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.

Categories: ChildhoodDisorders, Psychology