School factors and anxiety disorder among Hispanic youth: Results from the 2016 US National Survey on Children’s Health

Abstract

Anxiety disorders continue to be a major mental health problem among Hispanic youth. A greater understanding of particular risk factors among this at-risk population may assist school health professionals in developing psychosocial interventions designed to mitigate this growing problem. The present study evaluated a variety of school factors related to anxiety among a national sample of Hispanic youth in the US. A secondary analysis of the 2016 National Children’s Health Survey was conducted. A total of 2,138 of Hispanic adolescents aged 12- to 17-years-old participated in the study. A sizeable percentage (10.9%) of Hispanic youth reported anxiety. Results from the final multivariate regression model indicated that bullying others or excluding them, being bullied or excluded by others, not doing all required homework, and school contact to parents about their child’s behavior were all significant risk factors for anxiety among Hispanic adolescents in the US. These risk factors should be considered when planning school health and psychology interventions for Hispanic adolescents in the US.

Keywords

anxiety epidemiology Hispanic youth mental health school

Anxiety disorders continue to be a major mental health problem worldwide (Polanczyk, Salum, Sugaya, Caye, & Rohde, 2015). In the United States specifically, the American Psychiatric Association (2013) reports that 12% to 15% of individuals are diagnosed with an anxiety disorder. Moreover, anxiety continues to be problematic, specifically for minority youth (Potochnick & Perrieira, 2010). Data from the National Comorbidity Survey—Adolescent Replication Supplement revealed that Hispanic youth are at the highest risk for mood/anxiety disorders compared to their ethnic counterparts (Georgiades, Paksarian, Rudolph, & Merikangas, 2018). Despite numerous prevention efforts and programs, anxiety disorders continue to be a pressing public health concern, with over 32.3% of adolescents hospitalized for anxiety and other mood disorders returning to the emergency department more than once every year (Newton et al., 2010).

Regarding sex differences in anxiety disorders, females are twice as likely to be diagnosed with anxiety disorder (Cervone, 2015), although some research suggests that males have a higher prevalence of anxiety than females (Potochnick & Perrieira, 2010). Pertaining to ethnic differences, non-Hispanic Whites have a higher rate of anxiety than their other ethnic counterparts (Breslau, Aguilar-Gaxiola, Kendler, Su, Williams, & Kessler, 2006). Regarding sex and ethnic differences, non-Hispanic females have the highest prevalence of anxiety disorders (Breslau et al., 2006).

Several risk factors for the development of anxiety disorders have been identified including psychosocial, school, and biological (Cervone, 2015; Grills-Taquechel, Norton, & Ollendick, 2010). Highlighting school factors, social acceptance and social support have been identified as possible risk factors for increased anxiety (Grills-Taquechel et al., 2010). Furthermore, peer victimization, defined as several behaviors (e.g., name-calling, violence) intended to hurt the individual, is also an additional risk factor for the development of anxiety among youth (Stapinski et al., 2014). Anxiety disorders are concurrent with a multitude of other inimical health behaviors and phenomena including depression, substance abuse, and self-mutilation (American Psychiatric Association, 2013; Ross & Heath, 2002).

School environment

Overall, school climate has a profound effect on the developing adolescent. The school represents a structure in which adolescents develop their educational attainment, create prosocial behaviors and tendencies, and are exposed to a variety of factors that may enhance or deter their psychological development. Furthermore, the school includes a set of norms, beliefs, and values, that contribute to the development of the school, its students, and teachers/staff (Thapa, Cohen, Guffey, & D’Alessandro, 2013).

Outcomes associated with school environments

A positive school environment has been shown to improve self-esteem, self-concept, self-criticism, and decrease incidences psychiatric problems. Early research by Hoge and colleagues (1990) show a direct link between positive school environments and increased self-esteem. Furthermore, other factors such as admittance into advanced classes, commitment to schoolwork, and other academic-related measures (e.g., perceptions of teachers) were directly related to higher self-esteem and overall school experience.

Moreover, a negative school environment can hinder the typical development of youth, and can expose them to several pernicious environments and behaviors (e.g., substance use, development of anxiety; Thapa, Cohen, Guffey, & D’Alessandro, 2013). Risk factors such as bullying, and delinquency may introduce feelings of anxiety and depression among youth. Rivers and colleagues (2009) found that those who witnessed bullying had more feelings of anxiety and hostility. Additionally, those who witnessed bullying or who were bullies themselves reported more psychological symptoms (e.g., paranoid ideation) and had a higher risk for substance use. These and other relationships may hold true for Hispanic youth.

The present study

Although a range of school factors have been identified in predicting anxiety disorders, several methodological concerns remain when examining anxiety disorders among Hispanic youth. First, there is a paucity of literature examining school factors and anxiety disorders among Hispanic youth (Potochnik & Perreira, 2010). Since the Hispanic population is projected to increase by 45% by 2050 (Colby & Ortman, 2015), additional research is needed to elucidate the mechanisms of school climate on the development of anxiety disorders among Hispanic youth. Additionally, the Hispanic population is twice as likely to seek mental health care in non-clinical settings (Merianos, Vidourek, & King, 2017), making the school a prime target for possible treatment of anxiety disorders. Furthermore, many adolescents and youth report not feeling safe in school and other research is warranted into specific risk factors for anxiety (Thapa et al., 2013). Moreover, the lack of nationally representative surveys examining school factors and anxiety among minority youth has created an obfuscated environment to effectively treat anxiety disorders among Hispanic youth.

Using a nationally representative survey in the US, the present study examined school factors related to lifetime anxiety among Hispanic youth. The present study will contribute to the dearth of literature utilizing a national sample of Hispanic youth to analyse school factors associated with anxiety. Specifically, the present study sought to address the following:

What percentage of parents reported Hispanic youth (ages 12- to 17-years-old) having anxiety?

Does lifetime youth anxiety prevalence differ based on sex?

Does lifetime youth anxiety prevalence differ based on school factors?

Methods

A secondary analysis of the 2016 National Survey of Children’s Health (NSCH) was conducted across the United States and the District of Columbia. The National Survey on Children’s Health is a nationwide survey conducted by the US Center for Health Statistics. The purpose of the NSCH was to provide nationwide and statewide prevalence of children and adolescent’s well-being, health, and psychosocial indicators. The survey contained an extensive array of questions about children and adolescent’s health including disease prevalence, parental health, and environmental factors such as school and neighborhood factors. The overall weight response rate for the 2016 NSCH was 40.7%.

Telephone interviews were conducted with parents and adolescents using a random-digit-dial sample of households with children. One child was selected from each household to be the subject of the survey. The target population consisted of child and adolescents ages 17-years-old or younger. Interviews were conducted in English, Spanish, and several Asian languages. The interview completion rate for the NSCH was 54.1% for the landline sample and 41.2% for the cellphone sample (National Center for Health Statistics, 2017). To ensure confidentiality purposes, the survey was conducted on a secure computer. Participation was voluntary. To maximize response rate, several initiatives including cash ($2–$5), an invitation letter, additional mailings, and a paper questionnaire were used to sample participants. Other methodological details of the 2016 NCHS are detailed elsewhere (National Center for Health Statistics, 2017). All data collection procedures for approved by the NCHS Research Ethics Review Board. The National Children’s Health Survey has established good reliability (National Center for Health Statistics, 2017).

Measures

Demographics

Several questions regarding adolescent sex, age, household composition and federal poverty level were asked. Regarding sex, the question ‘What is the sex of the child?’ was asked. Data were binary in nature (1 = Female; 0 = Male). Age was assessed by the question, ‘How old is the child?’. Data were split into three categories (1 = 0 months to 6-years-old; 2 = 7- to 11-years-old; 3 = 12- to 17-years old). Household composition was determined by the question ‘What is the family structure of the child?’. Data were categorial in nature (1 = Two-parent biological; 2 = Two-parent stepfamily; 3 = Single mother; or 4 = Other family type). Federal Poverty Level was determined by the question, ‘What poverty level do you consider yourself as?’. Data were categorical in nature (1 = 0% to 99% FPL, 2 = 100% to 199% FPL; 3 = 200% to 399% FPL; or 4 = 400% FPL or greater) (see table 1).

School factors

Six questions were asked about school activities. Questions about school activities were: (1) ‘Does the child care about doing well in school?’, (2) ‘Has the child repeated any grades since kindergarten?’, (3) ‘Child bullies others, picks on them or excludes them?’, (4) ‘Child has been bullied, picked on or excluded by others?’, (5) ‘Child does all required homework?’, and (6) ‘How many times has the school contacted you about the child’s behavior?’. Data were binary in nature (1 = Yes; 0 = No). For the school contacting the parent question, data were also binary in nature (1 = One or more times; 0 = None)

Extracurricular activities

Two questions assessing extracurricular activities were utilized. Questions about extracurricular activities were: (1) ‘Does the child participate in participate in organized activities outside of school?’, and (2) ‘Child participates in community service or volunteer work at school or church?’. Data were binary in nature (1 = Yes; 0 = No).

Lifetime anxiety

Lifetime anxiety was determined by the question, ‘Does your child have one or more health conditions: Anxiety (3–17 years)?’. Data were categorical in nature (1 = Does not have condition; 2 = Ever told, but does not currently have condition; 3 = Currently has condition). For the purposes of the present study, data were dichotomized (1 = Does have condition; 0 = Does not have condition). The use of dichotomization was employed for several methodological reasons (e.g., simplification of results, relative strengths of associations; Farrington & Loeber, 2000).

Data analyses

All data analyses were conducted via SPSS Version 23.0 (Statistical Package for Social Sciences). Missing data were minimal (0.2% to 2.1%) and were handled with the default Maximum Likelihood estimation algorithm. Additionally, we used SUDAAN software (v. 7.3) to adjust for sample weights and the complex sampling design. Furthermore, we checked for potential outliers of the data. Preliminary data analyses revealed minimal outliers (<1%), which were excluded from the analyses. Frequencies were performed to determine the prevalence of anxiety and demographic characteristics. A series of odds ratios via unadjusted logistic regression analyses were computed to determine differences in anxiety based on school factors. All significant variables were retained, and a final multivariate logistic model was created. To determine model adequacy, a non-significant Hosmer-Lemeshow test was used. In addition, R² was used for model fit and to determine the proportion of variance accounted for in the dependent variable. All findings were evaluated at the p < 0.05 significance level.

Results

Demographics

The sample size for the current analysis was 2,138 (50.4% male, 49.6% female) adolescents ages 12- to 17-years-old (M = 14.61, SD = 1.70). A total of 10.9% of parents of Hispanic youth reported that their youth (N = 234) had anxiety. No significant sex differences with regards to anxiety were found (X²= 1.16, p = 0.119). Regarding family composition, 61.2% identified as two-parent biological, 9.0% identified as two-parent stepfamily, 18.3% identified as single-mother, and 9.0% identified as other family type.

Lifetime anxiety based on school factors

School factors significantly predicted anxiety. Specifically, parents reported that if their youth repeated grades, youth were 1.77 times more likely to have anxiety (p < 0.001). Likewise, parents reported that if youth not care about doing well in school, they were 2.57 times more likely to have anxiety (p < 0.001), and those who did not do all required homework were 2.88 times more likely to have anxiety (p < 0.001) (See Table 2). Additionally, parents reported that adolescents were 4.28 times (p < 0.001) more likely to experience anxiety if they bullied, picked on, or excluded others. Moreover, parents reported adolescents were close to 5 times more likely (p < 0.001) to have anxiety if they were being bullied, excluded or picked on by others.

Table 1.

Characteristics of youth participants.

Sociodemographic characteristics	N (%)
Adolescent age	M = 14.61, SD = 1.70
Child gender
Male	1078 (50.4)
Female	1060 (49.6)
Household composition
Two-parent biological	1308 (61.2)
Two-parent stepfamily	193 (9.0)
Single mother	391 (18.3)
Other family type	192 (9.0)
Household poverty level
0%–99% FPL	950 (44.4)
100%-199% FPL	321 (15.0)
200%–399% FPL	246 (11.5)
400% FPL or greater	621 (29.0)

N = 2,138; percent refers to valid percent; missing values excluded.

Table 2.

School factors and lifetime anxiety among Hispanic adolescents.

Variable	Lifetime anxiety disorder
Variable	Does Not Have Anxiety	Does have Anxiety	OR	(95% CI)
Does the child care about doing well in school?
True^a	1445 (89.9)	163 (10.1)	1.00
False	411 (77.5)	119 (22.5)	2.57***	(1.98, 3.33)
Has the child repeated any grades since kindergarten?
No^a	1727 (87.4)	249 (12.6)	1.00
Yes	129 (79.6)	33 (20.4)	1.77***	(1.18, 2.66)
Child bullies others, picks on them or excludes them?
No^a	1787 (88.1)	242 (11.9)	1.00
Yes	69 (63.3)	40 (36.7)	4.28***	(2.84, 6.46)
Child has been bullied, picked on, or excluded by other children?
No^a	1804 (88.0)	247 (12.0)	1.00
Yes	52 (59.8)	35 (40.2)	4.92***	(3.14, 7.70)
Child does all required homework?
Yes^a	1314 (91.1)	129 (8.9)	1.00
No	542 (78.0)	153 (22.0)	2.88***	(2.23, 3.71)
Child participates in organized activities outside of school?
Yes^a	1515 (88.0)	207 (12.0)	1.00
No	341 (82.0)	75 (18.0)	1.61***	(1.21, 2.15)
Child participates in community service or volunteer work at school or church?
No^a	1019 (88.5)	133 (11.5)	1.00
Yes	837 (84.9)	149 (15.1)	1.36**	(1.06, 1.75)
How many times has the school contacted you about child’s behavior?
0 times^a	1479 (91.7)	134 (8.3)	1.00
1 or more times	377 (71.8)	148 (28.2)	4.33***	(3.34, 5.62)

Note: ^aReferent. N = 2,138; percent refers to valid percent; missing values excluded.

***

p < 0.001; **p < 0.01; *p < 0.05.

Lifetime anxiety based on extra-curricular activities and performance

Results also indicated that extra-curricular activities and performance significantly predicted anxiety. Adolescents who had not participated in organized activities outside of school were 1.61 times more likely (p < 0.001) to experience anxiety. Furthermore, adolescents were 1.36 times more likely (p < 0.001) to experience anxiety if they did not do community service or volunteer at school or church. Additionally, if the school contacted parents about children’s behavior, adolescents were 4.33 times more likely (p < 0.001) to experience anxiety.

Multivariable logistic regression

As mentioned above, unadjusted odds ratios revealed that repeating grades, not caring about doing well in school, being bullied or bullying others, not doing required all required homework, not participating in community service or organized activities, and schools that contacted parents about child’s behavior were all significant variables in predicting lifetime anxiety. These variables were retained and included in the final multivariable logistic regression model which significantly predicted lifetime anxiety (omnibus Χ²= 168.33, df = 8, p < 0.001) and accounted for 7.6% to 14.0% of the variance in lifetime anxiety (See Table 3). In addition, the Hosmer-Lemeshow test indicated that the model fit well (X² = 5.432, df = 4, p = 0.134). Those at highest risk for anxiety were those who bullied, picked on, or excluded others (OR = 2.140, p < 0.001), those that were bullied, excluded or picked on by others (OR = 2.386, p < 0.001), those who did not do all required homework (OR = 1.571, p < .01), and those whose parents were contacted by the school more than once about their behavior (OR = 2.933, p < 0.001).

Table 3.

Final multivariable regression model for lifetime anxiety.

Item	β	SE	Wald	Exp b	(95% CI)
Cares about doing well in school (No)	0.093	0.182	0.259	1.097	(0.767, 1.569)
Child has repeated grades (Yes)	0.242	0.222	1.192	1.274	(0.825, 1.969)
Child bullies or excludes others (Yes)	0.761	0.232	10.769	2.140	(1.359, 3.371)***
Child is bullied or excluded by others (Yes)	0.870	0.250	12.102	2.386	(1.462, 3.895)***
Child does all required homework (No)	0.452	0.178	6.435	1.571	(1.108, 2.227)**
Child participates in after school activities (No)	0.095	0.165	0.332	1.100	(0.796, 1.519)
Child volunteers after school (No)	0.079	0.140	0.319	1.082	(0.823, 1.424)
School has contacted parents about children’s behavior more than once (Yes)	1.076	0.120	499.053	2.933	(2.194, 3.923)***

N = 2,138; percent refers to valid percent; missing values excluded.

***

p < 0.001; **p < 0.01; *p < 0.05.

The model significantly predicted lifetime anxiety (omnibus X²= 168.33, df = 8, p < 0.001) and accounted for 7.6% to 14.0% of the variance in lifetime anxiety.

Discussion

Anxiety disorders continue to be a major health concern worldwide. The present study examined the relationship between school factors and anxiety among a national sample of Hispanic youth in the US Results indicated that 10.9% of Hispanic parents reported their youth had anxiety, which is slightly higher than previous research (10.4%, Georgiades et al., 2018). Such rates are of utmost concern, since many youth with anxiety tend to avoid school, participation in class, and/or do poorly in school (Ladwig & Kahn, 2007). School health professionals may need to keep these rates in mind when dealing with minority youth. School psychologists and professionals may use several techniques to decrease anxiety, as recommended by the Anxiety and Depression Association of America (2018): Breathing and relaxation techniques, incorporating education, identifying triggers for anxiety among minority youth, and/or helping youth get involved in class or out of class.

Swearer and colleagues (2001) found evidence that youth who were bullied or excluded by others were more likely to experience anxiety; our study documented these same associations within a Hispanic population in the US. Moreover, Pottie and colleagues (2015) found that first-generation immigrant adolescents face higher rates of bulling than second-generation and third-generation immigrant adolescents. Peer victimization may lead to difficulty maintaining friendships, self-blame, being ostracized, and damage emotional support. Beck and Clark (1997) suggested a model of social anxiety that proposed a cyclic nature to the development of anxiety. Once a person enters a social situation or negative social event, feelings of anxiousness start to increase. Other research corroborates this fact, with increased anxiety as a result of frequent bullying (Juvonen & Graham, 2014). Teaching youth to recognize signs of bullying (e.g., emotional outbursts, name-calling, victimization) may, in turn, decrease anxious situations. Interventions designed to decrease anxiety when bullied are warranted.

Conversely, the present study found that Hispanic youth who bullied or excluded others were at significant risk for anxiety. This finding is unique, as previous research has found that Hispanics are less likely to be classified as ‘bullies’ (Peskin, Tortolero, & Markham, 2006). Moreover, those who classify as ‘bullies’ are more likely to suffer from psychiatric problems, such as depression and anxiety (Dake, Price, & Telljohann, 2003). Acculturative Stress Theory posits that entering a new environment with novel cultural norms poses the development of several health consequences including anxiety (Smart & Smart, 1995). It may be the case where a Hispanic adolescent develops anxiety emanating from cultural stress, and to ease stress, they may lash out or bully others as a coping mechanism. School health professionals should implement culturally-competent interventions designed to decreased acculturative stress and bullying behaviors among Hispanic adolescents. Specifically, focusing on cultural barriers (e.g., language, norms) and how to interact with these in their environment may ease anxious and bullying behaviors among Hispanic adolescents.

The present study revealed that Hispanic youth are nearly three times more likely to experience anxiety if the school contacted their parents about their behavior. Here, perhaps the greater contact about the youth’s behavior may lead to possible disciplinary actions at home, which in turn can exacerbate feelings of anxiety. Previous research by Wang and Khalil (2014) suggests a direct link between parental involvement and healthy emotional functioning of the adolescent, with greater involvement leading to more positive academic and mental health benefits. School psychologists should incorporate these findings in psychosocial interventions. Specifically, school psychologists should talk with the parents, inform them of their child’s behavior, and develop specific parenting strategies (e.g., helping child with school, working on self-esteem) to enhance adolescent morale.

Results revealed that Hispanic youth who do not complete all of their required homework are at increased risk for anxiety. Perhaps youth who do not understand the concepts tend to succumb and fall behind in school, thus increasing anxiety. As discussed by Cheema and Sheridan (2015), homework anxiety leads to less academic achievement and more increased feelings of anxiousness. Hudson and Kendall (2002) suggested that working with the child on homework and course assignments helps them to enhance their academic skills, demonstrate knowledge, and master difficult concepts. Parental involvement in homework could perhaps lead to better achievement (Wang & Khalil, 2014) and less anxiety for at-risk youth. Some potential strategies to aid in their child’s learning could be weekly reading and math sessions or creative games to make learning/homework more enjoyable. Thus, parents should continue to be encouraged to consistently assist their children in honing their academic skills.

Limitations

Limitations are to be noted when interpreting the results of this study. First, data from this survey are self-reported by the adolescents’ parents and therefore limited by honesty and accurate recall. Second, the sample consisted solely of Hispanic adolescents; therefore, findings may not necessarily generalize to youth of other ages and ethnicities. Third, data was cross-sectional in nature and thus was unable to determine any causal relationships.

Conclusions

The present study sought to examine school factors related to anxiety among a national sample of Hispanic youth in the US. Results revealed a sizeable percentage of Hispanic youth were diagnosed with lifetime anxiety. Additionally, results from the final multivariate logistic regression model found being bullied, bullying others, not doing all required homework, and repeated school contact with the parents about adolescents’ behavior were all risk factors for anxiety. Findings from the current study could assist school health educators in further developing prevention initiatives and programs aimed at reducing anxiety. Prevention messages (e.g., anti-bullying campaigns, school interventions) framed around the association among specific school factors (e.g., bullying) and the development of anxiety are warranted.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

R. Andrew Yockey, MS, is a first-year PhD student in the Health Promotion and Education Program at the University of Cincinnati. His research interests include child/adolescent health risk behaviors, statistical methods and design, and college student development.

Keith A. King, PhD, MCHES, is Professor of Health Promotion and Director of the Center for Prevention Science. His research emphases include child/adolescent health promotion, suicide, violence and substance abuse prevention, and mental health promotion.

Rebecca A. Vidourek, PhD, CHES, is an Assistant Professor of Health Promotion and Education at the University of Cincinnati. She also serves as the Assistant Director of the Center for Prevention Science. Her research emphases include child/adolescent health promotion, substance abuse prevention, positive youth development, school health education and violence prevention.

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