Clinical and Research Uses of an Adolescent Mental Health Intake Questionnaire

What Kids Need to Talk About

Irwin Epstein, Ken Peake, Daniel Medeiros

• Publisher: Routledge
• Year: 2014
• Print ISBN: 9780789026736
• eBook ISBN: 9781317825104
• Topic: Psicologia
• Subtopic: Psicologia dello sviluppo

Learn how to better clinically serve risky adolescentsfrom the clients themselves!

Clinical and Research Uses of an Adolescent Mental Health Intake Questionnaire: What Kids Need to Talk About explores the research on adolescent behavior culled from the answers to a clinician-designed intake questionnaire given to adolescent clients asking how they view their own risks, what they worry about, and what they wish to talk about. Respected authorities discuss the enlightening findings and present ways to reshape services, taking into account customer preference, risk and worry, and youth development (YD) perspectives while presenting practical clinical strategies to engage at-risk adolescents in mental health treatment.

Clinical and Research Uses of an Adolescent Mental Health Intake Questionnaire: What Kids Need to Talk About provides conceptual models that practitioners and organizations can use to develop reflective practices and to understand better how to engage adolescent clients in treatment. The book includes three case studies that illustrate an organization's experience in developing ways for organizational learning, including the clinicians' own accounts of their experience in conducting practice-based research. Two chapters describe the development and the clinical uses of the intake questionnaire and offer guidelines for other practitioners to develop their own. The book discusses specific findings about adolescent risk, worries, and desire to talk across a wide range of psychosocial domains such as education and work, sex and sexuality, safety, substance abuse, and family and friends. Other research examines adolescent risk and vulnerability profiles of lesbians, gays, and bisexuals, as well as the impact of racism. Finally, the book builds upon this empirical analysis to address the clinical challenge of engaging risky adolescents in counseling.

Clinical and Research Uses of an Adolescent Mental Health Intake Questionnaire: What Kids Need to Talk About analyzes:

• adolescent risks, worries, and coping
  
• adolescent help seeking and desire to talk in counseling
  
• youth development (YD) and adolescent vulnerability
  
• urban adolescents' health and mental health concerns
  
• effectively engaging adolescents in counseling
  
• collaborative strategies for clinicians and managers
  
• reflectivity and learning in human service organizations
  
  Clinical and Research Uses of an Adolescent Mental Health Intake Questionnaire: What Kids Need to Talk About presents essential information for social workers, mental health professionals who work with adolescents, adolescent researchers, pediatricians and adolescent medicine practitioners, teachers, students, and youth workers.
  

Part I

Including At-Risk Adolescents in Their Own Health and Mental Health Care: A Youth Development Perspective

Angela Diaz
Ken Peake
Michael Surko
Kalpana Bhandarkar

Angela Diaz, MD, MPH, is Director, Mount Sinai Adolescent Health Center and Professor of Pediatrics and Chief of Adolescent Medicine, Mount Sinai School of Medicine. Ken Peake, DSW, is Assistant Director, Mount Sinai Adolescent Health Center. Michael Surko, PhD, is Coordinator, ACT for Youth Downstate Center for Excellence, Mount Sinai Adolescent Health Center. Kalpana Bhandarkar, BA, is Program Assistant, Down-state Center for Excellence. Mount Sinai Adolescent Health Center is located at 320 East 94th Street, New York, NY 10128.

SUMMARY. As urban adolescents encounter serious health and mental health risks, they present the allied health professions with important opportunities for health promotion and risk reduction interventions. However, the prevailing emphasis on adolescents’ risk behaviors rather than on their vulnerability has limited our capacity to understand and serve them. Further limiting are the widely held myths that adolescents as a whole have few health problems and that they are poor judges of their own needs. This article presents an overview of current theories of adolescent risk and vulnerability and suggests Youth Development as an overarching framework for understanding both. Experience within a comprehensive, adolescent health and mental health center demonstrates how to meaningfully engage adolescents in their own health care from the start. [Article copies available for a fee from The Haworth Document Delivery Service: 1-800-HAWORTH. E-mail address: <[email protected]> Website: <http://www.HaworthPress.com> © 2004 by The Haworth Press, Inc. All rights reserved.]

KEYWORDS. Adolescent, youth development, vulnerability, risk, mental health, professional competencies

Introduction

This article presents an overview of current theories of adolescent risk and vulnerability and suggests Youth Development (Pittman, Irby, & Ferber, 2000) as an overarching framework for understanding both. Experience within a comprehensive, adolescent health and mental health center–the Mount Sinai Adolescent Health Center (AHC)–will be presented to demonstrate how to meaningfully engage adolescents in their own health care from the start. Embedded in the article is a discussion of commonly experienced barriers to implementing Youth Development (YD) principles and efforts undertaken at AHC to address them.

Despite popular images of adolescence as a period of mindless fun and self-absorption, adolescents present enormous challenges for health and mental health agencies and are classified as a “population at-risk” (U.S. General Accounting Office, 1996, p. 1). Experimentation and risk-taking put this group at particularly high risk for social morbidities such as unplanned pregnancy, alcohol and drug addiction, and HIV/AIDS, problems that often have lifelong impact and great social cost. Social and environmental factors influence the health risks of many adolescents. Lack of health insurance and access to health care, the easy availability of drugs, and the psychosocial sequela to violence in schools and communities combine with normative adolescent risk behaviors to produce an often-volatile mix.

By the millennium, there were already more than 39 million young people in the U.S. ages 10 to 19, with more than 35% belonging to racial and ethnic minorities (U.S. Bureau of the Census, 2001). The numbers of minority adolescents are growing at a faster rate than their white compeers, with greater concentrations of minority youth living in urban areas (National Adolescent Health Information Center, 2000). More than 25% of all adolescents live in poverty–a factor that exacerbates their health risks (Millstein, Irwin, & Brindis, 1991). More than 14% do not have health insurance of any kind (Newacheck, Brindis, Uhler, & Cart et al., 1999), and far fewer have coverage for mental health care, leaving many of their health and mental health needs unmet.

Uninsurance rates are higher in minority communities: black and Latino adolescents are much more likely than white adolescents to be uninsured (40% and 300%, respectively) (Newacheck et al., 1999). In addition to lack of insurance, poverty in inner cities brings many associated problems that further undermine the health of adolescents. These include economically depressed and dangerous neighborhoods, poor academic education, poor access to health care, lack of providers competent to address their specific health needs, and lack of opportunities that promote adolescents’ healthy development (Blum, McNeely, & Nonnemaker, 2002).

Myths about Adolescence

The myth that adolescents don’t need health care because they are a naturally robust population disguises the fact that adolescents as a group have serious health risks and lack access to needed medical and mental health care.

Adolescents are vulnerable for both health (Neinstein, 1996) and mental health problems (Burke, Burke, Regier, & Rae, 1991). One in five adolescents has a serious health problem and a much higher proportion has pressing health care needs, such as access to contraception, and one in five has a diagnosable mental health problem (Dougherty, 1993). Explanations for their vulnerability may be social as much as developmental (Blum et al., 2001; Eccles, Midgely, & Wigfield et al., 1993; Powers, Hauser, & Kilner, 1993). Furthermore, minority adolescents as a group are less healthy than white adolescents. Among white parents, 54% rated their adolescent’s health as excellent, compared with 43% of Latino parents and only 39% of black parents (National Institutes of Health [NIH], 1997).

Despite this vulnerability, rates of physician visits for 11-21-year-olds are low. In 1994, for instance, adolescents made 9.1% of physician visits but represented 15.4% of the total population. Minority adolescents were significantly underrepresented relative to their percent of the population. Black adolescents made 8.3% of visits though they constituted 15.5% of the adolescent population. Latino adolescents made 9.3% of visits, though they constituted 13.6% of the adolescent population. By contrast, white adolescents accounted for 78.5% of physician visits, though they represented 67.6% of the total adolescent population (Ziv, Boulet, & Slap, 1999). Although 20% of adolescents have a diagnosable mental health disorder (Dougherty, 1993), only one fifth of these receive mental health care (Kerstenbaum, 2002).

Differential rates of health care access are not related to the greater health care needs of white adolescents but rather to barriers to care of minority adolescents (NIH, 1997). These barriers include poverty, lack of health insurance, and lack of culturally competent health services. The absence of long-term and trusting relationships with health care providers suggests that the bio-psychosocial problems of many minority adolescents are never identified or addressed–unless they get into trouble of some kind. And, many do get into trouble.

So, for example, while 11% of all adolescents who enter high school leave before graduation, rates of high school dropout for blacks and Latinos are consistently higher than those for whites. Further, youth in low-income families are six times as likely as their peers in high-income families to drop out of school (National Center for Education Statistics, 2001). Although school dropout may not seem to be a health problem, it is a significant risk indicator and is correlated with poorer health outcomes both in the short-run and over the course of their lives (Millstein et al., 1991).

Dryfoos (1990) classifies over 25% of all U.S. teenagers as either high risk or very high risk of some kind. Within poor, inner-city communities, the normative risk-taking of adolescence is likely to have more serious and long-lasting negative consequences. Adolescents in these communities are more likely to engage in multiple, co-occurring risk behaviors, including use of drugs and alcohol, unprotected sex, violent activity, or school dropout.

Understanding Adolescent Vulnerability

The foregoing problems of urban minority adolescents require more effective health and mental health intervention strategies. More specifically, this means better engagement and assessment of individual adolescents at-risk and identification of broad risk groups. Yet, considerable ambiguity remains concerning identification of adolescents most at-risk and best practices in identification (Stanton, Fang, Li, Feigelman, Galbraith, & Ricardo, 1997). Moreover, the overarching term at-risk masks demographic vulnerabilities such as poverty, minority status and single parent households (Blum et al., 2001).

Furthermore, our understanding of adolescent vulnerability and its relation to risk has been hampered by the fragmentation of research on adolescent risk into specific problem areas such as violence, sexual activity, teen pregnancy, and substance abuse (Dougherty, 1993). Funding streams for services have been similarly fragmented, leading to intervention approaches that are more problem-focused than holistic.

Though recent theories of adolescent risk consider the interaction of risk factors, they continue to emphasize risk behaviors. Gateway Theory (Kandel & Yamaguchi, 1993) suggests that adolescents engage in escalating risk behaviors. It has been particularly influential in substance abuse prevention–for example smoking cessation can be viewed as a strategy for preventing escalation to other substance use. One area of interest that is evolving from this perspective is the study of risk antecedents and markers (Resnick & Burt, 1996).

Serial Risk Behavior Theory (Stanton et al., 1997) suggested by longitudinal studies of long-term risk behaviors has looked at the endurance of risk behaviors. This theory suggests that many adolescents shift from one risk behavior to another over time, with no apparent escalation in the total number of risk behaviors they engage in concurrently.

Together these theories have contributed much to our thinking about adolescent risk but raise as many questions as they answer, as they do not address the issue of why adolescents appear to take risks.

In contrast, Problem Behavior Theory (Blum et al., 2001; Donovan, Jessor, & Costa, 1985; Jessor, 1991) focuses on the co-occurrence of risk behaviors within high-risk groups and suggests that adolescents who are attracted to one risk behavior will be attracted to others. Its premise is that risk behavior is goal directed, rather than random thrill seeking, and that perceived risk is balanced against perceived and actual developmental benefits. Problem Behavior Theory suggests that adolescents who are attracted to one risk behavior will be attracted to others. Dryfoos (1990), in particular, suggests that risk behaviors co-occur in large numbers of adolescents, with the same high-risk groups engaging in multiple risk behaviors.

Concurrently, we need an increased understanding of how risk factors affect subsets of the adolescent population, particularly with respect to the influence of community and family contexts (Blum et al., 2001; Jessor, 1993; Mechanic, 1991). Adolescents who seem low-risk in their own behaviors might be at risk due to the behaviors of friends and associates (Bailey, 1992), or due to social factors rather than individual risk behaviors (Blum et al., 2001). Risk behaviors may also have different consequences for different subgroups, though this also has received little attention in research efforts (Shapiro & Seigel, 1998).

Clearly, too little is understood about social and environmental influences on adolescent risk and vulnerability (Eccles et al., 1993; Fahs, Smith, & Ata et al., 1999; Blum et al., 2001). Blum et al. (2001) build on Jessor’s (1991) concept of adolescent risk as a product of five contributing domains: Biological/genetic factors, social environment, the environment as perceived by the adolescent, personality, and behavior. Blum and his colleagues suggest that in addition to these five domains, risk theory be built on an ecological systems model that incorporates study of childhood antecedents of risk behaviors, factors that contribute to positive health outcomes, and the influence of macro-level factors such as politics, youth laws and policies, economics, and historical events. While this offers a promising framework for research, it is unlikely that at any time soon we will have an overarching theory that can be used to improve the efficacy of prevention and treatment programs.

Empirical Knowledge Versus Clinical Lore: The Myth of Adolescent Self-Perceived Invulnerability

The myth that adolescents perceive themselves as invulnerable prevents many clinicians from asking them directly about their health and mental health needs and from taking their responses seriously.

Despite the increase in empirical theory-testing concerning adolescents (Zaslow & Takanishi, 1993), a dichotomy still exists between the clinical construction of adolescence, as a phase of life full of sturm und drang, and research findings (Quadrell, Fischoff, & Davis, 1993). Many clinicians regard adolescents’ supposed grandiosity and feelings of invulnerability as defenses against the supposedly inevitable storm and stress of adolescence. Such ideas, though not supported empirically, can appear to provide compelling reasons why individual youth...

Table of contents

• Cover
• Title
• Copyright
• CONTENTS
• PART I
• PART II
• Index