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Contextual Overview of Adolescent Mental Health Concerns
Failed efforts to cope with the anxieties and difficulties in life can lead to mental health problems. Prevalence rates of 12% for mental health disorders and 15% for maladjustment disorders for the nation's youth are common (Institute of Medicine, IOM, 1994; McCabe as cited in Walker & Townsend, 1998). Preventing psychological problems has become as important as intervening when they arise. Mental health counselors need to acquaint the profession with prevention models that can work for at-risk children and youth.
Promoting mental health can prevent further behavioral problems and improve the quality of life for youth (Walker & Townsend, 1998). New initiatives in mental health counseling need to include primary, secondary, and tertiary prevention efforts designed to detect, treat, and forestall mental health problems before they take hold.
Premise and Purpose
Multiple challenges face adolescents who experience numerous risk factors. Mental health and school counselors can team up to reduce adolescent stress and increase their coping strategies. The rationale for building partnerships is that environments can produce or reduce stress; therefore, services need to be available in the environmental settings where adolescents live and work.
We hope to provide mental health counselors with three pieces of information: first, we offer a critical overview of the empirical literature on primary prevention programs that target adolescent mental health concerns. Second, we promote partnerships between mental health and school counselors that can best utilize community resources within a given geographic region. Adolescent coping and self-esteem can be increased when services are coordinated and when they target specific risk factors. Third and finally, we want to convince mental health practitioners that prevention models can guide clinical research and practice.
Three critical elements are prerequisites to any effective prevention program: a group orientation, a sound theoretical foundation, and a proactive stance (Cowen, 1982). Of course, prevention programs target at-risk groups who have the potential to develop problems.
Three areas of prevention can be initiated, according to the Institute of Medicine. Prevention initiatives can be selective, universal, or indicated. First, selective prevention targets specific at-risk populations. Second, universal prevention targets the general population. Third, indicated prevention targets individuals who do not meet the criteria for a mental disorder but who nevertheless present symptoms associated with a certain mental disorder (IOM, 1994).
Prevention is useful when any one of four distinct prevention approaches is evoked. First, programs can focus exclusively on improving skills (cognitive, behavioral, affective) without directly addressing environmental variables. Second, programs can target both skills and the environment. Third, programs can have multiple components that target the relationships of youth with significant adults. Finally, programs can have multiple components that target the group level rather than the individual level (Weissberg & Bell, 1997).
Prevention program models address the complexity and nature of adolescents' mental health concerns when they identify risk factors (potential causes) of mental problems and when programs are designed to minimize the impact of these risk factors (Dulmus & Wodarski, 1997).
Bloom (1996) suggests using his configural equation in several ways. This model is a conceptual tool as well as a "best practices" treatment guide. In this article we show mental health counselors how to intervene in three key dimensions of adolescent life.
Bloom's first dimension requires us to increase individual strengths and decrease individual limitations. In this dimension, mental health counselors determine the cognitive, affective, behavioral, and biological factors that could explain the origin of adolescent mental health problems. We advocate a holistic perspective because we want to emphasize the impact that environmental variables have in shaping psychological disturbance in teens.
Bloom's second dimension requires us to increase social support and to decrease social stress. In this dimension, mental health counselors look for ways to assess contribution of diverse groups (i.e., primary, secondary, and sociocultural), of the physical environment (both natural & built), and of life course events to psychological disorders. We already know that parents and peers clearly contribute to the mental health and, conversely, to the mental deterioration of youth (Dryfoos, 1996; Dulmus & Wodarski, 1997; Garmezy, 1983; Gillham, Shatte, & Freres, 2000), but we do not know how to specifically intervene in these relationships in order to prevent environmental contributions to mental health disturbances. Nevertheless, we know that prevention programs will be effective to the extent that they assess the relative contribution of individuals important to adolescents as they influence their mental health outcomes.
Blooms third dimension requires us to look at environmental variables as we develop our prevention programs. One environmental factor is poverty for its consequences clearly affect adolescent mental health (Dryfoos, 1996; Garmezy, 1983; Patros, 1989). A second environmental variable is natural disaster, for its consequences immediately challenge adolescent security. Mental health professionals can educate the community regarding the impact of environmental factors such as poverty and natural disasters and can make available to the community supportive resources (Bloom, 1996). A third environmental variable is the availability of community programs for youth, for their presence in a community can buffer the stresses inherent in adolescent life. Regardless of whether the target is poverty, natural disasters, or lack of community programs for youth, when mental health counselors enlist adolescents to create and protect environmental resources, youth can experience their sense of agency and competency.
In addition to Bloom's configural model of prevention, there is another effective prevention model: Albee's incidence formula (Albee & Gullotta, 1977). To prevent psychological maladjustment we must decrease the negative effect of biology and stress, and we must increase the positive effect of strengthening coping skills, improving self-esteem, and bolstering supportive systems. Overall, Albee's model helps mental health counselors improve adolescent motivation to responsibly improve their mental health outcomes.
Adolescent Mental Health
One example of effective prevention for adolescents is the Multidimensional Family Prevention model (Liddle & Hogue, 2000). This model decreases anti-social behavior among adolescents through two methods: traditional (curriculum-based, protective orientation) and psychosocial (assess and solve problems within the context of key relationships). This model emphasizes an individualized plan to satisfy a family's unique needs. The robust element in this model is its success in creating a resilient family environment that allows at-risk adolescents to protect themselves against traumatic environmental influences.
A second example of effective prevention for adolescents is Ellis's multi-factor, multi-system, multi-level comprehensive prevention program (Ellis, 1998). Ellis accepts the reality that adolescent mental health problems are caused by multiple factors and systems and insists that effective prevention requires us to address all relevant risk, need, and protective factors facing the adolescent across multiple systems and environments. Mental health counselors who are serious about preventing adolescent mental disturbances will look at three types of intervention: multi-factor, system, and level.
Multi-factor interventions are those that address all risk, need, and protective factors existing within the adolescent environment. Multi-factor prevention plans contain both an individual and a collective component. Individually, the plan is specific to the needs of each adolescent; collectively, the plan provides sufficient resources to meet the needs of all individuals in the target population (Ellis, 1998; p. 62).
Multi-system interventions are those that address the factors that exist in every social context in which the individual interacts. Furthermore, the author stresses that because the risk factors are interactive and the systems interact with one another it is critical to understand the role of each system in the life of each individual.
Multi-level interventions are those that address the need to provide resources at both the micro (individual) and macro (collective) level. Ellis believes that sufficient intervention and prevention resources must be in place and accessible at both levels. At the macro level of prevention planning, there are three critical questions to ask about service availability: Do people know that these services exist? Do people have ready access to these services? and, Do people know that they need the services that are offered?
One recent longitudinal study on preventing substance abuse for high-risk second and third grade students found that prevention is effective. Positive program effects for children were found in the increased use of personal competency skills which include: refusing wrongdoing, solving peer and school problems, showing courteousness to teachers and other school personnel, and behaving ethically. Positive program effects were also found in children's report of good feelings toward school and grades. From this study, we see that mental health counselors can work with schools to provide a buffer from the multiple risks in children's lives (St. Pierre & Kaltreider, 2001).
One meta-analysis on primary prevention mental health programs for children and adolescents found that outcome evaluations of 177 primary prevention programs were effective. Problems were significantly reduced, competencies were significantly increased, and children were better able to adjust in several aspects of their lives (Durlak & Wells, 1997; p. 137). Importantly, this meta analysis also revealed that primary prevention programs are designed to improve practical areas of life and functioning in youth. A second meta-analysis of 156 educational, behavioral, and psychological interventions indicated that participants were functioning within the normal range and within the range achieved by other interventions in the behavioral and social sciences (Lipsey & Wilson, 1993). In sum, meta-analyses reveal that mental health preventions are effective as tools for change in both normal and disturbed adolescent populations.
Finally, D'Andrea's (1984) Family Development Project is an example of a successful systemic prevention program. Designed to help young women in their transition to parenthood, this program includes four components: educational consultation, individual counseling, psychosocial system consultation, and research and evaluation services. Overall, data on effectiveness showed that participants perceived that their psychosocial networks were stronger, more elaborate, and more responsive as a result of their participation in the program.
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