Review of "Reducing Adolescent Risk"

Mental health at this time of its scientist-practitioner renewal is nevertheless polarized around issues of treatment for children and adolescent.  Controversy dominates the press and chat rooms: use medication or not, what does this really do in a developing brain?  Do the suicidal thoughts of some children and adolescent constitute a pathway to completed suicide, and are they the same thing?  While we worry about risk, this book worries about the changing view on adolescent risk-taking behaviors, such as drugs, sex, gambling and smoking cigarettes (rock and roll are presumably exempt).  Risk taking may be part of the invulnerability of youth, or at least colored by youthful perceptions of immortality, but as any insurance policy actuary will tell you, it's a dangerous time to be taking risks: but what about fun, is there such a thing for the jaded teenager of today, faced with the Ipods and Playstations we didn't even dream of in the 50's and 60's?  It's a new world, and we have little idea as to how to promote health, normal adolescent development.

Daniel Romer is the research director of the Adolescent Risk Communication Institute, an offspring of the endowment that led to the formation of the Annenberg Public Policy Centre of the University of Pennsylvania.  The USA, and other countries, often have none, or poorly formulated youth development plans, rather, the fire-fighting post-hoc approach to youthful damage prevails in most countries.  Youth are a resource, but costly in terms of risk factors, largely related to stimulation and fun, fun, fun.  The idea is to develop national rather than regional strategies, to avoid the current fragmentation of approaches.

To this end, a conference was organized around seven risk topics, the result of which was the current book, which reviews the state of the art of the approaches to the risk factors identified for the conference. What emerged is the issue of overlap between the risk factors, one being co-morbid with the other, or rather, a high incidence of co-occurrence was clear.

The book begins with a first section devoted to adolescents as decision makers.  The executive functions develop late in humans, and consequently binding events across time, and contemplating which behaviors in the here and now influence temporally distant outcomes is not a strong suite of most youth, with outcomes hardly considered by some who later get into strife with risk taking and poor decision making.  However, such neurological based assumptions turn out not to be a given, nor do ideas of ignorance of consequence or vulnerability.  Most will struggle with the difference between what risks should be taken, and what should be avoided.

James Byrnes looks at both the process of making decisions that result in being in perilous situations as well as the way decisions as to what to do are made when the you-know-what has hit the fan.  He pays attention to the early ideas around risky behavior.  For instance, a past belief was that younger adolescents needed to gain information about risk, and then would modify their exposure, but of course that is not the case: knowledge does not discriminate the risk taker from the abstainer.  The idea of perception of invulnerability is likewise questionable, with risk takers seeing themselves as less vulnerable compared to their risk-avoidant peers, and more importantly, risk taking depends on the amount of opportunity to take risks is offered, influencing risk potential findings in gender, age, knowledge and so on, as discrepant from the propensity to take risk. I personally think that varies according to the risk.  Certainly adolescents might seek sexual contact, and opportunity plays a large role in what constitutes risk, but gambling may include distorted perception as to the positive outcome despite experience, a factor that does not enter the arena in the back seat of a car.  Lawrence Steinberg addresses the definitions of whether examining the concept of decision making, or mature decision making, and as I do, ponders whether this is a existent capacity in such young humans, with Daniel Lapsley introducing the concept of optimism, fables and belief systems that are protective, and hence defend against depression and belief in morbid outcomes in favor of a more Pollyanna view. 

Steinberg questions whether decision-making models adequately reflect risk in a process that is rather more volitional than actually decided upon, or pondered upon, an issue of judgment rather than decision-making.  Many activities are in groups, rather than lone wolf kind of activities.  The issue here as well is that of the emotional arousal which provides a context for much risk taking, and the anxiety rather than pleasure that accompanies filling in psychological questionnaires, and the immaturity of judgment in embarking on risky behavior.  Adolescents are less self-reliant, more shortsighted in terms of the temporally distant future, and more impulsive in Sternberg's view, but accentuated by high levels of emotional arousal.  This arousal appears greater when the subject is in the presence of peers, rather than alone.  In this context too, when adolescents are pushed into decision making, rather than impulsive pleasure, there is less clarity that they will embark on the considered, determined pathway, any more than an adult would.

Lapsley continues from there, working with Elkind's 1967 work around cognitive egocentrism, which leads to themes of invulnerability, omnipotence, personal uniqueness with regard to risk and other ideas around self as distinct to others, a set of personal fables or myths.  There are two sides to this, one leading to risk behaviors and another to more adaptive outcomes, based on the "I will succeed" motif.  The omnipotent fable is thus correlated with positive adaptive outcomes, and predicts self-worth, mastery, coping and superior adjustment, and its presence was protective against depressive affect and suicidal ideation. Personal uniqueness, as a fable, lacks these positive values, whereas the invulnerability fable cut both ways, encompassing both negative and positive influences on the psychosocial interactions of the bearer.

The second section of this first part of the book is devoted to the effect of emotion, with Millstein and Slovic, introducing the ideas of a crucial affective threshold, and an affective heuristic, leading to the heart controlling, not the head. Advertising, positive portrayal of human traits and images, all contribute to what the affective affinity for a certain act might be, without consideration of consequences such as addiction inherent in trying such attractive behavior-image options.  This is thus a process model of adolescent risk, with an attentional phase, and an appraisal phase (primary and secondary), which may lead to a "healthy dose of positive illusions".  I did not find Millstein's a very contributory chapter, but the model may have merits elsewhere in the scheme of things.  Reliance on affect and emotion, or what Slovic refers to as experiential thinking, color decision making, and advertising exploits this.  Smoking a cigarette one smoke at a time does not promote or support the cumulative effect of thousands of these, given the slow accumulation of risk across 200-300, 000 cigarettes.  Eventually, with addiction comes the belief that the cigarette fulfils some inherent need, although what each one really does is relieve the withdrawal from the previous one, but attributions are everything.  Slovic puts forward some solutions on the basis that 80% would never have started smoking in the first place if the risk factors were cognitively processed, challenging the opener from Romer on knowledge as cognition, rather than knowledge as affective heuristic.

Fishbein writes on risk in HIV prevention research.  There is a negative relationship between perceived risk and HIV protective behaviors, so those carrying out risky behaviors perceive that they are at risk.  Not only this, there is a negative relationship between perceived risk and intentions to engage in health protective behaviors.  The greater the perceived risk, the less likely engagement in risk management is likely to be.  In other words, past behavior is a good predictor of future behavior.  These findings change however, when Fishbein and colleagues analyze the data differently with regard to specific behaviors in relation to specific risks, which do predict future, adaptive behaviors.

Johnston follows, with a chapter on perceptions in drugs and alcohol.  It is now accepted that those who use one class of drugs are more likely to use another, even if one compares caffeine, or OTC pills, or the street corner stuff, and a greater propensity for deviance overall, but there is research enlarging this perspective as well:

"It means that each individual behavior in the larger domain of risk behaviors, whether defined in terms of deviance or risk taking or sensation seeking…..likely has many specific determinants that do not act on the other behaviors in the domain" (page 62).

Again, and again in this book, our assumptions are challenged by research.  Risk and protective factors in this domain robustly boil down to four connections to institutions such as church, school, family, namely religiosity as measured by church attendance and rated value of religion, number of days of school cut in the prior four weeks, academic grades and number of evenings out of the family home per week for fun and recreation.  When changes in use occur, there is likely to be a strong inverse connection to perceived risk.  There is however the risk of generational forgetting, with younger groups entering the market without the perception of risk that dropped use in the preceding generation, as with LSD, PCP, and condom use in HIV in Gay men.  This reinforces the use of information with regard to personal risk routinely passed on or rather pressed upon in Motivational Enhancement Therapy.

The first section closes with Gerrard, Gibbons and Gano on the subject of risk perception and behavioral willingness, again, on the non-decided, non-intentional but volitional argument: respondents will swear blind that they will not drink, use a drug, or drive drunk and so on, but about 20% respond a year later that they have indeed done so, without contemplating such activity ahead of time.  One path to risk is thus reasoned or intentional, another is the social, reactional path. In this latter pathway, the behavior finally carried out was previously not thought of as an eventuality, and thinking about such an eventuality may even have been avoided, as if taboo, declaring the possibility that they had not thought about not doing it either. As with most motivational thinking, this is ambivalence. Willingness is only implied, but they have no plans to: it just happened.  Behavioral willingness is thus is an openness to risk opportunity, a willingness to tolerate situations where the risky behavior is on offer, or likely to be on offer. This is then associated with risk behavior despite and separate to contemplation around doing it or not.  Intentions and willingness are thus independent of each other as predictors of adolescent risk behavior, but complementary, and behavioral willingness appears to be a better predictor of the risk-taking behaviors in younger adolescents.  Curiosity killed the kitty after all.  Willingness and perceived risk are thus interwoven, the latter inhibiting the former, but willingness is associated with behavior independent of intention.  Risk perceptions inhibit willingness to take advantage of risk opportunities more than they inhibit intentions to engage in risk behavior.

The third section of Part I of the book involves problem solving approaches, with Shure focusing on preventing early, high risk behaviors in children and preteens, using the identified aspects of interpersonal cognitive problem solving, those cognitive skills that are associated with interpersonal competence and social adjustment.  Griffin follows with school-based prevention approaches such as social resistance, competence enhancement and normative education approaches, and argues for multicomponent programs.  Parker and Fischhoff return to the issue of decision-making competence and demonstrate their research into identifying a unitary measure, an underlying construct of decision-making competence.  Fong and Hall begin with what I mention earlier, the concept of linking current behavior to distant outcomes in time, later outcomes if you will, and the capacity to bind those events across time in a causal way; defining a time perspective construct, with a questionnaire shared with us to evaluate time perspectives.

Russo and Selman work with the idea of school atmosphere, using a relationship questionnaire, Rel-Q, which serves, they say, as an indicator of school health.  These authors work on the idea that perceptions of risk are determined by an interplay of developmental variants and the contexts in which they occur, the school being important in terms of the interactions and attitudes which color the particular school's culture.

In this vein, Part Two examines the common pathways and influences on adolescent risk behavior, starting with a section on multiple problem youth.  Biglan and Cody kick off with ides on prevention, focusing on interrelationships among problems behaviors, as I mentioned in beginning.  Prevention begins in pre-adolescence, prenatal, perinatal and early childhood included. A discussion of all the programs identified is brief, bringing them to our intention really without too much commentary, and more could be made of their closing comments on the realization of the potential of these interventions.  Severson, Andrews and Walker write on the concept of reducing substance abuse by screening and intervening early with antisocial youth.  The basis for this is a longitudinal study which identified the role of early overt aggression, poor social skills, and weak school adjustment as predictors for tobacco use and acknowledging the predictive value of overt social aggression on its own in multiple problem behaviors later.  Such children drift towards others who have similar problems and are similarly rejected by the mainstream, marginalizing them into groups. Teaching of anger management, conflict resolution, impulse control and empathy appears to have an effect.  Winters, August and Leitten present views on externalizing disorders, in this way picking up on the principal of early social aggression, good editing again seen here as before by Romer.  The key here is preventative action, targeting emotional regulation, adaptive pro-social peer affiliation and literacy.

Section B now follows, looking at personality and other putative predispositions. Lerman, Patterson and Shields look at the minimal contribution of genes, and the mediating effects of personality traits.  The contribution of the latter is for more effective early prevention, but does not look promising, and is fraught with social labeling difficulties.  Prevention is the focus for Donohew, Palmgreen, Zimmerman, Harrington and Lane's contribution on health risk takers, with the most interesting part reserved for a footnote on page 169, discussing research into the neurotransmission substrate of stimulation and reward seeking pathways. Alloy, Zhu and Abramson pursue cognitive vulnerability in depression, and the role of depression in adolescent risk-taking behaviors and maladaptive outcomes such as substance abuse. Abramson continues reference to her work in 1989 around hopelessness, and Beck's work and other vulnerability-stress models resorting to cognitive style as a risk factor. Interesting is their discussion of the effects of rumination in dysphoria, and the risks associated with it. Some time is also spent on evaluating modeling and parental inferential feedback, as well as parenting style as antecedents of cognitive vulnerability.

Section C looks at peers and parents, beginning with Rodgers' views on EMOSA modeling and policy and program implications.  The chapter is too short for its level of complexity, referring as well to Dawkins's MEME, the idea equivalent of a gene, so that smoking, drinking, sex are all potential memes to an adolescent, and the transfer of behavior via the experience of one teenager to the other, inexperienced teenager, is the basis of EMOSA modeling.  Not complex enough, Gladwell's tipping point, rules of epidemics, law of the few, stickiness factors, all of this makes the contribution of this chapter limited.  Stanton and Burns move from policy making to methods of sustaining and broadening the effect of interventions, combining peer interventions with parent interventions against a backdrop of core values and perceptions of social norms, looking like a lot of negotiated interventions.

Section D of Part II kicks entertains the effect of media interventions.  Delaney looks at adolescent risk behavior research and media based health messages, and concludes on the benefits of in-market research conducted by advertising industry professionals, based on her experiences with the Partnership for a Drug-Free America.  Capella, Yzer and Fishbein return to the positive-negative consequences of risky behaviors as the informant in designing message interventions, evaluating belief versus persuasive arguments, accepted and not accepted beliefs, and the use of the tool they have used to evaluate messages.

Part Three embarks on gambling, as part of the general view of perspectives from different risk research traditions. Griffiths is first with adolescent gambling, more specifically lotteries, scratch cards and slot machines.  Lotteries may be a first step in learning how to gamble, perceived as 'soft'; scratch cards are not, they are, like slot machines, considered 'hard', with high event frequency and fast payout.  Attention is given to risk factors and this is most valuable, as are the listed difficulties with researching gambling and intervention and prevention for adolescent gamblers and the recommendations that go with this.  A similar chapter follows, by Derevensky, Gupta, Dickson, Hardoon and Deguire, laying down a more conceptual framework with a call for longitudinal research.  Potenza relates gambling to other risk behaviors with similar views to the preceding chapter. Volberg continues this trend about the dangers of adolescent gambling, again joining her colleagues in a call for attention by researchers.  Its clear from the thinness of this vital section, that more needs to be done.

Part III, Section B looks at sexual behavior. Kirby begins with teen pregnancy, with some startling figures, such as 40%+ American teenagers are pregnant before 20 years of age.  Another startling fact is the success rate of Service Learning Programs, despite their non-sexual focus, there is spin off into reducing risk in sexual activity.  Moore and Brooks-Gunn look at health sexual development, and Fortenberry on the rhetoric of risk.  His comments on the frailty of condoms are as startling as other aspects of these chapters, and most telling is his commentary on sexual adventuring that certainly appears to be a facet of normal adolescence. Any sexual activity, such as mutual masturbation, may give rise to "unanticipated emotional reactions", to which he replies that such activities, including oral sex, are educating, pleasurable and self-affirming, all things that are alien to the risk perspective.  The philosophy that is extended to sexual behavior would then regard only abstinence as risk-free.  We are never to ride skateboards, climb trees, play on playground equipment more than a meter in the air, or fiddle around on the back seats of cars: a dull and dreary childhood indeed.  To then engage in any activity has risk, and some would say this amorphous "unanticipated emotional reaction" is meaningless, the whole point of activity is to learn, stretch the envelope, and prepare us for what is to come.  If abstinence is important, until what comes as an adult comes without risk, then how ill prepared will youngsters be, for such important, defended mature (read marital) activity?  In this way, the level of importance adolescent boys attach touching, and the capacity of teenage girls for orgasm, remain virtually taboo for risk researchers. It is the social perils of adolescent sexuality that are being addressed, so is risk-taking research really finding solutions or applying social control and a Judeo-Christian morality?

And so to suicide in Part III Section C.  Gould examines adolescent risk, in a very thorough analysis, weighting mental illness, family characteristics, and stressful life events as key.  As with most things in this book, the problem is polymorphic, and predisposing and vulnerability characteristics interact with more proximal factors and events to produce risk: not a simple matter to evaluate, as one interacts with the other to form a constellation of events, rather than a syndrome.  Again, risk for one problem is correlated with risk for other events, all interacting in the thing we call a dangerous world.

Brent provides strategies for intervention and prevention mostly, a sad three and a half pages.  Joe tackles a focus on Black youth from the perspective of self-destructive behaviors instead of suicidal ones, namely then focusing on multiple problem behaviors as opposed to single, such as suicide, versus a whole plethora of risk factors common to both, and within an intergenerational strain framework.

Section D, on alcohol, tobacco and drugs, begins with Hornik associating risk for one, with risk of all three, again a theme of the entire book.  Marijuana is a risk taken up after alcohol and tobacco use as precursors, and only if they are present as precursors, and one predicts the other in turn, and together, the cannabis use.  As with all the above risks in this section, research is still lacking.

Part IV takes on a wider view, that of approaches and recommendations for future research, as noted above, a subject close to all the chapter's collective hearts. Flay comments on an approach to positive youth development, with the seemingly common view that many kinds of risky behavior are covariate with each other.  The theory boils down to a triad of influences, mapped out in a table on page 351, operating at different levels of causation.  Roth and Brooks-Gunn join to talk on a similar subject, namely healthy development via youth programs, again with a call for more research. DiClemente, Wingood and Crosby (the first of fame in motivation), look at the importance of the milieu in HIV and other STDs, at various levels, societal, relational, community and family. Countering the media is an apparent focus, as are attitudes and beliefs, countering and changing community norms, social marketing and media interventions, and so on. Jamison, and the editor, close off the discussion that emanated from the conference which gave rise to this book, concluding that universal interventions that promote healthy adolescent development have great promise, and all is not lost. We can teach better decision making, integrate programs into schools, foster attachment to protective institutions like parents, schools, family, aftercare environments, work at multiple levels, address the confusion around what is acceptable sexual experimentation, and also attend to which youth and which risk need targeted interventions which are less generic in the risk they attend to.

The overview of the book is that we have allowed a modern world to exist with a culture that promotes risky behavior. Advertising, gambling, access to firearms, progression from legal to illegal drugs, and of course, the requirement of ever more research to address these issues, are key features of this approach.  The last one-quarter of the book is referential material.

Overall it's a vital beginning for Romer, and he has to be congratulated.  Sadly, the book shows just how much and just how little we equally do not know, and really need to know if we are to make the world and exciting but safe place to live.  Commonsense assumptions appear to be flawed, and more than any other endeavor, we need to explore what being in the world today as an adolescent means, and how to control the risk to acceptable proportions.  Class values are a challenge, and poverty and racial identity are still risk factors in everything from head injury to obesity.  The things we use to escape from misery entail both excitement and risk, and managing those is difficult enough as an adult, let alone an apprentice adult.

Anyone who sees anyone for any reason in the helping professions needs to read this work, a collection of expertise seldom seen in print.

 

© 2004 Roy Sugarman

 

Roy Sugarman, PhD, Clinical Director: Clinical Therapies Programme, Principal Psychologist: South West Sydney Area Health Service, Conjoint Senior Lecturer in Psychiatry, University of New South Wales, Australia.