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Predictors of somatic symptoms in younger rural adolescents.

An individual's life is marked by thousands of events, which vary in magnitude, duration, and meaning. Why one individual reacts differently to a similar life event than another individual is a complex question and the heart of stress research. Stress has been viewed as a motivator for achievement, as well as a destroyer of capabilities. Hans Selye's (1956) biological definition of stress, wherein stress is a reaction to a stimulus which disrupts the balanced state of the body, has provided a dominant theoretical framework of the study of stress. The Schedule of Recent Life Events created by Holmes and Rabe (1967) was modeled after Selye's framework and established a link between stressful life events and adverse health conditions. Within the past twenty-five years, studies have firmly linked stress reduction with emotional and physical health (Dohrenwend & Dohrenwend, 1974; Zakowaski, Hall, & Baum, 1992). Adding yet another dimension to stress studies was the inclusion of smaller stressors or daily hassles, which exert cumulative demands on the individual (Lazarus & Cohen, 1977; Lazarus & DeLongis, 1983; Johnson & Sherman, 1997). Lazarus and DeLongis (p. 247) defined daily hassles as the "irritating, frustrating, distressing demands and troubled relationships that plague us day in and day out." Some investigations suggest that major life events have a direct impact on daily hassles, but daily hassles better predict the onset or presence of pathology; therefore, daily hassles appear to be a better measure of stress (Pillow, Zautra, & Sandler, 1996; Dohrenwend & Dohrenwend; Chamberlin & Zika, 1990; Johnson & Sherman, 1997).

Unlike adults, children and adolescents are subject to many events over which they have little control; therefore, their identified stressors and what they perceive as stressful are often different from those of adults. Adolescence, that period between childhood and early adulthood, has been characterized as a stressful period of development. The experiences of a child making the transition into adolescence (e.g., early adolescence) have become recognized as very different from those of the teenager making the transition out of adolescence (Brooks-Gunn, 1992). Early adolescence has specifically been viewed as a highly stressful period specifically in relation to its "age-graded experiences," including physical, cognitive, and social changes that mark the middle or junior high school years (Swearingen & Cohen, 1985). During this period, adolescents must cope with stressors that include puberty, new experiences, increased responsibilities, and future-oriented plans and goals.

Along with awareness of the differences between younger and older adolescents, there is an increased acknowledgment of gender differences. Adolescent girls report and exhibit higher levels of psychological stress and symptomatology than do adolescent boys, especially in regard to depression (Wilson, Pritchard, & Revalee, 2005; Wade, Cairney, & Pevalin, 2002; Broderick & Korteland, 2002; Thoits, 1991). This difference in symptomatology seems to be partially attributed to a difference in the means by which males and females cope with stress. Gilligan (1982) noted that when girls reach puberty, their coping resources such as self-esteem and self-efficacy fall off sharply, thus leaving girls more susceptible to the negative effects of stress. Furthermore, Sethi and Nolen-Hoeksema (1997) found that girls' thoughts are more internally and relationally focused, while boys tend to exhibit more external focusing. Therefore, when faced with stress, females are more likely than males to use ruminative coping, a method shown to be strongly related to depression (Broderick & Korteland, 2002). Lastly, research by Broderick and Korteland suggests that gender may not be the distinguishing factor in coping styles, but rather the gender roles. Thus, their research suggests that there are implicit rules in regard to coping strategies which imply that rumination is more appropriate for females while distraction is appropriate for males.

Male and female adolescents share a number of similar coping strategies such as listening to music and watching television; however, males and females also use different coping strategies (Frydenberg & Lewis, 1991; Patterson & McCubbin, 1987). Specifically, females use social support (e.g., peers and parents), distress expression (e.g., self-blame), and avoidant coping significantly more often than their male counterparts who typically use more humor, anger expression (e.g., ventilation), and physically active strategies (Bird & Harris, 1990; Rossman, 1992; Recklitis & Noam, 1999). Recent findings have continued to support the notion that gender-role orientation, instead of gender itself, predicts differences in adolescent coping strategies as a result of socialization (Washburn-Ormachea, Hillman, & Sawilowsky, 2004).

Regardless of gender, whether major life events or daily hassles result in dysfunction or enhanced growth is due to mediating factors including the meaning held within the individual; the ability to regulate one's emotional state, resources available for coping with the events or hassles; and the efforts made to cope with the event (Compas, 1987; Kirsch, Mearns, & Catanzaro, 1990; Patterson & McCubbin, 1987). Two mediating factors include coping and negative mood regulation. Coping refers to cognitive and behavioral efforts which serve to manage environmental demands that exceed an individual's resources. Negative mood regulation refers to a cognitive component of generalized response expectancy that enables a person to alleviate negative mood states. On the other hand, Rossman (1992), in a study that combined children's coping with emotion regulation, revealed that certain emotion regulation coping did not have a significant blocking effect on the negative reactions of stress.

Undoubtedly, the major focus of stress research has been on inner city and urban adolescents, yet rural areas represent distinctly different social and economic characteristics (Kelleher, Taylor, & Rickert, 1992). According to Miller and Luloff (1981), rural areas are defined socioculturally, occupationally, and ecologically--a concept that has not been recently contested. The sociocultural dimension is a set of values, including social conservatism, provincialism, and fatalism; the occupational dimension includes extractive or productive industries, such as agriculture; and the ecological dimension focuses on low population density and relative isolation.

Rural youth, who are often overlooked by researchers and thus underrepresented in studies, experience different stressors than those of urban youth. Mental health studies of rural adults have reported high rates of suicide attempts, family violence, depression, and alcohol abuse (Kelleher et al., 1992). In regard to adolescents, Forrest (1988) found that rural youth experience high levels of stress, especially those brought on by isolation and loneliness. Further, she found that limited resources coupled with concerns about anonymity when seeking mental health care compound the problem of intervention. Peden, Reed, and Rayens (2006) reported that 37% of rural youth manifested a high level of depression. Also, depressive symptomatology was greater in their rural adolescent sample in comparison to the National Longitudinal Study of Adolescent Health (AddHealth), which includes both urban and rural youth. Lastly, their study also supported previous findings that the rate of suicide among rural adults is rising.

A few studies were uncovered that examined the stressors and coping mechanisms of rural adolescents. Elgar, Arlett, and Groves (2003) reported that rural stressors may include "geographic insolation, loneliness, barriers to health services, and economic instability attributable to heavy reliance on primary industries (e.g., agriculture, mining, and fishing)" (p. 579). In addition, they found that rural adolescents were affected by high unemployment rates, and poverty and emigration from their communities. Although their study did not find significant differences between urban and rural adolescents in regard to stress levels, they did report that interpersonal difficulties may have a greater impact on rural adolescents' social and emotional functioning, as there are fewer people in rural areas which therefore limits their choice of peers. Additional stressors for rural adolescents include attempted or completed suicide by a friend or family member, poor family relationships, and lack of coping strategies (Peden et al., 2005). Lastly, in regards to coping, rural adolescents have been found to use higher levels of avoidance coping types, which can lead to depression (Mi Sung, Puskar, & Sereika, 2006), while family closeness and active coping are protective factors against depression (Peden et al. 2005).

In summary, stress and stressors have been linked to physical and psychological maladjustment. Coping behaviors and negative mood regulation expectancies have been found to buffer the stress-to-illness relationship. Age, gender, and geographic determinants have been projected to affect the stressors that adolescents experience, as well as the cognitive and social resources available to deal with stress. This study examined the presence and strength of the relationship between daily hassles, coping style, and somatic symptomatology in middle/ junior high age, rural adolescents. It further differentiated this relationship in boys and girls to explore hypothesized differences between genders. Also, the study examined the importance and impact of negative mood regulation on coping choices and whether certain coping behaviors are more likely to buffer the stress-to-illness relationship than others.

METHOD

Participants

Of the 140 early adolescents who entered the study, 138 completed the instruments. These were 7th and 8th grade students who ranged in age from 12 to 15 with a mean age of 13.7 years. There were 60 males and 78 females. Subjects attended one of three small (less than 600 students in kindergarten through 12th grade) school districts in a rural midwestern state. The area is conservative and homogeneous in ethnical makeup (94% Anglo), with agriculture as the economic base. Participation in the study was on a voluntary basis and a parent permission form had to be signed and returned before data could be collected (140 of approximately 250 returned their parental permission form). The only students excluded were those of low intelligence who would have experienced difficulty understanding a number of the instrument items.

Procedure

Each subject participated in an hour-long assessment session during a normally scheduled English class. All measures were administered in a group format. The instruments included: a demographic survey with questions designed to ascertain general demographic data including personal information regarding gender, age, race, religion, educational status, number of siblings, and parents' marital status and level of education; the Adolescent Perceived Events Scale (APES), a modified version of the Adolescent-Coping Orientation for Problem Experiences (A-COPE); the Negative Mood Regulation Scale (NMR); and the Battery for Health and Illness-Adolescent Symptom Checklist (BHI-A).

The APES, developed by Compas, Davis, Forsythe, and Wagner (1987), is a self-report paper-and-pencil inventory designed to record the degree to which adolescents experience stress stemming from major life events and daily hassles. Originally the items were measured on three nine-point Likert scales; desirability, perceived impact, and frequency of stressor. For this study, a previously used modified version of the APES was utilized (Raber, 1992). The revised hassle scale used junior high school identified hassle items that were associated with school, home, and friends. This scale included 34 items which are scored on a four-point Likert scale that ranges from positive/neutral (0) to extremely bad/undesirable (3). The alpha computed on the research sample was .89.

The A-COPE was developed by Patterson and McCubbin (1987). It is a self-report paper-and-pencil inventory with a Likert-type scale ranging from 1 (Never) to 5 (Most of the time). The test is designed to record the various coping strategies utilized by adolescents to manage problems and stressful situations. Originally 12 coping factors were obtained. Since Patterson and McCubbin's original factor analytic study, several researchers have questioned their factor structure due to concerns about the broad age range and type of factor analysis utilized (Bird & Harris, 1990; Jorgensen & Dusek, 1990; Kurdek, 1987). Because of these concerns, as well as the younger age of the children included in the present study and the unique rural environment of the population, a new oblique factor analysis was devised to determine new factors. The factors obtained and their alphas are: Interpersonal coping (alpha = .78)--e.g., joke and keep a sense of humor; Seeking professional support (alpha = .35)--e.g., use drugs prescribed by a doctor; Passive distractions (alpha = .72)--e.g., go to a movie or rent a movie; Substance use (alpha = .83)--e.g., smoke; and Ventilating without problem-solving (alpha = .67)--e.g., get angry and yell at people. With the exception of seeking professional support, the internal consistencies were adequate. However, seeking professional support was retained as a factor since the items comprising the scale were consistent--seek help from a doctor, counselor, or minister.

The NMR (Catanzaro & Mearns, 1990) assesses beliefs regarding the subject's ability to successfully alleviate a negative mood state. Subjects were asked to respond on a 1 (strongly disagree) to 5 (strongly agree) scale of 30 items that complete the stem, "When I'm upset, I believe that ..." Sample items include, "I can usually find some way to help myself feel better," or "Telling myself it will pass will help me calm down." High scores indicate strong beliefs in one's ability to improve a negative mood state; scores may range from 30 to 150. Alpha for the sample was .87.

The BHI-A symptoms checklist developed by Bruns and Disorbio (1988) utilizes the underlying theory that psychosomatic illness results from an inability to cope effectively with stress and anxiety. Therefore, psychosomatic symptoms are substituted for feelings of depression, stress, and anxiety. It is a self-report paper-and-pencil inventory comprised of a composite of scales addressing various health symptomatology. The scale consists of 64 common somatic symptoms (e.g., nausea?, pain in joints?, "butterflies" in your stomach?) Responses are scored on a four-point Likert scale with choices ranging from 1 (Never a problem) to 4 (Big problem). Alpha for the study samples was .97 and indicated excellent internal consistency.

RESULTS

The analyses completed for this study were stepwise multiple regressions assessing the differential contribution of variables in the prediction of symptomatology. The predictor variables were daily hassles and coping factors, which included interpersonal coping, cognitive distractions, seeking professional support, substance use, passive distractions, and ventilating feelings without problem solving. Also included were the interaction variables, substance use by professional support, interpersonal coping by cognitive distraction, as well as grade-by-gender interaction. Interactions examined were determined empirically by significant correlations between the variables. The .05 level of significance was used in all analyses to determine whether there was a significant contribution by one or more predictor variables.

Table 1 illustrates the contribution of the significant variables in this equation. Hassles were the most predictive of somatic symptomatology. Substance use, female gender, and professional support all added to the equation with positive beta weights. Interpersonal coping was the only negative weight or variable related to a decrease in symptomatology.

The data were analyzed through two stepwise regression analyses, one for males and one for females with interaction variables. There were variables which contributed significantly to the prediction of symptomatology and these were different for boys and girls. Both equations included hassles as the most significant contributor. For boys (see Table 2), the equation included hassles and the interaction term of substance use by professional support, attaining an [R.sup.2] of .35. For girls (see Table 3), the equation included hassles, grade level, interpersonal coping factors, and substance use by professional support; the equation attained an [R.sup.2] of .37.

Next, the data were analyzed with negative mood regulation included as a predictor variable. The data analysis was completed on the entire sample with interaction terms. Interaction variables for this analysis included those used in previous analyses as well as the negative mood regulation interaction terms of interpersonal coping by negative mood regulation and cognitive distractions by negative mood regulation. Table 4 indicates that the equation accounted for 32% of the variance with a gender effect noted.

The data, including NMR, were analyzed separately by gender through two stepwise regression analyses, one for males and one for females, with interaction variables. There were variables which contributed significantly to the prediction of symptomatology and these were different for boys and girls. Both equations included hassles as the most significant contributor, but neither included negative mood regulation as a significant contributor to symptomatology. When the interaction terms were entered, the results for the girls did include the interaction of negative mood regulation with the interpersonal coping factor (see Table 5).

Boys, when analyzed separately, did not demonstrate negative mood regulation to be a significant contributor to the equation, even when it was within an interaction; therefore, the results were the same as those summarized in Table 2.

DISCUSSION

Consistent with previous studies (Lazarus & Cohen, 1977; Lazarus & DeLongis, 1983; Johnson & Sherman, 1997; Wagner, Compas, & Howell, 1988), hassles were most predictive of symptomatology in the equations. Also consistent with previous studies (Boyle, Offord, Racine, Szatmari, Fleming, & Links, 1992; Peden et al., 2005), substance use was added to the prediction of symptomatology. The predictive ability of the factor, seeking professional support, to symptomatology seems to be a function of the situation that individuals do not usually seek professional support until they are already sick, either emotionally or physically. Thus, this coping mechanism may serve to ameliorate stress, but the individuals utilizing this method already have strong symptoms. The contribution of the interaction variable, substance use by professional support, can be explained by the same reasoning used to explain these factors' individual contribution. Both coping mechanisms tend to be used by those who are not dealing well with the stress they are experiencing and thus have strong symptoms. The contribution of the interaction variable grade by gender indicates that the developmental ages of the sample interact with gender.

The coping factor, interpersonal relationships, was a significant negative contributor to the equation. This was the only coping factor that significantly reduced the prediction of symptomatology. All other factors were either nonsignificant, neither contributed nor detracted from symptomatology, or significantly contributed to the prediction of symptoms.

When the 7th and 8th grade boys and girls were analyzed separately, hassles were determined to be most predictive of symptomatology in both equations. For males, the second and third variables added were the coping factors of substance use and professional support. Both contributed to the equation in a positive direction. For females, the second variable added to the equation was grade with coping factors following. The addition of grade indicates that females' developmental differences are more predictive of symptomatology within this equation than are male developmental differences. This difference is consistent with research suggesting that gender poses differential biological and social events, which are gender specific in their effects (Brooks-Gunn, 1992).

The next variable entered into the equation was interpersonal coping. Girls were found to utilize interpersonal coping more than did boys. This gender difference is consistent with research which suggests that females use social support and close friends more often than do males in their coping repertoire (Bird & Harris, 1990; Frydenberg & Lewis, 1991). This interpersonal coping factor was found to contribute to the equation in a negative direction. In other words, this factor tended to buffer the stress to illness equation for girls but not for boys.

Another difference which is important to note was the differential predictive ability for the coping mechanism of substance use for boys and girls. This factor contributed significantly for the boys but not for the girls, suggesting that boys are using substances as a coping mechanism more often than are girls.

Contrary to recent research (Catanzaro & Greenwood, 1994; Kirsch, 1990; Kirsch et al., 1990), which suggests that negative mood regulation is associated with a person's chosen coping response and subsequent pathology, this study found no significant contribution by negative mood regulation when entered independently. When negative mood regulation was entered within an interaction term, which included the coping strategy of utilizing interpersonal interactions, it did contribute significantly and in the direction expected.

These results can be interpreted within the context of the sample studied. Previous work with negative mood regulation has been with college age and high school age samples. This research was completed on a middle school/junior high age population. Again, developmental differences need to be taken into account when interpreting these data. Although negative mood regulation did not contribute significantly to the equation, a trend toward significance was observed and is in the expected negative direction. This finding suggests that the ability to regulate one's mood is developing in this age group, but is not yet effective in significantly contributing (negatively) to the prediction of symptomatology.

This developmental explanation of the limited contribution of negative mood regulation to the equation is supported by the studies demonstrating the maturation of children's ability to utilize metacognition--the ability to be aware of one's own learning and memory capabilities and of what tasks can realistically be accomplished (Cavanaugh & Perlmutter, 1982; Duell, 1986). Children's metacognitive awareness is significantly related to their school learning and metacognitive skills improve with age (Peterson, 1988). It is also supported by the research on locus of control and the developmental shift from external to internal focus as children get older. Research suggests that people with an internal locus of control are less apt to accept negative events as factors outside of their control and are therefore more likely to take action and utilize their supportive networks to alleviate stressors (Vinokur & Selzer, 1975). Locus of control is related to negative mood replacement, and evidence from this research suggests that just like locus of control, there is a developmental factor. Lastly recent research has demonstrated the developmental nature of coping strategies. According to Recklitis and Noam (1999), as the ego continues to develop throughout the adolescent years, youth begin to utilize more adaptive coping strategies such as "interpersonal, reflective, and emotional coping styles rather than the more aggressive style of ventilation" (p. 98).

Research and Practical Implications

Because research on rural populations is not prevalent, generalization from this study is limited. However, further research utilizing these results as a comparison and replicating the study with an urban population would contribute to our understanding of the influence of the environment on the relationship between hassles, coping, negative mood regulation, and symptomatology.

As with previous studies, hassles contributed most significantly to symptomatology. This connection is important for those working with children, within both the medical and psychological realm. It would be beneficial when treating early adolescents to assess the hassles they experience in order to accurately diagnose and treat their symptoms.

Another important finding of this study which needs greater attention, is gender differences in coping. The differences observed suggest that professionals need to understand and appreciate these unique differential gender contributions. Specifically noted in this study was that for boys, substance use significantly exacerbated the prediction of symptoms while for girls, substance use was not a significant contributor. In addition, the differences in the means suggest that boys are using substances as a coping mechanism more than are girls at this age. Further research to determine why this is so would be beneficial.

There was a gender difference in the use of interpersonal relationships as a coping mechanism. This strategy was the only factor which demonstrated a significant ameliorating effect and was used more by girls than by boys. This finding suggests that interpersonal relationships in adolescents need to be promoted by agencies working with children; further research exploring the intricacies of this relationship, as well as the differential gender effects, would be beneficial.

This study reinforces the need to learn about effective coping strategies. Promising strategies have been proposed by Nolen-Hoeksema (1992), and Rice, Herman, and Peterson (1993). Nolen-Hoeksema suggests three coping strategies: reconstructing the event in more positive ways, using positive imagery to dampen fear and frustration, and developing reasonable proximal goals. Preliminary data from the Rice et al. (1993) internal/personal and external/interpersonal psycho-education program "designed to help young adolescents learn effective coping responses to the challenges of the early adolescent transition" (p. 144) indicate that participants reported a significant increase in perceived coping abilities and improved relationships with peers.

In summary, these data indicate that hassles are a significant predictor of somatic symptomatology in addition to the coping strategies of substance use and professional support. The coping factor of inter-personal coping proved to have the only buffering relationship to symptomatology. Further, both developmental and gender differences were uncovered. Demonstrated by this study and consistent with previous research, many naturally occurring coping strategies prove ineffective in altering the effects of stress for the younger rural adolescent. Therefore, parents/guardians and professionals need to assist adolescents in gaining interpersonal coping strategies for effectively dealing with daily hassles and major life events during these critical, contradictory, and affect-laden years.

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Lois M. Christiansen, RE-iValley School District, Sterling, CO.

Ellis P. Copeland, The Chicago School of Professional Psychology.

Erika B. Stapert, The Chicago School of Professional Psychology.

Send reprint requests to Ellis P. Copeland, Department of School Psychology, The Chicago School of Professional Psychology, Chicago, IL 60610. E-mail: ecopeland@thechicagoschool.edu
Table 1
Stepwise Multiple Regression Analvsis of 7th and 8th Graders' Somatic
Symptomatology on Daily Hassles, Coping Factors, and Gender (No
Interaction Variables Included)

Variable [R.sup.2] F Prob<F Beta

Hassles .20 4.47 .0000 .34 *
Substance Use .25 2.69 .0080 .20 *
Gender .28 3.65 .0004 .31
Professional Support .31 3.20 .0018 .24 *
Interpersonal Coping .34 -2.69 .0082 -.24 *
constant = 31.04

* = p <.05

Table 2
Stepwise Multiple Regression Analysis of 7th and 8th Grade Boys'
Somatic Symptomatology with Interaction Variables

Model [R.sup.2] F Prob<F Beta

Hassles .27 5.43 .0000 .47 *
Substance use by Professional .35 3.26 .0016 .30 *
support constant = 29.78

* = p <.05

Table 3
Stepwise Multiple Regression Analysis of 7th and 8th Grade Girls'
Somatic Symptomatology with Interaction Variables

Model [R.sup.2] F Prob<F Beta

Hassles .22 2.83 .0056 .25 *
Grade level .28 3.86 .0002 .33 *
Interpersonal coping .33 -3.11 .0024 -.25 *
Substance use by Professional .37 2.96 .0038 .24 *
support constant = 14.79

* = p <.05

Table 4
Stepwise Multiple Regression Analysis of 7th and 8th Grade Boys and
Girls' Somatic Symptomatology, Including Negative Mood Regulation and
Interaction Variables

Model [R.sup.2] F Prob<F Beta

Hassles .23 6.69 .0000 .41
Substance use by
 Professional support .29 4.16 .0000 .25 *
Grade level by gender .30 2.57 .0109 .16 *
Negative mood regulation
 by interpersonal coping .32 -1.99 .0484 -.13 *
constant = 36.9

* = p<.05

Table 5
Stepwise Multiple Regression Analysis of 7th and 8th Grade Girls'
Somatic Symptomatology, Including Negative Mood Regulation and
Interaction Variables

Model [R.sup.2] F Prob<F Beta

Hassles .22 3.04 .0029 .25 *
Grade level .29 3.85 .0002 .32 *
Negative mood regulation by
 interpersonal coping .34 -3.28 .0014 -.26 *
Substance use by Professional .38 2.82 .0057 .22 *
support constant = 11.39

* = p<.05
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Author:Christiansen, Lois M.; Copeland, Ellis P.; Stapert, Erika B.
Publication:Adolescence
Article Type:Report
Geographic Code:1USA
Date:Dec 22, 2008
Words:5469
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