Keywords

Introduction

Early in February 2013, National Public Radio (NPR; Greene, 2013a, b) produced a week-long series of reports highlighting current issues on the island of Puerto Rico. The strengths mentioned in the broadcast served as a contrast to the severe realties currently faced by Puerto Ricans residing on the island (Greene, 2013a, b). Duly noted in the NPR stories were the myriad positive aspects of life in Puerto Rico, such as strong family ties that cross generations and the Latin-Caribbean music and rhythms that create a particular warmth and positive energy. The beauty and joy of Puerto Rico’s people and its lifestyle are, however, marred by poverty, emigration, and violence. Indeed, the NPR reporter questioned whether the current scenario in Puerto Rico—one where the unemployment rate is at 14 % (Greene, 2013b) and violent crime surpasses levels in the USA as a whole by a factor of six (Greene, 2013a)—will provide Puerto Rican youth the kind of environment needed to be able to grow, prosper, and, ultimately, take advantage of future opportunities. This chapter addresses one particular aspect of the issue of youth and health, that of psychological well-being , in a sample of Puerto Rican children and adolescents, their families, and their teachers. In the upcoming pages, stressors and supports as viewed by children, parents, and educators are discussed within the context of life on the Caribbean Island of Puerto Rico.

The Island of Puerto Rico: Demographics and Health Care

Puerto Rico is a very small island, measuring approximately 100 miles long and 30 miles wide. Puerto Rico, situated approximately 1000 miles south of Miami and 700 miles north of Venezuela, was claimed by Christopher Columbus under the Spanish flag in 1493. The island remained colonized under Spanish rule for approximately 400 years prior to being ceded to the USA upon Spain’s defeat in the Spanish-American war (Ayala & Bernabe, 2009). In 1917, President Wilson signed a bill making Puerto Rico an official US Territory and granting its residents US citizenship. Puerto Ricans continue to carry US passports and are American citizens, although, as a protectorate, they cannot vote in federal elections (presidential) and the island has no voting representation in Congress; residents possess voting rights only at the island level (local candidates). However, federal programs offering supports such as food stamps, low-income housing programs, student loans, and Medicare and Medicaid are available to the island’s residents.

According to the 2010 US Census (U.S. Census Bureau, 2010b), Puerto Rico, whose population is 98.8 % Hispanic and home to over 3.9 million residents, is “the poorest state in the nation.” The average income in Puerto Rico is estimated at nearly US$ 27,000 per year in 2010 (U.S. Census Bureau, 2010b). According to the Puerto Rico Community Survey of 2007–2011 (U.S. Census Bureau, 2012a), approximately 1.1 million children and adolescents, or 28 % of the island’s population, range in age from 0 to 19 years. Nearly 504,000 of the island’s residents are school-aged children: 355,115 students were enrolled in grades prekindergarten through grade 8, while 148,520 students registered between 9th and 12th grades in 2008 (U.S. Census Bureau, 2010a).

The Puerto Rico Health Department (Departamento de Salud de Puerto Rico, 2012) reported that 37.2 % of children on the island live in homes headed by a female, adding that “the impact of childhood poverty on health and well-being is well known” (p. 52) and more common in single-parent homes. The low socioeconomic conditions on the island impact the public system overall, including education and health care. Although impoverished families receive access to public health centers through the Puerto Rican government, these services function poorly. That is, they exist largely in name due to the extremely limited availability of practitioners and sites, resulting in long wait times and required travel distance.

The majority of the island’s children, an estimated 95 %, possess health insurance of some kind (Kaiser Family Foundation, 2010). However, this government-sponsored health care suffers from severe access limitations. The Puerto Rican Department of Health Title V funding proposal (Departamento de Salud de Puerto Rico, 2012) highlights serious problems with the public system of 330 primary health centers even in terms of service provision for very basic care, such as infant vaccinations.

When parents attempt to access the system, difficulties and challenges regarding actual service delivery for children and adolescents in need of health care are rampant. One example includes long wait times that extend to the better part of the day, as noted by this vignette:

One has to write down their name on the list at seven o’clock when they [the doctor] open the office. But the pediatrician can arrive anytime between eleven or twelve noon and even later around one o’clock. Sometimes I make number 20 and I end up leaving the office between four or five o’clock in the afternoon. The pediatrician is only in the office on Tuesdays and Wednesdays. (Departamento de Salud de Puerto Rico, 2012, p. 75)

Other issues include doctors who charge patients for services that should be provided for free. A serious lack of specialists, such as pediatricians, psychiatrists, and other specialists who work with children is evident:

I got up, you know, around four o’clock in the morning. I was the first to arrive and when I got there she [the pediatrician’s secretary] said, “Ah, the doctor gets here around 9:30 am.” I returned home and when I got back to the office, she [the secretary], told me, “Look, the pediatrician is in another town today. You have to go to [name of town].” (Departamento de Salud de Puerto Rico, 2012, p. 76)

Mental Health and Puerto Rican Youth

In the face of this dire lack of services, youth in Puerto Rico still demonstrate significant need for mental health supports. The Puerto Rico Health Department Needs Assessment (Departamento de Salud de Puerto Rico, 2012) specifically states that “the principal health conditions [during adolescence] are related to unhealthy behaviors and psychosocial factors” (p. 57). High-risk-taking behaviors include traumatic accidents, unprotected intercourse resulting in pregnancy and the spread of sexually transmitted infections (STIs), smoking, drug use, delinquency, and suicide. Results from the biannual Administration of Mental Illness and Anti-Addiction Services (ASSMCA) Survey by the Puerto Rico Department of Health (2010), titled “Monitoring the Future,” showed that during 2005–2007, adolescents suffered from a range of serious mental health issues. In terms of specific mental health diagnoses, the survey results indicated alcohol use and abuse as the most prevalent mental health concern among Puerto Rican adolescents (19.4 %), followed by attention-deficit/hyperactivity disorder (13.1 %), major depressive disorder (11.5 %), and conduct disorder (4.8 %). As is commonly observed in gender comparisons in other cultures, female Puerto Rican adolescents demonstrated higher rates of depression (14.8 %) than males (8.2 %). Conversely, and also in line with research from other settings, adolescent males on the island were more frequently identified as presenting with conduct problems (6.7 %) than females (2.9 %).

Mental health conditions are also of concern for children between the ages of 5 and 14 years in Puerto Rico. According to the Departamento de Salud de Puerto Rico (2012), pediatricians participating in the Annual Meeting of the American Academy of Pediatricians, Puerto Rico Chapter, indicated mental health issues among the top reasons for patient referrals. The report mentions that “the most common conditions seen at the office are: upper respiratory infections, obesity, and hyperactivity syndrome” (p. 57). Thus, the second and third most common reasons for which parents of elementary- and middle-school-aged children seek a pediatrician’s assistance are mental health issues, notably hyperactivity or are physical health problems linked to psychosocial factors, such as obesity (Jacobson & Melnyk, 2012; Lu et al., 2012; Tiffin, Arnott, Moore, & Summerbell, 2011).

In terms of specific mental health diagnoses, the following conditions were indicated as most frequent among children from 5 to 14 years of age (Departamento de Salud de Puerto Rico, 2012): hyperkinetic syndrome of childhood (59.2 %), adjustment disorders (10.1 %), affective psychoses (5.7 %), neurotic disorder (5.5 %), and, finally, specific delays in development (5.3 %). In terms of school-based services, the US Department of Education (2012) reported that, from 2008 to 2009, 21 % of school-aged children in Puerto Rico were classified as requiring educational supports. The 103,118 students on the island who qualified for school-based special education services were categorized in the following order of frequency: specific learning disabilities, speech and language impairment, mental retardation, autism, emotional disturbance, multiple disabilities, hearing impairment, visual impairment, orthopedic impairment, and “other” (p. 58; cf. Departamento de Salud de Puerto Rico, 2012).

Mental health concerns extend to the preschool population in Puerto Rico as well. The Departamento de Salud de Puerto Rico (2012) reports that the most common concern from parents and teachers of preschoolers is developmental delays (58.7 %), which represent over half of the diagnoses at this age. Next, but at a much lower level, mental health conditions include hyperactivity (17.5 %), psychoses with origin specific to childhood (7.7 %), adjustment disorders (5.3 %), and emotional disturbance (3.5 %).

Social Emotional Development in Puerto Rico

A notable amount of the Puerto Rico Health Department Needs Assessment (Departamento de Salud de Puerto Rico, 2012) is dedicated to the serious concerns expressed by Puerto Rican parents and professionals regarding social–emotional well-being in children between the ages of 5 and 14 years. The report states, “In virtually all health dialogues with health professionals (staff, members of regional boards, and the Healthy Start Consortium), the socio-emotional development of children was an issue of great concern” (p. 80). Respondents to the needs assessment survey indicated specific concerns regarding suicide, depression, and attentional problems in Puerto Rican children. Survey respondents also made mention of the high levels of violence on the island, particularly domestic violence, and its negative impact on the island’s youth. Health professionals who contributed to the report made specific requests for improvements in family education and child rearing, as well as increased resources for mental health providers. The section of the report on socio-emotional development in elementary and middle school-aged children concluded: “While mental health is seen as a serious issue, mental health services are extremely scarce for children…[and there is] little capacity to tend to the needs of cases in Puerto Rico” (p. 81).

Similar concerns have been expressed for both preschool and adolescence. In terms of preschoolers, approximately 34,000 between the ages of 1 and 4 years are enrolled in Head Start programs on the island. Of those, 10.6 % were classified as being overweight and 5.2 % diagnosed with a conduct disorder (Departamento de Salud de Puerto Rico, 2012). The Puerto Rican government indicated that 39.2 % of children whose mothers are enrolled in the Women Infants and Children (WIC) program, a federal support provided to mothers and children until age 5 who meet federal poverty guidelines and are at nutritional risk (US Department of Agriculture, n.d.), are considered overweight for their age and height.

Regarding adolescents and mental health in Puerto Rico, respondents to the Puerto Rico needs assessment (Departamento de Salud de Puerto Rico, 2012) mentioned “mental health as a serious issue in the adolescent population” in “most health dialogues” (p. 87). Critical issues within this age group included “suicidal ideas, suicidal attempts, depression and low self-esteem” (p. 87). Youth may receive up to six mental health visits without parental authorization according to Law 408. Several factors were indicated as prohibitive for youth who wished to take advantage of this right. First and foremost among these barriers is an “insufficiency of mental health services for the adolescent population” (p. 87). Other issues raised were related to the broader concern about a lack of mental health providers, highlighting problems including the lack of the Administration of Mental Health and Anti-Addiction Services to meet the mental health needs of Puerto Rican adolescents and broad layoffs of psychologists by the Department of Family Services. Other barriers were cultural and educational, such as stigma indicated by the view that mental health services are for “crazy people” and the fact that few adolescents know they have a right to psychological services without the permission of their parents or legal guardians.

A developing area of need in terms of psychological well-being for Puerto Rican adolescents is aggression and violence. When high school students are asked about the most serious problems in their schools, a majority identify fighting between friends and among students. Some youth who responded to the Puerto Rico Mental Health Youth Health Promoters Program indicated “a lot of pressure to provoke fighting” as a result of conflicts over jealousy, gossip, and teasing (Departamento de Salud de Puerto Rico, 2012). Although provoking fights was rarely seen as justified by youth, defending oneself was considered acceptable. As one adolescent explained:

Whenever you have a problem with another person and they want you to fight with that person they start shouting many things at you. They pressure you to hit the person. You think, I am not going to let them tell me those things…I better hit. (Departamento de Salud de Puerto Rico, 2012, p. 87)

The Need for Mental Health Services in Puerto Rico

The recognition of mental health and well-being as areas of concern by professionals, parents, and many young people on the island of Puerto Rico is reflected in the words of one respondent to the Puerto Rico needs assessment (Departamento de Salud de Puerto Rico, 2012):

A child living in a family with no good mental health, this family is unable to give the child a good example of how to deal with situations in a correct way. If the child always sees that the family members often shout at each other, use aggressive gestures and raise their fists, they [children] will most likely perceive the world in a twisted way. When you go out you see mothers who scream at the small children, threatening them to “break their faces.” The child’s socioemotional health gets adversely affected (p. 84).

Recommendations for improving psychological well-being for children and youth include parental education programs, positive child-rearing workshops, resources for psychologists, and prevention and intervention in the schools. Although mental health is seen as a serious issue in Puerto Rico, few resources are provided to help inform the public; develop, implement, and evaluate programs; or provide serious psychological services on an individualized basis.

In summary, the most recent data on Puerto Rican children and youth indicate serious mental health needs. Many youngsters are diagnosed with mental health conditions for which very few services are available. Others may neither have a diagnosis nor demonstrate behaviors reaching a threshold level for receiving a diagnosis. However, regarding these children, health professionals have made it clear to the government of Puerto Rico that further development is required in terms of understanding and work in these areas as well; a significant need for prevention and intervention exists and must be addressed. The current study aims to further elucidate these critical areas in mental health specifically within the Puerto Rican context. The current study describes data from a Puerto Rican sample that was collected as part of the Promoting Psychological Well-Being Globally (PPWBG; Nastasi & International Psychological Well-Being Research Team, 2012) project.

Methodology

Data for the Puerto Rican sample were collected from August to December of 2011. Two private schools, both of Catholic origin, participated. Each school is considered in the middle range for tuition fees and both are located on the western side of the island. The US Census Bureau (2012b) reported that the median income in Puerto Rico in 2011 was US$ 18,600 with a margin of error of US$ 358, suggesting that the middle-range two-parent family similar to those of participants in the current study would have a household income of approximately US$ 40,000.

Participants

Participants included 41 students (ages 5–17 years), 13 teachers, 10 parents (8 mothers, 2 fathers), and 8 school support personnel (security and cleaning staff). Students were recruited according to school-level groupings: 6 elementary school children, ranging in age from 5 to 10 years; 16 middle school students, ages 11–14 years old; and 19 high school students, ages 15–17 years. In terms of gender, the sample consisted of 19 girls and 22 boys. The elementary school participants included two females and four males; middle school, seven females and nine males; high school, ten females and nine males. All students were Hispanic Puerto Ricans.

Procedures

Data for the present study were collected at two medium-sized private Catholic schools in a mid-sized town on the island of Puerto Rico. In order to gather data, contact was made with the school principals , and an orientation about the PPWBG project offered to the schools’ administrators. Upon receiving permission from the school principals , a brief written summary of the project and a consent form were sent home with children who met the age requirements for participation in the project. Students who returned parental consent forms were scheduled for interviews.

The focus group interviews were conducted in the following manner: Boys and girls met in separate groups on different days. They were interviewed by the same undergraduate student from the University of Puerto Rico. Student interviews were carried out in the same classroom in their school. The group interview for parents was conducted in a different classroom at their child’s school. Those parents who were unable to attend an in-person interview due to work and family constraints were interviewed individually over the phone by psychology students. Of the ten parents who participated in the study, four attended a focus group meeting and six were interviewed individually via phone. Teachers and school support personnel interviewed individually in school premises by undergraduate students of psychology. Teachers were interviewed in their classrooms and support personnel was interviewed in their primary office building which is located on school grounds separate from the main structure.

Data were coded according to the criteria established for the PPWBG study (described in Chap. 2). First, students were divided by age and grade. Subsequently, responses to each question were categorized depending on its content. The labeling of interview data by speaker (respondent) permitted the coding of responses at individual as well as collective (group) levels. The same process was followed for parent, teacher, and school personnel responses.

Limitations

Certain factors affected the data collection, mostly the dropout rate of the participants, which was approximately 20 %. As with many school-based projects, finding adequate space to complete interviews presented a challenge. Typically, interviews were conducted in offices or classrooms, where ambient noise was evident, ventilation was inadequate, or other school workers would need to enter on occasion. Furthermore, this sample is limited by including private school students only, and those who attend a Catholic school. It may be that students in other academic settings have different stressors or distinct support systems .

Results

This section presents findings from focus groups , and individual interviews conducted with adults and students. Findings are organized by source or participant group: school support personnel, classroom teachers, parents, and students. For each source, findings are organized around themes based on questions posed to the respective participants.

School Support Personnel

School support personnel included janitors and security guards. They were asked to respond to questions regarding definitions of psychological well-being and psychologically healthy environment, factors affecting psychological well-being of students, the roles of parents and community members in facilitating well-being of children and youth, and methods for promoting their well-being. The findings for each topic are summarized in this section.

Defining a Psychologically Healthy Environment

When asked to describe a “psychologically healthy environment,” school support personnel explained that a psychologically healthy environment is one that facilitates engagement in work that is rewarding in some way. More specifically, they indicated that a positive environment facilitates sharing with others, effectively being a good influence or example by working well within the system, and encouraging social interaction and engagement among others, particularly students, teachers, parents, and staff.

Psychological Well-Being and Students

Personnel at the participating schools shared the observation that the psychological well-being of children and adolescents is affected by a variety of factors. Specific factors mentioned included interfamily relationships (abuse, mistreatment, etc.), physical health (both the students and that of their caregivers and relatives), the home environment (fighting, stressors, divorce, etc.), and the economy.

Role of Parents and Community

School support personnel stated that family support is critical. Personnel generally indicated that school and family must be supportive of children and youth, but set reasonable limits as well. That is, support staff recommended a combination of rules combined with warmth and caring. In terms of the roles of community and society, school personnel indicated a need for society to guide and educate children and youth as well as to contribute to the overall well-being of youngsters on their island.

Methods for Promoting Psychological Well-Being

School support personnel recommended several methods for promoting the psychological well-being of children and adolescents in the school context. These were: (a) being understanding when students need to talk about their lives, (b) emphasizing respect between students and adults in the school setting, (c) establishing firm rules that help reduce conflicts and aggression, and (d) providing education about conflict management to the staff at the school.

Classroom Teachers

Teachers responded to questions about the roles of teachers , parents, and students. They provided information about the cultural expectations for students and adults (teachers, parents, and community members) and the responsibilities of adults for promoting psychological well-being of children and adolescents. Teachers also responded to questions about students’ stressors and behavioral challenges .

Teacher Expectations

Teachers indicated expectations of students within their particular classrooms, while also sharing some general expectations for teachers and teacher–student interactions. Teachers working with children in middle school and high school expressed the desire to be supportive of their students, in combination with a strong commitment to student learning. In terms of behavioral expectations, the teachers concurred that teaching their students to be responsible, cooperative, internally motivated to learn, and succeed academically is all important. The teachers further emphasized the importance of respect, both between students and between teachers and students. Overall, the teachers indicated a strong desire to help their students learn academics while also guiding them as they develop into upstanding citizens. Furthermore, interest and enthusiasm for learning were of key importance for teachers and students.

Role of the Teacher in Student Psychological Well-Being

Participating teachers saw themselves as key to facilitating development of the qualities related to student well-being. The teachers shared an interest in helping their students distinguish between positive and negative influences and encouraging students to trust that they can share their concerns with teachers. Should a student face a particular challenge in life, teachers felt it was important for them to listen and talk with their students about the problem, thereby facilitating psychological well-being . The teachers reported that they see themselves as being “frontline” responders in that they feel responsible for knowing their students well enough to recognize when a student may be in need of help and support.

Roles of Parents and Community

The roles teachers considered key for parents in terms of facilitating psychological well-being of students are for mothers and fathers to set a positive example for their children. Teachers indicated the importance of parents modeling problem-solving and respect and reinforcing the same. Furthermore, teachers stated that parents must be figures of authority for children and must teach values in the home. Teachers also think that parents must spend time with their children in order to help them progress academically and develop emotionally. In this way, parents will be aware of the well-being of their children and need for further support. In addition to emphasizing the role of parents themselves in a child’s well-being, teachers shared that extended family members also can help youth develop in an emotionally and intellectually positive manner by spending time with them and supporting good study habits.

In terms of teacher perspectives of the role of the community and society, some contradictions were observed. Some teachers (47 %) stated that the role of society is to help children develop as civic-minded individuals. This implies providing parent education regarding child rearing, fostering study habits, emphasizing the importance of studying, and cultivating the development of values through training and modeling. Other teachers (53 %) placed a lesser emphasis on the role of society and community in teaching skills or knowledge to children. Instead, they put greater emphasis on society and community as providers of extracurricular activities and infrastructure, such as libraries and community centers. These teachers further suggested that society and community offer events for the public that allow parents and children to spend free time together.

Stressors

Teachers reported that the most common source of stress for their students was grades. This was followed by stress related to making and maintaining friendships, family problems, and low self-esteem. Teachers indicated the belief that their reports represent an accurate reflection of student stressors since it is common for students to approach teachers when they have problems and seek teacher guidance. Students who do not typically look to their teachers for support tend to demonstrate behavioral changes when they are under stress; these students become more withdrawn or act out, their mood becomes more volatile, and their grades start slipping. In general, educators indicated they reach out to students under these circumstances and attempt to offer them support. When this is ineffective, the teachers contact the child’s parent or legal guardian.

In terms of addressing student stress, teachers offered a variety of solutions. Typically, the first response is to attempt to alleviate the problem. If the student indicates the issues are at home, teachers will counsel the student informally, find school-based supports, or, when necessary, contact the authorities. When a student is under significant stress due to academic pressure or learning challenges, attempts are made to help the student address this issue. This may be through discussions with the teacher to help improve confidence or tutoring on specific topics.

Teachers who participated in the interviews expressed concerns that there are few resources to help their students when they are under significant stress or face problems. Teachers shared that, in addition to themselves, parents, the school’s guidance counselor, the principal, and other personnel do their best to help students when they are in need. However, the teachers specifically bemoaned the lack of mental and behavioral health professionals, particularly psychologists, in the school setting. The educators believe that one reason students often seek inappropriate means of alleviating stress is that there are no dedicated mental health resources in schools in Puerto Rico.

Behavioral Challenges

Teachers reported that their primary disciplinary concern is the lack of values among students toward property and other persons, as well as failing to respect adults. They manage these challenges by implementing rules and making expectations as clear as possible. Students also are penalized, as necessary, for breaking classroom rules. Even though the teachers reported to prefer dialoguing with students and achieving compromise as their primary means of discipline, they stated that sometimes disciplinary measures such as reprimands or a referral to the director’s office can be more effective. For this reason, teachers indicated that they carefully consider their responses to inappropriate behaviors.

Disciplinary measures taken when students consistently break classroom rules and fail to follow school policy typically consist of removal of privileges. Students may lose opportunities to have social activities, such as parties in the classroom, or lose bonus points toward their grades. If the problem is not resolved through removal of privileges, teachers meet with parents and/or refer the child to the guidance counselor or principal. When teachers face these significant problems, they seek the support of their colleagues in helping make determinations about how to proceed. If these prior efforts do not result in behavior change from a student, the school has a discipline board that is consulted.

Parents

Mothers ( n = 8) and fathers ( n = 2) were interviewed in group or individual format. They were questioned about their expectations for children and adolescents, the stressors experienced by children, and the behavioral challenges they faced in socializing their children. They also responded to questions about the role of parents, school, and community in supporting their children’s psychological well-being . Findings are organized by topic.

Parent Expectations

Mothers and fathers of students indicated that their predominant expectation was that their children finish high school, continue their studies at a vocational or college level, and, ultimately, achieve their goals. They also expected their children to become good citizens who contribute to their communities and recognize right from wrong. Furthermore, parents shared that they would like their children to give 100 % effort to their endeavors in order to become responsible and respectable adults. Finally, parents emphasized the expectation that their children would have faith in God.

Role of the Parent in Promoting Student Psychological Well-Being

Parents said that the way they best contribute to the well-being of their children is by being good role models and providing positive examples for their sons and daughters to follow. Responses from parents indicated consensus that a parent is the person who facilitates responding to a child’s needs and guiding the development of character. Parents further shared that they believe it is important to be available to one’s children, to help them, and to continue to grow themselves, as parents and persons, in order to encourage positive psychological development in youngsters.

Role of Schools and Community in Promoting Student Psychological Well-Being

Parents said that the role of teachers and schools was to educate their children. However, parent responses indicated recognition of an expansion of the role of educators: Whereas the school setting might have previously been largely focused on academics, it now includes development of morals and values. Furthermore, the parents in the Puerto Rican sample indicated that the role of the community is to provide a positive environment in which children can socialize and be able to develop as professionals. However, parents expressed concerns that community and society often espouse norms and values that contradict those taught in the home. They worry that society has become a negative influence and the government and religious organizations within the community often offer examples that cause more harm than good.

Stressors

Parents indicated that the stressors their children experience are based largely on societal pressures. For example, parents indicated that disorders such as bulimia and anorexia result from portrayals of “the perfect look” for young women. Furthermore, parents indicated that the pressure to be “cool” and “in style” weighs on them and their children. Additionally, school assignments and demands cause stress. Often, their children must balance being in class, completing homework, and attending extracurricular activities. Parents shared that they perceive peer pressure as a stressor in that their children try to be someone they are not in order to obtain acceptance at school and in social circles. Their children and teens further demonstrate frustration when they are not allowed to do what they want or when they set expectations extremely high (i.e., achieving perfection) for the activities in which they engage.

Parents said that they perceive high levels of stress in their children and adolescents by observing their behavior. For example, their child might close themselves in their room, refuse to talk or eat, seem flat in terms of affect, or demonstrate significant sadness and lose their sense of humor. Parents attempt to address these situations by counseling their children through advice or sharing time together to help encourage relaxation and distraction (i.e., going for a walk, seeing a movie, and playing a game). Sometimes they pray with their child. In general, parents in Puerto Rico stated that communication is critical to helping their youngsters manage stress. Parents indicated that when they were unable to help their child, they were willing to seek professional help or to consult the extended family.

Behavioral Challenges

Parents noted that the TV, music, and the Internet compete with them as behavioral examples for their children. In general, parents indicated that it is difficult to manage all of the demands on their time (i.e., home, work, and relationships) and that consistently managing their child’s behavior is not easy. On occasion, for example, the parents disagree about how to address behavioral issues. However, respondents indicated a consistent interest in establishing norms and following through with them. Parents prefer to begin with positive communication.

Common disciplinary techniques reported by Puerto Rican parents included removing privileges, grounding children, or discussing issues of right and wrong when problems arise. Many respondents shared an inclination toward spanking, stating that “time-out” does not work. When parents need further support to address disciplinary issues, they talk to church clergy, family members, or professionals.

Students

Students were interviewed on a number of topics. They were asked to identify the cultural expectations for youth in the role of student, friend, and citizen and the roles of teachers and parents. They also were questioned about common emotional experiences of youth. Findings are summarized by topic.

Defining “Good” and “Bad” Students

Students were asked to distinguish the characteristics of “good” and “bad” (or poor) student. They described a “good student” as one who is dedicated to their school responsibilities and completes his or her work, one who earns good grades, and on who listens to and respects the teacher. The majority of respondents (75 % of individuals within focus groups) indicated that being respectful to the teacher and kind to peers is a highly desired characteristic in the school setting. A “bad student” was described as one who earns low grades, in large part due to his or her inappropriate behavior and lack of following school rules. Furthermore, “poor students” typically are unwilling to improve, choosing to continue in their pattern of irresponsible decisions. The most common description of a “poor student,” reported by 85 % of students in focus group interviews, is one who does not respect anyone.

Defining Friendship

According to student respondents, a good friend is a person who is always willing to offer support and give advice. This friend is available through good and bad times. True friends demonstrate unconditional respect, confidence, fidelity, and acceptance of one another. Students indicated that a person who cannot be considered a friend is one who “uses you,” is a hypocrite, lies or misleads you, and is not available in times of need. In general, this person pretends to be a good friend but treats you badly, often criticizing you, and is someone in whom you cannot confide, since they give away secrets. Bad friends are also cruel and engage in behaviors like talking about you behind your back.

Defining Citizenship

A good citizen is cooperative and helpful, according to students. That is, a good citizen worries about other people, the community, and the environment. Respondents in this study consistently used descriptions such as “a person who is respected by others” to define a good citizen. The opposite of a good citizen is someone who pays little attention to community or environment and instead focuses on his or her own needs. This person may go further than ignoring his or her surroundings to the point of damaging them. That is, a bad citizen is one who steals, pollutes, or litters and does not follow laws designed for the well-being of everyone. In summary, this person cares only for his/ herself.

Defining Parenthood

A “good” parent is a person who is consistently available to his or her children and offers them unconditional support, even when the child is experiencing the worst possible circumstances. Student participants in these interviews stated that a good parent worries about his or her children and desires the best for them. In addition to providing emotional support and security, students described a good parent as one who provides children with food to eat, a home to live in, and an “emotionally healthy” (i.e., a nurturing or positive/abuse-free) environment. In addition, parents offer advice and understanding when their children seek this from them. In contrast, a “poor” parent demonstrates little interest in, or care for, his or her children. Poor parents also may physically and emotionally abuse children, fail to provide them emotional support, and, furthermore, dedicate little time to the children.

Defining the Role of Teachers

According to student respondents, a “good” teacher is someone who worries about and cares for students. Teachers express their concerns for students specifically by working hard to teach well and ensure student learning. Furthermore, teachers are professionals that students respect and who possess the ability to help children. Good teachers were further defined as being very patient individuals. “Poor” teachers were described as those who are disinterested in student learning and academic progress. These teachers also commonly demonstrate a lack of respect toward students and may yell in the classroom, are highly impatient, or even embarrass students in front of their peers. Poor teachers were also defined by inadequate teaching skills and a lack of mastery of material they are charged to teach their students.

Commonly Experienced Emotions Reported by Students

Student participants reported commonly experienced emotions as including happiness, concern, anger, love, and sadness. Participants described how they expressed feelings, how they identified them in others, and, in the case of feelings of distress (concern, anger, and sadness), how they coped with the feelings or helped others cope. The only feeling that all age groups shared was happiness. Sadness was expressed by children (ages 5–10), but not by adolescents (ages 12–17). In contrast, only adolescents talked about concern, anger, and love.

Happiness

In general, when the students are happy, they dance, play, and laugh. Happiness is typically observed by children and adolescents through outright expressions such as smiles and laughter. Students identify happiness in their peers by paying attention to behavior. In addition to noting laughter as a sign of happiness, children reported recognizing happiness through increased sociability and playfulness and facial expressions. Students express their happiness the same way they perceive it in others, that is, laughter, smiles, and facial expressions. More emphatic ways of expressing happiness include dancing or singing. The respondents in these interviews stated that happiness can occur through a domino effect. That is, if one person is happy, it tends to lead to others feeling happy as well. By default, people maintain the good ambiance making the happiness last.

Concern

This feeling was identified by adolescents (12–17), not younger children (ages 5–11). Results regarding this item should be interpreted with caution as responses suggest students answered the question in terms of how they feel about or worry for others, rather than addressing their source of their own concerns. Students indicated that they know when others are preoccupied by noticing a person in deep thought who seems distracted, overwhelmed, or as if they are trying to make a decision. The students express “preoccupation” by talking about the source of these thoughts and attempting to act in a manner distinct from their typical patterns. In order to feel better when they are deeply concerned, students try to focus on something different or even ignore the source of the problem. On occasion, they mention they prefer to address the issue directly to resolve it and alleviate the stress. The best way to help someone who is preoccupied, according to this sample of Puerto Rican youth, is to offer advice.

Anger

Similar to worry/concern, this feeling was identified by adolescents (12–17 years of age) rather than children (5–11 years of age). In general, students experience anger when they find themselves in the middle of a disagreement or when being mistreated, like being insulted, pushed, or hit. Students shared that they can identify an angry person by their mood, attitude, and facial expressions. Specifically, an angry person is negative, does not smile, tends to glare at others, and shows body signs of being tense and upset. When they themselves become angry, adolescents reported a tendency to express their anger by breaking and throwing objects, yelling or screaming at others, and hurling insults. Normally, however, respondents said they try to find someone to help them calm down and deal with the situation that is causing them to feel angry. When this is not possible, they attempt to distract themselves and calm down before the situation escalates. In terms of helping their peers work through angry feelings, adolescents shared that they are willing to listen to their friends and let them vent and talk about their problems.

Love

Similar to the aforementioned emotions , with the exception of happiness, love was selected only by adolescent participants. The majority of teens (95 %) in this study indicated that they feel warmth and caring in association with feelings of love. However, many also mentioned that it is important to love oneself before focusing on gaining the love of others. Adolescents relate love with tranquility, happiness, and caring about themselves and others. In terms of identifying others who are experiencing love, students said a person who is in love becomes more lovely and happy than usual, particularly when he or she is close to the person that generates this feeling. They also reported the presence of “a sparkle in their eye” as a major behavioral indicator of love. However, there is also the most direct way of showing love, telling someone you love them. The most common way to express love was described by students as hugging, kissing, and telling others you love them. Similar to the response regarding happiness, love was described by adolescents as having a domino effect on people.

Sadness

Sadness was identified by children (5–11 years of age), not adolescents. Children between the ages of 5 and 11 indicated they feel sad when their toys are taken away, when they are grounded or scolded, and when they fight with others. The main way children recognize sadness in others is when they observe someone cry or when someone indicates that they prefer being left alone. The young respondents in this study indicated that they express their sadness by engaging in fights with others, screaming and yelling (25 %); crying (65 %); or being alone (10 %). To deal with the sadness, children typically ask parents or another authority figure for help. They also try to distract themselves by playing or sharing with others. Sometimes, if they notice another child is sad, an attempt will be made to talk to him or her and make them feel better.

Conclusions

Data from the Puerto Rico Department of Health (Departamento de Salud de Puerto Rico, 2012) make it clear that psychological well-being is an area that requires greater attention and resources on the island. The situation regarding poverty, stress, and violence on the island has become so severe that it has been covered in news reports, such as the NPR series mentioned at the outset of this chapter. The results from interviews with school personnel, teachers, parents, and students highlight the critical need for mental health support. Although students possess numerous strengths and understand emotions , they clearly face myriad circumstances and challenges that require additional preventive and intervention services. This need was specifically indicated by their teachers .

Certainly, addressing psychological well-being is a complex proposal under any circumstances. In Puerto Rico, where cultural and identity issues combine with economic challenges and significant poverty and violence (Departamento de Salud de Puerto Rico, 2012), this may be an even greater challenge. It is generally recognized that many well-trained professionals leave the island to pursue opportunities in the USA (Caribbean Business News, 2013; U.S. Census Bureau, 2010a) and this is true of psychologists. In order to provide the support for parents and teachers interested in providing positive contexts for their children, an effort should be made to retain mental health professionals.

Psychologists could directly address issues highlighted as critical by teachers, parents, and other educators. For example, problem solving was designated as an important need. Numerous universal prevention programs, most with Spanish language versions, could be administered in the school setting to help improve these skills. These could include programs such as Life Skills Training (Botvin & Griffin, 2004) and Promoting Alternate Thinking Strategies or PATHS (Greenberg, Kusche, Cook, & Quamma, 1995). Stress related to school and social pressures could also be addressed by psychologists and/or mental health teams using instruction in methods such as time management, exercise, and healthy habits.

Given the significant need on the island, further work in culturally and developmentally appropriate methods for helping children, youth, and their families acquire appropriate skills to address mental health issues is of great importance. Puerto Rico is an island with inspiring natural beauty, a rich cultural heritage and, above all, caring people who are oriented toward family and community. In order to ensure that its children and youth live the healthiest, happiest lives possible, it is important to address their psychological well-being.