- Email: [email protected]
Adolescents' beliefs about the fairness of exclusion of peers with mental health problems
Journal of Adolescence 42 (2015) 59e67
Contents lists available at ScienceDirect
Journal of Adolescence journal homepage: www.elsevier.com/locate/jado
Adolescents' beliefs about the fairness of exclusion of peers with mental health problems Claire O'Driscoll a, Caroline Heary a, *, Eilis Hennessy b, Lynn McKeague b a b
National University of Ireland, Galway, Ireland University College Dublin, Dublin, Ireland
a r t i c l e i n f o
a b s t r a c t
Article history: Available online
Stigma research suggests that exclusion of peers with mental health problems is acceptable, however, no research has explored young people's beliefs about the fairness of exclusion. Group interviews with 148 adolescents explored judgements about the fairness of excluding peers with ADHD or depression from dyads and groups. Young people evaluated exclusion of peers with ADHD or depression from dyads and groups, with the exception of group exclusion of the peer with ADHD, as mostly unfair. Beliefs about the fairness of exclusion were influenced by the attributions that they applied to the target peer's behaviour, social obligations and loyalty within friendships and concerns about the adverse psychological effects of exclusion. Furthermore, their evaluations were influenced by personal beliefs about the social and personal costs of including the target peer. Evaluations of exclusion highlight novel avenues for to develop knowledge on the stigma of mental health problems. © 2015 The Foundation for Professionals in Services for Adolescents. Published by Elsevier Ltd. All rights reserved.
Keywords: Stigma Exclusion ADHD Depression Thematic analysis Adolescence
Young people with mental health problems are some of the most chronically excluded individuals in school playgrounds (Chen & Li, 2000; Hoza et al., 2005). The adverse peer relationships experienced by these young people are well documented (Elkington et al., 2012; Moses, 2010) and marked by themes of the loss of friendships following the onset of symptoms, teasing and harassment by peers, and experiences of isolation and loneliness. These persistent findings imply that exclusion or rejection of young people with mental health problems is socially acceptable to their peers. The consequences of exclusion are alarming; especially when one considers research that suggests that peer acceptance is protective for maintaining good mental health (Warren, Jackson, & Sifers, 2009) and promotes recovery from mental health problems (Meadows, Brown, & Elder, 2006). This literature highlights the importance of developing effective anti-stigma interventions. Stigma is a multi-dimensional construct that incorporates derogatory cognitive (stereotypes), affective (prejudices) and behavioural (discrimination) responses towards people with mental health problems. In adolescence, discrimination manifests as exclusion from activities and social groups, friendship rejection or avoidance (Brown & Bigler, 2005). Traditionally, stigma is explored by assessing pre-defined stereotypes, prejudices and discrimination towards vignettes that describe labels, or more commonly behavioural descriptions, of hypothetical peers with mental health disorders. Inherent in this methodological approach is the assumption that the symptoms and labels of mental illness evoke negative cognitive and affective responses that justify rejection. While there is evidence to support the theory that the symptoms and labels underpin stigma
* Corresponding author. School of Psychology, National University of Ireland Galway, Galway, Ireland. Tel.: þ353 91 495059. E-mail address: [email protected] (C. Heary). http://dx.doi.org/10.1016/j.adolescence.2015.03.008 0140-1971/© 2015 The Foundation for Professionals in Services for Adolescents. Published by Elsevier Ltd. All rights reserved.
60
C. O'Driscoll et al. / Journal of Adolescence 42 (2015) 59e67
(Corrigan et al., 2007), arguably, however, it only accounts for a portion of why stigma occurs. Absent from the existing literature is an account of the influence of other factors such as social norms and conventions and moral judgements about the fair treatment of others within the peer group. According to Social Domain Theory (SDT, Turiel, 1983) these value-laden factors provide a culture that fosters or condemns the acceptability of rejection of minority individuals or groups (see Killen, Mulvey, & Hitti, 2012). To explore the influence of social norms and moral judgements on beliefs about exclusion, SDT researchers present participants with vignettes that describe exclusion scenarios involving hypothetical peers (Killen, Rutland, Abrams, Mulvey, & Hitti, 2013). Participants' views on the fairness of the exclusion and their rationale for such evaluations are then explored. In the context of sex, race, and ethnicity, SDT research suggests that when evaluating peer exclusion scenarios, children and adolescents use moral (“it's not fair because she will feel sad”), social conventional (“it's better for the rest of the group if he is not invited”) and psychological reasons (“it's her personal choice whom she befriends”). An overriding theme to emerge from SDT research is that exclusion is often deemed acceptable to maintain status differences and to uphold cohesion in the peer group (Killen et al., 2012). Stigma and SDT research, respectively, point to sex and age as important factors in shaping how young people think about peers with mental health problems and peer exclusion. In the stigma literature, research generally implicates males as more stigmatising towards mental illness compared to females (Jorm & Wright, 2008; Williams & Pow, 2007) and that stigma worsens with age (Wahl, 2002). However, when explored together, research shows that often developmental and sex trends are inter-dependent, such that differences in responses are contingent on the perceivers' sex and age, the target peer's sex and mental health disorder (O'Driscoll, Heary, Hennessy, & McKeague, 2012; Swords, Heary, & Hennessy, 2011). In the SDT literature, research shows that young people increasingly rationalise about exclusion by reflecting on group functioning and group identity (Aboud, 2008); consequently, exclusion tends to become more acceptable with age (Malti, Killen, & Gasser, 2012; Park & Killen, 2010). Furthermore, SDT research suggests that females tend to show greater concern for inclusivity of peers across a variety of exclusion contexts (Malti et al., 2012; Park & Killen, 2010). To date, no research has explored young people's views on the acceptability of exclusion of peers with mental health problems. However, when asked to explain why hypothetical peers with depression or attention deficit hyperactivity disorder (ADHD) were excluded, young people justified exclusion because the target peers could not conform to the social rules and conventions attached to friendship dyads and groups (O'Driscoll, Heary, Hennessy, & McKeague, 2014). Furthermore, they reported that including a peer with a mental health problem posed social and personal risks to members of the peer group. Although, this study provided insight into the function of exclusion it did not report data on the acceptability of exclusion. Thus we continue to have little understanding of how young people reason about exclusion decisions specific to peers with mental health difficulties. Drawing from the lessons learned in the racial and gender literature, we argue that developing a comprehensive understanding of peer values and norms that underpin the existence of stigma can enhance future development of anti-stigma interventions. The present study provides an exploratory insight into young people's beliefs about the fairness of exclusion of peers with mental health problems. ADHD and depression were chosen as they are two of the most common childhood mental health disorders (Merikangas, Nakamura, & Kessler, 2009). Reasoning about exclusion is often context dependent (Killen, Kelly, Richardson, Crystal, & Ruck, 2010); thus dyad and group contexts were employed. To gain a cross-developmental perspective, responses of young people in early and mid-adolescence were explored. This paper aims to advance knowledge on the exclusion of peers with mental health problems in adolescence. Specifically, the aims were (a) to explore adolescents' beliefs about the fairness of excluding peers with either ADHD or depression; (b) to examine any age and sex patterns in adolescents' responses; and (c) to investigate any common or unique views across the two exclusion contexts as well as the two target disorders. Method Participants The sample consisted of seventy-two 10e11 year olds (M ¼ 10.77 years; SD ¼ 0.46 years: 34 boys and 38 girls) and seventysix 15e16 year olds (M ¼ 15.5 years; SD ¼ 0.46 years: 34 boys and 42 girls). Participants were white and their socio-economic status, as determined by the highest educational level achieved by the consenting adult, was 42% low (second-level completion only), 28% medium (post-second level diploma or certificate), and 29% high (bachelor's degree or higher). All participants verbally assented to take part and had written parental consent. Data collection Data were collected during class time in three randomly selected rural primary and secondary schools in the western region of the Republic of Ireland There were 37 same-sex self-selected groups in total, which were facilitated by the lead author. Each group consisted of between 3 and 5 participants; there were three groups with 3 participants, 31 groups with 4 participants, and three groups with 5 participants. Group interviews were deemed suitable, as the group context is a familiar setting for most young people (Hennessy & Heary, 2004). We anticipated that replicating a group environment would help participants draw on the peer context and potentially enhance the ecological validity of their responses. Furthermore, given that our aim was to qualitatively explore themes and not quantify responses, the group context was considered an appropriate setting to collect data.
C. O'Driscoll et al. / Journal of Adolescence 42 (2015) 59e67
61
Each group was randomly assigned to one of two conditions and were read two age and sex-matched vignettes (see Tables 1 and 2). The first condition consisted of a story character with ADHD experiencing exclusion in a dyadic social situation and a story character with depression experiencing exclusion in a group social situation. In the second condition, the pairing of the story characters and the exclusion scenarios was reversed, such that the story character with depression experienced exclusion in a dyadic social situation and the story character with ADHD experienced exclusion in a group social situation. In each condition, the order of the vignettes was counterbalanced. As single sex focus groups were employed, participants always read about a peer with ADHD and a peer with depression who was the same sex as them. Psychiatric labels did not accompany the vignettes, instead behavioural descriptions were used as they are deemed to be more ecologicaly valid and control for confounding mental health literacy. To explore beliefs about the fairness of the exclusion scenarios, following each vignette participants were asked: Is it ok or not ok for Paul/Paula to decide that he/she does not want to be friends with [target peer]/Is it ok or not ok for the class to decide not to invite [target peer]? Why, is it ok or not ok for Paul/Paula to decide that he/she does not want to be friends with [target peer]/Why is it ok or not ok for the class to decide not to invite [target peer]? Probes were frequently employed (e.g. Tell me more about that? Why do you think that? Can you give me an example? What else do you think?). Typically, when participants provided a response they were asked to elaborate until they declined from providing more information (e.g. I've nothing else to add). As participants within the group often responded to the views of their peers, probes were not systematically utilised but instead were used judiciously. Frequent summaries were provided and used to elicit clarifications or confirmation that participant responses were accurately understood and interpreted (Murphy & Dingwall, 2003; e.g. You said X, have I understood you correctly?). All interviews were audio recorded and subsequently transcribed verbatim. The lead author facilitated the group interviews. She was a PhD candidate with an interest in adolescents' perceptions of peers with mental health problems and their understanding of the presentation of psychiatric symptoms in their peers. As part of her doctoral studies she completed training in qualitative data collection and analyses. She was of the same nationality and ethnicity as participants and had no personal experience of mental illness or peer exclusion. Ethical approval was granted for this study by the National University of Ireland, Galway Research Ethics Committee. Data analysis The data were analysed thematically (Braun & Clarke, 2006). In light of the existing body of research on young people's beliefs about exclusion of out-group peers, but not peers with mental health problems, a hybrid approach of inductive and deductive coding (Fereday & Muir-Cochrane, 2006) was adopted. The process of analysis involved the following steps: 1) an a priori coding manual was developed using codes from published research on peer exclusion; 2) the coding template was applied to a random sample of six transcripts; 3) deductive codes were modified, if necessary, and inductive codes were developed from the data; 3) a revised coding framework incorporating remaining deductive codes and inductive codes was constructed; 4) with input from the second author a final coding framework was developed and applied to all transcripts;
Table 1 Sample of vignettes and exclusion scenarios.a ADHD vignette provided to 10e11 year olds boys Jake is in the same class as you. In school he seems to pay more attention to things going on around him than his own work. Sometimes he forgets what his teacher has told him to do and needs to be reminded. When the teacher asks the class a question, Jake often blurts out the answer before the teacher has a chance to finish. Jake often finds it hard to stay sitting down when he is supposed to and gets up or fidgets a lot. He has difficulty waiting his turn and butts into his classmates' conversations. In his spare time, Jake likes to play his computer and train with his athletic club. When his parents ask him to help around the house he sometimes doesn't seem to hear them. He often does not finish his homework or chores. Jake talks non-stop when his family is watching TV. He finds it hard to organise his bedroom and regularly loses his books, computer games and other things he needs. Exclusion scenario: Paul another boy in Jake's class does not want to be his friend. Depression vignette provided to 15e16 year old girls Lauren is in the same year as you. She used to love playing sports and hanging out with her friends after school. Last year, she was the captain of her school football team, however, recently she has stopped going to training. Her classmates have noticed that she isn't interested in anything lately and doesn't hang out with them anymore. She doesn't smile or laugh as much as she used to. Lauren is falling behind in her school-work. When Lauren's teacher asked her about this, Lauren explained that she is feeling tired all the time and is finding it difficult to sleep at night. She wants to do better but thinks that she is not good at anything. Lauren spends a lot of time thinking about all the things that she is not able to do and other sad thoughts. Exclusion scenario: In school, Lauren overhears her classmates planning a trip to the cinema at the weekend, but they don't invite her. a
There were four versions of each vignette: male and female, early and mid-adolescence.
62
C. O'Driscoll et al. / Journal of Adolescence 42 (2015) 59e67
Table 2 Combination of vignettes and exclusion scenarios presented to participants. Condition one Vignette Exclusion scenario
ADHD Dyad: Paul/a another boy/girl in [target peer's] class does not want to be his/her friend
Condition two Depression Group: In school, [target peer] overhears his/her classmates planning a trip to the cinema at the weekend, but they do not invite him/her
Depression Dyad: Paul/a another boy/girl in [target peer's] class does not want to be his/her friend
ADHD Group: In school, [target peer] overhears his/her classmates planning a trip to the cinema at the weekend, but they do not invite him/her
5) codes were collapsed or developed into themes. QSR NVivo.9 was used to code and manage the data set. A detailed audit trail documenting the development of codes and themes was kept throughout the process. Results Interview findings The qualitative nature of this study permitted elaborate discussions on the issues of fairness and the data revealed that young people rarely held dichotomous views on the fairness of exclusion. Initially most participants evaluated exclusion of the target peers, except the peer with ADHD in the group context, as unfair; however, when asked to explain their evaluations the reasons that they provided to support their initial evaluations were riddled with caveats. This pattern may have been a function of the group context, whereby the interactive and discursive nature of the group allowed participants to be more reflective rather than steadfast in their opinions. To fully appreciate the richness and complexity of the findings, we have not quantified how many participants condemned or condoned exclusion as to do so would misrepresent the data. Instead, within five themes, the data focuses on documenting the reasons adolescents provided for when exclusion is fair or not and considers the factors that they believe are important when evaluating the fairness of exclusion. Furthermore, the present study also aimed to explore sex and age differences in adolescents' reasoning about exclusion. However, reliable differences did not emerge in the data; thus the findings are presented as common emerging patterns across the included age and sex groups. It depends on why they are behaving like that: attributions & causal factors Most participants sought to understand the target peer's behaviour by considering responsibility attributions and causal factors. In response to the peer with ADHD, many young people suggested that exclusion was unfair if the target peer's behaviour was explained by a mental health problem. Explicit in such justifications was the belief that if the target peer had a diagnosis of ADHD he or she was less responsible or to blame for his or her behaviour. Well if he has something wrong with him like ADHD you might think because it's not his fault, then it [the rejection] might be wrong but it depends like … If he does have ADHD then his friend will understand, if it is his personality then it kind of changes the situation (Connor, 16, ADHD, dyad exclusion). Similarly, Phil (15, ADHD, group exclusion) said, “He sounds like he has ADHD so if he does you have to cut him a bit of slack because it's not his fault”. John (15, ADHD, dyad exclusion) who initially evaluated exclusion as legitimate, also marked his evaluation with a caveat pertaining to whether or not this peer has control over his behaviour “he sounds like a bit annoying, if he is doing it on purpose”. Fewer participants constructed attributions for the behaviour of the peer with depression. However those that reflected on attributes drew on them to inform their evaluations of the exclusion scenarios. For example, Mary (15, depression, dyad exclusion) condemned exclusion stating “you can't just leave her on her own … I kind of feel like she is depressed”. Of note, the presence of an identifiable trigger or cause for depression was an important factor in shaping positive exclusion evaluations. However, if depression occurred in the absence of a life event then many believed that the exclusion was justified. John (10, depression, dyad exclusion) stated, “It's [exclusion] not ok if something actually happened like somebody died or something, because you'll get over that, but if he is just depressed for no reason, getting down and all, he'll probably make you feel bad as well.” Similarly, Daniel (16, depression, dyad exclusion) said: You wouldn't do that [exclude target peer]. You would find out what is wrong with him first and then if it is a serious reason then you would stick by him but if it is not [a serious reason] then you wouldn't. In general, when most participants believed that the peers with ADHD and depression were not responsible for their behaviour, they were more accepting of these individuals as inferred by their perceptions of exclusion as unfair. The findings highlight the potentially important links between knowledge about causes and symptoms of depression and ADHD and acceptance of peers with these disorders.
C. O'Driscoll et al. / Journal of Adolescence 42 (2015) 59e67
63
It depends on the type of friendship or group: inclusion rules The type of relationship one has with another influenced perceptions of fairness associated with social inclusion, as different types of relationships were associated with varying levels of inclusion obligations. For most participants in the group context, inclusion obligations hinged on whether or not the excluded peer was a member of the group. Laura (16, depression, group exclusion) explained that “the class is usually split up into different groups of friends and like it depends if it's like her friends that are going to the cinema or the other group of friends”. Tara (16, ADHD, group exclusion) also endorsed a similar view: As much as a hyper person annoys me, I'd still feel obliged to ask them … the fact that it's a class thing and then I think she should definitely be invited. But if it was like just a group of friends, like I'm best friends with Annie, we kind of have our own cliques, I wouldn't expect her to come out and personally ask me to go with that clique because … you're not obliged. Of note, however, Annie (15, ADHD, group exclusion) staunchly disagreed with the inclusion rules that Tara suggested. Reflecting on her experience of witnessing the negative effects of exclusion on her brother with ADHD, she said, “I'm completely against it [exclusion] because it's really mean and I've seen that it does affect him [her brother]”. However, the majority did not endorse Annie's beliefs about inclusion. Similar to Tara, Joe (15, ADHD, group exclusion) said: If they are going with like part of the school and everyone from the school is going then he probably should be invited. Like they don't have to invite him if it's kind of nothing to do with school and it is just a personal kind of thing. These comments indicated that in more exclusive groups, exclusion is legitimate. This guideline about inclusion was summarised by Adam (11, depression, group exclusion): “if you are going to invite everybody else you might as well invite everybody”. In response to the dyad exclusion involving the peer with depression, many participants discussed that the type of friendship one had prior to the onset of the target peer's depression influenced the fairness of the exclusion. There was a general agreement that rejection was unfair if the peer was rejected after the onset of the depressive episode. For example, Shannen (15, depression, dyad exclusion) explained, “if she's been friends with her a long time … she can't just leave her alone altogether”. Maeve (16, depression, dyad exclusion) also endorsed a similar sentiment: Lauren is in like a bad place and maybe she just needs a friend … if I was feeling like depressed or something, like Lauren is feeling. I'd certainly want my friends by my side like, I wouldn't want them to say well I don't want to be your friend anymore because of the way you're acting. The findings indicate that the type of relationship one has with another is important in determining evaluations of exclusion; generally young people assess the legitimacy of exclusion by evaluating the type of relationship with the target peer and reflecting on associated obligations to this individual. She should try to help her: positive consequences of inclusion Specific to the peer with depression, many participants condemned exclusion of this peer by drawing on beliefs about their responsibility to support peers when distressed. For example, Isabel (16, depression, group exclusion) said, “if they're her friends they should try and see what's up and try and make it better and try and help anyway”. Similarly, Shannen (15, depression, dyad exclusion) argued that, “she should really see if there's some way she could help her”. Specifically, participants believed inclusion would “cheer him up” (Jack, 10, depression, dyad exclusion) and “make her like more herself again” (Marie, 15, depression, group exclusion), thus helping to alleviate some of the depressive symptoms. The powerful effect of inclusion was summarised by Sarah (10, depression, dyad exclusion) who said: Lots of people are ignoring her now because she's sadder and she (Paula) should think do I want to be like everybody else, neglecting her and leaving her by herself or do I want to change that for her, do I want her to feel like she's wanted. Many young people also reflected on the adverse psychological consequence of exclusion. In response to both the peer with depression and ADHD they acknowledged that failing to accept such peers would induce adverse mental health consequences: “It might just make him worse if you just tell him you won't want to be his friend anymore, because he is acting differently” (Daragh, 16, depression dyad exclusion). Clara (15, depression, group exclusion) suggested exclusion “might make her more depressed and she might take extreme measures.” Caitlin (15, ADHD, group exclusion) suggested, “She'll feel like nobody likes her or she has no friends. Then like she'll probably, you know the way she's really talkative, she mightn't be as talkative anymore, she might lose her personality”. Similarly, Maeve (15, ADHD, group exclusion) suggested that, “her self esteem and her confidence might go down because of what happened, she might feel like she isn't wanted.” By identifying that acceptance could ameliorate symptoms of depression and persistent rejection could potential threaten the mental health of the peer with ADHD, the findings suggest that adolescents are acutely aware of the power of positive peer relations and acceptance to protect and foster mental health. Thus when making exclusion decisions most adolescents consider the impact of their actions on the well being of the target peer.
64
C. O'Driscoll et al. / Journal of Adolescence 42 (2015) 59e67
Including him could be bad for us: adverse consequences of inclusion All participants who explicitly condoned exclusion reflected on potential adverse consequences, for them as individuals and for the group, of including the target peers. In response to group exclusion of the peer with ADHD, most participants initially evaluated exclusion as fair by reflecting on this peer's apparent inability to engage in appropriate conduct and their belief that he or she would disrupt the normative functioning of the group. If you have known him for a long time and he has always been like that you might not want to try and be friends because of how he acts … so you might think it is justified not to invite him because he might ruin it [the film] for everyone else. (Reece, 15 ADHD, group exclusion). It wouldn't be that fair on the other people because if they did invite her because, as you were saying in the story, she was like talking during class and wasn't listening to anyone, like she would probably be doing that in the movie so I don't think it would be ok to invite her. (Alana, 10, ADHD, group exclusion). While most young people condemned dyad exclusion of the peer with ADHD, those who evaluated exclusion as fair also reflected on the negative interpersonal consequences that may accompany this disorder. For example, Sue (16, ADHD, dyad exclusion) said, “I think it's ok if she doesn't want to be friends with her because I'd probably find Jane annoying, the way she just like butts in and stuff.” A few participants drew on the belief that the peer's depressive mood would put others at risk of depression to condone dyad and group exclusion. For example, Molly (10, depression, dyad exclusion) said: “Lauren, she's being like all sad and everything and you don't really want to be around a person who is all sad … because she'd just like bring you down.” The findings suggest that adolescents considered pertinent self and other costs when evaluating exclusion of the target peers. The adverse consequence of including the peer with ADHD were more likely to impact on social group cohesion and concurrently were saliently and openly discussed. In contrast, the cost of including the peer with depression was specific to one's own mental health and was not suggested by the majority. It's both fair and unfair: the complexity of peer exclusion Most participants explicitly endorsed conflicting exclusion evaluations, whereby exclusion was both fair and unfair. In doing so, young people weighed up the adverse consequences of exclusion for the target peer relative to their own need and desire for positive peer experiences. For example, Beth (15, ADHD, group exclusion) stated, Well I think it's kind of both ways because it's kind of mean of them not to invite her, I don't think it's fair on her but at the same time if she … if she talks the whole time, she's going to do the same thing at the cinema so I kind of understand why they wouldn't invite her. Comparable responses were provided in response to the peer with depression. For example, Lisa (16, depression, group exclusion) said, If she's like always down and stuff then they should be inviting her places to make her like more herself again … but it kind of is ok for them not to invite her in some ways though because if she doesn't talk to them there's no point in making an effort when she's so grumpy. The tension between right and wrong when evaluating these hypothetical exclusion scenarios highlights the complexity of successfully navigating the peer social world; which was aptly summarised up by Alana (10, ADHD, group exclusion) “They are both not fair, so it's kind of hard to tell the difference”. Discussion This study aimed to explore young people's beliefs about the fairness of excluding peers with either ADHD or depression. Although the study also sought to identify any sex or age differences in the explanations that were provided, no obvious or reliable differences emerged. The findings highlighted that when young people are asked to evaluate the fairness of excluding peers with ADHD or depression from dyads and groups, with the exception of ADHD in the group context, exclusion was generally perceived as unfair. However, when they reflected on their evaluations, a complex picture emerged, whereby their initial evaluations which endorsed moral fair treatment of their peers were peppered with caveats. The findings showed that young people's beliefs about the fairness of exclusion were influenced by the attributions that they applied to the peer's behaviour, as well as concerns about the adverse psychological effects of exclusion. For some participants, their decision to include the target peers imposed social and personal costs, such that inclusion would disrupt normative dynamics with the dyad or group. Thus suggesting that inclusion decisions involve weighing up the costs and benefits to self versus other. Furthermore, beliefs about social obligations based on the nature of the relationship also influenced their evaluations; the more intimate the relations, the greater the responsibility on the individual to accept the target peers. The finding that the majority of participants initially evaluated group exclusion of the peer with ADHD as fair stood in contrast to the majority view that exclusion of the peer with depression and dyad exclusion of the peer with ADHD was unfair.
C. O'Driscoll et al. / Journal of Adolescence 42 (2015) 59e67
65
This finding is explained by perceived difficulties of upholding group cohesion due to the externalising symptoms that accompany ADHD. However, other research suggests that it appears to be more socially acceptable to explicitly stigmatise peers with ADHD compared to peers with depression (O'Driscoll et al., 2012), thus it is possible that young people experienced less perceived pressure to respond in a socially desirable manner towards the peer with ADHD. Young people's perceptions of fairness were often influenced by the attributions they applied to the target peers behaviour. Supporting consistent findings from Attribution Theory (e.g. Corrigan et al., 2007; Weiner, Perry, & Magnusson, 1988) and emerging trends from SDT (e.g. Killen & Stangor, 2001) exclusion was mostly perceived as unfair if the target peer's behaviour was attributed to a mental health problem or an external cause. However, in relation to depression, the findings also highlighted the complexity of the relationship between attributions and fairness evaluations of exclusion. Many participants discussed that if there was not an external cause for the target peer's low mood then exclusion was legitimate. This finding is consistent with research that shows that young people are more accepting of peers with depression when the target individual is thought to have little personal control over the cause of depression (Dolphin & Hennessy, 2014). Thus the present study highlights the important role of attributes and knowledge in shaping exclusion evaluations and consequently indicates the potential value of providing psychoeducation about the aetiology of depression and ADHD in anti-stigma interventions. Many participants believed that their peers are valuable sources of support for others with depression and believe that positive peer interactions will alleviate low mood. This finding complements research from the help-seeking literature that shows that peers are endorsed as important sources of emotional support (Schonert-Reichl & Muller, 1996), but that young people are more likely to recommend peers as a source support for peers with depression, but not for ADHD or conduct disorder (Hennessy & Heary, 2009). Participants were also acutely aware of the negative consequences of exclusion such that it could exacerbate a sense of being different and lower self-esteem. Thus, the peer group is perceived as a context in which, if one is accepted, one can flourish and overcome adversity, but exclusion can be detrimental to one's mental health. These findings tentatively suggest that encouraging young people to develop and adopt ownership for the consequences of their exclusion decisions could potentially offer a fruitful avenue for anti-stigma interventions to induce effective change. Young people who evaluated exclusion as legitimate provided a context for the prevailing findings from quantitative research that indicates young people with mental health problems are frequently excluded by their peers (Blachman & Hinshaw, 2002; Hoza et al., 2005). Exclusion of both peers was evaluated as fair when young people believed that including this individual would threaten cohesive peer dynamics and impose a personal cost to them or others within the peer group. These individuals believed that the peer with depression could induce low mood in others, while the externalising behaviour exhibited by the peer with ADHD would impinge on their ability to enjoy the activity. Although participants' beliefs about how including the peer with depression would induce low mood in others was considered a minority view, other research on this topic shows that when young people reflect on why peers with depression are excluded they frequently draw on the stereotype that depression is contagious (O'Driscoll et al., 2014). Limitations & recommendations A qualitative methodology was employed to facilitate new insights on young people's views of exclusion; however, caution should be heeded when generalising the findings of qualitative research. The data were gathered in response to fictional peers in two hypothetical exclusion scenarios, thus young people may reason differently about real-life exclusion decisions that they face in their social world. The data pertains to same-sex peers only. Research shows that attitudes differs across the sex of the perceiver but also depends on the sex of the peer with a mental health problem (Swords et al., 2011), thus future research should explore beliefs about exclusion of opposite sex peers. Furthermore, future research should explore young people's responses to the exclusion of peers with other mental health problems in a variety of social situations, such as sleep-overs, parties, study groups, and sports events. Data on participants' behavioural and emotional profiles were not collected. Adolescents with a mental health problem may have different views on this topic compared to those without disorders. Thus, future research should employ a more homogeneous sample or conduct this research on more defined target groups (i.e. those with personal experiences, those with experience in their social or familial circle and those with limited experience). Friendship group interviews also have some limitations; the group context ensures that one cannot entirely assume that participants expressed their own individual view on the topic. Given that individual interviews allow each participant ‘protected’ space to relay their views (Morgan, 1997) and preliminary research suggests individual interviews yield a wider range of ideas when compared to focus groups (Fern, 1982; Heary & Hennessy, 2006), replication with individual interviews is warranted. The social influences inherent in the group context precluded quantitative analyses of the data. Building on these exploratory findings, future research should gather quantitative data to explore how young people reason about exclusion of peers with mental health disorders. Given that SDT and stigma research that is analysed quantitatively consistently reveals age and sex differences, quantitative research on this topic could shed light on whether the absence of developmental and sex differences that were observed in the present study were a function of the qualitative method used or specific to the exclusion of peers with mental health disorders. Furthermore, quantitative data would permit analyse of whether beliefs about acceptability of exclusion differed as per the exclusion context across the two disorders. Exploring whether it is more
66
C. O'Driscoll et al. / Journal of Adolescence 42 (2015) 59e67
acceptable for adolescents to reject a peer with a mental health problem from dyadic rather than group activities would have important implications for intervention strategies. Attribution models consistently highlight that beliefs about responsibility for symptoms and behaviour associated with mental health difficulties are key variables in predicting peer acceptance (Corrigan et al., 2007; Swords et al., 2011), but that attributions alone do not tell the whole story. The present study highlights other variables that could be tested in research on conceptual models of acceptance. For example, researchers could consider the mediating effect of beliefs about the negative consequences of acceptance for the group or self, as well as altruistic beliefs about positive consequences of acceptance for the peer with a mental health difficulty. Furthermore, given that this study highlighted that the acceptability of exclusion also hinged on the context of exclusion and associated social friendship rules, models of exclusion could attend to these variables. Conclusions The findings of this study provided an initial investigation into what young people think about the exclusion of peers with mental health problems. While the overwhelming trend in the published literature implies that the exclusion of young people with mental health problems is acceptable, the current findings highlight that reasoning about exclusion is not straightforward. Specifically, the evaluations offered to condemn exclusion provides an insight into principles that should be fostered in anti-stigma interventions, while the justifications offered to support exclusion highlights areas for targeted change. Acknowledgements The co-operation of all participating schools, parents and students is gratefully acknowledged. This publication is independent research funded by the Health Research Board in Ireland under Grant No: HRA/2009/269. Any opinions, findings, conclusions or recommendations expressed are those of the authors and not necessarily those of the XXX. No conflict of interest declared. References Aboud, F. E. (2008). A social cognitive developmental theory of prejudice. In S. M. Quintana, & C. McKown (Eds.), Handbook of race, racism, and the developing child (pp. 55e71). Hoboken, NJ: Wiley. Blachman, D. R., & Hinshaw, S. P. (2002). Patterns of friendship among girls with and without attention-deficit/hyperactivity disorder. Journal of Abnormal Child Psychology, 30, 625e640. Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3, 77e101. Brown, C. S., & Bigler, R. S. (2005). Children's perceptions of discrimination: a developmental model. Child Development, 76, 533e553. Chen, X., & Li, B. (2000). Depressed mood in Chinese children: development significance for social and school adjustment. International Journal of Behavioural Development, 24, 472e479. Corrigan, P. W., Watson, A. C., Otey, E., Westbrook, A. L., Gardner, A. L., Lamb, T. A., et al. (2007). How do children stigmatize people mental illness. Journal of Applied Social Psychology, 37, 1405e1417. Dolphin, L., & Hennessy, E. (2014). Adolescents' perceptions of peers with depression: an attributional analysis. Psychiatry Research. http://dx.doi.org/10. 1016/j.psychres.2014.04.051. Elkington, K., Hackler, D., McKinnon, K., Borges, C., Wright, E. R., & Wainberg, M. L. (2012). Perceived mental illness stigma among youth in psychiatric outpatient treatment. Journal of Adolescent Research, 2, 290e317. Fereday, J., & Muir-Cochrane, E. (2006). Demonstrating rigor using thematic analysis: a hybrid approach of inductive and deductive coding and theme development. International Journal of Qualitative Methods, 5, 1e11. Fern, E. F. (1982). The use of focus groups for idea generation: the effects of group size, acquaintanceship, and moderator on response quantity and quality. Journal of Marketing Research, 19, 1e13. Heary, C., & Hennessy, E. (2006). Focus groups versus individual interviews with child: a comparison of data. Irish Journal of Psychology, 27, 58e68. Hennessy, E., & Heary, C. (2004). Valuing the group context: the use of focus groups with children and adolescents. In S. M. Greene, & D. M. Hogan (Eds.), Researching children's experience: Approaches and methods. London: Sage. Hennessy, E., & Heary, C. (2009). The development of children's understanding of common psychological problems. Child & Adolescent Mental Health, 14, 42e47. Hoza, B., Mrug, S., Gerdes, A. C., Hinshaw, S. P., Bukowski, W. H., Gold, G. A., et al. (2005). What aspects of peer relationships are impaired in children with attention-deficit/hyperactivity disorder? Journal of Consulting and Clinical Psychology, 73, 411e423. Jorm, A. F., & Wright, A. (2008). Influences on young people's stigmatising attitudes towards peers with mental disorders: national survey of young Australians and their parents. British Journal of Psychiatry, 192, 144e149. Killen, M., Kelly, M., Richardson, C., Crystal, D., & Ruck, M. (2010). European American children's and adolescents' evaluations of interracial exclusion. Group Processes and Intergroup Relations, 13, 283e300. Killen, M., Mulvey, K. L., & Hitti, A. (2012). Social exclusion in childhood: a developmental intergroup perspective. Child Development, 84, 772e790. Killen, M., Rutland, A., Abrams, D., Mulvey, K. L., & Hitti, A. (2013). Development of intra- and intergroup judgments in the context of moral and socialconventional norms. Child Development, 84, 1063e1080. Killen, M., & Stangor, C. (2001). Children's reasoning about social inclusion and exclusion in gender and race peer group contexts. Child Development, 72, 174e186. Malti, T., Killen, M., & Gasser, L. (2012). Social judgments and emotion attributions about exclusion in Switzerland. Child Development, 83, 697e711. Meadows, S. O., Brown, J. S., & Elder, G. H., Jr. (2006). Depressive symptoms, stress, and support: gendered trajectories from adolescence to young adulthood. Journal of Youth and Adolescence, 35, 93e103. Merikangas, K. R., Nakamura, E. F., & Kessler, R. C. (2009). Epidemiology of mental disorders in children and adolescents. Dialogues in Clinical Neuroscience, 11, 7. Morgan, D. L. (1997). Focus groups as qualitative research (2nd ed.). London: Sage. Moses, T. (2010). Being treated differently: stigma experiences with family, peers and school staff among adolescents with mental health disorders. Social Science & Medicine, 70, 985e993. Murphy, E., & Dingwall, R. (2003). Qualitative methods and health policy research. New York: Walter de Gruyter.
C. O'Driscoll et al. / Journal of Adolescence 42 (2015) 59e67
67
O'Driscoll, C., Heary, C., Hennessy, E., & McKeague, L. (2012). Explicit and implicit stigma towards peers with ADHD and depression in childhood and adolescence. Journal of Child Psychology & Psychiatry, 53, 1054e1062. O'Driscoll, C., Heary, C., Hennessy, E., & McKeague, L. (2014). Adolescents' explanations for the exclusion of peers with mental health problems: an insight into stigma. Journal of Adolescent Research. http://dx.doi.org/10.1177/0743558414550246. Park, Y., & Killen, M. (2010). When is peer rejection justifiable?: children's understanding across two cultures. Cognitive Development, 25, 290e301. Schonert-Reichl, K. A., & Muller, J. R. (1996). Correlates of help-seeking in adolescence. Journal of Youth and Adolescence, 25, 705e731. Swords, L., Heary, C., & Hennessy, E. (2011). Factors associate with acceptance of peers with mental health problems in childhood and adolescence. Journal of Child Psychology & Psychiatry, 52(9), 933e941. Turiel, E. (1983). The development of social knowledge: Morality and convention. Cambridge: Cambridge University Press. Wahl, O. F. (2002). Children's views of mental illness: a review of the literature. Psychiatric Rehabilitation Skills, 6, 134e158. Warren, J. S., Jackson, Y., & Sifers, S. K. (2009). Social support provisions as differential predictors of adaptive outcomes in young adolescents. Journal of Community Psychology, 37, 106e121. Weiner, B., Perry, R. P., & Magnusson, J. (1988). An attributional analysis of reactions to stigmas. Journal of Personality and Social Psychology, 55, 738e748. Williams, B., & Pow, J. (2007). Gender differences and mental health: an exploratory study of knowledge and attitudes to mental health among Scottish teenagers. Child & Adolescent Mental Health, 12, 8e12.
Contents lists available at ScienceDirect
Journal of Adolescence journal homepage: www.elsevier.com/locate/jado
Adolescents' beliefs about the fairness of exclusion of peers with mental health problems Claire O'Driscoll a, Caroline Heary a, *, Eilis Hennessy b, Lynn McKeague b a b
National University of Ireland, Galway, Ireland University College Dublin, Dublin, Ireland
a r t i c l e i n f o
a b s t r a c t
Article history: Available online
Stigma research suggests that exclusion of peers with mental health problems is acceptable, however, no research has explored young people's beliefs about the fairness of exclusion. Group interviews with 148 adolescents explored judgements about the fairness of excluding peers with ADHD or depression from dyads and groups. Young people evaluated exclusion of peers with ADHD or depression from dyads and groups, with the exception of group exclusion of the peer with ADHD, as mostly unfair. Beliefs about the fairness of exclusion were influenced by the attributions that they applied to the target peer's behaviour, social obligations and loyalty within friendships and concerns about the adverse psychological effects of exclusion. Furthermore, their evaluations were influenced by personal beliefs about the social and personal costs of including the target peer. Evaluations of exclusion highlight novel avenues for to develop knowledge on the stigma of mental health problems. © 2015 The Foundation for Professionals in Services for Adolescents. Published by Elsevier Ltd. All rights reserved.
Keywords: Stigma Exclusion ADHD Depression Thematic analysis Adolescence
Young people with mental health problems are some of the most chronically excluded individuals in school playgrounds (Chen & Li, 2000; Hoza et al., 2005). The adverse peer relationships experienced by these young people are well documented (Elkington et al., 2012; Moses, 2010) and marked by themes of the loss of friendships following the onset of symptoms, teasing and harassment by peers, and experiences of isolation and loneliness. These persistent findings imply that exclusion or rejection of young people with mental health problems is socially acceptable to their peers. The consequences of exclusion are alarming; especially when one considers research that suggests that peer acceptance is protective for maintaining good mental health (Warren, Jackson, & Sifers, 2009) and promotes recovery from mental health problems (Meadows, Brown, & Elder, 2006). This literature highlights the importance of developing effective anti-stigma interventions. Stigma is a multi-dimensional construct that incorporates derogatory cognitive (stereotypes), affective (prejudices) and behavioural (discrimination) responses towards people with mental health problems. In adolescence, discrimination manifests as exclusion from activities and social groups, friendship rejection or avoidance (Brown & Bigler, 2005). Traditionally, stigma is explored by assessing pre-defined stereotypes, prejudices and discrimination towards vignettes that describe labels, or more commonly behavioural descriptions, of hypothetical peers with mental health disorders. Inherent in this methodological approach is the assumption that the symptoms and labels of mental illness evoke negative cognitive and affective responses that justify rejection. While there is evidence to support the theory that the symptoms and labels underpin stigma
* Corresponding author. School of Psychology, National University of Ireland Galway, Galway, Ireland. Tel.: þ353 91 495059. E-mail address: [email protected] (C. Heary). http://dx.doi.org/10.1016/j.adolescence.2015.03.008 0140-1971/© 2015 The Foundation for Professionals in Services for Adolescents. Published by Elsevier Ltd. All rights reserved.
60
C. O'Driscoll et al. / Journal of Adolescence 42 (2015) 59e67
(Corrigan et al., 2007), arguably, however, it only accounts for a portion of why stigma occurs. Absent from the existing literature is an account of the influence of other factors such as social norms and conventions and moral judgements about the fair treatment of others within the peer group. According to Social Domain Theory (SDT, Turiel, 1983) these value-laden factors provide a culture that fosters or condemns the acceptability of rejection of minority individuals or groups (see Killen, Mulvey, & Hitti, 2012). To explore the influence of social norms and moral judgements on beliefs about exclusion, SDT researchers present participants with vignettes that describe exclusion scenarios involving hypothetical peers (Killen, Rutland, Abrams, Mulvey, & Hitti, 2013). Participants' views on the fairness of the exclusion and their rationale for such evaluations are then explored. In the context of sex, race, and ethnicity, SDT research suggests that when evaluating peer exclusion scenarios, children and adolescents use moral (“it's not fair because she will feel sad”), social conventional (“it's better for the rest of the group if he is not invited”) and psychological reasons (“it's her personal choice whom she befriends”). An overriding theme to emerge from SDT research is that exclusion is often deemed acceptable to maintain status differences and to uphold cohesion in the peer group (Killen et al., 2012). Stigma and SDT research, respectively, point to sex and age as important factors in shaping how young people think about peers with mental health problems and peer exclusion. In the stigma literature, research generally implicates males as more stigmatising towards mental illness compared to females (Jorm & Wright, 2008; Williams & Pow, 2007) and that stigma worsens with age (Wahl, 2002). However, when explored together, research shows that often developmental and sex trends are inter-dependent, such that differences in responses are contingent on the perceivers' sex and age, the target peer's sex and mental health disorder (O'Driscoll, Heary, Hennessy, & McKeague, 2012; Swords, Heary, & Hennessy, 2011). In the SDT literature, research shows that young people increasingly rationalise about exclusion by reflecting on group functioning and group identity (Aboud, 2008); consequently, exclusion tends to become more acceptable with age (Malti, Killen, & Gasser, 2012; Park & Killen, 2010). Furthermore, SDT research suggests that females tend to show greater concern for inclusivity of peers across a variety of exclusion contexts (Malti et al., 2012; Park & Killen, 2010). To date, no research has explored young people's views on the acceptability of exclusion of peers with mental health problems. However, when asked to explain why hypothetical peers with depression or attention deficit hyperactivity disorder (ADHD) were excluded, young people justified exclusion because the target peers could not conform to the social rules and conventions attached to friendship dyads and groups (O'Driscoll, Heary, Hennessy, & McKeague, 2014). Furthermore, they reported that including a peer with a mental health problem posed social and personal risks to members of the peer group. Although, this study provided insight into the function of exclusion it did not report data on the acceptability of exclusion. Thus we continue to have little understanding of how young people reason about exclusion decisions specific to peers with mental health difficulties. Drawing from the lessons learned in the racial and gender literature, we argue that developing a comprehensive understanding of peer values and norms that underpin the existence of stigma can enhance future development of anti-stigma interventions. The present study provides an exploratory insight into young people's beliefs about the fairness of exclusion of peers with mental health problems. ADHD and depression were chosen as they are two of the most common childhood mental health disorders (Merikangas, Nakamura, & Kessler, 2009). Reasoning about exclusion is often context dependent (Killen, Kelly, Richardson, Crystal, & Ruck, 2010); thus dyad and group contexts were employed. To gain a cross-developmental perspective, responses of young people in early and mid-adolescence were explored. This paper aims to advance knowledge on the exclusion of peers with mental health problems in adolescence. Specifically, the aims were (a) to explore adolescents' beliefs about the fairness of excluding peers with either ADHD or depression; (b) to examine any age and sex patterns in adolescents' responses; and (c) to investigate any common or unique views across the two exclusion contexts as well as the two target disorders. Method Participants The sample consisted of seventy-two 10e11 year olds (M ¼ 10.77 years; SD ¼ 0.46 years: 34 boys and 38 girls) and seventysix 15e16 year olds (M ¼ 15.5 years; SD ¼ 0.46 years: 34 boys and 42 girls). Participants were white and their socio-economic status, as determined by the highest educational level achieved by the consenting adult, was 42% low (second-level completion only), 28% medium (post-second level diploma or certificate), and 29% high (bachelor's degree or higher). All participants verbally assented to take part and had written parental consent. Data collection Data were collected during class time in three randomly selected rural primary and secondary schools in the western region of the Republic of Ireland There were 37 same-sex self-selected groups in total, which were facilitated by the lead author. Each group consisted of between 3 and 5 participants; there were three groups with 3 participants, 31 groups with 4 participants, and three groups with 5 participants. Group interviews were deemed suitable, as the group context is a familiar setting for most young people (Hennessy & Heary, 2004). We anticipated that replicating a group environment would help participants draw on the peer context and potentially enhance the ecological validity of their responses. Furthermore, given that our aim was to qualitatively explore themes and not quantify responses, the group context was considered an appropriate setting to collect data.
C. O'Driscoll et al. / Journal of Adolescence 42 (2015) 59e67
61
Each group was randomly assigned to one of two conditions and were read two age and sex-matched vignettes (see Tables 1 and 2). The first condition consisted of a story character with ADHD experiencing exclusion in a dyadic social situation and a story character with depression experiencing exclusion in a group social situation. In the second condition, the pairing of the story characters and the exclusion scenarios was reversed, such that the story character with depression experienced exclusion in a dyadic social situation and the story character with ADHD experienced exclusion in a group social situation. In each condition, the order of the vignettes was counterbalanced. As single sex focus groups were employed, participants always read about a peer with ADHD and a peer with depression who was the same sex as them. Psychiatric labels did not accompany the vignettes, instead behavioural descriptions were used as they are deemed to be more ecologicaly valid and control for confounding mental health literacy. To explore beliefs about the fairness of the exclusion scenarios, following each vignette participants were asked: Is it ok or not ok for Paul/Paula to decide that he/she does not want to be friends with [target peer]/Is it ok or not ok for the class to decide not to invite [target peer]? Why, is it ok or not ok for Paul/Paula to decide that he/she does not want to be friends with [target peer]/Why is it ok or not ok for the class to decide not to invite [target peer]? Probes were frequently employed (e.g. Tell me more about that? Why do you think that? Can you give me an example? What else do you think?). Typically, when participants provided a response they were asked to elaborate until they declined from providing more information (e.g. I've nothing else to add). As participants within the group often responded to the views of their peers, probes were not systematically utilised but instead were used judiciously. Frequent summaries were provided and used to elicit clarifications or confirmation that participant responses were accurately understood and interpreted (Murphy & Dingwall, 2003; e.g. You said X, have I understood you correctly?). All interviews were audio recorded and subsequently transcribed verbatim. The lead author facilitated the group interviews. She was a PhD candidate with an interest in adolescents' perceptions of peers with mental health problems and their understanding of the presentation of psychiatric symptoms in their peers. As part of her doctoral studies she completed training in qualitative data collection and analyses. She was of the same nationality and ethnicity as participants and had no personal experience of mental illness or peer exclusion. Ethical approval was granted for this study by the National University of Ireland, Galway Research Ethics Committee. Data analysis The data were analysed thematically (Braun & Clarke, 2006). In light of the existing body of research on young people's beliefs about exclusion of out-group peers, but not peers with mental health problems, a hybrid approach of inductive and deductive coding (Fereday & Muir-Cochrane, 2006) was adopted. The process of analysis involved the following steps: 1) an a priori coding manual was developed using codes from published research on peer exclusion; 2) the coding template was applied to a random sample of six transcripts; 3) deductive codes were modified, if necessary, and inductive codes were developed from the data; 3) a revised coding framework incorporating remaining deductive codes and inductive codes was constructed; 4) with input from the second author a final coding framework was developed and applied to all transcripts;
Table 1 Sample of vignettes and exclusion scenarios.a ADHD vignette provided to 10e11 year olds boys Jake is in the same class as you. In school he seems to pay more attention to things going on around him than his own work. Sometimes he forgets what his teacher has told him to do and needs to be reminded. When the teacher asks the class a question, Jake often blurts out the answer before the teacher has a chance to finish. Jake often finds it hard to stay sitting down when he is supposed to and gets up or fidgets a lot. He has difficulty waiting his turn and butts into his classmates' conversations. In his spare time, Jake likes to play his computer and train with his athletic club. When his parents ask him to help around the house he sometimes doesn't seem to hear them. He often does not finish his homework or chores. Jake talks non-stop when his family is watching TV. He finds it hard to organise his bedroom and regularly loses his books, computer games and other things he needs. Exclusion scenario: Paul another boy in Jake's class does not want to be his friend. Depression vignette provided to 15e16 year old girls Lauren is in the same year as you. She used to love playing sports and hanging out with her friends after school. Last year, she was the captain of her school football team, however, recently she has stopped going to training. Her classmates have noticed that she isn't interested in anything lately and doesn't hang out with them anymore. She doesn't smile or laugh as much as she used to. Lauren is falling behind in her school-work. When Lauren's teacher asked her about this, Lauren explained that she is feeling tired all the time and is finding it difficult to sleep at night. She wants to do better but thinks that she is not good at anything. Lauren spends a lot of time thinking about all the things that she is not able to do and other sad thoughts. Exclusion scenario: In school, Lauren overhears her classmates planning a trip to the cinema at the weekend, but they don't invite her. a
There were four versions of each vignette: male and female, early and mid-adolescence.
62
C. O'Driscoll et al. / Journal of Adolescence 42 (2015) 59e67
Table 2 Combination of vignettes and exclusion scenarios presented to participants. Condition one Vignette Exclusion scenario
ADHD Dyad: Paul/a another boy/girl in [target peer's] class does not want to be his/her friend
Condition two Depression Group: In school, [target peer] overhears his/her classmates planning a trip to the cinema at the weekend, but they do not invite him/her
Depression Dyad: Paul/a another boy/girl in [target peer's] class does not want to be his/her friend
ADHD Group: In school, [target peer] overhears his/her classmates planning a trip to the cinema at the weekend, but they do not invite him/her
5) codes were collapsed or developed into themes. QSR NVivo.9 was used to code and manage the data set. A detailed audit trail documenting the development of codes and themes was kept throughout the process. Results Interview findings The qualitative nature of this study permitted elaborate discussions on the issues of fairness and the data revealed that young people rarely held dichotomous views on the fairness of exclusion. Initially most participants evaluated exclusion of the target peers, except the peer with ADHD in the group context, as unfair; however, when asked to explain their evaluations the reasons that they provided to support their initial evaluations were riddled with caveats. This pattern may have been a function of the group context, whereby the interactive and discursive nature of the group allowed participants to be more reflective rather than steadfast in their opinions. To fully appreciate the richness and complexity of the findings, we have not quantified how many participants condemned or condoned exclusion as to do so would misrepresent the data. Instead, within five themes, the data focuses on documenting the reasons adolescents provided for when exclusion is fair or not and considers the factors that they believe are important when evaluating the fairness of exclusion. Furthermore, the present study also aimed to explore sex and age differences in adolescents' reasoning about exclusion. However, reliable differences did not emerge in the data; thus the findings are presented as common emerging patterns across the included age and sex groups. It depends on why they are behaving like that: attributions & causal factors Most participants sought to understand the target peer's behaviour by considering responsibility attributions and causal factors. In response to the peer with ADHD, many young people suggested that exclusion was unfair if the target peer's behaviour was explained by a mental health problem. Explicit in such justifications was the belief that if the target peer had a diagnosis of ADHD he or she was less responsible or to blame for his or her behaviour. Well if he has something wrong with him like ADHD you might think because it's not his fault, then it [the rejection] might be wrong but it depends like … If he does have ADHD then his friend will understand, if it is his personality then it kind of changes the situation (Connor, 16, ADHD, dyad exclusion). Similarly, Phil (15, ADHD, group exclusion) said, “He sounds like he has ADHD so if he does you have to cut him a bit of slack because it's not his fault”. John (15, ADHD, dyad exclusion) who initially evaluated exclusion as legitimate, also marked his evaluation with a caveat pertaining to whether or not this peer has control over his behaviour “he sounds like a bit annoying, if he is doing it on purpose”. Fewer participants constructed attributions for the behaviour of the peer with depression. However those that reflected on attributes drew on them to inform their evaluations of the exclusion scenarios. For example, Mary (15, depression, dyad exclusion) condemned exclusion stating “you can't just leave her on her own … I kind of feel like she is depressed”. Of note, the presence of an identifiable trigger or cause for depression was an important factor in shaping positive exclusion evaluations. However, if depression occurred in the absence of a life event then many believed that the exclusion was justified. John (10, depression, dyad exclusion) stated, “It's [exclusion] not ok if something actually happened like somebody died or something, because you'll get over that, but if he is just depressed for no reason, getting down and all, he'll probably make you feel bad as well.” Similarly, Daniel (16, depression, dyad exclusion) said: You wouldn't do that [exclude target peer]. You would find out what is wrong with him first and then if it is a serious reason then you would stick by him but if it is not [a serious reason] then you wouldn't. In general, when most participants believed that the peers with ADHD and depression were not responsible for their behaviour, they were more accepting of these individuals as inferred by their perceptions of exclusion as unfair. The findings highlight the potentially important links between knowledge about causes and symptoms of depression and ADHD and acceptance of peers with these disorders.
C. O'Driscoll et al. / Journal of Adolescence 42 (2015) 59e67
63
It depends on the type of friendship or group: inclusion rules The type of relationship one has with another influenced perceptions of fairness associated with social inclusion, as different types of relationships were associated with varying levels of inclusion obligations. For most participants in the group context, inclusion obligations hinged on whether or not the excluded peer was a member of the group. Laura (16, depression, group exclusion) explained that “the class is usually split up into different groups of friends and like it depends if it's like her friends that are going to the cinema or the other group of friends”. Tara (16, ADHD, group exclusion) also endorsed a similar view: As much as a hyper person annoys me, I'd still feel obliged to ask them … the fact that it's a class thing and then I think she should definitely be invited. But if it was like just a group of friends, like I'm best friends with Annie, we kind of have our own cliques, I wouldn't expect her to come out and personally ask me to go with that clique because … you're not obliged. Of note, however, Annie (15, ADHD, group exclusion) staunchly disagreed with the inclusion rules that Tara suggested. Reflecting on her experience of witnessing the negative effects of exclusion on her brother with ADHD, she said, “I'm completely against it [exclusion] because it's really mean and I've seen that it does affect him [her brother]”. However, the majority did not endorse Annie's beliefs about inclusion. Similar to Tara, Joe (15, ADHD, group exclusion) said: If they are going with like part of the school and everyone from the school is going then he probably should be invited. Like they don't have to invite him if it's kind of nothing to do with school and it is just a personal kind of thing. These comments indicated that in more exclusive groups, exclusion is legitimate. This guideline about inclusion was summarised by Adam (11, depression, group exclusion): “if you are going to invite everybody else you might as well invite everybody”. In response to the dyad exclusion involving the peer with depression, many participants discussed that the type of friendship one had prior to the onset of the target peer's depression influenced the fairness of the exclusion. There was a general agreement that rejection was unfair if the peer was rejected after the onset of the depressive episode. For example, Shannen (15, depression, dyad exclusion) explained, “if she's been friends with her a long time … she can't just leave her alone altogether”. Maeve (16, depression, dyad exclusion) also endorsed a similar sentiment: Lauren is in like a bad place and maybe she just needs a friend … if I was feeling like depressed or something, like Lauren is feeling. I'd certainly want my friends by my side like, I wouldn't want them to say well I don't want to be your friend anymore because of the way you're acting. The findings indicate that the type of relationship one has with another is important in determining evaluations of exclusion; generally young people assess the legitimacy of exclusion by evaluating the type of relationship with the target peer and reflecting on associated obligations to this individual. She should try to help her: positive consequences of inclusion Specific to the peer with depression, many participants condemned exclusion of this peer by drawing on beliefs about their responsibility to support peers when distressed. For example, Isabel (16, depression, group exclusion) said, “if they're her friends they should try and see what's up and try and make it better and try and help anyway”. Similarly, Shannen (15, depression, dyad exclusion) argued that, “she should really see if there's some way she could help her”. Specifically, participants believed inclusion would “cheer him up” (Jack, 10, depression, dyad exclusion) and “make her like more herself again” (Marie, 15, depression, group exclusion), thus helping to alleviate some of the depressive symptoms. The powerful effect of inclusion was summarised by Sarah (10, depression, dyad exclusion) who said: Lots of people are ignoring her now because she's sadder and she (Paula) should think do I want to be like everybody else, neglecting her and leaving her by herself or do I want to change that for her, do I want her to feel like she's wanted. Many young people also reflected on the adverse psychological consequence of exclusion. In response to both the peer with depression and ADHD they acknowledged that failing to accept such peers would induce adverse mental health consequences: “It might just make him worse if you just tell him you won't want to be his friend anymore, because he is acting differently” (Daragh, 16, depression dyad exclusion). Clara (15, depression, group exclusion) suggested exclusion “might make her more depressed and she might take extreme measures.” Caitlin (15, ADHD, group exclusion) suggested, “She'll feel like nobody likes her or she has no friends. Then like she'll probably, you know the way she's really talkative, she mightn't be as talkative anymore, she might lose her personality”. Similarly, Maeve (15, ADHD, group exclusion) suggested that, “her self esteem and her confidence might go down because of what happened, she might feel like she isn't wanted.” By identifying that acceptance could ameliorate symptoms of depression and persistent rejection could potential threaten the mental health of the peer with ADHD, the findings suggest that adolescents are acutely aware of the power of positive peer relations and acceptance to protect and foster mental health. Thus when making exclusion decisions most adolescents consider the impact of their actions on the well being of the target peer.
64
C. O'Driscoll et al. / Journal of Adolescence 42 (2015) 59e67
Including him could be bad for us: adverse consequences of inclusion All participants who explicitly condoned exclusion reflected on potential adverse consequences, for them as individuals and for the group, of including the target peers. In response to group exclusion of the peer with ADHD, most participants initially evaluated exclusion as fair by reflecting on this peer's apparent inability to engage in appropriate conduct and their belief that he or she would disrupt the normative functioning of the group. If you have known him for a long time and he has always been like that you might not want to try and be friends because of how he acts … so you might think it is justified not to invite him because he might ruin it [the film] for everyone else. (Reece, 15 ADHD, group exclusion). It wouldn't be that fair on the other people because if they did invite her because, as you were saying in the story, she was like talking during class and wasn't listening to anyone, like she would probably be doing that in the movie so I don't think it would be ok to invite her. (Alana, 10, ADHD, group exclusion). While most young people condemned dyad exclusion of the peer with ADHD, those who evaluated exclusion as fair also reflected on the negative interpersonal consequences that may accompany this disorder. For example, Sue (16, ADHD, dyad exclusion) said, “I think it's ok if she doesn't want to be friends with her because I'd probably find Jane annoying, the way she just like butts in and stuff.” A few participants drew on the belief that the peer's depressive mood would put others at risk of depression to condone dyad and group exclusion. For example, Molly (10, depression, dyad exclusion) said: “Lauren, she's being like all sad and everything and you don't really want to be around a person who is all sad … because she'd just like bring you down.” The findings suggest that adolescents considered pertinent self and other costs when evaluating exclusion of the target peers. The adverse consequence of including the peer with ADHD were more likely to impact on social group cohesion and concurrently were saliently and openly discussed. In contrast, the cost of including the peer with depression was specific to one's own mental health and was not suggested by the majority. It's both fair and unfair: the complexity of peer exclusion Most participants explicitly endorsed conflicting exclusion evaluations, whereby exclusion was both fair and unfair. In doing so, young people weighed up the adverse consequences of exclusion for the target peer relative to their own need and desire for positive peer experiences. For example, Beth (15, ADHD, group exclusion) stated, Well I think it's kind of both ways because it's kind of mean of them not to invite her, I don't think it's fair on her but at the same time if she … if she talks the whole time, she's going to do the same thing at the cinema so I kind of understand why they wouldn't invite her. Comparable responses were provided in response to the peer with depression. For example, Lisa (16, depression, group exclusion) said, If she's like always down and stuff then they should be inviting her places to make her like more herself again … but it kind of is ok for them not to invite her in some ways though because if she doesn't talk to them there's no point in making an effort when she's so grumpy. The tension between right and wrong when evaluating these hypothetical exclusion scenarios highlights the complexity of successfully navigating the peer social world; which was aptly summarised up by Alana (10, ADHD, group exclusion) “They are both not fair, so it's kind of hard to tell the difference”. Discussion This study aimed to explore young people's beliefs about the fairness of excluding peers with either ADHD or depression. Although the study also sought to identify any sex or age differences in the explanations that were provided, no obvious or reliable differences emerged. The findings highlighted that when young people are asked to evaluate the fairness of excluding peers with ADHD or depression from dyads and groups, with the exception of ADHD in the group context, exclusion was generally perceived as unfair. However, when they reflected on their evaluations, a complex picture emerged, whereby their initial evaluations which endorsed moral fair treatment of their peers were peppered with caveats. The findings showed that young people's beliefs about the fairness of exclusion were influenced by the attributions that they applied to the peer's behaviour, as well as concerns about the adverse psychological effects of exclusion. For some participants, their decision to include the target peers imposed social and personal costs, such that inclusion would disrupt normative dynamics with the dyad or group. Thus suggesting that inclusion decisions involve weighing up the costs and benefits to self versus other. Furthermore, beliefs about social obligations based on the nature of the relationship also influenced their evaluations; the more intimate the relations, the greater the responsibility on the individual to accept the target peers. The finding that the majority of participants initially evaluated group exclusion of the peer with ADHD as fair stood in contrast to the majority view that exclusion of the peer with depression and dyad exclusion of the peer with ADHD was unfair.
C. O'Driscoll et al. / Journal of Adolescence 42 (2015) 59e67
65
This finding is explained by perceived difficulties of upholding group cohesion due to the externalising symptoms that accompany ADHD. However, other research suggests that it appears to be more socially acceptable to explicitly stigmatise peers with ADHD compared to peers with depression (O'Driscoll et al., 2012), thus it is possible that young people experienced less perceived pressure to respond in a socially desirable manner towards the peer with ADHD. Young people's perceptions of fairness were often influenced by the attributions they applied to the target peers behaviour. Supporting consistent findings from Attribution Theory (e.g. Corrigan et al., 2007; Weiner, Perry, & Magnusson, 1988) and emerging trends from SDT (e.g. Killen & Stangor, 2001) exclusion was mostly perceived as unfair if the target peer's behaviour was attributed to a mental health problem or an external cause. However, in relation to depression, the findings also highlighted the complexity of the relationship between attributions and fairness evaluations of exclusion. Many participants discussed that if there was not an external cause for the target peer's low mood then exclusion was legitimate. This finding is consistent with research that shows that young people are more accepting of peers with depression when the target individual is thought to have little personal control over the cause of depression (Dolphin & Hennessy, 2014). Thus the present study highlights the important role of attributes and knowledge in shaping exclusion evaluations and consequently indicates the potential value of providing psychoeducation about the aetiology of depression and ADHD in anti-stigma interventions. Many participants believed that their peers are valuable sources of support for others with depression and believe that positive peer interactions will alleviate low mood. This finding complements research from the help-seeking literature that shows that peers are endorsed as important sources of emotional support (Schonert-Reichl & Muller, 1996), but that young people are more likely to recommend peers as a source support for peers with depression, but not for ADHD or conduct disorder (Hennessy & Heary, 2009). Participants were also acutely aware of the negative consequences of exclusion such that it could exacerbate a sense of being different and lower self-esteem. Thus, the peer group is perceived as a context in which, if one is accepted, one can flourish and overcome adversity, but exclusion can be detrimental to one's mental health. These findings tentatively suggest that encouraging young people to develop and adopt ownership for the consequences of their exclusion decisions could potentially offer a fruitful avenue for anti-stigma interventions to induce effective change. Young people who evaluated exclusion as legitimate provided a context for the prevailing findings from quantitative research that indicates young people with mental health problems are frequently excluded by their peers (Blachman & Hinshaw, 2002; Hoza et al., 2005). Exclusion of both peers was evaluated as fair when young people believed that including this individual would threaten cohesive peer dynamics and impose a personal cost to them or others within the peer group. These individuals believed that the peer with depression could induce low mood in others, while the externalising behaviour exhibited by the peer with ADHD would impinge on their ability to enjoy the activity. Although participants' beliefs about how including the peer with depression would induce low mood in others was considered a minority view, other research on this topic shows that when young people reflect on why peers with depression are excluded they frequently draw on the stereotype that depression is contagious (O'Driscoll et al., 2014). Limitations & recommendations A qualitative methodology was employed to facilitate new insights on young people's views of exclusion; however, caution should be heeded when generalising the findings of qualitative research. The data were gathered in response to fictional peers in two hypothetical exclusion scenarios, thus young people may reason differently about real-life exclusion decisions that they face in their social world. The data pertains to same-sex peers only. Research shows that attitudes differs across the sex of the perceiver but also depends on the sex of the peer with a mental health problem (Swords et al., 2011), thus future research should explore beliefs about exclusion of opposite sex peers. Furthermore, future research should explore young people's responses to the exclusion of peers with other mental health problems in a variety of social situations, such as sleep-overs, parties, study groups, and sports events. Data on participants' behavioural and emotional profiles were not collected. Adolescents with a mental health problem may have different views on this topic compared to those without disorders. Thus, future research should employ a more homogeneous sample or conduct this research on more defined target groups (i.e. those with personal experiences, those with experience in their social or familial circle and those with limited experience). Friendship group interviews also have some limitations; the group context ensures that one cannot entirely assume that participants expressed their own individual view on the topic. Given that individual interviews allow each participant ‘protected’ space to relay their views (Morgan, 1997) and preliminary research suggests individual interviews yield a wider range of ideas when compared to focus groups (Fern, 1982; Heary & Hennessy, 2006), replication with individual interviews is warranted. The social influences inherent in the group context precluded quantitative analyses of the data. Building on these exploratory findings, future research should gather quantitative data to explore how young people reason about exclusion of peers with mental health disorders. Given that SDT and stigma research that is analysed quantitatively consistently reveals age and sex differences, quantitative research on this topic could shed light on whether the absence of developmental and sex differences that were observed in the present study were a function of the qualitative method used or specific to the exclusion of peers with mental health disorders. Furthermore, quantitative data would permit analyse of whether beliefs about acceptability of exclusion differed as per the exclusion context across the two disorders. Exploring whether it is more
66
C. O'Driscoll et al. / Journal of Adolescence 42 (2015) 59e67
acceptable for adolescents to reject a peer with a mental health problem from dyadic rather than group activities would have important implications for intervention strategies. Attribution models consistently highlight that beliefs about responsibility for symptoms and behaviour associated with mental health difficulties are key variables in predicting peer acceptance (Corrigan et al., 2007; Swords et al., 2011), but that attributions alone do not tell the whole story. The present study highlights other variables that could be tested in research on conceptual models of acceptance. For example, researchers could consider the mediating effect of beliefs about the negative consequences of acceptance for the group or self, as well as altruistic beliefs about positive consequences of acceptance for the peer with a mental health difficulty. Furthermore, given that this study highlighted that the acceptability of exclusion also hinged on the context of exclusion and associated social friendship rules, models of exclusion could attend to these variables. Conclusions The findings of this study provided an initial investigation into what young people think about the exclusion of peers with mental health problems. While the overwhelming trend in the published literature implies that the exclusion of young people with mental health problems is acceptable, the current findings highlight that reasoning about exclusion is not straightforward. Specifically, the evaluations offered to condemn exclusion provides an insight into principles that should be fostered in anti-stigma interventions, while the justifications offered to support exclusion highlights areas for targeted change. Acknowledgements The co-operation of all participating schools, parents and students is gratefully acknowledged. This publication is independent research funded by the Health Research Board in Ireland under Grant No: HRA/2009/269. Any opinions, findings, conclusions or recommendations expressed are those of the authors and not necessarily those of the XXX. No conflict of interest declared. References Aboud, F. E. (2008). A social cognitive developmental theory of prejudice. In S. M. Quintana, & C. McKown (Eds.), Handbook of race, racism, and the developing child (pp. 55e71). Hoboken, NJ: Wiley. Blachman, D. R., & Hinshaw, S. P. (2002). Patterns of friendship among girls with and without attention-deficit/hyperactivity disorder. Journal of Abnormal Child Psychology, 30, 625e640. Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3, 77e101. Brown, C. S., & Bigler, R. S. (2005). Children's perceptions of discrimination: a developmental model. Child Development, 76, 533e553. Chen, X., & Li, B. (2000). Depressed mood in Chinese children: development significance for social and school adjustment. International Journal of Behavioural Development, 24, 472e479. Corrigan, P. W., Watson, A. C., Otey, E., Westbrook, A. L., Gardner, A. L., Lamb, T. A., et al. (2007). How do children stigmatize people mental illness. Journal of Applied Social Psychology, 37, 1405e1417. Dolphin, L., & Hennessy, E. (2014). Adolescents' perceptions of peers with depression: an attributional analysis. Psychiatry Research. http://dx.doi.org/10. 1016/j.psychres.2014.04.051. Elkington, K., Hackler, D., McKinnon, K., Borges, C., Wright, E. R., & Wainberg, M. L. (2012). Perceived mental illness stigma among youth in psychiatric outpatient treatment. Journal of Adolescent Research, 2, 290e317. Fereday, J., & Muir-Cochrane, E. (2006). Demonstrating rigor using thematic analysis: a hybrid approach of inductive and deductive coding and theme development. International Journal of Qualitative Methods, 5, 1e11. Fern, E. F. (1982). The use of focus groups for idea generation: the effects of group size, acquaintanceship, and moderator on response quantity and quality. Journal of Marketing Research, 19, 1e13. Heary, C., & Hennessy, E. (2006). Focus groups versus individual interviews with child: a comparison of data. Irish Journal of Psychology, 27, 58e68. Hennessy, E., & Heary, C. (2004). Valuing the group context: the use of focus groups with children and adolescents. In S. M. Greene, & D. M. Hogan (Eds.), Researching children's experience: Approaches and methods. London: Sage. Hennessy, E., & Heary, C. (2009). The development of children's understanding of common psychological problems. Child & Adolescent Mental Health, 14, 42e47. Hoza, B., Mrug, S., Gerdes, A. C., Hinshaw, S. P., Bukowski, W. H., Gold, G. A., et al. (2005). What aspects of peer relationships are impaired in children with attention-deficit/hyperactivity disorder? Journal of Consulting and Clinical Psychology, 73, 411e423. Jorm, A. F., & Wright, A. (2008). Influences on young people's stigmatising attitudes towards peers with mental disorders: national survey of young Australians and their parents. British Journal of Psychiatry, 192, 144e149. Killen, M., Kelly, M., Richardson, C., Crystal, D., & Ruck, M. (2010). European American children's and adolescents' evaluations of interracial exclusion. Group Processes and Intergroup Relations, 13, 283e300. Killen, M., Mulvey, K. L., & Hitti, A. (2012). Social exclusion in childhood: a developmental intergroup perspective. Child Development, 84, 772e790. Killen, M., Rutland, A., Abrams, D., Mulvey, K. L., & Hitti, A. (2013). Development of intra- and intergroup judgments in the context of moral and socialconventional norms. Child Development, 84, 1063e1080. Killen, M., & Stangor, C. (2001). Children's reasoning about social inclusion and exclusion in gender and race peer group contexts. Child Development, 72, 174e186. Malti, T., Killen, M., & Gasser, L. (2012). Social judgments and emotion attributions about exclusion in Switzerland. Child Development, 83, 697e711. Meadows, S. O., Brown, J. S., & Elder, G. H., Jr. (2006). Depressive symptoms, stress, and support: gendered trajectories from adolescence to young adulthood. Journal of Youth and Adolescence, 35, 93e103. Merikangas, K. R., Nakamura, E. F., & Kessler, R. C. (2009). Epidemiology of mental disorders in children and adolescents. Dialogues in Clinical Neuroscience, 11, 7. Morgan, D. L. (1997). Focus groups as qualitative research (2nd ed.). London: Sage. Moses, T. (2010). Being treated differently: stigma experiences with family, peers and school staff among adolescents with mental health disorders. Social Science & Medicine, 70, 985e993. Murphy, E., & Dingwall, R. (2003). Qualitative methods and health policy research. New York: Walter de Gruyter.
C. O'Driscoll et al. / Journal of Adolescence 42 (2015) 59e67
67
O'Driscoll, C., Heary, C., Hennessy, E., & McKeague, L. (2012). Explicit and implicit stigma towards peers with ADHD and depression in childhood and adolescence. Journal of Child Psychology & Psychiatry, 53, 1054e1062. O'Driscoll, C., Heary, C., Hennessy, E., & McKeague, L. (2014). Adolescents' explanations for the exclusion of peers with mental health problems: an insight into stigma. Journal of Adolescent Research. http://dx.doi.org/10.1177/0743558414550246. Park, Y., & Killen, M. (2010). When is peer rejection justifiable?: children's understanding across two cultures. Cognitive Development, 25, 290e301. Schonert-Reichl, K. A., & Muller, J. R. (1996). Correlates of help-seeking in adolescence. Journal of Youth and Adolescence, 25, 705e731. Swords, L., Heary, C., & Hennessy, E. (2011). Factors associate with acceptance of peers with mental health problems in childhood and adolescence. Journal of Child Psychology & Psychiatry, 52(9), 933e941. Turiel, E. (1983). The development of social knowledge: Morality and convention. Cambridge: Cambridge University Press. Wahl, O. F. (2002). Children's views of mental illness: a review of the literature. Psychiatric Rehabilitation Skills, 6, 134e158. Warren, J. S., Jackson, Y., & Sifers, S. K. (2009). Social support provisions as differential predictors of adaptive outcomes in young adolescents. Journal of Community Psychology, 37, 106e121. Weiner, B., Perry, R. P., & Magnusson, J. (1988). An attributional analysis of reactions to stigmas. Journal of Personality and Social Psychology, 55, 738e748. Williams, B., & Pow, J. (2007). Gender differences and mental health: an exploratory study of knowledge and attitudes to mental health among Scottish teenagers. Child & Adolescent Mental Health, 12, 8e12.