Risk behaviour in Swedish adolescents: is shared physical custody after divorce a risk or a protective factor?

Mid Sweden University

This is a published version of a paper published in European Journal of Public Health.

Citation for the published paper:

Carlsund, Å., Eriksson, U., Löfstedt, P., Sellström, E. (2013)

"Risk behaviour in Swedish adolescents: is shared physical custody after divorce a risk or a protective factor?"

European Journal of Public Health, 23(1): 3-8 URL: http://dx.doi.org/10.1093/eurpub/cks011

Access to the published version may require subscription.

Permanent link to this version:

http://urn.kb.se/resolve?urn=urn:nbn:se:miun:diva-17604

http://miun.diva-portal.org

doi:10.1093/eurpub/cks011 Advance Access published on 1 March 2012

...

Risk behaviour in Swedish adolescents: is shared physical custody after divorce a risk or a protective factor?

A˚sa Carlsund ¹ , Ulrika Eriksson ¹ , Petra Lo¨fstedt ² , Eva Sellstro¨m ¹

1 Department of Health Sciences, Mid Sweden University, O ¨ stersund, Sweden

2 Department of Children and Older People’s Health, Swedish National Institute of Public Health, O ¨ stersund, Sweden

Correspondence: A ˚ sa Carlsund, Department of Health Sciences, Mid Sweden University, SE-831 25 O¨stersund, Sweden, tel: +46(0)63165665, fax: +46(0)63165626, e-mail: asa.carlsund@miun.se

Background: The increase in shared physical custody in Sweden has been dramatic; 20 years ago only a small percentage of adolescents lived in shared physical custody, but currently 30% of the adolescents whose parents have separated or divorced divide their residence between parents. We hypothesized that living in shared physical custody or in a single-parent family is associated with a higher prevalence of adolescent risk behaviour than living in a two-parent family. Methods: Data on 15-year-old adolescents from the 2005/2006 to 2009/2010 Swedish Health Behaviour in School-aged Children (HBSC) survey were analysed using logistic regression. Results:

Adolescents living in shared physical custody had slightly higher rates of risk behaviour compared with adolescents from two-parent families, but significantly lower rates than their counterparts from single-parent families. Their odds of being a smoker or having been drunk were 60 and 50% higher, respectively, than those of their coun- terparts in two-parent families. Conclusion: Shared physical custody after marriage break-up seems to constitute a health protective factor for adolescents’ health and problem behaviour. In order to deepen our understanding of the positive and negative aspects of shared physical custody, our study should be followed by qualitative analyses and longitudinal studies of adolescents’ experiences.

...

Introduction

I n Sweden, an increasing number of couples with children split up every year.

This has several consequences for children and adolescents.

Divorce usually engages a transfer in household membership and a reorganization of family member’s roles, which in turn interrupt family routines and may result in an inconsistent family situation.

Accordingly, several studies have pointed to decreased well-being in adolescents following parental divorce,

and family disruption has been shown to be related to behaviour problems or disorders in adolescence.

Historically, following a divorce, the child usually lived with one parent, typically the mother,

and the increased risk of behavioural problems in ado- lescents living with a single parent has been supported by numerous studies.

These findings have, to a certain extent, been attributed to the lost contact with the absent parent (usually the father).

According to the recent statistics, 60% of the Swedish adoles- cents aged 13–15 years live in two-parent families. Among families who have split up, 30% of all adolescents share their residence between parents.

The increase in shared physical custody has been dramatic in Sweden; 20 years ago, only a small percentage of adolescents lived in shared physical custody.

Such residence ar- rangements have been considered beneficial because they allow ado- lescents regular access to both parents, who continue to share the responsibilities of raising the children.

The positive impact of fathers’ involvement and accessibility in the lives of adolescents has been established;

however, shared physical custody seems to be less beneficial when children experience their parents’ relationship as highly conflicted.

Thus, the benefits to child and adolescent well-being of shared physical custody remain in dispute.

Risk behaviour in adolescents might be influenced by factors related to family break-up and residency arrangements. We found only one recent study on family break-up and its association to risk behaviours in adolescents; it showed that adolescents living with their parents in shared physical custody were at a 26% higher risk

of excessive alcohol consumption, smoking or drug use compared with adolescents from two-parent families.

There are several factors that could confound the association between adolescent risk behaviour, family break-up and subsequent family structures. Parental support is crucial to adolescent well-being,

and lack of such support can contribute to behaviour problems.

It is not far-fetched to believe that such support can be deficient after a divorce.

The association between adolescent risk behaviour and family socio-economic position is supported by numerous studies,

and divorce can reduce the family’s resources, such as money and time.

Further, adolescents in immigrant families, especially non-European girls, are less likely to use alcohol and binge drink, and have also been shown to have a later sexual debut than their Swedish peers.

In order to control for such confounding factors, variables measuring socio-economic position and parental support have been included in this study. We hypothesized that living either in shared physical custody or in a single-parent family would be associated with a higher risk of negative behavioural outcomes, such as having been drunk, having smoked habitually, or having had an early sexual debut or conduct problems, than living in a two-parent home.

Methods

Material

The WHO international survey, Health Behaviour in School-aged Children (HBSC) has a cross-sectional design.

The present study is based on data from the 2005/2006 to 2009/

2010 cohorts in Sweden, in which a total of 11 294 students from Grades 5, 7 and 9 (11–15 years) participated. The current study draws upon 3699 Grade 9 (15-year-old) adolescents, 1531 from the 2005/2006 and 2170 from the 2009/2010 cohort. The combined response rate was 75%.

The sampling was carried out with a two-step cluster design. First, a randomized sample of schools was made separately for each grade.

In the second step, one class per grade was selected for participation,

at Mittuniversitetet on March 1, 2013 http://eurpub.oxfordjournals.org/ Downloaded from

and all children in each sampled class were invited to participate.

The self-completed questionnaires were administered in the classroom, and the children were informed that participation was voluntary and that responses would be treated anonymously.

Measurements

Outcomes

Three variables pertaining to adolescents’ risk behaviour and one variable measuring behaviour problems were examined in this study.

Whether the 15-year-olds were smokers (cigarettes, cigars or pipe) was based on the question: ‘How often do you smoke nowadays, more than a puff?’ The adolescents were classified as smokers if they responded ‘every day’, ‘at least once a week’ or ‘less than once a week’ (=1) and as non-smokers if they did not smoke at all (=0).

Having been drunk was based on the question: ‘Have you ever had so much alcohol that you became really drunk?’ Responses were coded as yes = 1 and never = 0.

Sexual debut was based on the question: ‘Have you ever had sex/

gone all the way,’ with response options as yes (=1) and no (= 0).

Behavioural problems, i.e. conduct problems, were measured with a modified version of the commonly used and validated instrument, the Strengths and Difficulties Questionnaire.

One subscale on that questionnaire enquires about conduct problems with five items: ‘I get very angry and often lose my temper’, ‘I usually do as I am told’,

‘I fight a lot’, ‘I can make other people do what I want’, ‘I am often accused of lying or cheating’, ‘I take things that are not mine from school or elsewhere’. Response options (not true = 3, somewhat true = 2, certainly true = 1) were compiled into a sum score, ranging 5–15. The sum score was then dichotomized into no problems (=0) and problems (=1) with a cut-off set at eight.

Explanatory variable: family structure

A variable was created to reflect the family structure of the adolescent. The variable grouped the adolescents into three categories: living in a two-parent family, in shared physical custody or in a single-parent family. These categories were based on the answers to five questions: who do you live with?; which household do you live in most of the time or always (mother’s, father’s or other)?; do you have another (second) home (yes, no)?;

how often do you stay in the second home (half the time, regularly but less than half the time, sometimes or almost never)?; with whom do you live in the second home (mother, father, other person)?; and living in a ‘two-parent family’ refers to living with both parents in the same household. ‘Shared physical custody’ refers to living half-time with one parent in one home and half-time with the other parent in a second home, for example, every second week.

‘Single-parent family’ refers to living with one parent in a single household and staying with the non-resident parent less than half the time. Adolescents who indicated other living arrangements or answered inconsistently were excluded (n = 362, 9.8%).

Control variables

Data on the adolescents’ gender (boy = 0, girl = 1) were included.

The family’s economic position (Economy) was measured with the question: ‘How well off is your family?’ The responses were dichotomized into satisfying economy = 1 (very good, pretty good, average) and non-satisfying economy = 0 (not so good, not good at all). Parental employment was measured by one question each:

‘Does your father/mother work?’ coded yes = 1 and no = 0. Foreign background was based on the question: ‘Where were your parents born?’ coded as ‘parents born in Sweden’ = 0 and ‘at least one parent born outside Sweden’ = 1. Two variables indicating parental support (able to talk to father/mother) were measured with one question each: ‘How easy is it for you to talk with your father/mother

about things that really bother you?’ The response options were dichotomized into not difficult = 0 (easy or very easy to talk to father/mother) and difficult = 1 (hard or very hard to talk to father/mother).

Statistical analyses

Descriptive analyses were carried out. Table 1 presents separate bivariate analyses, using 

tests for each outcome variable and ex- planatory variable.

Multivariate logistic regression models were constructed separately for each outcome variable (table 2). All statistical analyses were carried out in SPSS version 18. P < 0.05 were considered significant.

Ethical considerations

The Mid Sweden University Research Ethics Committee reviewed the study and found no cause to object (reg. no. 2009:71273).

Results

The material includes an equal number of boys and girls. In total, 3699 adolescents were included and of those 10% (n = 372) were excluded because of inadequate answers. Sixty-one per cent of the adolescents (n = 2256) lived in two-parent families and the rest 29%

(n = 1071) lived in a split-up family. Of those adolescents, 75%

(n = 801) lived with a single parent, while 25% (n = 270) lived in shared physical arrangements. Approximately 18% of the adoles- cents (n = 621) were smokers, 40% (n = 1462) had been drunk and 30% (n = 1101) had debuted sexually. About a fifth of adolescents (19%; n = 675) reported conduct problems.

Most parents, 88% (n = 2875) of the mothers and 93% (n = 2962) of the fathers, were gainfully employed. Non-satisfying family economy was reported by 7% (n = 193) of adolescents. In total, 88% (n = 2832) of the parents were born in Sweden. Difficulties talking to fathers were reported by 39% (n = 1187) and to mothers by 23% (n = 713), respectively.

Bivariate analyses

Table 1 shows the associations between included variables.

Adolescents living in a single-parent family and those living in shared physical custody were more apt to smoke (24.1%, 19.8%) than adolescents living in two-parent families (13.5%) (

= 48.5, P < 0.000).

Adolescents in single-parent families had significantly higher prevalence of having been drunk (51.1%) than those in shared physical custody families (46.2%) and two-parent families (34.4%) (

= 73.4, P < 0.000).

Sexual debut at the age of 15 years or younger was more prevalent among adolescents in single-parent families (40.9%) and shared physical custody families (30%) than in two-parent families (25.5%) (

= 66.4, P < 0.000).

Adolescents living in single-parent families had more conduct problems (22.9%) than those living in shared physical custody (17.4%) and two-parent families (16.1%; 

= 18.0, P < 0.000).

Multivariate analyses

In table 2, separate multivariate logistic regression models were con- structed for the four outcome variables. Model 1 displays increased odds of being a smoker in adolescents living in shared physical custody [odds ratio (OR) 1.60, 95% confidence intervals (CIs) 1.13–2.27] and in single-parent families (OR 1.80, 95% CI 1.40–

2.32), compared with adolescents in two-parent families. Further, the model indicates that the odds of being a smoker were increased among girls (OR 1.34, 95% CI 1.08–1.66) and among adolescents living in families with unsatisfying economy (OR 1.64, 95% CI 1.08–

4 European Journal of Public Health

at Mittuniversitetet on March 1, 2013 http://eurpub.oxfordjournals.org/ Downloaded from

Table 1 Frequencies, percent distributions and bivariate analyses of variables by family structure, control and outcome variables (%)

Variables Two-parent

family n (%)

Shared physical custody n (%)

Single-parent family n (%)

Significance:

v

test; df; P Gender

Boy 1111 (49.6) 144 (53.7) 353 (44.6) 8.843; 2; 0.012

Girl 1129 (50.4) 124 (46.3) 440 (55.4)

Father got work?

Yes 2111 (94.3) 261 (97.0) 590 (87.8) 41.481; 2; 0.000

No 127 (5.7) 8 (3.0) 82 (12.2)

Mother got work?

Yes 2003 (89.8) 246 (91.1) 626 (82.7) 30.011; 2; 0.000

No 227 (10.2) 24 (8.9) 131 (17.3)

Economy

Not satisfying 73 (3.3) 15 (5.6) 106 (13.4) 107.625; 2; 0.000

Satisfying 2159 (96.7) 253 (94.4) 687 (86.6)

Foreign background?

No 1897 (84.1) 258 (95.6) 677 (84.5) 25.346; 2; 0.001

Yes 359 (15.9) 12 (4.4) 124 (15.5)

Able to talk to father

No difficulties 1420 (63.7) 172 (64.7) 363 (56.0) 13.450; 2; 0.001

Difficulties 808 (36.3) 94 (35.3) 285 (44.0)

Able to talk to mother

No difficulties 1756 (79.2) 209 (78.6) 551 (74.0) 8.872; 2; 0.012

Difficulties 462 (20.8) 57 (21.4) 194 (26.0)

Being a smoker?

No 1864 (86.5) 206 (80.2) 577 (75.8) 48.503; 2; 0.000

Yes 291 (13.5) 51 (19.8) 184 (24.2)

Been drunk?

No 1455 (65.5) 143 (53.8) 383 (48.7) 73.444; 2; 0.000

Yes 768 (34.5) 123 (46.2) 403 (51.3)

Sexual debut <15 years

No 1657 (74.5) 187 (70.0) 464 (59.1) 66.410; 2; 0.000

Yes 566 (25.5) 80 (30.0) 321 (40.9)

Conduct Problems

No 1852 (83.8) 219 (82.6) 602 (77.1) 18.001; 2; 0.000

Yes 357 (16.2) 46 (17.4) 179 (22.9)

Table 2 Multivariate logistic regression models showing the OR with 95% CI for adolescent risk behaviours and conduct problem

Variables Model 1 Model 2 Model 3 Model 4

Being a smoker Been drunk Sexual debut < 15 years Conduct problems

OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI)

Gender

Boy (ref.) 1 1 1 1

Girl 1.34** (1.08–1.66) 1.11 (0.95–1.30) 1.09 (0.92–1.29) 0.42*** (0.34–0.52)

Father got work?

Yes 1 1 1 1

No 1.24 (0.82–1.87) 0.98 (0.70–1.37) 1.12 (0.79–1.59) 0.92 (0.60–1.39)

Mother got work?

Yes 1 1 1 1

No 0.96 (0.67–1.36) 0.83 (0.63–1.08) 0.93 (0.70–1.24) 1.15 (0.83–1.60)

Economy

Satisfying (ref.) 1 1 1 1

Not satisfying 1.64** (1.08–2.49) 1.14 (0.79–1.64) 1.25 (0.86–1.82) 1.93** (1.29–2.90)

Foreign background?

No 1 1 1 1

Yes 0.91 (0.65–1.27) 0.63*** (0.49–0.80) 0.63** (0.48–0.84) 1.05 (0.77–1.44)

Able talk to father

No difficulties (ref.) 1 1 1 1

Difficulties 1.22 (0.95–1.55) 1.23*** (1.02–1.48) 1.1 (0.91–1.34) 1.56*** (1.23–1.99)

Able talk to mother

No difficulties (ref.) 1 1 1 1

Difficulties 1.47*** (1.34–2.25) 1.47*** (1.20–1.81) 1.41** (1.14–1.75) 1.73*** (1.34–2.23)

Family structure

Two-parent family (ref.) 1 1 1 1

Shared physical custody 1.60** (1.13–2.27) 1.50** (1.15–1.96) 1.23 (0.92–1.63) 1.06 (0.74–1.52)

Single-parent family 1.80*** (1.40–2.32) 1.79*** (1.47–2.19) 1.89*** (1.54–2.32) 1.33* (1.04–1.72)

*P < 0.005, **P < 0.01, ***P < 0.001.

at Mittuniversitetet on March 1, 2013 http://eurpub.oxfordjournals.org/ Downloaded from

2.49). Difficulty talking to their mother also significantly predicted the risk of being a smoker (OR 1.47, 95% CI 1.34–2.25).

In Model 2, it was shown that the odds of having been drunk were significantly higher in adolescents in shared physical custody (OR 1.50, 95% CI 1.15–1.96) and in single-parent families (OR 1.79, 95%

CI 1.47–2.19); lower in adolescents with foreign background (OR 0.63, 95% CI 0.49–0.80) than in adolescents with Swedish background; and significantly higher in adolescents with difficulties talking to their fathers (OR 1.23, 95% CI 1.02–1.48) and mothers (OR 1.47, 95% CI 1.20–1.81).

In the model for sexual debut, Model 3, adolescents from single-parent families were almost twice as likely to have had sexual debut by age 15 years than adolescents in two-parent families (OR 1.89, 95% CI 1.54–2.32). The odds of early sexual debut in adolescents in shared physical custody were not signifi- cantly higher than in adolescents from two-parent families (OR 1.23, 95% CI 0.92–1.63).

The odds were significantly lower among adolescents with a foreign background (OR 0.63, 95% CI 0.48–0.84). In adolescents reporting difficulties talking to their mother the risk of having had a sexual debut was 40% higher than in those with no difficulties talking to their mother (OR 1.41, 95% CI 1.14–1.75).

Model 4 displays determinants of conduct problems. Compared with adolescents from two-parent families, adolescents living in shared physical custody were not at significantly higher risk for conduct problems (OR 1.23, 95% CI 0.92–1.63); whereas in adoles- cents from single-parent families, the odds of reporting conduct problems were significantly higher (OR 1.33, 95% CI 1.04–1.72).

Girls had a significantly lower risk of reporting conduct problems than boys (OR 0.42, 95% CI 0.34–0.52). The odds of reporting conduct problems were twice as likely in adolescents from families with unsatisfying economy as in adolescents from families with satisfying economy (OR 1.93, 95% CI 1.29–2.90). Adolescents reporting difficulties talking to their fathers were more at risk of having conduct problems (OR 1.56, 95% CI 1.23–1.99). Similarly, the odds of having difficulties talking to their mothers were signifi- cantly higher in adolescents reporting conduct problems (OR 1.73, 95% CI 1.34–2.23).

In the models presented, between 62% and 85% of respondents were correctly classified. Multicollinearity of the independent variables were tested and in no case was the tolerance value <0.1, nor did the VIF value exceed 10 (P = 0.05).

In sum, for all models presented, single-parent status is associated with increased risk of negative behaviours in adolescents compared with two-parent status as well as shared custody.

Discussion

This study represents a significant input to the health literature as it is one of few studies exploring the relationship between residence arrangements, especially shared physical custody, and adolescent risk behaviour and conduct problems. A major strength of the present study is its large sample size and the sampling procedures which make the results representative for Swedish 15-year-olds. In our study, 25% of the adolescents with split-up parents reported that they lived in shared physical custody, and that corresponds well with official statistics.

An important finding is the clear pattern of increased risk of negative outcomes not only in adolescents living in single-parent families but also in those living in shared physical custody. The results are net of factors known to influence adolescent outcomes, as we have controlled for important potential confounders, i.e.

socio-economic status and parental support. Odds for adolescents from single-parent families of being a smoker, having been drunk or having had a sexual debut were almost double those of adolescents living in two-parent families. Those results were not surprising and they are supported by numerous studies.

Among adolescents in

shared physical custody, the results were less striking. Their odds were 50% higher for being a smoker and 60% higher for having been drunk than those for adolescents living in two-parent homes, and insignificantly different for sexual debut and conduct problems. Our findings are supported by the only other study we found on the relationship between residence arrangements and health-related outcomes in adolescents.

In a sample of adolescents from an urban environment, Jablonska et al. established an increased risk of unhealthy lifestyles in adolescents from single-parent families and, to a lesser extent, also in adolescents from shared physical custody arrangements.

In our study, we can show that these patterns are not limited to urban environments, as we analyse data from a nationally represen- tative sample, including adolescents from small towns and rural areas. To conclude, the findings from the study of Jablonska and Lindberg

are restricted to one area while the present study covers a national sample.

Interpretation of these findings requires considerable care. Any effect of residence arrangements on adolescent outcomes cannot be disentangled from effects connected to the breakup of the family and possible subsequent family conflicts. The lower risks for adolescents in shared physical custody compared with those from single-parent families support previous evidence of the positive impact of fathers’ involvement and accessibility on adolescent health outcomes.

Recent research suggests lower levels of inter-parental conflict in many shared physical custody arrangement than in other residence solutions after divorce, and adolescents in shared physical custody describe the positive opportunity of close relations with both their parents.

Thus, for adolescents, shared physical custody might be considered a health-protective alternative to living in a single-parent arrangement.

There are certain limitations to this study. First, the cross- sectional design implies that reversed causality cannot be ruled out, e.g. that adolescents with negative health outcomes actually increase the likelihood of their parents’ marital breakdown and the subsequent change in living arrangements. However, the existing literature does not support such an interpretation.

Secondly, the family structure variable is based on four questions, categorizing the adolescents into three mutually exclusive categories. Adolescents who had other residential arrangements or answered inconsistently were excluded from the analyses.

Therefore, we have no reason to believe that our results are biased due to misclassification of adolescents’ residence arrangements,

especially as the distribution of adolescents in these categories reflects what is reported from the official Swedish statistics.

The truthfulness of the adolescents’ respondents to the questions about their behaviour may also come into question. If they responded according to what is socially acceptable, their risks may have been underestimated. If such underestimation is systematic and biased, i.e. if adolescents who live in shared residence or single-parent households are more likely than adolescents from two-parent families to underreport risk behaviour, it would create a systematic error in the study.

However, we have no reason to assume that any group would underreport more than the others, and in fact previous adolescent self-report surveys have shown good reliability and validity.

Further, the prevalence reported in this study corresponds to the official statistics on health behaviours in adolescents.

It may also be questioned whether having sex at the age of 15 years should be considered problem behaviour. Earlier studies have shown that young people, especially girls, with an early sexual debut, are at risk of psychological and social problems as well as unintended pregnancy.

Hence, it is relevant in this study and elsewhere to consider early sexual debut as risk behaviour. Finally, it is possible that adolescents who were not present in school on the day of the study are those most likely at risk; for example, truancy may co-vary 6 European Journal of Public Health

at Mittuniversitetet on March 1, 2013 http://eurpub.oxfordjournals.org/ Downloaded from

with problem behaviours.

If those adolescents are more likely to come from broken families, our reported OR might be underestimated and the real risks could be even higher.

In conclusion, this study adds an important contribution to an essentially unexplored field.

Shared physical custody following a family breakup represents a phenomenon that still occurs most often in the Nordic countries, and might constitute a health protective factor for adolescents. In order to deepen our understanding of the positive and negative aspects of shared physical custody our study should be followed by qualitative analyses and longitudinal studies of adolescents’

experiences.

Acknowledgements

The authors are grateful to Maria Corell of the Swedish National Institute of Public Health for her valuable comments on earlier drafts of the article.

Funding

This study was funded by the Department of Health Science, Mid Sweden University, O ¨ stersund, Sweden.

Conflicts of interest: None declared.

Key points

 Adolescents from single-parent families have almost doubled odds of risk behaviour in contrast to adolescents living in two-parent families.

 Adolescents in shared physical custody are 60% more likely to smoke and 50% more likely to have been drunk than adolescents living in two-parent families.

 Increased odds of risk behaviour in adolescents in shared physical custody are not limited to urban environments;

data from a nationally representative sample, including ado- lescents from small towns and rural areas show similar results.

 In order to deepen our understanding of the positive and negative aspects of shared physical custody, our study should be followed by qualitative analyses and longitudinal studies of adolescents’ experiences.

References

1 Statistics Sweden. Swedish Population Tables. (In Swedish) Tabeller o¨ver Sveriges befolkning. Stockholm: Statistics Sweden, 2010.

2 Statistics Sweden. Children of today - a description of childrens conditions based on CRC (Committee on the rights of the child). (In Swedish) Barn i dag - en beskrivning av barns vilkor med Barnkonventionen som utga˚ngspunkt. Temarapport 2009:2.

Stockholm: Statistics Sweden, 2009.

3 Ga¨hler M, Hong Y, Bernhardt E. Parental divorce and union disruption among young adults in Sweden. J Fam Issues 2009;30:688–713.

4 Brolin-La˚ftman S. Children’s living conditions: studies on health, family and school.

Stockholm University, doctoral thesis no. 77. Swedish Institute of Social Research, 2009.

5 Carlson MJ, Corcoran ME. Family structure and children’s behavioral and cognitive outcomes. J Marriage Fam 2001;63:779–92.

6 Amato PR. The consequences of divorce for adults and children. J Marriage Fam 2000;62:1269–87.

7 Amato PR. The impact of family formation change on the cognitive, social, and emotional well-being of the next generation. Future Child 2005;15:75–96.

8 Rousit C, Chaix B, Chauvin P. Family breakup and adolecents’ psychosocial mal- adjustment: public health implications of family disruption. Pediatrics

2007;120:984–91.

9 Kerr D, Beaujot R. Family relations, low income, and child outcomes: a comparison of Canadian children in intact-, step-, and lone-parent families. I J CompSociol 2002;43:134–52.

10 Breivik K, Olweus D. Children of divorce in a Scandinavian welfare state: are they less affected than US children? Scand J Psychol 2006;47:61–74.

11 Currie C, Gabhain S, Godeau E, et al. Inequalities in young people’s health. Health behaviour in school-aged children. International report from the 2005/2006 survey.

Edinburgh: World Health Organisation, 2008.

12 Kelly JB. Children’s living arrangements following separation and divorce: insights from empirical and clinical research. Fam Process 2006;46:35–52.

13 Ringba¨ck-Weitoft G, Hjern A, Haglund B, Rose`n M. Mortality, severe morbidity, and injury in children living with single parents in Sweden: a population-based study. Lancet 2003;361:289–95.

14 Pagani LS, Japel C, Vaillancourt T, et al. Links between life course trajectories of family dysfunction and anxiety during middle childhood. J Abnorm Child Psychol 2008;36:41–53.

15 Griesbach D, Amos A, Currie C. Adolescent smoking and family structure in Europe. Soc Sci Med 2003;56:41–52.

16 Simons-Morton B, Pickett W, Boyce W, et al. Cross-national comparison of adolescent drinking and cannabis use in the United States, Canada, and the Netherlands. Int J Drug Policy 2009;21:64–9.

17 Levin K, Currie C. Family structure, mother-child communication, father-child communication, and adolescent life satisfaction. Health Educ 2010;110:152–68.

18 Dunlop R, Burns A, Bermingham S. Parent-child relations and adolescent self-image following divorce: a 10 year study. J Youth Adolesc 2001;30:117–34.

19 Amato PR, Meyers C. Changes in nonresistent father child contact from 1976 to 2002. Fam Relat 2009;58:41–53.

20 Statistics Sweden. Children and their families 2006. (In Swedish) Barn och deras familjer. Demografirapport 2007:4. Stockholm: Statistics Sweden, 2007.

21 King V, Sobolewski JM. Nonresident fathers’ contributions to adolescent well-being.

J Marriage Fam 2006;68:537–57.

22 Kelly JB, Emery RE. Children’s adjustment following divorce: risk and resilience perspectives. Fam Relat 2003;52:352–62.

23 Jablonska B, Lindberg L. Risk behaviours, victimisation and mental distress among adolescents in different family structures. Soc Psychiatry Psychiatr Epidemiol 2007;42:656–63.

24 Morgan A, Currie C, Due P, et al. Mental well-being in school-aged children in Europe: associations with social cohesion and socioeconomic circumstances. WHO/

HBSC 2007: 12–25. Report of the WHO/HBSC FORUM WHO. Copenhagen, http://www.euro.who.int/Document/E91921.pdf.

25 Ahrons CR. Family ties after divorce: long term implications for children. Family Process 2006;46:53–66.

26 Svensson M, Hagquist C. Adolescent alcohol and illicit drug use among first- and second-generation immigrants in Sweden. Scand J Public Health 2010;38:184–91.

27 Holmberg LI, Hellberg D. Characteristics of relevance for health in Turkish and Middle Eastern adolescent immigrants compared to Finnish immigrants and ethnic Swedish teenagers. Turk J Pediatr 2008;50:418–25.

28 Currie C, Nic Gabhainn S, Godeau E, et al. Young people’s health in context: health behaviour in school-aged children. International report from the 2005/2006 study.

Europe: World Health Organization, 2006.

29 Danielson M. Health behaviour in school-aged children. National report from the 2005/2006 study. Stockholm: Swedish National Institute of Public Health, 2006.

30 Swedish National Institute of Public Health. Health behaviour in school-aged children. National report from the 2009/2010 study. (In Swedish) Statens folkha¨lsoinstitut. Svenska skolbarnsha¨lsovanor 2009/2010. 2011;27, Swedish Natinal Institute of Public Health, O ¨ stersund. Sweden.

31 Goodman R. The strengths and difficulties questionnaire: a research note. J Child Psychol Psychiatry 1997;38:581–6.

32 Barrett AE, Turner RJ. Family structure and substance use problems in adolescence and early adulthood: examining explanations for the relationship. Addiction 2005;101:109–20.

33 Bjarnason T, Andersson B, Choquet M, et al. Alcohol culture, family structure and adolescent alcohol use: multilevel modelling of frequency of heavy drinking among 15-16 year old students in 11 European countries. J Stud Alcohol 2002;3:200–8.

at Mittuniversitetet on March 1, 2013 http://eurpub.oxfordjournals.org/ Downloaded from

34 Fomby P, Cherlin AJ. Family instability and child well-being. Am Sociol Rev 2007;72:181–204.

35 Bauserman R. Child adjustment in joint-custody versus sole-custody arrangements:

a meta-analytic review. J Fam Psychol 2002;16:91–102.

36 Hjern A. Children’s health. (In Swedish) Barns ha¨lsa. Swedish National Institute of Public Health, 56– 61. Stockholm: The National Board of Health and Wellfare, 2008.

37 Lintonen T, Ahlstrom S, Metso L. The reliability of self-reported drinking in ado- lescence. Alcohol 2004;39:362–8.

38 Madkour AS, Farhat T, Halpern CT, et al. Early adolescent sexual initiation and physical/psychological symptoms: a comparative analysis of five nations. J Youth Adolesc 2010;39:1211–25.

39 Hagga˚rd-Gran U, Hallqvist J, La˚ngstro¨m N, Mo¨ller J. The role of alcohol and drugs in triggering criminal violence: a case crossover sudy. Addiction 2006;101:100–8.

40 Andersen A, Holstein BE, Due P. School-related risk factors for drunkness among adolescents: risk factors differ between socio-economic groups. Eur J Public Health 2006;17:27–32.

...

European Journal of Public Health, Vol. 23, No. 1, 8–13

 The Author 2012. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.

doi:10.1093/eurpub/cks050 Advance Access published on 27 April 2012

...

Frequency and effects of meeting health behaviour guidelines among adolescents

Daniel Mejı´a ¹ , Andre´ Berchtold ¹ , Richard E. Be´langer ¹ , Emmanuel N. Kuntsche ² , Pierre-Andre´ Michaud ¹ , Joan-Carles Surı´s ¹

1 Research Group on Adolescent Health, Institute of Social and Preventive Medicine (IUMSP), Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland

2 Addiction Info Switzerland, Research Institute, Lausanne, Switzerland

Correspondence: Dr Joan-Carles Surı´s, Research Group on Adolescent Health (GRSA), Institute of Social and Preventive Medicine (IUMSP), Baˆtiment Biopoˆle 1, Rte de la Corniche 2, 1066 Epalinges, Switzerland. Tel: +41 21 314 7375, Fax: +41 21 314 7373, e-mail: Joan-Carles.Suris@chuv.ch

Background: To assess the relationship between overweight status and the concomitant adherence to physical activity, daily screen time and nutritional guidelines. Methods: Data were derived from the Swiss Health Behaviour in School-aged Children Survey 2006. Participants (n = 8130, 48.7% girls) were divided into two groups: normal weight (n = 7215, 44.8% girls) and overweight (n = 915, 34.8% girls), using self-reported height and weight. Groups were compared on adherence to physical activity, screen time and nutritional guidelines. Bivariate analyses were carried out followed by multivariate analyses using normal-weight individuals as the reference category. Results:

Regardless of gender, overweight individuals reported more screen time, less physical activity and less concomitant adherence to guidelines. For boys, the multivariate analysis showed that any amount exceeding screen time recommendations was associated with increased odds of being overweight [>2–4 h: adjusted odds ratio (AOR) = 1.40; >4–6 h: AOR = 1.48; >6 h: AOR = 1.83]. A similar relation was found for any amount below physical activity recommendations (4-6 times a week: AOR = 1.67; 2–3 times a week: AOR = 1.87; once a week or less: AOR = 2.1). For girls, not meeting nutritional guidelines was less likely among overweight individuals (0–2 recommendations:

AOR = 0.54). Regardless of weight status, more than half of the adolescents did not comply with any guideline and <2% met all three at the same time. Conclusions: Meeting current nutritional, physical activity and screen time guidelines should be encouraged with respect to overweight. However, as extremely low rates of concomitant adherence were found regardless of weight status, their achievability is questionable (especially for nutrition), which warrants further research to better adapt them to adolescents.

...

Introduction

O ver the past decades, the prevalence of overweight and obesity has increased in the paediatric population and Switzerland is no exception.

Many concerns have been voiced, as evidence shows that overweight and obesity in children and youths increase the odds of similar conditions in adulthood with all its consequences.

Thus, a great deal of effort has been spent investigating the underlying mech- anisms of this rise in order to understand it and devise prevention and treatment programs accordingly.

This increase in overweight and obesity is thought to be caused by a complex mix of genetic and environmental factors.

Biro and Wien

stated that the majority of the studies were focused on the effect of environmental and behavioural factors with three major topics: physical activity (PA), sedentary behaviour (television, video games and computers) and dietary factors. Independent relations to excess weight were also reported for each of these three topics.

Furthermore, interactions between those three

factors were described: for example, high television time was associated with reduced amounts of PA

and higher food intake after food advertisement exposure,

which would lead to an imbalance between energy intake and expenditure, favouring weight gain.

Specific Swiss guidelines for screen time,

PA

and nutrition

have been published and prevention programmes have been launched to promote their adherence and awareness. However, recent evidence suggests that these recommendations are largely unmet.

The combined effect of meeting more than one guideline and its relation to overweight has been, to our knowledge, investigated only once.

Sanchez et al.

found that a low observance of guidelines is associated with a higher likelihood of being overweight. However, the sample used was not representative at a national level, and certain aspects relative to the screen time and nutritional guidelines were not investigated (namely computer time and several nutritional variables, respectively). Therefore, the aim of 8 European Journal of Public Health

at Mittuniversitetet on March 1, 2013 http://eurpub.oxfordjournals.org/ Downloaded from