Social Problems

1
Social Problems

• A Cost Effective Psychosocial Prevention Paradigm

2
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.

3
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.

4
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.

5
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.

6
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.

7
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)

8
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.

9
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.

10
Social ProblemsTeenage 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.

11
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.

12
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.

13
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.

14
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.

15
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.

16
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.

17
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.

18
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.

19
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.

20
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.

21
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.

22
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.

23
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.

24
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.

25
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.

26
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.

27
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.

28
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.

29
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.

30
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.

31
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.

32
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.

33
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.

34
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 6th out of 20
  countries.
• In 1986 the United States ranked 13th 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.

35
Behavioral Social WorkA 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.

36
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.

37
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

38
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.

39
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.

40
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.

41
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.

42
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.

43
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.

44
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.

45
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.

46
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.

47
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.

48
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.

49
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.

50
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.

51
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.

52
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.

53
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.

54
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.

55
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.

56
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.

57
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.

58
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.

59
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.

60
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.

61
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.

62
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.

63
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.

64
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.

65
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.

66
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.

67
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.

68
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.