Strategies for Preventing High-Risk Behavior

This book began with the hypothesis that a definable segment of America’s youth is so disadvantaged that this group will not be able to grow up into productive adults unless they receive immediate attention. An analysis of successful prevention programs has documented that enough information is now available to launch the necessary interventions to change the prospects for many of these young people. In Chapters 3 to 7, the prevalence and overlap in high-risk behavior were described and quantified; Chapter 8 reviewed the organizational structure that defines categorical programs; and Chapters 9 to 13 compiled extensive information on successful prevention programs. In this final chapter, we build on those findings to outline specific procedures that may lead to the development of more rational and effective strategies for changing the life trajectories for millions of children. These strategies rely heavily on the concept of centralized Youth Development Agencies, at the local, state, and federal levels. Such structures would be empowered to package the various program components so that they would have greater impact and efficiency. . . . Who Is At Risk? . . . It should be well understood by now that approximately one in four children of the 28 million aged 10 to 17 are in dire need of assistance because they are at high risk of engaging in multiple problem behaviors—in other words, of being substance abusers, having early unprotected intercourse, being delinquents, and failing in school. Based on current population estimates, this means that 7 million young people living primarily in disadvantaged neighborhoods are in the target population for intensive care. Minority youth have higher prevalence rates and are more visible in densely populated urban areas; nevertheless, the majority of these multiproblem youth are white (and male). Another 7 million young people—25 percent—practice risky behavior, but to a lesser degree, and are therefore less subject to negative consequences. And, it is estimated that about half of the youth population, 14 million, are not currently involved in high-risk behaviors and appear to be moving through the educational system at expected levels. However, their problem-solving skills need sharpening and they need access to a higher quality of education, as do all children.

Classification and Organization of Programs

Simulated risk estimates provide a quantitative framework for addressing the need of a significant number of children in the United States who are in dire straits: failing in school, delinquent, taking drugs, and having unprotected intercourse. Of the 28 million girls and boys aged 10 to 17, it is estimated that 1 in 10 (almost 3 million) are in critical situations. Another group of 4 million (15%) have excessively high prevalence rates for some but not all of the high-risk behaviors. Thus the future of 7 million youth—one in four in this country—is in jeopardy unless major and immediate changes are made in their school experiences, in their access to opportunities for healthy adolescent development, and in the quality of life in their communities. The children and their families require intensive support services to ameliorate their problems. The school systems must undergo rapid reorganization to respond to the needs of the families in these communities. Another 25 percent of youth (7 million) are at moderate risk, because of school problems, minor delinquencies, light substance use, and early, but protected, intercourse. These young people would make up the target population for concentrated prevention approaches including school remediation, counseling, and comprehensive services. About half of the nation’s youth (14 million) experience few problems and are probably at low risk of negative consequences from their behavior, but they too require general preventive services and health promotion programs. And, of course, effective schools are a social necessity for everyone. From these rough estimates, it may be possible to conceptualize a more logical, less fragmented strategy for implementing programs aimed at reducing problem behaviors. It is apparent that some children need a great deal of help, others a little, and some not any. Interventions aimed at the common predictors or antecedents of behaviors may have a better chance of success than those that are focused on only one behavior, such as drugs or sex. It seems reasonable to conclude that fewer children would be failing to achieve if the separate categorical interventions of the past had been more successful.

The Setting: A Description of Adolescents in the United States

Before problem behaviors are examined in detail, it is important to understand the current status of American youth and what comprises so-called “normative” behaviors. It is not sufficient to describe the situation only in aggregate terms; there are such vastly different life scripts that are being experienced by the subgroups in this complex and diverse society. Many books on adolescents solve this problem by presenting an array of vignettes from children’s lives with detailed accounts of individuals and quotations from them. This makes more interesting reading than statistics, but vignettes are not necessarily generalizable to the whole society. For an overview of the “setting,” describing the youth population and the social and economic characteristics of various subpopulations, we turn largely to census data. For a look at health status, we rely on national health statistics. However, to gain an understanding of adolescent developmental issues, different kinds of information are required. For these insights, the works of social and behavioral scientists based on small samples of subjects and personal observations will be explored. In 1987, there were about 28 million 10- to 17-year-olds in the United States, with half a million more boys than girls. More males are born than females, but the sex ratio reverses as populations grow older. This becomes an important factor when individuals reach the age of marriage (about 23 for females and 25 for males) because it controls the pool of partners, a particular problem for marriage-age black females, who outnumber marriage-age black males. The number of young people will increase over the next decade by about 10 percent because the number of births has increased every year since 1973, when the current 15-year-olds were born. One way to understand the expected change is to compare the number of births in 1986, almost 3.76 million, with the number in 1973, 3.13 million. By the year 2000, babies born in 1986 will be 14 years old, right in the center of our population of interest. This group will be enlarged by immigrants as well as by increased numbers of births.

Common Concepts of Successful Prevention Programs

The review of four major fields—prevention of delinquency, substance abuse, teen pregnancy, and school failure (in Chapters 9 to 12)—yielded about 100 different programs that appear to have potential for changing behavioral outcomes. Most of the selected programs reported evaluation data that showed improvements in social behavior or school achievement or reductions in substance abuse or unprotected sexual intercourse. However, 20 of the programs were included as examples of new interventions based on proven theories of behavioral change but with incomplete evaluations. These programs represent a cross-section of thousands of efforts to change the lives of children and youth in all parts of the country. In each chapter, the programs were loosely categorized by type. Among all the models discussed, about 10 percent fell into the category of early child or family intervention, 60 percent were school-based interventions, and 30 percent community-based or multiagency programs. Among the school-based programs, one-third involved specialized curricula, one-third provided nonacademic services in schools, and one-third dealt with school organization or were alternative schools. As we will see, the successful programs share a number of common elements, more than might be expected given the extensive differences in size, complexity, goals, and level of documentation. Among the program models are those directed at very small groups of selected high-risk children and those directed at an entire school or community. Some of the programs had a single purpose (smoking prevention), while others had multiple goals (dropout and pregnancy prevention). Some were offered at one site, while others were multisite. The criterion of primary prevention was loosely applied; some of the most successful models combined identification and counseling or teaching of potential high-risk children with treatment of those who already had the problem. The evaluation of some of the programs accepted here as models was admittedly less than ideal, demonstrating only short-term effects with imperfect control groups. However, for other models, the evaluation meets scientific standards. More than half of the evaluations were carried out by the “designers” of the programs, typically testing their own curricula in schools.

Prevention of Substance Abuse

The literature on prevention of substance abuse is extensive, diverse, uneven, and difficult to summarize. It encompasses intensive reviews of drug education research in general, well-documented experiments with specific school-based interventions, more cursory articles promoting a program but lacking any outcome data, pamphlets advertising curricula, and assorted other materials. This range reflects the fuzziness of the subject of substance abuse prevention and the specialized interests of those who work on it. Some efforts focus only on preventing cigarette smoking, others on alcohol abuse, a few include all substance-related behaviors. In programs directed toward alcohol abuse, there is no agreement on whether the goal should be abstinence or responsible decision making. There is little agreement about whether programs should focus only on substance abuse or deal with more general issues related to the predictors of substance use, such as family bonding and school failure. One school of thought adheres to the position that substance abuse issues should be dealt with in the context of comprehensive health education. Another approach to the prevention of substance abuse takes us away from school-based programs into the area of public policy. This view suggests that behavioral change will result from enforcing restrictive laws and policies and creating broader media efforts aimed at the whole society rather than youth. Many people attribute the decline in cigarette smoking to drastic shifts in public opinion about its social acceptability and safety following the release of a Surgeon General’s report 25 years ago that documented the negative health consequences of smoking. It is true that the changes in behavior even among adolescents took place in the late 1970s, prior to the initiation of most smoking prevention programs in schools in the early 1980s. Teen smoking behavior has changed much less during this decade than the prior one. The Advocacy Institute has proposed a number of priority policy actions to prevent smoking which include creating smoke-free workplaces and public spaces, increasing excise taxes on cigarettes (assuming a 10 percent increase in tax produces a 12 percent reduction in smoking!), compelling cigarette manufacturers to assume liability for smoke-caused deaths and diseases, neutralizing or reducing cigarette advertising and promotion, and restricting sales to minors.

Prevalence of School Failure and Dropping Out

In this chapter, we turn to the risk behavior that appears to underlie many of the problems addressed so far. Low achievement in school has been shown to be an important predictor of substance abuse, delinquency, and early sexual intercourse. And as we will see, not only are many of the antecedents of poor school performance the same as those for other problem behaviors, so are the consequences. Moreover, low academic achievement is both a predictor and a consequence of other kinds of risk behavior, as well as being a problem in itself. Understanding the epidemiology of school failure and dropping out is fundamental to this book’s argument: that high-risk behaviors are interrelated and, therefore, interventions must be comprehensive. School failure is a process rather than a single risk event. A young person initiates hard drug use or has early unprotected sexual intercourse or first commits a delinquent act at a specific time and place. Usually these actions are voluntary and follow a personal decision (although they are heavily influenced by the social environment). Low achievement results from an array of forces, many of which are outside the control of the child. The quality of the school is, of course, a major factor, as are the actual classroom practices and attitudes of the teacher. Estimates of the risk of other problem behaviors can be projected based on individual characteristics. Children with certain attributes are more likely than others to get involved in certain behaviors. This is not necessarily the case for estimating the risk of school failure since the probabilities are conditioned by both individual characteristics and the quality of the school. Children from disadvantaged households have been shown to succeed in excellent schools, while some schools are so inadequate that success is an exception. Unlike the other behaviors, risk of educational failure is measured routinely for almost all children at frequent intervals. Report cards inform children about their progress and, in aggregate, these marks produce a grade point average for each student.

Prevalence of Delinquency

The term delinquency suggests a wide range of behaviors from socially unacceptable acts performed early in childhood that parents describe as “naughty” and psychologists call “acting out” to violent and destructive illegal behaviors. The seriousness of the act and the age of the perpetrator further sharpens the definition. Acts such as robbery, aggravated assault, rape, and homicide are not age-related offenses. They are criminal acts whether committed by juveniles or adults and are categorized by the Federal Bureau of Investigation as index offenses. Other less serious offenses, such as running away, truancy, drinking under age, sexual promiscuity, and uncontrollability are categorized as status offenses, because they are performed by youth under a specified age which classifies them as juvenile offenses. States differ in their penal codes in regard to the age at which an individual moves from juvenile to adult jurisdiction. About three-fourths of the states have set age 18 as a maximum for defining juveniles, two states have set age 19 as a cutoff, seven states use 17, and four states (including New York) 16. Thus, running away from home at age 17 may be an offense in one state but not another. Almost every child at one time or another acts out, defies parents or teachers, tells lies, or commits minor acts of vandalism. Clearly, they are not all current or potential juvenile delinquents. Many of the behaviors that are considered delinquent are included in a psychiatric diagnosis called conduct disorder. The symptoms of this diagnosis include multiple behaviors extended over a six-month period; 17 behaviors are listed including truancy, stealing, cheating, running away, firesetting, cruelty to animals or persons, “unusually early” sexual intercourse, substance abuse, breaking and entering, and excessive fighting, among others. When three or more of these behaviors co-occur before age 15, and a child is considered unmanageable or out of control, then the clinical diagnosis is conduct disorder. Kazdin defines this disorder as a “pattern of antisocial behavior, when there is significant impairment in everyday functioning . . . and the behaviors are regarded as unmanageable by significant others.”

Prevention of Delinquency

As we have seen in Chapter 3 (Prevalence of Delinquency), the phrase “juvenile delinquency” may refer to the “continuum of behavior that transgresses social norms,” ranging from socially unacceptable behavior (acting out in school) to status offenses (running away) to criminal acts (burglary). This broad definition sets wide boundaries on a discussion of prevention. Preventing disruptive behavior in the early elementary grades is quite a different task from preventing major criminal acts among high-school-age gangs. The former focuses more on altering individual and family functioning, while the latter involves alterations in the peer culture, the school experience, and the broader social environment. In any case, a review of the literature on prevention of delinquency produces few programs that can be cited as models of primary prevention at early or late stages. A very small number of programs could generate evidence that they stopped the onset of delinquent behavior. Interventions were cited, however, that have an indirect effect on later delinquency by modifying “acting out” and conduct disorders at very early ages. Many of the programs discussed in the literature focus on secondary prevention, working with adjudicated juvenile delinquents to lower the rates of recidivism (repeat offenses), and almost none of those appear to meet with great success. The dearth of successful prevention programs in the area of delinquency is not surprising in light of the complexity of the problem and its deep-seated causes. The usual difficulties with evaluation design are compounded in this field by murky definitions. Repeated reviews of literally thousands of studies have produced almost none with adequate evaluations. Leitenberg’s commentary on the “state-of-the-art” is not very encouraging: . . . My thoughts about primary prevention programs in delinquency tend to be pessimistic. Unless the larger political, organizational, economic and social issues are addressed . . . we will make small headway. . . . I think the most productive area is not within the realm of psychology, sociology, psychiatry, social work, or criminology—it is within the area of politics. . .

Prevalence of Adolescent Pregnancy

Once a young person experiences coitus, she or he acquires “risk status.” Unquestionably, young people who are not sexually active are not at risk of pregnancy, unless they are forced to have sex (which is not a rare event). However, once the decision is made to initiate sexual activity, risk of pregnancy is high for those who do not use contraception consistently. And since no contraception is 100 percent effective, an unplanned pregnancy may occur. Once pregnant, a young woman must decide whether to carry the pregnancy to term. She may decide to have an abortion, if that option is available to her. If a child is born, the mother may decide to give the child up for adoption. While this series of decisions seems relatively straightforward, there is little consensus in our society about how to intervene at any point along the way and prevent the negative consequences. Differing perceptions of the problem shape the range of solutions. One set of conflicts centers on the morality of premarital sex. Some people believe that the only response to the issue of adolescent pregnancy is to promote abstention. Others believe that premarital sexual activity has become a normative behavior and, therefore, interventions should focus on teaching responsible sexual behavior and providing access to contraception. A second set of conflicts is focused on the abortion issue. Once pregnant, should a girl be required to maintain the pregnancy and encouraged to put the baby up for adoption if she cannot care for it, or should she be assisted to obtain an abortion if that is what she wants? We can turn to many sources of data to gain insights into these questions. The problem of adolescent pregnancy has received a great deal of attention over the past decade and numerous studies have been produced from which we can learn about the antecedents, prevalence, and consequences of early sexual activity, contraceptive use, and pregnancy among teenagers.

Prevention of School Failure and Dropping Out

At least three different kinds of interventions are suggested in discussions of schools and high-risk children: preventing school failure, preventing school dropouts, and finding and reinstating students who have already dropped out. The first set is touched on in the effective schools literature, assuming that improving the quality of education will result in higher achievement for all children. Thus, the interventions are primarily aimed at school reform and organization. The second set is described in the dropout prevention literature, with much more attention to individual needs and support services, along with alternative school structures. Because official dropout statistics are generally calculated only for high schools, most of the interventions are directed toward older students, although there is increasing recognition of the need for early intervention. Reinstating students in school is approached largely through employment and “recovery” programs for young people over the age of 18. Because this book is focused on 10- to 17-yearolds, the third set of interventions relating to job placement and programs for older youth will not be included. That subject has been thoroughly addressed by the Grant Foundation Commission on Work, Family, and Citizenship and other sources. The public has been deluged with studies focusing on the crisis in American education. The rationale for intensified concern is that unless the quality of education is improved we as a nation will not be able to compete with foreign countries (the Japanese educational system is most often cited as a model). One source reported that more than 275 education task forces had been organized in the mid- 1980s and “reform literature [has become] a cottage industry among scholars.” States enacted more than 700 pieces of legislation between 1983 and 1985, mostly stressing a return to basics. Most recommendations directed toward raising quality call for higher standards for graduation from high school, higher college admission standards, teacher competency tests, and changes in teacher certification requirements.