The Journal of School Nursing2024, Vol. 40(5) 547–557© The Author(s) 2022Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/10598405221121655journals.sagepub.com/home/jsn
Abstract
This study examined the relationships between current anxiety problems and school engagement, community service or volunteer work, and paid work among U.S. adolescents. The 2018–2019 National Survey of Children’s Health (NSCH) dataset was analyzed and included 24,609 adolescents ages 12–17 years. We conducted unadjusted and adjusted logistic regression analyzes. A total of 12.6% of adolescents had healthcare provider-confirmed current anxiety problems. Adolescents with current anxiety were at decreased odds of engaging in school (aOR = 0.35, 95%CI = 0.29, 0.41) and participating in community service or volunteer work (aOR = 0.72, 95%CI = 0.59, 0.86) compared to adolescents without current anxiety. Adolescents with current anxiety were at increased odds of participating in paid work (OR = 1.18, 95%CI = 1.01, 1.38). This study reports that U.S. adolescents with anxiety were less likely to engage in school and participate in community service or volunteer work, but were more likely to participate in paid work compared to their peers without anxiety. Results should inform future interventions targeting adolescents.
Keywordsmental health, anxiety, school engagement, employment, health education, middle/junior/high school, adolescents
Mental health disorders are a major public health problem among U.S. adolescents. Anxiety is the most common type of disorder among adolescents with 15% and 25% having current (30-day) and past year (12-month) anxiety, respectively (Kessler et al., 2012). There are different types of anxiety disorders (e.g., generalized anxiety disorder), which are broadly characterized as having excessive fear and emotionally responding to real or perceived threats and related behavioral disturbances (American Psychiatric Association, 2013). The median age of anxiety onset is about age 11 (Kessler et al., 2005), and the incidence of anxiety disorders rises from adolescence and beyond, until it peaks in middle adulthood (Bandelow & Michaelis, 2015). Therefore, it is important to assess adolescent anxiety problems and associated consequences that may continue into adulthood such as lower psychosocial functioning (Essau et al., 2014), educational attainment (Mojtabai et al., 2015), and higher healthcare costs (Pella et al., 2020).
Adolescence is a key period of development due to the ongoing growth and maturing of the brain, which brings changes to psychosocial and cognitive functioning that may impact adolescents’ susceptibility to psychopathology including anxiety disorders (National Academies of Sciences, Engineering, and Medicine et al., 2019). Specific to cognitive functioning, there has been a consistent relationship found in the literature between anxiety and cognitive performance (Eysenck et al., 2007; Moran, 2016). Additionally, adolescents with current anxiety problems may have decreased overall school functioning including learning and academic performance compared to those without anxiety problems (Mychailyszyn et al., 2010). Research indicates that adolescents with anxiety may have difficulty concentrating on work, in addition to difficulties working on and completing assignments (Nail et al., 2015). Additionally, adolescent anxiety has been associated with increased truancy and school absences that are either unexcused or related to anxiety or emotional distress (Finning et al., 2019).
There is a gap in the literature on the association between current anxiety problems and school engagement, a broad term encompassing cognition, emotion, and behavior such as caring about doing well in school and doing schoolwork (Fredricks et al., 2004; Salmela-Aro et al., 2021; Wang & Eccles, 2013). Adolescent school engagement is important to consider since increased engagement can play a significant protective role and promote school achievement such as higher test scores (Mikami et al., 2017; Wang & Holcombe, 2010), and decrease risky health behaviors such as increased substance use and delinquent behaviors (Fall & Roberts, 2012; Li et al., 2011; Wang & Fredricks, 2014). Therefore, it is important to understand how current anxiety problems may predict school engagement among adolescents nationwide.
One prosocial behavior for promoting increased cognitive, social, and academic health outcomes among adolescents is volunteering or community service work (Hernantes et al., 2019). Specifically, studies show that volunteering during adolescence can have psychosocial and behavioral benefits over time including increased academic performance and prosocial behaviors such as future volunteering (Moorfoot et al., 2015; Zaff et al., 2003). Additionally, adolescent employment can have positive effects on youth development (Mortimer, 2010). Parents have cited that involvement in paid work can build their adolescents’ intrinsic work ethic, time management, financial responsibility, and prosocial skills (Usher et al., 2014). However, parents have also reported concerns about their adolescents falling behind on school work (Shankar et al., 2021). Despite the potential benefits of volunteering and paid work participation, to our knowledge, there are no studies that have assessed their associations with current anxiety problems among adolescents. However, prior research indicates that transition-aged youth with psychiatric disabilities experience employment-related barriers such as lack of control of related symptoms and lack of employment experience (Noel et al., 2017). Additionally, poor mental health has been identified as a risk factor of unemployment during adulthood (Olesen et al., 2013). Encouragingly, having early supports such as employment programming in conjunction with usual mental health treatment has been shown to overcome these barriers and engage youth to improve employment outcomes over time (Gmitroski et al., 2018). Therefore, research is also needed to fill the gaps in the literature between current anxiety problems, volunteering or community service participation, and paid work participation among U.S. adolescents.
We examined the relationships between current anxiety problems and school engagement and prosocial behavior participation, including community service or volunteer work and paid work, among a sample of U.S. adolescents. We hypothesized that U.S. adolescents with current anxiety problems would be less likely to engage in school compared to adolescents without current anxiety problems. Additionally, we hypothesized that U.S. adolescents with current anxiety problems would be less likely to participate in either community service or volunteer work and paid work compared to adolescents without current anxiety problems.
The 2018–2019 National Survey of Children’s Health (NSCH) combined data set was analyzed in this study (Child and Adolescent Health Measurement Initiative, 2021). The NSCH is conducted on an annual basis by the U.S. Census Bureau with the direction of the U.S. Maternal and Child Health Bureau to assess key emotional and physical health and wellbeing indicators of the U.S. child population ages 0–17 years. The NSCH questionnaire topics (Child and Adolescent Health Measurement Initiative, 2019, 2020) and methodology reports can be referenced for greater detail (U.S. Census Bureau, 2019, 2020). In brief, the 2018 NSCH was conducted from June 2018–January 2019 with a 43.1% overall response rate (N = 30,530), and the 2019 NSCH was conducted from June 2019–January 2020 with a 42.4% overall response rate (N = 29,433). U.S. households were invited by mail to complete a screener questionnaire to identify any children ages 0–17 years in the household. Parents completed the screener questionnaire by either the internet or mail, depending on their preference. When more than one child was a household member, one child was selected as the sampled child at random, but with oversampling of those ages 0–5 years and/or with special healthcare needs. When the sampled child was selected, parents filled out one of three topical questionnaires for three age groups: 0–5 years, 6–11 years, and 12–17 years. For the purpose of this study, we delimited our analysis to the oldest age group (N = 24,817), and excluded adolescents missing data on current anxiety problems (n = 208). Therefore, this study assessed a total of 24,609 adolescents ages 12–17 years. The current study was approved by the University of Cincinnati’s institutional review board, and was determined as not human subjects research and exempted from review.
Current anxiety problems. Current anxiety problems, the independent variable of interest in this study, was assessed using a yes/no question: “Has a doctor or other health care provider EVER told you that this child has … anxiety problems?” (Child and Adolescent Health Measurement Initiative, 2019, 2020). If the parent responded “yes” to this question, then another yes/no question was asked: “Does this child CURRENTLY have the condition?” If parents answered “yes” to this additional question, then the adolescent was considered as having current anxiety problems.
School engagement. School engagement, a dependent variable in this study, was also included in the “This Child’s Health” section and asked parents two questions starting with “How often …” (1) “Does this child care about doing well in school?” and (2) “Does this child do all required homework?” The response options for the two questions were “always,” “usually,” “sometimes,” and “never” (Child and Adolescent Health Measurement Initiative, 2019, 2020). The NSCH combined the two questions and defined adolescents as being engaged in school if they “always” cared about doing well in school and “always” did their required homework (Child and Adolescent Health Measurement Initiative, 2021). The NSCH-provided, dichotomized school engagement indicator variable was used in the current study due to the original variables having right-skewed distributions.
Community service or volunteer work participation. Community service or volunteer work participation in the past 12-months, another dependent variable in this study, was included in the “This Child’s Schooling and Activities” section and asked parents one yes/no question starting with, “DURING THE PAST 12 MONTHS, did this child participate in … Any type of community service or volunteer work at school, church, or in the community?” (Child and Adolescent Health Measurement Initiative, 2019, 2020). Adolescents were defined as participating in community service or volunteer work if they had a “yes” response.
Paid work participation. Paid work participation in the past 12-months, the final dependent variable in this study, was also included in the “This Child’s Schooling and Activities” section and asked parents one yes/no question starting with, “DURING THE PAST 12 MONTHS, did this child participate in … Any paid work, including regular jobs as well as babysitting, cutting grass, or other occasional work?” (Child and Adolescent Health Measurement Initiative, 2019, 2020). Adolescents were defined as participating in paid work if they had a “yes” response.
Adolescent characteristics. Adolescent characteristics that were assessed as covariates were: adolescent age, adolescent sex, adolescent race/ethnicity (non-Hispanic White, non-Hispanic Black, non-Hispanic Other/Multiracial, and Hispanic), parent education level (high school graduate/equivalent or lower, some college, and college degree or higher), family household structure (two currently married parents, two not currently married parents, single parent, and other) and federal poverty level (0–199%, 200–299%, 300–399%, and ≥400%) defined as the household poverty level ratio following U.S. Census Guidelines. The 2018–2019 NSCH provided federal poverty level for analysis of the public data in order to protect the confidentiality of households (Child and Adolescent Health Measurement Initiative, 2021).
Analytic guidelines of the 2018–2019 NSCH were followed and sampling weights were used to adjust for survey nonresponse and to generalize findings to adolescents nationwide (U.S. Census Bureau, 2019, 2020). Using SPSS Complex Samples version 28.0, we computed descriptive statistics and present unweighted counts and weighted percents. As a first step, we assessed the relationships between adolescent characteristics and current anxiety problems using an independent samples t-test for adolescent age and chi-square tests for the remaining characteristics that were categorical in nature (e.g., adolescent sex). Then, we conducted unadjusted and adjusted logistic regression analyzes to assess the associations between current anxiety problems and school engagement, community service or volunteer work participation, and paid work participation. For the unadjusted models, we present unadjusted odds ratios (ORs) and 95% confidence intervals (CIs). For the adjusted models that include all adolescent characteristics, we present adjusted odds ratios (aORs) and 95%CIs. Specific to paid work participation, we conducted a sensitivity analysis and assessed the association between current anxiety problems and paid work participation, while controlling for adolescent age only. Statistical significance was set at p < .05.
The average age of U.S. adolescents was 14.49 (0.03) years, 51.2% were male, and 49.9% were non-Hispanic white (Table 1). A total of 47.0% of adolescents lived with parents who had at least a college degree, 60.9% lived with two currently married parents, and 31.5% had a federal poverty level of ≥400%.
Concerning healthcare provider-confirmed anxiety, 12.6% (n = 3,731) of adolescents had current anxiety problems. Concerning differences between adolescent characteristics and current anxiety problems, an independent samples t-test revealed that adolescent age differed based on current anxiety problems with those who were older (M = 14.72, SE = 0.07) having the highest reports of current anxiety problems (p < .001; see Table 1). A chi-square test revealed that adolescent sex differed based on current anxiety problems with female adolescents (14.9%) having the highest percent of current anxiety problems compared to male adolescents (10.5%, p < .001). Additionally, non-Hispanic White (15.7%) and Hispanic (7.8%) adolescents had the highest percents of current anxiety problems compared to non-Hispanic Black (10.5%) and non-Hispanic Other/Multiracial (9.4%) adolescents (p < .001). Parent education level also differed based on current anxiety problems with adolescents who had parents who obtained an education of some college (13.9%) and a college degree or higher (13.6%) having the highest percents of anxiety compared to adolescents whose parents obtained an education of high school graduate/equivalent or lower (10.3%, p = 0.003). Family household structure differed based on current anxiety problems with adolescents who were living in another family type (16.1%) and with a single parent (14.2%) having the highest percents of current anxiety problems compared to adolescents who lived with two parents who were currently married (11.7%) and not currently married (11.1%, p = 0.017). No relationship was found between poverty level and current anxiety problems (see Table 1).
A total of 46.8% (n = 11,066) of adolescents were engaged in school (i.e., always cared about doing well in school and always did their required homework). Unadjusted logistic regression model results indicated that adolescents with current anxiety problems were at decreased odds of being engaged in school (OR = 0.40, 95%CI = 0.33, 0.47) compared to adolescents without current anxiety problems (Table 2).
Adjusted logistic regression model results indicated that adolescents with current anxiety problems were at decreased odds of being engaged in school (aOR = 0.35, 95%CI = 0.29, 0.41) compared to adolescents without current anxiety problems, while controlling for the covariates of adolescent age, adolescent sex, adolescent race/ethnicity, parent education level, family household structure, and family federal poverty level. With the exception of adolescent age, all covariates were significant in the adjusted logistic regression model (see Table 2).
A total of 52.8% (n = 14,234) of adolescents participated in community service or volunteer work at their school, church, or community in the past 12-months. Unadjusted logistic regression model results indicated that adolescents with current anxiety problems were at decreased odds of participating in community service or volunteer work (OR = 0.83, 95%CI = 0.71, 0.98) compared to adolescents without current anxiety problems (Table 3).
Adjusted logistic regression model results indicated that adolescents with current anxiety problems were at decreased odds of participating in community service or volunteer work (aOR = 0.72, 95%CI = 0.59, 0.86) compared to adolescents without current anxiety problems, while controlling for the adolescent covariates. All covariates were significant in the adjusted logistic regression model (see Table 3).
A total of 37.5% (n = 11,547) of adolescents participated in paid work, such as regular jobs, babysitting, cutting grass, or other occasional work, in the past 12-months. Unadjusted logistic regression model results indicated that adolescents with current anxiety problems were at increased odds of participating in paid work (OR = 1.18, 95%CI = 1.01, 1.38) compared to adolescents without current anxiety problems (Table 4).
Adjusted logistic regression model results indicated that there was no significant relationship between current anxiety problems and paid work participation. Most adolescent covariates were significant in the adjusted logistic regression model, with the exception of adolescent sex and family household structure (see Table 4).
As a sensitivity analysis, we removed most covariates with the exception of adolescent age to further assess the associations between current anxiety problems and paid work participation, above and beyond adolescent age. Similar to the main model findings, current anxiety problems (aOR = 1.08, 95%CI = 0.90, 1.28, p = 0.425) remained nonsignificant, but adolescent age remained significant in this model with older adolescents being at increased odds of participating in paid work (aOR = 1.48, 95%CI = 1.42, 1.54, p <.001).
Aligning with our hypothesis, adolescents with current anxiety problems were less likely to be engaged in school compared to adolescents without current anxiety problems, even after controlling for adolescent characteristics. This finding is consistent with a recent systematic review that revealed that adolescents with anxiety disorders experience significant problems with social and academic functioning including impairment at school (de Lijster et al., 2018). The current study also found sex differences based on school engagement, with female adolescents at over two-fold odds of engaging in school compared to their male peers, which has been reported in previous research (Lam et al., 2016). We also found that Hispanic adolescents and non-Hispanic Other/Multiracial students had increased likelihood of school engagement, but no differences were found between non-Hispanic Black and non-Hispanic White adolescents.
It was further observed that adolescents living in household structures of two not currently married parents or a single parent and adolescents who had parents with lower educational attainment were less likely to be engaged in school compared to adolescents living with two currently married parents and parents with at least a college degree, respectively. Additionally, adolescents with a 300–399% family federal poverty level were less likely to have reports of school engagement. Thus, these collective results are similar to prior studies that report inverse associations between socioeconomic status and school engagement (Li & Lerner, 2011) and expectations and success (Burger & Mortimer, 2021). Despite these noted school engagement-related differences, a systematic review and meta-analysis of school-based anxiety prevention programming found that interventions significantly decreased symptoms of anxiety (Feiss et al., 2019).
This study’s findings showed that adolescents with current anxiety problems were less likely to participate in community service or volunteer work at their school, church, or community in the past 12-months compared to adolescents without current anxiety problems, accepting our hypothesis. Our findings aligned with previous studies that reported volunteering or community service participation is positively associated with mental health benefits among adolescents (Kim & Morgül, 2017; Wray-Lake et al., 2019). This study expands on these studies that focused on general mental health and depression by focusing on current anxiety problems among adolescents. Additional research indicates that adolescents who make the personal choice to volunteer typically have more positive psychological states (e.g., self-esteem, self-concept) (Cemalcilar, 2009), and that volunteering during adolescence significantly predicts favorable mental health (e.g., lower depressive symptoms), health behavior (e.g., reduced risky health behaviors), and socioeconomic status (e.g., household income) outcomes in adulthood (Ballard et al., 2019). Therefore, it is important to consider promoting civic engagement such as volunteering or community service participation among adolescents.
Interestingly, unadjusted results indicated that adolescents with current anxiety problems were more likely to participate in paid work including regular jobs, babysitting, cutting grass, or other occasional work in the past 12-months, but there was no association found in the adjusted results. Nevertheless, adolescent age, adolescent race/ethnicity, parent education level, and family federal poverty level were significant covariates in the adjusted model. Specifically, older adolescents were more likely to have reports of paid work participation, but adolescents who were racially/ethnically diverse, had parents who obtained a lower education of high school graduate/equivalent or lower, and were in the lowest (0–199%) family federal poverty level were less likely to have reports of paid work participation. This is consistent with prior research that found similar prevalence of adolescent employment of about 31%, and concluded that as adolescents advance in age, this typically leads to higher employment (Parker et al., 2019). Interestingly, however, the sensitivity analysis results also showed no significant association between current anxiety problems and paid work participation, while adjusting for adolescent age only. Similar racial/ethnic and socioeconomic differences were also stated in the literature with White adolescents and those with lower parent education having higher participation in paid work during the school year (Bachman et al., 2013). More research is needed to assess the influence of current anxiety problems and participation in paid work among adolescents.
The study limitations should be noted. Specifically, the NSCH data are cross-sectional and parents answer all questions about the sampled adolescents. Therefore, the current study could not assess longitudinal relationships and parents may have under-reported or over-reported their responses to questions due to recall bias or social desirability bias. Additionally, the NSCH assessed healthcare provider-confirmed current anxiety problems and did not assess potential anxiety problems among adolescents who did not visit a healthcare provider. Therefore, future research should consider assessing current anxiety symptomatology among adolescents to capture those who may not routinely visit a primary care provider or did not disclose their anxiety problems to their parents or providers. Studies should also consider asking adolescents the same questions and use data from other sources such as medical records to confirm current anxiety problems and school records to assess school engagement.
The current study reports that U.S. adolescents with current anxiety problems were at reduced odds of engaging in school and participating in community service or volunteer work compared to their peers without current anxiety problems, including when controlling for adolescent characteristics. Results should inform future interventions targeting adolescents. School nurses can play a vital role in addressing mental health problems among adolescents. A recent integrative review indicated that school nurses perceive themselves as trusted school community members and recognize the importance of mental health care competence and standards of practice (Kaskoun & McCabe, 2022). Therefore, in the school setting, school nurses can help to train other school personnel on identifying potential anxiety symptoms as well as providing education on how to meet the individual needs of their students who have current anxiety problems. In turn, this may lead to early detection of current anxiety problems, in addition to increasing in-school supports for adolescents with these problems, which may increase their school engagement and overall feelings towards school.
A randomized controlled trial study evaluated the feasibility and preliminary impact of the Child Anxiety Learning Modules (CALM) intervention to reduce youth anxiety (Ginsburg et al., 2021). This pilot study’s results indicated that the brief, school nurse-delivered intervention was feasible and nurses had high satisfaction and adherence to intervention delivery. Encouragingly, children’s anxiety symptomatology and severity decreased, whereas their functioning increased (Ginsburg et al., 2021). These findings further highlight that school nurses can be important resources for positively impacting adolescents with current anxiety problems. Therefore, another potential suggestion for school nurses based on the current study’s findings is to consider asking about adolescents’ engagement in school and community service or volunteer work. School nurses are uniquely positioned to identify both health- and school-related concerns among adolescents, and can serve as a liaison between stakeholders (e.g., educators, school counselors, families, and communities) to improve adolescents’ current anxiety symptoms as well as promote their engagement in school and prosocial behaviors.
It is also important to note that a recent integrative review revealed that best practices and systems to address mental health concerns among students need to be established to increase preparedness and support for nurses in the school setting (Hoskote et al., 2023). Therefore, school nurses should be involved in, and advocate for, school-based policies that would increase their support and preparedness to help students with current anxiety problems. In summary, school nurses can have an important role in working with adolescents, families, schools, and communities to reduce current anxiety problems and associated symptomatology while increasing adolescents’ engagement in school and prosocial behaviors to promote positive, healthy development, especially among adolescents with current anxiety problems.
None.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) received no financial support for the research, authorship, and/or publication of this article
Ashley L. Merianos https://orcid.org/0000-0002-5640-7227
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Kayleigh A. Gregory, PhD, MSW, LISW, is a graduate assistant at the School of Human Services, University of Cincinnati, Cincinnati, OH, USA.
Rebecca A. Vidourek, PhD, CHES, is a professor at the School of Human Services, University of Cincinnati, Cincinnati, OH, USA.
Keith A. King, PhD, CHES, is a professor at the School of Human Services, University of Cincinnati, Cincinnati, OH, USA.
Ashley L. Merianos, PhD, CHES, is an associate professor at the School of Human Services, University of Cincinnati, Cincinnati, OH, USA.
1 School of Human Services, University of Cincinnati, Cincinnati, OH, USA
Corresponding Author:Ashley L. Merianos, PhD, School of Human Services, University of Cincinnati, Cincinnati, OH 45221, USA.Email: ashley.merianos@uc.edu
