Adolescents: Practice Interventions
Abstract and Keywords
This chapter summarizes literature and research related to advances in direct practice work with adolescents. Social workers are on the forefront of developing and utilizing a variety of evidence-based practices to address complex client and community needs.
History and Demographics
Adolescence is a period of physical, social, and emotional transition from childhood to adulthood. The World Health Organization (WHO) defines adolescence as the period of life between ages 10 and 19. In the United States adolescence is more commonly thought to begin around ages 12–13, and there are more than 17 million adolescents (U.S. Census Bureau, 2006). Research findings indicate that 1 of 20 children has definite or severe difficulties in emotions, concentration behavior, or being able to get along with others, and these difficulties affect children's home life, friendships, learning, and leisure activities (Simpson, Bloom, Cohen, Blumberg, & Bourdon, 2005).
Adolescence is a time of rapid dramatic change marked by the onset of puberty. The physical and biological changes associated with puberty follow a sequential order for males and females, although the changes vary considerably in the timing of each event. Puberty is a stage in which a child develops secondary sex characteristics, triggered by hormonal changes resulting in rapid maturation of the gonads (ovaries in girls and testicles in boys) (Tanner, 1962). Often these hormonal increases are not fully matched by corresponding maturation in brain development, particularly those related to the frontal cortex and advances in executive functioning governing cause-and-effect thinking. Teens may look and sound like physically mature adults, but they may not be in a position to “think” and therefore “act” like a fully mature adult. One of the paradoxes of adolescence is that although health (strength, stamina), ability (speed, reaction time), and resilience (immune response) indicators are extremely high during this period, so is adolescent mortality, which increases dramatically from childhood to late adolescence, and primarily relates to problems controlling behavior and emotions. In 2002, suicide mortality rates increased from 1.2% per 100,000 in 10- to 14-year-olds to 7.4% per 100,000 in 15- to 19-year-olds. Similarly, mortality rates related to homicide deaths increased from 1.02% per 100,000 in 10- to 14-year-olds to 9.3% per 100,000 in 15- to 19-year-olds (Centers for Disease Control and Prevention, 2006).
A number of psychological theories identify important dimensions of adolescence. In 1904 Hall (1904) coined the phrase “storm and stress” to characterize three key aspects of adolescence: mood disruptions, conflict with parents, and risky behaviors. Although not all adolescents exhibit these behaviors, adolescence is a developmental period when these behaviors are more likely to be evident. Risky behaviors related to alcohol and drug use, sexual promiscuity, fighting, and high-sensation seeking are more likely to occur together, rather than in isolation. Stage theorists such as Freud (1958) and Erikson (1959) viewed adolescence in a sequence of age-related periods, each with its own defining characteristics or challenges. Erikson identified crucial struggles between individual psychological growth and interacting societal supports and pressures in which each stage is marked by a crisis for which successful resolution revolves around an important event. For example, in adolescence the developmental crisis of identity versus identity diffusion is seen as a crucial period of increased vulnerability and heightened potential. The important event during this period (12–18) is peer relationships because they provide the vehicle for adolescents to experiment and discover a deeper and more stable sense of self. Identity diffusion results when there is turmoil and lack of understanding about one's sexual, occupational, and self definition. According to Erikson, by the end of adolescence, one must accomplish a satisfactory level of self-integration or remain defective and conflict-laden.
Cognitive theorists, such as Jean Piaget, were also interested in describing how children and adolescents thought and constructed knowledge. Cognitive development refers to the development and maturation of the thinking and organizing systems of the brain. These systems include such aspects as language, reasoning, problem solving, and memory. For Piaget, the last stage of cognitive maturity is typically reached between ages 12 and 15, leading to “formal operational” thinking. During this stage the form of thinking is important, not just the content. Consequently, the adolescent learns to recognize underlying connections and relationships in such a way as to abstract hypothetical solutions to situations that may never actually occur (Dilut, 1972).
Cognitive differences are particularly important when we consider the way adolescents are able to reason and solve problems. More recent studies suggest that changes in adolescent brain development may not reach full maturity until the mid-20s, (Sowell, Thompson, Holmes, Jernigan, & Toga, 1999; Sowell, Thompson, Tessner, & Toga, 2001). For instance, amygdala, the center of impulsive and emotional reactions, matures earlier than the frontal cortex, which is responsible for executive decision-making. Thus, the adolescent brain may not be able to fully anticipate the outcomes of its hormone-driven decisions (Strauch, 2003). Environmental excesses such as alcohol, drugs, violence, and stress may hinder brain development, while supportive environments that provide proper stimulation, team activities, and problem-solving activities may help brain development.
Positive youth development promotes a belief that all young people can grow into successful adults if they have a supportive environment in which to build skills, exercise leadership, and contribute to their communities (Catalano, Berglund, Ryan, Lonczak, & Hawkins, 1998; National Clearinghouse on Families and Youth, 2006). Helping young people reach their potential is the best way to prevent them from engaging in risky behaviors. The Family and Youth Services Bureau (2006) encourages communities to support young people through positive youth development. This comprehensive youth strategy involves focusing on strengths and competencies of youth instead of their weaknesses, promoting ongoing relationships and connections with adults and adult role models, providing safe places to go after school, and providing opportunities for community involvement.
Much of the biological and physical science research on child development since the mid-1980s has focused on the brain—its internal architecture and responsiveness to key environmental influences. At the same time, much of the social science research has concentrated on articulating and studying the socio-emotional context of youth development, with an emphasis on fostering development of essential assets and competencies in nurturing environments. This dynamic interplay between “nature” and “nurture”—between brain development and socio-emotional development—provides the strongest theoretical foundation for conceptualizing effective prevention and direct practice approaches.
Latest Comorbidity Research
There is a general consensus in the adolescent research literature supporting the substantial overlap or comorbidity among adolescent problem behaviors related to delinquency, sexual promiscuity, drug abuse, exposure to violence, victimization, mental health problems, and school problems (Thornberry, Huizinga, & Loeber, 1995). Of adolescents receiving mental health services, half have a co-occurring substance abuse disorder (Greenbaum, Foster-Johnson, & Petrila, 1996), and adolescents having a substance abuse disorder have an increased risk of experiencing other mental disorders (Beitchman, Adlaf, Douglas, & Atkinson, 2001). It is not surprising that the SAMHSA Report to Congress on the Prevention and Treatment of Co-occurring Substance Abuse Disorders and Mental Disorders (Substance Abuse and Mental Health Services Administration, (2002) recommends systematic screening procedures to identify mental health, substance abuse, and treatment needs for all at-risk youth, especially in settings such as juvenile justice and child welfare, where large concentrations of high-risk youth reside.
It is evident that problems experienced by adolescents in the domains of mental health, substance abuse, and violence stem from a complex web of interrelated individual, family, environmental, and social factors (Dishion, Capaldi, Spracklen, & Li, 1995; Loeber et al., 2005). The common or shared risk factor model and biopsychosocial causal model (Dawes et al., 2000; Lahey, Waldman, & McBurnett, 1999; Riggs, 2003; Tarter, 2002) have contributed significantly to our understanding of comorbid youth. The common risk factor model has shown that a number of risk factors increase the chances of youth developing health or behavior problems. Adolescent suicide has associated risk factors significantly related to mental health problems. Up to 90% of adolescents who commit suicide have mental health problems that contribute to this tendency (Shaffer & Craft, 1999). The most common disorders are mood disorders, with or without co-occurring substance abuse problems (Shaffer et al., 1996), and certain types of anxiety disorders. Population studies show that at any one time, between 10 and 15% of the child and adolescent population has some symptoms of depression (Smucker, Craighead, Craighead, & Green, 1986). Proponents of the biopsychosocial causal model further speculate that a subset of risk-exposed youth experience a progressive cascade whereby biopsychosocial vulnerabilities, chronic adversities, early behavioral problems, and family dysfunction lead to movement down a developmental trajectory that includes school failure, deviant peers, and social marginalization. This results in a vulnerability to victimization, violence, substance use disorders, and mental health problems. In both of these conceptualizations, individual and environmental risk conditions interact with social and family experiences to significantly impair a child's developmental course, adaptation, and later functioning in life.
Identification of risk factors is an important first step in understanding the circumstances that lead to the development of adolescent problem behaviors. Eliminating or minimizing these risks, in conjunction with increasing assets that mediate or moderate their effects, is a fundamental goal of most effective therapeutic interventions. The general goal of most prevention and intervention models is to reduce risk factors and enhance protective factors across multiple life domains (that is, individual, family, peer, situational, and community). Prevention research suggests that protective factors can help to shield youngsters from the full impact of individual, family, and environmental adversities (National Research Council Institute of Medicine, 2002) and include a broad range of individual, family, and community variables (Garmezy, 1985; Jessor, Turbin, & Costa, 1998). It is hypothesized that reductions in substance abuse and violence may be more strongly impacted by treatment approaches that also focus on improving protective factors, specifically adaptive functioning (Luthar & Goldstein, 2004; Rutter, 2003; Sroufe, Carlson, Levy, & Egeland, 1999). According to youth development experts (Catalano, Berglund, Ryan, Lonczak, & Hawkins, 2002), programs are more successful if they include enhanced competence rather than just risk reduction (Flannery et al., 2003). It is therefore difficult to separate pure prevention strategies from intervention strategies, as in theory and practice they are often integrated to address multiple-need populations across different contexts. For the present discussion, we define practice interventions in relation to indicated prevention strategies targeting youth who have significant symptoms of a disorder but do not meet diagnostic criteria, and treatment interventions targeting those who have high symptom levels or diagnosable disorders (Weisz, Sandler, Durlak, & Anton, 2005).
A broad range of terms are used interchangeably (but not equally) to describe “best” practices. These terms include the following: best, proven, promising, model, effective, evidence-based, emerging, exemplary, and commendable. In addition, there is the question whether “best practice” should refer to principles, approaches, or specific programs. The most commonly used term, evidence-based practice (EBP), is defined by the Institute of Medicine as the integration of best-researched evidence and clinical expertise with patient values (Institute of Medicine, 2001). McNeese and Thyer (2004) refer to evidence-based practice as intervention based on the best available science while Macdonald (1999) has described it as the integration of scientific knowledge with values, resources, and clinical judgment. Emerging best practices are treatments and services that are promising but less thoroughly documented than evidence-based practices (Institute of Medicine, 2001). Implicit in these definitions is the inextricable link between science and practice; however, there is much disparity among scientists and practitioners regarding the definition of evidence-based practice.
Several parallel initiatives have developed across fields (substance abuse, education, violence prevention, child welfare) and organizations that seek to develop both a central program registry site and a standardized methodology to review and rate programs. Organizations such as the Center for the Study and Prevention of Violence (2006; Blueprints for Violence Prevention), Substance Abuse and Mental Health Services Administration (SAMHSA's Model Programs), Washington State Institute for Public Policy, and the Child Welfare League of America (2006; Research to Practice Initiative) have sought to utilize the continuum of research practices to catalog and grade programs and services. Although each varies to some extent regarding nomenclature and selectivity, each generally allows for differential recognition of programs based upon a hierarchy characterizing the type and level of evidence supporting each program. In addition to examining outcomes and research design, many of these initiatives also examine factors such as theory behind interventions, costs and benefits, fidelity, overall utility, and cultural and age appropriateness. Programs are evaluated and endorsed with respect to a variety of outcome dimensions. Practitioners working with adolescents can easily consult such registries when considering a direct practice model.
Research has found that several important themes need to be taken into account when developing or implementing adolescent practice interventions. The first theme is that early, immediate intervention should be prioritized, as behavioral problems, aggression, and other risk factors can be identified at an early age (Guerra, Huesmann, Tolan, Acker, & Eron, 1995; Tremblay, Kurtz, Masse, Vitaro, & Phil, 1995).
A second theme is that theory-based behavioral or cognitive-behavioral programs with specific behavioral targets show the greatest treatment effect. Most effective programs are based on social–behavioral theories or combinations of theories with specific behavioral-change targets.
A third theme is the need for well-coordinated, multicomponent, prevention and intervention models that impact key risk and protective factors across multiple life domains. (Henggeler, Melton, & Smith, 1992; Tolan, Guerra, & Kendall, 1995). Programs that include a family focus and attempt to change the environment where a child operates (for example, the school climate, the family, the peer group) are also more effective than programs that attempt to address factors solely at the level of the individual. Generally, comprehensive and multicomponent interventions are superior to single component interventions because they are able to address a range of delinquent behaviors by orchestrating different methodologies in an integrated fashion (Flannery & Huff, 1999). An additional benefit to such programming is that these types of interventions often address interrelated problem clusters and therefore have additional positive benefits promoting healthy youth development and functioning.
Fourth, programs need to be of sufficient intensity and duration to obtain the desired treatment effect. The notion of dosage is key in that clients are successfully engaged, remain in treatment, and receive a sufficient amount of the intervention to achieve the desired outcomes. Finally, while many effective treatment programs have manuals and offer training, it is imperative to have mechanisms with ongoing training, coaching, and implementation monitoring to assure fidelity to the underlying principles and change mechanisms of effective treatment models (Fixsen, Naoom, Blase, Friedman, & Wallace, 2005).
Challenges, Trends, and Implications
There are a wide range of intervention practices that are considered effective in working with adolescents. Over the next decade, most of the adolescents receiving social work interventions should be benefiting from evidence-based models. A current trend for social work education, therefore, is to train practitioners in the use of evidence-based models. Since many of the evidence-based models address single disorders with mainstream client populations, researchers and practitioners will need to work collaboratively to expand the evidence-base of adolescent direct practice interventions. Research on clinical practices that effectively address the needs of vulnerable, comorbid, and culturally diverse adolescents and their families is limited. Further research is needed to develop intervention models that can effectively address the complex client characteristics and interacting social and community conditions that define the realities of modern social work practice with adolescents.
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