Social Problems

A Cost Effective Psychosocial

Prevention Paradigm
Introduction
From a cost-benefit perspective, the
interventions the social service system has
chosen are extremely costly and highly
unproductive for both client and practitioner in
terms of targets, timing of intervention, ages,
and contexts.
Social, cognitive, and academic skills that adults
must master should provide the focus for
intervention from a life-span development
perspective.
Prevention Versus Remediation
Prevention is especially appropriate to dealing
with the problems of the young.
Prevention provides an early developmental
focus for intervention, which may forestall
development of future problems.
Prevention provides a view of the person that is
optimistic.
The approach is economic and mass-oriented
rather than individual-oriented and seeks to build
health from the start rather than to repair
damage that has already been done.
Prevention
The life skills training intervention model is
proposed as the treatment of choice.
This model has rationale and elements in
common with other prevention programs
that are based on a public health
orientation.
Such prevention programs consist of three
essential components: education, skills
training, and practice in applying skills.
Prevention
The Teams-Games-Tournament (TGT) model
consists of the same components as other
prevention programs, except for an additional
component: It uses peers as parallel teachers.
The prevention approach to intervention has
implications for the traditional role of the human
services practitioner and for the timing of the
intervention.
The prevention approach places major
emphasis on the teaching and skills-building
components of the intervention process.
Prevention
Practitioners do not take a passive role in the
intervention process, but instead attempt to help
clients learn how to exert control over their own
behaviors and over the environments in which
they live.
Professional knowledge, expertise, and
understanding of human behavior theory and
personality development are used by the
practitioner in the conceptualization and
implementation of intervention strategies.
Need for Prevention Programs
Deficit-ridden state and local governments are
cutting back prevention programs in order to
balance their budgets.
This proves to be cost-ineffective on every level.
One example: family planning services and teen
pregnancy programs.
Savings in public medical costs alone are
estimated to be $4.40 for each $1 spent in
contraceptive services. (Forrest & Singh, l990)
Need
Almost 10 million women of reproductive age have no
insurance, and more that 5 million women are insured
under plans that do not provide, largely for financial
reasons, maternity coverage. (U.S., GAO,1990)
The largely disorganized publicly funded family planning
system we now have provides contraceptive services for
about 4.5 million women, most of whom are at high risk
for unplanned pregnancies.
Without these services there would be an estimated 1.2
million additional unintended pregnancies each year and
over 500,000 additional births.
Need
Infant mortality rates (IMRs) would only be
greater.
Federal and state governments spend
approximately $400 million annually for
contraceptive services.
They save approximately $1.8 billion on services
that would have to be rendered to those women
who would otherwise give birth.
These trends underscore the importance of
supporting, rather than cutting, prevention and
early prevention programs.
Social Problems:
Teenage Pregnancy
The high incidence of teenage pregnancy
is the result of a decrease in the average
age of menses, combined with increasing
sexual activity among adolescents.
Many health problems are affecting
adolescents at younger ages.
The decline in age at first intercourse has
produced increased rates of sexually
transmitted diseases among adolescents.
Teenage Pregnancy
By the time they are 18 years old, 65% of boys
and 51% of girls are sexually active.
Approximately 50% of American adolescents do
not use contraceptives the first time they have
intercourse.
Half of premarital pregnancies occur within the
first 6 months after sexual initiation.
Each year 11% of adolescent women become
pregnant, and 4% have an abortion.
Teen Pregnancy
Adolescents who become pregnant while
in high school are more likely to drop out
of school, become dependent on welfare,
and become single parents.
Between 1950 and 1985 the nonmarital
birth rate among adolescents younger
than age 20 increased 300% for Whites
and 16% for Blacks.
Teenage Pregnancy
Approximately 2.5 million adolescents
have had an STD, and 1 in 4 sexually
active adolescents will contract an STD
before graduating from high school.
STD rates are substantially higher among
Black adolescents.
Teenage Pregnancy
The National Research Council estimates that,
for each year a first birth is delayed, a familys
income when the mother reaches 27 is
increased by $500.
Every year a first birth is delayed (up to age 20)
the chances of a woman and her family having
an income below poverty level are reduced by
about 22%
The Childrens Defense Fund reports that
women who first give birth as teens have about
half the lifetime earnings of women who first give
birth in their twenties.
Teenage Pregnancy
The Center for Population Options determined
that the federal government spent $21.6 billion
in l989 on families begun by teen mothers.
Based on the assumption that families begun by
a teen birth comprise 53% of the welfare-
recipient population, they consume 53% of the
funding of these programs (AFDC, Food stamps,
Medicaid)
The CPO estimates that the families begun in
1989 by a teen birth will have cost the public
treasury $6.4 billion by the year 2009.
HIV/AIDS
More than two thirds of adolescents with AIDS
were infected through sexual contact with adults.
Although only 440 people with AIDS (fewer than
1%) are between ages 13 and 19, the
prevalence of HIV infection among adolescents
is a source of concern.
It takes an estimated 5 to 10 years for the HIV
infection to result in AIDS; many young adults
who have AIDS contracted the virus as
adolescents.
HIV/AIDS
Approximately 20% of people identified as
having AIDS are between ages 20 and 29 (AMA,
1991).
The United States spent about $10 billion on
HIV-related activities in 1991.
Hellinger (1990) estimates the direct medical
costs of AIDS in 1991 to have been $5.8 billion,
with the cost of treating an HIV-infected person
averaging $5,150 yearly and the cost of treating
a patient with full-blown AIDS averaging $32,000
yearly.
HIV/AIDS
The Centers for Disease Control (CDC)
estimates that over 500,000 persons in
this country are HIV infected and do not
know it.
The costs of HIV-related expenses are
expected to continue rising until some type
of cure or solution is found.
Substance Abuse
The United States has become a chemical
culture.
The use and abuse of chemical substances
exact an incalculable cost for substance abusers
and non-abusers alike.
In 1987, it was estimated that 100,000 to
120,000 deaths are directly attributable to
substance abuse, and another 120,000 to
150,000 deaths are substance abuse related.
Substance Abuse
Many adolescents experience confusion and turmoil as
they strive to achieve autonomy.
Adolescents perceive taking psychoactive substances as
on of their few pleasurable options.
The use and abuse of mood-altering chemical
substances are now an integral part of growing into
adulthood in the United States.
Morrison (1985) notes that two thirds of high school
students use drugs and alcohol at least three times a
week.
Additionally, 65% to 70% of junior high school students
use drugs and alcohol two to three times weekly.
Substance Abuse
Long range consequences of teenage
substance misuses include the failure to
formulate goals for the future and stigmatization
following an arrest while under the influence of
drugs.
Patterns of substance abuse also have
significant health consequences.
Yet more teenagers die in alcohol and drug
related motor vehicle accidents than any
disease.
Substance Abuse
One fourth of all alcohol and drug related
motor vehicle fatalities involve males ages
16 and 19.
Tragically, drug overdoses also result in
88% of all adolescent suicides.
Drug related problems begun in
adolescence, or earlier, mount to
staggering proportions as young addicts or
abusers age.
Substance Abuse
In 1989, the Justice Department estimated
the social costs generated by each addict
to have been about $200,000 per year.
Drug related criminal justice costs have
since skyrocketed.
According to Rice and colleagues, 26% of
our total policy protection expenditures
can be attributed to drug related crime.
Substance Abuse
The total economic costs to the nation of alcohol
misuse were estimated by Rice and colleagues
to have bee $70.3 billion in 1985, a year in
which 94,765 deaths were attributed to alcohol.
A National Institute on Drug Abuse study found
that American firms spend at least 25% on
substance abusing employees wages
responding to their performance deficiencies.
The National Council on Compensation
Insurance estimates that substance abuse cost
American business $16 billion in workers
compensation alone in 1987.
Substance Abuse
The total cost to society of drug abuse was
$44.1 billion, whereas for alcohol it was
$70.3 billion.
Core costs for drug abuse were $10.6
billion for 1989, during which 6,118 deaths
were attributed to drugs.
Core costs for alcohol were $58.2 billion,
yet alcohol attributed deaths numbered
94,765.
Smoking
Cigarette smoking is the single most preventable
cause of death in the United States.
It is directly responsible for one in six deaths
22% of all deaths among men and 11% of all
deaths among women.
An estimated 30% of all cancer deaths, 87% of
lung cancer deaths, 21% of deaths from
coronary heart disease, 18% of stroke deaths,
and 82% of deaths from chronic obstructive
pulmonary disease are attributed to cigarette
smoking.
Smoking
Americans spent a record breaking $44 billion
on tobacco products in 1990 $41.8 billion on
cigarettes alone.
Warner estimated that nonsmokers pay 62% of
the economic costs of cigarette smoking.
If that is true, the external costs of smoking in
1985 may have been as much as $22 billion in
health care and as great as $38 billion in lost
productivity.
Children at Risk for Abuse
From 1980 to 1986 the reported incidence
of child abuse and neglect increased by
66% from 9.8 to 16.3 children per 1,000.
The National Clinical Evaluation Study
described in Daro (1988) made the
following findings:
Approximately 30% suffered chronic health
problems.
Approximately 30% displayed cognitive or
language disorders.
Children at Risk
Study (continue):
Approximately 22% had learning disorders requiring
special education.
Approximately 50% had been disciplined at school for
misconduct or poor attendance.
Approximately 50% suffered severe socioemotional
problems such as low self-esteem, lack of trust, or low
frustration tolerance.
Approximately 14% engaged in self-mutilative or self-
destructive behavior.
Other Children At Risk
Five major studies of births in the United
States, Canada, and Wales found that
21% to 30% of the incidence of low birth
weight was due to maternal smoking.
An estimated 3.2% of pregnant women
drink alcohol while pregnant, resulting in
an estimated incidence of 59 fetal alcohol
syndrome babies per 1,000 live births.
Other Children At Risk
Over 11% of the population admit to some
cocaine use; 1.4% admit to using crack.
The National Association for Prenatal Addiction
Research and Education estimates that 375,000
drug-exposed babies are born each year, most
of whom have been exposed to cocaine.
The U.S. GAO estimates that 280,000 pregnant
women were in need of drug treatment services
in 1990.
Less than 11% received care even though $32
million for treatment was provided.
Racial Disparities
An examination and comparison of social
indicators rates of unemployment,
delinquency, substance abuse, and
teenage pregnancy - show that Blacks
were relatively worse off in the 1990s than
in the 1960s.
Blacks are 23% more likely than Whites to
abstain from drinking.
Racial Disparities
Blacks experience far more social and
medical problems associated with heavy
drinking than do Whites.
The unexpected disparity in adverse
consequences may perhaps be explained
by the greater underreporting of drinking
among Blacks, variations in drinking
patterns, or racial differences in biological
vulnerability to alcohol.
Racial Disparities
Even though American infant mortality rates (IMR) have
fallen a great deal during the last century, the relative
position has deteriorated dramatically.
In 1918, the United States ranked 6
th
out of 20 countries.
In 1986 the United States ranked 13
th
out of 20
countries.
In 1975, the total IMR stood at a historical low of 16.1
deaths per 1,000 live births.
The figure for White babies was 14.2; for Black babies it
was 26.2.
Behavioral Social Work:
A Means to a Solution
Behavioral social work involves the systematic
application of intervention derived from learning
theory and supported by empirical evidence to
achieve behavior changes in clients.
The behavioral social worker must possess both
theoretical knowledge and an empirical
perspective regarding the nature of human
behavior and the principles that influence
behavioral change.
Behavioral Social Work
The work also must be capable of translating
this knowledge into concrete behavioral
operations for practical use in a variety of
practice settings.
The behavioral social worker must possess a
solid behavioral science knowledge base as well
as a variety of behavioral skills.
Theory, practice, and evaluation are all part of
one intervention process.
Knowledge Base
The central emphasis of behavioral social
work is on employing empirically
supported procedures that are aimed at
the solution of the clients difficulties.
The body of knowledge that the behavioral
practitioner needs to possess in order to
be an effective agent of change includes:
Knowledge Base
A thorough understanding of the scientifically
derived theories of human learning as they
relate to human behavior, which research shows
are necessary conditions, but not sufficient in
themselves, for therapeutic change.
The ability to make accurate behavioral
assessments that include the specification of
those conditions that are antecedent and
consequential to the problem behaviors under
consideration.
Knowledge Base
The ability to formulate behaviorally relevant and
specific treatment goals.
The ability to implement effectively a treatment
plan designed to modify those target behaviors
identified by the clients as problematic.
The ability to evaluate objectively any treatment
procedure and outcome and to formulate new
treatment strategies when those that had been
formulated originally have proven ineffective.
Assessment
An effective intervention addresses
assessment prior to initiation of change.
Rapid assessment techniques have
become increasingly popular with
practitioners and agencies alike.
Social workers have begun to identify the
utility of rapid assessment instruments to
collect large quantities of and better quality
data.
Assessment
Schwartz (1993) found that clients who
were given rapid assessment instruments
throughout treatment made more
improvement on their goals, terminated
from treatment less often, and were in
general more satisfied with treatment.
These instruments are more efficient as
well as more accurate.
Implementation of Change Strategy
Individual vs. group treatment:
The casework relationship is unlike most
situations faced in daily interactions.
The group interaction more frequently typifies
many kinds of daily interactions.
Services facilitating the development of
behaviors that enable people to interact in
groups are likely to better prepare them for
participation in larger society.

Individual vs. Group Treatment
Groups provide a context where behaviors
can be tested in a realistic atmosphere.
These theoretical rationales indicate that
treating clients in groups should facilitate
the acquisition of socially relevant
behavior.
Group treatment is equally effective as
individual service.
Individual vs. Group Treatment
In instances where an individual does not
possess the necessary social behaviors to
engage in group, a one to one treatment
relationship may provide the best
treatment context.
However, as soon as they develop the
necessary social skills, therapeutic
changes are likely to be further facilitated if
they can be placed in a group.
Macrolevel Intervention
If a change agent decides that a client is
exhibiting appropriate behaviors for his or
her social context but that a treatment
organization or institution is not providing
adequate reinforcers for appropriate
behaviors or that it is punishing
appropriate behavior, the change agent
must then decide to engage in
organizational or institutional change.
Macrolevel Intervention
In social work practice, the primary focus
has been on changing the individual.
Practitioners must restructure their
thinking.
Inappropriate behavior exhibited by a
client must be examined according to who
defined it as inappropriate and where
requisite interventions should take place.
Generalization and Maintenance of
Behavior Change
Considerable study is needed to delineate those
variables that facilitate the generalization and
maintenance of behavior change.
These may include substituting naturally
occurring reinforcers, training relatives or other
individuals in the clients environment, gradually
removing or fading the contingencies, varying
the conditions of training, using different
schedules of reinforcement, and using delayed
reinforcement and self-control procedures.
Client Outcomes
The first requisite for the use of research
in practice is the delineation of the
possible outcomes for the client.
It is evident that professional and clients
values, theoretical orientation, agency
goals, sociopolitical factors, available
resources, and practice context affect the
chosen outcomes.
Specific Applications to
Adolescents
Peers:
For teenagers, actions detrimental to health
frequently occur in situations involving peers.
Although teenagers may understand health
risks, this understanding is insufficient to
counter the social significance of indulging.
Specific cognitive and behavioral skills are
needed to resist external pressures and to
successfully negotiate interpersonal
encounters where pressure occurs.
Applications
Peers:
Adolescents often lack these skills, not
because of individual pathology, but for
developmental reasons.
Age brings increased opportunity to engage in
previously unknown or prohibited activities.
Lack of experience and prior learning
opportunities hamper youths abilities to deal
with new situations and new behavioral
requirements.
Life Skills Training Intervention
Model
The skills training model described here has
rationale and elements in common with other
preventive approaches based on a public health
orientation.
The interventive goal is skill building to
strengthen adolescents resistance to harmful
influences in advance of their impact.
Three components compose this model: health
education, skill training, and practice applying
information skills in troublesome situations.
Health Education
Information only programs have had few long
lasting effects.
Accurate perception, comprehension, and
storage of new information is a complex process
dependent on individual receptivity and on the
nature of the information presented.
Perceptual errors such as selectively ignoring,
misreading, or mishearing certain fact or
selectively forgetting information can create
discrepancies between facts presented and facts
received and remembered.
Health Education
The model proposed here addresses this
potential problem by asking teenagers to
periodically summarize presented content
in written and verbal quizzes.
Correct responses are then reinforced and
errors detected and clarified.
Peers are used as teachers, thus
enhancing their commitment to healthy
behaviors.
Health Education
Called relational thinking, this is the process by
which abstract information becomes part of an
individuals everyday reality.
This relational or personalization process is best
accomplished by actively involving adolescents
in gathering and assimilating information.
Also helpful for information personalization are
direct discussion of illusions and faulty thinking
patterns used to conveniently ignore important
health facts.
Skills Training
Even personalized information is of little value if
adolescents lack the skills to use it.
Translating health information into everyday
decision making and behavior involves cognitive
and behavior skills.
The model emphasizes skills for making
effective short- and long-term decisions and
assertive and communication skills needed to
implement decisions.
Skills Training
Realistic decisions about how to act must,
consider responses of significant others.
The ability to anticipate both interpersonal and
health consequences of behavior, generate
alternative action strategies, and arrive at the
best choice are all crucial to health-promotive
decision making.
Training also focuses on behavioral skills
necessary to transform decisions into action.
Skills Training
Training presents verbal and nonverbal
aspects of good communication to help
adolescents learn to initiate difficult
interactions, practice self-disclosure of
positive and negative feelings. Refuse
unreasonable demands, request changes
in anothers behavior, ask others for
relevant information and feedback, and
negotiate mutually acceptable solutions.
Practice Applying Skills
In the final and most important phase of
the model, adolescents practice applying
skills in a variety of potentially risky
interpersonal situations.
Extended role-play interactions provide
adolescents with opportunities to recall
and make use of health information,
decision making techniques, and
communication skills.
Practice Applying Skills
In role-playing, teenagers practice
responding to increasingly insistent
demands and receiving feedback,
instructions, and praise to enhance
performance.
Practice also takes the form of homework
assignments involving written contracts to
perform certain tasks outside the training
environment.
Practice Applying Skills
Although all phases of the interpersonal
skills training model can be conducted with
individuals, groups provide the most
efficient and effective training context for
this final practice phase.
Group settings allow teenagers to try out
skills with various partners, give feedback
and encouragement to each other, and
learn from a variety of models.
Teams-Games-Tournaments
Model
The most important socialization agent in
adolescents lives are their peers, with schools
providing a natural environment for peer
influence.
The TGT technique is an innovative small group
teaching technique.
The technique alters the traditional classroom
structure and gives each student an equal
opportunity to achieve and to receive positive
reinforcement from peers by capitalizing on
team cooperation, the popularity of games, and
the spirit of competitive tournaments.
TGT
Group reward structures set up a learning
situation wherein the performance of each
group member furthers the overall group
goals.
This has shown to increase individual
members support for group performance,
to increase performance itself under a
variety of similar circumstances, and to
further enhance the groups goals.
TGT
The use of the group reward structure with
adolescents is significant in that it capitalizes on
peer influence and reinforcement, which are
considered to be two of the most potent
variables in the acquisition, alternation, and
maintenance of prosocial behavior in youth.
It facilitates learning among low academic
achievers who have less attachment to prosocial
norms and peers, a group that is at greater risk
to develop health problems.
TGT
Peer relationships play a significant role in the
adolescents socialization and health behavior.
The information is provided in a group context to
help student practice necessary social skills to
develop adequate behavior in regard to their
health.
TGT capitalizes on the power of peers to
influence the acquisition and subsequent
maintenance of behavior.
Issues
Family Intervention:
Data indicates that parents whose adolescents are at
risk of engaging in actions detrimental to their health
face multiple social and psychosocial difficulties.
The clearest empirical finding with regard to such
adolescents seems to be the lack of consistency by
the parent or parents in the handling of their child and
the consequent lack of effectiveness in managing the
childs behavior in a manner that facilitates his or her
psychological and social development.
Issues
Family Intervention:
It has also been pointed out that another common
feature of relationships between parents and
adolescents at risk is unrealistic expectations by the
parents regarding appropriate behavior for their child.
Another empirical finding of substance is the high
degree of strain evident in families with children at
risk.
Each intervention package must have an attractive
and effective parent curriculum.
Issues
Timing of the Intervention:
Recent research executed on various
populations indicated that intervention should
occur in the fourth, fifth, and sixth grades to
psychologically inoculate children for the risks
that they are going to face.
All interventions discussed should be
executed as early as possible.
Issues
Curriculum:
Curriculum updates should occur periodically.
Material that is included in the curriculum
should be easily comprehended and
presented in an attractive manner.
All updates should include information that is
relevant for the skills that are being acquired.
Role-playing exercises that involve over
learning and repetition should be included.