4
A Time of Opportunity

Although much attention in prior years has focused on adolescent risks and problem behaviors, more recent research is directed toward interactions that are associated with positive health and development. Longitudinal studies such as the Adolescent Health Survey have highlighted the importance of such constructs as youth engagement, connectedness, and decision-making processes, which are now attracting increased interest by researchers and practitioners involved in the design of prevention and health promotion interventions (Centers for Disease Control and Prevention, 2003). As Ron Dahl put it, adolescence is “a time when kids become passionate about ideas and about ideals—[they can] become passionate about a sport, or music or literature or dance or changing the world.” Thus adolescence is a time to capture and channel kids’ passions and emotions toward constructive activities and relationships. This perspective on adolescents has been the guiding principle for many programs designed to engage teenagers, head off problems, build skills, and create settings that connect youth with caring adults who can help them cope with stresses that pose risks to their health and well-being.

POSITIVE YOUTH DEVELOPMENT

The approach known as positive youth development is based on the conviction that while adolescents face risks and experience stress and trauma, a problem-centered approach may not be adequate or sufficient to help them navigate this time of life and grow into successful, productive



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A Study of Interactions: Emerging Issues in the Science of Adolescence - Workshop Summary 4 A Time of Opportunity Although much attention in prior years has focused on adolescent risks and problem behaviors, more recent research is directed toward interactions that are associated with positive health and development. Longitudinal studies such as the Adolescent Health Survey have highlighted the importance of such constructs as youth engagement, connectedness, and decision-making processes, which are now attracting increased interest by researchers and practitioners involved in the design of prevention and health promotion interventions (Centers for Disease Control and Prevention, 2003). As Ron Dahl put it, adolescence is “a time when kids become passionate about ideas and about ideals—[they can] become passionate about a sport, or music or literature or dance or changing the world.” Thus adolescence is a time to capture and channel kids’ passions and emotions toward constructive activities and relationships. This perspective on adolescents has been the guiding principle for many programs designed to engage teenagers, head off problems, build skills, and create settings that connect youth with caring adults who can help them cope with stresses that pose risks to their health and well-being. POSITIVE YOUTH DEVELOPMENT The approach known as positive youth development is based on the conviction that while adolescents face risks and experience stress and trauma, a problem-centered approach may not be adequate or sufficient to help them navigate this time of life and grow into successful, productive

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A Study of Interactions: Emerging Issues in the Science of Adolescence - Workshop Summary adults. The point is not to ignore the importance of prevention strategies or the need for intervention and treatment with troubled adolescents, but rather to develop a broader framework that serves their needs and promotes positive outcomes for all young people, not just those who are already in trouble. Examples of programs that incorporate this approach include mentoring, school-based community service programs and other volunteer programs, school-to-work transition activities, and programs for arts, recreation, and the development of parenting skills (National Research Council and Institute of Medicine, 2002). The positive youth development approach represents a significant departure from earlier conceptions of adolescence, as Richard Lerner explained in a presentation that explored shifts in thinking over the past century as well as current links among theory, practice, and policy. Lerner grounded his discussion of phases in thinking about adolescence in the context of changing theoretical paradigms regarding human development over the entire life span. He pointed to the work of William Overton, who moved the field from a focus on the “nature versus nurture” dichotomy to the current conception of development as a process in which multiple levels of organization—ranging from the inner biological through the psychological to the physical, ecological, sociocultural, and historical—all play a role. Pioneering studies of adolescence actually predate the nature versus nurture dichotomy. G. Stanley Hall, who published the first textbook on adolescence in 1904 (Hall, 1904), concurred with his contemporaries in viewing human development as a mirror of the evolutionary history of the species, in which humans evolved from beast-like to civilized persons. Adolescence, he argued, was the period during which young people needed to overthrow their beast-like impulses and become mature and civilized. This struggle accounted for the “storm and stress” characteristic of these years. As Lerner explained, this deficit model—or focus on the upheavals and risks of the adolescent years—dominated research on adolescence throughout the first half of the 20th century even as researchers moved beyond many of the specifics in Hall’s thinking. By the 1960s, researchers began to question whether stress and disruption were universal elements of adolescence. Many young people do not experience the second decade of life as stormy, they value their relationships with their parents very much, their core values frequently are consistent with those of their parents, and they generally select friends who share those core values. Individual differences in the ways young people respond to challenges, including the concept of resiliency, began to emerge as a more important focus.

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A Study of Interactions: Emerging Issues in the Science of Adolescence - Workshop Summary Nevertheless, research continued to focus on tackling problems that resulted from the deficits associated with adolescents, such as alcohol abuse, unsafe sex and teenage pregnancy, crime and delinquency, and others. Beginning in the 1990s, a number of researchers began to rethink this approach. While not ignoring the consequences of the observation that an estimated 50 percent of adolescents have problems in at least one of the four primary categories (teenage pregnancy and parenting; unsafe sex; alcohol use and abuse; and school underachievement, failure, and dropout), Lerner explained, these researchers explored the implications of the interrelated systems model of human development for adolescence.1 At the same time, practitioners began to achieve significant success with programs based on young people’s positive potential, rather than their tendency to get into trouble. In exploring the sources for these programs’ success, Lerner explained, the academic community proposed some theoretical foundations to help explain and interpret practitioners’ observations. The theoretical basis for positive youth development is developmental regulation, a view of the ways in which individuals seek to integrate the many levels that influence development, from the biological to the sociocultural. In this view, the unit of analysis is the bidirectional linkage between the individual and the context, and the twin goals are to understand both differences in a single individual over time and differences across many individuals at the same time. Lerner argued that new research designs and measures are necessary to adequately explore these differences. He identified the need for measures in longitudinal and sequential study designs that can examine physiological change while also taking into account such factors as generation and historical change; subgroupings by gender, race, ethnicity, and religion; and such contexts as family, community, culture, and urban/rural setting. In other words, he explained, efforts to combine qualitative and quantitative data could help researchers capture the complexity of the adolescent experience. This emphasis on diversity provides the basis for examining the circumstances in which the potential exists for change and for positive inter- 1   The 50 percent figure is subject to some dispute. A summary of Centers for Disease Control and Prevention data on adolescent health risks provides additional information on the statistical prevalence of a range of risks, supporting the general observation that many youth experience a variety of risks (Centers for Disease Control and Prevention, 2004).

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A Study of Interactions: Emerging Issues in the Science of Adolescence - Workshop Summary vention, rather than focusing solely on the near-inevitability of dysfunction. Thus, the key facets of the positive youth development approach are emphasis on youth strengths and the promotion of positive development; belief that all youth have the potential to develop positively; recognition that youth are embedded in families, schools, and communities that can nurture or impede their development; recognition that both youth and their ecologies are active contributors to the developmental process; and belief that aligning the strengths of youth with the resources for healthy development present within their ecologies can promote positive development. These facets provide a way of replacing the deficit view of adolescence with a view that all adolescents have strengths. The “five Cs” identified in the NRC report Community Programs to Promote Youth Development (National Research Council and Institute of Medicine, 2002)—competence, confidence, character, caring, and connection—have been proposed as a way of focusing on the contributions young people can make, and these now provide the basis for many youth programs. Successful positive youth development programs, Lerner explained, have three major characteristics. They promote caring youth-adult relationships, they emphasize the development of life skills, and they promote youth participation in every aspect of the program. Lerner described some approaches to testing the theoretical underpinnings of positive youth development and evaluating the effectiveness of programs based on this approach. He acknowledged that the relationship among theory, research, and application regarding positive youth development is just getting under way and that more rigorous efforts are needed to identify key variables and processes. To make this connection concrete, Angela Diaz described the work of the Mt. Sinai Adolescent Health Center in New York City, a program that uses the positive youth development approach in serving the health needs of 15,000 adolescents annually. A SAFETY NET FOR NEW YORK CITY’S YOUTH The population of New York City includes large numbers of low-income young people who lack adequate health insurance and who face the

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A Study of Interactions: Emerging Issues in the Science of Adolescence - Workshop Summary challenges of adolescence in a context that can be stressful and sometimes dangerous. The Adolescent Health Center run by Mt. Sinai Hospital in Manhattan provides this population with physical, mental health, and reproductive health care in a way that integrates prevention and positive youth development. As Diaz explained, it would be easy to focus exclusively on prevention when working with these young people: 98 percent of them are poor, and 76 percent have no health insurance. In the youth population that is served by the center, for example, 71 percent have witnessed violence, 37 percent have been victims of violence, 30 percent have been sexually abused, and 25 percent have been threatened or assaulted with a weapon. Nevertheless, the program uses a “learner’s permit” approach to adolescent health, in which adolescents are treated as partners in their care who need guidance to improve their decision-making skills and to gain competence and a sense of mastery over their situations. The goal for staff is to identify and draw on each child’s strengths and experiences, take their perspectives seriously, and offer them the option of a supportive relationship. In this way, the center addresses the need for psychological and physical safety, but also involves the children in decision making about their care, as well as in responsibility for exploring resources in their local environments. The center deals with a high rate of problems, such as easily available drugs and substance abuse, the psychosocial effects of violence in schools and communities, and unplanned pregnancies and sexually transmitted diseases. Yet it considers its primary focus to be the promotion of positive outcomes, as opposed to the triage of problems. Health care appointments are used as opportunities to gain teens’ trust, provide a safe environment in which they can air concerns and questions, and build such skills as regulating emotions, health risk management, and critical thinking. Diaz explained that young people frequently are eager to talk and ask questions about their experiences, and that simply asking in a non-judgmental way is often enough to open the door for intervention and education. At the same time, the center offers young people a variety of positive ways to be involved and to take on a sense of responsibility for others, including service on a youth advisory group that participates in evaluation of the center’s work, involvement in the design of center materials to ensure that they will be accessible and meaningful to their peers, and employment at the center to help with peer health education. Diaz noted that many adults are resistant to the idea that young people should have the degree of autonomy over their health care that is encour-

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A Study of Interactions: Emerging Issues in the Science of Adolescence - Workshop Summary aged at the center. She explained that while some research has provided evidence of the effectiveness of programs that operate according to this model in reducing problem behaviors and promoting positive ones, more studies are certainly needed. In particular, opportunities to combine this framework with cross-disciplinary research focusing on biological markers and neurobehavioral systems could provide great benefit in testing the model’s efficacy and effectiveness with selected groups. LINKING RESEARCH TO INTERVENTION The discussion of Mt. Sinai’s program for adolescents provided an important reminder of the immediate need for strategies that work with young people by influencing their decision-making processes, their selection of friends and social networks, and their engagement with health care professionals, teachers, and other service providers (see Box 4-1 for an illustrated example focusing on the development of a vaccine for the human papillomavirus). Brian Flay offered a comprehensive attempt to link research-based theories of adolescent behavior with intervention strategies. Flay’s model, based on a theory of triadic influence, reinforces much of the workshop discussion about the interactions among factors that affect adolescents. The basic model structure is illustrated in Figure 4-1. The first element of the model is that both behavioral choices and development are influenced by a complex system of genetic and environmental factors that act through three streams of influence. These three streams are intrapersonal or psychological, interpersonal or social, and sociocultural or attitudinal influences on action. At the same time, the three streams are affected by both cognitive and affective influences. Each area of influence has the potential to increase or reduce both risk factors and protective factors. For example, a negative sense of self can increase risk, while a positive sense of self can serve as a protective factor. For an adolescent growing up in a disadvantaged community, a negative community or family influence can increase the effects of a poor sense of self if other supports are not available. This type of analysis calls attention to the factors that contribute to the formation of self-identity and opportunities to intervene in these fundamental processes. The feedback loop is an important dynamic in this model. Once a behavior, such as trying marijuana, occurs, the reaction—changes in thoughts or feelings, relationships with parents—feeds back and influences the original causes of the behavior.

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A Study of Interactions: Emerging Issues in the Science of Adolescence - Workshop Summary Box 4-1 Influences on Adolescent Decision Making—The HPV Vaccine The complexity of influences on adolescents’ thinking is of more than academic interest for many reasons. One context in which understanding how adolescents make decisions is particularly important is that of health care. Jessica Kahn described the benefits of a new vaccine for human papillomavirus (HPV)—a common sexually transmitted infection that can cause severe health problems, including cervical cancer. She used that example to frame questions about the influence of contextual factors on adolescent decision making about health issues (Kahn, 2005). The HPV vaccine, which is likely to come on the market soon, has the potential to protect young women and their sexual partners from serious health problems, but it poses several public health challenges. First, the vaccine will be most effective if it is administered prior to first sexual contact. Parental consent is likely to be required for administration of the vaccine to young people under age 18, and many parents may be reluctant to address the issue with their children, or they may be concerned that by allowing the vaccine they would signal an expectation that their children will be sexually active. At the same time young people themselves may misunderstand the protections the vaccine affords and perhaps develop a false sense of protection from other risks associated with sexual activity. Young people who interact with the health care system without the guidance of a parent may not adhere to a vaccination schedule (multiple doses may be necessary) or return for follow-up Pap screenings (the vaccine is not 100 percent effective). The potential benefits of the HPV vaccine, Kahn explained, are affected by parental attitudes, interactions between parents and their children, peer attitudes, relationships with the health care providers, and other factors. For the vaccine to have the maximum benefit—and it, together with Pap testing and HPV screening, could prevent virtually all cervical cancer deaths—adolescents, parents, and health care providers will all need education that is developmentally, linguistically, and culturally suitable. Theoretical approaches to adolescent decision making, as well as further explorations of additional contextual factors—such as individual, organizational, cultural, and socioeconomic factors—could all assist public health professionals in supporting the successful adoption of the vaccine. Such a success, and the research that could support it, could in turn be beneficial for other public health issues in which adolescent decision making plays a part.

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A Study of Interactions: Emerging Issues in the Science of Adolescence - Workshop Summary FIGURE 4-1 The basics of the theory of triadic influence. SOURCE: Flay (2005). At the same time, related behaviors, such as smoking and drinking, have similar causes, so the feedback loop may influence these other behaviors as well. Flay links the major causes of risky behaviors to the three primary streams of influence, and in turn reasons for changing behavior, and intervention strategies, as shown in Table 4-1. He identified a number of implications from this model for intervention and prevention strategies. First, the model illustrates why approaches that address only one stream of behavior are not likely to succeed. A program that simply provides information, for example, or focuses solely on values or the development of resistance skills, does not address the range of factors that influence the behavior in question. Flay did not argue for dropping traditional approaches, but rather he advocated for broader approaches that can be sustained after the intervention has ended. A program that taps the potential in each of the three main categories is far more likely to be successful. It might incorporate family involvement and the teaching of parenting skills as well as the teaching of a variety of skills to teenagers that affect their self-image as well as their social skills and views of the risky behavior. At the same time, sociocultural influences could be tackled to reduce the risks that youth encounter in their social settings.

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A Study of Interactions: Emerging Issues in the Science of Adolescence - Workshop Summary TABLE 4-1 Major Reasons for Doing Risky Things and Corresponding Reasons for Behavioral Change and Behavioral Change Strategies Streams of Influence Reasons for Doing Risky Things Reasons for Behavioral Change Behavioral Change Strategy Sociocultural, attitudinal It makes me feel good; it’s good for me It will be good for me; to gain benefits or avoid negative consequences; to improve myself (health) in ways I value Information: make benefits salient and visible Values clarification: make goals/ improvements clear Social Others want me to; it’s what others expect of me; everyone else is doing it; to gain social acceptance Others want me to; it’s what others expect of me; everyone else is doing it; to please others Modeling/ demonstrating behavior Social reinforcement/ support Intrapersonal I don’t know how not to or how to change; things remind me of it (cues); I can’t help myself I am confident that I can do it; I think I have the skill to do it; I have the will to do it Teach/learn/practice skills Build in prompts, cues, reminders   SOURCE: Flay (2005). Examples include limits on the sales and advertising of alcohol and tobacco products to minors and other measures such as the placement of social marketing, prevention, and health promotion strategies in the environments of youth.2 2   One recent report that has advocated a comprehensive strategy to address underage drinking is the study Reducing Underage Drinking: A Collective Responsibility (National Research Council and Institute of Medicine, 2004). Another example of environmental forces that influence adolescent health decision making is addressed in the study Food Marketing to Children and Youth: Threat or Opportunity? (Institute of Medicine, 2006).