Spirituality, health and medical care of children and adolescents.

A personal connection to the Creator, often termed personal devotion, is the most robust protective factor identified to date in the research field of adolescent health and mental health. Adolescents who turn to God for guidance and direction in making daily choices have lower rates of morbidity with respect to the most prevalent forms of mental illness and physical risk taking behavior: substance use and abuse, depression, conduct disorder, drunk-driving, exposure to sexually transmitted disease, weapon-carrying, poor nutrition and lack of exercise. (1) Personal devotion is more robustly protective than the well-established secular protective factors of social support, parental bonding style, and school attendance, as well as the most frequently researched religious variables of religious denomination, attendance at services, and close adherence to creed. Intertwined with personal devotion are the widely researched concepts of spiritual coping and daily spiritual experience, also shown to be associated with health and well-being and protective against depression in adolescents. (2)

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Spiritual social support, usually measured through participation in youth group or involvement in a faith-based community, also has been shown to protect against a range of morbidity in adolescents, particularly in those adolescents at health risk due to poverty, psychopathology or parental psychopathology. Oetting and colleagues (3) infer from this consistent finding across the literature that spiritual social support might exert an indirect effect on adolescent health by imbuing the context surrounding adolescents with values, role models, and daily opportunities for prosocial interactions (as well as decrease community-wide access to drugs and alcohol).

Spiritual social support and personal devotion have been shown to be mutually facilitating, are mildly to moderately correlated, and yet exert independent and distinct protective effects against morbidity in adolescents. (4)

Personal devotion has been shown in twin studies to have a heritable contribution. Approximately 30% of the variance in a large sample of female adults is attributable to broad heritability. (5) With the onset of puberty, protective qualities of personal devotion against depression in adolescent girls indicate the concomitant burgeoning of personal spirituality with fertility.

Environmental factors shown to strengthen personal devotion in adolescents include degree of parental faith and parent-child interaction around faith, participation in a faith community or youth group, and for youth facing a dearth of parental support, spiritual input from adults outside of the family. (1)

From a developmental perspective, personal devotion in adolescents is closely associated with an individuation process in which the adolescent is clarifying and owning personal beliefs that were once appropriated from family and community. Crucial to the facilitation of the development of adolescent personal devotion is adult respect and receptivity for the incumbent questioning, moral struggle, and deepening of faith.

Younger children have also been often shown to have a strong spiritual orientation, with a personal connection to the Creator. Young children in the developmental stage of concrete operations exhibit interest and understanding around issues of life and death, which have been shown to be clinical strengths, as well as treatment imperatives, in coping with severe illness and suffering. (6)

Psychopathology can distort the developmental course of personal devotion across childhood. Children who grow up for many years under the psychological "rain-cloud" of depression, either due to early onset childhood depression or through maternal recurrent depression, may tend to show in adulthood a depressogenic form of personal devotion characterized by guilt and over-responsibility. (7) Similarly, "grownup" children of substance abusers are at risk both for substance abuse and the concomitant tendency toward very low rates of personal devotion. (8) Note, however, that while still children, offspring of parents with depression and substance abuse show normative rates of personal devotion, with its full protective qualities.

Distortion in the normative development of spirituality may interweave with a life-time course of psychopathology, potentially in a mutually degrading iterated process. Particularly among offspring of parents with severe psychopathology, childhood marks a window of opportunity for intervention to facilitate the development of personal devotion. This possibility gains support from research on children of substance abusers who exhibit "selective religious socialization" toward protective elements of parental spirituality and against those dimensions of parental spirituality posing risks for substance use. (8)

In light of the strong evidence supporting the protective qualities of personal devotion against morbidity in youth, psychotherapy has begun to integrate personal spirituality into treatment for youths and families. Avoidance of personal spirituality, in light of this evidence, has been discussed within the American Psychiatric Association as potentially causing iatrogenic harm. In the case of treatment for a child or an adolescent patient by an adult psychotherapist, some concerns around coercion have been expressed in the treatment literature leading to the recent articulation of a child-centered spiritual stance. (9) A child-centered approach holds as primary the lived spiritual experience and beliefs of the child, and allows the child to use their spiritual beliefs in coping with the event to precipitate treatment.

For treatment of anxiety, symptoms of stress, and to enhance attention, recently mindfulness-meditation (derived from contemplative Easter traditions) has been adapted for youths. Preliminary findings support the feasibility and potential helpfulness of mindfulness-meditation with under-served populations of poor children with very high levels of chronic stress. (9)

Family therapy may benefit from the integration of a spiritual perspective, particularly when reframing crisis exclusively from an obstacle to an opportunity for spiritual growth and understanding in the family. Gravely ill children and their families prefer their treating physician to inquire about their spiritual beliefs, suggesting that spirituality is central to the treatment experience and is germane to the healthcare team. Spiritually-oriented family treatment may improve family functioning (10) and constitute prevention against distortion in the personal spirituality of the child.

References

1. Miller L, Kelley BS. Relationships of religiosity and spirituality with mental health and psychopathology. In: Handbook of Psychology and Religion New York, Guilford, 2005.

2. Cotton S, Zebracki K, Rosenthal SL Religion/spirituality and adolescent health outcomes: a review. J Adolesc Health 2006;38:472-480.

3. Oetting ER, Deffenbacher JL, Donnermeyer JF. Primary socialization theory. The role played by personal traits in the etiology of drug use and deviance. II. Subst Use Misuse 1998;33:1337-1366.

4. Smith C. Theorizing religious effects among American adolescents. J Sci Study Relig 2003;42:17-30.

5. Kendler KS, Gardner CO, Prescott CA. Religion, psychopathology, and substance use and abuse; a multimeasure, genetic-epidemiologic study. Am J Psychiatry 1997;154:322-329.

6. Kazak AE, Barakat LP, Meeske K, Christakis D. Posttraumatic stress, family functioning, and social support in survivors of childhood leukemia and their mothers and fathers. J Consult Clin Psychol 1997;65:120-129.

7. Miller L, Weissman M, Gur M, et al. Adult religiousness and history of childhood depression: eleven-year follow-up study. J Nerv Ment Dis 2002;190:86-93.

8. Miller L, Weissman M, Gur M, et al. Religiousness and substance use in children of opiate addicts. J Substance Abuse 2001;13:323-336.

9. Miller L, Kelley B. Spiritually oriented psychotherapy with youth: a child-centered approach. In: The Handbook of Spiritual Development in Childhood and Adolescence. London, Sage, 2006.

10. Houskamp BM, Fisher LA, Stuber ML. Spirituality in children and adolescents: research findings and implications for clinicians and researchers. Child Adolesc Psychiatr Clin N Am 2004;13:221-230.

Lisa Miller, PhD

From the Department of Psychology, Columbia University, New York City, NY.

Reprint requests to Dr. Lisa Miller, Box 25, TC, Columbia University, 525 West 120th Street, New York, NY 10027. Email: [e-mail]

Lisa Miller is an Associate Professor in the Clinical Psychology Program at Teachers College, Columbia University. Her research on spirituality is supported by the William T. Grant Foundation (Faculty Scholars Award).