Table of Contents

• Abstract
• Objectives
• Introduction
• Positive Youth Development and Critical Social Frameworks
• Role of The Family
• Role of The School
• Role of the Community
• Conclusion
• References

Introduction

Children are maturing earlier than they did even a generation ago. Some of the high-risk behaviors that were formerly prevalent in the teen years are now being found in younger aged children (Shure & Israeloff, 2000; Ozer, Brindis, Millstein, Knopf, & Irwin, 2003). In order to reduce this trend, primary health care providers need to take a more assertive approach in guiding children and parents in the development of protective life skills. These skills include the ability to recognize and resist social influences to engage in problem behaviors, as well as the capacity to generate and suggest positive alternatives for staying out of trouble while maintaining friends, in advance of the adolescent years (Hawkins, Catalano, Kosterman, Abbott, & Hill, 1999).

Shure & Israeloff, (2000) have found that children are aware of the activities of their peer group as early as eight years of age and that behavioral and emotional problems begin to peak during the fourth and fifth grades. As preteens transition to middle school or junior high they express concern about their ability to assert themselves, as well as the pressure to use drugs (Shure & Israeloff, 2000). Melnyk and colleagues (2002) identified the top five worries of school-age children and teens to be:

1. knowing how to cope with things that stress them,
2. anxiety,
3. depression,
4. self-esteem problems and
5. relationship with parent.

Additionally, the changing demographics in today's society bring new complexity, opportunities, and challenges. Data from the 2000 census give important facts: almost 20 million children under the age of 18 do not live with either biological parent, over 11 million children below the age of 18 live in poverty, and over 2 million grandparents are the primary adult caretakers for their grandchildren (Pastor, Makuc, Ruebin, & Xia, 2002). Another 500,000 children live in foster care (Howze, 2002). For all adolescents, the top three causes of death are unintentional injury, homicide, and suicide. Disparities exist for different gender and racial groups. For example, over one quarter of Black youth and Hispanic youth live in poverty (Pastor et. al., 2002). With these increases in diversity, poverty, and homelessness, as well as escalating health and safety issues, nurses need access to culturally appropriate information and resources to care for adolescents and their families today.

The American Medical Association addresses cultural diversity in the publication Delivering Culturally Effective Health Care to Adolescents (Fleming & Towey, 2001). The American Psychological Association (APA) provides a thorough summary of adolescent development in Developing Adolescents (APA, 2002). Information about effectively communicating with adolescent clients is available in the American Nurses Association's continuing education unit entitled, Working with Adolescents: A Time of Opportunity (Krisman-Scott, Buxby, Weill, Bosnick, & O'Sullivan, 2002). This current module focuses on helping nurses empower parents and other primary adult caretakers. By appreciating the early changes in adolescent development, the transition from childhood to adulthood becomes a time of opportunity for successful and affirmative growth. Supporting the critical social frameworks for adolescence - home, school, and community - promotes positive youth development.

Positive Youth Development and Critical Social Frameworks

The American Nurses Foundation (ANF), supported by the Office of Adolescent Health (OAH) of the Maternal Child Health Bureau (MCHB) in the Health Resources and Services Administration (HRSA), participates in interorganizational activities focused on the promotion of adolescent health and positive youth development. In a document entitled Toward a Blueprint for Youth: Making Positive Youth Development a National Priority, (U.S. Department of Health and Human Services, 2003) positive youth development is defined as "an approach toward all youth that builds on their assets and their potential and helps counter the problems that might affect them." The key elements of positive youth development, supported by a number of youth serving organizations, are presented in Table 1.

While critical social frameworks for the adolescent are the home, school, and community, youth first learn to develop a sense of self in the safe context of home and family (Neumark-Sztainer, 1999; Resnick et al., 1997). This personal growth is then cultivated in the school and community environments by supportive adult and peer relationships and in the positive activities of youth serving organizations. Being a valued member of a group creates conducive attachments and builds mutual regard and encouragement. This process begins in the family (Kingon & O'Sullivan, 2001).

Role of The Family

Between eight and twelve years of age, preteens develop an increasing allegiance toward peers and a growing independence from family. Often, young people show a preoccupation with their attractiveness with the impending physical changes of puberty. Conflicts with parents and pressures to engage in high-risk behaviors mount (Green, 2002). This is a very confusing and anxious time for both the adult caregivers and their preteen as things seem to change rapidly during this period.

Importantly, despite these rapid changes, parents and other primary adult caretakers promote the sense of identity, respect, belonging, security, and inclusion that adolescents are seeking. In addition, an adolescent's strong self-worth has been shown to provide protection against engaging in unsafe conduct (Alessi, 2000; Resnick, 2000; Resnick et al., 1997). Quality time with caring parents builds protective life skills during the preteen years. Three major areas are crucial to the parent-adolescent relationship: a sense of connection, adult monitoring, and support in the development of psychological autonomy (Focus Adolescent Services, 2003c).

A Sense of Connection. The relationship between connected parents and adolescents is characterized by warmth, kindness, love, and stability. By making time, on a daily basis, to talk and listen to the preteen, caretakers discover how the child feels and thinks about diverse topics. Utilizing open-ended questions to understand both the "what" and the "why" of the youth's point of view, parents encourage the preteen to give voice to thoughts and feelings. Parents then present their own views and together, with the older child, consider the consequences of individual opinions.

Through this type of sensitive discussion, the adult caretaker demonstrates in both words and action that the child is a unique, important individual. This encourages the young person to develop a sense of personal power and control along with the ability to problem-solve in a variety of situations. (Shure & Israeloff, 2000) Pre-adolescents with a strong sense of self use reason and judgment to resist other points of view that have no merit and to seek out other friends who share the same values and ideals (Blum, Beuhring, & Rinehart, 2000). Research has confirmed that the more open the communication with parents, the safer the adolescent is from high-risk behaviors (Alessi, 2000; Resnick et al., 1997; Santelli, DiClemente, Miller, & Kirby, 1999). Table 2 summarizes addition tips on understanding young adolescents.

Caring adults also communicate through observable behavior. Adolescents are bombarded with mixed messages that simultaneously denounce and glorify high-risk behaviors. Smoking, drinking, violence, and sexual activity are topics foremost in the mind of the "adult-in-training". Although dialogue regarding these issues is imperative, demonstration by action has been shown to have an even greater effect (Alessi, 2000). Adolescents want their parents to model the behavior they expect by avoiding high-risk behaviors themselves.

Adolescents need to feel connected in groups as well. The family provides for the first appropriate group activities. Considering the busy schedule of all family members, parents have a difficult role in creating strategies for family connection, involvement, and caring. Protecting family routines and activities is an important parental task. Adolescents appreciate that if you are a part of a group you "hang out together". If teens do not get this sense of belonging and cohesiveness from the family then they may seek it elsewhere (Bauman & Riche, 1998; Resnick, 2000).

Adolescents need to belong to groups outside the family as well. Caretaker support of youth serving groups that promote positive development is especially worthwhile. Parental participation in teen activities as well as approval and recognition of other group members strengthens the benefits of positive youth programs. In addition, engaging in activities that reflect each member's interests shows appreciation of each member's uniqueness. Caring adults have another difficult task in balancing how they communicate and maintain family bonds while encouraging adolescent independence in outside relationships.

Parental Monitoring. Parental monitoring is the second major area crucial to the parent-adolescent relationship. Adolescents are less likely to get into trouble when their parents know who their friends are and what they are doing during their free time. Again balance between supervision and the promotion of adolescent's growing independence is important (Green, 2002). According to Green (2002), health providers play an important role in helping families negotiate this balance.

Development of Psychological Autonomy. Rules are powerful tools in the development of psychological autonomy. Adolescents who learn to abide by a set of rules regarding conduct fare better than their peers in avoiding high-risk behaviors (Resnick, 2000). Caring adults have the responsibility to establish the family "rules of order" regarding acceptable methods of behavior during early childhood years. As children mature into adolescents, however, young people will learn to set and abide by rules as this process becomes more collaborative (Shure & Israeloff, 2000). Establishing rules with appropriate consequences guide decision-making as the teen matures into adulthood.

Relinquishing some control regarding the decision-making process can be frightening for parents but it is essential for healthy adolescent development. Beginning during the preteen years, young people are able to learn how rules are made, what they mean, and what the consequences are when they are not followed through active participation in family decisions. The young person internalizes family values when everyone is given the chance to talk about the merits of agreed upon rules as well as the opportunity to decide collectively when they need to change. The shift in control regarding appropriate behaviors from the adult to the adolescent is gradual as the teen demonstrates responsible behavior. Parents also have the opportunity to continually reinforce morals and values while inviting their adolescent to do the same.

Consistency provided by rules and consequences gives stability to a teen's life when they make sense to the teen (Shure & Israeloff, 2000; Smith, 2001). Natural and logical consequences motivate young people to make responsible decisions (Bauman & Riche, 1998). When consequences are not enforced, adolescents learn to rationalize or minimize culpability. Likewise, when adolescents receive praise for positive results, psychological autonomy is supported. Guidelines for this process can be found in Table 3.

Role of The School

While parents and family have been identified as the primary protective influence on an adolescent's inclination towards high-risk behaviors, the school environment plays a very important role as well (Neumark-Sztainer, 1999; Resnick et al., 1997). This is where young people spend the majority of their time and develop most of their personal relationships. The transitional year between elementary school and junior high is often fraught with feelings of uncertainty and stress due to the number of developmental changes that are occurring (Lingren, 2001; Shure & Israeloff, 2000). The teen who has a positive attitude toward school is more likely to proceed through adolescence without engaging in such behaviors as drinking, smoking, drug use, violence, and early, unprotected sexual activity (Resnick, et. al., 1997; Resnick, 2000).

Academic success may not be attainable if the adolescent's basic need for self-actualization and belonging are not achieved. Schools provide the setting for peer interactions, known to take on even greater significance in adolescent years. In addition school attachments are crucial because adolescents need positive, supportive relationships with other caring adults. Parents get to know the other adults who also have a dramatic in their teen's life by attending teacher conferences and school activities. When parents show that school involvement is important to them then the adolescent will be exhorted to feel the same. Having previously engaged the preteen in ongoing conversations about what is important and interests him or her, caring adults now encourage the maturing child to expand talents by participating in various school activities.

An early indication that an adolescent may be at risk for school failure is the lack of connection with the school (Focus Adolescent Services, 2003b). Other indications include absenteeism, poor grades, attention problems, and lack of confidence, as well as limited goals for the future and grade retention. Parents and teachers who are aware of these early indications may be able to intervene more effectively. Additional strategies for encouraging school success are presented in Table 4.

Role of the Community

Just as the roles of the family and the school are not viewed as a single dimension, so too, the role of community includes a variety of direct and indirect influences on adolescents' high-risk behaviors. Directly, communities offer opportunities for health-enhancing or health-compromising behaviors through the availability and monitoring of cigarette vending machines, food selections available at the corner store, the existence of bike lanes on major streets and the enforcement of curfews or alcohol minimum age laws. Indirectly, the media (exposing adolescents to models of unprotected sex, violence, and alcohol consumption), the local school board (through school policy), or a city council (with local ordinances) affects a teen's behavior. Dissonant images enhance confusion and weaken the intended message. When programs are designed to be consistent at a community level, high-risk behaviors may be postponed or prevented.

Community-wide approaches to preventing or reducing opportunities for high-risk behaviors are successful when one has agreement on, commitment to and coordination of the messages to be delivered and the strategies to be developed (Perry, Kelder, & Komro, 1993). For example, consider the coordination of efforts on prom nights. Multiple interventions deliver the same consistent message: don't drive when drunk or ride with a drunken friend, call for a ride any time and no questions will be asked, or rent vans or limos to go to the many parties before and after proms. Additionally, many communities sponsor all night parties in the neighborhood at a community center, eliminating the need for transportation by car to continue the celebration.

Youth -serving organizations, churches, community agencies and schools can provide programs that promote pro-social attitudes and activities, enhance adolescents' self-esteem, present positive role modeling, and give supervision for young people. Rather than substituting for parental monitoring, these programs provide additional resources and settings to strengthen and extend parental monitoring (Rinehart & Kahn 2000). While the goals of most organizations are "prevention, motivation, and stimulation," teens want "fun and friends" and parents wish for "safety and opportunities for success." Positive youth serving organizations can achieve all these goals simultaneously. Specific tips on advocating for "youth as assets" communities are presented in Table 5.

A major improvement in some communities is the availability of after-school programs for young people. These programs offer physical, educational, and social opportunities. For example, involvement in team sports socializes preteens to community norms on issues such as fair play and provides an opportunity to interact with significant adults such as coaches. Tutors who help with homework promote academic success while leaders of special interest activities give more opportunity for developing relationships with caring adults and peers.

The community also offers older adolescents the opportunity for work. Besides developing a sense of productivity and accomplishment, employment helps many teens become more responsible with their time and money. Working too much, however, can have a negative effect. Adolescents who work more than 20 hours a week experience greater fatigue, report higher levels of emotional stress, have more leisure income to buy and use illicit drugs, and often engage in earlier sexual activity (Carnegie Council on Adolescent Development, 1992; Green, 2002). Unfortunately, some teens do not participate in any positive activities. Early adolescents who have been labeled as "troublemakers" may have difficulty fitting into the group and some youth workers may lack the skill and training to work with these teens (Loeber & Farrington, 2000). Additionally, fewer interesting programs exist for older adolescents (Pettit, et.al., 1999). Other barriers include problems with transportation and cost and knowledge deficits about available programs.

Positive youth organizations are no longer a luxury but a necessity. Successful outreach is vital to engage the participation of at-risk youth. Family and youth-friendly communities are created when parents and caring adults exercise their voting rights and citizen responsibilities. Advocacy for assets-based communities where adolescents are valued is imperative (Rinehart & Kahn, 2000).

Conclusion

Since multiple social, environmental, and personal factors interact to influence teen behavioral patterns, a multifaceted approach is needed to help parents motivate adolescents to make mature choices. Learning to problem-solve when young and then practicing on everyday kinds of problems with appropriate consequences can reduce the incidence of high-risk behaviors in adolescents. A young person who trusts his or her ability to make sound choices is empowered to resist compelling outside pressures to engage in hazardous behaviors. Implementing preventive interventions at a younger age, rather than waiting for full-blown problems, exerts an enduring positive effect on academic development and the avoidance of health-risk behaviors. Collaborative efforts among adolescents, parents, schools, and communities are imperative to provide each adolescent with resilience to confront multiple risks and avoid negative outcomes (Resnick, 2000). Health care providers can help ease the transition from childhood and adolescence by imparting essential anticipatory guidance to both the young person and the caring adults in her or his life. The family, school, and community context are the most fundamental forces that reduce adolescent high-risk behaviors. Interventions aimed at promoting connectedness in these environments will do much to build protective life skills and ultimately promote the health of our youth.

Table 1. Key elements for promoting positive youth development Providing youth with safe and supportive environments. Fostering relationships between young people and caring adults who can mentor and guide them. Providing youth with opportunities to pursue their interests and focus on their strengths. Supporting the development of youths' knowledge and skills in a variety of ways, including study, tutoring, sports, the arts, vocational education, and service-learning. Engaging youth as active partners and leaders who can help move communities forward. Providing opportunities for youth to show that they care-about others and about society. Promoting healthy lifestyles and teaching positive patterns of social interaction. Providing a safety net in times of need. Note: Adapted from US Department of Health and Human Services, 2003.

Table 2. Tips for understanding your adolescent Try to understand first, and then be understood. Pay attention-this means not watching TV or talking on the phone when you're talking to your teen. Listen patiently as though you have plenty of time. Encourage talking and avoid cutting teens off before they have finished speaking. Watch the nonverbal messages such as tone of voice, facial expressions, energy level, posture, or changes in their behavior patterns. Keep your perspective and share your thoughts even if they are different from your adolescent's. Stamp out secrets wherever you can…they are not the same as privacy. Remember your sense of humor - it often creates new possibilities. Note: Adapted from American Medical Association, 2000, p. 4 and Focus Adolescent Services, 2003a.

Table 3. Guidelines to establishing and maintaining rules of conduct Set and implement a reasonable set of rules. All rules must have value and purpose. State your rules clearly. Limit the number of rules you impose. Expect your teen to test the rules. Change the rules only when it is reasonable and appropriate to do so. Make sure that your rules can be enforced. Make sure you are willing to enforce the consequence of your teen's behavior before you tell him about it. Note: Adapted from Smith, 2001.

Table 4. Strategies for Encouraging School Success Be a model of respectful, cooperative, positive behavior. Participate in school events. Show interest. Be involved with your child's academic activities. Maintain regular contact with your child's teacher. Monitor your child's homework completion and work with him or her that on homework assignments that involve family participation. Be present when things go wrong. Meet your child's friends, and their parents. Ask school leaders what you can do to support them. Volunteer at school. Nominate effective school leaders for local awards. Note: Adapted from Blum, Beuhring, & Rinehart, 2000.

Table 5. Youth as Assets Communities Start with the gifts, talents, knowledge, and skills of young people. Find out what they like to do and what they are good at doing. Look for the positives in each unique individual. Explore useful work and service opportunities for young people. Distinguish between real work and games or simulations, because young people can. Eliminate age segregation. Youth today are the most age-segregated generation in our history. Let those who can, help those who can't. Ensure active participation for youth on community boards. Cultivate opportunities for young people to teach and lead. Reward and celebrate creativity, energy and effort - loudly and with spirit. Appreciate young people, they are our solution. Note: Adapted from Rinehart & Kahn, 2003.

References

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American Medical Association. (2000). Talking to your teen ages 11-14: Connecting through communication. Chicago: American Medical Association.

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Bauman, L., & Riche, R. (1998). The ten most troublesome teen-age problems and how to solve them. New York: Citadel Press.

Blum, R. W., Beuhring, T., & Rinehart, P. M. (2000). Protecting teens: Beyond race, income and family structure. Center for adolescent health: University of Minnesota. Retrieved June 1, 2001, from www.atoz.com.

Blum, R. W., McNeeley, C. A., & Rinehart, P. M. (2002). Improving the odds: The untapped power of schools to improve the health of teens. Minneapolis, MN: Office of Adolescent Health.

Carnegie Council on Adolescent Development (1992). A matter of time: Risk and opportunities in the nonschool hours. Recommendations for strengthening community programs for youth. Washington, D.C.: Author.

Fleming, M. & Towey, K. (2001). Delivering culturally effective health care to adolescents. Elk Grove, IL: American Medical Association.

Focus Adolescent Services. (2003a). How can parents model good listening skills? Retrieved March 10, 2003 from, www.focusas.com/ListeningSkills.html.

Focus Adolescent Services. (2003b). If a teen begins to fail at school, what can parents and teachers do? Retrieved March 10, 2003 from, http://focusas.com/School.html. Focus Adolescent Services. (2003c). Parenting teens. Retrieved March 10, 2003 from, http://focusas.com/Parenting.html.

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Authors

Christine Krause MSN, CRNP is a Pediatric Nurse Practioner at the Wade-Towend Paoli Memorial Hospital in Paoli, Pennsylvania. She specializes in the care of adolescent females.

Ann O'Sullivan PhD, CPNP, FAAN is Professor of Primary Care Nursing at the School of Nursing, University of Pennsylvania in Philadelphia, PA. Dr. O'Sullivan is a nationally known and an internationally consulted expert on working with teen mothers, particularly those under seventeen years of age. Her work was recognized with the receipt of the 1998 American Nurses Association Honorary Practice Award.

Susan Terwilliger MS, RNCS, PNP has worked as a Pediatric Nurse Practitioner for 24 years. She is currently on the faculty at the Decker School of Nursing, SUNY Binghamton University, Binghamton, NY and is serving as the Project Director for the American Nurses Foundation's federally funded grant program: " Partners in Program Planning for Adolescent Health (PIPPAH) which funded this independent study module.

Nicole Nierstedt BSN Student Nicole Nierstedt, BSN student at the Decker School of Nursing, SUNY Binghamton University, Binghamton, NY.

Staff:

Debbie Lao, BS Health Science, LPN serves as the Project Manager, PIPPAH Grant Program, ANF.

RoAnne Dahlen-Hartfield, DNSc, RN, Administrator, Center for Continuing Education & Professional Development, ANA.

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