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Abstract

Family has a major impact on adolescents’ mental health, influencing their emotional and behavioral well-being. This study aims to explore differences in family functioning between community and clinical adolescents and to investigate their perceptions. A mixed-methods approach was used, involving 80 adolescents with mental disorders and 612 non-clinical adolescents (53% girls, Mage = 14.86 years). The Youth Self Report (YSR) and the Family Adaptability and Cohesion Evaluation Scale (FACES IV) were administered. Ten participants from the community group and ten participants from clinical group were interviewed. Significant differences between the groups were found in all dimensions of YSR (p < 0.001), as well as in cohesion (p < 0.001), flexibility (p < 0.001), disengaged (p < 0.001), chaotic (p < 0.05), communication (p < 0.001), and satisfaction (p < 0.001). Family functioning was found to be a strong component in differentiating clinical and non-clinical adolescents (χ² (8) = 60.38, p < .05); however, the only significant predictor was family satisfaction (β = −.09***). Consistent with quantitative findings, responsiveness and supervision emerged as the most common themes in interviews with non-clinical adolescents, while conflicts and authoritarian control were prevalent among clinical adolescents. These findings highlight the importance of fostering positive family dynamics to support adolescent mental health, suggesting directions for future interventions and research.

Keywords

family functioning adolescents’ mental health well-being YSR FACES

Introduction

Epidemiological studies have shown that mental health problems mostly have their first age of onset during adolescence (Essau et al., 2014; Solmi et al., 2022). Globally, one in seven youth experiences a mental disorder (UNICEF, 2021). Therefore, there is increasing attention on the factors that put adolescents at risk of developing mental health problems, with a specific focus on family functioning (Ortiz-Sanchez et al., 2023; Yöntem, 2019). Over the last few decades, the role of family functioning in the development of adolescents’ mental health problems has received increased attention in research, as it can predict both positive and negative outcomes (Buehler, 2020; Sander & McCarty, 2005). On the one hand, adolescents in functional families are less likely to develop mental health problems (Vizard et al., 2020), due to provision of secure attachment, support, and acceptance (Buehler, 2020). On the other hand, studies have illustrated that family functioning is a risk factor, as it has been found to be significantly related to anxiety (Bogels & Brechman-Toussaint, 2006), depression (Daches et al., 2018) and aggression (Perez-Fuentes et al., 2019).

Several family components have been found to be associated with functioning and adolescents’ mental health. Firstly, family communication facilitates the fulfillment of adolescents’ self-esteem (Trong Dam et al., 2023), helps them cope effectively with decision-making (Boele et al., 2024), works against the development of distress (Wong et al., 2023), increases feelings of belonging (Shannon, 2022) and provides satisfaction (Hodge et al., 2017). In comparison, dysfunctional parent-child communication has been associated with adolescents’ depression, anxiety, and behavioral problems (Hawes et al., 2021). Secondly, adolescents who reported being satisfied with their parents have been found to be at a decreased risk of developing anxiety (Essau et al., 2014), delinquency behaviors (Kenny et al., 2013) and antisocial behavior (Theobald & Farrington, 2012). Thirdly, family conflicts and criticism have been identified as indicators for dysfunctional families (Benson & Buehler, 2012). Specifically, Fosco and Lydon-Staley (2020) illustrated that family models characterized by conflicts are associated with low mood, aggressiveness, and lack in cohesion. Finally, another component, parental rejection, including lack of warmth, has been found to be negatively associated with ODD and internalizing disorders (Scully et al., 2020).

To narrow the gap between research and community-based adolescents’ mental health, assessing a clinical sample is a priority. Existing research on adolescents with mental disorders has shown significantly higher rates of emotional and behavioral problems and poorer family functioning compared to children from community settings (Brown & Wright, 2003). Adolescents diagnosed with mood disorders experience miscommunication and behavioral control from their parents, predictors that contribute to the onset of nonsuicidal self-injury in this population (Qiao et al., 2024). Similar findings were reported by Vujovic (2024), who examined juvenile delinquents and found that the predictors of delinquent behavior included parental rejection, overprotection, and lack of monitoring. As argued by Oltean et al. (2020), parents who are affectively involved with their children and solve their problems interfere with the development of autonomy and decision-making skills during depressed and anxious situations, which affects the presence of anxiety and depressive symptoms. The same pattern exists with behavioral problems, where positive parental control and involvement have been found to be associated lower odds of ODD and conduct disorder (Childs et al., 2022; Fairchild et al., 2019).

Differences in family functioning can be found between clinical and community samples of adolescents. Specifically, a study by Santesteban-Echarri et al. (2018) found that adolescents with mental illness were less satisfied with their families compared to non-help-seeking youth, due to impairments in family dynamics and interactions in the families of mentally ill adolescents. A similar study by Pereira et al. (2015), which included qualitative data, showed that depressed adolescents are raised in families lacking affection, experiencing conflict and existing in unstable environment, compared to adolescents without mental disorders who are raised in functional families. Due to the lack of affection and the presence of conflicts, these children learn to hide their emotions and feelings, which contributes to stress, situations that increase the severity of depressive symptomatology (Pereira et al., 2015).

The Present Study

The overall purpose of the present study was to examine the relationship between family functioning and adolescents’ mental health problems. This study predicted that adolescents from clinical setting would have significantly higher scores on emotional and behavioral problems compared to the adolescents from community setting and that family functioning factors would predict adolescents’ mental health problems. In support of this, we predicted that there would be significant group differences in family factors, with adolescents from clinical setting scoring higher on unbalanced factors and lower on cohesion, flexibility, family communication, and family satisfaction compared to the adolescents from community settings. At the same time, these predictors were explored through interviews with adolescents to assess their perceptions on their families’ functioning and to examine their views about its impact on their mental health.

To address these aims, this study uses integrated findings from a mixed-method design. A mixed-method approach was utilized to highlight family functioning factors that predict adolescents’ mental health problems alongside their real experiences and thoughts about their families. The timing of these research methods was carried out sequentially, with the quantitative research taking place prior to the qualitative research. This order provides an integrated approach, as the nature of the study is to use qualitative data to refine and explain in more depth the statistical results from the first phase, which provide a general understanding of the study's aims. Additionally, this research builds upon existing literature in this field by comparing the perspectives of community and clinically referred adolescents.

Method

Participants

Adolescents consisted of six hundred and ninety-two (N = 692) Greek-speaking Cypriot adolescents, aged 12 to 17 years. Specifically, the community sample consisted of a total of 612 adolescents and the clinical sample included 80 adolescents. The mean age of the participants was 14.86 (SD = 1.46). Participants were approximately equally divided between males and females (324 males; 368 females) and reported living in rural (52.6%) and urban (47.4%) areas across all cities in Cyprus. Most of the adolescents came from intact families (n = 593, 85.7%), 35 adolescents were from restructured families (5%), 58 adolescents were from single-mother families (8.4%), and a small number of 6 adolescents were from single-father families (0.9%). A cluster-sampling method was used.

The qualitative sample includes a subgroup of 20 adolescents from the quantitative sample. Specifically, ten (n = 10) adolescents were from community sample and ten (n = 10) were from clinical sample. Half of these participants were males (10 males; 10 females). The mean age of the participants was 14.45. All participants from the community sample came from intact families, whereas 5 adolescents from clinical sample were from single-mother families (50%). All ages and living areas were represented in this phase. The approach to qualitative sampling did not aim to recruit a nationally representative sample, but rather to reflect the demographics of each sample group.

Measures

Demographics: Adolescents reported their gender, age, family structure, residential area, and city of residence.

Youth Self-Report (YSR; Achenbach, 1991): The YSR contains 112 items, 98 of which examine emotional and behavioral problems, and 14 assess positive qualities. The questions are divided into eight syndromes: Withdrawn, Somatic Complaints, Anxious/Depressed, Delinquent Behavior, Aggressive Behavior, Social Problems, Thought Problems, and Attention Problems. Each item is rated from 0 (not true) to 2 (very true). The YSR showed good reliability, ranging from 0.65 to 0.95 (Achenbach, 1991; Verhulst et al., 2003). The criterion-related validity of the scale demonstrated significant discrimination between clinical and non-clinical adolescents (p < 0.01), and the concurrent validity showed significant correlations with both anxiety and affective problems (p < 0.01) (van Lang et al., 2005). The internal consistency of the scale for the present study was 0.96 for the clinical sample, 0.94 for the community sample and 0.84 for the total number of participants.

Family Adaptability and Cohesion Evaluation Scale (FACES IV; Olson, 2011): The FACES IV was used to evaluate family functioning. It contains 62 items, which are subdivided into two balanced scales and four unbalanced scales. The two balanced scales, Cohesion and Flexibility, measure superior family functioning. The four unbalanced scales, Disengaged, Enmeshed, Rigid, and Chaotic assess inferior family functioning. The FACES IV also contains items that measure Communication and Satisfaction. Items are rated using a 5- point Likert scale, ranging from 1 (Strongly disagree) to 5 (Strongly agree). The FACES IV showed satisfactory reliability, ranging from 0.77 to 0.89 (Olson et al., 2019; Rivero et al., 2010). The discriminant validity was adequate between problematic and non-problematic families (Olson, 2011). Regarding its convergent and divergent validity, strong correlations were found between balanced and unbalanced scales and family communication and satisfaction, while moderate to weak correlations were found between FACES IV factors and parent attachment (Baiocco et al., 2013). For this study, the internal consistency was 0.90 for the community sample, 0.85 for the clinical sample, and 0.86 for the total number of participants.

Qualitative Measure : The interview schedule included a semi-structured format to ensure consistency in data collection, provide the opportunity to explore and discuss issues relevant to their families, and enable adolescents to describe how these factors affect them. The interview schedule contained nine open-ended questions, starting with a general inquiry about how adolescents feel about the way their parents raise them. Following the first question, adolescents were asked about decision-making procedures and family rituals. Subsequent questions referred to family roles and openness in discussing family and personal problems. There was also a question about adolescents’ opinions on their parents’ perspectives regarding peer relationships and interactions. Furthermore, a question addressed how adolescents communicate with their parents. Finally, the last question asked about the factors that make them either happy or unhappy within their family environment.

Procedure

Prior to data collection, the necessary ethical approvals were obtained from the Cyprus National Bioethics Committee, the Cyprus Ministry of Health, the Cyprus Ministry of Education, Culture, Sport and Youth and the University of Roehampton Ethics Board. In the first phase, for the community sample, twenty (20) public Junior High Schools and twenty (20) Senior High Schools from all five districts of Cyprus were randomly selected from a list of hundred and twenty (120) schools. All Heads of these schools were contacted and asked if they were interested in participating in this study. Only ten (10) Junior Schools and ten (10) Senior High Schools agreed to participate. The Head of each school circulated the consent forms for both the parents and the adolescents and had the right to decide which classes would participate. Consent forms were taken home to be signed, and only adolescents who returned a signed consent were able to complete the survey. The completion of the questionnaires took place in their classrooms on a specific day and time, in the presence of their teacher and the researcher. On the first page of the questionnaire, there was a question asking adolescents if they had experienced any kind of distress or serious problems the past 12 months. Those who indicated that they had any kind of mental health issue were excluded from the study.

For the clinical sample, adolescents were recruited from the Child and Adolescent Mental Health Services of Cyprus (CAMHS) across all cities in Cyprus. Participants in this group were selected by the psychologists of CAMHS based on their diagnosis and the severity of their symptomatology. Specifically, adolescents with extremely severe symptomatology and diagnoses of disorders that interfere their functioning were excluded. Psychologists provided a list of children, and all of them were informed about the study. Those who were interested in participating were given a consent form, which was taken home to be signed. Once the consent forms were signed, an appointment was arranged in a designated room in the Mental Health Unit to complete the questionnaire. The researcher and a member of staff were present throughout the completion process.

For both the community and clinical samples, adolescents completed the questionnaires anonymously. Additionally, they were informed in writing that their participation was voluntary and that they could withdraw at any time without any interference or penalties. Consent forms included a section where participants were asked to provide contact details in case they were interested in participating in an interview at a later stage. The questionnaires took approximately 45 min to complete. Upon completion, the adolescents were given a debriefing sheet.

In the second phase, a random sample of those who provided their contact details was selected. First, a new consent form was provided and signed by both the adolescents and their parents. The interview then took place in a quiet public location in the adolescents’ hometown and lasted approximately 30 min. It was emphasized that the interview was confidential and would only be used for research purposes. Subject to the participants’ agreement, the interviews were audio recorded, and the recordings were transcribed for analysis. The participants were assigned a unique study number so that only a record number could be linked to their data, ensuring complete confidentiality. At the end, a debrief sheet was provided.

Data Analysis

SPSS 29.0 was used to analyze the quantitative data. Multivariate analyses of variance (MANOVA) were performed to assess group differences in mental health problems and family factors separately. Prior to the analyses, all the assumptions of MANOVA were examined and confirmed, expect for homogeneity of variance-covariance matrices. The results of the Box's M tests were found significant (Box's M test for family factors =113.97, p < 0.01; Box's M test for mental health problems =345.39, p < 0.01), indicating that the matrices were not the same and that this assumption was violated. Therefore, Pillai's Trace Test (V value) was considered. Logistic Regression was conducted to examine the predictors of family functioning on adolescents’ mental health problems. Sample groups were used as binary outcomes, and FACES subscales were included as predictors, using the entry method. The sample size was 692 participants, indicating medium to large effect (Miles & Shevlin, 2001). To assess multicollinearity Spearman's Correlation coefficients were checked among the predictor variables in the model. Intercorrelations among predictors above .80 signal a problem, and those variables should be removed (Cohen, 1988). There were no variables with a correlation higher than .80; thus no variables caused multicollinearity. Therefore, all the FACES subscales were included in the logistic regression model. Residuals were also checked prior to the analysis. The predicted probabilities and residuals were used to examine the goodness of fit of the model. Standardized residuals were used to check that no more than 5% of cases had an absolute value above 2, no more than 1% had an absolute value above 2.5 and no case exceeded 3 (indicating an outlier). Based on this, no cases were excluded. Cook's distance values above 1 were examined and no cases needed to be excluded. The average leverage of the model was calculated (.01) to identify leverage values greater than three times this average value (.03). There were no cases of leverage values above .03; thus no cases needed to be removed. Finally, DFBeta values greater than 1 were checked, and none were found. After checking the residuals, none of the participants were excluded from further analysis. The significant level was set as 0.05. Effect sizes and confidence intervals were calculated.

Due to the fact that data from the community sample were collected from different classes, calculating the ICC was considered necessary to check for the impact of clustering variable (i.e., classes). The ICC examines the proportion of the total variance attributed to the variability between clusters; a large ICC indicates a high degree of heterogeneity across clusters (McCoach & Adelson, 2010). For the present study, the ICC for YSR total score was found to be 0.014, for the FACES cohesion total score it was 0.015, and for the FACES flexibility total score it was 0.014. As argued by Killip et al. (2004), a very small value of ICC indicates that the variation within clusters is much greater than the variation between clusters. Considering the fact that the ICC scores of the present study are small, it can be argued that differences among adolescents within the same class are larger that the differences among the classes themslves. Therefore, clustering may not have a significant effect on the measurements being studied, allowing for analyses at the individual level rather than at the cluster level. Nevertheless, it is important to clarify that the present study does not interested in drawing interferences between school classes.

For the analysis of the qualitative data, Thematic Analysis (Braun & Clarke, 2006) was used. The recordings were fully transcribed and coded on a line-by-line basis by the researcher. A detailed reading and preliminary coding of the data were conducted to identify different concepts. Each concept was written on a card with a short quotation from the interview that was relevant to it. The aim of this stage was not to record every instance of a concept but to include examples that added further meaning to the concept. A provisional list of codes (N = 22) was drawn up, and they were redefined or discarded as further analysis took place. Once the coding of concepts was complete, the concepts were refined by checking the cards against the transcripts. Definitions were then written for the concepts to establish a link between them and to generate the main themes. At the end of this stage, there were four themes for both sample groups. The themes involved the construction of several thematic maps to confirm that they aligned with the overall analysis and research aims. The analysis was conducted at the latent level, aiming to uncover underlying ideas, assumptions, and patterns within the data.

Results

Group Differences on Adolescent Mental Health Problems

MANOVA revealed a significant main effect of adolescents’ setting, V = .18; F_(9,682)= 16.50, p < 0.01, η²= .18. Follow-up univariate tests on each emotional and behavioral problem were conducted. ANOVAs revealed significant group effect on all YSR subscales including total score (Table 1). Adolescents from the clinical setting reported significantly more mental health problems than those from community setting. The effect size was small to medium for all variables.

Table 1.

Group Effect on Adolescents YSR Syndromes.

YSR Syndromes	Community		Clinical
YSR Syndromes	M	SD	M	SD	F(9,682)	η²
Internalizing Problems
Withdraw	2.93	2.44	5.94	3.38	97.39***	.12
Somatic Complaints	2.53	2.57	4.55	4.65	288.39***	.05
Anxious/Depressed	6.64	4.71	11.73	7.17	71.68***	.09
Externalizing Problems
Delinquent Behavior	3.27	3.09	6.64	5.71	65.82***	.09
Aggressive Behavior	9.27	5.56	15.44	8.82	74.12***	.10
Social Problems	2.45	2.06	5.43	3.77	116.37***	.14
Thought Problems	2.35	2.33	4.44	3.48	49.56***	.07
Attention Problems	4.78	3.00	8.21	4.04	84.26***	.11
Total YSR Problems	39.19	22.01	70.41	35.60	120.17***	.15

***p < 0.001

Group Differences on Family Functioning Variables

MANOVA revealed a significant main effect of the participants’ settings, V = .09; F_(9,682)= 8.54, p < 0.01, η²= .09. Follow-up univariate tests revealed significant group effect on Cohesion, Flexibility, Disengaged, Chaotic, Communication and Satisfaction (Table 2). Specifically, adolescents from the community setting reported significantly higher scores on the Cohesion, Flexibility Communication and Satisfaction, whereas adolescents from the clinical settings reported significanlty higher scores on Disengaged and Chaotic. No significant differences were found for the Rigid and Enmeshed variables. The effect size was small for all variables.

Table 2.

Group Effect on FACES Variables.

Family Functioning	Community		Clinical
Family Functioning	M	SD	M	SD	F(9,682)	η²
Balanced Cohesion	24.50	4.69	21.29	6.39	30.35***	.04
Balanced Flexibility	23.67	4.52	21.19	6.06	19.53***	.03
Disengaged	17.25	4.62	19.39	6.29	13.72***	.02
Enmeshed	18.03	3.66	17.50	4.89	.14	.00
Rigid	20.14	4.20	19.86	4.75	0.30	.00
Chaotic	17.35	4.56	18.76	6.04	6.21*	.01
Family Communication	36.35	7.86	30.48	10.55	36.23***	.05
Family Satisfaction	37.01	7.85	29.20	10.38	64.56***	.09

*p < 0.05, ***p < 0.001

Predictors of Adolescents Mental Health Problems

A logistic regression was conducted to investigate the impact of family functioning factors on the likelihood of experiencing a mental disorder. The model was statistically significant, χ²(8) = 60.38, p < .05, explaining between 8% (Cox & Snell R Square) and 16% (Nagelkerke R Square) of the variance in the clinical sample and correctly classifying 89% of cases. This result indicates that family functioning predicts the likelihood of developing mental health problems in adolescence. The estimates for the coefficients of predictors included in the model showed that the coefficient for family satisfaction was significant with Confidence Intervals (CI) for exp (B) from 0.88 to 0.95. This indicates that adolescents from the clinical setting reported being less satisfied with their parents than adolescents from the community setting (Table 3), suggesting that negative perceptions of family satisfaction are strongly related to the risk of experiencing mental health problems in adolescents. It should be noted that the Hosmer and Lemeshow test of goodness of fit of the model, χ2(8) = 19.60, p < .05, showed a poor fit, as the model predicted values that are were significantly different from those observed.

Table 3.

Logistic Regression for Predicting The Group (Adolescents from Community and Clinical Settings) of the Participants.

Variable	β	SE β	Wald (df = 1)	OR	95% CI for OR
Variable	β	SE β	Wald (df = 1)	OR	LL	UL
Constant	1.47	1.00	2.15	4.37
Balanced Cohesion	−.05	0,04	1.42	.95	.93	1.03
Balanced Flexibility	.02	0.04	.186	1.02	.93	1.11
Disengaged	−.01	0.03	.13	.99	.93	1.07
Enmeshed	−.01	0.04	.04	.99	.91	1.08
Rigid	.05	0.04	1.77	1.05	.98	1.13
Chaotic	−.01	0.04	.02	.99	.93	1.07
Family Communication	−.02	0.02	.63	.98	.94	1.03
Family Satisfaction	−.09***	0.02	17.88	.92	.88	.95

Note. OR = odds ratio; CI = confidence interval; LL = lower limit; UL = upper limit; R²= 0.08 (Cox & Snell); R²= 0.16 (Nagelkerke); Model χ² (8) = 60.38, p < 0.01.

***p < 0.001

Themes from Community Setting

Support and Responsiveness: Most of the adolescents described their parents as supportive, expressing that they could discuss their problems and feelings openly. For example, one girl said, “I can talk to them. I can express myself and they always help me… Both my parents are close to me. We discuss my problems whenever I have something to say”. Two boys indicated that discussing with their parents increased their sense of belonging. Parental responsiveness to adolescents’ expression was a significant predictor of a “better family environment”, as noted by a girl. Additionally, more than half of the adolescents reported feeling heard in family discussions and decision-making. As one girl stated, “I express myself and they accept my opinion. I tell them when I don’t like something in their behavior and ask them to change it… I like this because I feel that I am an equal member of the family”. A few adolescents who talked about family decision-making even used the word “democracy” to describe how decisions are made, indicating that they felt like active and respected members of their family. Interestingly, less than half of the adolescents reported not being able to spend as much time with their parents as they would like. However, a few of them characterized their relationships with their parents as “balanced” because they have “quality time together, even if this time is limited”. One boy remarked, “I may not like the fact that we have only one day per week when we do things all together, but when we do, we have a really good time, and it is very nice”.

Parental Involvement: About a third of the adolescents seemed to keep their parents involved in their social lives, perceiving this as “supervision”. One girl expressed, “My parents always share their opinion about my friends. They tell me when they like someone or not, and…I want them to know.. They help me”. Parental involvement was linked to adolescents’ problem-solving. Although more than half of the adolescents preferred to tackle their problems independently, they felt encouraged to seek parental support when necessary. As the adolescents mentioned in their interviews, their parents were very open to hearing and accepting their problems and were willing to help. One boy stated, “When I have a problem, especially something personal, I try to solve it on my own. If I can’t or if it is something really really big and difficult, I’ll ask them and discuss it with them to see what they have to say.”

Themes from Clinical Setting

Authoritarian and Unsupportive Parenting: A few adolescents mentioned feeling rejected because their parents were often unsupportive of their problems. One girl, who stated that her parents were not open to discussions, said, “I don’t get the attention I want… Many times my parents don’t accept my opinion and don’t support my decisions… They don’t like what I say. So no matter what my parents say, I will do what I want”. Adolescents’ narratives indicated that their parents do not understand them, don’t help them, impose strict rules and fail to involve them in family decision-making. As one boy expressed, “I don't really ask my parents for help when I have a problem. Why should I? They can’t help me. It is my problem, and I know that they won’t understand my point, so they won’t help me either”. Additionally, extreme controlling and monitoring of adolescents’ friendships characterized parental involvement in their social lives. For example, ‘crossing the line’ was a term a boy used to describe his mother's approach towards his friends. Feelings of criticism were also expressed by adolescents in this context. As one girl stated, “I have my own life…there is no need for my mother to know my friends, because when she meets them, she always has something bad to say… And I can’t stand this”.

Conflicts: A highly conflicted relationship between adolescents from the clinical setting and their parents was evident. Confict was often linked to demanding parenting styles and feelings of pressure. Many adolescents reported experiencing conflicting norms due to differing expectations between themselves and their parents, which led to feelings of stress and sadness. One girl expressed, “I fight all the time with my parents. They always want something more from me, and I don't like this. It makes me anxious and stressed…Sometimes they don't let me go out and meet my friends because I didn't study or clean my room”. Another source of conflict was parental authority. A few adolescents indicated that they became agreesive towards their parents when not allowed to go out and meet friends before finsihing their homework. School performance was a significant point of contention. For example, one girl said, “Every time my mother says ‘no’ to me, I become reactive and we fight. She can’t understand that she can’t have everything her own way…I know that we have rules in the home but my parents are very strict.”

Discussion

The present cross-sectional study aimed to explore differences in mental health problems between adolescents in clinical and in community settings. Additionally, it sought to examine the premise that family functioning impacts adolescents’ psychopathology. Drawing on results from both surveys and interviews, this study found that family functioning significantly affects adolescents’ mental health problems.

Firstly, findings from quantitative data indicated that adolescents in the clinical setting reported significantly higher levels of emotional and behavioral problems compared to their peers in the community setting. This aligns with previous research, which found that clinically referred adolescents experience distress related to worry (Üstün & Kennedy, 2009), aggressive family dynamics, and suicide attempts (Korell et al., 2024). Additionally, adolescents often demonstrate less psychosocial competence and satisfaction (Memmott-Elison et al., 2020), characteristics closely linked to their mental health conditions.

Secondly, a key finding of the present study is the significant impact of family functioning on adolescents’ mental health problems. Adolescents in the clinical setting reported their families as more disengaged and chaotic and noting high levels of conflict and criticism. Specifically, adolescents in the clinical sample were more likely to experience decreased family cohesion, flexibility, communication, and satisfaction, alongside increased enmeshment, disengagement, and chaotic environment. This aligns with Meeus (2016), who argues that adolescents play a crucial role in shaping their family environment. Previous research indicates that deficiencies in family functioning lead to reduced support, increased conflicts (Yöntem, 2019), and place adolescents at greater risk for developing mental health problems such as depression (Stavropoulos et al., 2015). Fosco and Lydon-Staley (2020) demonstrated that conflict during adolescence is associated with negative mood, while family disengagement can lower self-esteem and confidence, factors that adversely affect mental health. In contrast, adolescents from the community setting reported their families as flexible and supportive, consistent with findings Byrne et al. (2017), which linked parental monitoring, supervision, and open communication to better mental health outcomes. Additionally, aggressive behaviors were found to decrease in environments characterized by parental knowledge, family communication and expressiveness (Lippold et al., 2014).

However, it is important to note that this evidence is correlational, suggesting a potential bi-directional. Parenting a child with mental disorder may present challenges that negatively impact family functioning. While family functioning has been shown to influence adolescents’ emotional and behavioral problems, it is also possible that these problems shape adolescents’ perceptions of their parents and family dynamics. For instance, adolescents whose parents effectively monitor their behavior have fewer opportunities to engage in emotional and behavioral problems (Yang et al., 2024). Those raised in dysfunctional families characterized by lower cohesion and flexibility are at higher risk for mental health problems (Mastrotheodoros et al., 2020). Conversely, research predicts poorer adjustment and increased emotional dysregulation, which can subsequently affect parental monitoring, involvement and support (Lansford et al., 2018; Sander & McCarty, 2005). Collectively, these findings suggest a reciprocal influence between family functioning and adolescents’ mental health.

Lastly, the results showed that only family satisfaction was a significant predictor of adolescents’ mental health problems. This finding stands in contrast to existing literature, which suggests that a range of family factors, including communication, cohesion, support, and control, are typically important predictors of psychopathological symptoms in adolescents (Ronan et al., 2008). Notably, low communication, low cohesion, low support, and high parental control have been closely linked to family satisfaction (Shittu et al., 2014). These elements may highlight the connection between family functioning and adolescents’ mental health, as they can have either direct or indirect effect on adolescents’ sense of fulfillment within their families (Marshall & Henderson, 2014).

Limitations

Several limitations should be considered when interpreting the findings. First, while logistic regression is a robust analytical method, caution is warranted regarding the interpretation of results. Second, the cross-sectional design of the study limits the ability to assess causality; further longitudinal studies are needed to better understand the trajectories of mental health problems in adolescents and to clarify the nature of the association observed. Third, there was a lack of control and acknowledge regarding the clinical diagnoses of adolescents, as these were not confirmed within the sample group. clinical adolescents’ diagnosis as it was not confirmed by this sample group. This limitation complicates the ability to draw conclusions about the influence of symptomatology on the examined associations. Fourth, the two sample groups were unequal, with a greater representation from the community sample. Finally, the study focused solely on family factors, making it challenging to develop a comprehensive understanding on the risk and protective factors related to adolescents’ mental health. Future research should consider collecting data from multiple aspects of the social environment, such as school and peer influences, to gain a more holistic understanding of adolescents’ mental health problems.

Conclusion

In conclusion, adolescents from clinical settings exhibited higher rates of mental health problems compared to those from community setting. While differences in family functioning were noted, only family satisfaction emerged as a significant predictor of mental health problems. Interestingly, qualitative findings highlighted that support, responsiveness, and parental involvement in adolescents’ problem-solving and decision-making processes significantly influenced their mental health. Conversely, unsupportive parenting, conflict, and authoritarian control were identified as critical factors affecting clinically referred adolescents. Thus, even though family functioning and communication did not statistically predict mental health problems, the interviews indicated that they do have an impact. This underscores the value of employing a mixed-method approach in this study. Future research should further investigate the role of socio-demographic variables in the relationship between family functioning and adolescents’ mental health to gain a deeper understanding of how family dynamics affect adolescent well-being.

Footnotes

Acknowledgments

I would like to thank Ministry of Education, Sport and Youth, Ministry of Health and Child and Adolescent Mental Health Services and all children participated.

ORCID iD

Constantina Demetriou

Ethical Considerations

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional, national research committees and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This study was approved by the Cyprus National Bioethics Committee, No. ΕΕΒΚ ΕΠ 2011/05), the Cyprus Ministry of Education Culture Sport and Youth (No. 7.19.46.7/16), the Cyprus Ministry of Health (No: M.H.S.5.34.3) and the University of Roehampton London (No. PSY10/055).

Consent to Participate

Written informed consent was obtained from all children included in the study and from their parents. Participants signed informed consent regarding publishing their data.

Consent for Publication

In the consent form, gained from all children and their parents, there was a clear statement indicating that they consent to publish the results of the study on the condition that their identity cannot be revealed.

Funding

The author received no financial support for the research, authorship, and publication of this article.

Declaration of Conflicting Interests

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

Author Biography

Dr. Constantina Demetriou is an Assistant Professor of Clinical Psychology at the Department of Social and Behavioral Sciences of European University Cyprus. Her research interests are adolescent's psychopathology, risk and protective factors with a focus on family environment and attachment. She is also interested in peer relations. Parallel, she works on projects focuses on child abuse.

References

Achenbach

T. M.

(1991). Manual of the child behavior checklist/4-18 and 1991 profiles. Burlington.

Baiocco

Cacioppo

Laghi

Tafa

(2013). Factorial and construct validity of FACES IV among Italian adolescents. Journal of Child and Family Studies, 22(7), 962–970. https://doi.org/10.1007/s10826-012-9658-1

Benson

M. J.

Buehler

(2012). Family process and peer deviance influences on adolescent aggression: Longitudinal effects across early and middle adolescence. Child Development, 83(4), 1213–1228. https://doi.org/10.1111%2Fj.1467-8624.2012.01763.x

Boele

Bülow

Beltz

A. M.

de Haan

Denissen

J. J. A.

de Moor

M. H. M.

Keijsers

(2024). Like no other? A family specific network approach to parenting adolescents. Journal of Youth and Adolescence, 53(4), 982–997. https://doi.org/10.1007/s10964-023-01912-5

Bogels

S. M.

Brechman-Toussaint

M. L.

(2006). Family issues in child anxiety: Attachment, family functioning, parental rearing and beliefs. Clinical Psychology Review, 26(7), 834–856. https://doi.org/10.1016/j.cpr.2005.08.001

Braun

Clarke

(2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77–101. https://doi.org/10.1191/1478088706qp063oa

Brown

L. S.

Wright

(2003). The relationship between attachment strategies and psychopathology in adolescence. Psychology and Psychotherapy: Theory, Research and Practice, 76(4), 351–367. https://doi.org/10.1348/147608303770584728

Buehler

(2020). Family processes and children’s and adolescents’ wellbeing. Journal of Marriage and Family, 82(1), 145–174. https://doi.org/10.1111/jomf.12637

Byrne

M. L.

Badcock

P. B.

Simmons

J. G.

Whittle

Pettitt

Olsson

C. A.

Mundy

L. K.

Patton

G. C.

Allen

N. B.

(2017). Self-reported parenting style is associated with children’s inflammation and immune activa-tion. Journal of Family Psychology, 31(3), 374–380. https://doi.org/10.1037/fam0000254

10.

Childs

K. K.

Brady

C. M.

Cameron

A. L. J.

Kaukinen

(2022). The role of family structure and family processes on adolescent problem behavior. Deviant Behavior, 43(1), 1–16. https://doi.org/10.1080/01639625.2020.1771128

11.

Cohen

(1988). Statistical power analysis for the behavioral sciences (2nd ed.). Routledge. https://doi.org/10.4324/9780203771587

12.

Daches

Vine

Layendecker

K. M.

George

C. J.

Kovacs

(2018). Family functioning as perceived by parents and young offspring at high and low risk for depression. Journal of Affective Disorders, 226, 355–360. https://doi.org/10.1016/j.jad.2017.09.031

13.

Essau

C. A.

Lewinsohn

P. M.

Olaya

Seeley

J. R.

(2014). Anxiety disorders in adolescents and psychosocial outcomes at age 30. Journal of Affective Disorders, 163, 125–132. https://doi.org/10.1016/j.jad.2013.12.033

14.

Fairchild

Hawes

D. J.

Frick

P. J.

Copeland

W. E.

Odgers

C. L.

Franke

Freitag

C. M.

De Brito

S. A.

(2019). Conduct disorder. Nature Reviews Disease Primers, 5(43). https://doi.org/10.1038/s41572-019-0095-y

15.

Fosco

G. M.

Lydon-Staley

D. M.

(2020). Implications of family cohesion and conflict for adolescent mood and wellbeing: Examining within- and between-family processes on a daily timescale. Family Process, 59(4), 1672–1689. https://doi.org/10.1111/famp.12515

16.

Hawes

D. J.

Allen

J. L.

Essau

C. A.

Fisher

(2021). The role of the family in child and adolescent psychopathology. In Allen

J. L.

Hawes

D. J.

Essau

C. A.

(Eds.), Family-Based intervention for child and adolescent mental health: A core competencies approach (pp. 14–28). Cambridge University Press. https://doi.org/10.1017/9781108682053

17.

Hodge

C. J.

Duerden

M. D.

Layland

E. K.

Lacanienta

Goates

M. C.

Niu

X. M.

(2017). The association between family leisure and family quality of life: A meta-analysis of data from parents and adolescents. Journal of Family Theory & Review, 9(3), 328–346. https://doi.org/10.1111/jftr.12202

18.

Kenny

Dooley

Fitzgerald

(2013). Interpersonal relationships and emotional distress in adolescence. Journal of Adolescence, 36(2), 351–360. http://doi.org/10.1016/j.adolescence.2012.12.005

19.

Killip

Mahfoud

Pearce

(2004). What is an intracluster correlation coefficient? Crucial concepts for primary care researchers. Annals of Family Medicine, 2(3), 204–208. http://doi.org/10.1370/afm.141

20.

Korell

A. M.

Peer

S. O.

Sharp

(2024). Psychosocial competencies among clinical-referred and community-based children: Known-groups validity of the Psychosocial Strengths Inventory for children and adolescents. Research on Child and Adolescent Psychopathology, 52(6), 1009–1022. https://doi.org/10.1007/s10802-023-01160-y

21.

Lansford

J. E.

Rothenberg

W. A.

Jensen

Lippold

M. A.

Bacchini

Bornstein

M. H.

Chang

Deater-Deckard

Giunta

L. D.

Dodge

K. A.

Malone

P. S.

Oburu

Pastorelli

Skinner

A. T.

Sorbring

Steinberg

Tapanya

Tirado

L. M. U.

Alampay

L. P.

Al-Hassan

(2018). Bidirectional relations between parenting and behavior problems from age 8 to 13 in nine countries. Journal of Research on Adolescence, 28(3), 571–590. https://doi.org/10.1111/jora.12381

22.

Lippold

M. A.

Greenberg

M. T.

Graham

J. W.

Feinberg

M. E.

(2014). Unpacking the effect ofparental monitoring on early adolescent problem behavior: Mediation by parental knowledge and moderation by parent–youth warmth. Journal of Family Issues, 35(13), 1800–1823. https://doi.org/10.1177/0192513(13484120

23.

Marshall

Henderson

(2014). The influence of family context on adolescent depression: A literature review. Canadian Journal of Family and Youth, 6(1), 163–187. https://doi.org/10.29173/cjfy21488

24.

Mastrotheodoros

Canario

Gugliandolo

M. C.

Merkas

Leijsers

(2020). Family functioning and adolescent internalizing and externalizing problems: Disentangling between-, and within- family associations. Journal of Youth and Adolescence, 49(4), 804–817. https://doi.org/10.1007/s10964-019-01094-z

25.

McCoach

D. B.

Adelson

J. L.

(2010). Dealing with dependence (Part I): Understanding the effects of clustered data. Gifted Child Quarterly, 54(2), 152–155. https://doi.org/10.1177/0016986210363076

26.

Meeus

(2016). Adolescent psychosocial development: A reviw of longitudinal models and research. Developmental Psychology, 52(12), 1969–1993. https://doi.org/10.1037/dev0000243

27.

Memmott-Elison

M. K.

Holmgren

H. G.

Padilla-Walker

L. M.

Hawkins

A. J.

(2020). Associations between prosocial behavior, externalizing behaviors, and internalizing symptoms during adolescence: A meta-analysis. Journal of Adolescence, 80(1), 98–114. https://doi.org/10.1016/j.adolescence.2020.01.012

28.

Miles

J. N. V.

Shevlin

(2001). Applying regression and correlation: A guide for students and researchers. Sage.

29.

Olson

D. H.

(2011). FACES IV the Circumplex model: Validation study. Journal of Marital and Family Therapy, 3(1), 64–80. https://doi.org/10.1111/j.1752-0606.2009.0015.x

30.

Olson

D. H.

Waldovogel

Schlieff

(2019). Circumplex model of marital and family systems: An update. Journal of Family Theory and Review, 11(12), 199–211. https://doi.org/10.1111/jftr.12331

31.

Oltean

I. I.

Perlman

Meyer

Ferro

M. A.

(2020). Child mental illness and mental health service use: Role of family functioning (family functioning and child mental health). Journal of Child and Family Studies, 29(2), 2602–2613. https://doi.org/10.1007/s10826-020-01784-4

32.

Ortiz-Sanchez

F. A.

Brambila-Tapia

A. J. L.

Cardenas-Fulita

L. S.

Toledo-Lozano

C. G.

Samudio-Cruz

M. A.

Gomez-Diaz

Garcia

Rodriguez-Arellano

M. E.

Zamora-Gonzalez

E. O.

Lopez-Hernandez

(2023). Family functioning and suicide attempts in Mexican adolescents. Behavioral Sciences, 13(2), 120. https://doi.org/10.3390/bs13020120

33.

Pereira

M. L.

Ferraz

M. P.

Pecanha

D. L. N.

Mesquita

M. E.

Finazzi

M. E. P.

Bordin

I. A. S.

(2015). Family functioning in adolescents with major depressive disorder: A comparative study. Estudos de Psicologia (Campinas), 32(4), 641–652. https://doi.org/10.1590/0103-166X2015000400007

34.

Perez-Fuentes

M. D. C.

Jurado

M. D. M. M.

Martın

A. B. B.

Linares

J. J. G.

(2019). Family functioning, emotional intelligence, and values: Analysis of the relationship with aggressive behavior in adolescents. International Journal of Environmental Research and Public Health, 16(3), 478. https://doi.org/10.3390/ijerph16030478

35.

Qiao

Lin

Huang

Zhou

Huang

Shang

Zhang

Xie

(2024). An exploration of the association between family functioning and nonsuicidal self-injury among Chinese adolescents with mood disorders. The European Journal of Psychiatry, 38(1), 1–8. https://doi.org/10.1016/j.ejpsy.2023.100226

36.

Rivero

Martinez-Pampliega

Olson

D. H.

(2010). Spanish adaptation of the FACES IV questionnaire: Psychometric characteristics. The Family Journal: Counselling and Therapy of Couples and Families, 18(3), 288–296. https://doi.org/10.1177/1066480710372084

37.

Ronan

G. F.

Dreer

L. E.

Gerhart

J. I.

(2008). Adolescent psychiatric patients and their parents: Comparison with a non-clinical cohort. International Journal of Adolescent Medicine and Health, 20(4), 405–418. https://doi.org/10.1515/ijamh.2008.20.4.405

38.

Sander

J. B.

McCarty

C. A.

(2005). Youth depression in the family context: Familial risk factors and models of treatment. Clinical Child and Family Psychology Review, 8(3), 203–219. https://doi.org/10.1007%2Fs10567-005-6666-3

39.

Santesteban-Echarri

MacQueen

Goldstein

B. I.

Wang

J. L.

Kennedy

S. H.

Bray

Lebel

Addington

(2018). Family functioning in youth at-risk for serious mental illness. Comprehensive Psychiatry, 87, 17–24. https://doi.org/10.1016/j.comppsych.2018.08.010

40.

Scully

McLaughlin

Fitzgerald

(2020). The relationship between adverse childhood experiences, family functioning and mental health problems among children and adolescents: A systematic review. Journal of Family Therapy, 42(2), 291–316. https://doi.org/10.1111/1467-6427.12263

41.

Shannon

C. S.

(2022). #Family: Exploring the display of family and family leisure on Facebook and Instagram. Leisure Sciences, 44(4), 459–475. https://doi.org/10.1080/01490400.2019.1597792

42.

Shittu

R. O.

Issa

B. A.

Olanrewaju

G. T.

Mahmoud

A. O.

Odeigah

L. O.

Sule

A. G.

(2014). Family dysfunction among depressed HIV/AIDS patients on HAART, in a secondary health institution, in north central Nigeria. HIV & AIDS Review, 13(2), 50–55. https://doi.org/10.1016/j.hivar.2014.02.005

43.

Solmi

Radua

Olivola

Croce

Soardo

Salazar de Pablo

Shin

J. II.

Kirkbride

J. B.

Jones

Kim

J. H.

Kim

J. Y.

Carvalho

A. F.

Seeman

M. V.

Correll

C. U.

Fusar-Poli

(2022). Age at onset of mental disorders worldwide: Large-scale meta-analysis of 192 epidemiological studies. Molecular Psychiatry, 27(1), 281–295. https://doi.org/10.1038/s41380-021-01161-7

44.

Stavropoulos

Lazaratou

Marini

Dikeos

(2015). Low family satisfaction and depression in adolescence: The role of self-esteem. Journal of Educational and Developmental Psychology, 5(2), 109–118. https://doi.org/10.5539/jedp.v5n2p109

45.

Theobald

Farrington

D. P.

(2012). Child and adolescent predictors of male intimate partner violence. Journal of Child Psychology and Psychiatry, 53(12), 1242–1249. https://doi.org/10.1111/j.1469-7610.2012.02577.x

46.

Trong Dam

V. A.

H. N.

Thi Vu

T. B.

K. L.

H. M.

Thi Nguyen

N. T.

Nguyen

T. T.

Thi Vu

T. M.

Thi Nguyen

T. P.

Auquier

Boyer

Fond

Latkin

C. A.

C. S. H.

R. C. M.

(2023). Associations between parent-child relationship, self-esteem, and resilience with life satisfaction and mental wellbeing of adolescents. Frontiers in Public Health, 11, 1–11. https://doi.org/10.3389/fpubh.2023.1012337

47.

United Nations Children’s Fund. (2021). The state of the world’s children 2021: On my mind – promoting, protecting and caring for children’s mental health. https://www.unicef.org/media/114636/file/SOWC-2021-full-report-English.pdf

48.

Üstün

T. B.

Kennedy

(2009). What is “functional impairment?” Disentangling disability from clinical significance. World Psychiatry, 8(2), 82–85. https://doi.org/10.1002/j.2051-5545.2009.tb00219.x

49.

van Lang

N. D. J.

Ferdinand

R. F.

Oldehinkel

A. J.

Ormel

Verhulst

F. C.

(2005). Concurrent validity of the DSM-IV scales affective disorders and anxiety disorders of the youth self-report. Behaviour Research and Therapy, 43(11), 1485–1494. https://doi.org/10.1016/j.brat.2004.11.005

50.

Verhulst

F. C.

Achenbach

T. M.

van der Ende

Erol

Lambert

M. C.

Leung

P. W. L.

Silva

M. A.

Zilber

Zubrick

S. R.

(2003). Comparisons of problems reported by youths from seven countries. American Journal of Psychiatry, 160(8), 1479–1485. https://doi.org/10.1176/appi.ajp.160.8.1479

51.

Vizard

Sadler

Ford

Newlove-Delgado

McManus

Marcheselli

Davis

Williams

Leach

Mandalia

Cartwright

(2020). Mental health of children and young people in England, 2020: Wave 1 follow up to the 2017 survey. Health and Social Care Information Centre. https://www.infocop.es/pdf/mhcyp_2020_rep.pdf

52.

Vujovic

(2024). Re-examining the association between parental monitoring, parental rearing behaviors and family risk factors in influencing juvenile delinquency among boys and girls. Families in Society: The Journal of Contemporary Social Services, 105(2), 324–333. https://doi.org/10.1177/10443894231221280

53.

Wong

R. S.

Tung

K. T. S.

Chow

K. H. T.

Law

A. R. M.

F. K. W.

Chan

K. L.

(2023). Exploring the role of family communication time in the association between family dinner frequency and adolescent psychological distress. Current Psychology, 42, 13868–13876. https://doi.org/10.1007/s12144-021-02639-x

54.

Yang

Lippold

M. A.

Schlomer

G. L.

Feinberg

M. E.

Fosco

G. M.

(2024). Protective effect of parental monitoring on early-to-mid adolescents displaying high-level and increasing aggressive behavior. Applied Developmental Science, 28(3), 375–390. https://doi.org/10.1080/10888691.2023.2221437

55.

Yöntem

M. K.

(2019). Development of family functions and relationship in families: A mixed-design study. The American Journal of Family Therapy, 47(5), 344–359. https://doi.org/10.1080/01926187.2019.1673259

Family Functioning and Adolescents’ Mental Health Problems: A Mixed-methods Analysis of Community and Clinical Samples

Abstract

Keywords

Introduction

The Present Study

Method

Participants

Measures

Procedure

Data Analysis

Results

Group Differences on Adolescent Mental Health Problems

Group Differences on Family Functioning Variables

Predictors of Adolescents Mental Health Problems

Themes from Community Setting

Themes from Clinical Setting

Discussion

Limitations

Conclusion

Footnotes

Acknowledgments

ORCID iD

Ethical Considerations

Consent to Participate

Consent for Publication

Funding

Declaration of Conflicting Interests

Author Biography

References