Risky Business

The sound of a train whistle grows louder and then recedes in the fading light of a winter afternoon, a familiar sound in this southeast Baltimore neighborhood of rowhouses and corner bars

The hours after school in this community offer little diversion for young people, except perhaps for those activities that could get a kid into trouble. But one exception is found in a middle school in the neighborhood’s heart. At the school on this afternoon a dozen girls are practicing a hip hop dance routine in a room next to the gym. They do knee moves and twirl while a boom box plays tunes by Nina Sky and Usher. “Okay, do you have the beat now?” shouts dance instructor Kenda Watson. The girls nod while catching their breath, and tug on shirts to fan their sweaty bodies.

In a narrow room on the other side of the gym, kids sit around a long table creating Japanese scroll paintings. Down the hall, some boys and girls play a race car video game while an instructor coaches them on winning strategies. On other days of the week, these pre-teens take classes in yoga, etiquette, cooking, fashion design, tae kwon do, or computer science. Friday is field trip day. Each day, the children also receive tutoring and homework help.

These kids attend the Southeast Youth Academy, an after-school program for middle school students that is partly funded by a grant from the U.S. Department of Education. Academy staff hope to boost academic performance in this impoverished neighborhood. But educators aren’t the only ones interested. Public health leaders are beginning to study whether teens who attend programs like this one are less likely to use drugs, have unsafe sex, get into physical fights or engage in other risky behaviors.

For decades, “just say no” has been the guiding principle behind interventions aimed at stemming problem health behaviors among teenagers. One of the most popular prevention programs is Drug Abuse Resistance Education (DARE), taught in 75 percent of school districts, in which police officers teach students about drugs, alcohol and tobacco. “When you look at the history of health promotion programs for youth what you see is that most of them have been focused on that negative side of the equation,” says Robert Blum, the William H. Gates Sr. Chair of Population and Family Health Sciences. “There’s significant evidence that a lot of those approaches have not been terribly successful.”

Now some health researchers, like the Bloomberg School’s CleaMcNeely, are taking a different tack: They are studying the positive side of the equation. Specifically, these researchers are looking at factors that appear to protect youth from risk—factors such as doing well in school, having a mentor, participating in extracurricular activities. They are also studying programs for youth that take a broader approach toward youth development—some programs do not even mention the words “cigarettes,” “drugs” or “alcohol”—to test whether these approaches promote healthy lifestyles in teens. McNeely, an assistant professor in Population and Family Health Sciences, is now evaluating the Southeast Youth Academy to see if it garners such success. Hers is one of several studies run out of the School’s Center for Adolescent Health Promotion and Disease Prevention.

“We actually know a lot about programs proven to reduce risky behaviors among youth,” says Freya Sonenstein, director of the School’s Center for Adolescent Health, whose mission is to promote the healthy development of urban youth, while working in partnership with community organizations and with youth themselves. The Center conducts research and disseminates information about practices that have been proven to promote healthy youth development. In the past 15 years, Sonenstein says, adolescent health researchers have collected an enormous amount of scientific evidence showing which strategies work—and which do not.

Scare tactics would now appear to fit into that latter list. Remember those driver’s education films of yore that showed horrific crashes, all twisted metal, blood and gore—images meant to sear their way into teenage minds? Or programs such as Scared Straight, which took juvenile delinquents behind bars to go face to face with tough-talking convicts as a means of deterring violent behavior?

While fear may be an effective tool in changing behavior in certain cases, research suggests that many of these programs do not reduce risky behaviors in the long term. This past October, a panel of scientists convened by the National Institutes of Health to examine the research on reducing youth violence concluded that scare tactics have not proven effective and can even cause harm.

Likewise, research appears to cast doubt on the effectiveness of many popular health curricula designed to decrease risk. “We know that health education didactic programs don’t have much effect on behavior,” says Cheryl Alexander, a professor of Population and Family Health Sciences and the founding director of the Center for Adolescent Health. “They improve knowledge, but not behavior.”

A conversation with members of the Center for Adolescent Health’s Youth Advisory Committee (YAC) offers anecdotal support to Alexander’s hypothesis. During a meeting of the group at the School one night this past winter, teen committee members agreed to answer a visitor’s questions about health risks, including which health education efforts had made an impact on them.

“Health education is a waste of time,” one girl began.

Several members of the committee mentioned films they’ve seen that show former smokers with wrinkled, leathery faces or who now have cancer. A talkative girl named Jessica described an anti-smoking poster that showed a woman smoking a cigarette, her face covered with a bubbling mass of tar. The message: If people could see what smoking does to you, they might not smoke.

“Things that say, ‘You’ll look like this if you smoke,’—No, you won’t look like this. They overdo it. They lie,” Jessica says.

“They exaggerate,” added a girl seated next to her named Ikia.

Most of the 12 assembled nodded their heads in agreement.

Blum says such responses are common among many teenagers. “Information doesn’t change behavior,” he says. “Ask anyone who smokes cigarettes. They have the information.”

So if the “fear factor” isn’t effective and the didactic approach isn’t much better, what does work?

Many adolescent health experts now favor examining the factors that protect youth from risk, as much as those that drive them to take risks. Consider: The vast majority of teens, even those from high-risk environments, do not develop problem behaviors, notes Blum.

McNeely is exploring a notion called “school connectedness,” which she suspects is one of those protective factors. Using the results of the National Longitudinal Study of Adolescent Health, an in-school questionnaire given to 20,000 American students in grades 7 through 12, McNeely found a strong relationship between the student-teacher bond and students’ participation in risky behaviors such as cigarette smoking, alcohol use, marijuana use, sex, violence and suicide attempts. “When kids felt teachers cared and were fair, they were less likely to initiate all of those problem behaviors,” says McNeely.

She believes such results suggest that public health has a larger role to play in the schools. “The public health community for a long time has seen schools as delivery trucks: This is where you deliver lessons about good nutrition, health education, sex education,” says McNeely. But public health leaders might also explore strategies that promote health by enhancing the school environment, possibly through smaller class sizes, additional teacher training, increased family involvement, and a greater number of extracurricular activities.

After-school programs like the one in Southeast Baltimore offer additional opportunity. According to McNeely, an effective program should include an academic component, have high expectations for what youth can achieve, include a variety of fun activities, require some degree of parent participation, give kids choices about how the program is run and what it offers, and enforce respect between staff and youth.  In her evaluation of theSoutheast Youth Academy, McNeely will follow a group of students enrolled in the program as they progress from 6th through 8th grade. She will note rates of alcohol use, smoking, drug use, fighting and other anti-social behaviors, as well as rates of depression and other mental health problems, and compare those rates to national data.

Though it’s too early to tell whether the academy will help reduce rates of problem behavior, some youth development programs have yielded such results. In 2002, a National Academy of Sciences panel commended a number of programs for their successes youth behavior. One of those earning praise from the NAS panel was Big Brothers/Big Sisters, the national organization that pairs adult mentors with youth. Independent researchers found that youth who had a Big Brother or Sister mentor were less likely to start using drugs or alcohol, less likely to hit a person and less likely to skip school, compared to youth who were on a waiting list for the program.

“The underlying theory is that you have an adult who cares about you, who teaches you by modeling and talking,” says Cheryl Alexander, who served on the NAS committee.

Another project the NAS committee lauded was Quantum Opportunities, which focused on teenagers living in public housing. The students began as ninth graders and remained through high school graduation. They participated in a variety of educational, service and cultural activities, ranging from peer tutoring to visiting museums, and spent one-third of their time volunteering for agencies and community service organizations. Here, too, the results were promising: fewer teen pregnancies, fewer arrests and a better high school graduation rate.

In addition, Alexander points to another highly successful program called Project Northland. Admin- istered by the University of Minnesotawith the goal of delaying alcohol use among middle school students, the project reached well beyond schools to involve families, media, merchants and community leaders. These success stories demonstrate that good programs often require many years and several different levels of intervention, involving not just kids, but kids and their families, schools, communities and the media, says Alexander. “Kids don’t live in isolation,” she says. “They live in families, in communities. They go to school.”

According to some public health experts, one prong in that multi-pronged approach should be laws and policies designed to protect youth from the risks they will inevitably take.

By the time they graduate from high school, most teens have experimented with cigarettes and alcohol—and probably have engaged in reckless, sometimes dangerous, activities like driving too fast. As adults, how many of us have watched our own teens do something risky and wondered to ourselves: What were they thinking?

Recent brain science suggests that teens’ brains may in fact be partly to blame. Imaging studies have shown that brain development progresses from the back of the brain toward the front where the frontal lobes are located. During this process, connections between neurons are pruned and neurons themselves are coated with the insulation called myelin. In adolescence, an enormous amount of development is still occurring in the brain’s frontal lobes, the center for planning, understanding cause and effect, foreseeing consequences, and controlling impulses—“the brakes of the brain,” says Sara Johnson, a doctoral candidate in Health Policy and Management.

The bottom line, she says: The frontal lobes “are a work-in-progress until the early 20s.”

Imaging also reveals that the motivational circuitry in the brain requires more input to become activated in teenagers than in young adults—a possible explanation for why some teens seek out thrills and risks, says Johnson. “An adult might get a rush driving 75 miles per hour, while a teen might not get the same thrill until going 100 miles per hour.”

Johnson is using her doctoral dissertation to translate findings such as these into strategies for reducing injuries among teenagers. Some scientists believe that the adolescent brain needs practice making decisions that can involve risk. Continual practice may give the brain a chance to master impulse control and become more efficient at making decisions and understanding consequences.

According to this view, says Johnson, “Kids need to take risks and to understand boundaries. But it’s a double-edged sword. In order to do that they may put themselves in peril.”

She and some other injury prevention researchers point to one solution: policies that make the environment safer for teenagers but don’t eliminate their opportunities to practice making decisions. She cites graduated licensing laws as one example. These laws grant full driving privileges to teenagers in stages. In some states, for example, brand new drivers can only drive during the daytime hours, or without other teens in the car.

Susan Baker, a professor of Health Policy and Management, and Li-Hui Chen, an assistant scientist in the same department, are analyzing the effects of graduated driver licensing. Their preliminary results, says Baker, “indicate a definite benefit.” In an earlier study, Chen and Baker found that teenage drivers steadily increase their risk of dying in a car crash with each passenger they carry. A 16-year-old driver is three times more likely to die in a car crash when carrying three passengers than when transporting one passenger. Passengers in their teens and 20s raise this risk most.

Restricting the number of passengers a teen driver is allowed to carry in  an automobile would substantially reduce teen auto fatalities, Baker believes. She notes that motor vehicle crashes are the number one cause of death among 15- through 19-year-olds.

In another study, David Bishai, an associate professor of Population and Family Health Sciences, developed a mathematical model to examine how various government policies influenced adolescent risk-taking behaviors. He found that where states imposed beer taxes, teenagers drank less. In regions with laws restricting the placement of cigarette vending machines, teenage smokers consumed fewer cigarettes. Teens were also more likely to follow safe sex practices in communities that had more family planning clinics, Bishai concluded. “Teens are influenced by their own decision making, by what their parents do, by what their peers do and by what governments do,” says Bishai. “This is the legislative piece. It is a bit of a buffer, a bit of a safety net.”

While many public health experts are reaching beyond the classroom to find strategies that prevent risky behavior among youth, the school-based programs have not remained static either. DARE, for example, has introduced a revamped version of its curriculum.

The “New DARE” includes more interactive exercises and small group discussions (DARE officers now serve as “coaches” who guide students in learning how to resist peer pressure to use drugs), as well as high-tech imagery to show students how drugs affect brain functions. The program is also moving beyond elementary school to offer “booster sessions” in middle and high school. An evaluation of a different, revised middle school DARE program—DARE Plus—has found that it produces lower rates of drug use and violence among boys (but not girls). “I believe what made the project successful was the combination and coordination of multiple components of the program [classroom curricula, peer leadership, parental involvement, community action] that were synergistic,” saysCheryl Perry, who was the principal investigator of the study, conducted at the University of Minnesota School of Public Health.

These results are encouraging to Sonenstein. They demonstrate that program planners are adopting lessons learned from years of behavior and prevention research. Likewise, she is heartened by data showing declines in rates of drug, alcohol and tobacco use, pregnancies, and violence among adolescents. Heartened, but not sanguine. “Even though there has been a decline, rates are going down slowly,” she says. Teen pregnancies in the U.S. still surpass rates in other industrialized countries. And while drug abuse and other risky behaviors have declined among youth overall, those rates are still unacceptably high in certain pockets of society, notes Sonenstein.

“If you’re looking for kids who have no level of risk taking, that’s probably not realistic,” says Sonenstein. “Because that’s what adolescence is all about.”

Some teens have more options in their lives than others, more alternatives to risky behaviors. What distinguishes the kids who do not get into trouble is that they do well in school, do well on the football team, excel at a hobby, says Blum. Creating such opportunities is what motivates people to avoid risky behavior, he says, and more kids need those chances.