Family, Health, and Adolescence

NICOLAS ZDANOWICZ, M.D., PH.D.

PASCAL JANNE, PH.D.
CHRISTINE REYNAERT, M.D., PH.D.

The present research examined the correlations between types of family relationships and adolescents beliefs about their own health. Healthy adolescents (N765) completed both the Multidimensional Health Locus of Control questionnaire and Olsons scale assessing family cohesion
and adaptability. They were compared to a group of 358 adolescents diagnosed with mental disorders. Cohesion in the family of origin was a significant factor in the adolescents feeling of
control over their own health as well as in the level of power they attributed to other people.
Among these adolescents, adaptability of the family of origin was positively correlated with
stronger feelings of control over ones own health and with lower levels of belief in chance. Family relations were significant in the adolescents acquisition of feelings of control over their own
health.
(Psychosomatics 2004; 45:500507)

bout 10 years ago, the development of preventive

medicine became a major objective in many developed countries. The populations that are targeted to benefit
from these campaigns of prevention are teenagers, young
adults, and their parents. These populations are considered
more likely to be influenced and to adopt behaviors in favor
of their health. However, what do we really know about
the evolution of health at this age and about its correlates
with family dynamics? Until now, the largest number of
studies on the evolution of health have been conducted
with the Multidimensional Health Locus of Control
(MHLC),1 even though new instruments for addressing
these issue have since been developed.
In 1978, Wallston and colleagues developed the
MHLC, which measures the respondents beliefs about his
or her responsibility in determining his or her own health
status. This scale is multidimensional as it enables the iden-

Received June 5, 2003; revision received March 23, 2004; accepted April
7, 2004. From the Universite Catholique de Louvain. Address reprint
requests to Dr. Zdanowicz, Service de psychosomatique, Clinique de
Mont-Godinne, Universite Catholique de Louvain, 5530 Yvoir, Belgium;
nicolas.zdanowicz@pscl.ucl.ac.be (e-mail).
Copyright 2004 The Academy of Psychosomatic Medicine.

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tification of three different types of belief: two are external in nature, and one is internal. Internally controlled
individuals tend to believe that the reinforcements they encounter depend on the behaviors they perform. This dimension is measured with the subscale for internality
health locus of control. Externally controlled individuals
tend to believe 1) that their health is either the result of
chance or fate (this belief is assessed by the subscale for
chance health locus of control) or 2) that it results from
others actions (this belief is assessed by the subscale for
powerful others health locus of control). Finally, the relation between internal and external tendencies can be calculated through the internality/externality ratio.2 The development of this scale has triggered considerable research,
including a review by Pauwels et al.,3 which has indicated
that, especially through primary and secondary individual
preventive attitudes, the MHLC is a good predictor of respondents medical as well as psychiatric health. It is nevertheless important to remember that, as with all scales, the
MHLC suffers from several limitations and seems particularly less appropriate for assessing respondents will to
control and the value they assign to health.4
After reviewing the relevant literature on this topic,
Psychosomatics 45:6, November-December 2004

Zdanowicz et al.
we found only two studies that have used the MHLC with
adolescents. Besides confirming the usefulness and stability of the MHLC during adolescence, the study by Stanton
et al.5 also pointed at gender differences in locus of control.
More specifically, Stanton and associates found that the
levels of attribution of health locus of control to chance
and to powerful others vary between the ages of 13 and 15
but only among female subjects. The second study, conducted by Nada-Raja and colleagues,6 included more than
800 young people 15 years old. While this research did not
study the influence of age on MHLC scores, it still found
gender differences in levels of internality regarding health
locus of control (higher levels among male subjects) and
in levels of attribution to powerful others (lower among
male subjects). In addition, the preceding research showed
that negative life events and mothers beliefs about their
own locus of control had a significant influence on their
daughters level of internality. A positive correlation of internality with a high level of social support and/or selfperception of strength was also found among male subjects.
One particularity of the MHLC is that item 7, which
is used to assess belief in powerful others as a locus of
control over health, measures respondents belief in the
influence their families have over their own health. However, we do not know of any study that has ever been published on this particular item. No study has demonstrated
whether, as we can reasonably assume, peoples attitudes
toward their own health are influenced by their familys
educational as well as relational patterns. Thus, while a
particular family might promote in its members a sense of
control over their individual health, another might promote
a more fatalistic disposition. In addition to research measuring the relationship between MHLC scores and adolescence, other studies have used Olsons scale7 to investigate
the relationship between family functioning and illness
among adolescents. More precisely, Olsons circumplex
model aims at assessing two dimensions (axes) of a given
relational system at work: cohesion and adaptability. Cohesion is defined as the emotional ties each member of
a family develops towards the other members, and adaptability is defined as the conjugal or family systems ability to change its power structure and relational rules and
roles in response to a stressful situation or development.
A self-rating version of this scale is the FACES III (Family
Adaptability and Cohesion Evaluation Scale),8 which enables a quick, quantitative evaluation of the two axes,
thereby describing the interactive and structural style
within the system under study. The model is conceived in
Psychosomatics 45:6, November-December 2004

such a way that family health is found in the median

values of the two axes. In other words, family cohesion
is measured by a value found on the separated-linked
continuum, and system adaptability is measured by a
value found on the structured-flexible continuum.9 Studies with adolescents have shown significant differences in
family functioning between families containing an adolescent member with psychiatric or medical pathology and
families without an ill adolescent (Table 1).
Thus, we have, on the one hand, some information
about the evolution of feelings about ones control over
ones health during adolescence and, on the other hand,
information about the role played by family dynamics in
some disorders. However, research on the effect of family
dynamics on feelings about control over health is lacking.
Our objective was to try to build a bridge between family
dynamics and adolescents attributions of responsibility for
their own health. In order to test the hypothesis that these
variables are associated, we studied the correlations between the functioning of the family of origin and the
MHLC scores of a group of healthy adolescents and
compared those to similar correlations for a group of adolescents with psychiatric disorders (henceforth referred to
as unhealthy adolescents). For the latter group, we
avoided selecting any particular pathology for two reasons.
First, the research conducted with Olsons scale included
a great variety of disorders (Table 1), and second, the research results described by Prange et al.15 and by us17 suggest that family characteristics are associated with vulnerability to disorders in general rather than to a particular
one.
METHOD
The present research took place between December 1998
and June 1999. The subjects completed the MHLC and the
FACES III questionnaires. We used Fontaines French version of Olsons scale18 and Mortreus French version of the
MHLC.19
Participants and Procedure
The healthy subjects were selected by using two different strategiesa procedure that aimed at including adolescents from varied cohorts and backgrounds. The first
recruitment took place in each of the 6 grades of three
secondary public schools (i.e., with ages normally ranging
from 12 to 18 years) in the province of Namur (Belgium).
Under a psychiatrists supervision, these adolescents were
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Family, Health, and Adolescence

asked to answer a sociodemographic questionnaire (age,
gender, high school level, nationality) and to complete the
MHLC and Olsons scale assessing their family of origin.
The second group of subjects was selected by 4th-year psychology students at the Catholic University of Louvain,
who distributed to adolescents they were acquainted with
an anonymous questionnaire whose items included sociodemographic variables (birth date and gender) as well as
the MHLC and Olsons scale. It should be noted that the
healthy subjects were considered normal by default.
Thus, although they were not recruited in a hospital or
another health facility, we cannot exclude the possibility
that some of them might actually have been hospitalized
for one or another reason. To limit this possibility and because of the frequency of depressive disorders at this age,
the young people completed the Zung Self-Rating Depression Scale.20
The unhealthy group was constituted from data that
were systematically collected from 1989 to December 1998
among hospitalized patients in the Psychosomatic Medicine and Psychopathology Units at the Mont-Godinne University Clinics of the Catholic University of Louvain. At
the very beginning of their hospitalization, the patients systematically completed the MHLC and Olsons scale and

TABLE 1.

provided general sociodemographic data (birth date and

gender) under the supervision of a psychologist. For each
patient it was the first hospitalization, the admission was
voluntary, and the patient was not coming from any residential type of service. In an attempt to control the effect
of the length of the enrollment period, every result was
controlled by using the date of admission as a covariate.
We disregarded these patients diagnoses in order to respect
the diagnostically nonspecific nature of our hypotheses.
The patients diagnoses are shown in Table 2 for information purposes only. Patients who were initially enrolled
on the basis of DSM-III-R diagnoses have been rediagnosed with DSM-IV on the basis of their initial DSM-IIIR diagnosis, symptoms at admission, and past psychiatric
history. For the most frequent disorders, such as mood disorders, we have previously reported our results.21
Regardless of whether they belonged to the healthy or
unhealthy group, the candidates had to be 1) between the
ages of 13 and 25 years, 2) single or living as an unmarried
couple, 3) unemployed, receiving public assistance, or a
student. The World Health Organization22 proposed these
three criteria as determining the condition of adolescence. In order to further homogenize our groups, the subjects had to be Caucasian, French-speaking, and students.

Previous Studies Using Olsons Scale7 to Assess the Cohesion and Adaptability of Families of Children or Adolescents With
Psychiatric or Other Medical Illnesses
Adolescents Condition
or Treatment Goal

Authors
10

Age and/or Sex

Coburn and Ganong

Bulimia

Female university students

Kashani et al.11

Depression

13 years

Lawler et al.12

Diabetes control

1518 years

Lundholm and Waters13

Eating disorders

Female university students

Michaels and Lewandowski14

Learning and writing disabilities

612 years

Prange et al.15

Affective disorders

1218 years

Tubiana et al.16

Diabetes control

713 years

Zdanowicz et al.17

Healthy versus unhealthy

1025 years

Family Cohesion and/or Adaptability

Bulimic adolescents families were weakly
cohesive; adaptability had no influence
Depressive childrens families were
disengaged; adaptability had no influence
Diabetes control correlated with family
cohesion; families of disengaged patients
had the worst results
Female university students with eating
disorders had extreme familiesa
Children with learning disabilities had
extreme familiesa
Adolescents with affective disorders had
disengaged families; weak family
cohesion positively correlated with a high
level of psychopathology
Cohesion and adaptability were proportional
to patients compliance with their
treatment; rigid and disengaged families
lacked control over patients diabetes
Families of healthy subjects had high levels
of cohesion and adaptability

In the circumplex model of cohesion and adaptability, an extreme family is one scoring at either extreme of either the cohesion axis or the
adaptability axis.

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Psychosomatics 45:6, November-December 2004

Zdanowicz et al.
Analysis
SPSS for Windows 95/98/NT Advanced Model 9.0S
was used for our statistical analyses. Given the considerable number of observations, the necessity to analyze the
influence of several covariates, and the need not to change
statistical methods during the analysis, we used only parametric tests. Pearsons chi-square test was used to compare
proportions. Pearsons r coefficient was used to assess correlations between continuous variables, eventually controlled for partial correlation (with a covariate). Students
t test was used for comparisons of quantitative variables.
The significance levels were tendency, significance (p
0.05), and strong significance (p0.01). All the statistics
were two-tailed. Results are displayed in the following order: analysis of the demographic variables (age and gender), discussion of the impact of these variables, comparisons of the scores for the two groups on Olsons scale and
the MHLC, and hypothesis testing (results of the correlations between the MHLC and Olsons scale). Other standard demographic variables, such as ethnic origin, occupation, and educational level, were not considered relevant
in the present study since the first two had already been

TABLE 2.

DSM-IV Axis I Diagnoses of 358 Adolescents

During Their First Psychiatric Hospitalization

Diagnostic Variablea
Number of diagnoses
None
One
More than one
Specific diagnosis
Major depressive disorder
Dysthymic disorder
Anxiety disorders, combined
Posttraumatic stress disorder
Panic disorder
Obsessive-compulsive disorder or phobia
Anxiety-depressive state
Alcohol dependence
Alcohol abuse
Other chronic substance abuse
Factitious disorders
Somatization disorder
Conduct disorder, oppositional defiant
disorder, or disruptive behavior
disorder not otherwise specified
Schizophrenia or other psychotic disorder
Eating disorders
Adjustment disorders
Mental retardation
Learning disorders

30
207
121

8.4
57.8
33.8

154
6
51
7
12
6
25
31
12
63
1
24

43.0
1.7
14.2
2.0
3.4
1.7
7.0
8.7
3.4
17.6
0.3
6.7

50
17
27
11
2
8

14.0
4.7
7.5
3.1
0.6
2.2

There were a total of 464 diagnoses.

Psychosomatics 45:6, November-December 2004

established as criteria for selection in the research design

and the educational level is directly dependent on age.
RESULTS
Ten healthy subjects exceeded the threshold score of 0.699
on the Zung scale (suspicion of depressive state), and 39
were excluded from the protocol because of missing data.
Demographic Characteristics
The total study group comprised 1,123 subjects, ages
13 to 25 years, with a mean age of 18.8 (SD3). The
unhealthy group included 358 subjects, ages 14 to 25, normally distributed, with a mean age of 20.5 (SD3). The
healthy group included 765 subjects, ages 13 to 25, normally distributed, with a mean age of 18.3 (SD3). The
difference in age between the healthy and unhealthy groups
was statistically significant (t13.18, df1121,
p0.001).
In the healthy group, the sex ratio was 0.75 (329 men
for 436 women) as compared to a sex ratio of 0.56 (129
men for 229 women) in the unhealthy group. This betweengroup difference was statistically significant (Pearsons
v269.11, df1, p0.001).
Not only were the differences between the two groups
in age and sex distribution meaningful, but previous research (see introduction) also suggests that both gender and
age influence the results on the MHLC and Olsons scale.
Consequently, it seems clear that these variables have to
be controlled.
Groups Differences on MHLC and FACES III
As Table 3 shows, Students t tests indicate significant
differences both on the MHLC and Olsons scale between
the healthy and unhealthy groups. These results replicate
both the patterns typically found in the literature for the
MHLC and Olsons scale (see introduction), i.e., more cohesive and adaptive families among healthy subjects,
greater internality in regard to health locus of control, and
less attribution of control over health to higher powers.23
Consequently, they can be considered as a control of the
validity of this study.
Hypothesis Testing
Table 4 confirms our hypothesis about a link between
beliefs about control over health and family dynamics. For
the entire study group, there were positive relationships
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Family, Health, and Adolescence

between cohesion in the family of origin and the results for
internality and belief in powerful others control over
health. A positive relationship was also found between
family adaptability and the results for internality and the
internality/externality ratio. Finally, a negative relationship
TABLE 3.

was observed between family adaptability and belief that

chance controls health.
If we examine the influence of the dichotomous variable of belonging to either the healthy or unhealthy group,
we can add three observations. First, this dichotomous vari-

Scores on the Multidimensional Health Locus of Control Questionnaire (MHLC) and Olsons Scale of Family Cohesion and
Adaptability for 765 Healthy Adolescents and 358 Adolescents Hospitalized for Psychiatric Disorders
Score

Measure and Group

Analysis

Mean

SD

33.8
28.0

7.1
8.7

26.5
25.2

5.7
6.3

24.1
22.6

4.7
6.1

19.2
22.3

5.8
6.3

17.9
19.9

5.5
5.8

df

11.60

1121

0.001

3.43

1121

0.001

4.50

1121

0.001

7.96

1121

0.001

5.76

1121

0.001

8.63

1121

0.001

Olsons scale
Family cohesion
Healthy group
Unhealthy group
Family adaptability
Healthy group
Unhealthy group
MHLC1
Belief in internality as locus of control over health
Healthy group
Unhealthy group
Belief in external factors as locus of control over health
Powerful others
Healthy group
Unhealthy group
Chance
Healthy group
Unhealthy group
Internality/externality ratio
Healthy group
Unhealthy group

TABLE 4.

1.40
1.12

0.5
0.4

Correlations, Controlled for Gender and Age, Between Scores on the Multidimensional Health Locus of Control Questionnaire
(MHLC) and Olsons Scale of Family Cohesion and Adaptability for Healthy Adolescents and Adolescents Hospitalized for
Psychiatric Disorders
Axis of Olsons Scale7
Family Cohesion

Group and MHLC1 Measure

Total group (N1,123)
Belief in internality as locus of control over health
Belief in external factors as locus of control over health
Powerful others
Chance
Internality/externality ratio
Healthy group (N765)
Belief in internality as locus of control over health
Belief in external factors as locus of control over health
Powerful others
Chance
Internality/externality ratio
Unhealthy group (N358)
Belief in internality as locus of control over health
Belief in external factors as locus of control over health
Powerful others
Chance
Internality/externality ratio

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Family Adaptability
p

0.11

0.001

0.10

0.06
0.03
0.05

0.051
0.34
0.14

0.00
0.08
0.08

0.95
0.02
0.02

0.07

0.10

0.01
0.10
0.07

0.77
0.01
0.10

0.06
0.19
0.09
0.04

0.15
0.001
0.82
0.38

0.002

0.08

0.14

0.11

0.04

0.12
0.05
0.04

0.03
0.35
0.50

0.06
0.00
0.03

0.25
0.94
0.58

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Zdanowicz et al.
able does not seem to influence the relationship between
family cohesion and internality (v20.63, df1,
p0.43), but in contrast, the relationship between cohesion and belief in powerful others as a health locus of control appears stronger (r2) and more genuine (p) among the
healthy subjects (v23.66, df1, p0.05). This finding
is troubling since we know that in the healthy group cohesion is high and the belief in powerful others as a locus
of control is less (see Table 3). However, we also know
that among the healthy adolescents, age has a negative influence on the belief in powerful others control (Figure 1)
and that age is also correlated with decreasing family cohesion (see Figure 2). Hence, the findings seem to suggest
that the combined effects of the interaction of age with
belief in powerful others and the interaction of age with
family cohesion are stronger than the effect of the interaction between family cohesion and belief in powerful others (in which the influences of age and gender do not appear because they are statistically controlled). It thus
appears that the first two combined effects tend to limit or
even weaken the latter.
Second, the dichotomous variable, healthy versus unhealthy, does not seem to influence the association either
between family adaptability and the internality/externality
ratio (v20.92, df1, p0.34) or between family adaptability and internality (v22.30, df1, p0.13).
FIGURE 1.

Relationship Between Age and Belief in Powerful

Others Control Over Healtha for 762 Healthy
Adolescentsb

Third, with regard to the link between family adaptability and belief in chance as a locus of control over
health, it is interesting that whereas the adaptability of the
healthy adolescents families was correlated with less belief in chance, this influence was not present among the
unhealthy adolescents (v23.78, df1, p0.05).
DISCUSSION
In the studies that have explored the relationships between
family variables and pathology among adolescents (Table
1), the most interesting finding we uncovered is their
missing link aspect. Indeed, while reviewing this literature, one can only wonder about the origin of the mechanisms that link family functioning to pathology. In the present research, it appears that the style of family dynamics
is significant in the formation of adolescents attributive
judgments as to who or what is responsible for their health.
It thus appears that a cohesive family supports its adolescent members beliefs in their own ability to influence
their health, as does a minimal degree of trust in the other
(which is necessary in a patient-doctor relationship). It also
appears that flexible families ensure an internal/external
attributive judgmental process that fosters their adolescent
members belief in their sense of worth and diminishes
healthy adolescents attribution of health control to chance
or fate.
It is true that one can also interpret the results preFIGURE 2.

Relationship Between Age and Family Cohesiona for

734 Healthy Adolescentsb

45

30
Score for Family Cohesion

Score for Belief in Powerful Others

as Locus of Control Over Health

35

25
20
15
10
5
0

18 19 20 21 22 23 24 25
Age (years)
a
This measure is a subscale of the Multidimensional Health Locus of
Control questionnaire.1
b
Pearsons partial correlation between healthy subjects age and
belief in powerful others as a locus of control over health, controlled
for gender: r0.17, p0.001. Data were derived from previous
research.26
13

14

15

16

17

Psychosomatics 45:6, November-December 2004

40
35
30
25
20

18 19 20 21 22 23 24 25
Age (years)
a
This measure is one of the axes in Olsons scale for family cohesion
and adaptability.7
b
Pearsons partial correlation between healthy subjects age and
family cohesion, controlled for gender: r0.10, p0.008. Data were
derived from previous research.26
13

14

15

16

17

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Family, Health, and Adolescence

sented here differently and approach the pathology-family
link in the reverse order: i.e., How does illness influence
our beliefs, and how do these beliefs shape our family system? If we cannot disregard the fact that our interactions
partially follow this logic as well, its probability is nevertheless quite weak for at least two reasons. First, it makes
more intuitive sense to assume that the direction of these
interrelations originates in the family, as it is itself formative of beliefs about locus of control, than to assume a
reverse order. Second, although we know of no prospective
research on the MHLC (except the 5-year longitudinal
work by Thomas and Hooper,24 which studied the probability of social integration among 65-year-olds as a function of their MHLC scores rather than investigating pathology proper), there is indirect evidence that supports this
point of view.3 Thus, as is the case in adult diabetes, for
which internality can be correlated with patients better
control over pathology,25 we can posit that beliefs about
locus of control influence health rather than the other way
around.
Limitations
The main restriction on the present study is the weak
proportion of explained variance, but we would have been
astonished (and a bit worried) if attitudes toward health
depended solely on family variables. The second restriction
regarding the validity of our results is the duration of recruitment of the unhealthy subjects. Indeed, the fact of having controlled the results for the date of hospitalization
does not allow us to totally exclude sociocultural condi-

tions (e.g., divorce, illness of parents), pharmacologic

treatment, or other factors (e.g., childhood medical conditions) that might have influenced our results.
Conclusions
From a practical point of view, we wonder whether the
enhancement of health among young people would warrant
the deployment of preventive measures whereby parents
would be encouraged to adopt more flexible and cohesive
health-related attitudes with their adolescent children rather
than rigid and poorly structured ones. Such a message
could be conveyed both during medical consultations and
through media campaigns. From a therapeutic point of
view, the results of this study suggest that parents must be
supported in the same sense during their adolescent childrens pathological afflictions. From a theoretical point of
view, it seems that we can speak of a developmental aspect
of health in the same way that we speak of a developmental
aspect of pathology. Health, especially ones effort to control ones health, is an ever-evolving attribute from childhood to adulthood to which we must attend. Furthermore,
such a developmental approach to heath is not reduced to
a child or an adolescents individual condition but is developing in the midst of a family system. This theoretical
aspect evokes the psychodynamic clinicians emphasis on
adolescence as a salutary crisis that contributes to health.
This theoretical developmental perspective nevertheless introduces a fundamental difference: it approaches pathology
as an insufficient development of health, rather than as a
manifestation that contributes to more health. Of course,
we need outcome studies to confirm all this.

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