5
The Influence of Environment

The workshop discussions of biobehavioral and psychological perspectives on adolescent risk behavior alluded repeatedly to the importance of the cultural and social contexts in which young people develop. Presenters described research on the ways family, peers, schools, communities, and media and technology influence adolescent behavior and risk-taking.

FAMILY

There are strong reasons to think that families, and their economic circumstances in particular, influence both parents’ and children’s emotions and behaviors, Rand D. Conger explained. He described some of the evidence for these effects, the specific processes involved, and some of the implications for intervention. Nancy A. Gonzales described the relationship between family influences and particular risk behaviors, as well as interventions that have been developed to alter these influences.

Effects of Economic Distress

The social causation model, Conger explained, provides a framework for considering the way in which economic disadvantage and social conditions affect family functioning and the ways that children develop.

Recent studies have provided evidence that economic factors influence families. Costello and colleagues (2003), for example, found that chil-



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5 The Influence of Environment T he workshop discussions of biobehavioral and psychological per- spectives on adolescent risk behavior alluded repeatedly to the importance of the cultural and social contexts in which young people develop. Presenters described research on the ways family, peers, schools, communities, and media and technology influence adolescent behavior and risk-taking. FAMILY There are strong reasons to think that families, and their economic circumstances in particular, influence both parents’ and children’s emo- tions and behaviors, Rand D. Conger explained. He described some of the evidence for these effects, the specific processes involved, and some of the implications for intervention. Nancy A. Gonzales described the relation - ship between family influences and particular risk behaviors, as well as interventions that have been developed to alter these influences. Effects of Economic Distress The social causation model, Conger explained, provides a framework for considering the way in which economic disadvantage and social con - ditions affect family functioning and the ways that children develop. Recent studies have provided evidence that economic factors influ- ence families. Costello and colleagues (2003), for example, found that chil- 

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 THE INFLUENCE OF ENVIRONMENT dren whose families were lifted out of poverty when a gambling casino opened on an Indian reservation showed improvement in both psychiatric symptoms and conduct problems. Specifically, this study found that exter- nalizing signs, including such behavior disorders as conduct disorder, improved, but that families’ improved economic circumstances did not affect the rate of internalizing psychiatric problems, such as depression. The researchers concluded that the improvements came about in part because of improved parenting practices. Experimental studies, such as the New Hope study (Huston et al., 2003), have also shown that interven - tions that increased employment and reduced poverty resulted in similar improvements. Researchers have described three primary models for thinking about how economic factors influence families: the family stress model, the investment model, and the interactionist model. Research on the family stress model goes back to the 1930s, Conger said, and has since been well replicated using many samples from diverse backgrounds. It is based on evidence from both human and animal studies that punishing experi- ences, such as economic pressure,1 exacerbate negative affect, which can take many forms, such as despondency, depression, anger, or aggression (Berkowitz, 1969). These sorts of emotions can disrupt family relation - ships. The effect of the hardship depends on the way it affects daily life—in other words, the emotional response of the family and the indi - vidual are what determines the psychological effect of the event. When parents become depressed, angry, and sullen with one another and have increased conflict, the result is often harsh and inconsistent parenting or withdrawal. For adolescents, that can mean increases in risky behavior and less development of the sorts of competencies that protect them from those risks. Conger observed that other sorts of distress may also affect families in the same way. That is, when stress and challenge are high for parents, they generally have an increase in emotional and behavioral problems, which in turn affect family functioning and increase risks for children. The model, which is consistent with findings from numerous studies (Conger et al., 2010; Conger and Conger, 2008; Conger and Donnellan, 2007), is illustrated in Figure 5-1. Some interventions based on this model have focused on improving families’ economic circumstances. However, although the downward spiral can occur very quickly, such interven- 1 Conger noted that family income is not a reliable measure of hardship because even families with high incomes may face severe economic challenges, for example, if a medical calamity occurs in a family with inadequate health insurance. Thus, researchers consider other factors, such as negative financial events, sudden economic demands, or sudden changes in income.

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0 THE SCIENCE OF ADOLESCENT RISK-TAKING tions work much more slowly. Thus, in Conger’s view, interventions that reduce the harm during the economic transition are also needed. Promis- ing targets include: • Reducing parental distress, • Reducing parental conflict and relationship difficulties, • Promoting effective parenting, and • Incorporating the children’s perspectives, that is, encouraging them to feel that they are part of the solution to the family’s difficulties. While these approaches appear to hold promise, Conger identified areas in which further research is needed. For example, not enough is known about potentially lasting effects of hardship experienced by young children and how they might affect adolescent behavior and risk-taking. The role of self-regulatory and personality processes, which can play a protective role, could also be better understood. Economic Hardship 1. Low Income 2. High debt, low assets 3. Negative financial events Economic Pressure 1. Unmet material needs 2. Unpaid debts 3. Painful cutbacks Parent Distress 1. Emotional problems 2. Behavioral problems Disrupted Family Relations 1. Interparental conflict /withdrawal 2. Harsh, inconsistent parenting Child and Adolescent Adjustment 1. Emotional, behavioral problems 2. Impaired competence FIGURE 5-1 The family stress model of economic hardship. Fig 5-1.eps SOURCE: Conger and Conger, 2008. Reproduced with permission from Sage Publications. Copyright © 2008 by Sage.

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 THE INFLUENCE OF ENVIRONMENT Influences and Interventions Gonzales focused in greater detail on the ways in which families influence adolescent risk behavior and effective interventions. Effective parenting, she explained (nurturing, supportive parenting that includes clear and consistent discipline), can prevent negative behaviors and also promote prosocial behaviors and values. It also helps children develop various competencies that are also protective. Parental monitoring and supervision may prevent children from associating with deviant peers. High levels of family conflict and poor communication skills disrupt parenting and family relations, reduce children’s emotional security, and reinforce the use of aggression and interpersonal hostility. Family mem - bers may model risk behaviors and deviance or effective emotional and social skills, and they may also endow their children with genes that predispose them to certain risks (e.g., substance abuse). Thus, most family interventions are attempts to change one or more of these processes, and a variety of evidence from cross-sectional, longitu- dinal, and experimental prevention trials has yielded support for several conclusions (NRC and IOM, 2009): • Parents who form warm relationships with their children and have minimal conflict with them, provide adequate monitoring and supervision, and do not provide models of drug use can protect youth from developing substance use disorders. • Lack of strong positive relationships with parents increases involvement with deviant peers, which increases adolescents’ risk for a variety of problems, including precocious transitions, such as early pregnancy, premature independence from parents, and school dropout. • Parental monitoring and positive parental relationships have been linked with later sexual debut, fewer sexual partners, and increased condom use. Many social risk factors have been shown to increase the likelihood that adolescents will engage in risk behaviors as well as to disrupt parent- ing and family processes. Thus, parenting and family processes are the most common targets of interventions for families experiencing adversity, such as economic hardship; parental divorce, death, or mental illness; or parental criminal activity. Research has shown that these core processes work the same way across many racial and ethnic groups; where cultural differences are evi- dent, they reveal differences in the magnitude of the effect. Core family values, expectations, and goals, however, do vary across ethnic groups, and these differences must be taken into account when implementing

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 THE SCIENCE OF ADOLESCENT RISK-TAKING family interventions, Gonzales said. Different risks as well as protective family resources are common in different groups, and these can also be addressed through culturally tailored interventions. Two examples of such programs are the Strong African-American Families Program2 and the Familias Unidas Program.3 Both have reduced early onset of substance use and sexual intercourse, as well as problem behaviors. Although the evidence for the effectiveness of interventions that tar- get these processes is strong, the challenge is to identify and reach the families that need them. Gonzales used the ecological transactional frame- work, shown in Figure 5-2, to illustrate the array of influences that affect adolescents. She explained that the family plays a central role in negotiat - ing these influences and has the potential to help protect the adolescent or the reverse. Families vary, for example, in the extent to which they encourage and support education, monitor and manage peer activities, Ecological Niche Public Policy Mass Media Family Peers School Families monitor Families suppor t and and manage peers promote education Adolescent Economic Neighborhood Context Families protect from Cultural neighborhood risk Context Fig 5-2.eps FIGURE 5-2 Ecological transactional framework. SOURCE: Gonzales, 2009. 2 See http://www.cfr.uga.edu/saaf1. 3 See http://www.familias-unidas.org.

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 THE INFLUENCE OF ENVIRONMENT and so forth. Different neighborhoods present different sets of risks and require different strategies. Prevention researchers distinguish among universal interventions (delivered to all members of a population), selective interventions (deliv - ered to segments of a population identified as being at high risk for a particular outcome), and indicated interventions (delivered to individuals already showing signs of a particular risk). Some interventions operate across these levels, depending on need and risk. Interventions may also focus on a range of ages. Those that focus on young children tend to have comparatively stronger effects, Gonzales observed, because younger children are more malleable. It is often possible to have broader impact on a range of risks with early intervention. Home visits to new mothers, designed to instill positive parent-child interactions from the beginning, is an early intervention that has shown promise. Effects for this approach include reduced physical abuse, aggression, and harsh parenting, as well as reduced antisocial behavior (a precursor to many problem behaviors) in children. The effects are strongest for families in the greatest adversity. Research to document the long-term effects on adolescent behavior, how - ever, has been limited. Interventions also target stages of transition across development, each of which may present not only new risks, but also new opportunities for influencing outcomes. That is, a developmental turning point may be a place where a negative trajectory is established or an opportunity for adolescents to develop new skills. Many middle school interventions are designed around this idea, Gonzales noted. This is an important stage, Gonzales said, because it is when many risk behaviors are initiated and adolescents face many new challenges, including puberty and the grow- ing importance of peer groups. The Strengthening Families intervention, for example—a universal intervention that addresses the parenting skills of individuals with children ages 10 to 14—has shown success in reducing conduct problems and affiliation with antisocial peers.4 Another example of an early intervention is the Raising Healthy Children program, an ele - mentary school-based intervention designed to improve family bonding with the school while also building children’s competencies for resisting risk (Catalano et al., 2003). Intervening later in adolescence is more challenging because nega- tive trajectories are often well established by then. One approach that has had success is multisystemic therapy for youth with serious behavior problems (Henggeler et al., 2002). This is a very intensive individualized intervention that focuses on strengthening parenting and family relations 4 See http://www.strengtheningfamiliesprogram.org.

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 THE SCIENCE OF ADOLESCENT RISK-TAKING (working with families in their homes) and also on removing youth from deviant peer groups, improving their school and work performance, and developing social networks. Evaluations have shown long-term reduc - tions in rates of criminal offending, recidivism, rearrest, and out-of-home placement. Looking across the literature, Gonzales concluded that meta-analyses and numerous randomized controlled trials have demonstrated strong empirical support for interventions designed to improve parenting and family functioning. These interventions demonstrate effects on many problem behaviors and produce lasting benefits in many cases for ethni - cally diverse families. Evidence suggests that interventions that simul - taneously address risk across contexts may be necessary, particularly at the later ages and also when implemented with youth in low-income neighborhoods and families. The relatively few economic analyses that have been conducted consistently show that benefits outweigh the costs of these interventions. Research is needed, in Gonzales’s view, to explore how these inter- ventions can be integrated and sustained on a larger scale and how they can be made accessible to parents who have restrictions on their time and mobility. PEERS The influence of peers is similarly complex, as Mitchell J. Prinstein and Kenneth A. Dodge demonstrated. Influences and Interventions Prinstein began by explaining that, in general, the research literature on peer influence and the interventions related to it are less mature than those on families. A topic that has received considerable research atten- tion is the strong association between adolescents’ attitudes and behaviors and those of their peers. Two possible explanations for this association have emerged. One possible explanation for adolescents’ tendency to belong to homogeneous peer groups is that they select individuals who are already similar to themselves. The other is that, when an individual socializes with particular people, he or she tends to adopt the behaviors or traits they have. Researchers who have explored this question have largely concluded that in most cases both effects are important (Dishion and Owen, 2002; Hall and Valente, 2007; Kandel, 1978; Popp et al., 2008), Prinstein explained. Researchers in this area have focused primarily on a few behaviors. Figure 5-3 illustrates the degree of support that exists for the influence of

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 THE INFLUENCE OF ENVIRONMENT • Externalizing Symptoms Substantial Empirical Suppor t – Illegal /violent behavior – Aggression • Substance Use – Alcohol, nicotine use – Marijuana use – “ Hard” drugs • Sexual risk behaviors Emerging Empirical Suppor t • Internalizing Symptoms – Depressive symptoms – Suicidality • Other Health Risk Behaviors – Weight-related behaviors New Area for – Nonsuicidal self injury Research • Prosocial and Health-Promotion Behaviors FIGURE 5-3 What behaviors are influenced by peers? Fig 5-3.eps SOURCE: Prinstein, 2009. peers on different problem and risk behaviors. He noted that several very important areas have received very little attention, such as weight-related behaviors and damaging behaviors, such as self-cutting. Furthermore, almost all of the research has focused on the influence of adolescents’ best friends. While the best friendship does seem to be an important influence, emerging evidence indicates that other peers also play an important role. Adolescents are quite likely to emulate the behavior of popular peers. They have a strong investment in social com - parison and reflected appraisal and with meeting the demands of those considered the most popular in their peer group. Prinstein noted the important distinction between adolescents who are well liked and those who are identified as popular, the latter signifying those who are at the top of a dominance hierarchy. It is the dominant individuals who seem to be the most influential, particularly with regard to high-risk behaviors. They tend to be both aggressive and more than usually prone to those behaviors. Moreover, it is rare for friendship dyads to occur in isolation; more typically they occur within a friendship network or clique. These social patterns are very difficult to study, he added, because they evolve so rapidly. Even those who do not interact with one another within the

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 THE SCIENCE OF ADOLESCENT RISK-TAKING peer crowd might feel the need to adopt the attitudes or behaviors of the crowd with which they would like to associate. The influence of romantic partners has also just begun to receive attention, and Prinstein commented that researchers have not always been careful to distinguish these different sorts of peer relationships. Further research is also needed to illuminate the ways adolescents negotiate these complex relationships—how they decide whom to heed among the many possible sources of influence. A facet of that question is that of nonconfor- mity. Adolescents who choose not to conform to the attitudes and behav- iors of their peers are under the illusion that their behavior is therefore free of peer influence. But, in fact, by adopting the opposite behaviors, they are still very much cognizant of and influenced by the social norms of their peer group, although they might not realize that their behavior is being influenced by those perceived norms. Prinstein mentioned strong theoretical reasons to think that times of transition, such as puberty, school transitions, and certain stages of friendships, appear to be key times when peer influence is strongest. These are times when adolescents tend to be particularly sensitive to peer feedback as a source of understanding of their own identity. Adopting the behaviors of those with whom one would like to be friends is a strategy for seeking the relationship. Few researchers have done empirical work in this area or on the question of how peer influence works. Possibilities include explicit peer pressure and social mimicry, and researchers have also proposed an identity-based theory in which it is adolescents’ own perceptions of the behavior in which their peers engage that is the domi- nant factor in decisions to adopt that behavior. Related to that possibility is emerging evidence that aggressive and rejected youth, who already have a range of risk factors, also seem to have a difficult time accurately estimating the behaviors of their peers. Youth who have already engaged in a particular behavior also tend to assume that they are in the majority and that others are engaging in similar risk behaviors. Another possible mechanism for negative peer influence is a process called deviancy training, in which specific types of interactions within friendship dyads may reinforce talk about deviant behaviors. Such talk is strongly associated with subsequent engagement in that behavior. When neither member of a pair of friends has engaged in deviant behavior, laughter and other support usually follows discussion of normative (non- deviant) behaviors. In pairs of friends who have both engaged in a devi- ant behavior, however, laughter and other encouragement follows talk of rule-breaking. This tendency for adolescents to positively reinforce talk about deviant acts is a very powerful indicator of their long-term likeli- hood of engaging in the behavior.

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 THE INFLUENCE OF ENVIRONMENT Some researchers have shed light on the question of which young people are most susceptible to peer influence. High levels of social anxi - ety or low levels of self-esteem tend to make adolescents more likely to adopt the perceived behaviors of their peers, as are those who have been rejected. Poor family relationships make adolescents more likely to attract and affiliate with deviant peers and to adopt their attitudes. This is another area in which further research is needed, Prinstein observed. Deviant Peer Groups The primary public policy approach to deviant adolescents in the United States today is to aggregate them with other deviant adolescents, Dodge pointed out. Mental health providers offer group therapy and residential treatment to a significant portion of patients. The public edu - cation system is increasingly likely to segregate youth with behavior and other problems through academic tracking, special education, in-school suspension, and alternative schools. Youth who end up in the juvenile justice system are placed in training schools, boot camps, or incarcerated, in each case together with other deviant youth. Although there are some potential benefits to interventions that occur in the context of peer groups, there are also very significant adverse effects. Peers can be a source of reward, satisfaction, and identity develop- ment. Meta-analyses, however, have shown that interventions that are effective with individuals are significantly less so when administered to peer groups, as shown in Table 5-1. Research identified here, on programs that treat delinquency and antisocial behavior, shows that in some cases the effect is not just a decrement in the effect but an adverse effect. If the peer group is composed exclusively of deviant youth, there is even greater decrement, as shown in Figure 5-4. In a study of high-risk boys who were randomly assigned either to a summer peer group camp or to a control group, researchers showed that boys who were placed in the camp for two summers had significantly worse 30-year outcomes than the control subjects (McCord, 1992). Another study (Dishion and Andrews, 1995) showed similar results: high-risk 11- to 14-year-olds were randomly assigned to peer group intervention, fam- ily intervention, or a control. Those in the peer group intervention had the worst outcomes, and it was those who were initially only modestly deviant who had the worst outcomes. Another study, Dodge said, showed that although deviant boys in all-deviant groups got worse, deviant boys in mixed groups improved (Feldman et al., 1983). Similar effects are evident in naturally occurring contexts, such as schools. The growing practice of using in-school suspension to punish students for infractions is one example. Students typically are placed

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 THE SCIENCE OF ADOLESCENT RISK-TAKING TABLE 5-1 Interventions Are Less Effective When Administered to Peer Groups Administration Decrement Individual Group (%) Juvenile justice (Lipsey, 2006) .10 .07 (30) Court counseling (Lipsey, 2006) .12 .08 (33) Child mental health (Weitz et al., 1987) 1.04 .62 (40) Child mental health (Weitz et al., 1995) .63 .50 (21) School social skills (Ang and Hughes, 2002) .78 .55 (30) SOURCE: Ken Dodge presentation. 0.8 0.6 Mean Individual Effect 0.4 Mixed Group Size Deviant Group 0.2 0 Immediately Directly Follow Post Up Observed Treatment Behavior FIGURE 5-4 All-deviant peer groups worsen outcomes beyond mixed peer Fig 5-4.eps groups: Meta-analysis of social skills training interventions. SOURCE: Dodge, 2009. Data from Ang and Hughes, 2002.

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 THE INFLUENCE OF ENVIRONMENT stayed in the poor, urban neighborhoods to graduate from high school, attend college, and be employed and had higher wages. Yet studies of longer term effects were more mixed, showing, for example, that although boys who moved out were less likely to be arrested or convicted for drug offenses than those who stayed, girls who moved were more likely to be convicted of criminal offenses than their peers who stayed. Another example is the Moving to Opportunity program,10 in which 4,000 families were randomly assigned either to receive a housing voucher that would support them in moving to private housing in a low-poverty urban (not suburban, as in the Gautreaux program) neighborhood or not (there was also a third group that received somewhat different benefits). This study also showed somewhat mixed results, with significantly more positive effects for girls than for boys, as well as a number of areas in which there were no effects, positive or negative (delinquency, sexual behaviors, achievement, and physical health). Leventhal explored the theoretical frameworks that might explain the influence of neighborhoods. First, she suggested, it is likely that neighbor- hood structure could have both direct and indirect effects on adolescent risk behavior, but it is also likely that there are specific intermediary mechanisms, such as social processes. Thus, one model for linking neigh - borhood structure to adolescent outcomes is the institutional resources model, or the hypothesis that young people are influenced by the qual - ity, quantity, diversity, and affordability of neighborhood resources (e.g., schools, health and social services, recreational and social programs, employment opportunities). A second model posits that the “norms and collective efficacy” characteristic of a neighborhood are the primary source of influence. That is, a neighborhood’s collective capacity to work together for common goals and to reinforce prosocial (that is, positive behavior that demonstrates concern for others and constructive goals) norms and values can reduce threats to residents, such as violence and the availabil - ity of illicit substances. The third model focuses on the relationships and ties in the neighborhood and highlights the role of families. This model suggests that neighborhood disadvantage contributes to family stress and economic hardship, which, in turn, can have negative consequences on parental well-being, parenting, and adolescent outcomes. Gorman-Smith also touched on theoretical issues, identifying four similar mechanisms through which community influences young people: social connection and support, social norms, informal social control, and routine activities. She noted that although there is reason to think that the social organization of a neighborhood is important, the census-level data 10 See http://portal.hud.gov/portal/page/portal/HUD/programdescription/mto.

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0 THE SCIENCE OF ADOLESCENT RISK-TAKING are not an ideal tool for investigating this complex construct. She showed data from several small studies of neighborhood social organizations showing that concentrated disadvantage and the social organization of neighborhoods are only mildly correlated (Gorman-Smith and Reardon, 2008). That is, neighborhoods with comparable poverty levels had very different levels of social organization, and those with less poverty did not necessarily have better social organization than those with more poverty. The important question not easily answered, she suggested, is how some neighborhoods develop social supports and others do not. Like Leventhal, Gorman-Smith has found that living in a disadvan - taged neighborhood may be associated with many poor outcomes for youth, including delinquency, violence, substance use, lower academic achievement, problems with social competence, and mental health prob- lems. The association with violence may be the most studied of these links, she suggested, but the research has not clearly illuminated the rea - sons why some young people are affected so much more seriously than others. Although some data suggest that different aspects of neighbor- hoods have independent effects, it seems likely that the effects interact, a situation that presents a difficult research challenge. Emerging research suggests a role for social and recreational resources in the link between low socioeconomic neighborhood status and adoles - cent risk behaviors. Leventhal explained, however, that the evidence for the relationship-and-ties model is much more mixed. The most compel - ling evidence currently available is for the social norms and collective effi- cacy model. These factors seem to play a strong role in the link between neighborhood poverty and adolescent delinquency and sexual risk behav- ior. The strength of that evidence, she suggested, highlights the value of community-level supervision and monitoring of youth. Gorman-Smith also discussed interventions, noting that there have been three primary approaches to keeping communities intact (as opposed to changing their demographic composition). One is to work with indi - viduals and families to manage or cope with the stresses of living in a disadvantaged neighborhood. An example is the SAFE Children pro- gram (Schools and Family Education) (Gorman-Smith et al., 2007), which provides families whose children go to school together with support in building networks of social support.11 Another approach is to develop community coalitions or partnerships to address specific social problems in a neighborhood. A third approach is to focus on economic develop- ment to improve neighborhood conditions, for example, through business 11 See http://casat.unr.edu/bestpractices/view.php?program=107#desc (accessed Septem - ber 2010).

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 THE INFLUENCE OF ENVIRONMENT development. Although research on neighborhood effects on adolescent development has produced mixed results, it may be due to the limited nature of this research to date. Most of the research has focused on census data to define disadvantage and poverty, but this may be too limiting a conceptualization of neighborhood. More attention to factors other than information found in census data may be necessary to more fully under- stand how neighborhood context may influence adolescent development. These data may include information about crime, community businesses and organizations, social factors such as perceptions of fear, or adult monitoring. In addition, Leventhal noted, it may be necessary to exam - ine mediating factors that may help explain neighborhood effects and moderating effects that neighborhoods may have to either exacerbate the negative effects of other risks or enhance the positive effects of adolescent assets and resources. Most of the research to date has focused on the direct or main effects of neighborhoods. MEDIA AND TECHNOLOGY Among the environmental influences that affect teenagers’ develop- ment, perhaps the most difficult to study is the wide, fast-evolving array of media and technologies that are part of their lives. Any list of the sorts of devices and programming to which young people may have access is likely to be at least somewhat outdated within months, but researchers have begun actively exploring both the effects of media on adolescent behavior and ways of structuring both their interactions with it and inter- ventions designed to address media-related problems, as Michael Rich, Jane D. Brown, and Blair Johnson explained. Rich began with the point that media—that is, modes of electronic communication and entertainment—are portable, ubiquitous, and inte - grated into virtually all aspects of adolescents’ lives. He presented some data on media use and its effects, cautioning that the field has not been well funded and that much of the data are cross-sectional and based on self-reports. He focused on data from the Center on Media and Child Health related to the links between media consumption and adolescent sexuality.12 First, he described current patterns of use. On average, 8- to 18-year- olds use media actively for 6 hours and 21 minutes of every day, often using multiple media at the same time (Roberts et al., 2005). Because nearly a quarter of teenagers use two or more media at the same time, they may be cumulatively exposed to more than 8.5 hours of content per day. Researchers have been able to determine little about teenagers’ fore- 12 See http://cmch.typepad.com/ (accessed May 2010).

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 THE SCIENCE OF ADOLESCENT RISK-TAKING ground and background attention to this media use or other specific ques- tions about its impact, but there is some information about its content. During the 2001-2002 television season, 71 percent of programs included sexual content, with an average of 6.1 such scenes per hour. Among programs directed at teenagers, 82 percent included sexual talk and two- thirds included sexual behavior (4 percent portrayed sexual intercourse) (Farrar et al., 2003). In a survey, 75 percent of college students reported that they were first exposed to sex in the media when they were minors, and 15 percent had persistent imagery and thoughts related to that expo - sure. In 1996, more than two-thirds of movies released that year portrayed sexual behavior, and Rich indicated that the percentage has increased each year since (Cantor et al., 2003). Internet access, now widely promoted even for very young children through toy-related game websites designed as part of product promotion campaigns and the like, has introduced a new source of influence with complex implications. In 2007, there were 44 million Internet users under the age of 18, and 47 percent of 8- to 18-year-olds went online every day (Roberts et al., 2005). Average use was 1 hour per day, although some reported being online as long as 10 to 14 hours per day. And 42 percent had clicked on pornographic sites; 4 percent had been asked for sexual pictures of themselves by someone they did not know (Wolak et al., 2007). Rich cautioned that all of these figures have probably grown since 2007. Usage of social networking sites has also grown exponentially, and Rich noted that recent data suggest that 90,000 of the 110 million users of MySpace are registered sex offenders (“90,000 Sex Offenders Axed in MySpace Clean-Up,” 2010). While sexual predation by adults is actually quite rare, other kinds of influence may also cause concern. Rich described weblogs created by teens who have chosen anorexia nervosa and bulimia as a lifestyle and post tips for others who would like to adopt it to live life as an extremely thin person. Social isolation related to social networking usage, cyber bullying, and sexting (sending sexual images or text via cell phone) are all new problems for adults to understand and address. Text and images transmitted electronically may in some cases be impossible to expunge, and because the legal code related to the Internet is in its infancy, young people may face serious lasting consequences from a single impulsive act. A total of 70 percent of adolescents have been exposed to pornography on the Internet, and two-thirds of college students report that they consider doing so acceptable (Rideout et al., 2005). What are the effects of this exposure? A number of studies, Rich indi- cated, have shown that the more sexual content young people have seen on television, the more likely they are to initiate sexual activity (Collins et al., 2004). As one example, in one study, 12- to 14-year-olds exposed to

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 THE INFLUENCE OF ENVIRONMENT sexuality in television, movies, music, and magazines were more than twice as likely than those not exposed to have sex by age 16 (Brown et al., 2006). Another study showed that 6- to 8-year-olds who watched adult program- ming were significantly more likely than those who did not to engage in sex by ages 12 to 14 (Delgado et al., 2009). Another showed that youth whose parents limited television to less than 2 hours per day had half the rate of sexual initiation as those whose parents spoke to their children about not having sex but did not limit their viewing (Ashby et al., 2006). Theoretical Perspectives Researchers with several theoretical perspectives have examined pos- sible links between media exposure and changes in sexual attitudes and behaviors, Rich observed. Social learning theory, which has also been applied in the study of media violence, suggests that when individuals see a behavior portrayed in a positive way, they have a tendency to imi- tate and adopt it. Cultivation theory suggests a slightly different expla - nation, that what individuals see on television supersedes their own perceptions of the real world around them. Thus, if the social norm on television is extremely prevalent sexuality, individuals who watch the programming begin to think that it is the social norm and believe sexual- ity is more prevalent than it actually is. A third theoretical model posits that adolescents use media as part of their individuation process. They use their preferences for programming or music to convey messages about their social identity, in the same way that their choices of clothing and peer groups do. Rich sees media use as so pervasive as to be both a public health and environmental health issue. “It is like the air they breathe, the water they drink, the food they eat. They are neutral. They are not malignant. They are not bad. But they are very powerful. They can be used to do great good or, used thoughtlessly, they can harm,” he suggested. Johnson focused on the value of applying contemporary persuasion theory to the use of media strategies to influence adolescent behavior. He acknowledged that researchers have not fully explored this approach, so his discussion was largely theoretical. Researchers have posited at least five different current persuasion theories, he explained, although they converge on several significant points.13 One is that there is a trade-off between what he called effortful and noneffortful thinking. That is, when 13 Models include the information processing model (McGuire, 1968), the heuristic system- atic model (Chaiken, 1980), the unimodel (Kruglanski and Thompson, 1999), the cognition in persuasion model (Albarracín, 2002), and the elaboration likelihood model (Petty and Cacioppo, 1986).

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 THE SCIENCE OF ADOLESCENT RISK-TAKING the recipient of a message is highly motivated to expend effort processing it and is well able to grasp the content, there is the potential for the infor- mation to alter attitudes, and the content of the message makes a signifi - cant difference in the outcome. However, for a recipient whose motivation and ability are low and who is thinking in a relatively shallow fashion, it is the incidental features in which the message is enveloped that may mat- ter more. Thus, for example, marketers tend to rely heavily on peripheral cues that require very little attention to process in developing advertise - ments. These advertisements succeed because they are repeated over and over, so the message can be imprinted without any effort on the part of the recipient. Johnson pointed out that children and adolescents are most likely to process in a shallow way and to be receptive to peripheral cues, such as strategies that invoke emotional responses. Several other factors are likely to affect the way individuals process information, and these change in the course of development. Strong atti- tudes or habits (likely to become more entrenched with age), skepticism (which increases with education), and links to peer groups whose atti- tudes and behavior may be in opposition to a message all tend to make individuals more resistant to messages that seem discrepant in some way. Thus, Johnson explained, it would be logical to expect that media effects would vary with developmental stage. For preadolescent children, emotional and other nonverbal cues are likely to be most powerful. At that stage, children behave more impulsively than they do later, and the influence of both peers and family are strong. They are open-minded and not terribly skeptical. By early adolescence, the power of emotional cues decreases somewhat, and peer influence becomes stronger. At this stage, young people may be more responsive to content-rich messages. Late adolescents begin to resemble adults in their processing. While still responsive to emotional and nonverbal cues (as all adults can be), young people at this stage have strong attitudes and are capable of defending them. Johnson, however, cautioned that this hypothesis has not been clearly verified with empirical research. Researchers have demonstrated the influence that media can have on adolescent health, Johnson said. The results of a meta-analysis of health promotion interventions done through 2003 demonstrated a num - ber of significant effects on changes, as shown in Table 5-4 (Johnson et al., 2010). Johnson added, however, that the meta-analysis also showed that effect sizes for health promotion efforts (looking not just at media cam - paigns) are generally much smaller for children and youth than for adults, as Figure 5-6 shows (Johnson et al., 2010). He concluded that many fac- tors influence the outcomes. When adolescents are given intensive skills training and supplied with the resources to change their behavior (e.g.,

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 THE INFLUENCE OF ENVIRONMENT TABLE 5-4 How Much Can Interventions Improve Adolescent Health? Health Promotion Interventions’ Effects on Behavior Behavior k of studies M age of sample d1 Abstinence (Silva, 2002) 12 14 0.044 Pregnancy rates (DiCenso, 2002) 30 14.79 0.050 Pregnancy rates, sexual behavior, birth control use (Guyatt et al., 2000) 30 14.82 -0.027 Condom use (Johnson et al., 2003) 42 15 0.073 Frequency of sexual encounters (Johnson et al., 2003) 38 15.1 0.049 Unprotected intercourse (Mullen et al., 2002) 13 15.46 0.19 Number of sexual partners (Mullen et al., 2002) 8 15.75 0.29 NOTE: Mean effect sizes (d+) are positive for differences that favor health promotion in the treatment group (usually relative to a control group) and are expressed as the standardized mean difference effect size. Two meta-anaylses having only two studies are omitted. SOURCE: Johnson, 2009. Data from Johnson et al., 2010. Standardized M Effect size (d+) Medium Small Very small! M age (years) of participants in meta-analysis FIGURE 5-6 Age in meta-analyses of health promotion literatures. SOURCE: Johnson, 2009. Data from Johnson et al., 2010. Fig 5-6.eps

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 THE SCIENCE OF ADOLESCENT RISK-TAKING given condoms), effect sizes were significantly greater than when they were just the targets of an education campaign. Looking more broadly, he reinforced the theme present in many of the workshop discussions that family, community, peer, and other influences all affect the way adolescents process and respond to public health interventions and mes - sages. At the same time, negative media influences are very powerful— Johnson pointed out that tobacco companies have $20 to use in marketing their product for every $1 states have to use on prevention efforts. Nev- ertheless, as a 1998 Florida antismoking campaign demonstrated, media campaigns can be effective (Sly et al., 2001). Evaluation of the “Truth Campaign” indicated that it reduced the number of smokers in the state by 29,000, was shown to prevent adolescents from smoking debut, and may have affected young people who do take up smoking by making them more conscious of how often and how much they smoke (CDC, 1999; Sly et al., 2001). Interventions Brown picked up on the potential for media to be used as a positive force in young people’s lives, focusing on three media-based strategies.14 Perhaps the most familiar to many people is the use of social marketing approaches for media campaigns. Borrowing some of the expert adver- tising strategies from the world of commerce, public health experts have targeted large audiences with specific messages, presented in the media used by those audiences. Such messages are usually designed to achieve clear goals, such as increasing knowledge or changing specific attitudes or behaviors. However, Brown explained, social marketers typically do not have the resources to sustain these messages for long periods or repeat them, in the way that commercial marketers can—that saturation cover- age may be an important component in the success of commercial mar- keting. Meta-analysis of the effectiveness of social marketing campaigns has shown that, on average, 4 to 8 percent of those exposed to a social marketing campaign change their behavior (Derzon and Lipsey, 2002; Snyder and Hamilton, 2002). This may sound small, she acknowledged, but media campaigns can reach many more young people than a school- or community-based program could. Brown also noted that media campaigns are good at raising aware- ness of problems but more successful at changing behavior when com- bined with other measures. She likened them to air support for a military 14 Much of Brown’s presentation was based on reports from the National Campaign to Prevent Teen and Unplanned Pregnancy (Brown, 2008).

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 THE INFLUENCE OF ENVIRONMENT ground campaign. In Montana, for example, a program saturated the media with a message about the harmful effects of methamphetamine use at the same time that law enforcement efforts targeted the problem; the effect was a significant decline in use. More generally, in Brown’s view, media campaigns are most successful when they: • are guided by theory, such as a model of health behavior or social learning. • target a clearly defined, engaged audience. • are presented through multiple channels (or saturate a single, well-chosen channel). • stimulate the target audience to communicate about the issue. • are sustained over time. • are presented in an environment that supports the desired out- come in other ways (e.g., including water or lower fat snacks in vending machines at school at the same time a media campaign to promote their use is launched). Brown described a television campaign developed by researchers at the University of Kentucky that promoted safer sexual practices. Based on a model of the targeted behaviors (which indicated that they should target older adolescents who were highly sensation-seeking and prone to impulsive decision making), the program consisted of public service announcements that saturated particular channels over 21 months. The advertisements were designed using fast cuts and loud music to appeal to the target audience. Data about adolescents’ condom use were collected in the target city and a control city in which there were no such advertise - ments, and the researchers estimated that there was a 13 percent increase in the practice of safe sex in the targeted city (Zimmerman et al., 2007). Researchers have also begun to use new media to reach adolescents, although this approach has been less thoroughly studied. Examples include providing public health messages or answers to individual ado - lescents’ questions via text messaging, interactive CD-ROMs, and DVDs providing information about sexually transmitted diseases, HIV preven - tion, and the like, which are available in pediatricians’ offices, schools, and websites designed as peer communities that can provide information. Most media campaigns are expensive, Brown noted, and research- ers have not perfected the art of devising effective messages. It can also be difficult to evaluate the effectiveness of such campaigns, particularly when they are conducted on a national level, where so many competing influences may affect young people’s thinking and behavior. She also acknowledged that the results can be unpredictable and that a campaign

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 THE SCIENCE OF ADOLESCENT RISK-TAKING could have undesirable unanticipated consequences, such as introducing some young people to a behavior they had not previously considered. A second approach is to embed public health messages in entertain- ment programming, which, Brown explained, may produce less resistance in target audiences. An example is a collaboration between the National Campaign to Prevent Teen and Unplanned Pregnancy and the magazine Seenteen, to develop an article called “Why Are So Many Girls Still Get- ting Pregnant?” (Kuster, 2008). The article included interviews with girls about their views and information about ways to avoid pregnancy. Celeb - rities whom adolescents view as what Brown called “super-peers” can also play a useful role. Adolescents tend to admire and want to imitate role models they see in the media, so involving a rap star, for example, in a public service campaign can make the message much more palatable to the young people who admire him or her. Challenges to this approach include identifying sympathetic media producers willing to produce such messages, the difficulty of controlling messages once a celebrity takes on the role, and sustaining the message over time. Moreover, as with media campaigns, Brown explained, it is very difficult to evaluate the effective - ness of these messages. Promoting media literacy is the third strategy Brown identified for helping adolescents understand public health topics.15 It can be very valu- able to educate adolescents to be more critical users of media, for example, by asking them to keep journals about their reactions to what they see or to engage them in discussion of spoof advertising designed to help them discern hidden messages, in her view. When adolescents can deconstruct the content in what they see, it is easier for them to analyze and adjust their own media diet. They may also be encouraged to create their own media and to respond actively to what they see. Brown pointed out that there has been little evaluation of this sort of education, and schools and educators have been somewhat reluctant to take it on. Schools have not been encouraged to view media literacy as an important educational goal, nor have teachers been trained to address this topic.16 SUMMARY The experience of adolescence is complicated by a variety of influences that can have both positive and negative effects. A range of research has 15 Brown identified two sources for more information about media literacy: the American Coalition for Media Education (www.acmecoalition.org) and the National Association for Media Literacy Education (www.amlainfo.org [accessed May 2010]). 16 The Centers for Disease Control and Prevention offers health standards for youth, which in- clude indicators for media literacy; see http://www.cdc.gov/healthyyouth/sher/standards/ (accessed September 2010).

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 THE INFLUENCE OF ENVIRONMENT shown that economic hardship is associated with dysfunctional families and with a range of difficulties for adolescents, including risk-taking. This sort of stress is likely to have a negative effect on parenting, yet positive parenting can also profoundly affect outcomes for young people. Adoles- cents also tend both to seek out peers like themselves and to become more like the peers with whom they associate—and here, too, the net effect may be positive or negative, although the precise mechanisms of these fluid relationships have not been systematically traced. Similarly, strong bonds with teachers and peers at school can be a positive influence, but many characteristics of middle and high school are not conducive to the development of such bonds. Communities also may have structural characteristics that are supportive of positive ado - lescent development—such as social networks and resources for young people—but research has not yet answered specific questions about how schools and communities can develop more favorable structures and cul- tures. Finally, the rapidly expanding universe of media devices and ven- ues is having a profound influence on the experience of adolescence, with effects that include evolving norms for many behaviors—and particularly a loosening of sexual attitudes and an increase in sexual activity. At the same time, the media provide a potentially powerful tool for influencing young people in a positive direction. Interventions that address these influences may target broad popula - tions or specific families and individuals who have shown signs of dis - tress. Many focus on key transition points; like the presenters on specific risk behaviors, the presenters on external influences also stressed the value of targeting the youngest adolescents before problems become more firmly established.