Journal of Youth and Adolescence, Vol. 6, No. 3, 1977

Adolescents View Their Mental Health Goldine Gleser, l's R o s l y n Seligman,: Carolyn Winget, a and Joseph L. R a u h 4

Received February 15, 1977 A new 40-item behavioral checklist, the Adolescent Life Assessment Checklist (ALAC), was devised to be used with patient and nonpatient samples. A comparable form obtains information from a parent or guardian, Responses o f 356 adolescents from three sources were analyzed for differences attributable to race, sex, age, sample source, and their interactions. A factor analysis was carried out on the average within-race-sex-source subgroup correlation matrix, resulting in seven meaningful and six usable oblique factors. Subscales were developed and corrections were computed to remove estimated differences due to race, sex, and age. Corrected scales significantly differentiate the three samples.

This study was supported in part by MCHS Grant No. MC-R-390201, the Adolescent Clinic Foundation, and USPHSMH Fellowship Grant No. 0597921. 1Professor of Psychology and Director, Psychology Division, Department of Psychiatry, University of Cincinnati. Received her Ph.D. in psychology from Washington University, St. Louis; received a Foundations Fund for Research in Psychiatry interdisciplinary research-teaching grant, 1959-1965. Current research interests include test development, evaluation, and personality research. 2Associate Professor of Child and Adolescent Psychiatry, Department of Psychiatry, University of Cincinnati. Received her M.D. from Medical College of Georgia at Augusta; her medical internship was at Michael Reese Hospital, Chicago, Illinois. Current research interests include stress, coping, and adaptation in children and adolescents. 3Senior Research Associate, Department of Psychiatry, University of Cincinnati. She is a licensed psychologist with the State of Ohio, with an M.A. from the University of Cincinnati. Current research interests include verbal behavior, psychotherapeutic efficacy, and dream research. 4Professor of Pediatrics, Department of Pediatrics, University of Cincinnati, and Director, Division of Adolescent Medicine, Children's Hospital Medical Center. Received his M.D. from College of Medicine, University of Cincinnati; his medical internship was with Boston City Hospital, and he is the founder of the Adolescent Clinic, Cincinnati General Hospital. Current research interests include growth and development and medical/social problems at adolescence. s All correspondence should be addressed to Goldine (2. Gleser, Ph.D, Department of Psychiatry, University of Cincinnati Medical Center, 231 Bethesda Avenue, Cincinnati, Ohio 45267. 249 9 1977 Plenum Publishing Corp., 227 West 17th Street, New Y o r k , N . Y . 10011. To promote freer access to published material in the spirit of the 1976 Copyright Law, Plenum sells reprint articles from all its journals. This availability underlines the fact that no part of this Publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise, without written permission of the publisher. Shipment is prompt; rate per article Is $7.50.

250

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Numerous rating scales, inventories, and checklists provide the means of collecting standard self-assessments from adult patients seen in outpatient clinics. Likewise, various rating forms are available to collect information about children and adolescents seen in clinics from their parents, teachers, and other caretakers. However, such forms are seldom used to solicit information from the young person per se, despite therapists' claims that parents often misperceive or lack understanding of how the young person really feels. This is particularly true in the adolescent period when independence-dependence is a prominent issue. Personality tests and self-concept inventories developed for use with adolescents in specific contexts have not generally been shown to be applicable to a clinic population. The Jesness Inventory (Jesness, 1962) has been developed primarily for use with delinquents. The Offer Self-Image Questionnaire (Offer, 1967; Offer and Howard, 1972) was constructed as a personality test to select modal middle-class adolescents for further study. None of the scales we have encountered provides separate normative data for Black adolescents. In a previous study of adolescents referred to a clinic for psychological and/or behavior problems, a semi-structured interview and assessment form (ALAS) was used. It was inadequate in that (1) it was structured around the medical concept of a chief complaint; (2) it necessitated an interviewer to fill it out; (3) subscales were based on a priori judgment rather than empirical evidence of important areas of functioning; (4) it could not be used to provide peer norms. The checklist presented here can be used with adolescents as well as with their parents, objectifying and standardizing the two viewpoints and making it possible to compare them. It also provides items to assess adolescent mental health on the basis of peer norms rather than parental values. The present report is pertinent to this latter aim, presenting normative data regarding age, sex, and race differences in response to the checklist.

METHODOLOGY The Adolescent Life Assessment Checklist (ALAC) consists of 41 statements regarding feelings and behavior followed by five alternative responses ranging from "never" to "almost always." The parents' form parallels the items of the adolescent form, but statements are rephrased in terms of observable behaviors. Thus, whereas the adolescent form has the statement "felt sad and depressed," the correspor~ding item for the parent is "appeared sad and depressed." Seven items are not exactly parallel, although they are believed to tap the same underlying factors.

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251

The ALAC has been administered to three groups of subjects. The first sample consisted of 70 young people seen in the adolescent medical ward of General Hospital or the Children's Hospital Outpatient Adolescent Medical Clinic (medical sample). Both the adolescent and one of his or her parents completed the checklist. A second sample consisted of the first 174 patients referred to the Adolescent Clinic for behavioral and emotional problems during the 1974-1975 school year (clinic sample). Again, a parent or guardian also completed the form. The third (normative sample) consisted of 112 Black and White males and females ranging in age from 11 to 18. These were paid volunteers who took part in a more extensive demographic study of adolescent responses to various assessment instruments. In this study the parents were not involved. The present report deals only with the responses of the 356 young people in these three samples.

RESULTS Demographic information on the three samples is displayed in Table I. The medical sample has a significantly greater proportion of Blacks (60% versus 39%) and a larger representation of older adolescents than does the clinic sample. The normative sample was intentionally designed with equal numbers in each category o f age, sex, and race. In the subsequent analysis the medical and the stratified normative samples were combined and contrasted with the clinic sample. A multivariate 3-factor analysis of variance was performed with sex, race, and sample source (clinic versus nonclinic) as the factors. Two items were omitted for this analysis. Item 34 (wet the bed) was reported too infrequently to be Table I. Distr~ution of Adolescent Samples by Age, Race, and Sex

Males (total) Black White Females (total) Black White Age 11-12 13-14 15-16 17-18 19-20

Medical sample

Stratified normative sample

Clinic sample

No. Percent

No. Percent

No. Percent

32 22 10 38 20 18

46 32 14 54 28 26

56 28 28 56 28 28

50 25 25 50 25 25

88 31 57 86 37 49

51 18 33 49 21 28

176 81 95 180 85 95

1 28 20 15 6

1 40 28 21 9

28 28 28 28

25 25 25 25

32 71 55 16

18 41 32 9

61 127 103 59 6

Total

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meaningfully analyzed. Item 41 (unusual concern with religious ideas) was misinterpreted by many subjects and hence dropped. Three persons were dropped because of missing data. In the following sections, results of the multivariate analysis of variance are presented, as are the results of a factor analysis of the combined within-group correlation matrix. Also, subscales determined from the factor loadings plus examination of item intercorrelations are presented and analyzed for differences due to race, sex, age, and subject source. Sex, Race, and Sample, Source Differences in Response As a group, the young people in our samples claimed they often had someone they felt close to, sometimes or often participated in sports and hobbies, had someone to confide in, and satisfying contacts with the opposite sex, but also sometimes had arguments at home, difficulty with school subjects, headaches, difficulty sleeping, and became sad and depressed, nervous, tense, and irritable. Only a very small proportion of the sample admitted to problems with drinking, smoking cannabis, or taking other street drugs, getting into trouble with the law, or to having thoughts of suicide. For statistical purposes the responses were assigned the numbers from 0 to 4, with 0 corresponding to "never" and 4 to "almost always." The average scores on each item of the ALAC for each race-sex-source subgroup are shown in Table II, together with the within-group standard deviation. The multivariate analysis o f variance revealed highly significant differences in means for sex, race, and source (p < 0.0001 in each case) and also a significant race-by-source interaction (p < 0.02). Sex Of the 39 variables; 19 differentiated the sexes at or below the 0.05 level of significance. Females more often than males claimed they felt nervous and tense, had crying spells, difficulty keeping friends, used street drugs, spent time daydreaming, lost their tempers over little things, had numerous fears, someone to confide in, and someone they felt close to. Females also more often than males reported such symptoms as loss of appetite, stomach pains, headaches, nausea, and physical inability to keep going. Males got in trouble with the law more often and participated in sports and hobbies more than did females. While the overall statistical test for sex • source interaction effects was not significant, seven items exhibited such differences. For all seven items, clinic females had higher means than nonclinic females, whereas the clinic males had either the same or lower means than nonclinic males. Four of these items have to do with depression, i.e., sad and depressed, thoughts of suicide, irritable, worthless. The other three are more varied, i.e., trouble remembering; accidents;

Adolescents View Their Mental Health

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and nausea, vomiting. This last symptom could relate to difficulties with menses or to early pregnancy-conditions which might be related to clinic referral.

Race Only eight items differentiated subjects on the basis of race and two of these held only for clinic patients. Blacks more often than Whites responded that they had trouble remembering things, had accidents, and got into fights. However, they were less likely to feel nervous and tense, irritable, or have problems about drinking or sex. There was also a significant race • source interaction. Those Blacks seen in the clinic claimed more often than Whites to feel they had done something bad or shameful, whereas no difference occurred for normals. Blacks seen in the clinic claimed to take part in sports more frequently than did Whites, whereas for the nonclinic subjects the reverse was true.

Sample Source Nine items differentiated the clinic from the nonclinic response. Adolescents referred to the clinic more often felt nervous and tense; had difficulty with school subjects, concentrating, and making friends; more often cut classes; had more arguments at home; and more often felt worthless. They less often had difficulty sleeping and constipation or diarrhea.

Age Differences in Response Differences in response to each item of the questionnaire as a function of age were examined in two ways. First, a multivariate polynomial regression analysis was obtained using age as the independent covariate and sex, race, and source as independent factors. From this analysis it was determined that the linear regression of responses on age was highly significant and no curvilinear effect was indicated. Secondly, a four-way multivariate analysis of variance was carried out with age dichotomized at 11-15 and 16-20 years. Again, age proved to be a significant variable, as did the triple interaction between age, race, and source. Stomach pains occurred more frequently for older than younger Blacks seen at the clinic whereas the reverse was true for White patients, while little difference with age occurred for adolescents seen elsewhere. Headaches decreased with age for all groups except the Blacks seen at the clinic, for whom headaches increased with age. Sexual problems increased with age in all groups, but the increase was greatest for Blacks seen in the clinic and for Whites in the nonclinic sample. Finally, older Black patients claimed less trouble with the law than younger Blacks, whereas the reverse was true for White patients, and no age difference on this variable was evidenced in the nonclinic groups.

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Differences between age groups were significant for nine items. The younger adolescents claimed more difficulty sleeping and more accidents than the older, but they were less irritable and spent less time daydreaming, had fewer dates and fewer sex problems, used less marijuana and other street drugs, and cut classes less often. Three items were significantly related to age on the basis of the linear regression analysis, but not on the dichtomized variable. The scores on these items-fighting, borrowing without asking, and difficulty making friends-decreased with age. Factor Analysis A principal axis factor analysis was performed on the average within-cell item intercorrelations. These were used in order to eliminate factors due to race, sex, and source p e r se. Eleven factors were obtained with eigenvalues greater than 1.00. They accounted for .58% of the variance. The first eigenvalue alone, however, accounted for 21% of the variance, indicating a strong general factor. After communalities were obtained by iteration, principal axes were rotated to orthogonal simple structure using a normalized varimax program. Seven factors were retained after inspection. The recalculated factors were rotated to oblique simple structure, resulting in the pattern matrix shown in Table III. The correlations among these factors ranged from - 0 . 0 3 to 0.52, with the first four factors substantially intercorrelated. The first factor, Affective Distress, has highest weightings on depression, feelings of worthlessness and thoughts of suicide. The second factor, Cognitive Unproductivity, relates to such items as difficulty concentrating, daydreaming, and trouble remembering. The factor, Somatic Complaints, is mainly evidenced by stomach pains, headaches, and nausea. The next two factors have to do with interpersonal relations. Factor IV, Alienated Peer Relations, deals with concerns about making and keeping friends, possibly resulting in or evidenced by getting into fights, having difficulty with school subjects, and accompanied by feelings of having done something bad or shameful. Factor V, Tolerance of Intimacy, deals with close and satisfying relations with others. Factor IV, Sociopathy, could be called "substance abuse" since it is given large weights by items regarding use of street drugs, marijuana, and alcohol. However, it also accounts for some variance in the items for truancy and trouble with the law. The last factor, tentatively labeled Social Ineptness, is a rather weak factor, with 0.40 as its highest weight. It appears related to overeating and also to accidents and borrowing without asking.

ComparisonsUsing Subscales Our reason for performing a factor analysis was to determine how many meaningful subscales to use. Items were assigned to subscales by a clustering

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procedure, starting with the items most highly loaded on the different factors as nuclei. Additional items were then assigned to the clusters with which they were most highly correlated (Loevinger et al., 1953). For this analysis, age as a covariate was also removed from the intercorrelations. Six subscales were formed with items corresponding fairly closely to those loaded most highly on the first six factors. Their internal consistency reliabilities ranged from 0.61 for Tolerance o f Intimacy to 0.83 for Affective Distress. Intercorrelations among the subscales ranged from - 0 . 2 2 to 0.67. A multivariate analysis of covariance was run on these scales, corrected for age differences. In this analysis, the normative sample and the medical sample were kept separate. The mean subscale scores by sex, race, and referral source are shown in Table IV. Again, the effects of age, sex, race, and referral source were all highly significant. The largest effects for sex were in the scales for Affective Distress, Somatic Complaints and Cognitive Unproductivity. In all three, females had the higher scores. Race differences centered largely in the affective area, were Blacks indicated less distress. This difference was augmented by their expression of somewhat more complaints in the somatic area. Both the clinic sample and the medical patients differed sharply from the stratified normative sample on every scale save Tolerance of Intimacy. They differed from each other primarily on Unproductivity and Alienation, where the clinic scores were higher, and Somatic Complaints, where the medical patients scored higher. In the areas o f sociopathy and tolerance of intimacy, significant differential trends emerged for Blacks and Whites depending on referral source. The white medical patients scored particularly high on the Sociopathy scale, whereas those in the stratified normative sample scored low. Significant age effects occurred for Somatic Complaints and Alienated Peer Relations, on which scores decreased with age, and for Sociopathy and Tolerance of Intimacy, on which scores increased. Correction factors that can be used to take into account sex, race, and age differences are shown in Table V. To use this table, one applies the correction factors to the obtained score. Thus, the corrected score for Affect Distress for a 16-year-old Black male who had an Table V. Correction Factors for Race, Sex, and Age to Be Applied to Observed Scores on the ALAC Race Affective Distress Cognitive Unproductivity Somatic Complaints Alienated Peer Relations Sociopathy Intimacy

Sex

Black

White

Male

Female

1.00 0.14 -0.13 -0.12 0.14 -0.14

-1.00 -0.14 0.13 0.12 -0.14 0.14

1.70 0.87 1.29 0.25 0.14

-1.70 -0.87 -1.29 -0.25 -0.14

Age -0.06 0.17 0.31 0.41 -0.19 -0.31

(age -14) (age -14) (age -14) (age -14) (age -14) (age -14)

Adolescents View Their Mental Health

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observed score of 10 would be 10 + 1 + 1.7 - 0.06 ( 1 6 - 14)= 12.6

DISCUSSION As mentioned earlier, the ALAC was constructed to replace the structured interview and subsequent interviewer rating used previously in the adolescent clinic evaluation. Thus, items were selected to tap the same general areas of functioning. That this was successful seems indicated by the fact that six of the seven factors correspond fairly closely to those obtained previously. One major difference is the separation of a factor of Cognitive Unproductivity from that of Alienated Peer Relations. These appeared as a single factor in the previous study, but were separable by the addition of more items pertaining to cognitive difficulties. Another difference is in the replacement of the factor of Relations within the Family by Tolerance of Intimacy. A reason for this change in emphasis was our feeling that closeness within the family was not an important goal in treating adolescents and that the adolescent should be able to seek out and have close relationships with others of his choosing. An interesting finding that emerges from both factor analyses is that "shame" is related to difficulties in peer relations rather than to other affects such as "sad" or "fearful." Another finding in both studies is that drugs and alcohol load on a common factor. Factor VII, which is evidently not a very salient factor in the ALAC, is somewhat puzzling. It seems to correspond to a factor in the interview that we called "obesity" because weight was the main item loading on it. Smaller loadings were obtained for "disturbed body function" and negative effect on friendship. In the ALAC, overeating, borrowing without asking, fights and accidents, were involved in this factor, together with an absence (negative weight) of nervous and tense feelings. This factor seems to define a socially clumsy, inept person who uses eating as a defense against anxiety, or who lacks affective awareness. Additional items defining this factor would be helpful. At present it is too weakly represented for adequate assessment. The only other factor analysis of a behavior checklist that we have found in the literature is one reported by Arnold and Smeltzer (1974). Their behavioral checkhst was administered to the parents of adolescents and represents the parents' perception of behavior. The 81 items contain many value-laden statements such as wants help in things he shouM do alone; sullen, sulky; blames others for his mistakes; gets revenge in a sneaky manner; refuses to admit he's wrong. It is not surprising, therefore, that the dominant factor in their ratings is "Unsocialized Aggression," a factor which seems missing in our checklist. To find items to tap this dimension of behavior would be useful if it could be done with less emphasis on parental value systems.

262

Gleser, Seligman, Winget, and Rauh

One of the major findings of this study is the large number of items on which sex differences occurred. Most of the items on which females rated themselves higher than males fell on three sclaes: Affective Distress, Cognitive Unproductivity, and Somatic Complaints. It should be noted, again, that sex differences p e r se did not contribute to this clustering. That is to say, the items tend to cluster together in both sexes. However, higher scores are obtained for females than for males overall and particularly in the clinic and medical samples. These differences substantiate findings in our previous clinic samples but extend them both in scope and in applicability to nonclinic samples. Studies using these scale scores will do well to analyze male and female scores separately, correct them as indicated in Table V, or make sure that all comparisons are based on equal numbers of males and females. Very little is available in the literature on race differences in adolescent self-reports. One recent publication deals with race, sex, and age differences in patterns of aggression (Luchterhand and Weller, 1976). The sample consisted of 1844 inner-city youth, aged 13 to 19. The investigators found that Black boys claim to control their tempers and to blow up less over little things than do White boys. A similar racial trend was indicated for girls. Furthermore, the White youth tended to be verbally aggressive when aroused, whereas the Blacks used physical assault. A comparison of items 15 and 28 in Table II of our data yields confirmation of their findings, particularly for the normative samples. Race differences in our data center in only one scale, Affective Distress. The relatively low frequency of feelings of nervousness and tension reported by Black males replicates a finding of our previous study. Furthermore, there is concurrence on a greater incidence of accidents for Blacks. However, the previous study reported that Blacks had more problems regarding sex than did Whites, whereas in the present data the Whites are higher. Very likely, therefore, any difference is due to sampling fluctuations, which are large because of the skewed distributions, relatively few individuals admitting to problems in this area. An additional finding from the present questionnaire is that both Black males and females coming to the clinic claim to have done something bad or shameful more often than White teenagers. One wonders if this relates to their feelings about coming to the clinic and possible peer disapproval. Many of the items related to age appear in the scale we have tentatively called Sociopathy. Scores on this scale increase with age. This is at variance with scores on the Sociopathy factor from the Arnold and Smeltzer (1974) Behavior Checklist, which was shown to decrease significantly with age as does their factor of Unsocialized Aggression. This difference could arise from the difference in the respondent (parent versus adolescent) but more likely is a function of the type of behavior tapped. The Arnold and Smeltzer factor deals with lying, stealing, running away, denying wrongdoing, and seeking revenge. Many of these behaviors continue as the child gets older but the parent may not be as aware of them. On

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263

the other hand, the ALAC probably touches on these behaviors too lightly, hence misses the sociopathy o f the younger age g r o u p - a s s u m i n g they would admit these behaviors. That the subscales o f the ALAC make valid differentiations concerning mental health seems evident judging from the highly significant differences occurring with sample source. The mean scores obtained on the clinic sample were considerably higher than those obtained from the normative sample but differed little from the medical sample. Of particular interest is the fact that somatic complaints occurred with greater frequency among medical patients than among clinic patients, and affective s y m p t o m s occur to approximately the same degree in the two samples. In fact, from the adolescent's perception, there seems little to determine whether he or she will be seen at a medical or a psychiatric clinic. It will be interesting to compare the responses o f parents to those o f their adolescent offspring on the ALAC. This comparison should clarify some o f the questions we have raised regarding difference in perception as a function o f respondent.

ACKNOWLEDGMENTS We acknowledge with thanks the participation o f Marilyn Jerome, B. S., Mary Kapp, and Mark Leisgold, B.S., in the data collection.

REFERENCES

Arnold, L. E., and Smeltzer, D. J. (1974). Behavior Checklist factor analysis for children and adolescents. Arch. Gen. Psychiat. 30: 799-804. Jesness, C. F. (1962). The Jesness Inventory. Consulting Psychologists Press, Pale Alto, Calif. Loevinger, J., Gleser, G. C., and Dubois, P. H. (1953). Maximizing the discriminating power of a multiple-score test. Psychometrika 18: 309-317. Luchterhand, E., and Weller, L. (1976). Effects of class, race, sex and educational status on patterns of aggression of lower-class youth. J. Youth Adoles. 5 : 59-71. Offer, D. (1967). Normal adolescents: Interview strategy and selected results. Arch. Gen. Psychiat. 17: 285-290. Offer, D., and Howard, K. I. (1972). An empirical analysis of the Offer Self-Image Questionnaire for Adolescents. Arch. Gen Psychiat. 27: 529-533.