Parental Support and Adolescents' Coping with Academic Stressors: A Longitudinal Study of Parents' Influence Beyond Academic Pressure and Achievement

Adolescents face many academic pressures that require good coping skills, but coping skills can also depend on social resources, such as parental support and fewer negative interactions. The aim of this study was to determine if parental support and parental negative interactions concurrently and longitudinally relate to adolescents' ways of academic coping, above and beyond the impact of three types of academic stress, students' achievement at school (i.e., grades in school), and age. Survey data were collected from 839 Australian students in grades 5 to 10 (Mage = 12.2, SD = 1.72; 50% girls). Students completed measures of support and negative interactions with parents; academic stress from workload, external pressure (teachers/parents) to achieve, and intrapsychic pressure for high achievement; and ways of academic coping that were grouped into two positive and two negative types. Hypothesized associations were tested concurrently and from one year to the next using path modeling. Beyond the numerous significant influences of academic stress and achievement on coping, and control for age and COVID-19 timing, adolescents with more parental support reported more use of engagement coping (e.g., strategizing) and comfort-seeking, whereas those who reported more negative interactions with parents reported more use of disengagement coping (e.g., concealment) and escape. In the longitudinal model, parental support predicted an increase in engagement and comfort-seeking and a decrease in disengagement coping, whereas negative interaction with parents predicted an increase in disengagement coping. Overall, the findings support the view that coping with academic stressors will continue to depend on parent-adolescent relationships even into the teen years.

The role of coping in processes of resilience: The sample case of academic coping during late childhood and early adolescence

Developmentalists have increasingly concluded that systems approaches to resilience provide a useful higher-order home for the study of the development of coping. Building on previous work on the complementarity of resilience and coping, this paper had two goals: (1) to propose a set of strategies for examining the role of coping in processes of resilience, and (2) to test their utility in the academic domain, using poor relationships with the teacher as a risk factor, and classroom engagement as an outcome. This study examined whether coping serves as a: (1) promotive factor, supporting positive development at any level of risk; (2) pathway through which risk contributes to development; (3) protective factor that mitigates the effects of risk; (4) reciprocal process generating risk; (5) mechanism through which other promotive factors operate; (6) mechanism through which other protective factors operate; and (7) participant with other supports that shows cumulative or compensatory effects. Analyses showed that academic coping at this age was primarily a mediator of risk and support, and a promotive factor that added to engagement for students with multiple combinations of risk and support. Implications are discussed, along with next steps in exploring the role of coping in processes of resilience.

A pattern-centered analysis of adolescents' concerns and hopes about future crises: Differences in ways of coping and personal adjustment

INTRODUCTION

Many adolescents are concerned about global and future crises, such as the health of the planet or terrorism/safety. Yet, adolescents can also express hope about the future. Thus, asking adolescents about their concern and hope could yield subgroups with different ways of coping and personal adjustment.

METHOD

Australian adolescents (N = 863; age 10-16) completed surveys to report their concern (worry and anger) and hope about the planet, safety, jobs, income, housing, and technology, as well as their active and avoidant coping, depression, and life satisfaction.

RESULTS

Four distinct subgroups were identified using cluster analysis: Hopeful (low on concern and high on hope across all issues, 32%), Uninvolved (low in concern and hope; 26%), Concerned about the Planet (CP, 27%), and Concerned about Future Life (CFL, 15%). When compared (adjusting for age, sex, and COVID timing), the CP subgroup was highest in active coping (e.g., taking action) but moderate in personal adjustment. Hopeful had the most positive adjustment, whereas CFL had the poorest adjustment. Uninvolved were lowest in coping but moderate in adjustment.

CONCLUSIONS

Findings suggest ways of coping and adjustment may not always align, in that CP is connected with more active coping but also some cost to personal adjustment, whereas Hopeful is associated with optimal adjustment but perhaps at the cost of active coping. In addition, although CFL adolescents emerged as the at-risk group, the low levels of hope and coping in Uninvolved adolescents raise the possibility that they are at risk of future problems.

Motivation in the Wild

Among the many factors that shape academic motivation and engagement, the interpersonal relationships that students share with their parents, teachers, and peers are central. The contributions of each of these social partners have been clearly documented, but they tend to be studied separately. The growing view is that students are operating within a changing multilevel social world in which peer, teacher, and parent relationships work together to create a complex social ecology. Over the next 10 years, such a paradigm shift to highlight relationships would enrich the study of motivational development and guide interventions designed to foster social systems that better support student motivation and development.

Is Academic Motivation a Tree Trunk, a Fan, a Wall, a Rope, a Snake, or a Spear?

The field of achievement motivation is concept and data rich, populated by well-articulated and well-researched theories. However, these tens of thousands of studies have largely proceeded within separate, siloed theoretical territories. The result is a splintered, complex, and confusing picture of student motivation. Little attention has been devoted to sorting out, comparing, or integrating constructs from different theories. Hence, despite the breadth, depth, and differentiation of achievement motivation research to date, its complexity and lack of coherence threaten to impede theoretical and empirical progress and interfere with the design of comprehensive interventions in the classroom. This fragmentation represents the most fundamental limitation in contemporary motivation theory and research today.

Parent and teacher warm involvement and student's academic engagement: The mediating role of self-system processes

BACKGROUND

Parents, teachers, and researchers all share the goal of optimizing students' academic engagement (Handbook of social influences in school contexts: Social-emotional, motivation, and cognitive outcomes, 2016, Routledge, New York, NY). While separate lines of research have demonstrated the importance of high-quality relationships and support from parents and teachers, few studies have examined the collective contributions of adults' warm involvement or the processes by which support from both parents and teachers shapes students' engagement. According to the self-system process model of motivational development, warm involvement from key social partners fosters students' sense of relatedness, competence, and autonomy, (Minnesota Symposium on Child Psychology, Vol. 23: Self processes in development, 1991, University of Chicago Press, Chicago, IL; Theory and Research in Education, 2009, 7, 133), which subsequently fuels their engagement with academic tasks and challenges (Journal of Educational Psychology, 2003, 95, 148).

AIMS

The current study sought to examine whether a sense of relatedness, competence, or autonomy could explain the relation between parents' and teachers' warm involvement and changes in students' academic engagement across a school year.

SAMPLE

Data was drawn from 1011 third, fourth, fifth, and sixth graders.

METHOD

Students reported on adult warm involvement, self-system processes, and engagement in the fall and spring of a single school year.

RESULTS

Structural equation␣models demonstrated that parent and teacher warm involvement each uniquely, positively, and indirectly predicted changes in students' academic engagement through a combination of students' sense of relatedness, competence, and autonomy, though these patterns differed slightly across adults.

CONCLUSIONS

Implications for optimizing students' academic engagement are discussed, including the need for intervention efforts focused on both parents and teachers and students' self-system processes.

“I get knocked down but I get up again”: Integrative frameworks for studying the development of motivational resilience in school

Many subareas share a common interest in students’ motivational resilience, defined broadly as patterns of action that allow students to constructively deal with, overcome, recover, and learn from encounters with academic obstacles and failures. However, research in each of these areas often progresses in relative isolation, and studies rarely utilize developmental or social-contextual approaches. As a result, we do not yet have a clear understanding of how to help children and adolescents develop a rich and flexible repertoire of tools to deal productively with everyday academic challenges and difficulties. In this article, we knit together these disparate areas of work to create an integrated developmental and social-contextual framework that can guide the future study of these processes. First, we summarize nine areas of work that focus on students’ actions on the ground when they encounter academic difficulties: academic resilience, mastery versus helplessness, engagement and re-engagement, academic coping, self-regulated learning, adaptive help seeking, emotion regulation, and buoyancy as well as tenacity, perseverance, and productive persistence. In each area, we highlight work that is explicitly developmental and that depicts key social-contextual factors that shape motivational resilience. Second, we sketch an overarching social-contextual and developmental framework that holds a place for each of these processes. Third, we identify multiple areas where cross-fertilization among researchers can contribute to improved educational practice and study of the development of motivational resilience. An overarching goal of this article (and the special section more generally) is to take first steps toward “field building” on this crucial topic.

The development of academic coping across late elementary and early middle school: Do patterns differ for students with differing motivational resources?

The way that students cope with the difficulties and setbacks they encounter daily in their academic work can make a material difference to their learning, school success, and capacity to re-engage with challenging educational activities. Because of their potential importance to students’ everyday academic resilience, educators and researchers are interested in the development of adaptive and maladaptive ways of coping—both how they improve or deteriorate over students’ educational careers and the factors that underlie their differential development. Using information on self-reports of 5 adaptive and 6 maladaptive ways of coping, collected from 1,018 American third through sixth graders in fall and spring of the same school year, this study examined (1) the normative progression of these 11 ways of coping across fall of third to spring of sixth grade, and (2) whether developmental patterns differed for students with differing motivational resources. A generally stable profile of constructive coping was evident during Grades 3 and 4 (in which adaptive strategies were high and maladaptive responses low), followed by modest improvements across fourth to fifth grades. Marked shifts were apparent across the transition to middle school. Compared to spring of fifth grade, students in fall of sixth grade reported lower levels of all adaptive and higher levels of all maladaptive ways of coping, and this trend persisted across the first year of middle school. Although motivational resources did not produce differing developmental trends, they did seem to organize coping. Highest levels of adaptive coping were found for students high in both personal and interpersonal assets, just as the highest levels of maladaptive coping were found for students high in both personal and interpersonal liabilities. Findings suggest that both motivational and developmental approaches are needed to fully account for patterns of age-graded trends in academic coping across late elementary and early middle school.

Development of a multidimensional, multi-informant measure of teacher mindfulness as experienced and expressed in the middle school classroom

In response to growing interest in mindfulness as a support for educators, the current study sought to create and test a new multidimensional and multi-informant measure of teacher mindfulness in the classroom. To counter some of the limitations of context-general self-reports, we designed two theoretically based classroom-specific measures that capture the experience and expression of mindful teacher behavior from the perspective of teachers and students. Drawing on emerging consensus from experts on mindfulness in education, the measures incorporated three dimensions of mindfulness, namely, Calm, Clear, and Kind teacher behavior in the classroom, as well as their antitheses, namely, Reactive, Distracted, and Critical teacher behavior. Utilizing data from 78 sixth- to eighth-grade teachers and 550 of their students, teacher- and student-report item sets tapping these dimensions were tested for reliability and validity across three time points. Based on confirmatory factor, reliability, structural invariance, and correlational analyses, subscales generally demonstrated satisfactory psychometric properties, cross-year stabilities, convergent and criterion validity with multiple established measures, and some overlap across reporters. In terms of connections to observer ratings from the CLASS-S, teacher subscales showed consistent but modest connections, whereas student subscales showed higher correlations (especially at time 2), suggesting that students and observers converged in their perceptions of teachers’ expressions of mindfulness. Possible improvements to both measures as well as implications for future research on teacher mindfulness are discussed.

Is psychology suffering from an epidemic of “contagion”? Moving from metaphors to theoretically derived concepts and methods in the study of social influences

The term “contagion” has become increasingly popular as an omnibus catch-all to depict all kinds of mutual influences between people of equal status (or “peers”). We argue that some of these influences may qualify as “contagion,” but others denote alternative processes better described, for example, as exchange, transactions, or diffusion. To transform the term contagion from a loose metaphor to a precise and empirically useful concept, we propose that the paradigmatic case of contagious diseases can be used to identify multiple criteria that a social process must meet in order to qualify as contagion. Based on these essential elements, we describe the developmental signature of contagion, contrast contagion pathways with other temporal pathways of influence, and highlight empirical strategies needed to detect contagion. Finally, we conclude that interpretations about the nature of social influences and their labels should follow from (and not precede) empirical identification of the specific mechanisms that orchestrate transmission.

Science in the Learning Gardens (SciLG): a study of students' motivation, achievement, and science identity in low-income middle schools

BACKGROUND

Science in the Learning Gardens (henceforth, SciLG) program was designed to address two well-documented, inter-related educational problems: under-representation in science of students from racial and ethnic minority groups and inadequacies of curriculum and pedagogy to address their cultural and motivational needs. Funded by the National Science Foundation, SciLG is a partnership between Portland Public Schools and Portland State University. The sixth- through eighth-grade SciLG curriculum aligns with Next Generation Science Standards and uses school gardens as the milieu for learning. This provides the context to investigate factors that support success of a diverse student population using the motivational framework of self-determination theory.

RESULTS

This study reports results from 113 students and three science teachers from two low-income urban middle schools participating in SciLG. Longitudinal data collected in spring of sixth grade in 2015 and fall of seventh grade in 2015 for the same set of students included a measure of students' overall motivational experiences in the garden (that combined their reports of relatedness, competence, autonomy, and engagement and teacher-reports of re-engagement in garden-based learning activities) to predict four science outcomes: engagement, learning, science grades, and science identity. Findings suggest that garden-based activities show promise for supporting students' engagement and learning in science classes and in fostering students' interest in pursuing science long-term.

CONCLUSIONS

As concern for social justice is growing based on the underachievement of students from minority groups, resurgence of the school garden movement over the last several decades provides an opportunity to tip the scales by engaging students in authentic, real-world learning of science and cultivating their interests in science with holistic garden-based learning. This study highlights the role of students' views of themselves as competent, related, and autonomous in the garden, as well as their engagement and re-engagement in the garden, as potential pathways by which garden-based science activities can shape science motivation, learning, and academic identity in science. Findings also suggest that the motivational model based on self-determination theory can be useful in identifying some of the "active ingredients"-in pedagogy, curriculum, and social relationships-that engage students in these garden-integrated science learning activities.

Review

Attachment theorists have described the parent–child attachment relationship as a foundation for the emergence and development of children’s capacity for emotion regulation and coping with stress. The purpose of this review was to summarize the existing research addressing this issue. We identified 23 studies that employed validated assessments of attachment, which were not based on self-report questionnaires, and separated the summary into findings for toddlers/preschool, children, and adolescents. Although most associations were weak and only a minority of the multiple possible associations tested was supported in each study, all studies (but one) reported at least one significant association between attachment and emotion regulation or coping. The evidence pointed to the regulatory and coping problems of toddlers showing signs of ambivalent attachment or the benefits of secure (relative to insecure) attachment for toddlers, children, and adolescents. Toddlers who showed signs of avoidant attachment relied more on self-related regulation (or less social-oriented regulation and coping), but it was not clear whether these responses were maladaptive. There was little information available regarding associations of ambivalent attachment with school-age children’s or adolescents’ emotion regulation. There were also few studies that assessed disorganized attachment.

Children's Beliefs about Control, Means-ends, and Agency: Developmental Differences during Middle Childhood

A new action-theoretical conceptualisation was used to study developmental differences in children's generalised perceived control. According to this conceptualisation, controland action-related beliefs are multidimensional and may include not only (1) expectancies about the extent to which an agent (e.g. the self) can obtain desired outcomes (referred to as control beliefs), but also (2) expectancies about the extent to which certain causes or means produce outcomes (means-ends beliefs), as well as (3) expectancies about the extent to which the agent possesses the potential means (agency beliefs). Cross-sectional age differences in these three sets of beliefs were studied in 240 boys and girls from age 7 to 12. The results of age comparisons in mean level indicated that: (1) perceived control of positive events is greater than that of negative events at all ages; (2) the categories of means-ends beliefs (i.e. for the causes effort, attributes, powerful others, luck, unknown) are increasingly differentiated from each other as to their level of perceived effectiveness; (3) agency beliefs for effort, attributes, and powerful others are high across middle childhood. The increase in the perceived accessibility of powerful others is an especially noteworthy finding. Surprisingly few sex differences were found, with the exception that boys rates the cause "attributes" as more effective than girls. The pattern of age differences in control, means-ends, and agency beliefs not only adds to our understanding of the development of generalized expectancies involving control and action across middle childhood, but also holds promise for future research on the origins of these beliefs and on how they influence children's behaviour and action.

The Origins of Young Children's Perceived Control: Mother Contingent and Sensitive Behavior

The notion that caregiver sensitive and contingent behavior is closely related to children's perceived control has been proposed both by theorists interested in the effects of parent-child interactions and by those focusing on the origins of control beliefs. The present study investigated this relationship by analyzing the interactions between mothers and their 3-1/2-to 4-1/2-year-old children ( N = 120) during a problem-solving task. First, using separately derived indices of contingency, sensitive responsiveness, and sensitive initiation, a correlational analysis revealed that children's perceived control (assessed using an open-ended measure) was most closely related to mother sensitive initiation; all three mother behaviors were interrelated and correlated with child active engagement in the problem-solving task. Second, a conditional probability analysis showed that the relation between mother sensitive initiation and child engagement was reciprocal in that mother sensitive initiation increased the probability of child active engagement and child passivity increased the probability of mother low sensitive initiation. The advantages of a differentiated conception of caregiver behavior and of perceived control are discussed.

What Causes Success and Failure in School and Friendship? Developmental Differentiation of Children's Beliefs across Middle Childhood

A study was conducted to examine the development of domain-specific perceived control during middle childhood. Four hundred and twenty children, ages 7-12 years, reported the perceived effectiveness of five causes (effort, attributes, powerful others, luck, and unknown factors) in producing outcomes in two life domains, namely, school performance and friendship. Analyses of mean level differences between domains revealed that effort was perceived as a more effective cause in the academic domain and that attributes, powerful others, and luck were viewed as more important to friendship outcomes. Furthermore, for effort and powerful others, these domain differences increased with age. In contrast, the perceived effectiveness of attribute causes became more similar across domains as children became older. The potential of these findings is discussed with respect to explaining developmental change in the relations between domain-specific perceived control and corresponding aspects of behaviour.

Review: The development of coping across childhood and adolescence: An integrative review and critique of research

Despite consensus that development shapes every aspect of coping, studies of age differences in coping have proven difficult to integrate, primarily because they examine largely unselected age groups, and utilize overlapping coping categories. A developmental framework was used to organize 58 studies of coping involving over 250 age comparisons or correlations with age. The framework was based on (1) conceptualizations of coping as regulation to suggest ages at which coping should show developmental shifts (Skinner & Zimmer-Gembeck, 2009), and (2) notions of hierarchical families to clarify which coping categories should be distinguished at each age (Skinner, Edge, Altman, & Sherwood, 2003). Developmental patterns in coping (e.g., problem-solving, distraction, support-seeking, escape) were scrutinized with a focus on common age shifts. Two kinds of age trends were discerned, one reflecting increases in coping capacities, as seen in support-seeking (from reliance on adults to more self-reliance), problem-solving (from instrumental action to planful problem-solving), and distraction (adding cognitive to behavioural strategies); and one reflecting improvements in the deployment of different coping strategies according to which ones are most effective in dealing with specific kinds of stressors. Results were used to formulate guidelines for future research on the development of coping.

Challenges to the developmental study of coping

We summarize progress in the developmental study of coping, including specification of a multilevel framework, construction of definitions of coping that rely on regulation as a core concept, and identification of developmentally graded members of families of coping. We argue that these accomplishments are a prelude to the real tasks of a developmental agenda: (1) identifying age-graded shifts in how children and adolescents recognize, react to, and deal with the stressors they encounter in their daily lives; (2) determining the developmental processes that underlie these shifts; and (3) describing and explaining differential pathways for negotiating these normative transitions.

The Development of Coping

Research on coping during childhood and adolescence is distinguished by its focus on how children deal with actual stressors in real-life contexts. Despite burgeoning literatures within age groups, studies on developmental differences and changes have proven difficult to integrate. Two recent advances promise progress toward a developmental framework. First, dual-process models that conceptualize coping as "regulation under stress" establish links to the development of emotional, attentional, and behavioral self-regulation and suggest constitutional underpinnings and social factors that shape coping development. Second, analyses of the functions of higher-order coping families allow identification of corresponding lower-order ways of coping that, despite their differences, are developmentally graded members of the same family. This emerging framework was used to integrate 44 studies reporting age differences or changes in coping from infancy through adolescence. Together, these advances outline a systems perspective in which, as regulatory subsystems are integrated, general mechanisms of coping accumulate developmentally, suggesting multiple directions for future research.

Searching for the structure of coping: a review and critique of category systems for classifying ways of coping

From analyzing 100 assessments of coping, the authors critiqued strategies and identified best practices for constructing category systems. From current systems, a list of 400 ways of coping was compiled. For constructing lower order categories, the authors concluded that confirmatory factor analysis should replace the 2 most common strategies (exploratory factor analysis and rational sorting). For higher order categories, they recommend that the 3 most common distinctions (problem- vs. emotion-focused, approach vs. avoidance, and cognitive vs. behavioral) no longer be used. Instead, the authors recommend hierarchical systems of action types (e.g., proximity seeking, accommodation). From analysis of 6 such systems, 13 potential core families of coping were identified. Future steps involve deciding how to organize these families, using their functional homogeneity and distinctiveness, and especially their links to adaptive processes.

Searching for the structure of coping: a review and critique of category systems for classifying ways of coping

From analyzing 100 assessments of coping, the authors critiqued strategies and identified best practices for constructing category systems. From current systems, a list of 400 ways of coping was compiled. For constructing lower order categories, the authors concluded that confirmatory factor analysis should replace the 2 most common strategies (exploratory factor analysis and rational sorting). For higher order categories, they recommend that the 3 most common distinctions (problem- vs. emotion-focused, approach vs. avoidance, and cognitive vs. behavioral) no longer be used. Instead, the authors recommend hierarchical systems of action types (e.g., proximity seeking, accommodation). From analysis of 6 such systems, 13 potential core families of coping were identified. Future steps involve deciding how to organize these families, using their functional homogeneity and distinctiveness, and especially their links to adaptive processes.

Quality of care and outcomes of adults with asthma treated by specialists and generalists in managed care

BACKGROUND

The growth of managed health care in the United States has been accompanied by controls on access to specialty physician services. We examined the relationship of physician specialty to treatment and outcomes of patients with asthma in managed care plans.

METHODS

We conducted a mail survey of adult asthma patients who were enrolled in 12 managed care organizations and had at least 2 contacts for asthma (International Classification of Diseases, Ninth Revision, Clinical Modification code 493.x) during the previous 24 months; we also surveyed their treating physicians. This report concerns 1954 patients and their 1078 corresponding physicians. Treatment indicators included use of corticosteroid inhalers, use of peak flow meters, allergy evaluation, discussion of triggers, and patient self-management knowledge. Outcome measures included canceled activities, hospitalization or emergency department visits, asthma attacks, workdays lost, asthma symptoms, physical and mental health, overall satisfaction with asthma care, and satisfaction with communication with physicians and nurses.

RESULTS

Significant differences were noted for patients of specialists and experienced generalists compared with those of generalist physicians. Peak flow meter possession was reported by 41.9% of patients of generalists, 51.7% of patients of experienced generalists, and 53.8% of patients of pulmonologists or allergists. Compared with patients of generalists, outcomes were significantly better for patients of allergists with regard to canceled activities, hospitalizations and emergency department visits for asthma, quality of care ratings, and physical functioning. Patients of pulmonologists were more likely to rate improvement in symptoms as very good or excellent.

CONCLUSIONS

In a managed health care setting, physicians' specialty training and self-reported expertise in treating asthma were related to better patient-reported care and outcomes.

Comparison of quality of care by specialist and generalist physicians as usual source of asthma care for children

OBJECTIVE

To determine whether care for children was more consistent with national asthma guidelines when a specialist rather than a generalist was the usual source of asthma care.

DESIGN

Cross-sectional survey.

SETTING

Two large managed care organizations in the United States.

PARTICIPANTS

A total of 260 parents of children with asthma.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Parent reports of the physician primarily responsible for asthma care (specialist, generalist, or both equally) and whom they would call (specialist or generalist) for questions about asthma care were used to define usual source of care. We assessed consistency of care with 1997 National Asthma Education and Prevention Program guidelines using 11 indicators in 4 domains of asthma care: patient education, control of factors contributing to asthma symptoms, periodic physiologic assessment and monitoring, and proper use of medications.

RESULTS

In all 4 domains, care was more likely to be consistent with guidelines when specialists were the usual source of care. These differences remained after adjustment for symptom severity, recent care encounters, and parent demographics. Greatest differences for specialist versus generalist management were for use of controller medications (odds ratio [OR] 6.7; 95% confidence interval [CI]: 1.5-30.4), ever having a pulmonary function test (OR 6.5; 95% CI: 2.4-18.1), and having been told about asthma triggers and how to avoid them (OR 5.9; 95% CI: 1.3-26.2).

CONCLUSIONS

In these managed care organizations, asthma care in children was more likely to be consistent with national guidelines when a specialist was the primary provider. Greater use of specialists or altering generalist physicians' care may improve the degree to which the care of children with asthma is consistent with national guidelines.

Race and sex differences in consistency of care with national asthma guidelines in managed care organizations

BACKGROUND

In the United States, morbidity from asthma disproportionately affects African Americans and women. Although inadequate care contributes to overall asthma morbidity, less is known about differences in asthma care by race and sex.

SUBJECTS AND METHODS

To examine the relationships of race and sex with asthma care, we analyzed responses to questionnaires administered to adults enrolled in 16 managed care organizations participating in the Outcomes Management System Asthma Study between September and December 1993. Indicators of care consistent with National Asthma Education and Prevention Program (1991) recommendations were assessed. Of a random sample of 8640 patients asked to participate, 6612 (77%) completed the survey. This study focused on 5062 (14% African American, 72% women) patients with at least moderate asthma symptom severity.

RESULTS

Fewer African Americans than whites reported care consistent with recommendations for medication use (eg, daily inhaled corticosteroid use, 34.9% vs 54.4%; P =.001), self-management education (eg, action plan, 42.0% vs 53.8%; P =.001), avoiding triggers (37.6% vs 53.6%; P =.001), and specialist care (28.3% vs 41.0%; P =.001). Differences in asthma care by sex were smaller and tended to favor women except for daily inhaled corticosteroid use (women vs men: 49.6% vs 58.3%; P =.001) and having specialist care (37.7% vs 43.1%; P =.001). Similar race and sex differences were observed after adjusting for age, education, employment, and symptom frequency.

CONCLUSIONS

Even among patients with health insurance, disparities in asthma care for African Americans compared with whites exist and may contribute to race disparities in outcomes. Women generally reported better asthma care but may benefit from greater use of inhaled corticosteroids.

Consistency of care with national guidelines for children with asthma in managed care

OBJECTIVE

To evaluate the consistency of pediatric asthma care with the National Asthma Education and Prevention Program Guidelines.

DESIGN

Cross-sectional survey at 2 managed care organizations in the United States (winter 1997-1998). The participants were parents of children (n = 318) age 5 to 17 years with asthma. There were no interventions. The outcome measures were indicators of care in 4 domains: (1) periodic physiologic assessment, (2) proper use of medications, (3) patient education, and (4) control of factors contributing to asthma severity.

RESULTS

Of 533 eligible patients with asthma, 318 (60%) parents responded; 59% of children were male, 76% were white, and 60% were aged 5 to 10 years. Deficiencies in care were identified in all care domains including, for patients with moderate and severe persistent symptoms, only 55% used long-term control medication daily, 49% had written instructions for handling asthma attacks, 44% had instructions for adjustment of medication before exposures, 56% had undergone allergy testing, and 54% had undergone pulmonary function testing.

CONCLUSIONS

There are significant opportunities to improve the quality of care for children with asthma enrolled in managed care. A comprehensive approach to improving care may be necessary to address multiple aspects of care where opportunities exist.

Nocturnal asthma in children affects school attendance, school performance, and parents' work attendance

CONTEXT

Asthma symptoms that occur at night may signal worse asthma control, but the nighttime occurrence may have additional clinical significance. To date, however, there have been few studies of the impact of nocturnal awakening from asthma on children with the disease, including problems with daytime functioning.

OBJECTIVE

To determine if school absenteeism and school performance in children and work absenteeism in their parents are associated with nocturnal awakenings from asthma.

DESIGN

Cross-sectional survey during the winter of 1997 through 1998.

SETTING

Three managed care organizations in the United States.

PARTICIPANTS

Parents of 438 children with asthma, aged 5 to 17 years, who were enrolled in managed care organizations.

INTERVENTION

None.

MAIN OUTCOME MEASURES

Parent's reports of number of days their child missed school and parent missed work and how often the child's education suffered because of asthma in the past 4 weeks.

RESULTS

Overall, more than 40% of children had nocturnal awakenings from asthma in the past 4 weeks. Multivariate analyses were performed that adjusted for child age, race, overall symptom severity, and use of reliever medications. Compared with children who did not awaken from asthma, there were greater odds of missed school days in children who awakened 1 to 3 nights (odds ratio [OR], 3.6; 95% confidence interval [CI], 2.1-6.2), 4 to 7 nights (OR, 4.4; 95% CI, 2.0-10.0), and more than 7 nights (OR, 14.7; 95% CI, 5.9-37.0). Similarly, there were greater odds of education suffering in children who awakened 1 to 3 nights (OR, 2.3; 95% CI, 1.4-3.7), 4 to 7 nights (OR, 2.1; 95% CI, 0.9-4.6), and more than 7 nights (OR, 2.3; 95% CI, 1. 0-5.4), and parents missing work in children who awakened 1 to 3 nights (OR, 4.0; 95% CI, 2.2-7.1), 4 to 7 nights (OR, 6.5; 95% CI, 2.7-16), and more than 7 nights (OR, 3.2; 95% CI, 1.3-7.9). Greater overall symptom severity and high use of reliever mediation were also associated with missed school, education suffering, and parent absenteeism.

CONCLUSIONS

Nighttime awakenings in children with asthma may affect school attendance and performance, as well as work attendance by parents. Nighttime symptoms have independent prognostic value, even when overall asthma symptom severity is accounted for. By addressing whether there are nighttime awakenings in children with asthma, clinicians may be able to tailor the therapeutic regimen to counter these symptoms.

Treatment patterns among adult patients with asthma: factors associated with overuse of inhaled beta-agonists and underuse of inhaled corticosteroids

BACKGROUND

Overuse of inhaled beta-agonists and underuse of inhaled corticosteroids by patients with asthma may have adverse consequences. This study was performed to identify factors associated with misuse of these types of asthma medication.

METHODS

We examined baseline data from a longitudinal survey of adult patients with asthma. The setting was a consortium of 15 national managed care organizations serving 11 large employers. Baseline surveys were completed by 6612 health plan enrollees at least 18 years old who had had at least 2 visits with a diagnostic code for asthma in the preceding 2 years. The main outcome measures were the overuse of inhaled beta-agonists and the underuse of inhaled corticosteroids. Independent variables were patient and process of care factors.

RESULTS

Among patients with moderate or severe asthma, 16% of users of inhaled beta-agonists reported overuse (>8 puffs per day on days of use), and 64% of users of inhaled corticosteroids reported underuse (use on < or =4 days/wk or < or =4 puffs per day). Overuse of inhaled beta-agonists was most strongly associated with concomitant treatment with inhaled corticosteroids or anticholinergic agents, increased asthma symptom severity, problems in obtaining asthma medication, and male sex. Underuse of inhaled corticosteroids was associated with nonwhite race, younger age (18 to 34 years), lower use of inhaled beta-agonist, lower symptom severity, and not possessing a peak flow meter. Rates of misuse of medication also varied by speciality of the patient's provider (generalist, allergist, or pulmonologist).

CONCLUSIONS

Overuse of inhaled beta-agonists may be caused by symptom severity, while underusers of corticosteroids may interrupt use as symptoms abate. This study demonstrated an important opportunity to improve medication use among patients with asthma.

Individual differences and the development of perceived control

Research on individual differences demonstrates that children's perceived control exerts a strong effect on their academic achievement and that, in turn, children's actual school performance influences their sense of control. At the same time, developmental research shows systematic age-graded changes in the processes that children use to regulate and interpret control experiences. Drawing on both these perspectives, the current study examines (1) age differences in the operation of beliefs-performance cycles and (2) the effects of these cycles on the development of children's perceived control and classroom engagement from the third to the seventh grade. Longitudinal data on about 1,600 children were collected six times (every fall and spring) over 3 consecutive school years, including children's reports of their perceived control and individual interactions with teachers; teachers' reports of each student's engagement in class; and, for a subset of students, grades and achievement tests. Analyses of individual differences and individual growth curves (estimated using hierarchical linear modeling procedures) were consistent, not only with a cyclic model of context, self, action, and outcomes, but also with predictors of individual development over 5 years from grade 3 to grade 7. Children who experienced teachers as warm and contingent were more likely to develop optimal profiles of control; these beliefs supported more active engagement in the classroom, resulting in better academic performance; success in turn predicted the maintenance of optimistic beliefs about the effectiveness of effort. In contrast, children who experienced teachers as unsupportive were more likely to develop beliefs that emphasized external causes; these profiles of control predicted escalating classroom disaffection and lower scholastic achievement; in turn, these poor performances led children to increasingly doubt their own capacities and to believe even more strongly in the power of luck and unknown causes. Systematic age differences in analyses suggested that the aspects of control around which these cycles are organized change with development. The beliefs that regulated engagement shifted from effort to ability and from beliefs about the causes of school performance (strategy beliefs) to beliefs about the self's capacities. The feedback loop from individual performance to subsequent perceived control also became more pronounced and more focused on ability. These relatively linear developmental changes may have contributed to an abrupt decline in children's classroom engagement as they negotiated the transition to middle school and experienced losses in teacher support. Implications are discussed for future study of individual differences and development, especially the role of changing school contexts, mechanisms of influence, and developmentally appropriate interventions to optimize children's perceived control and engagement.

The prevalence and impact of self-reported hip fracture in elderly community-dwelling women: the Women's Health and Aging Study

To estimate the prevalence and impact of self-reported hip fracture in elderly women an age-stratified random sample of 3841 community-dwelling women aged 65 years and above were interviewed to determine the occurrence of 13 chronic conditions and difficulty performing 15 tasks. Associations were examined using multiple logistic regression analysis. The weighted prevalence of hip fracture was 4.7 per 100. Prevalence increased with increasing age from 2.9 per 100 in women aged 65-74 years to 12.6 per 100 in women aged 85 years and above, and was higher in white women than black women. Women with hip fracture were significantly more likely to report concomitant Parkinson's disease (age-adjusted odds ratio [aOR] = 2.8) and stroke (aOR = 1.8). After adjustment for potential confounding variables, women with hip fracture were significantly more likely to report difficulty performing 11 activities that map into domains of mobility/exercise tolerance, self-care tasks and higher functioning domains. Hip fracture is common among elderly community-dwelling women and is associated with difficulty in performing activities of daily living.

Methodology and feasibility of a home-based examination in disabled older women: the Women's Health and Aging Study

BACKGROUND

To ascertain disease and functional capacity in community-resident disabled older women in the Women's Health and Aging Study (WHAS), a prospective investigation of the causes and course of disability, a home-based standardized physical examination and performance test battery were developed. Thirty-nine tests were administered, 9 by a lay interviewer and 30 by a nurse. This scope and intensity of testing had not been performed previously in a home environment or on such a functionally limited population. Thus, substantial developmental work was required. This report describes the administrative procedures and field experience for each exam component, highlighting innovations pertinent to home administration.

METHODS

Exclusion criteria, safety issues, administration time, completion rates, and reasons for incomplete data are reported. Administration time is based on 30 exams conducted over a 3-week period 90% of the way through baseline data collection. Completion status was determined using all 1,002 participants and is categorized as follows: complete; partial; not done, health; not done, other; and refused.

RESULTS

Seventy-two percent of the screened, eligible respondents completed the 30-min interviewer-administered physical assessment and the 2-hr, 10-min nurse examination. Classifiable data were obtained for 90% of participants on 36 examination items. Lower completion rates were obtained on the other three tests primarily due to exclusions for health-related conditions; environmental constraints and participant refusal were minimal.

CONCLUSION

Extensive, research-oriented physical evaluation can be successfully and safely performed in a home setting. In future studies, home-based examination may be preferable, as participation in the WHAS examination substantially exceeded rates for clinic-based exams in similar populations.

Self-sufficiency at ages 27 to 33 years: factors present between birth and 18 years that predict educational attainment among children born to inner-city families

OBJECTIVES

Some inner-city infants grow to be successful, self-sufficient adults. This study is designed to identify characteristics from early childhood that foster or impede favorable outcomes and are useful for formulation of public policy.

POPULATION

2694 children (G-2s), born 1960 through 1965, to 2307 inner-city women (G-1s) enrolled in the Johns Hopkins Collaborative Perinatal Study.

DATA

1) prospective observations (birth through 8 years) of neurologic and cognitive development, health, behavior, and family and neighborhood socioeconomic characteristics and 2) completed interviews with 1758 G-2s (age 27 to 33) and 1552 G-1s, bridging the period from age 9 to present status. An intergenerational, life course model of development identified significant characteristics and events associated with G-2 outcome (education, physical and mental health, healthy lifestyle, and financial independence of public support, emphasizing educational attainment of a high school diploma or a graduate equivalency degree). Multiple logistic regression equations identified independent, predictive variables during infancy, preschool and early school years, and adolescence. The probability of a good outcome was estimated in the presence of combinations of the six variables most strongly associated with that outcome.

RESULTS

Among G-2s, 79% had a successful outcome for education, 60% health, 70% lifestyle, and 76% for financial independence. Black G-2s had more favorable outcomes than white G-2s in education and lifestyle, whites for financial outcome; health did not differ by race. The six variables most predictive of adult education were: G-1 education at G-2 birth and G-2 attainment of honor roll, average or better reading skills at 8 years, avoidance of regular smoking, and pregnancy before age 18, and not repeating a grade in school.

CONCLUSIONS

Substantial proportions of inner-city children become successful adults. Attention to improving public education, particularly language and reading skills, and the prevention of smoking and adolescent pregnancy are clearly indicated.

A guide to constructs of control

An integrative framework, designed to organize the heterogeneous constructs related to "control", is based on 2 fundamental distinctions: (a) objective, subjective, and experiences of control; and (b) agents, means, and ends of control. The framework is used to analyze more than 100 terms, such as sense of control, proxy control, and primary control. It is argued that although many terms reflect aspects of perceived control (both distinct and overlapping), some are more usefully considered aspects of objective control conditions (e.g., contingency), potential antecedents of perceived control (e.g., choice), potential consequences (e.g., secondary control), sources of motivation for control (e.g., mastery), or other sources of motivation (e.g., autonomy). Implications for theory, measurement, research, and intervention are explored.

How will outcomes management work?

A consortium of employers and managed health care organizations has come together to test the feasibility and usefulness of an outcomes management system, a new strategy for providing information on what types of medical care are effective, for whom, and under what circumstances. Systematic measurement of health outcomes can provide the information that patients, providers, and insurers/employers need to make informed choices among alternative treatments and services. A pilot project in thirteen sites found that outcomes management is feasible for evaluating ongoing care for chronic conditions but is difficult to apply for short-term diagnostic or treatment episodes. Further, successful implementation requires a commitment of substantial organizational resources.

What motivates children's behavior and emotion? Joint effects of perceived control and autonomy in the academic domain

This study examined the contribution of perceived control and autonomy to children's self-reported behavior and emotion in the classroom (N = 246 children ages 8-10 years). Multiple regression analyses revealed unique effects of autonomy over and above the strong effects of perceived control. In addition, both sets of perceptions (and their interaction) were found to distinguish children who were active but emotionally disaffected from those who were active and emotionally positive. Specific predictions were also tested regarding the effects of (a) control attributions to 5 causes and (b) 4 reasons for task involvement that differed in degree of autonomy on children's active (vs. passive) behavior and 4 kinds of emotions: boredom, distress, anger, and positive emotions. Implications of the findings for theories of children's motivation are discussed, as well as for diagnostic strategies to identify children at risk for motivational problems

What motivates children's behavior and emotion? Joint effects of perceived control and autonomy in the academic domain

This study examined the contribution of perceived control and autonomy to children's self-reported behavior and emotion in the classroom (N = 246 children ages 8-10 years). Multiple regression analyses revealed unique effects of autonomy over and above the strong effects of perceived control. In addition, both sets of perceptions (and their interaction) were found to distinguish children who were active but emotionally disaffected from those who were active and emotionally positive. Specific predictions were also tested regarding the effects of (a) control attributions to 5 causes and (b) 4 reasons for task involvement that differed in degree of autonomy on children's active (vs. passive) behavior and 4 kinds of emotions: boredom, distress, anger, and positive emotions. Implications of the findings for theories of children's motivation are discussed, as well as for diagnostic strategies to identify children at risk for motivational problems