UC Berkeley

Educational attainment is a well-established social determinant of health, such that higher attainment predicts better health. However, less is known about how experiences within the educational environment may shape – or nuance our understandings of – this association. One common experience among students in US schools is punitive discipline. Purported to increase or maintain school safety, punitive discipline policies deploy exclusionary practices, like suspension and expulsion, to punish students for perceived misbehavior. However, evidence suggests that these practices not only fail to make schools safer but may actually create harm, with education and legal system ramifications extending over the lifecourse. Further, minoritized students are disproportionately monitored for perceived misbehavior, designated for punitive discipline, and prescribed harsher disciplinary action suggesting punitive discipline is a mechanism through which structural marginalization creates population-level inequity in lifecourse outcomes. While plausible that experiencing punitive discipline may also influence health outcomes, through mechanisms like educational disruption or by triggering stress pathways, the extent to which this has been studied is unclear. The overall objective of this dissertation is therefore to assess the role of punitive school discipline, and its sequelae of education disruption, on US population health and health inequity throughout the lifecourse.

In Chapter 1, I begin by proposing a novel conceptual framework to describe plausible mechanisms through which punitive discipline may shape population health and health inequity. I then present findings from a systematic review of the social sciences and health literature on the relationship between punitive discipline and health among school-aged young people in the US. Specifically, I examine the quantity and quality of existing research on punitive discipline and health, how indicators of punitive discipline and health have been conceptualized and operationalized, any associations that have been documented, and the extent to which studies have examined how associations vary by indicators of structural marginalization. Overall, I find that across the 19 studies that met the systematic review inclusion criteria, punitive discipline was associated with persistent depressive symptoms, depression, borderline personality disorder, anti-social behavior, mental health service use, injury, suicide death, sexually transmitted infection, pregnancy in adolescence, tobacco use, and later drug use disorder. Further, several of these studies examined variation in associations by individual-level indicators (e.g., race, socioeconomic status) of structural marginalization (e.g., racism, classism). After summarizing these findings, I conclude by revisiting the \textit{a priori} conceptual framework to gauge if it is consistent with studies to-date and identify what may be missing from this literature. While additional research - for example, exploring proposed underlying mechanisms and outcomes in older adulthood - is warranted, I find that this literature consistently suggests young people who experience punitive discipline are at increased risk for numerous health outcomes, with documented implications for health inequity.

To build from these findings, Chapter 2 examines whether education disruption, a sequelae of punitive school discipline, influences health in mid-life above and beyond educational attainment. Specifically, I assess if the varying educational trajectories – characterized by both timing and type of credential – that US adults pursue to their terminal degrees over their lifecourse differentially predict hypertension at age 50 and if associations vary by participant gender, race, and gender and race combined. In National Longitudinal Survey of Youth 1979 cohort data, I use a novel application of sequence and cluster analyses to identify groups of similar educational trajectories that participants followed from age 14-48. I find that both type of terminal credential (i.e., educational attainment) as well as timing to that credential are associated with differences in hypertension outcomes. Further, I find some evidence that these associations may vary by individual-level indicators of structural marginalization. These findings suggest that documenting the nuanced ways in which complex educational trajectories are associated with health could elucidate underlying mechanisms linking punitive discipline and later life health outcomes and inform systems-level interventions for health equity.

Given evidence from Chapter 2 that both type and timing of attainment does indeed differentially influence health over the lifecourse, in the third chapter I formally assess if these educational trajectories are a mechanism through which punitive discipline is associated with later health. Further, given a prior literature documenting how punitive discipline policies and practices are shaped by structural racism, I assess whether there are racial/gender inequities in both exposure to punitive discipline and subsequent associations with health. Specifically, I examine if suspension and/or expulsion in early life predicts dementia risk by approximately age 70; if this association varies by participant gender, race, and gender and race combined; and if the relationship between early-life punitive discipline and dementia risk is mediated by the educational trajectories. I conduct this analysis in the National Longitudinal Survey of Youth 1979 cohort data as well, using a novel dementia risk score calculator to generate the outcome and again using sequence analysis and cluster analysis to construct the age 14-48 educational trajectory groups. I find that both suspension and expulsion, which Black men and women in the sample disproportionately experienced in early life, are associated with increased dementia risk and that the association is partially mediated by participants’ educational trajectories. Further, I find some evidence of effect modification: compared to White women, expulsion predicted higher dementia risk for White men and Black women, with even higher dementia risk for Black men. Taken together, these results suggest punitive discipline contributes to racial inequities in dementia risk, partly by altering people’s educational paths.

Findings across this dissertation indicate that experiences of punitive discipline are common and inequitably distributed among young people attending US schools. Further, I find that evidence to-date consistently suggests young people who experience punitive discipline are at increased risk for numerous adverse health outcomes throughout the lifecourse, with implications for health inequity. Adding documentation of health implications to the known harmful consequences of punitive discipline for education and legal system outcomes, this dissertation supports demands – from students, organizers, educators, and other affected groups – for schools to move away from punitive discipline and towards health affirming interventions to ensure school connectedness, safety, and wellbeing. As legislators at federal, state, and local levels revisit related policies, consideration of these public health implications is critical.