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Book Title: Treating and Preventing Adolescent Mental Health Disorders
> pp. [520]-[524]
UNDEFINED: AUTHORS
Treating and Preventing Adolescent Mental Health Disorders
Print ISBN 9780195173642, 2005
pp. [520]-[524]
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ventions have maximal impact? Programs work best when put in place before the target behavior is set in place. And, of course programs must be developmentally appropriate. Developers of programs that require metacognitive skills on the part of participants need to be sure that these skills exist (e.g., Gillham & Reivich, 2004).
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Structured is better. Programs that work best have a clear plan that is monitored on an ongoing basis.
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Accurate is better. Programs are most effective when implemented with fidelity. Our enthusiasm for youth development programs must be tempered by caution about bad (or at least slipshod) company.
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Supportive is better. The best programs are those in which youth have at least one supportive relationship with an adult.
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Active is better. The most effective programs actively teach skills related to the target outcome, through hands-on and minds-on engagement.
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Broad is better. The most effective programs target several systems simultaneously—e.g., home and school. Programs that work best provide ways for youth to not only think differently but also act differently.
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Socioculturally relevant is better. Programs work best when tailored to the cultural background of their participants.
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Contextual is better. Programs that work best take a sophisticated “person-in-environment” approach. They do not address just internal factors such as character strengths, and they do not address just external factors such as school safety. Instead, they address both.
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Theoretical is better. Along these lines, programs work best when guided by explicit theories about the causes of outcomes and the mechanisms of change.
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Not enough is known about the parameters of these truisms. All program evaluations report statistical significance levels but not necessarily effect sizes, making it difficult to say which of the features just described are more or less important in producing outcomes. Also, almost nothing is known about the cost-effectiveness of
different programs (or program features) with respect to various outcomes (see Newman, Smith, & Murphy, 2000). We do not know if promotion programs help troubled youth as much as they do youth in general, or if prevention programs are as helpful for youth per se as they are for young people at risk. We have no idea whether preexisting programs work better than “designer” programs. We are not sure whether programs in general are more effective when they target at-risk adolescents or young people per se, although violence prevention programs and eating disorder prevention programs seem more successful when they target at-risk individuals (Stice & Shaw, 2004). More generally, except for age and cultural background (ethnicity) of participants, we do not know if programs work better if matched to preexisting characteristics of youth (e.g., gender, temperament, religiosity) or whether one size indeed fits and benefits all. Although such positive characteristics as life satisfaction and strengths of character vary little across gender, ethnicity, and social class, the prevalence of psychological disorders varies considerably as a function of these contrasts, which means that they cannot be neglected in future research. For example, if the risk factors for a disorder vary by gender, do males and females require different prevention strategies? There is agreement about the most desirable features of program evaluation studies—i.e., random assignment, manualization and checks on program fidelity, and designs that are multivariate, multimethod, and longitudinal—and the importance of using explicit theory in designing interventions and studies (cf. Coalition for Evidence-Based Policy, 2003). Theory need not be ultimately correct (and it is unlikely that it will be), but is extremely helpful in making sense of research findings, both positive and negative. Compounding the difficulty in drawing conclusions from existing reviews is that many of those we surveyed were sponsored by private foundations or government agencies interested in bottom-line conclusions about what works and not in theories about why something works. The good news is that individual interventions are usually based on strong theories about youth
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development; the problem is that these underlying theories are often downplayed in commissioned reviews (see Eccles & Gootman, 2002, for an exception). In any event, a consensual theory of change would be a boon. Within other fields, e.g., public health, explicit theories of change such as the reasoned-action model (Fishbein & Ajzen, 1975), the health belief model (Becker, 1974), the social development model (Catalano & Hawkins, 1996), and the transtheoretical model of change (Prochaska, Redding, & Evers, 1997) are used to design and evaluate interventions. The youth development field would do well to follow these examples and use the same theory across different programs. Frequently cited as a program rationale is social learning theory (Bandura, 1986), but this “theory” is often applied metaphorically rather than rigorously.
As promised, we have made two arguments: (1) the sorts of psychological characteristics of interest to positive psychology—notably life satisfaction, strength of character, and competencies, but also positive emotions and the frequent experience of flow—are associated with reduced problems and increased well-being among youth; and (2) youth development programs with specifiable features can encourage these positive characteristics and at the same time increase the likelihood of the outcomes in which we are interested. We would like to treat these two statements as the components of a syllogism, but the implied conclusion, that programs reduce problems and increase desirable outcomes because they develop positive psychological features, may or may not follow. A number of the reviews we have mentioned attempted to identify mediators of effective interventions, but the included studies in almost all cases did not allow this to be done. Given the typical absence of long-term outcome data, we do not know with certainty whether positive youth characteristics, either naturally occurring or deliberately produced, limit, contain, or preclude subsequent adult problems (see Lonczak, Abbott, Hawkins, Koster
man & Catalano, 2002, for an exception). Said another way, we need to know whether youth intervention programs are palliative or curative. The disappointing fact about therapeutic interventions for adult disorders, whether psychosocial or pharmacological, is that they are rarely cures (Seligman, 1994). They usually need to stay in place for their benefits to remain. Are youth development programs somehow different? If so, they would represent a huge preventive investment for society. There is a methodological disconnect between intervention programs that attempts to prevent problems and promote well-being and the therapeutic interventions, psychosocial or pharmacological, reviewed in earlier sections of this volume. Most of the latter studies use individuals who satisfy certain DSM diagnoses and not others according to structured clinical interviews. In contrast, prevention and promotion interventions often use different ways of ascertaining problems: self-report symptom checklists or single-item indicators. We have no doubt that an adolescent formally diagnosed with depression also reports symptoms of depression on a self-report questionnaire and evidences problematic indicators, although the concordance will not be perfect. We also note that prevention programs exist for many of the common psychological problems among youth—anxiety, depression and suicide, alcohol and substance abuse—but there are fewer for the less common but often more severe disorders of schizophrenia and bipolar disorder. The relative absence of prevention programs for these problems may represent a deliberate choice on the part of prevention scientists to focus on more common disorders with less obvious genetic contributions. But heritable problems are not necessarily immutable. Perhaps prevention programs, if nothing else, might reduce the severity or chronicity of psychotic episodes, and some suggestive evidence supports this important possibility. There is little agreement, again because much of the relevant research is skeletal, whether positive characteristics are causes of program benefits or merely correlated markers. If they are causes, there is little agreement about the mechanisms by which different benefits might take
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place (mastery and internalization of prosocial norms are promising mediators). There is little agreement about which of these outcomes is more or less likely and whether they are independent or entwined. There is little discussion of the possibility that these positive characteristics might destigmatize disorders and as a result increase help-seeking and facilitate community reintegration of youth following treatment (Penn, 2003). Needed are studies of programs that look explicitly at what mediates gains. To do such studies, we would probably want to start with some of the best-practice programs (Table 26.1) and repeat their evaluations with multiple waves of data collection that explicitly measure hypothesized mediators. These studies would establish the relative salience and temporal or causal ordering of these characteristics. For whom do youth development programs not work? Even successful programs with a moderate effect size help only 60% of participants (cf. Rosenthal & Rubin, 1982). Do the other 40% of participants represent error or noise, or is there something more systematic that might be said about them? Indeed, we can even raise the issue of intervention casualties, participants in youth development programs who end up worse off for the intervention. We know that traditional psychotherapy can hurt some adults (cf. Mays & Franks, 1985). As unpalatable as the possibility may be, the matter also deserves attention within the youth development field. For example, participants in eating disorders programs may learn new ways to starve themselves and participants in substance abuse programs may be turned on to new drugs (cf. Mann et al., 1997; Shin, 2001). Finally, little is known about the benefits of positive youth development programs for adolescents already displaying a psychological disorder. We know that past problems predict future problems, which could lead to the unfortunate and gravely stigmatizing implication that young people who develop a disorder are beyond the help of youth development programs. The positive perspective challenges this implication, but there are no data showing, for example, that a youth development program can help a depressed teen achieve his or her full po
tential, transcending a diagnostic label to lead a satisfying life (Shih, 2004).
What Do We Urgently Need To Know?
Let us move from these general comments to propose studies that would advance our knowledge and practice of positive youth development vis-à-vis mental health and mental illness.
The Natural History of Positive Youth Development
What is a healthy child? We have concluded that the positive perspectives provides a consensual answer to this question, but it is only a snapshot. We know relatively little about who these young people are except that they can be found in all walks of life. Urgently needed is a broader characterization of youth who are doing well—where do they come from, where do they go, and what are the choices made and routes taken in between? A good first step has already been taken by studies already underway that use epidemiological samples followed over many years (e.g., Hawkins, Catalano, & Miller, 1992). We propose further studies of this sort that use the full array of positive measures and indicators now at our disposal. These studies should be patterned on the Terman ( 1925) study of adolescent geniuses and the Grant Study of the best and brightest of Harvard University undergraduates (Vaillant, 1977) in the sense that they be large scale—i.e., have big samples, longitudinal designs, and multiwave assessments—but not start with the most fortunate or the most privileged in our society. Dissemination of information about youth who are thriving might help combat negative stereotypes about teenagers. Realistic portrayals of young people, including their flaws and problems and how they cope with them, might inspire other teenagers to focus on what they do well and to eschew a victim mentality (Shih, 2004). We propose that these studies of the natural history of positive youth development include, obviously, measures of positive characteristics (positive emotions, flow, life satisfaction, character strengths, skills, talents, and callings), mea
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sures of risk, and measures of problems (negative emotions, risky behaviors, symptoms, and psychological disorders). It would be a shame if the positive psychology perspective leads researchers to repeat the error of business-as-usual psychology by ruling out a balanced view of youth and the adults they become. Inclusion of both positive and negative measures over time allows the critical questions we have posed to be answered with hard data (cf. deVries, 1992). Do positive characteristics preclude recurrence of problems? Do they limit them? Do they allow youth to learn lessons from crises, episodes of disorder, and misfortunes? Which positive characteristics provide the best buffers against depression, substance abuse, or anxiety disorders? A retrospective study we have done with several thousand adults asked respondents if they had ever experienced a severe psychological disorder and, if so, how well they had recovered from it (Park et al., 2003). We also measured their life satisfaction and various strengths of character. Individuals who had fully recovered from a disorder were just as satisfied with their lives as those who had never experienced a disorder. At least for some, there is light at the end of the psychopathology tunnel: “Tis an ill wind that blows no good.” And individuals who had fully recovered from a disorder also reported higher levels of specific strengths of character—i.e., appreciation of beauty, bravery, creativity, curiosity, forgiveness, gratitude, love of learning, and spirituality—compared to those who had never experienced a psychological disorder. Whether these character strengths were in place before the disorder and helped in recovery or whether they represent lessons learned during dark days is unclear from the research design; the need for a richer prospective study is implied (Linley & Joseph, 2004). Prospective studies of psychological problems need to be informed by varying base rates of different disorders. Depression and substance abuse are so common in the contemporary United States that their eventual onset can arguably be investigated in unselected samples of several hundred youth. In contrast, other sorts of problems—e.g., schizophrenia, bipolar disorder, anorexia, and bulimia—are less common, which
means that studies would need to oversample at-risk youth, but we stress that we are not calling for studies of only at-risk adolescents. That strategy would deny the premises of the positive perspective and preclude the lessons to be learned from charting the positive development of youth per se. We are interested in an approach to psychological disorder that we dub “dealing with it,” or keeping on with life despite problems. Our interest was stimulated by conversations with those in the military about how they train personnel to perform optimally under the most extreme circumstances. How does a sniper learn to shoot accurately after crawling into a position and staying there for 48+ hours? How does a pilot learn to fly skillfully in a dizzying free fall? How does a submariner learn to live and work with others in extremely cramped quarters? Business-as-usual psychologists would probably target and then relieve the negative emotional states that accompany these circumstances—boredom, fear, anxiety, fatigue, and discomfort. But that is not how the military proceeds. They teach their personnel how to perform in spite of these circumstances. They teach personnel to deal with aversive states, to do what needs to be done regardless of how they feel at the moment. If these examples are too militaristic to be compelling, then what of the identical lessons we learned from interviewing firefighters and paramedics who perform well—heroically, in our view—under frightening circumstances (Peterson & Seligman, 2004). In no case did anyone we interviewed say that they had eradicated their fear. Rather, they learned to do their job so well that their fear did not get in the way (cf. Rachman, 1990). One of our firefighters told us of rescuing an infant from a smoke-filled building: He lost control of his bladder, but never his grip on the baby. Extraordinary? Yes and no. Deserving of study are the more mundane among us who go to school or show up at work or raise our families even when we are depressed or anxious. Crucial in studying youth from a positive perspective is taking into account the institutions that influence them—programs, organizations, and communities; friends and families; mental health professionals; and the media. Needed
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here is an elaboration of institutions and their features that can be applied throughout the lifespan, and not just to youth (cf. Cameron, Dutton, & Quinn, 2003). The data from such studies can be productively examined with the techniques of causal modeling (e.g., Connell, Gambone, & Smith, 2000; Gambone, 1997; Halpern, Barker, & Mollard, 2000; Walker, 2001). Sample sizes must be large enough, especially to discern interactions between and among variables. But with adequately powered designs, these models allow inferences about what might prevent what and why. As already emphasized, explicit theory is imperative to specify hypothesized links prior to causal modeling.
Positive Interventions for At-Risk and Troubled Youth
Some practitioners in the youth development field have called for extremely ambitious community-level interventions, in which all of the institutions that influence youth development would be explicitly programmed and linked. Interventions would target all children and adolescents and presumably last for years. In the abstract, we understand the sentiment behind this recommendation and agree that the links among different institutions and socializing agents deserve study in terms of their effect on youth development. But in the real world, there are many objections to this research agenda (cf. Wandersman & Florin, 2003). On scientific grounds, community interventions cannot be easily manualized (i.e., explicitly described in detail and thus generalized), and if all youth in a given community are to be included, then what sorts of comparisons are possible? It is difficult to think of a meaningful control group to isolate the active ingredients of such global and enduring interventions. These problems can be surmounted, but it is still unlikely that a society with dwindling resources would be willing or able to initiate such grand interventions on a routine basis, which makes those already under way all the more worthy of attention. Thus with respect to urgently needed intervention studies, we believe that there are two promising research avenues to pursue that
are somewhat more modest but infinitely more feasible.
Positive prevention would use already-established best-practice youth development interventions to help at-risk youth. Although we know that these interventions in general make disorder less likely, we need to know more about why and how prevention works when it does, especially among those at-risk. We have proposed that prevention programs are effective because they cultivate the ingredients of the good life—i.e., positive emotions, flow, strength of character, competencies, and social engagement. An opposing hypothesis is that prevention directly undoes causes found in biological anomalies. By this view, the cultivation of the positive should be irrelevant in predicting who benefits from prevention programs, especially in the long run. Contrast the prevention of infectious diseases by strengthening the immune system instead of eradicating germs. Positive prevention is aligned with the first strategy as opposed to the second. Immunocompetence can be increased in specific ways (through vaccination) or in general ways (through good nutrition and physical fitness). Positive youth development programs similarly benefit young people in specific ways (e.g., by teaching techniques of disputation in the Penn Resiliency program) or in general ways (e.g., by providing supportive mentors in the Big Brothers and Big Sisters programs). Using what is known about optimal research design, investigators can randomly assign at-risk teenagers to manualized youth development programs of different sorts (and to no-intervention comparison groups). An important contrast among candidate programs is whether they are specific in their techniques and goals or are more general. There are best-practice examples of both (Table 26.1), and each has strengths and weaknesses. Specific programs are usually briefer, easier to characterize, and thus more generalizable; general programs are less so. But specific programs need to be created anew each time they are mounted, whereas general programs are already in place and sustained for repeated cohorts of youth by an infrastructure that need not be the concern of the researcher. Comparison and contrast of these two types of programs, not
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doi:10.1093/9780195173642.003.0027
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