍.001 ⬍.05 ⬍.001 ⬍.001 ⬍.001 ⬍.01 ⬍.01 ⬍.001 ⬍.001
⬍.01 ⬍.05 ⬍.001 ⬍.01 ⬍.01 ⬍.01 ⬍.001 ⬍.01
Violence
OR
p
OR
p
7.97
⬍.001
5.20 3.81
3.81 3.13 3.21 1.56 0.27 1.34 1.99 2.65 2.86 6.73 6.85 1.32 1.88 2.94 0.20 1.17 0.29 0.23 3.29 1.06 1.03 0.12 0.43 0.81 1.29 1.96 2.66
⬍.001 ⬍.01 ⬍.001 ⬍.01 ⬍.01
⬍.001 ⬍.001
2.37 79.35 1.85 0.75 0.60 5.70 7.36 4.04 14.48 9.63 1.87 3.36 4.90 0.35 0.78 1.09 0.37 3.36 1.93 0.93 0.24 0.44 1.92 1.47 1.91 1.33
⬍.001 ⬍.001 ⬍.001
⬍.01 ⬍.001 ⬍.001 ⬍.001 ⬍.05 ⬍.01 ⬍.001 ⬍.05 ⬍.01 ⬍.01 ⬍.001 ⬍.01 ⬍.001 ⬍.001
⬍.05 ⬍.001 ⬍.001 ⬍.001 ⬍.001 ⬍.001 ⬍.01 ⬍.001 ⬍.001 ⬍.001 ⬍.001 ⬍.001 ⬍.001 ⬍.05 ⬍.001 ⬍.01 ⬍.01 ⬍.001 ⬍.001 ⬍.05
OR ⫽ odds ratio.
attempts and five times the violence involvement as those without such distress. Factors associated with increased risk included: having had intercourse before the age of 12 years, weapon carrying, and substance use. Those young people with LDs who had a history of violence victimization were twice as likely to report emotional distress, 3 times as likely to report a history of a suicide attempt, and almost 80 times more likely to report to be engaged in violent activities than peers who did not report such victimization. Likewise, homosexual or bisexual orientation as well as a history of having initiated intercourse before the age of 12 years constituted a common set of risk explainers. At the family level, a history of suicide attempts or completions by a family member was associated with increased risk for each of the three outcome variables. Among school factors, a history of having re-
peated a grade and a history of trouble in school (both of which were more common among youth with LDs) were each associated with increased risk for all three outcomes. Among the factors associated with lower levels of emotional distress, suicide attempts and violence involvement, religious identity was one of the strongest individual level variables associated with lower risk for the three outcomes; however, it was statistically significant only for suicide. Additionally, appearing younger than peers was associated with reduced risk for both emotional distress and violence involvement for youth with LDs. Family connectedness was the most strongly associated with lower risk for the three study outcomes. However, across the individual, family, and school factors for each of the three outcomes, distress, violence, and suicide attempt, school connectedness was the factor associated with lowest risk.
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Discussion The analyses are based on a theoretical framework of risk and protection. Originally, articulated by Jessor and Jessor (14), the Health Risk Behavior Theory posited a set of factors (including individual, peer, family, and environmental) that was associated with increased participation by adolescents in a range of risk behaviors. Concurrently, research by Werner and Smith (15), Rutter (16), and numerous other researchers began to identify factors associated with resilience on the capacity of young people to bounce back in the face of adversity (17). Recently, analyzing data from Add Health, Resnick et al. (13) found that for youth in general in the United States, family connectedness, parental concerns regarding educational achievements, and a caring adult in school were all protective against a range of risk behaviors. The association between LDs and depression has been previously well described; for example, Maag and Behrens (18) indicated that severe depression was evident among one in five males and one in three females with LDs. These figures are relatively consistent with those of Weinberg and Rehmet (19) and Goldwin et al. (20), based on clinical and special samples, and those of Borowsky and Resnick (21), based on school sample. These studies, however, are all based on clinical or special samples. The present analyses found one in four boys and one in three girls with LDs to report severe emotional distress. This is two to three times higher than the average adolescent population. The association between emotional distress and suicide is obvious. Awareness is expanding toward the increased risk of suicide among adolescents with LDs because several studies reported this finding (22–25). What has not been previously reported was the higher suicide risk of youth with LDs. Kenny and Rohn (23) suggested that such may be the case in their study of young people who committed suicide. There they found that half of all young people who had suicide completions also had neurodevelopmental disabilities consistent with LDs. So, too, Hayes and Sloate (24) reported that counselors in Los Angeles County schools reported that 14% of all suicides were among youth with LDs. Given a national prevalence of LDs of 5%, this is significantly higher than anticipated. And while the data in the present study are alarming (twice the rate of suicide attempts for youth with LDs when compared with peers) at 4% for males and 9% for females, they are not as high as previous research has suggested. Still, we are
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finding nearly 1 in 11 females with LDs reported having attempted suicide in the past 12 months. As is true for emotional distress and suicide attempts, youth with LDs are significantly more likely than peers to have violence involvement. The relationship between violence and LDs has tended to focus on juveniles who are incarcerated with research indicating that as much as a range of 26% to 75% of the juvenile offender population have significant learning problems (26). Other studies suggest that young people with LDs are adjudicated twice as often as non-LD youth and experience greater recidivism and parole failure (26). Vallance et al. (6) have suggested that specific LDs such as expressive and receptive languages predisposes to social and behavioral maladjustment. Epstein et al. (27) noted the emergence of delinquency in the behavior patterns of both older boys and girls with LDs. They described the differences across ages and gender related to behavioral problems, especially in two areas: environmental conflict and personal disturbance. There are different theories posited to explain the link between aggressive behaviors and LDs. The school failure hypothesis proposes that LDs increase the risk for academic failure, which leads to a negative self-esteem, which in turn increases the odds for school dropouts, violence involvement, and delinquent activities. The susceptibility theory holds that adolescents with LDs have certain personality features that make them more prone to engage in delinquent activities (26). Waldie and Spreen (28) examined the persistence of delinquency of adolescents and young adults with LDs and concluded that the association may be the result of impulsiveness and poor judgment. In the present study, the correlation between LDs and violence was confirmed. Specifically, when controlling for other demographic variables, adolescents with LDs were twice as likely to be engaged in violent activities than their peers. Interestingly, the association between violence and LDs was stronger for adolescent girls than boys. The strongest single associated risk factor for adolescents with LDs was having been a victim of or a witness to a violent act. By itself it increased the odds of an adolescent with LDs participating in violence by approximately 80 times. A similar association was found in the general adolescent population (13). Protecting Youth With Learning Disabilities The present study may be the first to explore factors that are associated with diminished risk for emo-
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tional distress, suicide attempts, and violence involvement. Factors that emerge include: family connectedness, school connectedness, and religious identity. Together these variables suggest that a sense of belonging is central in diminishing risk and promoting emotional well-being. These findings are consistent with those of Resnick et al. (13) who found these same factors to be associated with diminished participation in a range of risk behaviors. Perhaps surprising is the important role of school connectedness and the protective role it appears to have for youth with LDs despite their poorer-than-average academic performance. This finding confirms what Resnick et al. (13) suggest, that there is a weak association between school performance and school connectedness. Additionally, youth with LDs are less likely to report experiencing prejudice in schools than their peers. Clearly, as with home, school has the potential of being an arena of comfort and not just a source of stress for youth with LDs.
Limitations This study has several limitations. It was conducted with school-going adolescents. Adolescents with LDs are at higher risk for adverse outcomes when they drop out of school. This could be one of the explanations why adolescents with LDs and substance use were not as prevalent in this study as in other studies conducted with adolescents in shelters or in the juvenile justice system (29). The different types and severity of LDs could not be determined. The only measure of IQ that was provided during the study was a computerized, abridged version of the Peabody Picture Vocabulary Test-Revised, limiting the ability to disaggregate LDs and intellectual impairments. Additionally, since the criteria for grade point average determinations were not homogeneous across schools, they could not be used as a consistent measure of academic success or achievement in school performance.
Conclusion According to results from the present analysis, an adolescent with LDs is: more frequently male (2:1), more likely to live in a single-parent family; and more likely to have a lower income on average than peers. Educational achievement is below that of peers; however, connectedness to school is comparable. So, too, is connectedness to parents. Both variables were identified as the strong protection-associ-
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ated variables for emotional distress, suicidal attempts, and violence involvement among adolescents with LDs in our study. Girls with LDs appear to experience more emotional distress and suicide attempts than their male counterparts. This is consistent with the general population. As is evident from the present analysis, youth with LDs are at significantly higher risk than peers for emotional distress, suicide attempts, and violence. Given this, it is extremely relevant that the adolescent with problems in school (e.g., skipping school, getting in trouble at school because of behavioral issues, and repeating a grade) receives a comprehensive and systemic evaluation to rule out the presence of an LD and/or emotional disorder. So, too, it is evident that there is an important role for families, schools, and institutions in diminishing the health risks to which youth with disabling conditions are exposed. Given this information, it is no longer sufficient to counsel families who have children with LDs to seek educational remediation; they need to understand their role and the role of school in diminishing the significant emotional sequelae. We thank Michael Resnick, Ph.D., Darryl Goetz, Ph.D., and Ann Garwick. Ph.D., for their thoughtful review and critique throughout the research in preparation of the manuscript. Additionally, Linda Boche’s attention to manuscript preparation throughout the multiple versions of this paper is greatly appreciated. These analyses were supported in part by the University of Minnesota’s Center for Children with Chronic Illness and Disability, National Institute on Disability Rehabilitation Research (Grant H133B40019). This research is based on data from the Add Health project, a program project designed by J. Richard Udry (PI) and Peter Bearman, and funded by grant P01-HD31921 from the National Institute of Child Health and Human Development to the Carolina Population Center, University of North Carolina at Chapel Hill, with cooperative funding participation by the National Cancer Institute; the National Institute of Alcohol Abuse and Alcoholism; the National Institute on Deafness and Other Communication Disorders; the National Institute on Drug Abuse; the National Institute of General Medical Sciences; the National Institute of Mental Health; the National Institute of Nursing Research; the Office of AIDS Research, NIH; the Office of Behavior and Social Science Research, NIH; the Office of the Director, NIH; the Office of Research on Women’s Health, NIH; the Office of Population Affairs, DHHS, the National Center for Health Statistics, Centers for Disease Control and Prevention, DHHS; the Office of Minority Health, CDC, DHHS; the Office Minority Health, Office of Public Health and Science, DHHS; the Office of the Assistant Secretary for Planning and Evaluation, DHHS; and the National Science Foundation. Persons interested in obtaining data files from the National Longitudinal Study of Adolescent Health should contact Jo Jones, Carolina Population Center, 123 West Franklin Street, Chapel Hill, North Carolina 27516-3997 (email: [email protected]).
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2. Lyon GR. Learning disabilities. Future Child 1996;6:54 –76. 3. Rock EE, Fessler MA, Church RP. The concomitance of learning disabilities and emotional/behavioral disorders: A conceptual model. J Learn Disabil 1997;30:245– 63. 4. Huntington DD, Bender WN. Adolescents with learning disabilities at risk? Emotional well being, depression, suicide. J Learn Disabil 1993;26:159 – 66. 5. Bender WN. Secondary personality and behavioral problems in adolescents with learning disabilities. J Learn Disabil 1987; 20:280 –5. 6. Vallance DD, Cummings RL. Mediators of the risk for problem behavior in children with language learning disabilities. J Learn Disabil 1998;31:160 –71. 7. Chapman JW. Cognitive-motivational characteristics and academics achievements of learning disabled children: A longitudinal study. J Educ Psychol 1988;80:357– 65. 8. Shapiro BK, Gallico RP. Learning disabilities. Pediatr Clin North Am 1993;40:491–505. 9. Carr M, Borkowski JG, Maxwell SE. Motivational components of underachievement. Dev Psychol 1991;27:108 –18. 10. Maag JW, Behrens JT, Di Dangi SA. Dysfunctional cognition associated with adolescent depression: Findings across special populations. Exceptionality 1992;3:31– 47. 11. Dalley MB, Bolocofsky DN, Alcorn MB, Baker C. Depressive symptomatology, attributional style, dysfunctional attitude, and social competency in adolescents with and without learning disabilities. School Psychol Rev 1992;21:444 –58. 12. Jackson SC, Enright RD, Murdock JY. Social perception problems in learning disabled youth: Developmental lag versus perceptual deficit. J Learn Disabil 1987;20:361– 4. 13. Resnick MD, Bearman PS, Blum RW, et al. Protecting adolescents from harm: Findings from the National Longitudinal Study of Adolescent Health. JAMA 1997;278:823–32. 14. Jessor R, Jessor S. Problem Behavior and Psychological Development: A Longitudinal Study of Youth. New York: Academic Press, 1977. 15. Werner E., Smith R. Vulnerable but Invincible. New York: McGraw Hill, 1982.
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16. Rutter, M. Resilience: Some conceptual considerations. J Adolesc Health 1993;14:626 –31. 17. Blum RW. Healthy youth development as a model for youth health promotion: A review. J Adolesc Health 1998;22:368 –75. 18. Maag JW, Behrens JT. Depression and cognitive self-statement of learning disabled and seriously emotionally disturbed adolescents. J Spec Educ 1989;23:17–27. 19. Weinberg W, Rehmet A. Childhood affective disorder and school problems. In: Cantwell DP, Carlson GA, eds. Affective Disorders in Childhood and Adolescence: An Update. New York: Spectrum Publications, 1983;109 –28. 20. Goldstein P, Paul GG, Sanfilippo-Cohen S. Depression and achievement in subgroups of children with learning disabilities. J Appl Dev Psychol 1985;6:263–75. 21. Borowsky I, Resnick MD. Environmental stressors and emotional status of adolescents who have been in special education classes. Arch Pediatr Adolesc Med 1998;152:377– 82. 22. Surgeon General’s Report. Mental Health in America. Washington, DC: Congressional Printing Office, 1999. 23. Kenny TJ, Rohn R. Visual-motor problems of adolescents who attempted suicide. Percept Mot Skills 1979;48:500 – 602. 24. Hayes ML, Sloate, RS. Preventing suicide in learning disabled children and adolescents. Acad Ther 1988;24:221–30. 25. McBride HEA, Siegel LS. Learning disabilities and adolescent suicide. J Learn Disabil 1997;30:652–9. 26. Larson K. A research and alternative hypothesis explaining the link between learning disability and delinquency. J Learn Disabil 1988;21:357– 63. 27. Epstein MH, Douglas C, Wills LJ. Behavior-problem patterns among the learning disabled: III. Replication across sex and age. Learn Disabil Q 1986;9:43–54. 28. Waldie K, Spreen O. The relationship between learning disabilities and persisting delinquency. J Learn Disabil 1993;26: 417–23. 29. Swain RC, Beauvais F, Chavez EL, Oetting ER. The effect of school dropout rates on estimates of adolescent substance use among three racial/ethnic groups. Am J Public Health 1997; 87:51–5.
FELLOWSHIP FORUM
Adolescents With Learning Disabilities: Risk and Protective Factors Associated With Emotional WellBeing: Findings From the National Longitudinal Study of Adolescent Health MARIA VERONICA SVETAZ, M.D., MARJORIE IRELAND, Ph.D., AND ROBERT BLUM, M.D.
Purpose: To identify differences in emotional wellbeing among adolescents with and without learning disabilities and to identify risk and protective factors associated with emotional distress. Methods: Cross-sectional analysis of adolescent inhome interview data of the National Longitudinal Study of Adolescent Health. A total of 20,780 adolescents were included in this study of whom 1,301 were identified as having a learning disability. Initially, emotional distress, suicidal behaviors, and violence involvement were compared among those adolescents with and without learning disabilities using Student’s t-test for the continuous or semicontinuous variables and Chi-square for the dichotomous variables. Subsequently, logistic regression analyses were conducted to identify which variables were most strongly associated with risk and protective factors for emotional distress. Results: Adolescents with learning disabilities had twice the risk of emotional distress, and females were at twice the risk of attempting suicide and for violence involvement than their peers. While educational achievement is below that of peers, connectedness to school is comparable. So, too, is connectedness to parents. Connectedness to parents and school was identified as most strongly associated with diminished emotional distress,
From the Division of General Pediatrics and Adolescent Health, University of Minnesota, Minneapolis, Minnesota Dr. Svetaz completed this work while a fellow in the Adolescent Health Program, University of Minnesota. She is currently in the Family Medicine Residency Training Program at Regions Medical Center, St. Paul, Minnesota. Address correspondence to: Dr. R.W. Blum, University Gateway, Department of General Pediatrics and Adolescent Health, Suite 260, 200 Oak Street S.E., Minneapolis, Minnesota 55455-2002. Manuscript accepted April 7, 2000. 1054-139X/00/$–see front matter PII S1054-139X(00)00170-1
suicide attempts, and violence involvement among adolescents with learning disabilities. Conclusions: Given the increased association with emotional distress, suicidal attempts, and violence involvement, clinicians need to assess social and emotional as well as educational and physical functioning of these young people. We also need to be aware of the role protective factors play in the lives of young people with learning disabilities. © Society for Adolescent Medicine, 2000 KEY WORDS: Adolescent health Emotional well-being Gender differences Learning disabilities Risk and protective factors Suicidal attempt Violence involvement
In the very early days of this century, when cyberliteracy and mastery of technology seem to be the basic ingredients for survival in the competitive job market, the number of children and adolescents with learning disabilities (LDs) appears to be increasing (1–3). Today, LDs appear to have a prevalence in the order of 5% of children and youth (2). The association between LDs and emotional problems has been well described (3– 6). Although the federal definition of LDs excludes those that are secondary to emotional disturbance, adolescents with LDs have a high incidence of emotional and behavioral problems (3–11). Additionally, Jackson et
© Society for Adolescent Medicine, 2000 Published by Elsevier Science Inc., 655 Avenue of the Americas, New York, NY 10010
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al. (12) found that compared with non–learning disabled peers, those with LDs saw themselves to be significantly less socially competent and were rated lower in social competency by their respective teachers. Given that a critical element of social skills is the ability to accurately perceive the environment and interpersonal relationships, this deficit contributes to social isolation. Deficits of social perception improve during developmental maturation; however, for those with LDs, it appears that a lag persists through adolescence (12). One limitation of previous research on youth with LDs is that most samples have been drawn from a clinical or relatively small school sample. Additionally, studies have rarely explored the association between LDs and risk behaviors. Finally, there is not much information about outcomes and risk and protective factors among adolescents with LDs and emotional distress. The present analysis focused on two questions: (a) How did individual, family, and school factors differ for a nationally representative sample of youth with LDs from peers without such conditions, and (b) which factors were associated with increased and diminished risk of emotional distress for youth with learning disabilities?
Methods The Sample Data were obtained from the National Longitudinal Study of Adolescent Health (Add Health Study). This is a longitudinal study of adolescents in grades 7 through 12 and the multiple social contexts in which they live. Initially 80 high schools were identified across the United States, a high school being defined as a school with at least 30 students and an 11th grade. Subsequently, the primary feeder school (e.g., middle or junior high school) was identified; however, since not all schools had a feeder school, a total of 134 schools were identified and agreed to participate (79% of the sample). Of those, 129 (96%) hosted an in-school confidential survey completed in 1994 –1995 by 90,118 young people. From this group plus the school rosters of all 134 schools, a subsample was identified of whom 20,780 youths in grades 7 through 12 agreed to participate in an in-depth interview. The first wave of the in-home interview was conducted between April and December 1995, took approximately 90 minutes to complete, and all the information was recorded directly onto a laptop
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computer using a CASI-technology, thereby minimizing data entry errors and enhancing response confidentiality for sensitive questions. Of those adolescents interviewed at home, a parent (usually a mother) was recruited to participate in an interview of 30-min duration. Also, 84.6% of young people had a parent respondent (n ⫽ 17,661). The present analysis drew on the subsample for whom both parent and adolescent data are available. In the present analysis, LD was defined as an affirmative response of parents to two questions: (a) Does your adolescent have a LD and (b) has he or she ever been in special education classes? The comparison group consisted of those adolescents whose parents answered “no” to both questions. Because of the complex sampling design, each case was assigned a weight so that the resulting analyses are generalizable to the U.S. adolescent population. These sample weights were used in the analyses. The final sample consisted of 16,340 adolescents (78.6%) of whom 1603 met the criteria for LDs. The sample of young people with LDs were disproportionally male (twice that of females), older than the comparison group, and more likely to be on welfare. In addition, they were slightly more likely to be African-American or Hispanic and less likely to be from two-parent families (Table 1). Measures The three outcome variables included: suicide attempt, emotional distress, and violent behavior. Suicide attempt was based on a dichotomous variable: “Have you attempted suicide in the last year?” Violence involvement was based on an eight-item scale that has a Cronbach ␣ of .83. Emotional distress was measured by a 17-item scale that had a Cronbach ␣ of .86. Details on scale construction have been previously reported (13). Independent variables were selected according to the theoretical framework using items in three domains that previously have been shown to be significant: individual characteristics, family context, and school context. Analysis Bivariate statistics were used to explore the first research question of similarities and differences between youth with LD and their peers, including Chi-square for dichotomous variables and the Student’s t-test for continuous or quasicontinuous variables (Tables 2 and 3).
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Table 1. Demographics Variables Demographics Variables Age (yr) Male Female Gender Male Female Race/Ethnicity European American African-American Hispanic Parents on welfare Two-parent family Male Female
Without Learning Disabilities % or Mean
Number (14,737)
15.6 15.4
With Learning Disabilities % or Mean
Number (1,603)
15.6 15.6
p Value NS NS
48.0% 52.0%
7,077 7,661
67.0% 33.0%
1,074 530
⬍.001 ⬍.001
91.2% 88.0% 89.7% 10.0% 55.0% 58.0% 53.4%
9,708 2,268 1,704 1,448 8,012 3,977 4,035
8.8% 12.0% 10.3% 18.0% 41.0% 40.0% 43.4%
933 308 196 263 605 389 216
⬍.001 ⬍.001 ⬍.01 ⬍.001 ⬍.001
NS ⫽ not significant.
Results Bivariate Comparisons Individual Context (Table 2). To explore the relationships of having a LD with the emotional outcomes of emotional distress, suicide attempts, and violence involvement, odds ratios were computed controlling for age, gender, grade, socio-economic status (SES), family structure, and race. Having a LD was associated with nearly double the odds ratio (OR) for emotional distress (OR 1.89 overall; 1.96 for males; 1.81 for females). Likewise, the OR was 1.67 overall for suicide (1.43 for males; 1.84 for females). Violence involvement was also greater for both males (OR ⫽ 1.25) and females (OR ⫽ 1.90), compared with peers. Adolescents with LDs were at least twice as likely as teens without LDs to report emotional distress: 24% vs. 12% for boys (⌾2 ⫽ 93.96; p ⫽ .001) and 33% vs. 12% for girls (⌾2 ⫽ 42.02; p ⫽ .001). Boys with LDs were also twice as likely to report suicidal attempts: 4% vs. 2% (⌾2 ⫽ 10.08; p ⫽ .002); the same was true for girls with LDs: 9% vs. 5% (⌾2 ⫽ 12.23; p ⫽ 0.001). Secondly, youths with LDs were significantly more likely than others to report involvement in violent behaviors: 31% vs. 25% for boys (⌾2 ⫽ 13.28; p ⫽ .001) and 20% vs. 11% for girls (⌾2⫽ 35.55; p ⫽ .001). They were also more likely to have witnessed or have been a victim of a violent act. This was especially true for adolescent girls (t ⫽ 4.66; p ⫽ .0001). Adolescents with LDs were more likely to report carrying weapons: 13% vs. 9%, with differences reported for both boys: 16.2% vs. 13.3% (⌾2 ⫽ 5.99;
p ⫽ .014) and girls: 7% vs. 4.3% (⌾2 ⫽ 5.68; p ⫽ .017). They felt that they were more likely to die at a younger age (t ⫽ ⫺5.08; p ⫽ .001) and they were less likely to have a religious identity (t ⫽ 10.83; p ⫽ .001). Both boys and girls with LDs were more likely than peers to perceive that they look younger than their current age: 15% vs. 8% (⌾2 ⫽ 70.29; p ⫽ .001). Adolescents with LDs reported initiating intercourse at a younger age than peers without LDs, a difference that was statistically significant only for boys (t ⫽ 2.59; p ⫽ .01). In addition, having intercourse before the age of 12 was more commonly reported for girls with LDs than peers (3% vs. 1%; ⌾2 ⫽ 17.10; p ⫽ .0001). Interestingly, there was no statistically significant difference between groups on the prevalence of pregnancy: 7% vs. 6% (⌾22 ⫽ 0.22; p ⫽ .639). Additionally, substance use (alcohol, marijuana, cigarettes, and other illegal drugs) was lower in youth with LDs than peers. Family Context (Table 3). Adolescents with LDs were as likely to report that they feel connected to their families as were those in the comparison group. They were less likely, however, to report that they engaged in activities with their parents (t ⫽ 8.16;p ⬍ .0001); but they reported more parental presence throughout the day, (e.g., a parent home after school t ⫽ 3.52; p ⫽ .0004). They perceived parental expectations for their successful school completion to be lower than did peers without learning disabilities (t ⫽ 10.15; p ⫽ .0001). Adolescents with LDs were also more likely to report a recent suicide in their family than the comparison group: 5.5% vs. 4.3%
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Table 2. Individual Context Variables, by Gender Independent Variables Variables Emotional distress* Male Female Suicide* Male Female Violence* Male Female Victim/Witness of violence* Male Female Carry weapon* Male Female Likelihood of untimely death* Male Female Religious identity** Male Female Chronic illness* Male Female Looks younger* Male Female Looks older* Male Female Age of sexual debut** (yr) Male Female Intercourse before 12 years old* Male Female Ever pregnant* Alcohol use* Male Female Marijuana use* Male Female Other illegal drug use* Male Female Smoking* Male Female
Without Learning Disabilities
With Learning Disabilities
p Value
% or Mean
Number
% or Mean
Number
12.0% 21.0%
832 1,561
24.0% 33.0%
228 161
⬍.001 ⬍.001
2.0% 5.0%
139 389
4.0% 9.0%
36 44
⬍.01 ⬍.001
25.0% 11.0%
1,741 816
31.0% 20.0%
292 94
⬍.001 ⬍.001
0.8% 0.3%
6,683 7,661
1.0 0.7
749 31
⬍.01 ⬍.001
13.3% 4.3%
908 326
16.2 7.0
152 412
⬍.01 ⬍.05
1.5% 1.5%
6,691 7,671
1.8 1.9
746 412
⬍.001 ⬍.001
6.2% 6.7%
6,704 7,690
5.0 5.7
772 430
⬍.01 ⬍.001
12.8% 11.6%
903 889
16.2% 21.0%
175 109
⬍.01 ⬍.001
9.0% 7.4%
613 553
14.3% 16.0%
132 73
⬍.001 ⬍.001
14.4% 13.0%
985 972
11.5% 11.0%
113 55
⬍.01 NS
14.0% 14.7
2,407 2,659
13.5 14.5
252 125
⬍.01 NS
5.0% 1.0% 6.0%
345 93 465
6.3% 3.0% 7.0%
68 18 29
⬍.05 ⬍.001 NS
32.2% 28.8%
2,182 2,167
22.0% 18.3%
203 87
⬍.001 ⬍.001
28.2% 24.8%
1,886 1,851
25.0% 16.6%
227 77
⬍.05 ⬍.001
12.3% 11.5%
836 868
9.8% 10.5%
91 50
⬍.05 NS
22.9% 24.0%
1,345 1,555
26.8% 20.0%
230 89
⬍.05 NS
* percentage: variable is a dichotomous or was dichotomized for the analysis (Chi-square). ** mean: variable is a scale 0 to 10 (Student’s t-test). NS ⫽ not significant.
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Table 3. Family and School Context Variables, by Gender Independent Variables Variables Family connectedness** Male Female Parent-Adolescent activities** Male Female Parental presence** Male Female Recent family suicide* Male Female Parental school expectation** Male Female Gun at home* Male Female School connectedness** Male Female Skip school** Male Female Trouble in school** Male Female Students are prejudged* Male Female Repeated a grade* Male Female
Without Learning Disabilities
With Learning Disabilities
p Value
% or Mean
Number
% or Mean
Number
7.5 7.3
6,703 7,684
7.4 7.3
768 425
⬍.05 NS
1.8 1.9
6,698 7,675
1.5 1.7
764 423
⬍.001 ⬍.001
7.2 7.2
6,654 7,592
7.3 7.3
751 418
⬍.05 ⬍.01
38 38
NS ⬍.01
3.4% 5.0%
233 383
4.0% 8.2%
8.6 8.6
6,651 7,589
8.0 8.0
732 400
⬍.001 ⬍.001
31.0% 18.5%
2,090 1,389
25.3% 14.0%
237 64
⬍.001 ⬍.01
6.4 6.4
6,695 7,665
6.3 6.3
765 427
⬍.05 NS
0.6 0.5
6,923 7,824
0.8 0.7
840 460
⬍.001 ⬍.05
1.0 0.9
6,836 7,678
1.3 1.1
814 441
⬍.001 ⬍.001
43.1% 43.3%
2,919 3,201
35.7% 33.3%
331 150
⬍.001 ⬍.001
20.3% 14.2%
1,395 1,076
49.3% 43.0%
476 207
⬍.001 ⬍.001
* percentage: variable is a dichotomous or was dichotomized for the analysis (Chi-square). ** mean: variable is a scale 0 to 10 (Student’s t-test). NS ⫽ not significant.
(OR ⫽ 1.3; ⌾2 ⫽ 4.15; p ⫽ .04). This was especially true and highly significant among females: 8.2% vs. 5% (OR ⫽ 1.67; ⌾2 ⫽ 8.55; p ⫽ .003). School Context (Table 3). School connectedness did not differ significantly for young people with or without LDs. Both boys and girls with LDs were less likely to report that they perceived prejudice from other students in their schools than did comparison groups. Among the girls, 33.3% of the LD group felt that the students were prejudiced, compared with 43.3% of the comparison group (⌾2 ⫽ 17.5; p ⫽ .001). Among the boys, 35.7% of the LD group reported that the students in their school were prejudiced, compared with 43.1% of the comparison group (⌾2 ⫽ 18.03; p ⫽ .001).
Adolescents with LDs were far more likely to report having repeated a grade than their peers: girls 42.52% vs. 14.24% (⌾2 ⫽ 273.3; p ⫽ .001); boys 49.3% vs. 20.36% (⌾2 ⫽ 388.7; p ⫽ .001). Both boys (t ⫽ 6.6; p ⫽ .0001) and girls (⌾2 ⫽ 5.26; p ⫽ .0001) were more likely than peers to report that they get into trouble in school. They were also more likely to report having skipped school without a clear reason (boys t ⫽ 3.96, p ⫽ .0001; girls t ⫽ 2.36, p ⫽ .018). Multiple Regression Analyses Significant intercorrelation was found among the three dependent variables for youth with LDs (Table 4). Specifically, youth with LDs who had emotional distress reported eight times the number of suicide
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Table 4. Risk and Protection-Associated Factors for Emotional Distress, Suicide and Violence Among Adolescents With Learning Disabilities Emotional Distress
Emotional distress Suicide Violence Perceived risk of untimely death Victim Somatic complaints Religious identity Looks younger Look older Weapon carrying Cigarette use Marijuana use Alcohol use Sexual orientation Even had sex Had sex before 12 years old Family connectedness Parental school expectation Parental activities Parental presence Family suicide Gun at home Parents’ education level School connectedness Grade point average School prejudice Skip school Trouble Repeat a grade
Suicide
OR
p
3.80 2.69 3.40 1.89 4.74 0.73 0.57 1.42 2.50 2.41 2.20 2.18 1.55 1.53 2.30 0.14 1.16 1.19 1.56 2.15 1.18 0.92 0.11 0.46 1.77 1.19 2.00 1.51
⬍.001 ⬍.001 ⬍.001 ⬍.01 ⬍.001 ⬍.05 ⬍.001 ⬍.001 ⬍.001 ⬍.01 ⬍.01 ⬍.001 ⬍.001
⬍.01 ⬍.05 ⬍.001 ⬍.01 ⬍.01 ⬍.01 ⬍.001 ⬍.01
Violence
OR
p
OR
p
7.97
⬍.001
5.20 3.81
3.81 3.13 3.21 1.56 0.27 1.34 1.99 2.65 2.86 6.73 6.85 1.32 1.88 2.94 0.20 1.17 0.29 0.23 3.29 1.06 1.03 0.12 0.43 0.81 1.29 1.96 2.66
⬍.001 ⬍.01 ⬍.001 ⬍.01 ⬍.01
⬍.001 ⬍.001
2.37 79.35 1.85 0.75 0.60 5.70 7.36 4.04 14.48 9.63 1.87 3.36 4.90 0.35 0.78 1.09 0.37 3.36 1.93 0.93 0.24 0.44 1.92 1.47 1.91 1.33
⬍.001 ⬍.001 ⬍.001
⬍.01 ⬍.001 ⬍.001 ⬍.001 ⬍.05 ⬍.01 ⬍.001 ⬍.05 ⬍.01 ⬍.01 ⬍.001 ⬍.01 ⬍.001 ⬍.001
⬍.05 ⬍.001 ⬍.001 ⬍.001 ⬍.001 ⬍.001 ⬍.01 ⬍.001 ⬍.001 ⬍.001 ⬍.001 ⬍.001 ⬍.001 ⬍.05 ⬍.001 ⬍.01 ⬍.01 ⬍.001 ⬍.001 ⬍.05
OR ⫽ odds ratio.
attempts and five times the violence involvement as those without such distress. Factors associated with increased risk included: having had intercourse before the age of 12 years, weapon carrying, and substance use. Those young people with LDs who had a history of violence victimization were twice as likely to report emotional distress, 3 times as likely to report a history of a suicide attempt, and almost 80 times more likely to report to be engaged in violent activities than peers who did not report such victimization. Likewise, homosexual or bisexual orientation as well as a history of having initiated intercourse before the age of 12 years constituted a common set of risk explainers. At the family level, a history of suicide attempts or completions by a family member was associated with increased risk for each of the three outcome variables. Among school factors, a history of having re-
peated a grade and a history of trouble in school (both of which were more common among youth with LDs) were each associated with increased risk for all three outcomes. Among the factors associated with lower levels of emotional distress, suicide attempts and violence involvement, religious identity was one of the strongest individual level variables associated with lower risk for the three outcomes; however, it was statistically significant only for suicide. Additionally, appearing younger than peers was associated with reduced risk for both emotional distress and violence involvement for youth with LDs. Family connectedness was the most strongly associated with lower risk for the three study outcomes. However, across the individual, family, and school factors for each of the three outcomes, distress, violence, and suicide attempt, school connectedness was the factor associated with lowest risk.
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Discussion The analyses are based on a theoretical framework of risk and protection. Originally, articulated by Jessor and Jessor (14), the Health Risk Behavior Theory posited a set of factors (including individual, peer, family, and environmental) that was associated with increased participation by adolescents in a range of risk behaviors. Concurrently, research by Werner and Smith (15), Rutter (16), and numerous other researchers began to identify factors associated with resilience on the capacity of young people to bounce back in the face of adversity (17). Recently, analyzing data from Add Health, Resnick et al. (13) found that for youth in general in the United States, family connectedness, parental concerns regarding educational achievements, and a caring adult in school were all protective against a range of risk behaviors. The association between LDs and depression has been previously well described; for example, Maag and Behrens (18) indicated that severe depression was evident among one in five males and one in three females with LDs. These figures are relatively consistent with those of Weinberg and Rehmet (19) and Goldwin et al. (20), based on clinical and special samples, and those of Borowsky and Resnick (21), based on school sample. These studies, however, are all based on clinical or special samples. The present analyses found one in four boys and one in three girls with LDs to report severe emotional distress. This is two to three times higher than the average adolescent population. The association between emotional distress and suicide is obvious. Awareness is expanding toward the increased risk of suicide among adolescents with LDs because several studies reported this finding (22–25). What has not been previously reported was the higher suicide risk of youth with LDs. Kenny and Rohn (23) suggested that such may be the case in their study of young people who committed suicide. There they found that half of all young people who had suicide completions also had neurodevelopmental disabilities consistent with LDs. So, too, Hayes and Sloate (24) reported that counselors in Los Angeles County schools reported that 14% of all suicides were among youth with LDs. Given a national prevalence of LDs of 5%, this is significantly higher than anticipated. And while the data in the present study are alarming (twice the rate of suicide attempts for youth with LDs when compared with peers) at 4% for males and 9% for females, they are not as high as previous research has suggested. Still, we are
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finding nearly 1 in 11 females with LDs reported having attempted suicide in the past 12 months. As is true for emotional distress and suicide attempts, youth with LDs are significantly more likely than peers to have violence involvement. The relationship between violence and LDs has tended to focus on juveniles who are incarcerated with research indicating that as much as a range of 26% to 75% of the juvenile offender population have significant learning problems (26). Other studies suggest that young people with LDs are adjudicated twice as often as non-LD youth and experience greater recidivism and parole failure (26). Vallance et al. (6) have suggested that specific LDs such as expressive and receptive languages predisposes to social and behavioral maladjustment. Epstein et al. (27) noted the emergence of delinquency in the behavior patterns of both older boys and girls with LDs. They described the differences across ages and gender related to behavioral problems, especially in two areas: environmental conflict and personal disturbance. There are different theories posited to explain the link between aggressive behaviors and LDs. The school failure hypothesis proposes that LDs increase the risk for academic failure, which leads to a negative self-esteem, which in turn increases the odds for school dropouts, violence involvement, and delinquent activities. The susceptibility theory holds that adolescents with LDs have certain personality features that make them more prone to engage in delinquent activities (26). Waldie and Spreen (28) examined the persistence of delinquency of adolescents and young adults with LDs and concluded that the association may be the result of impulsiveness and poor judgment. In the present study, the correlation between LDs and violence was confirmed. Specifically, when controlling for other demographic variables, adolescents with LDs were twice as likely to be engaged in violent activities than their peers. Interestingly, the association between violence and LDs was stronger for adolescent girls than boys. The strongest single associated risk factor for adolescents with LDs was having been a victim of or a witness to a violent act. By itself it increased the odds of an adolescent with LDs participating in violence by approximately 80 times. A similar association was found in the general adolescent population (13). Protecting Youth With Learning Disabilities The present study may be the first to explore factors that are associated with diminished risk for emo-
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tional distress, suicide attempts, and violence involvement. Factors that emerge include: family connectedness, school connectedness, and religious identity. Together these variables suggest that a sense of belonging is central in diminishing risk and promoting emotional well-being. These findings are consistent with those of Resnick et al. (13) who found these same factors to be associated with diminished participation in a range of risk behaviors. Perhaps surprising is the important role of school connectedness and the protective role it appears to have for youth with LDs despite their poorer-than-average academic performance. This finding confirms what Resnick et al. (13) suggest, that there is a weak association between school performance and school connectedness. Additionally, youth with LDs are less likely to report experiencing prejudice in schools than their peers. Clearly, as with home, school has the potential of being an arena of comfort and not just a source of stress for youth with LDs.
Limitations This study has several limitations. It was conducted with school-going adolescents. Adolescents with LDs are at higher risk for adverse outcomes when they drop out of school. This could be one of the explanations why adolescents with LDs and substance use were not as prevalent in this study as in other studies conducted with adolescents in shelters or in the juvenile justice system (29). The different types and severity of LDs could not be determined. The only measure of IQ that was provided during the study was a computerized, abridged version of the Peabody Picture Vocabulary Test-Revised, limiting the ability to disaggregate LDs and intellectual impairments. Additionally, since the criteria for grade point average determinations were not homogeneous across schools, they could not be used as a consistent measure of academic success or achievement in school performance.
Conclusion According to results from the present analysis, an adolescent with LDs is: more frequently male (2:1), more likely to live in a single-parent family; and more likely to have a lower income on average than peers. Educational achievement is below that of peers; however, connectedness to school is comparable. So, too, is connectedness to parents. Both variables were identified as the strong protection-associ-
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ated variables for emotional distress, suicidal attempts, and violence involvement among adolescents with LDs in our study. Girls with LDs appear to experience more emotional distress and suicide attempts than their male counterparts. This is consistent with the general population. As is evident from the present analysis, youth with LDs are at significantly higher risk than peers for emotional distress, suicide attempts, and violence. Given this, it is extremely relevant that the adolescent with problems in school (e.g., skipping school, getting in trouble at school because of behavioral issues, and repeating a grade) receives a comprehensive and systemic evaluation to rule out the presence of an LD and/or emotional disorder. So, too, it is evident that there is an important role for families, schools, and institutions in diminishing the health risks to which youth with disabling conditions are exposed. Given this information, it is no longer sufficient to counsel families who have children with LDs to seek educational remediation; they need to understand their role and the role of school in diminishing the significant emotional sequelae. We thank Michael Resnick, Ph.D., Darryl Goetz, Ph.D., and Ann Garwick. Ph.D., for their thoughtful review and critique throughout the research in preparation of the manuscript. Additionally, Linda Boche’s attention to manuscript preparation throughout the multiple versions of this paper is greatly appreciated. These analyses were supported in part by the University of Minnesota’s Center for Children with Chronic Illness and Disability, National Institute on Disability Rehabilitation Research (Grant H133B40019). This research is based on data from the Add Health project, a program project designed by J. Richard Udry (PI) and Peter Bearman, and funded by grant P01-HD31921 from the National Institute of Child Health and Human Development to the Carolina Population Center, University of North Carolina at Chapel Hill, with cooperative funding participation by the National Cancer Institute; the National Institute of Alcohol Abuse and Alcoholism; the National Institute on Deafness and Other Communication Disorders; the National Institute on Drug Abuse; the National Institute of General Medical Sciences; the National Institute of Mental Health; the National Institute of Nursing Research; the Office of AIDS Research, NIH; the Office of Behavior and Social Science Research, NIH; the Office of the Director, NIH; the Office of Research on Women’s Health, NIH; the Office of Population Affairs, DHHS, the National Center for Health Statistics, Centers for Disease Control and Prevention, DHHS; the Office of Minority Health, CDC, DHHS; the Office Minority Health, Office of Public Health and Science, DHHS; the Office of the Assistant Secretary for Planning and Evaluation, DHHS; and the National Science Foundation. Persons interested in obtaining data files from the National Longitudinal Study of Adolescent Health should contact Jo Jones, Carolina Population Center, 123 West Franklin Street, Chapel Hill, North Carolina 27516-3997 (email: [email protected]).
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