People have a fundamental need to belong. When this need is satisfied, it is associated to mental and physical well-being. Social relationships play a central role in our lives. From infancy onward, we depend on others to help us meet basic needs of sustenance, shelter and protection, to provide instrumental and emotional support, to serve as sources of companionship, comfort and pleasure, and as partners in childbearing and childrearing [1]. Social exclusion is so aversive that it causes broad cognitive and behavioral changes in the regulation of an individual’s belonging status. The need to belong to others or to groups comes from the evolutionary history of human beings. Social exclusion or ostracism thwarts this need and therefore has broad negative consequences, reducing feelings of belonging, self-esteem, control and meaning [2].

The relation with parents may be a mitigating factor for social isolation. To provide basic material and physical needs, parents play a central role in regulating their children’s affection, behavior and physiology. The presence of a sensitive caregiver can buffer physiological responses to stressful events [1]. Communicating family rules and parental styles have been inversely associated to substance, alcohol and tobacco consumption during adolescence. This influence is essential for adolescents’ development up to adulthood. Communication between parents and adolescents emerges as a protective factor for alcohol, tobacco and substance use [3].

Tomé et al. [4] have found that the easier the relationship with peers, the easier the communication within the group, with an increased likelihood to exist some kind of positive or negative influence. But satisfaction in peer relationships is not a determinant influence in adolescent well-being. Results show that having a good communication with both parents and peers is a better predictor of healthy behaviour than having good communication with only one of the groups. We came upon the importance of the role that both parents and peers represent in adolescents’ health. So it seems the perception of parental support and friendship quality can pronounce high levels of self-esteem, social competence and less negative behaviour issues [4].

Adolescents’ health is influenced by their relationship with their parents and peers. When the communication with both is easy, youngsters are more satisfied with life and have less health negative symptoms. When compared with peers, parents positively influence adolescents’ health [4]. Camacho et al. considers that communication with parents emerges as the factor with the strongest impact in adolescents’ wellbeing, which has a stronger impact in health. This presupposes that a better communication with parents means stronger feelings of wellbeing and, as a result, healthier adolescents.

Interpersonal relationships have great importance during adolescence, especially for psychological well-being. The sensation of well-being during adolescence can depend on the integration and acceptance of the peer group [5]. Adolescents’ mental health may be affected by difficulties in maintaining social relationships with peers, through the absence of sense of belonging, rejection by peers, or a break in social relations. This interference may differ in gender. Girls are emotionally more affected, while boys demonstrate a greater influence on their behaviour. Girls tend to have more psychological and emotional symptoms, while boys outsource these problems through behaviour [6].

Developing and maintaining positive social relationships are among the most important developmental tasks of infancy, childhood and adolescence. Social relationships are thought to affect health via multiple pathways, including: direct impacts on negative and positive affections; changes in perceptions and responses to stressors; impacts on stresssensitive biological systems; and changes in health behaviors [1]. The immediate advantages of a friendship are clear: friends contribute to happiness and well-being. The detrimental effects of peer rejection are also clear: rejection gives rise to poor self-esteem, adjustment difficulties and loneliness [7].

The concept of alienation has received extensive treatment in social philosophy, psychology and sociology literature. While the term alienation is most commonly used to identify the feelings of estrangement or detachment from the self, others or society in general, it has also been used to refer to feelings of loss of self, despair, apathy, loneliness, rootlessness, powerlessness, pessimism, neutralism, disaffection, withdrawal, disengagement, indifference, anxiety, depersonalization, isolation, atomization and meaninglessness.

Social alienation refers to separation, exclusion or isolation. It is associated to people with greater social difficulties or who are not involved in community activities. Sometimes it is described as the shutdown of others, or of society in general, isolation, withdrawal and may affect young people’s perception of health [8]. Regarding health, it is associated to risks, with correlations between social alienation and anxiety, deviant behaviours, less involvement in school activities, fewer social skills, lower self-esteem and others [8].

Alienation among adolescents is predictive of deviant behaviour, such as drug use, truancy, crime and suicide and of health related outcomes, such as symptom load, drunkenness, alcohol use, less exercising and eating unhealthy food on a daily basis [9].

In Tomé et al.’s study [10], which aimed to construct and validate a tool to evaluate alienation in Portuguese adolescents, found that the alienation tool demonstrated differences among adolescents in terms of gender, grade and SES.

This study aims to analyze the influence of alienation scales validated in the previous study of Tomé et al. [10], in different areas of adolescent health.

Participants

Individuals that took part in the Portuguese study integrated in the European study HBSC-Health Behaviour in School-aged Children (http://www.hbsc.org; http://www.fmh.utl.pt/aventurasocial; http:// www.aventurasocial.com), carried out in Portugal in 2010.

The HBSC study was initiated in 1982 by a team of investigators from Finland, Norway and England, and since 1985/1986 it is carried out every 4 years. Throughout the years, the study has grown and nowadays 44 European and Northern American countries participate in it, in collaboration with the World Health Organization. The aim of the study is to achieve a new and expanded understanding of adolescents’ health behaviour and health and well-being in their social contexts, through the gathering of data that allow national and international comparisons.

The Portuguese study includes students from 6th, 8th and 10th grades of the public school system with an average age of 14 years (SD=1.85). The national sample consisted of 5050 students from 256 classes, part of 125 randomly selected Portuguese schools. This sample is representative of the mentioned school years and was stratified by Administrative Education Regions. Regarding gender distribution: 52.3% were girls and 47.7% were boys, distributed the following way in terms of grade: 30.8% in 6th grade, 31.6% in 8th grade and 37.6% in 10th grade. The response rate was 89.9%.

For this study only adolescents from 8th and 10th grades were considered, because the variables used were applied only to those students, comprising a total of 3494 students.

Procedure

The unity of analysis used in this study was the class. In each school, the classes were randomly selected. The teachers administered the questionnaires in the classroom. Student participation was voluntary and anonymous. The study occurred in January of 2010. This study was approved by the scientific committee, the ethical national committee and the Portuguese data protection authority.

Measures and variables

The data collection was conducted through the HBSC 2010 Questionnaire. This questionnaire provides information about demographic data, well-being indicators (quality of life related with health, happiness and satisfaction with life) and about the relationship with peers and family, among other variables [11].

The present study uses alienated scales validated in the previous study of Tomé et al. [10] (Table 1).

Table 1: Validation alienation scale (2015).

Life satisfaction was measured with the Cantril scale, graphically represented as a ladder, where step ‘10’ corresponds to “best possible life and step ‘0’ represents “the worst possible life”. Adolescents were asked to mark the one that best described their feelings at that moment. Relationship with family was measured with a similar scale. The variables Bullied were also used, with three response options (Never, Once, Once a week, several times a week), Bullied others with equally three response option (Never, once, once a week, several times a week) and Drunkenness, with four response options (Never, once, two times, more than 10 times). These variables were transformed through Z scores and used in linear regression models.

All the measures used and above described were collected from HBSC 2010 questionnaire. The measures were created by merging included questions in the questionnaire, allowing creating the variables described.

The results were analysed through the statistics program SPSS 21. Correlation analysis were conducted between the variables Social Isolation and Powerlessness (0.159), Meaninglessness (0.122), Alienation Total (0.657) and Bullied (0.160); Normlessness and Powerlessness (0.115), Meaninglessness (0.120), Alienation Total (0.262), Bullied (0.300), Bullied Others (0.655) and Drunkenness (0.252); Powerlessness and Meaninglessness (0.212), Alienation Total (0.773), Bullied (0.146), Bullied Others (0.146) and Drunkenness (0.087); Meaninglessness and Alienation Total (0.475), Bullied (0.041), Bullied Others (0.099) and Drunkenness (0.151); Alienation Total and Bullied (0.207) and Bullied Others (0.211); Life Satisfaction and Family Relationship (0.379); Bullied and Bullied Others (0.383) and Bullied Others and Drunkenness (0.157).

There is a strong correlation between Social Isolation and Alienation Total (0.657), between Powerlessness and Alienation Total (0.773) (Table 2).

Table 2: Correlations.

Multiple linear regressions

To understand the predictive effect of the variables analysed in the Alienation subscales, three multiple linear regression models were made for each one. The first contains possible predictive variables with observed significant correlations, with gender and socio economic status. The second model excluded gender and socio economic status. The third model was divided by gender analysis.

Total alienation: The regression equation for the first model of the Total Alienation subscale explained 29% of the variance (R²=0.287). In this model, the explanation of Total Alienation was obtained through the gender variables (boys with 1.16 lower probability of feeling alienated), SES (low SES with 1 higher probability of feeling alienated), Life Satisfaction (less satisfied adolescents have a 3.8 higher probability of feeling alienated), Family Relationship (adolescents with a worse relationship with parents have a higher probability of being alienated, 1.5), Bullied (adolescents who were victims have a higher probability of feeling alienated, 0.7) and, finally, Bullied Others (adolescents that harmed other adolescents have a higher probability of feeling alienated, 0.9).

Similar results are found in the model that excludes gender, number of school years and socio-economic status. The equation explains 27% of the variance (R²=0.271) and the Total Alienation subscale is explained by the variables Life Satisfaction, Family Relationships, Bullied and Bullied others, which show a similar trend to the previous model. In the boys’ model, the regression equation explained 28% (R²=0.281) of the variance, through the variables Life Satisfaction, Family Relationships and Bullied Others with a similar trend to the other models. In the girls’ model, the equation explains 29% of the variance (R²=0.286), through the variables Life Satisfaction, Family Relationships, Bullied and Bullied Others. In the boys’ model, the variable Bullied is not statistically significant, whereas in the girls’ model the variables Bullied and Bullied Others have more weight in the equation than in the general model or in the boys’ model (β=0.148 and β=0.112, respectively). The variables Life Satisfaction and Family Relationships suggest a bigger influence in the boys’ model than in the general or girls’ models (β=-0.430 and β=0.171, respectively). The influence Tendency does not change in any model (Table 3).

Table 3: Multiple linear regression – total alienation.

Social isolation: For Social Isolation, the variance explained 11% (R²=0.115) of the general model, through the variables Gender (boys have a 1.6 higher probability to feel social isolation), Grade (8^th grade adolescents have a 0.5 higher probability to be socially isolated), Life Satisfaction (less satisfied adolescents have a higher probability of feeling socially isolated, 1.1), Bullied (adolescents who are victims of bullying have a 1.1 higher probability to feel social isolation) and Drunkenness (adolescents who were drunk less often have a 2.3 higher probability of feeling social isolation). In the model from which gender, number of school years and SES were withdrawn, the variance was explained by 9% through the variables Life Satisfaction, Bullied, Drunkenness, with the same tendency as the previous model. In the boys’ model, the variance explained 11% of de model (R²=0.111) through the variables Life Satisfaction, Bullied and Drunkenness with the same tendency as the previous models. Regarding the girls’ model, the variance explained about 8% of the variance (R²=0.081) through the variables Life Satisfaction, Bullied and Drunkenness. Family Relationship did not reveal any influence in any of the Social Isolation Models. On the other hand, in the girls’ model, being a bullying victim has some influence in social isolation (β=0.154). The same does not occur in the boys’ model. However, Drunkenness has a bigger influence in the boys’ model (β=- 0.216) (Table 4).

Table 4: Multiple linear regression – social isolation.

Normlessness: In the Normlessness general model, the variance explained 46% of the model through the variables Gender (boys have a 1.4 higher probability of normlessness), Grade (8^th grade adolescents have a 0.4 higher probability of normlessness), Family Relationship (adolescents with a worst relationship with their family have a 0.6 higher probability of normlessness), Bullied (adolescents who are victims of bullying have a 0.5 higher probability of normlessness), Bullied Others (adolescents who act as aggressors have a 5.7 higher probability of normlessness) and Drunkenness (adolescents who were drunk more often have a 1.4 higher probability of normlessness).

In the model where gender, grade and SES were excluded, the variance explains about 46% of the model (R²=0.456), through the variables Bullied Others and Drunkenness, showing the same tendency as the previous model. In this model, the influence of Family Relationship is no longer significant.

In the boys’ model, the variance explains 43% of the equation (R²=0.434) through the variables Bullied, Bullied Others and Drunkenness. In the girls’ model, the variance explained 49% (R²=0.486), through the variables Family Relationship, Bullied, Bullied Others and Drunkenness. In the Normlessness models, the variable with the most influence in all models is Bullied Others (with β between 0.573 and 0.615). In the girls’ model, Family Relationships influences Normlessness, as opposed to the boys’ model. However, the variable with the most influence in girls is Bullied other, with a higher level of influence that in the boy’s model (β=0.615 e β=0-0.588). For Normlessness, the influence of Drunkenness is opposite to the influence of Social Isolation. However, for Social Isolation, the adolescents who were drunk less often are those who felt more isolated. For Normlessness, those who were drunk more often have the most influence (Table 5).

Table 5: Multiple linear regression – normlessness.

Powerlessness: The overall Powerlessness model’s variance explains 36% (R²=0.486) of the equation, through the variables Gender (girls have a 0.9% higher probability to feel powerless), Grade (older adolescents have a 0.4% higher probability of feeling powerless), SES (adolescents with a low SES have a 0.8% higher probability of feeling powerless), Life Satisfaction (adolescents who are less pleased with life have a 4.5% higher probability of feeling powerless), Family Relationships (adolescents who have a worse relationship with their family have twice the probability of feeling powerless) and Bullied Others (adolescents who act as aggressors have a 0.8% higher probability of feeling powerless). In the model that does not include gender, grade nor SES, the variance explains 35% of the equation (R²=0.351), through the variables Life Satisfaction, Family Relationships and Bullied Others, with the same tendency as the previous model. In the boys’ model, the variance explains 33% of the equation (R²=0.333), through the variables Life Satisfaction, Family Relationships and Bullied Others, with equal tendency to the previous models. In the girls’ model, the variance explains about 37% of the equation (R²=0.371), through the variables Life Satisfaction, Family Relationship, Bullied, Bullied Others and Drunkenness. In the Powerlessness models, as opposed to the other models, the girls present a higher probability of feeling powerless. In this model, the variable Bullied and Drunkenness have a significant influence in feelings of powerlessness, as opposed to the boys’ model. The variable with the highest influence in feelings of powerlessness if Life Satisfaction (Table 6).

Table 6: Multiple linear regression – powerlessness.

Meaninglessness: Finally, the variance of the Meaninglessness overall model explains around 8% of the equation, through the variables Gender (boys have a 1.1 higher probability to feel meaningless), Grade (younger adolescents have a 0.8 higher probability to feel meaningless), SES (adolescents with a low SES have a 1.5 higher probability to feel meaningless), Life Satisfaction (adolescent who feel less pleased with life have a 0.6 higher probability to feel meaningless), Family Relationship (adolescents with a worst relationship with their family have a 0.8 higher probability to feel meaningless) and Drunkenness (adolescents who were drunk more often have a 1.4 higher probability to feel meaningless). In the model where Gender, Grade and SES were not included, the variance explained 4% of the equation (R2=0.041) through the variables Life Satisfaction, Family Relationship, Bullied and Drunkenness, and presented the same direction of the previous model. In the boys’ model the variance explained 4% of the equation (R2=0.036), through the variables Life Satisfaction, Family Relationship and Drunkenness. In the girls’ model, the variance explained 5% of the equation (R2=0.047) through the variables Family Relationships, Bullied and Drunkenness. In girls, Life Satisfaction does not influence feelings of meaningless, as opposed to boys (Table 7).

Table 7: Multiple linear regression – meaninglessness.

Developing and maintaining positive social relationships are among the most important developmental tasks of infancy, childhood and adolescence. Social relationships are thought to affect health via multiple pathways, including: direct impacts on negative and positive affect; changes in perceptions and responses to stressors; impacts on stress-sensitive biological systems; and changes in health behaviours [1]. Adolescents’ health is influenced by their relationship with their parents and peers. The perception of parental support and friendship quality can pronounce high levels of self-esteem, social competence and less negative behaviour issues [4]. The mental health of adolescents may be affected by difficulties in maintaining social relationships with peers, through the absence of sense of belonging, rejection by peers, or a break in social relations.

Social alienation refers to separation, exclusion or isolation. It is associated to people with greater social difficulties or who are not involved in community activities. Sometimes it is described as the shutdown of others or of society in general, isolation, withdrawal and may affect young people’s perception of health [8]. Regarding health, it is associated to risks, with correlations between social alienation and anxiety, deviant behaviours, less involvement in school activities, fewer social skills, lower self-esteem and others [8].

Tomé et al. [10] identified differences in adolescents’ gender and number of school years within the analysed alienation sub-scales, indicating the need to explore demographic differences among adolescents regarding alienation in the identification of risks to mental health.

In the present study, the results also indicate some health risks in adolescents with higher levels of social alienation. Similarly to previous studies [12], there is a positive association between social isolation and risk behaviours to adolescents’ health, such as bullying victims. Other results highlight the need of interventions focused on the need of assisting young people in maintaining relationships and positive assets. These associate life satisfaction, relationship with family, are a bullying victim or be a bully and the analysed subscales. The feeling of unsatisfaction with life seems to have a lot of influence to feelings of powerlessness, while the biggest association is between normlessness and relationship with family. Be satisfied with life and have a good relationship with family is important assets in adolescent mental health. When these are negative they lead to feelings that may deteriorate wellbeing and mental health.

We cannot ignore the existing difference among genders in some subscales. In the case of feelings of alienation, boys are more influenced by satisfaction with life and the relationship they have with their family. Girls, on the other hand, present a higher association with feelings of alienation when being bullying victims or harming others. The same happens with feelings of powerlessness, where the bullying variable and drunkenness affect girls more than boys. These differences between genders confirm the need for a differentiated intervention for boys and girls for positive results.

The association between adolescent’s socio economic status and some alienation subscales must not be ignored. A lower socio economic status has a negative influence on alienation feelings among adolescents. This tendency is shown in previous works [10] and confirmed in greater detail in the present study.

In the present moment of national crisis witnessed by adolescents is an important factor, imposing more reflection of its negative influence on adolescent’s mental health and the need to act accordingly to those needs, in order to minimize negative consequences and decrease the increase of search for mental health support among young people.

A positive approach surfaced from this economic crisis and calls for an increased youth’s empowerment, social engagement and social participation in order to prevent alienation and promote well-being and positive youth development. This means an educational change that calls for a reinforcement of public policies in this area.