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Great Transitions: Preparing Adolescents for a New Century

Chapter Five: Promoting the Health of Adolescents

Early adolescence is characterized by exploration and experimentation--behaviors that in our culture are considered socially adaptive and age appropriate. But carried to extremes, especially if they become habitual, risk-taking behaviors can impair mental and physical health. The damage may be near term and visible, or it may be delayed and hidden, like a time bomb set in youth. Examples of near-term damage are sexually transmitted diseases and trauma from alcohol-related accidents or violence. Delayed consequences may include cardiovascular disease and cancer in adult life, partly induced by high-calorie, high-fat diets, inadequate exercise, and smoking initiated early in life.

Adolescents have generally been regarded as the healthiest of Americans and in the least need of health services. Research by the U.S. Congress's Office of Technology Assessment, however, indicates that one out of every five adolescents has a minimum of one serious health problem. Increasingly, these problems are behavioral in nature and include unintended teenage pregnancy, sexually transmitted diseases, motor vehicle accidents, gun-related homicides, the abuse of drugs, compulsive behaviors such as eating disorders, and depression sometimes leading to suicide.

Not surprisingly, there is a discrepancy between the knowledge and competence adolescents sometimes display and their behavior in everyday situations. Knowledge alone is no more sufficient for influencing health-related behaviors in adolescents than it is in adults. Like adults, adolescents show a tendency to wishfully minimize the potentially damaging effects of their risky behaviors, persisting in the belief that "it can't happen to me." Urgently needed are effective ways of instilling in adolescents not only the knowledge and skills but the values and motivation to foster their physical and mental health. Families, schools, health care institutions, community organizations, and the media can do more in the realm of health promotion, emphasizing education for health, life-skills training, and increased knowledge of human biology, so that young people can better understand the relationship between their own behavior and the state of their health and avoid damaging risks.

PROMOTING EDUCATION FOR HEALTH
Turn Schools into Health-Promoting Environments
Middle grade schools can play a crucial role in fostering health among young adolescents, creating an environment in which good health as well as education is pursued and reinforced throughout the day. This means education in proper nutrition in appropriate classes and the provision of a balanced diet in the cafeteria. It means smoke-free buildings and programs to eliminate student and staff use of tobacco. It means education on the effects of alcohol and illicit drugs on the brain and thinking processes, other organs of the body, and behavior. It means exercise for all in the school community, not just for those participating in varsity competitions. Not least, it means an emphasis on safety and the prevention of violence, including penalties for students engaged in drug dealing and carrying weapons in schools and on school grounds.

Three Generic Approaches
Three broad-based approaches, more powerful when combined, are of direct relevance for health promotion among young adolescents. These are a life sciences curriculum in the middle schools, life-skills training, and social support systems. The life sciences, emphasizing a distinctively human biology, can tap into the natural curiosity of young adolescents, who are already intensely interested in the nature of life by virtue of the changes taking place in their own bodies. Such a curriculum should include the scientific study of behavior, particularly behavior that bears strongly on health throughout the life span.

Life-skills training can provide a strong underpinning of protective knowledge as well as enhance skill in decision making and personal relationships. It can help students learn how to resist pressures to engage in high-risk behaviors, build solid friendships, resolve conflicts peacefully, and cooperate in groups, with lasting benefits. Social support programs, offered by a variety of organizations and institutions, including businesses, can provide youths, particularly those who suffer multiple problems, a range of human services. They can create healthy alternatives to substance abuse, gang membership, and early sexual activity and help young people earn respect and acquire a positive vision of the future.

Four Targeted Approaches
Categorical approaches that educate young people to specific risks do not have as broad a perspective on health promotion as generic approaches. But targeted efforts can be effective preventive interventions if they are offered in early adolescence. Families are naturally the first source of such vital education, but schools, youth organizations, places of worship, and health agencies can augment these family functions with special services.

Approaches to four specific risk-taking behaviors deserve mention. These are programs on human sexuality and reproduction, which can help to prevent unintended pregnancy and promote sexual health; on the preparation of adolescents for the challenges of raising a child when they become adults, which can help them make a more informed, thoughtful commitment when the time comes; on the prevention of violence, which can reduce young people's involvement in violence and teach nonviolent conflict resolution; and on the prevention of drug abuse, which can reduce young adolescents' use of "gateway" substances like tobacco, alcohol, and marijuana, reduce use of more dangerous drugs, and enhance personal and social competence.

LOWERING BARRIERS TO HEALTH CARE SERVICES FOR ADOLESCENTS
Instilling the values of a health-promoting lifestyle during early adolescence is certainly essential, but these measures must be matched by efforts to fill serious gaps in health services for young people. To meet adolescents' health care needs, developmentally appropriate services must be made more widely available in community health centers, school-based and school-linked health centers, physicians' offices, family planning clinics, health maintenance organizations, and hospitals.

Expand Health Insurance Coverage
As many as one in seven adolescents has no health insurance; one in three poor adolescents is not covered by Medicaid; and private insurance coverage of adolescents is increasingly restrictive. Preventive services, such as psychological and substance abuse counseling, are especially needed during adolescence and are not covered by many health insurance plans. As managed care spreads rapidly throughout the United States, it will be crucial for health maintenance organizations to include explicit provisions for comprehensive, developmentally appropriate coverage of adolescents.

Prepare Appropriate Health Personnel
A critical issue is the paucity of health care personnel who have training or experience to deal sensitively with adolescents' health needs, especially concerning problem behaviors, chronic diseases, and disabilities like attention deficit disorder. Training programs for physicians do not currently cover information about the skills needed to serve adolescents; nor are nurses, nutritionists, psychologists, and social workers adequately prepared. These health professionals need to learn how to take the time necessary to gain the confidence of adolescents, acquire the skills to identify their problems, be willing to ask them questions that might uncover alcohol and other drug abuse, high-risk sexual activity, or emotional distress, and help them avoid the pitfalls of dangerous behavior.

Expand School-Linked Health Services
A promising approach to filling the health service gap is the establishment of more school-based or school-related health facilities. At present, there are more than six hundred such health centers nationwide, supported by states and communities with assistance from the federal government and private donors. These are often staffed by local health professionals who work with the schools in providing needed services. They have demonstrated their ability to deal with even acute health problems of adolescents and have strong potential for becoming a major locus for disease prevention and health promotion. They are particularly effective when their services to adolescents are integrated with the school curriculum in the life sciences, athletic programs, and other aspects of school life.

Ultimately, achieving the health and well-being of young adolescents is going to require more than the protection and support of families, friends, and health professionals or of adults trained to work with this age group. It will require a community-wide commitment from the full range of institutions and adults with whom adolescents are involved. Were this goal to be reached, however, it could change the health outcomes of millions of young people growing into adulthood in the next century.

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New Jersey Offers Comprehensive Services for Youth

Trouble for many young adolescents comes in multiple doses. A young person may have parents who face unemployment and housing problems or may have a father or mother who is an alcoholic or drug abuser. The young person may be performing poorly at school, may lack adequate medical or dental care, and may know no reliable adult to whom to turn for advice.

Human service agencies that could help these young people may themselves be geographically dispersed, unattractively labeled, or socially unacceptable to adolescents, and not linked to one another. The agencies may rely heavily on informal referrals, with no systematic way of accepting students from the school system. Furthermore, if the agencies do not provide family counseling, they may be unable or unwilling to address problems in family relationships. One promising state-based model to provide needed help for adolescents is New Jersey's School-Based Youth Services Program, which brings together existing services for adolescents under one roof, most often at the school. State officials have found that schools offer the most effective sites for reaching and assisting large numbers of adolescents on a regular basis.

Led by then-Governor Thomas Kean, the New Jersey Department of Human Resources initiated the School-Based Youth Services Program in 1988 as a way of connecting the state's education, health, and human services, and creating "one-stop service centers" for adolescents and their families. By changing the traditional institutional arrangements of the state's agencies from a targeted approach to one that supports the overall well-being of the state's teenagers by providing comprehensive services, this program has encouraged teenagers to complete their education, obtain the skills they need for employment or for additional education, and lead healthy, productive lives. Today the program operates in thirty-seven sites in or near schools in urban, rural, and suburban communities. Sites are open during and after school, on weekends, and all summer long. They offer a core set of services, all of which require parental consent. Centers offer adolescents basic services: primary and preventive health services; referrals to health and social services; individual and family counseling; crisis intervention; drug and alcohol abuse counseling; employment counseling, training, and placement; summer and part-time job development; and recreation. Beyond this core of services, the state encourages centers to provide classroom-based health education; arts, cooking, and sports activities; transportation; family planning examinations and referrals; parenting skills instruction; violence prevention programs; child care; outreach to adolescents who have left school; or twenty-four-hour hotlines. Mental health services are the most frequently used service across the state, followed by other health, employment, education, and substance abuse services.

In 1991, about one of every three New Jersey teenagers--more than 19,000 students--participated in this state-sponsored program. A recent survey revealed that more than half of the students receiving services are African American and nearly a quarter are Hispanic. More than half of the adolescents are considered at risk for dropping out of school. Girls and boys use the service about equally, and they are most likely to be ninth and tenth graders.

Although evaluative data are not yet extensive, programs like New Jersey's appear to be efficient, cost-effective ways to connect adolescents and their families to critical services. Administratively, the state requires that each host community provide at least 25 percent of the program costs through direct financial contribution or in-kind services, facilities, or materials. Each site costs the state approximately $230,000 annually, or about $200 per student served. Stable funding is a strong factor in convincing community organizations and schools that they should work together on the program.

At Plainfield High School, in response to the incidence of teenage parenthood, the Plainfield School-Based Youth Services Program developed and implemented the Plainfield Teen Parent Program in collaboration with the Parent Linking Project of the New Jersey Chapter, National Committee for Prevention of Child Abuse, AT&T, Community Coordinated Child Care of Union County, and the Plainfield Health Center. The program provides a comprehensive array of services to mothers and their babies, including school-based child care, parent education classes, mentoring, tutoring, parent support groups for both pregnant and parenting teens, life-skills training, job skills training, health care, and information and referral to other social service agencies. Services are also provided to young fathers, grandparents, and guardians. All students who have children in the Plainfield Infant Toddler Center are required to enroll in a parenting class that teaches student-parent activities to enhance their child's development and to strengthen the parent- child relationship. Parent support groups provide an opportunity for students to talk about what it is like to raise children as they struggle for their own independence. Students are encouraged to share their ideas and experiences, to see their similarities and differences, and to help each other solve problems and work through tough times.

An evaluation of the project found that 84 percent of program mothers graduated from high school, compared to 41 percent of the control mothers. Two years after their first births, 11 percent of program mothers had a second birth, compared to 33 percent of the control mothers. Program mothers were more likely than comparison mothers to report having a regular source of medical care for their children. Stress associated with parenting decreased significantly among program mothers, while general self-esteem rose. Students and faculty at Plainfield High School generally supported the presence of a child-care center on the school grounds and felt that it made a difference in making it possible for some girls to graduate. This program was developed by and includes representatives from all segments of the community and private and public sectors.

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