3
Supporting Adolescents with Social Institutions

Communities and institutions that surround adolescents are increasingly challenged by the changing social and economic conditions in society. These conditions include the decline in economic security for poor and middle-class families, the increase in the number of single-parent households, and the rise in the number of neighborhoods with concentrated poverty that are spatially and socially isolated from middle-and working-class areas. Such trends place enormous stresses on public and private institutions—neighborhoods, schools, the health care delivery system, the workplace, and employment and training centers. For adolescents to be successful in a society that offers many choices and challenges, it is abundantly clear that they need support from all the settings and social institutions that make up a community.

NEIGHBORHOODS AND COMMUNITY SETTINGS

Most of the social interactions of families and adolescents are embedded within neighborhood settings. A neighborhood can be defined both spatially, as a geographic area, and functionally, as a set of social networks. However defined, neighborhood is a key setting for adolescent development. Neighborhood characteristics are increasingly viewed as part of the broader range of influences that can affect adolescents, although the magnitude of their impact is uncertain and difficult to measure. Neighborhood factors that influence adolescent health, development, and well-being include:



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Risks and Opportunities: Synthesis of Studies on Adolescence 3 Supporting Adolescents with Social Institutions Communities and institutions that surround adolescents are increasingly challenged by the changing social and economic conditions in society. These conditions include the decline in economic security for poor and middle-class families, the increase in the number of single-parent households, and the rise in the number of neighborhoods with concentrated poverty that are spatially and socially isolated from middle-and working-class areas. Such trends place enormous stresses on public and private institutions—neighborhoods, schools, the health care delivery system, the workplace, and employment and training centers. For adolescents to be successful in a society that offers many choices and challenges, it is abundantly clear that they need support from all the settings and social institutions that make up a community. NEIGHBORHOODS AND COMMUNITY SETTINGS Most of the social interactions of families and adolescents are embedded within neighborhood settings. A neighborhood can be defined both spatially, as a geographic area, and functionally, as a set of social networks. However defined, neighborhood is a key setting for adolescent development. Neighborhood characteristics are increasingly viewed as part of the broader range of influences that can affect adolescents, although the magnitude of their impact is uncertain and difficult to measure. Neighborhood factors that influence adolescent health, development, and well-being include:

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Risks and Opportunities: Synthesis of Studies on Adolescence the decline in economic security (including decreasing real earnings and rising levels of unemployment), especially for young adults; the increase in single-parent, usually female-headed, families; the relation of male joblessness to social disorganization and rational planning for families and adolescents; easy access to illegal drugs and guns; high rates of youth crime and juvenile detention; and the role of illegal or underground economies in providing for basic goods and services. These factors contribute to the absence of adult supervision and monitoring, a dearth of safe places to gather, the absence of constructive activities during idle periods, increased exposure to law enforcement and prison settings, and diminished opportunities for interaction with positive role models and needed institutional resources. Patterns of residential transience, often generated by poverty, represent another neighborhood factor that can influence youth development. Frequent household moves, disruptions in daily routines caused by unrelated individuals entering or departing the household, and mobility among neighbors can undermine community ties, weaken support networks, and reduce privacy. However, such transience does not inevitably disrupt development if adolescents have opportunities to sustain relationships with trusted adults. Encounters with neighborhoods are shaped not only by parenting processes and children's experiences, but also by class, gender, and ethnicity. There is a great deal of evidence that suggests that social class influences the character of the neighborhood organization and culture. For example, many poor adolescents are growing up in racially segregated and economically isolated neighborhoods. In these neighborhoods, a high proportion of adults are poor, unemployed, on welfare, or single parents. Research shows that these adolescents are in fact at increased risk for school failure and dropping out of school, unintended pregnancy, abuse of alcohol and other drugs, delinquency, and victimization and perpetration of violence. The strength and quality of social networks in neighborhoods also may affect the types of adult interactions that adolescents experience, which in turn can influence their choice of role models and life course options. The child's age and gender are also likely to result in sharply divergent experiences that modify the impact of neighborhoods on development. Girls typically are granted less autonomy and are subject to greater parental

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Risks and Opportunities: Synthesis of Studies on Adolescence control. Especially in low-income areas, boys often spend more time hanging out on the streets, and at younger ages. Thus, neighborhood influences may operate differently for different age groups by gender. A missing factor in the lives of adolescents in disadvantaged communities, especially black adolescents, is exposure to successful, upwardly mobile adults. Far too often, adults who become successful move out of the disadvantaged areas to higher-income urban or suburban communities. Lacking this exposure, adolescents in disadvantaged neighborhoods may have limited opportunities to learn about strategies for family financial planning, balancing work and child care responsibilities, and identifying educational and career opportunities across the life span. Research on social settings has increasingly called attention to the role of the unrelated adults who come into contact with adolescents in neighborhood and other social settings. They include teachers, mentors, coaches, employers, religious leaders, service providers, shop owners, and community leaders who may influence youth perceptions and behavior in their everyday settings. Researchers are exploring how the absence or presence of these individuals affects adolescents' perceptions of their own potential contributions and life options. Despite findings from the growing literature suggesting the importance of neighborhood influences on adolescent development, the evidence for direct neighborhood effects is weak and often inconsistent. Moreover, it is not clear how community resources translate into opportunities for families and their children. Research is therefore needed to better characterize the ways in which neighborhoods influence both negative and positive developmental outcomes among children and adolescents, as well as the ways in which neighborhood influences, economic influences, family influences, and other social resources collectively interact with one another to influence the development of children and adolescents. Research is also needed to help explain why some children and adolescents are more resilient than others in adverse situations, and what combination of factors serve to buffer against negative or potentially harmful influences. SCHOOLS Today, virtually all teenagers in the United States are enrolled in school; this is in stark contrast to 50 years ago when fewer than half of adolescents were enrolled in school. Students now spend more time in school (i.e.,

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Risks and Opportunities: Synthesis of Studies on Adolescence number of days) and remain in school for more years than they did in previous decades. While at the turn of the century high schools were intended for the elite, today the American education system is intended to meet the needs of a diverse and growing population. In addition, it is expected to provide youth with the knowledge, skills, and credentials needed for adulthood in modern society. Education is often considered the ticket out of poverty for children growing up in disadvantaged neighborhoods. For many adolescents, however, schools do not serve these functions nor do they successfully meet these needs, despite years of public debate and numerous efforts at school reform. Indeed, in recent years, there has been much debate about how to structure schools for young adolescents, given that students face two major school transitions during adolescence—moving from elementary school to the middle grades and, two or three years later, moving to high school. Each transition dramatically changes their educational experiences. As they move through the education system, students face increasing complexity: compared with elementary schools, middle and senior school facilities and the student body tend to be larger; they are more likely to use competitive motivational strategies; there is greater rigor in grading and an increased focus on normative grading standards; there is greater teacher control; and instruction is delivered to the entire classroom rather than to individuals or smaller clusters of students. These changes can be stressful for some adolescents, and research indicates that the experience of transition itself may have an independent negative effect on students' attitudes and achievement, especially in large urban schools. It is important to note that although some aspects of the transition into middle and high school may be difficult for students to negotiate, not all students experience the same degree of stress during these transitions. With each transition to a new school, more stratification occurs. Different teachers teach different subjects, and, within subject matter, students are often grouped by ability level. This grouping of students according to perceived ability is called tracking. Students placed in the lower tracks are at the greatest risk for being retained in a grade, and, by the same token, students who repeat a grade are likely to be placed in the lower tracks. The practices of tracking and grade retention are both grounded in tradition; they are intended to ensure that instruction is paced at students' ability to learn and that subjects are mastered before a student advances. An unintended consequence for some students is that they feel stigmatized: separated from many of their peers, they may develop a sense of uncertainty

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Risks and Opportunities: Synthesis of Studies on Adolescence and alienation toward school. More significantly, tracking and grade retention may imperil students' academic achievement. Because of stratification by social class and residence, students from poor families often receive their education in the poorest schools. These schools usually have fewer financial and material resources, and they often are unable to retain the most skilled administrators and teachers. Student achievement levels in these schools are significantly lower on virtually all measures than those of students in suburban schools. Compensatory education funds from federal and state sources are targeted toward disadvantaged and low-achieving students, but they have shown limited success, particularly among older adolescents. Dropout prevention programs for older adolescents are less effective when implemented as remedial or vocational add-ons to the regular curriculum. It has become apparent that the roots of poor achievement lie not only in the conditions of poverty or in individual differences, but also in the use of such instructional practices as tracking and grade retention, and the generally lower expectations for adolescents in schools in lower-income communities. Despite these shortcomings of today's educational system, it is clear that adolescents who complete high school are better off than those who drop out, not only in terms of earnings but also in terms of cognitive development. While much less is known about the impact of schools on adolescents' psychosocial development, it is clear that adolescents who drop out of school are at very high risk for problems, including (but not limited to) alcohol and other drug abuse, delinquency and involvement in criminal behavior, unintended pregnancies, and prematurely leaving or running away from home. Increasingly, schools are being transformed as community-based settings in which primary health and mental health services are being delivered, including prevention and health promotion interventions targeting a wide range of behaviors. In the past, school health officials focused on the prevention of infectious diseases, such as tuberculosis and chicken pox. Today schools seek to prevent or address a wide spectrum of health concerns, ranging from violence to substance abuse, risky sexual behaviors, tobacco use, inadequate physical activity, and poor dietary habits—the six issues at the core of 70 percent of all adolescent health problems, according to the Centers for Disease Control and Prevention. Many schools have turned to a comprehensive health program that integrates age-appropriate health education courses with physical education, course work in nutrition, health and psychological services, counseling, and other related services.

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Risks and Opportunities: Synthesis of Studies on Adolescence Although they may take many forms, comprehensive school health programs are characterized by complementary strategies, activities, and services designed to promote the optimal physical, emotional, social, and educational development of students. Increasingly, schools are also developing school-based or school-linked health care services as well as partnering with other community-based social service programs to offer students comprehensive primary health care and preventive services. Since they first were conceived, however, these programs have been hampered by poor coordination, inadequate or unreliable funding, and a lack of knowledge about the effectiveness of behavioral interventions. While many of the components needed to create a comprehensive service delivery system of care are in place in many communities, the schools and these communities often lack an infrastructure to facilitate coordination; in these cases, fragmentation of resources has generally limited their growth. HEALTH CARE DELIVERY SYSTEM During the past two decades, the field of adolescent health care has grown rapidly, as health care providers and health educators have come to better understand that the health care needs of teenagers are quite different from those of children and adults. There is consensus that the most significant threats to the health of today's adolescents are behavioral in nature and associated with psychosocial risks rather than natural causes. Unlike children and adults, adolescents are less vulnerable to disease or illness (e.g., cancer, infectious diseases, genetic or congenital diseases) and more vulnerable to death from injury, homicide, and suicide than any other age group, and this risk has been increasing during the past several decades. Other health problems include alcohol and drug abuse, infection with sexually transmitted diseases, unintended pregnancy and its outcomes, mental health problems (e.g., lack of self-esteem, depression, suicide), and physical and sexual abuse. In this area there are two important points to make. First, the leading causes of morbidity and mortality among adolescents are behavioral in nature, all are almost entirely preventable, and they have resulted in a movement away from traditional medical models that emphasize assessment, diagnosis, and treatment of diseases to a health promotion model. Health promotion involves screening for psychosocial and behavioral risk factors in an effort to prevent youth from engaging in risk behaviors. Adolescent

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Risks and Opportunities: Synthesis of Studies on Adolescence health care providers now also encourage healthy lifestyle patterns with respect to diet, exercise, and sleep in part because these behaviors are likely to persist into adulthood. The second important point to make is that health care providers now recognize that interventions introduced during the adolescent years could very well affect health outcomes during the adult and senior years. Indeed, it is now widely believed that adolescence is an important time to intervene in an effort to encourage people to adopt a healthy lifestyle that they may very well maintain into the adult years. Despite the recognized importance of providing these services to adolescents, many of them lack a consistent source of basic care over time. They are far less likely to visit a doctor's office or to have any regular source of medical care than are either young children or adults. Many of their health issues, such as drug use and sexual intercourse, are socially stigmatizing or difficult to discuss. Such issues make physician-patient relations particularly difficult; adolescents may be unwilling to discuss or deal with these problems in hospital-based or outpatient clinic-based health care delivery settings. The failure of the U.S. health care system to address the needs of adolescents is especially acute for those who engage in high-risk behavior. Few physicians specialize in adolescent health, and other practitioners are poorly trained to recognize or deal with adolescent health problems, particularly when the symptoms are psychosocial rather than physical in nature. The overall system is fragmented, which is a particular problem for adolescents because of the diversity of their needs. For many adolescents, the health care system lacks all of the essential elements of primary care: a consistent point of entry into the system, a locus of ongoing responsibility, adequate backup for consultation and referral services by adolescent specialists, and comprehensiveness. Adolescents from low-income families—precisely those who are at highest risk for health problems—are also those least likely to be covered by health insurance. Insurance coverage is the major determinant of whether children or adolescents have access to health care. This finding is consistent across many studies: compared with children who have insurance coverage, uninsured children have many unmet health care needs. As many as a quarter of adolescents are thought to have no health insurance benefits. Even when available, insurance may be inadequate for the many needs of adolescents. Most private plans emphasize treatment rather than prevention or outreach, and payment restrictions (maximums, coinsurance, deductibles) further reduce the range of services available. Moreover, the

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Risks and Opportunities: Synthesis of Studies on Adolescence amounts and services covered by Medicaid vary widely from state to state, and in some states Medicaid does not even provide coverage for adolescents; complicated regulations may also discourage adolescents from seeking care. Rules regarding parental notification, which have a deterrent effect in the case of contraceptive use and abortion, may also deter adolescents from seeking other health care services. Inadequate reimbursement schedules may cause providers to limit the number of Medicaid patients that they will serve. Mental health services share many of these same problems. It has been estimated that approximately 25 percent of all adolescents have a significant mental health problem, yet the mental health system is designed to serve only a few, select adolescents; these services typically are provided through special education in schools, community mental health centers, and inpatient facilities; the services are rarely integrated and are often unavailable to the adolescents who need them most. In short, the mental health system meets the needs of only a small minority of adolescents. Mental health services have also traditionally focused on treatment rather than prevention or mental health promotion. Even for young people with insurance benefits, mental health treatment often is offered on a short-term basis, in restrictive inpatient settings. In schools, less than one-third of all students in special education receive psychological, social work, or counseling services. Only about 2 percent of all adolescents receive service from a school psychologist; there is only one school psychologist per 2,500 students nationwide. When mental health services are offered, they have been focused on preventing behavioral problems such as substance abuse, violence, and delinquency, rather than on promoting emotional well-being. Children's health insurance became a subject of national debate early in 1997 when President Clinton and members of Congress began to develop a variety of competing proposals to expand coverage for children. After several months of active discussion and negotiation, Congress enacted the State Children's Health Insurance Program (SCHIP) as part of the Balanced Budget Act of 1997. With SCHIP, $24 billion of new funding is available to states over five years, including $20.3 billion for new initiatives based on private insurance coverage and $3.6 billion for Medicaid improvements. States may use SCHIP funds to broaden their Medicaid programs, to start up or expand state-sponsored or private insurance programs, or to support a combination of programs. The potential for flexibility in SCHIP designs appeals to most states because it gives them the

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Risks and Opportunities: Synthesis of Studies on Adolescence opportunity to provide coverage and services in ways that reflect the state's unique circumstances and characteristics, such as the availability of insurance products and providers, the geographic distribution of uninsured children, and the potential sources of financing, among others. This flexibility also raises some technical and practical issues. The most fundamental question is this: With so much variation possible, how will we know whether SCHIP is effective? Unless there is consistent reporting of reliable data within and across states, it will be difficult to evaluate the program's impact. At this very early stage in the program, it is vitally important to design and develop systems of accountability and to anticipate needs for information and communication based on experiences with other national and state programs, especially those that involve low-income working families. It is too early to tell what impact SCHIP will have on the health and well-being of children and adolescents. Over the next several years, however, it will be important to measure the extent to which the new children's health insurance programs alleviate the pressure on other sources of funding for uncompensated care. Unless better data systems are developed, this will be extremely difficult to measure. Thus, the advent of the SCHIP program offers a unique opportunity to track and measure changes in the number of uninsured children and to assess the program's effectiveness from its onset. Lessons learned from the evaluation of the program will have important implications for the likelihood and nature of future insurance expansions. CHILD WELFARE AND JUVENILE JUSTICE For many adolescents who enter its care, the child welfare system has become a high-risk setting. Demographic trends and the efforts aimed at deinstitutionalization in the 1970s and at community-based service alternatives in the early 1980s temporarily reduced the number of adolescents in the child welfare system, but by the mid-1980s the trend was reversed. Whether factors outside the service system, such as increased poverty and broken families, overwhelmed efforts to develop community service alternatives is not clear, but what is evident is that the system was not designed to address the challenges presented by troubled teens. A large number of adolescents become part of the child welfare system while still living in their parents' homes. They often come into the system because they are abused or neglected or because they are a sibling of a

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Risks and Opportunities: Synthesis of Studies on Adolescence younger child who has been abused or neglected. Services may be provided to small children and their parents, but it is unusual for adolescents to receive services. Many parents receive homemaker services and parent-training classes, for instance, and young children may receive day care services. But it is generally believed that the problems of adolescents will be resolved when a parent changes his or her behavior or when some of the stresses in a parent's life are relieved. Many professionals have observed that there are actually two child welfare systems—one for young children and another for adolescents. Although the system for young children is viewed as deeply flawed, the system for adolescents has even more complex and formidable problems. One example is the recruiting and retaining of foster parents. It is particularly difficult to find foster parents for adolescents, for whom family life is often a source of conflict and whose behaviors may be both destructive and difficult to control. Hence, it is often necessary to place adolescents in more restrictive living arrangements like group homes and residential treatment centers. Since the mid-1970s, the federal government and the states have sought noncorrectional alternatives for adolescents who engage in antisocial but not serious criminal activities. These adolescents were typically classified as ''minors in need of supervision," but they are neither treated as offenders nor incarcerated. A number of alternatives to community-based services have arisen to serve them.1 Delinquent adolescents who were once in the child welfare system now often shuttle between systems: detention or correctional centers operated by juvenile courts and correctional departments, on one hand, and group homes, residential treatment facilities, and halfway houses operated by the child welfare or mental health system, on the other. For adolescents who engage in more serious crimes, the corrections system then becomes the custodial parent. Both the juvenile and the adult criminal justice systems are generally failing in their efforts to rehabilitate offenders. The decline in confidence in the effectiveness of rehabilitation and escalating rates of imprisonment 1    The findings from these noncorrectional alternatives have not been discussed in published National Research Council and Institute of Medicine reports. However, a report synthesizing the findings of programs targeted to youth within the juvenile justice system, as well as other research findings regarding juvenile crime, is currently scheduled to be completed by the Panel on Juvenile Crime of the Committee on Law and Justice in 2000.

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Risks and Opportunities: Synthesis of Studies on Adolescence mean that adolescents caught in the juvenile and the adult criminal justice systems may live adult lives marked by unemployment, low-paying jobs, ill health, and crime. The juvenile justice system that emerged early in this century not only included training and reform schools and other forms of institutionalization, but it also made frequent use of suspended sentences and probation. Now the juvenile justice system has many of the adversarial and punitive characteristics of the adult system. The shift from an earlier emphasis on rehabilitation and treatment to the current emphasis on punishment has had important consequences for the sentencing and punishment of young offenders. Black and Hispanic adolescents make up an overwhelming majority of both victims and offenders of violent crime. Blacks constitute about 12 percent of the U.S. population and Hispanics about 8 percent, but both groups are arrested for a higher proportion of violent crimes. Blacks account for 40 percent of all people arrested for homicides, rapes, armed robberies, and aggravated assaults, and Hispanics account for about 14 percent of people arrested for these violent crimes. For less serious property crimes, blacks are arrested for a quarter to a third of all arsons, car thefts, burglaries, and larceny/thefts; Hispanics are arrested for about 11 percent of these property crimes. Scholarly efforts to explain these facts have focused on two possibilities. First, race-linked patterns of discrimination, segregation, and concentrated poverty may produce pervasive family and community disadvantages, as well as educational and employment difficulties, which in turn may cause high levels of delinquent and criminal behavior among young minority males. Second is the possibility that, at the hands of the juvenile and criminal justice systems, young black males may be victims of prejudice and discrimination in the form of more frequent arrests, prosecution, and punishment for delinquent and criminal behavior. Race-linked inequalities may further aggravate problems in many institutional settings in which blacks and whites meet. Because community-level policing practices have at times displayed discriminatory patterns, and because the justice system is nevertheless expected to embody high standards of fairness, justice system interactions have become particularly difficult forums for black-white relations. One result is that many minority inner-city adolescents grow up in environments that, in addition to other difficulties, are characterized by hostility toward the justice system.

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Risks and Opportunities: Synthesis of Studies on Adolescence REPORTS REFERENCED Adolescent Behavior and Health (1978) America's Fathers and Public Policy (1994) Losing Generations: Adolescents in High-Risk Settings (1993) New Findings on Poverty and Child Health and Nutrition (1998) Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research (1994) Schools and Health: Our Nation's Investment (1997) Youth Development and Neighborhood Influences: Challenges and Opportunities (1996)