514
HEALTH POLICY INITIATIVES IN ADOLESCENCE* ROBERT J. HAGGERTY, M.D. President William T. Grant Foundation New York, New York MsANY MYTHS HAVE GROWN UP ABOUT
adolescents. They are physically so healthy, at least in terms of traditional diseases, that there is little need to worry about health services for them; but they are all a problem with regard to their behavior, especially to their parents; adolescence is just a phase, best to be ignored. I want to dispel these myths, because if we do not do so, we shall not develop the policies necessary to deal with this important segment of our society. The truth lies closer to the following statements (Table I): Adolescents today have many health problems, especially if health is defined broadly; many of the problems are the result of a cluster of behaviors that coexist in the same young people; but the majority of adolescents are resilient, even under the most severe stressors, and are a neglected resource for our society. Comprehensive, coordinated services for adolescents are effective.
ADOLESCENT HEALTH MUST BE DEFINED BROADLY
Adolescents are generally considered to be very healthy-at least physically. This is in part true. They do have fewer traditional medical problems, including hospitalizations, than either infants or the elderly. But if we examine deaths, adolescents in the United States have high rates of death from causes that are not traditional medical disease. In the United States injuries, suicide, and homicide are the three leading causes of death for adolescents, and account for three fourths of all deaths. In New York City homicide is the leading cause of death for older adolescents (Table II). If one moves to common diseases and disability, defined here as anything that causes young people to be unable to function in society, adolescents have many health problems, ' and the causes are largely due to behavior: substance *Presented as part of a Conference on Strengths and Potentials in Adolescence held by the Committee on Public Health of the New York Academy of Mecicine March 8, 1991 Address for reprint requests: William T. Grant Foundation, 515 Madison Avenue, New York, NY 10022
Bull. N.Y. Acad. Med.
515 HEALTH POLICY INITIATIVES POLICY INITIATIVES515
HEALTh
TABLE I. HEALTH POLICY INITIATIVES IN ADOLESCENCE
Themes 1. Health Must be broadly defined 2. Hip bone connected to the thigh bone Multiple causes of multiple problems 3. Resilience/invulnerability More common than thought 4. Interventions Must be broad, comprehensive services, plus community policies
TABLE II. FIVE LEADING CAUSES OF DEATH FOR CHILDREN 15-19 YEARS NEW YORK CITY, 1989 Cause ofdeath Number Percent Homicide 229 50.1 Injuries 79 17.3 Malignant neoplasms 39 8.5 Suicide 24 5.3 Heart disease 13 2.8 All other causes 73 16.0 Reproduced by permission from the New York Department of Health Bureau of Statistics & Analysis
abuse (including alcohol), premature pregnancy, sexually transmitted diseases, school failure, apathy about the future, and risk taking that results in injuries. We termed these problems the "new morbidity" in the 1960s, but then we were thinking primarily of individual and family problems as the causes of this morbidity. Today the causes of the "new morbidity" must be broadened to include institutional and societal issues that have an adverse impact on the individual -poor schools, lack of jobs, unsafe neighborhoods, as well as individual causes. Palfrey, of Boston's Children's Hospital, has recently published a useful outline of how the important issues have changed in the health care of children during the twentieth century (Table III).2 This illustrates where we have come from and where we are today in thinking about these problems of children and youth. If we are to have an impact on the health of adolescents, defined as their functioning in society, we must define health very broadly. Some physicians define health issues more broadly today. A good example is the Harlem Hospital pediatrics and surgical departments, where, among Vol. 67, No. 6, November-December 1991
516
516
HAGGERTY R.J. HAGGERTY R.J.
TABLE III. TWENTIETH CENTURY TRENDS IN PEDIATRIC MORBIDITY
Classical pediatric morbidity (1900-1955) Infectious diseases High infant mortality rates Poor nutrition Few cures for chronic disease Diseases of overcrowding Epidemics, e.g., influenza, polio The new morbidity (1955-1990s) Family dysfunction Learning disabilities Coordination of care Emotional disorder Functional distress Educational needs Beyond the new morbidity (1990s onward) Social disarray Political ennui New epidemics, e.g., violence, AIDS, cocaine Increased survivorship High-technology care
other activities, the chairmen of these two departments conduct after-school recreation programs and art classes to try to prevent gunshot injuries by keeping young people off the streets, and by giving them a sense of accomplishment. The need is to expand the definition of health issues of adolescents and the necessary response of the health professions, but the problem to date is that funders of health services are reluctant to include such services under their health service reimbursements. While such services are a long way from traditional medicine, they are but a stage in the long history of pediatricians doing what is necessary to prevent death, illness, and disability. In the 1920s Dr. Martha Elliot, then a young faculty member at Yale, was studying rickets. Rather than relying on each mother to give cod liver oil to her child each day, Dr. Elliot persuaded milk companies to add Vitamin D to milk to prevent rickets, thereby effectively preventing the disease. We must do the same today by defining the health needs of youth broadly and stimulating the appropriate responses from the health professions. Unless we do, we shall not design interventions successful in improving the lot of most adolescents. We should acknowledge that the idea of such broad approaches to health care is not new. The Children's Bureau, founded nearly eighty years ago, linked child welfare, health, education, and even child labor into one agency, Bull. N.Y. Acad. Med.
HEALTH POLICY INITIATIVES
517
to take just such an approach. Although the Well Child Movement, begun in the 1920s, focused mainly on babies, it was comprehensive -its services included parent education and advice on the environment, as well as prevention of disease. In the 1960s the Neighborhood Health Center Movement included jobs and training as well as traditional medical care for inner city and rural residents in the health care system. But much of medical care in the past two decades has taken another direction, using a reductionistic disease-bydisease approach, and often successfully, we must admit-at least as far as treatment of traditional diseases goes. In prevention, smallpox eradication stands out as a successful targeted intervention. We do need to determine the problems for which a targeted approach will work best, and for which a more comprehensive approach is necessary. But my thesis is that for the major problems that remain for adolescents, these targeted approaches are unlikely to work well. We must define health for adolescents very broadly, to include behavior and social functioning and recognize the social and institutional causes of these problems if we are to deal effectively with most problems of youth today. MULTIPLE CAUSES OF MULTIPLE PROBLEMS
Most health problems have multiple causes, and appear in multiples in the same young person. I have described this phenomenon as "the hip bone connected to the thigh bone. (Figure 1)" A more elegant way to say it is that there is co-occurrence of problems, with multiple causes of multiple problems appearing in the same individual. School age pregnancy is a good example of this sort of major problem among youth. It has multiple causes (Figure 2), is related to a cluster of personality characteristics such as unconventionality (Table IV), early gateway behaviors such as smoking and alcohol use, and family, peer, and community characteristics. And in turn it is highly correlated with school failure and dropout, poor parenting (including high risk of injuries, both intentional and unintentional, in the offspring), depression, welfare dependency, and delinquency. Jessor's work in Colorado has most elegantly defined the dimensions of comorbidity,3,4 and the progression of these multiple problems in the same young people. In addition, there is a good deal of overlap between problem behaviors and health-compromising behaviors (Figure 3). These problems in part are linked to such social issues as unemployment. The William T. Grant Foundation Commission on Youth and America's Future found that lack of meaningful jobs was a major factor leading to Vol. 67, No. 6, November-December 1991
518
R.J. HAGGERTY
518
Biology
Environment I Physical
Risk
Social
Behaviors
Health Outcomes
Perceived
Personality
Behavior
Fig. 1 Hip bone connected to the thigh bone. Multiple causes of multiple behaviors
apathy, poor school performance, unprotected sexual behavior, and pregnancy.5 The lack of a job that would enable the father to support a family is a major reason why young pregnant women do not get married once pregnant. Thus my point that many of these problems are interconnected. I shall return to this issue in my discussion of interventions, since it makes a great deal of difference if one is trying to prevent a single problem with a single cause by a targeted approach, or if one plans to develop a more comprehensive program to deal with multiple causes to prevent multiple problems. RESILIENCE OR INVULNERABILITY
Adolescence is a time when most young people think that they are invulnerable. This often leads to problems, because adolescents have difficulty weighing the dangers of engaging in behaviors such as alcohol or drug abuse, drunk or reckless driving, or unprotected sex. But the more important point is that many adolescents with several strikes against them do not succumbthey are resilient. This is important, since if we could understand why some young people are resilient in the most vulnerable situations, we might be able Bull. N.Y. Acad. Med.
HEALTH POLICY ---- - INITIATIVES --------- --
519
---- - --- -
PROBLEM
CAUSES Personal Poor Self Peer Pressure
Religious Practice Physical Development
-
*
Teenage Pregnancy
Education
Family Breakdown Poverty
Work Potential
Fig. 2. Categorical approach. Multiple causality of a problem model
to incorporate these ingredients into interventions. Table V outlines a number of risk, as well as protective, factors in young peoples' environments. Garmezy and Rutter were among the first to enunciate this phenomenon.6 Two longitudinal studies have illuminated the issue very well. Werner followed a group of more than 500 individuals on the Island of Kauai from the prenatal period to adulthood (30 years of age).7 While the majority were born without complications, one third were born with the odds stacked against them. They had perinatal stresses, "grew up in chronic poverty reared by
TABLE IV. UNCONVENTIONALITY
Characteristics Risk taking Independence Lower religiosity Less regular sleep and eating patterns Lower school performance Lower self-esteem
Vol. 67, No. 6, November-December 1991
520
\. . havb/o
R.J. HAGGERTY
520
PROBLEM BEHAVIOR
/
f
HEALTH-COMPROMISING BEHAVIOR
~~~~~Drinking-Drivng Smoking
Delinquent
Sedentbry BEhavior\ Excesshv Caories
Smokeless Tobacco Use ExcessW
Use BeohaviorMarijuana AlcoholUse
Salt, Fat,
Coronaryrone
Other IllIcit Drug Use Drug Use & Driving
BehoaryiPor
\preocious Sex
dnaequate
Risk-TakingI
e
Unprotected Sex
Sleep
Fig. 3. Overlap between problem behavior and health-compromising behavior domains. Adapted from Perry and Jessor, 1985.
parents with little formal education, and lived in disorganized family environments. " While two thirds of this vulnerable group ("who encountered four or more of such cumulative risk factors before age two") did develop serious problems, one third "developed into competent, confident, and caring young adults by age 18." By age 30 it was clear that "the impact of reproductive stress diminished with time, and the developmental outcome of virtually every biological risk condition was dependent on the quality of the rearing environment. " Three clusters of protective factors characterized the resilient group: They had a personality or temperament that elicited positive responses from people-characteristics such as vigor, sociability, and at least average intelligence; they had close ties to some adults -grandparents, older siblings, or others, and they had an external support system (church youth groups, etc.) "that rewarded competence and provided them with a sense of coherence." The second study, by Furstenberg and Brooks-Gunn, was a follow-up of teen-aged mothers 15 years after the birth of their children, which demonstrated that most young women who have problems as teens had "staged recovery" by age 30.8 To put a realistic picture before you, however, I must Bull. N.Y. Acad. Med.
521
HEALTH POLICY INITIATIVES INITIATIVES
HEALTH POLICY
TABLE V. YOUTH RISKS & PROTECTIVE FACTORS Environment Social Risk Poverty Racial inequality Illegitimate opportunity Protective factor Quality schools Cohesive family Neighborhood resources Interested adults
Perceived Risk Models for deviance Parental conflict
Protective factor Models for conventional behavior Controls against deviance
add that this study also demonstrated that the children of these teen-aged mothers were doing poorly from the standpoints of both development and health in spite of their mothers' growing competence. The importance of good services to high-risk pregnant teen-agers was demonstrated by a similar follow-up study of pregnant teens in New Haven. The more such women had used a comprehensive service program, the better their outcome was 15 years later. While some factors in resilience are inborn, there is hope from these studies that high-risk youths can be helped if they are linked to supportive others. It is important that we in the service professions avoid labeling all young people as problems. As physicians, social workers, and psychologists, we tend to see disturbance everywhere and think that all teens are problems. The data from community surveys show quite a different picture. A number of studies have shown that at least one third of adolescents move through this transition period with little trouble. Another one third have some bumps and slumps, but regain equilibrium.9 We hear so much from the media and have the impression from our clinical experience with the biased sample of those who have serious, persistent problems that we fail to see the competent, contributing group. Only about one fifth to one third of adolescents have severe, persistent problems. That is not to minimize the problems this group causes themselves, their families, and society. But most adolescents have physical vitality, health, energy, and resilience, the ability to develop caring relations, resourcefulness, and commitment to their communities. Our task is to tap this latent ability in more adolescents and to turn it to better use for their sake and for society's. The most important issue may be to change our opinion and that of society about young people to a more positive view. Vol. 67, No. 6, November-December 1991
522
522
R.J. HAGOERTY HAGGERTY
As the National Crime Prevention Council pointed out in their publication, "Youth as Resources," most youths can serve society, and in doing so, enhance their capacity to avoid problems. 10 The recently passed legislation to support youth volunteer programs is a good beginning to develop organizations to tap this latent talent of youth. COMPREHENSIVE INTEGRATED SERVICES ARE EFFECTIVE
Head Start, the comprehensive program for preschool children, is a prototype of how services should be organized. It combines education, health, counseling, and social services. We must begin to do the same for teens, and develop programs that combine education, health, social services, empowerment of parents and youth, and change in communities. Admittedly it is more difficult to do this for teens, since we must include a broader social and physical environment in any successful strategy for this group than we had to do for the preschool group in Head Start. On a small scale, Olds's study of Nurse Home Visitors (Table VI) is an example of a successful program for pregnant teens.11 The Nurse Home Visitor does more than the traditional public health nurse. She does counseling, is available in off hours for crises, and helps these young women to stop smoking and drinking. It was a randomly controlled trial small, to be sure -but in the experimental group, with young women younger than 17 whose care had begun before four-and-a-half months of pregnancy, there was an increase in birth weight in the experimental groups, compared to controls. For smokers in particular the frequency of low birthweight and preterm delivery was reduced. Among the most interesting findings is that in the two years following the birth of the baby, reported child abuse in the young mothers reduced from 19% to 4%, and emergency room visits for accidental injuries reduced from 34% to 15%. Olds also looked at the cost benefit ratio, and shows that for every dollar invested there is, in fact, a multiplying effect of dollars saved in the long run, in part because more of these young women went back to work or to school, and had a meaningful role in society. Another approach is through prevention during early adolescence. Traditional health education, which generally emphasized only information, has been found fairly ineffective. But when training in social skills has been added to specific information about diseases and presented in all years of school, evidence of success in preventing many of these problems mounts. To deal with the most resistant of youth problems-violence, homicide, premature pregnancy, sexually transmitted diseases, etc. -we must add to Bull. N.Y. Acad. Med.
523
HEALTH POLICY POLICY INiTIATIVES INrMTIVES
HEALTH
TABLE VI. EFFECT OF NURSE HOME VISIT PROGRAM (OLDS) Younger than 17, Entered before 41/2 months Birth weight Smokers % Low birth weight % Preterm Child abuse Mother
HEALTH POLICY INITIATIVES IN ADOLESCENCE* ROBERT J. HAGGERTY, M.D. President William T. Grant Foundation New York, New York MsANY MYTHS HAVE GROWN UP ABOUT
adolescents. They are physically so healthy, at least in terms of traditional diseases, that there is little need to worry about health services for them; but they are all a problem with regard to their behavior, especially to their parents; adolescence is just a phase, best to be ignored. I want to dispel these myths, because if we do not do so, we shall not develop the policies necessary to deal with this important segment of our society. The truth lies closer to the following statements (Table I): Adolescents today have many health problems, especially if health is defined broadly; many of the problems are the result of a cluster of behaviors that coexist in the same young people; but the majority of adolescents are resilient, even under the most severe stressors, and are a neglected resource for our society. Comprehensive, coordinated services for adolescents are effective.
ADOLESCENT HEALTH MUST BE DEFINED BROADLY
Adolescents are generally considered to be very healthy-at least physically. This is in part true. They do have fewer traditional medical problems, including hospitalizations, than either infants or the elderly. But if we examine deaths, adolescents in the United States have high rates of death from causes that are not traditional medical disease. In the United States injuries, suicide, and homicide are the three leading causes of death for adolescents, and account for three fourths of all deaths. In New York City homicide is the leading cause of death for older adolescents (Table II). If one moves to common diseases and disability, defined here as anything that causes young people to be unable to function in society, adolescents have many health problems, ' and the causes are largely due to behavior: substance *Presented as part of a Conference on Strengths and Potentials in Adolescence held by the Committee on Public Health of the New York Academy of Mecicine March 8, 1991 Address for reprint requests: William T. Grant Foundation, 515 Madison Avenue, New York, NY 10022
Bull. N.Y. Acad. Med.
515 HEALTH POLICY INITIATIVES POLICY INITIATIVES515
HEALTh
TABLE I. HEALTH POLICY INITIATIVES IN ADOLESCENCE
Themes 1. Health Must be broadly defined 2. Hip bone connected to the thigh bone Multiple causes of multiple problems 3. Resilience/invulnerability More common than thought 4. Interventions Must be broad, comprehensive services, plus community policies
TABLE II. FIVE LEADING CAUSES OF DEATH FOR CHILDREN 15-19 YEARS NEW YORK CITY, 1989 Cause ofdeath Number Percent Homicide 229 50.1 Injuries 79 17.3 Malignant neoplasms 39 8.5 Suicide 24 5.3 Heart disease 13 2.8 All other causes 73 16.0 Reproduced by permission from the New York Department of Health Bureau of Statistics & Analysis
abuse (including alcohol), premature pregnancy, sexually transmitted diseases, school failure, apathy about the future, and risk taking that results in injuries. We termed these problems the "new morbidity" in the 1960s, but then we were thinking primarily of individual and family problems as the causes of this morbidity. Today the causes of the "new morbidity" must be broadened to include institutional and societal issues that have an adverse impact on the individual -poor schools, lack of jobs, unsafe neighborhoods, as well as individual causes. Palfrey, of Boston's Children's Hospital, has recently published a useful outline of how the important issues have changed in the health care of children during the twentieth century (Table III).2 This illustrates where we have come from and where we are today in thinking about these problems of children and youth. If we are to have an impact on the health of adolescents, defined as their functioning in society, we must define health very broadly. Some physicians define health issues more broadly today. A good example is the Harlem Hospital pediatrics and surgical departments, where, among Vol. 67, No. 6, November-December 1991
516
516
HAGGERTY R.J. HAGGERTY R.J.
TABLE III. TWENTIETH CENTURY TRENDS IN PEDIATRIC MORBIDITY
Classical pediatric morbidity (1900-1955) Infectious diseases High infant mortality rates Poor nutrition Few cures for chronic disease Diseases of overcrowding Epidemics, e.g., influenza, polio The new morbidity (1955-1990s) Family dysfunction Learning disabilities Coordination of care Emotional disorder Functional distress Educational needs Beyond the new morbidity (1990s onward) Social disarray Political ennui New epidemics, e.g., violence, AIDS, cocaine Increased survivorship High-technology care
other activities, the chairmen of these two departments conduct after-school recreation programs and art classes to try to prevent gunshot injuries by keeping young people off the streets, and by giving them a sense of accomplishment. The need is to expand the definition of health issues of adolescents and the necessary response of the health professions, but the problem to date is that funders of health services are reluctant to include such services under their health service reimbursements. While such services are a long way from traditional medicine, they are but a stage in the long history of pediatricians doing what is necessary to prevent death, illness, and disability. In the 1920s Dr. Martha Elliot, then a young faculty member at Yale, was studying rickets. Rather than relying on each mother to give cod liver oil to her child each day, Dr. Elliot persuaded milk companies to add Vitamin D to milk to prevent rickets, thereby effectively preventing the disease. We must do the same today by defining the health needs of youth broadly and stimulating the appropriate responses from the health professions. Unless we do, we shall not design interventions successful in improving the lot of most adolescents. We should acknowledge that the idea of such broad approaches to health care is not new. The Children's Bureau, founded nearly eighty years ago, linked child welfare, health, education, and even child labor into one agency, Bull. N.Y. Acad. Med.
HEALTH POLICY INITIATIVES
517
to take just such an approach. Although the Well Child Movement, begun in the 1920s, focused mainly on babies, it was comprehensive -its services included parent education and advice on the environment, as well as prevention of disease. In the 1960s the Neighborhood Health Center Movement included jobs and training as well as traditional medical care for inner city and rural residents in the health care system. But much of medical care in the past two decades has taken another direction, using a reductionistic disease-bydisease approach, and often successfully, we must admit-at least as far as treatment of traditional diseases goes. In prevention, smallpox eradication stands out as a successful targeted intervention. We do need to determine the problems for which a targeted approach will work best, and for which a more comprehensive approach is necessary. But my thesis is that for the major problems that remain for adolescents, these targeted approaches are unlikely to work well. We must define health for adolescents very broadly, to include behavior and social functioning and recognize the social and institutional causes of these problems if we are to deal effectively with most problems of youth today. MULTIPLE CAUSES OF MULTIPLE PROBLEMS
Most health problems have multiple causes, and appear in multiples in the same young person. I have described this phenomenon as "the hip bone connected to the thigh bone. (Figure 1)" A more elegant way to say it is that there is co-occurrence of problems, with multiple causes of multiple problems appearing in the same individual. School age pregnancy is a good example of this sort of major problem among youth. It has multiple causes (Figure 2), is related to a cluster of personality characteristics such as unconventionality (Table IV), early gateway behaviors such as smoking and alcohol use, and family, peer, and community characteristics. And in turn it is highly correlated with school failure and dropout, poor parenting (including high risk of injuries, both intentional and unintentional, in the offspring), depression, welfare dependency, and delinquency. Jessor's work in Colorado has most elegantly defined the dimensions of comorbidity,3,4 and the progression of these multiple problems in the same young people. In addition, there is a good deal of overlap between problem behaviors and health-compromising behaviors (Figure 3). These problems in part are linked to such social issues as unemployment. The William T. Grant Foundation Commission on Youth and America's Future found that lack of meaningful jobs was a major factor leading to Vol. 67, No. 6, November-December 1991
518
R.J. HAGGERTY
518
Biology
Environment I Physical
Risk
Social
Behaviors
Health Outcomes
Perceived
Personality
Behavior
Fig. 1 Hip bone connected to the thigh bone. Multiple causes of multiple behaviors
apathy, poor school performance, unprotected sexual behavior, and pregnancy.5 The lack of a job that would enable the father to support a family is a major reason why young pregnant women do not get married once pregnant. Thus my point that many of these problems are interconnected. I shall return to this issue in my discussion of interventions, since it makes a great deal of difference if one is trying to prevent a single problem with a single cause by a targeted approach, or if one plans to develop a more comprehensive program to deal with multiple causes to prevent multiple problems. RESILIENCE OR INVULNERABILITY
Adolescence is a time when most young people think that they are invulnerable. This often leads to problems, because adolescents have difficulty weighing the dangers of engaging in behaviors such as alcohol or drug abuse, drunk or reckless driving, or unprotected sex. But the more important point is that many adolescents with several strikes against them do not succumbthey are resilient. This is important, since if we could understand why some young people are resilient in the most vulnerable situations, we might be able Bull. N.Y. Acad. Med.
HEALTH POLICY ---- - INITIATIVES --------- --
519
---- - --- -
PROBLEM
CAUSES Personal Poor Self Peer Pressure
Religious Practice Physical Development
-
*
Teenage Pregnancy
Education
Family Breakdown Poverty
Work Potential
Fig. 2. Categorical approach. Multiple causality of a problem model
to incorporate these ingredients into interventions. Table V outlines a number of risk, as well as protective, factors in young peoples' environments. Garmezy and Rutter were among the first to enunciate this phenomenon.6 Two longitudinal studies have illuminated the issue very well. Werner followed a group of more than 500 individuals on the Island of Kauai from the prenatal period to adulthood (30 years of age).7 While the majority were born without complications, one third were born with the odds stacked against them. They had perinatal stresses, "grew up in chronic poverty reared by
TABLE IV. UNCONVENTIONALITY
Characteristics Risk taking Independence Lower religiosity Less regular sleep and eating patterns Lower school performance Lower self-esteem
Vol. 67, No. 6, November-December 1991
520
\. . havb/o
R.J. HAGGERTY
520
PROBLEM BEHAVIOR
/
f
HEALTH-COMPROMISING BEHAVIOR
~~~~~Drinking-Drivng Smoking
Delinquent
Sedentbry BEhavior\ Excesshv Caories
Smokeless Tobacco Use ExcessW
Use BeohaviorMarijuana AlcoholUse
Salt, Fat,
Coronaryrone
Other IllIcit Drug Use Drug Use & Driving
BehoaryiPor
\preocious Sex
dnaequate
Risk-TakingI
e
Unprotected Sex
Sleep
Fig. 3. Overlap between problem behavior and health-compromising behavior domains. Adapted from Perry and Jessor, 1985.
parents with little formal education, and lived in disorganized family environments. " While two thirds of this vulnerable group ("who encountered four or more of such cumulative risk factors before age two") did develop serious problems, one third "developed into competent, confident, and caring young adults by age 18." By age 30 it was clear that "the impact of reproductive stress diminished with time, and the developmental outcome of virtually every biological risk condition was dependent on the quality of the rearing environment. " Three clusters of protective factors characterized the resilient group: They had a personality or temperament that elicited positive responses from people-characteristics such as vigor, sociability, and at least average intelligence; they had close ties to some adults -grandparents, older siblings, or others, and they had an external support system (church youth groups, etc.) "that rewarded competence and provided them with a sense of coherence." The second study, by Furstenberg and Brooks-Gunn, was a follow-up of teen-aged mothers 15 years after the birth of their children, which demonstrated that most young women who have problems as teens had "staged recovery" by age 30.8 To put a realistic picture before you, however, I must Bull. N.Y. Acad. Med.
521
HEALTH POLICY INITIATIVES INITIATIVES
HEALTH POLICY
TABLE V. YOUTH RISKS & PROTECTIVE FACTORS Environment Social Risk Poverty Racial inequality Illegitimate opportunity Protective factor Quality schools Cohesive family Neighborhood resources Interested adults
Perceived Risk Models for deviance Parental conflict
Protective factor Models for conventional behavior Controls against deviance
add that this study also demonstrated that the children of these teen-aged mothers were doing poorly from the standpoints of both development and health in spite of their mothers' growing competence. The importance of good services to high-risk pregnant teen-agers was demonstrated by a similar follow-up study of pregnant teens in New Haven. The more such women had used a comprehensive service program, the better their outcome was 15 years later. While some factors in resilience are inborn, there is hope from these studies that high-risk youths can be helped if they are linked to supportive others. It is important that we in the service professions avoid labeling all young people as problems. As physicians, social workers, and psychologists, we tend to see disturbance everywhere and think that all teens are problems. The data from community surveys show quite a different picture. A number of studies have shown that at least one third of adolescents move through this transition period with little trouble. Another one third have some bumps and slumps, but regain equilibrium.9 We hear so much from the media and have the impression from our clinical experience with the biased sample of those who have serious, persistent problems that we fail to see the competent, contributing group. Only about one fifth to one third of adolescents have severe, persistent problems. That is not to minimize the problems this group causes themselves, their families, and society. But most adolescents have physical vitality, health, energy, and resilience, the ability to develop caring relations, resourcefulness, and commitment to their communities. Our task is to tap this latent ability in more adolescents and to turn it to better use for their sake and for society's. The most important issue may be to change our opinion and that of society about young people to a more positive view. Vol. 67, No. 6, November-December 1991
522
522
R.J. HAGOERTY HAGGERTY
As the National Crime Prevention Council pointed out in their publication, "Youth as Resources," most youths can serve society, and in doing so, enhance their capacity to avoid problems. 10 The recently passed legislation to support youth volunteer programs is a good beginning to develop organizations to tap this latent talent of youth. COMPREHENSIVE INTEGRATED SERVICES ARE EFFECTIVE
Head Start, the comprehensive program for preschool children, is a prototype of how services should be organized. It combines education, health, counseling, and social services. We must begin to do the same for teens, and develop programs that combine education, health, social services, empowerment of parents and youth, and change in communities. Admittedly it is more difficult to do this for teens, since we must include a broader social and physical environment in any successful strategy for this group than we had to do for the preschool group in Head Start. On a small scale, Olds's study of Nurse Home Visitors (Table VI) is an example of a successful program for pregnant teens.11 The Nurse Home Visitor does more than the traditional public health nurse. She does counseling, is available in off hours for crises, and helps these young women to stop smoking and drinking. It was a randomly controlled trial small, to be sure -but in the experimental group, with young women younger than 17 whose care had begun before four-and-a-half months of pregnancy, there was an increase in birth weight in the experimental groups, compared to controls. For smokers in particular the frequency of low birthweight and preterm delivery was reduced. Among the most interesting findings is that in the two years following the birth of the baby, reported child abuse in the young mothers reduced from 19% to 4%, and emergency room visits for accidental injuries reduced from 34% to 15%. Olds also looked at the cost benefit ratio, and shows that for every dollar invested there is, in fact, a multiplying effect of dollars saved in the long run, in part because more of these young women went back to work or to school, and had a meaningful role in society. Another approach is through prevention during early adolescence. Traditional health education, which generally emphasized only information, has been found fairly ineffective. But when training in social skills has been added to specific information about diseases and presented in all years of school, evidence of success in preventing many of these problems mounts. To deal with the most resistant of youth problems-violence, homicide, premature pregnancy, sexually transmitted diseases, etc. -we must add to Bull. N.Y. Acad. Med.
523
HEALTH POLICY POLICY INiTIATIVES INrMTIVES
HEALTH
TABLE VI. EFFECT OF NURSE HOME VISIT PROGRAM (OLDS) Younger than 17, Entered before 41/2 months Birth weight Smokers % Low birth weight % Preterm Child abuse Mother
