No good being early when problems incubate late

Prevention activity in children’s services focuses on infants and toddlers, in the belief that, by the time young people enter adolescence, problems will have materialized to such an extent that interventions can only be preventive in the sense of providing a damage limitation exercise.

But this view is misleading for several reasons. Some problems, such as certain mental illnesses, dependencies and psychological disorders, first manifest themselves in adolescence.

The view that these difficulties are earlier problems revealed or merely writ large is not accurate either. Particular problems are peculiar to adolescence.They are associated with transitions that have to be made to emotional and social independence and with the need to fashion new styles of relationships or to meet new social demands.

The risks tend to be compounded because several transitions have to be handled at the same time, and failure in one can affect progress in others.

So the problems encountered in delivering services to adolescents are different from those associated with young children. Some, such as winning commitment and securing cooperation, may be more taxing; others – to do with verbal communication or the need to travel to keep appointments, for example, are usually easier to solve.

With all this in mind, psychologists, from Norway, Belgium and Italy, have edited a special edition of the UK Journal of Adolescence which discusses examples of successful, well evaluated preventive work with adolescents.

Canadians Morietti and Obsuth present encouraging outcomes from a ten-week manualized Connect treatment program targeting parents of at-risk teens. It was based on group work and focused on the building blocks of secure attachment – parental sensitivity, cooperation, reflective capacity and effective didactic affect regulation.

When interviewed 12 months on, the participants reported more satisfaction and efficacy with their parenting, and less aggression, anti-social behavior and other mental health problems in their offspring.

Kerpelman and colleagues from the US tested the influence of a youth-focused relationships education curriculum to see if it was possible to reduce the serious consequences of unsatisfying romantic liaisons and the lack of positive role models. The improvements seemed durable at the one year follow-up, but were found to dwindle thereafter.

Garcia-Lopez and colleagues from Spain explored the relevance of Expressed Emotion (EE) in the treatment of social anxiety disorder. The parents of 16 adolescents who had received school-based, cognitive behavioral treatment were assessed for their EE, the diagnostic criteria being over involvement, criticism and hostility.

Adolescents whose parents had low EE displayed significantly lower levels of social anxiety; those whose parents were considered to have high EE did not. These outcomes persisted six months on, suggesting that the benefit of preventive work with parents will be felt by their teenage children.

In Italy, Giannota and others explored the contribution of a school-based writing intervention to reducing young people’s internalizing, post-traumatic stress symptoms and strengthening of their coping strategies. Adolescents were encouraged to write about difficulties, especially those they had experienced with peers. Coping strategies improved, but the effect on post-traumatic stress symptoms and the internalization of problems was less marked.

German psychologists led by Wenzel assessed the effect of the three-year life skills program, IPSY (information + psycho-social competence = protection), on school bonding and substance abuse. It was well received by teachers and students and it improved school bonding which in turn mediated effects on alcohol abuse.

The prevention of substance abuse was also the focus of a study from Sweden by Kimber et al. Over five years, social and emotional training was delivered in schools to grades 4-9. The effect on non users and light users was more marked than on heavy users.

Two studies explore the significance for Multisystemic Therapy (MST). The first from Canada linked improvements in maternal depression to better outcomes for young people, but only for those assessed as mixed internalizers/externalizers, as opposed to the pure externalizers.

The second, from Norway, concentrated on gender differences in responses to MST. Although girls may present a different profile from boys and the risk factors might be different, MST was found to be effective for most adolescents irrespective of their gender.

These are small scale studies covering a broad range of prevention and early intervention approaches, and therefore their significance is limited. Rigorous evaluation is also intrinsically difficult but the studies suggest some auspicious conditions. They include adequate funding, a clear implementation protocol faithfully applied; random allocation wherever possible; the cost of follow-up studies included in the design; and large samples in order to cover the key variables, allow for sample attrition and ensure sufficiently large sub-groups.

The editors conclude: “They are important contributions to the growing body of knowledge of what works in the prevention and treatment of youth problem behavior and in the promotion of health and competence.

“Some studies confirm common knowledge in the practice field, others challenge the way problems have been approached and handled in regular practice. Hopefully they are inspiring as well as challenging to both researchers and practitioners.”

See: Ogden T, Beyers W and Ciairano S (eds.), Journal of Adolescence, 32.6 December 2009