Who Is Really at Risk

Who is really at risk? p. 1

11/10/03

WORKING TITLE:

Who is really at risk: Splitting and lumping risks and the At-Risk Model of problem identification[1].

Art Maerlender, Ph.D. & Kathy Kovner-Kline, M.D., M.Div.

Introduction

Developmental trajectories p. 4

I. Definitions and history of the term “At-Risk” p. 6

II. Risks of “at-risk” p. 15

III. Levels of risk and protection p. 20

Perspectives from developmental psychopathology p. 22

IV. Cultural attitudes and impediments to optimizing children’s development. P. 34

A. Personal attitudes and values p. 34

B. Family attitudes and values p. 35

C. Religiosity and spiritual beliefs and attitudes p. 35

D. Socio-Economic Status (SES) p. 37

E. Environmental influences p. 38

F. Media behavior and attitudes p. 41

V. The health of the herd: Ecological perspectives p. 43

VI. From single ‘wires’ to global ‘grids’/from glia to globes: ecological strategies to optimize all development p. 46

Introduction

This paper will consider several inter-related questions: Does the “at risk” model help us to identify, or obscure the trends in which, despite our affluence, increasing numbers of our children are suffering from serious risks of violence, substance abuse, teen pregnancy, school failure and psychosocial maladjustment? What does being “at-risk” mean? What specifically puts children “at-risk?” We will look at the origins of the “at risk” model, and we will make the case that the current “at risk” model of thinking about children’s problems has been very productive for understanding these problems, but has serious deficiencies for driving policy and funding decisions.

Public health has had a long-standing interest in providing services and information that lowers the incidence of disease. As early as mid 1800's, ecological factors such as poverty and social class were studied in relation to health/disease, i.e., typhus epidemic.

Since World War II, the general public has supported this approach by adopting a more proactive attitude toward health that has also placed greater demands on medicine to increase its knowledge base relative to prevention and effective intervention (Matzen and Lang, 1993). Corporate and funding entities have asked for evidence of ‘cost-effectiveness’ as a means of managing limited resources. While these proofs are difficult – and impossible in the short term – the impetus has created approaches that value efficiency as well as effectiveness. One outgrowth of this public health focus has been the identification of levels of intervention, or ‘interference’ in the evolution of a morbid state or disease. These levels have been termed: primary, secondary and tertiary levels of intervention.

Primary prevention refers to system-wide efforts to prevent disease, usually without the identification of individual cases or affected members. The use of vaccines and controlling pollution are two examples of primary preventive efforts. Secondary prevention addresses early detection of the potential for development of the disease or condition. It also refers to the early identification of the existence of a disease while individuals are asymptomatic, thus allowing for positive interference to prevent, postpone or attenuate the symptomatic clinical state. Reducing plaque formation in order to prevent periodontal disease is an example from medicine/dentistry. Tertiary prevention refers to the treatment of an existing disease in order to prevent its further spread. The practice of quarantine for those with infectious disease, or the treatment of human immunodeficiency virus (HIV) to prevent the spread of AIDS are two examples of tertiary prevention.

Although public health has a long history examining environmental, social and economic determinants of health, more recent public health initiatives have emphasized individual risk factors and specific behavioral changes for guiding prevention efforts (Israel, 1999[2]). But according to Israel (1999), the emphasis on individual behavior and the role of professionals has led to an under-valuing of environmental and social factors in understanding health and disease. Practitioners and researchers in public health have called for more integrative and comprehensive approaches that includes attention to complex factors such as social and political issues that impact health at multiple levels. In effect, public health is returning to approaches developed earlier, with calls for implementation of ecological models that address multiple levels of behavior, influence and activity (see McLeroy et al, 1988)[3]. These levels include individual, interpersonal, community (including social and economic factors), organizational and governmental factors. These factors are seen as inter-related, and it is believed that programs aimed at one level will impact behaviors at other levels.

Within the field of psychology, the study of the role of risk and protective factors in the development of psychopathology has struggled with competing notions of specific versus multiple causes of maladjustment (Heister, et al, 1994[4]). Over the last twenty years there have been two, somewhat independent, conceptualizations of the term ‘risk.’ The causative approach views certain types of events as unique risk factors for specific disorders. An example from the adult literature is that the early loss of a parent is a risk factor for the development of depression, but not criminality (Bowlby, 1969/1982[5]). A second view is an additive model. It states that it is the number of often non-specific risk factors that increases the likelihood of the development of some form of psychopathology, such as the effects of life transitions on adolescent development (Simons and Blyth, 1987). Further, the type of pathology manifested (e.g., violence) is not necessarily directly or uniquely linked to a specific stressor. The nature of the pathology might depend on pre-existing vulnerabilities. This latter model stresses the relationship of biological factors and environmental events. Hiester (1994) maintains that the first model is the typical approach to biological risk factors, while the emphasis on cumulative factors is more popular in the study of environmental stressors.

Developmental trajectories

The interface between risk and development is also critical to consider. Kopp (1994) argues that not only must risk be studied in the context of development, but development must be studied in the context of risk. A primary care giver’s emotional unavailability due to the death of a spouse will have dramatically different effects depending on the age of the child.

Incorporating both the individual and the individual’s environment in efforts to promote healthy behavior is an application of ecological model (Bronfrenbrenner, 1973, 1979, 1986[6]). He described 3 levels of factors that need to be considered in research and intervention: microsystem, mesosystem, and exosystem. These points were demonstrated by Sameroff and Chandler (1975) in their seminal work on reproductive risk factors. In their model, cultural beliefs represent a ‘macrosystem,’ while aspects of community life and interaction represent an ‘exosystem,’ the child’s family setting represents a ‘microsystem,’ and within-individual factors represent individual ‘onotgeny.’ They noted that these systems inter-relate in a dynamic fashion and must be considered in total when assessing reproductive risk. While there is not perfect correspondence between the levels of the Sameroff and Chandler systems and the bio-psycho-social-cultural model, the salient point is the need to consider multiple levels of functional activity when observing or analyzing a specific set of characteristics, behaviors, individuals or groups.

As mental health providers, we recognize the need to address mental health issues in a similar fashion. In the medical-psychological worlds the general world-view is often referred to as the bio-psycho-social model. This model posits that activity at the biological level (i.e., cells, neurons, organs) interacts with psychological variables (e.g. personality, mood, psychological maladjustment), and both interact with social factors (e.g., social milieu, family structure). These interactions are dynamic and reciprocal. We are adding the idea that cultural factors such as values, shared beliefs and institutional behaviors are also important in effecting individual and group behavior, as well as psychological and biological functioning.

At issue are the relative merits of continuing to rely on secondary prevention and its focus on risk identification as the best strategy for optimizing the development of children and adolescents.

I. Definitions and history of the term “At-Risk”

“Risk factors are those characteristics, variables, or hazards that, if present for a given individual, make it more likely that this individual, rather than someone selected from the general population will develop a disorder” (Werner and Smith, 1992, Garmezy, 1983, quoted in Mrazek and Haggerty, 1994). Risk reduction strategies have been borrowed from public health. The term "at risk" came into parlance in the 1970’s, primarily from the field of epidemiology, a branch of medical science that deals with the incidence, distribution, and control of disease in a population, (Tompkins and Deloney, 1994, Webster, 1975). Epidemiology is the study of the distribution and determinants of states of health in populations (Susser, 1973). A major task of epidemiology is to identify risk factors for disease. The medical field adopted the term from the insurance industry, which has used it in relation to mathematical determinations of liabilities and insurance premium costs (Baizerman, 1990). In both medicine and the insurance industry, risk is identified by defining and measuring probabilistic outcomes, and it is defined in relation to a specific event (e.g., at risk of contracting a specific disease or of being involved in an automobile accident). The term “at risk” refers to a statistical probability that is based on group studies in which a particular trait or set of behaviors, environmental factors or the like have been linked to the outcome for a large number of individuals. It refers to a probability that the quality in question (or lack of a quality) will lead to dysfunction. It suggests only an increased probability of the disorder in question, and is not informative about the mechanisms of the disorder. In this sense it is a correlative term and not descriptive.

Derivative terms such as developmental risks, at-risk and established risk have been used as marker variables to signify that a child’s development is in jeopardy from biological, psychological, or socio-cultural conditions. By and large, developmental scientists have reached a consensus about the general meaning and implications of these terms (Kopp, 1994[7]). However, the term does not imply or connote explanation. When introduced as a variable in research it is difficult to operationalize or define such variables with precision because it tends to define a confluence of variables, but does not explain how relate to outcomes. For example low socioeconomic status (SES) is considered a risk factor for many psychosocial maladjustment problems, but this is a very broad construct. As a grouping variable, it does not explain the mechanisms by which low SES predicts or accounts for an outcome.

Despite methodological problems, the Centers for Disease Control, the Nation’s prevention agency, has codified the role of risk analysis in their research agenda. The first stage of research they engage in, ‘determinant research,’ examines how various risk and protective factors affect health. Knowledge about the determinants of healthy people and healthy communities is seen as essential for developing maximally effective interventions. A better understanding of such determinants as assets, resiliency, and social capital is needed to broaden the approach to public health from a disease-reduction focus. Research on determinants that influence multiple health outcomes is especially important.[8] Thus, the CDC is moving from primary to secondary prevention efforts by the nature of their research agenda.

“At risk” as a term implies a strategy for identifying our most vulnerable individuals or groups. As such, it is best characterized as a secondary prevention strategy. Further, medical use of the term carries with it an added implication that treatment or prevention of some kind is called for (Richardson et al., 1989). Selective preventive interventions for mental disorders are targeted to individuals or subgroups of the population whose risk for developing mental disorders is significantly higher than average. The risks may be imminent or lifetime. Risk groups can be identified on the basis of biological, psychological or social risk factors that are known to be associated with the onset of a mental disorder, such as depression or schizophrenia. Indicated preventive interventions are targeted to high-risk individuals who are identified as having minimal but detectable signs or symptoms (Mrazek and Haggerty1994).

As defined, risk factors are those characteristics, variables, hazards that, if present for a given individual, make it more likely that this individual, rather than someone selected at random from the general population, will develop a disorder (Werner and Smith, 1992). Thus to qualify as a risk factor, a variable must be present before onset and associated with increased probability of the disorder. Risk factors can ‘reside’ in the individual, family, community, or institutions surrounding the individual. They may be biological or psychosocial. Some are causal, others just markers[9] (Mrazek and Haggerty1994).

There is agreement about general risk factors, or factors that contribute to many different problems. Werner and Smith categorize these factors (Werner and Smith, 1992).

Table 1: General Risk Factors Common to Many Disorders

Precursor child factors

·  In utero environmental toxins (stress, physical trauma, heavy metals, substance abuse);

·  Low birth-weight;

·  Parent interaction difficulties due to difficult temperament, chronic physical illness, low intelligence, neurophysiological illness;

·  Gender – boys more vulnerable to physical and psychosocial stress (before age 10), then girls (10-20), then boys in early adulthood.

General family risk factors

·  Severe marital discord;

·  Social disadvantage;

·  Overcrowding or large family size;

·  Paternal criminality;

·  Maternal mental disorder;

·  Admission to care of local authorities.

Community factors

·  Social disadvantage (this is not necessarily due to low income, but is statistically more prevalent when one family member receives welfare);

·  Living in subsidized housing;

·  Living in area of high community disorganization;

·  Community institutions such as schools can either enhance or detract from intellectual social growth and development and thus can be either a protective or a risk factor.

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In Loeber’s extensive longitudinal study of adolescent risks and outcomes (1998[10]), they concluded that a diagnosis of ADHD, hyperactivity and impulsivity (behaviors without formal diagnosis of ADHD), and a lack of guilt were consistently related to multiple outcomes (e.g., substance abuse, sexual activity, aggression, school failure and depression). At the family level, only poor communication was consistently and generally related to multiple outcomes. Their findings included all of the factors identified above, but in their sample and with their statistical techniques, these behaviors were most strongly and consistently related to the multiple bad outcomes of multi-problem boys.