Epilepsy Research 117 (2015) 7–10

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Epilepsy Research
journal homepage: www.elsevier.com/locate/epilepsyres

Short communication

Short communication: Flourishing among adolescents with epilepsy:

Correlates and comparison to peers
Cathleen Odar Stough a,∗ , Laura Nabors b , Ashley Merianos b , Jiaqi Zhang b
a
Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue MLC 3015, Cincinnati,
OH 45229, USA
b
School of Human Services, College of Education, Criminal Justice, and Human Services, University of Cincinnati, 2600 Clifton Avenue Mail Location 0068,
Cincinnati, OH 45221, USA

a r t i c l e i n f o a b s t r a c t

Article history: This study was conducted to examine if adolescents with a seizure disorder/epilepsy display less flour-
Received 27 March 2015 ishing (thriving) than peers without seizures using data from the National Survey of Children’s Health
Received in revised form 24 July 2015 2011–2012. Adolescent demographics, symptom severity, and parents’ anger toward their child were
Accepted 5 August 2015
explored as possible predictors of flourishing. Adolescents with seizures exhibited lower flourishing
Available online 7 August 2015
than peers, and flourishing among adolescents with seizures was predicted by symptom severity, age,
race/ethnicity, sex, and parental anger. Study results suggest adolescents with a seizure disorder/epilepsy
Keywords:
should be targeted for interventions that promote flourishing.
Adolescents
Epilepsy © 2015 Elsevier B.V. All rights reserved.
Flourishing
National Survey of Children’s Health

Introduction focusing on a person’s well-being and mental wellness. Flourish-

Epilepsy impacts approximately 1% of children and adolescents
in the United States (US; Russ et al., 2012). Adolescents with
epilepsy (AWE) are at risk for a number of negative psychosocial
outcomes. AWE experience increased rates of psychological disor-
ders, such as depression, anxiety, conduct problems, and Attention
Deficit Hyperactivity Disorder (Rodenburg et al., 2005a; Russ et al.,
2012), and approximately 40% of AWE have been diagnosed with
a mental health condition (Wagner et al., 2015). AWE have also
been described as having a lower quality of life (Taylor et al., 2011),
greater academic problems (Bailet and Turk, 2000), and poorer
social skills (Rodenburg et al., 2005a) in comparison to peers. These
youth may also experience peer stigmatization, such that same-
aged peers have been found to be more reluctant toward developing
a friendship with AWE (Cheung and Wirrell, 2006).
Recent theory has highlighted the importance of not focusing
solely on impairments in functioning and symptoms indicative of
mental health problems, but also on positive behaviors, feelings,
and functioning (Keyes, 2002, 2007). This perspective emphasizes
∗ Corresponding author. Tel.: +1-513-803-0925; fax: +1-513-636-3677.
E-mail addresses: odarcc@gmail.com (C. Odar Stough), laura.nabors@uc.edu
(L. Nabors), ashley.merianos@uc.edu (A. Merianos), zhangjq@mail.uc.edu
(J. Zhang).
ing represents a positive mental health construct and has been
defined as “to live within an optimal range of human functioning,
one that connotes goodness, generativity, growth, and resilience”
(Fredrickson and Losada, 2005, p. 678).
Sociodemographic factors have been related to variations in
the prevalence of flourishing. Research conducted among adults
suggests gender differences in psychological well-being with
males and females displaying unique strengths in certain areas
(Roothman et al., 2003). For example, males experience higher
self-concept and positive automatic thoughts, while females show
higher religious well-being and expression of affect. Within ado-
lescents, mood and anxiety disorders are more prevalent among
females (Merikangas et al., 2010), and occurrence of these men-
tal health disorders may be a barrier to reaching positive mental
health and flourishing. Age differences in flourishing have also been
noted. Among adults, older age groups have the highest flourishing
(Keyes and Westerhof, 2011). However, a study with adolescents
found flourishing to be the most common mental health status
in youth 12–14 years (approximately 49% of youth were flourish-
ing), while being only moderately mentally healthy was the most
common mental health status among youth 15–18 years (with
only approximately 40% of youth meeting criteria for flourishing;
Keyes, 2006). Regarding racial and ethnic differences in flourish-
ing, African American adults display higher rates of flourishing than
their Caucasian peers (Keyes, 2009).

http://dx.doi.org/10.1016/j.eplepsyres.2015.08.004
0920-1211/© 2015 Elsevier B.V. All rights reserved.
8 C. Odar Stough et al. / Epilepsy Research 117 (2015) 7–10

Positive development, thriving, and flourishing among AWE Table 1

Participant demographics.
may be negatively impacted by their greater risk for poor behav-
ioral, mental health, academic, social, and quality of life outcomes, Adolescents with Adolescents without
especially during adolescence when a substantial portion of devel- epilepsy (n = 182) n (%) epilepsy (n = 23,617) n (%)
opment, independence, and self-definition occurs. Parental factors Sex
may also have a significant impact on adolescent development and Boy 94 (52%) 12,435 (53%)
thriving (e.g., Paley et al., 2000). Morris et al. (2007) found parental Girl 88 (48%) 11,156 (47%)
Missing 0 (0%) 26 (<1%)
displays of anger and negative parenting were related to poorer
Age
youth emotion regulation. This is particularly concerning for devel-
14 yrs 48 (26%) 5317 (23%)
opment in AWE, given parents of youth with epilepsy experience 15 yrs 42 (23%) 5719 (24%)
increased parenting stress (e.g., Chiou and Hsieh, 2008; Wirrell 16 yrs 40 (22%) 6222 (26%)
et al., 2008). In fact, familial and parental factors have been related 17 yrs 52 (29%) 6359 (27%)
to psychopathology and adjustment in AWE (Hodes et al., 1999; Race
Rodenburg et al., 2005b). White 139 (76%) 17,826 (75%)
Black 19 (10%) 2264 (10%)
The current study investigated whether adolescents with a
Other 23 (13%) 3007 (13%)
seizure disorder/epilepsy display lower rates of flourishing than Missing 1 (1%) 520 (2%)
their peers without seizures. The relations among adolescent
demographics, symptom severity, and flourishing also were exam- aforementioned questions on a 5-point scale (never, rarely, some-
ined to determine risk factors for lower flourishing as a guide for times, usually, or always). A flourishing composite score was
targeted prevention and intervention efforts. created from the three items. For this score a “1” indicated that the
parent provided an answer of “usually” or “always” to one of the
Material and methods items. A “2” or “3” indicated that a parent had provided a response of
usually or always to 2 or 3 of the questions, respectively. Since this
Data source and participants
outcome variable represented a frequency count of endorsed items
Data were drawn from the National Survey of Children’s Health rather than a categorical response, this variable was conceptualized
(NSCH) 2011–2012 (Child and Adolescent Health Measurement as a continuous variable with 0 representing no flourishing items
Initiative [CAHMI], 2013a). This is a national telephone based sur- endorsed.
vey in the US in which parents and legal guardians provided data Parents reported whether they felt angry with their child on a 5-
about one of their children’s health and development. Families point scale (never, rarely, sometimes, usually, always). Parents also
were recruited using cross-sectional list-assisted random digit dial rated how well they cope with the day to day demands of parent-
samples of landline telephone and cellphone numbers from all hood on a 4-point scale (very well, somewhat well, not very well,
50 US states including the District of Columbia and the US Vir- not very well at all). The child’s epilepsy was rated by parents as
gin Islands. Households with a child under 18 years and able mild, moderate, or severe. For inclusion in analyses, all categorical
to complete the phone interview in English, Spanish, Mandarin, predictor variables were dichotomized.
Cantonese, Vietnamese, or Korean met study inclusion criteria. If
multiple children lived in the home, one child was selected at ran- Data analyses
dom, and parents completed the interview about this single child.
The interview was completed with the parent or guardian with the Data were assigned a sampling weight for the probability of
most knowledge of the child’s health. Average interview length was selecting telephone numbers for the linear regression analysis and
approximately 33 min. Interview completion rate was 54.1% for the t-test. A t-test was conducted to examine whether flourishing
landline sample and 41.2% for the cell-phone sample. A complete differed between adolescents with and without a seizure disor-
description of the study methodology has been provided elsewhere der/epilepsy. A linear regression analysis was used to determine
(CAHMI, 2013a). whether flourishing was related to parent coping, parent anger,
The current study was approved by the authors’ university- severity of epilepsy, and adolescent demographic variables (sex,
based institutional review board and permission was provided by age in years, race). Prior to running analyses, the normality and dis-
the Data Resource Center for Child and Adolescent Health to con- tribution of the outcome variable (i.e., flourishing) was assessed,
duct analyses (CAHMI, 2013a,b). The NSCH 2011–2012 resulted in and the variable was found to be normally distributed. List-wise
95,677 interviews. Interviews were completed for 23,799 adoles- deletion was used if missing data was present.
cents between the ages of 14 to 17 years of age and were included
in the current analyses. One hundred and eighty-two of these ado- Results
lescents currently had epilepsy or a seizure disorder.
Participant demographics are presented in Table 1; parent
report of feeling angry with their child is presented in Table 2.
Description of study variables Results of a t-test indicated a statistically significant difference
in flourishing between adolescents with and without a seizure
Parent-report of youth well-being or thriving, which is termed disorder/epilepsy (t = 7.71, p < .001). Adolescents with a seizure
by the NSCH as “flourishing”, (CAHMI, 2013a) was used as the disorder/epilepsy displayed lower flourishing (M = 1.57, SD = 1.11)
outcome variable. Three questions were developed to assess
flourishing by an expert panel, including professionals with a Table 2
background in survey methodology, children’s health, commu- Frequency of parent anger toward their adolescent with epilepsy.

nity organizations, and family leaders, in conjunction with input n (%)

from a public comment period (CAHMI, 2013a). The three ques- Never 58 (32%)
tions assessed the adolescent’s (1) interest and curiosity in learning Rarely 61 (34%)
new things, (2) staying calm and in control when facing a chal- Sometimes 55 (30%)
lenge, and (3) following through with what he/she says he or she Usually 6 (3%)
Always 2 (1%)
will do. Interviewers recorded parent responses to each of the
 C. Odar Stough et al. / Epilepsy Research 117 (2015) 7–10
Table 3
Regression coefficients for predictors of flourishing among adolescents with epilepsy.
B Std error
Sex of the adolescent −.425 .004
Ethnic group −.187 .003
Adolescent age .080 .002
Angry with child −.243 .002
Severity of seizure disorder −.305 .005
than adolescents without a seizure disorder/epilepsy (M = 2.21,
SD = .98).
Among adolescents with a seizure disorder/epilepsy, a linear
regression was conducted with adolescent flourishing as a depend-
ent variable and severity of seizure disorder, age, ethnic group,
sex, and parent anger as predictors. This model explained about
19.5% of the variance in flourishing scores. All of the predictors in
our final model were statistically significant (see Table 3). Results
indicated that female, racial minorities (i.e., black and other racial
categories), and younger adolescents had lower flourishing scores.
Adolescents with parents who experienced more anger and who
reported having moderate/severe seizures also had lower flourish-
ing scores. A second linear regression that included parent coping
was also conducted, but the variance accounted for by the model
remained unchanged, and therefore, this variable was not included
in our final model.
Discussion
Our study findings were consistent with research indicating
that AWE experience lower well-being and increased risk for neg-
ative psychological outcomes than adolescents who do not have
a chronic illness (e.g., Bailet and Turk, 2000; Wagner et al., 2015).
AWE are also less likely to flourish during adolescence. Given ado-
lescents with epilepsy are at greater risk for psychopathology and
problems in academic, social, and family functioning, it may be the
case that positive development is difficult to achieve in the con-
text of these negative outcomes. Parental anger toward the child,
disease severity, and child demographic factors (i.e., sex, ethnic-
ity, age) accounted for approximately 20% of the variance in child
flourishing outcomes, suggesting that these factors are major con-
tributors to flourishing but that there are likely numerous other
unidentified factors contributing to flourishing outcomes. Future
research should explore the mechanisms by which AWE experience
barriers to thriving during adolescence.
Adolescents who are in minority racial groups, younger, and
female displayed lower flourishing scores. Past research has also
supported the relationship between sociodemographic factors and
flourishing (e.g., Roothman et al., 2003; Keyes, 2006). Interestingly,
however, the finding that children in minority racial groups dis-
played lower flourishing is in contrast to adult research showing
greater flourishing among African Americans (Keyes, 2009). It may
be that the relationship between flourishing and sociodemographic
factors is complex with the possibility of interaction effects where
the influence of certain demographic factors (e.g., ethnicity) varies
by other demographic factors (e.g., age). Also, our finding that older
youth displayed greater flourishing is in contrast to prior research
that has suggested flourishing is more common among younger
adolescents (i.e., 12–14 years) than older adolescents (i.e., 15–18
years; Keyes, 2006). More research is needed to gain a better under-
standing on why these findings differ from existing literature (e.g.,
whether predictors of flourishing vary between healthy youth and
youth with medical conditions). In providing patient care, health
providers should also be cognizant of the relationship between
severity of epilepsy and poorer flourishing and consider referral to
9
Beta t p
−.255 −98.14 <.001
−.176 −65.37 <.001
.101 38.096 <.001
−.284 −105.733 <.001
−.177 −67.84 <.001
support groups for youth with more severe symptoms when they
are not functioning well in school and report low well-being.
Adolescents whose parents displayed less anger toward them
showed greater flourishing outcomes. This is consistent with past
research that has demonstrated a connection between parental
anger and harsh parenting (which includes overt expressions of
anger) and child outcomes, such as externalizing behavior prob-
lems (Denham et al., 2000) and emotion regulation (Chang et al.,
2003). It will be important for health professionals to assess par-
ent anger toward their teenager and determine if parent anger is
impacting child functioning to the extent that referral for counsel-
ing is indicated. In addition, future research, assessing the interplay
among parent anger and child reactions, and severity of symptoms
of epilepsy is needed.
The survey was cross-sectional and based on parent-report.
Information about flourishing over time is needed and use of obser-
vational or more objective measures would be helpful. Future
research should examine the unique needs of AWE and their unique
barriers to thriving during adolescence and throughout their transi-
tion into adulthood, including among adolescents with more severe
symptoms and adolescents of color.
Conclusions
Initiatives promoting flourishing in AWE are warranted. A com-
prehensive approach to care for AWE should be considered as
mental health professionals may assist in appropriate psychoso-
cial development and adjustment. Prevention and intervention
programming for adolescents with more severe symptoms and
adolescents of color may help reach adolescents in need of pro-
motion of resilience factors to improve flourishing. Interventions
to promote flourishing should also consider a parent component
such as educating parents on the negative influence their anger
may have on their AWE and providing parents with information to
help them cope with their anger may increase flourishing scores in
these adolescents.
Acknowledgement
No financial assistance or funding was provided for the current
study.
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